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Hi, my name's Jo Gibson and I'm a clinical physiotherapy specialist, or at least I was until very recently at the Liverpool Upper Limb Unit. I now work as an upper limb rehabilitation specialist in a private clinic. But essentially I've specialised in treating patients with shoulder pain since 1995.

I've had a fantastic career. I've seen lots of different types of patients, and as you might know, I like to share some interesting cases or perhaps talk about some rehabilitation challenges or patients that have got me thinking and if you like, reflecting on the evidence and seeing really how we can use the best of that to keep reflecting on our practice and do the best for patients, but also to share some interesting cases.

A patient that I saw in clinic reminded me another patient I'd seen quite a long time ago, probably 15 years ago, with exactly the same problem.

And I thought it was a good opportunity to bring that to you. I'm going to give you a little bit of information about this guy, and then we're going to see if anybody can actually come up with a diagnosis or certainly what they might want to think about in terms of possible diagnosis, and then perhaps talk a little bit about the condition.

Now this guy was 38. He'd been referred from his general practitioner with a diagnosis of frozen shoulder. He didn't have any particular risk factors. He wasn't diabetic, he didn't have any thyroid issues and obviously at the age of 38, my immediate thoughts were this is a bit atypical.

He's a little bit outside the typical age range for frozen shoulder. There wasn't any particularly genetic history. This guy was Somalian. He'd lived in this country for a few years, but regularly traveled back to see his family. He wasn't currently working. He was struggling a bit in terms of benefits and stuff. Living with some friends, didn't have a job, didn't really seem to have any key focus but liked playing football with his friends, obviously had a good social network. I really picked around at the history, but there was no history of falls, no history of trauma, nothing that had preceded the onset of this stiffness.

Now, his general health, as I say, was good, but again, I'm thinking, are there any other risk factors for frozen shoulders? Is there anything fits this story? So I asked him a little bit more about his pain. And as you'll know with a true frozen shoulder, generally we will have that typical history where somebody has this insidious onset of pain, which escalates and gets really unpleasant, significantly affects sleep. They struggle to find a place to get comfortable. They may get some relief from analgesia, but sleep disturbance is debilitating and then we get that gradual loss of movement. This guy didn't really give that same history. He talked about the shoulder being a little bit stiff, that it'd been a bit achy, but over a period of time it was getting more sore, more of an intense ache, but not that typical acute pain.

Now, he was getting some sleep disturbance, but certainly that hadn't featured at the onset of symptoms. Now this guy actually had symptoms for eight months. He'd originally gone to see the GP complaining of his shoulder pain. The GP had sent him for an X-ray, which was normal, which was interesting because there wasn't any trauma at that stage, certainly nothing very worrying. He'd been referred for physiotherapy but for one reason or another, probably because of COVID, probably because of waiting list, for very many reasons, this guy actually hadn't been followed up. So I then met him in the clinic and it was obviously deteriorating. He was obviously not very happy and obviously was worried that there might be something seriously wrong.

Now guys, I've given you some key kind of hints there already. This guy's 38, which is atypical. He hasn't got any risk factors for frozen shoulder. He has got some shoulder pain and you could argue that because of the psychosocial situation, maybe a bit more angst, maybe protecting his shoulder a little bit more, so muscle stiffness is something I definitely need to consider. But there was some other little clues I gave you there that might want you to rule in another potential diagnosis, particularly in the presence of true stiffness. And there's no doubt, when I looked at this guy objectively and I looked at his external rotation range, he did have restriction. And it felt like a real almost like a bony end-feel rather than a capsular end-feel. But he, again, he was a little bit reticent to let me do that. So what might you be thinking already?

What I'm going to say to you is this particular diagnosis, what it turned out to be, up to 80% of patients are initially diagnosed with frozen shoulder when they present with this condition. Have we got any guesses yet? The clues that I gave you are the fact that this guy is Somalian and the fact that he's 38 and the fact that he regularly travels home. So what basically what this guy ended up having was TB, so extrapulmonary TB. So TB is obviously a bacterial infection. Most commonly it presents in the lung. So, pulmonary TB. There are different types. Some are associated with fistulas and puss and others are a dry form of TB . But the bottom line is it's a bacterial infection and it can be latent. So what you might find is that's somebody's been in contact with somebody with TB in the past.

But their body kind of manages to fight it and stop it spreading. But then if they become immunosuppressed, then it can flare up and they can start to get symptoms. So then they have active TB . One of the interesting things when I asked this guy a little bit more about his history when he'd been back. His mum hadn't been very well, she'd been coughing. A persistent cough had gone on for a period of time. He'd been in close proximity with her for several weeks.

He didn't get any symptoms himself at the time. He then came to this country. His mum was treated. He was never entirely sure what was the matter with her. So whether she had TB or not, we don't know. And remember, TB is not as infectious as something like a cold. You need prolonged contact for several hours and persistently.

So typically it's family members or people that you're living with. You can have contact and it can be one, two, even several years before it becomes active if indeed it does because of that immunosuppression. So maybe you've been a bit unwell, maybe you've got a virus, maybe you've had a vaccination, who knows?

But there could be lots of potential triggers that make that latency be become active. Now, it's important to say that it's very, very rare in terms of isolation in the shoulder. Certainly if you look at extrapulmonary TB in terms of affecting the joints and the bones, only between one and 3% of TB actually is specific to the joints and bones. That's that extrapulmonary cause. If you look at the shoulder within that group, then it only accounts for between one and 10%.

There are case studies described in the AC joint with an atypical swelling, not the redness that you'd necessarily associate with an infection. If you get a swelling, you're going to do X-rays, you're going to do some other investigations if it doesn't fit. Most commonly, it affects the humeral head and the glenoid.

Remember, this guy had an X-ray at the outset, but in the very early stages, often you won't see anything very dramatic. If that guy just started to get symptomology, obviously until it progresses and we start to see osteolytic lesions in the typical TB type lesions, then it can be a little bit down the line.

The other thing that's important to say is, again, obviously you've always gotta ask patients in terms of any persistent cough, if they're coughing up phlegm, if it's bloody, et cetera. Because again, if you look at the literature, anywhere between 12 and a half, up to 50% of people will have pulmonary TB and then will have a manifestation in the bones or the joints as well.

We obviously sent this guy for blood tests. He had a Mantoux test. There's this new interferon-gamma blood test that's becoming more popular. But essentially the Mantoux is like a skin test that can pick up latent and active TB . What's interesting, again, when you look at typical descriptions of people who have got TB affecting their shoulders, so affecting the joints specifically, we are always looking at systemic signs in terms of fever, night sweats, any wasting. But again, often these patients won't get those symptoms. So up to 50% of patients with local shoulder TB will not describe any particular systemic find. So again, just something to be a little bit aware of.

When we look at risk factors for this particular group of patients, what's absolutely clear is there's some key groups that more at risk.

In Europe, it's been practically eradicated. However, when you look at high prevalence areas, where really you're seeing more than 40 cases per hundred thousand population every year, then the common countries of origin are places like India, Pakistan, Romania, Bangladesh, Somalia, Asia, China, and what they call Sub-Saharan Africa, which basically means everywhere south of the Sahara desert. So again, just very important if people are traveling if they're from one of those countries, just searching out a little bit more about the history.

Again, what's interesting is, about 12% of patients may have had treatment for TB in the past and then they've had some then recurrence because of some untreated latency. They didn't complete their treatment.

When we look at other groups that are at risk, people with certain comorbidities, so HIV is a definite risk factor because of immunosuppressants, diabetes, end-stage chronic kidney disease, people having renal replacement therapy, gastrectomy, occupational lung disease, any hematological malignancy, people that are severely immunocompromised. And again, patients that have malnutrition. So again, you put all that with those other factors, just some interesting things to consider. The other thing is people taking immunosuppressive drugs. So obviously long stand duration of high dose steroids, chemotherapy, anti-tumor necrosis factor, any of the alpha biological treatments for inflammatory disease, again, seem to increase the risk of reactivation, specifically of latent TB . So if they've had that contact in the past.

And then the other are very deprived groups. So again, if we look at the homeless, so if you look at the most deprived 10% of the UK population, the TB rate is seven times higher than the least deprived 10% of the population.

So definitely some risk factors there, particularly people who are living in homeless shelters or hostels, day centers, people in prison or detention centers, again, because of particular exposure and also the kind of drug resistance TB are higher in those populations. Now those are clearly risk factors for developing active TB .

But the other really interesting thing is I certainly saw a guy years ago, no foreign travel no particular risk factors in terms of ethnicity, and it remained very confusing where this guy could have contacted TB in the first place. However, this guy that I saw recently, obviously there was some clear risk factors there. He'd stayed in a family house with lots of different people with his mum who was ill with a cough. And no doubt that was probably where he was exposed originally.

As I say, it can develop slowly. The key things about this guy that made me suspicious was it didn't fit the typical picture from a frozen shoulder. Not only in terms of his age, but also that initial onset. There was no history of trauma. He hadn't had surgery and being immobilised, but equally he hadn't had that very typical, horrible, painful phase with then that increasing stiffness. It was much more innate that became more prohibitive, that then started to limit his movement.

And certainly when we looked at the X-ray, he had significant destruction of his humeral head. And so one of the big things is, again, because it's a bacterial infection, the quicker it's picked up, the better. So arguably anybody who's had exposure to people in a foreign country with a high risk of TB , then doing simple things like the Mantoux test and some regular blood screening can be a useful thing to do.

Now the ESR may only be slightly raised again in those early stages. So the Mantoux test and this new interferon-gamma test probably give us better value.

So remember the majority of TB we'll see will be in the lungs and that's the persistent cough, breathlessness, those things that are worsening, and you can get patients who then get the joint version alongside that. And that reflects 12 to 50% of patients.

I just thought this was a really interesting one. I'm absolutely delighted that Afsanah actually got TB. I'm very impressed because it's not something we see a lot in the UK. And as I say, in western Europe, it's mainly been eradicated in western groups, but those different ethnic groups are definitely more at risk.

So just some other questions to think about. Factoring to somebody who comes with an atypical stiff shoulder that might help your diagnosis and the one time that an X-ray is definitely valuable. But if things still aren't fitting, thinking about your blood test and also importantly, thinking about potentially other imaging that may be more sensitive, like MRI.

So I hope that was useful, guys. As I say, I've probably seen four of these in total in my career, but it's been quite a long time since I've seen one. So when this guy came in, as I said, the key things. That made me suspicious was his ethnic origin, the fact that the history didn't fit with a frozen shoulder, the fact that his age didn't fit with a frozen shoulder, that the description of how it started didn't fit with a frozen shoulder, and yet he had stiffness. So TB is definitely something that you might actually then include in your differentials.

Tim saying he wouldn't have thought of that. No. And again, whenever I talk in lecture talking about stiff shoulders, it's always in my differential diagnosis and it comes back to this thing of, should we X-ray or should we not?

And oh, Joe, I learned a lot from your shoulder course only. Ah, thank you so much. That's fabulous. You're so welcome. Thank you. It's great to have you here on these Facebook lives.

But as I say, when I teach about the stiff shoulder, it's always something I put in my differential diagnosis, and it always brings up this question, do we need to X-ray everybody with a suspected frozen shoulder? Remember, I'm just going to mention this before I finish, that lovely paper by Roberts et al in 2019 that looked at 350 people that were sent with a diagnosis of frozen shoulder, the clinicians, the expert physios, basically notated whether they would've done an X-ray based on the history, i. e., did it sound like, look like, feel like a frozen shoulder, in which case, they wouldn't have X-rayed. Whereas the other people, they had signs and symptoms that didn't fit and they would've X-rayed.

Now, when they looked at the outcome of the 350 X-rays in those patients with a diagnosis of frozen shoulder, there were 342 that were normal. And importantly, those were the patients that the clinicians had said, looked, felt, sounded like a frozen shoulder. So actually those 342 X-rays arguably were unnecessary. In the other eight, I think there were six degenerative, one lucency and one fracture. And again, importantly, the clinicians based on a sound subjective, which remember is 80% of your decision making accurately identified those eight patients where features didn't fit.

So where does that leave us? Well, One, you have to be very careful what the local pathway is with you in terms of whether you have to X-ray, and certainly if you're going to do something invasive like an injection. Arguably an X-ray is a sensible thing to do, but again, it's which can you access quicker.

For me, in secondary care, then we have to X-ray everybody. Why? Because our radiologists are absolutely clear. And again, it's like TB. Remember one study showing 87% of people with TB in their shoulder had been diagnosed as a frozen shoulder. Now there are other studies that show that it's perhaps not quite that common, but it's just an important thing to consider when you think malignancy and other not so nice pathologies are often misdiagnosed as frozen shoulder.

So frozen shoulders is the most common misdiagnosis for nasty pathologies. So the radiologist would argue, look, do an X-ray. And if you are still not happy or there's still things that don't fit, you need to do an MRI because as we know, an X-ray isn't infallible because we need a lot of bone destruction before we see anything there.

But I think what this really illustrates, and I guess my key purpose of this particular guy is when features don't fit, don't try and make them. There were some key things that I shared with you about this guy's history in terms of how it started, how it progressed his age, that immediately made it less likely to be a frozen shoulder.

And when you're in that situation, you've gotta ask more questions, you've gotta find a way forward. And that's where our imaging our investigations and potentially blood tests and other types of tests are invaluable as being our safety net to make sure we get our patient to the right place.

So guys, I hope you enjoyed that and a slightly different one. As ever, if there's key things you'd like me to talk on here, always happy to talk about any things that specifically interest you. Thanks as ever for joining. And I'll look forward to seeing you very soon. Bye for now and enjoy the rest of your evening.