frozen shoulder
DESCRIPTION
mini referatTRANSCRIPT
Frozen Shoulder
Adhesive Capsulitis
Definition
Idiopathic inflammatory condition characterized by progressive shoulder pain, stiffness that spontaneously resolves and Restriction of motion movement in all planes
Epidemiology :
40-60 years
Women 2:1
Non-dominant limb more affected
Bilateral in 10-40%
2% of population
11% of diabetic population
Sedentary workers
Aetiology :
Poorly understood
Autoimmune theory proposed but not proven
Predisposing factors:
Immobility
Trauma (often trivial)
Cervical disc disease
Diabetes Mellitus
10-20% compared with 2% of general population
Bilaterality (40%)
> 10 years of IDDM risk
Thyroid disorders
Hyperthyroidism
Resolves with treatment of disease
Myocardial infarction
Intrathoracic disorders
TB
Carcinoma
Emphysema
Intracranial Pathology
Hemiplegia
Cerebral Haemorrhage
Cerebral tumours
Personality disorder
Not associated with
Osteoarthritis
Cuff Pathology
Classification :
Primary / idiopathic condition underlying
Secondary underlying disease (trauma, subsequent immobilization, DM, hypothyroid,hyperthyroid, hypoadrenalism, parkinson disease, surgical cardiac surgery
Apley
Three phases each lasting 4-8 months
Freezing
Increasing pain
Frozen
Decreasing pain
Increasing stiffness
Thawing
Decreasing stiffness
Pathogenesis & Pathology :
Initial synovitis of unknown cause
Results in
Capsulitis
Intra-articular adhesions
Obliteration of inferior axillary fold
Subsequent development of
Subacromial adhesions
Rotator cuff contracture
Then spontaneous resolution
Contracted, thickened joint capsule drawn tightly around the humeral head with relative lack of synovial fluid
See cellular changes of inflammation with fibrosis & perivascular infiltration in subsynovial layer of capsule (Nevaiser) similar appearance to Dupuytrens disease
Poor correlation between the microscopic & gross capsular changes
Capsular folds & pouches obliterated by synovial adhesions
Coracohumeral ligament is shortened & prevents ER
Rotator cuff bellies contracted fixed & inelastic
Few adhesions in subacromial bursa
Spontaneous resolution the rule
Look: On inspection, the arm is held by the side in adduction and internal rotation. Mild disuse atrophy of the deltoid and supraspinatus may be present.
Feel: On palpation, there is diffuse tenderness over the glenohumeral joint, and this extends to the trapezius and interscapular area owing to attempted splinting of the painful shoulder.
Move: In true frozen shoulder there is almost complete loss of external rotation. This is the pathognomonic sign of a frozen shoulder.1,2 w1-w3 Confirming that external rotation is impossible with active and passive movements is important. For example, if external rotation was easily possible with the help of the doctor, we would consider the diagnosis of a large rotator cuff tear, which would require completely different management. In frozen shoulder, all other movements of the joint are reduced, and if movement occurs this usually comes from the thoracoscapular joint.
Three classical stages (Apley) :
Three phases of clinical presentation
Painful freezing phase
Duration 10-36 weeks. Pain and stiffness around the shoulder with no history of injury. A nagging constant pain is worse at night, with little response to non-steroidal anti-inflammatory drugs
Adhesive phase
Occurs at 4-12 months. The pain gradually subsides but stiffness remains. Pain is apparent only at the extremes of movement. Gross reduction of glenohumeral movements, with near total obliteration of external rotation
Resolution phase
Takes 12-42 months. Follows the adhesive phase with spontaneous improvement in the range of movement. Mean duration from onset of frozen shoulder to the greatest resolution is over 30 months History
Insidious onset
No history of trauma
Pain
Initially
At site of deltoid insertion
At extremes of motion
Becomes more
Diffuse
Severe
Constant
Interferes with sleep
Then begins to decrease
Rest pain disappears
Pain only on movement
Stiffness
Develops after onset of pain
Difficulty reaching
Overhead
Behind back
Activities modified
Then stiffness slowly resolves
Examination :
Muscle atrophy
No point tenderness
Markedly ROM, especially
Abduction
Rotation
Pain on forced movement
Most sensitive indicator is pain on forced external rotation
Scapulothoracic movement substituted for glenohumeral movement
Investigations
imaging
Diagnosing adhesive capsulitis is primarily determined by history and physical examination, but imaging studies can
be used to rule out underlying pathology. Radiographs are
typically normal with adhesive capsulitis but can identify
osseous abnormalities, such as glenohumeral osteoarthri-
tis. Arthrographic findings associated with adhesive cap-
sulitis include a joint capsule capacity of less than 10 to
12 mL and variable filling of the axillary and subscapular recess.71,86,105
Magnetic resonance imaging (MRI) may help with the dif- ferential diagnosis by identifying soft tissue and bony ab- normalities.9,128 MRI has identified abnormalities of the capsule and rotator cuff interval in patients with adhesive capsulitis. findings in- cluded a thickened coracohumeral ligament and joint capsule in the rotator cuff interval and a smaller axillary recess vol- ume, but without axillary recess thickening. Using MRI, ax- illary recess thickening, joint volume reduction, rotator cuff interval thickening, and proliferative synovitis surrounding the coracohumeral ligament have been observed in patients with adhesive capsulitis.A recent study64 using ultrasonography with arthroscopic confirmation identified fibrovascular inflammatory soft tis- sue changes in the rotator cuff interval in 100% of 30 pa- tients with adhesive capsulitis with symptoms less than 12 months.Nevaiser suggested four stages
Stage I Mild reddened synovitis
Stage II Acute synovitis with adhesion of dependent folds
Stage III Maturation of adhesions
Stage IV Chronic adhesions
Differential Diagnosis
GHJ Osteoarthritis
Rotator cuff tear
Missed Post-GHJ Dislocation
RSD
AVN
Treatment
Nonoperative
Primary consideration is prevention
Early ROM after trauma or surgery
Educate care-givers
Supportive care primary goal
Reassurance as first treatment
HCLA 2nd line
Avoid physiotherapy as makes it more painful & doesn't ROM
Supportive
Careful explanation of
Nature of disease
Natural history
Reassurance
Freezing Phase
Directed towards pain relief
Simple Analgesics / NSAID
Sedatives
Sling
Ice
TENS
Physiotherapy & exercises of no benefit
Can make pain worse
Can be used to maintain strength of cuff & periscapular muscles?
Frozen Phase
Encourage hand use to avoid RSD
? Consider Hydrostatic Distension at this stage if desperate
Thawing Phase
Gentle ROM & strengthening
? MUA or Distension
Operative Treatment
MUA & steroid injection
Controversial
Technique (Nevaiser)
At least after 6/12 late Frozen or early Thawing
GA
Shoulder MUA to regain ROM out - up - in
External rotation first
Then abduction
Then internal rotation in abduction
Then HCLA
Sensation of tearing is the axillary fold tearing on A/S
Shoulder abduction 90 for 2/52
Postoperative physiotherapy
Results
Uncertain if alters natural history
Reports vary from
Shorter rehabilitation time
Decreased period of stiffness
No in course of disease
No benefit with significant complications
Contra-Indications of MUA
Osteopaenia
Previous fracture or surgery
PVD
History instability
Complications of MUA
Humeral fractures & dislocations
Cuff tears
Increased inflammation & scarring
Radial nerve palsy
Hydrostatic Distension
Uncertain at what stage to use : ? Frozen or Thawing
Technique
Needle into GHJ under LA
Joint forcefully distended by injection
5ml LA
1ml Steroid
Up to 40ml Saline
Distension until capsule ruptures
Sudden drop in resistance
Immediate postoperative physiotherapy
Results
Immediate resolution of pain
Normal functional ROM by 4/52
Other
Arthroscopy*
Open Capsulotomy
Dont release axillary pouch
*Capsule rent with MUA usually along anterior capsule & inferiorly through most of IGHL
Some surgeons now suggest controlled division of the capsule arthroscopically ie MUA without the risk of fractures & dislocations
Problem is arthroscopic access in frozen shoulder
Prognosis
Traditionally thought to be benign & self-limiting
Resolves after 12-36/12
Average 18 months (Chris Blenkin says 2-5 years is average)
Maximum 10 years
Most have no significant symptoms or functional restriction
But not as benign as previously thought
20% have mild pain
30-60% have ROM
Usually external rotation (limitation of ER to less than 60% of opposite)
Treat aggressively to avoid Osteoarthritis
See more at: http://www.orthofracs.com/adult/elective/shoulder/frozen-shoulder/frozen-shoulder.html#sthash.eAi1DZJA.dpuf Rotator cuff tears (positive Lag sign or drop- arm test)
Acromioclavicular joint pain (Positive Scarf test)
Pancoast tumour (apical lung tumour) hoarseness, dyspnoea or cough
Osteoarthritis
Cervical spine nerve root irritation posterior shoulder pain/whole are pain +/-paraesthesia/ anaesthesia
Visceral shoulder pain
- Angina = left shoulder tip pain
- Gall bladder disease / liver = right shoulder pain
- Subphrenic abscess = can present as severe rapid onset shoulder tip pain +/- unwell or abdominal symptoms.
Subacromial impingement syndrome (SAIS) :
Presentation
Age 4060
Pain anteriorly and lateral to shoulder (often over deltoid area)
Painful arc
Pain commonly with reaching or with overhead activity
No pain radiating past elbow
Nocturnal pain if rolls onto affected shoulder at night
Assessment
Subjective assessment: pain with overhead activities; movements of shoulder such as pushing reaching, pulling and lifting
Objective assessment:
- painful arc 90-120 degrees shoulder flexion
or abduction
- positive impingement tests (Hawkins and Kennedy and empty can)