“I need an injection in this shoulder before I lose my business — and I don’t want any blood tests”

Frozen shoulder (adhesive capsulitis) causes shoulder pain, often worse at night, followed by progressive stiffness with marked loss of both active and passive movement, typically affecting external rotation most. It is commonest between 40 and 60 and is more common in people with diabetes, so NICE CKS suggests checking for diabetes. It is a clinical diagnosis; imaging is not usually needed unless red flags or diagnostic doubt (an X-ray can exclude glenohumeral arthritis if movement is restricted after trauma or in older people). The condition usually passes through painful, stiff and recovery phases and most people improve, though it can take one to three years and some stiffness may remain. Management: analgesia, information, home exercises and physiotherapy, and an intra-articular corticosteroid injection, which can reduce pain and improve function in the early painful phase. In the UK FROST trial, early structured physiotherapy with a steroid injection was a reasonable first-line option, and surgical options offered no clear advantage for most people. Steroid injections can raise blood glucose for several days, which matters in diabetes. Refer if symptoms remain severe despite treatment. The consultation skill here is the hidden agenda: a refusal of blood tests before any are offered is a cue. Exploring it reveals fear rooted in a parent’s amputation; acknowledging that fear, explaining how different early diagnosis is, and linking the test to her own goals (a safe injection, keeping her business) makes it possible to agree an HbA1c. Supporting a self-employed patient’s work is part of good care.