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)