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FROZEN SHOULDER

By: Usman Farooq

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`• INTRODUCTION• HISTORICAL PERSPECTIVE• ANATOMY• PHYSICAL EXAMINATION• ETIOPATHOGENESIS• CLINICAL FEATURES AND DIAGNOSIS• INVESTIGATIONS• TREATMENT• RECENT ADVANCES

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INTRODUCTION• Frozen shoulder is defined as a glenohumeral

joint with pain and stiffness that cannot be explained on the basis of joint incongruity

• Also known as adhesive capsulitis as the pathology involves the capsule of the joint

• Seen in women more commonly than menduring the 5th to 7th decade

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• Bilateral involvement occurs in 10 to 40 % of cases

• Does not usually recur in the same shoulder• However, 20 to 30 percent develop the

condition in the opposite shoulder

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HISTORICAL PERSPECTIVE

• In 1934, Codman coined the term "frozen shoulder" but used it in association with tendinitis of the rotator cuff

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MUSCLES

• FLEXION: Anterior fibers of deltoid, pectoralis major• EXTENSION: posterior fibers of deltoid, latissimus

dorsi• ABDUCTION: Middle fibers of deltoid, supraspinatus• ADDUCTION: Pectoralis major, latissimus dorsi• LATERAL/EXTERNAL ROTATORS: infraspinatus, teres

minor• MEDIAL/INTERNAL ROTATORS: subscapularis,

latissimus dorsi

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ADDUCTION: 0 to 50 degrees

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ABDUCTION: 0 to 170 degrees

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FORWARD FLEXION: 0 to 165 degrees

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EXTENSION: 0 to 60 degrees

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INTERNAL ROTATION(in extension): 0 to 70 degrees

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INTERNAL ROTATION( in abduction): 0 to 70 degrees

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EXTERNAL ROTATION( in abduction): 0 to 100 degrees

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ETIOPATHOGENESIS

• Lundberg classified in to primary and secondary frozen shoulder

PRIMARY FROZEN SHOULDERNo inciting event, normal plain radiographs and no findings other than loss of motion

SECONDARY FROZEN SHOULDER Precipitant traumatic event

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PRIMARY FROZEN SHOULDER

• No inciting event but INTRINSIC AND EXTRINSIC predisposing factors present

• INTRINSIC factors like age between 40 and 60 years of age, Diabetes mellitus

• EXTRINSIC factors may include immobilization and faulty body mechanics

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PATHOLOGY

• Landberg evaluated the shoulder capsules of 14 patients. Histology showed increase in fibrous tissue, fibroblasts and vascularity

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• Hannafin and colleagues described three phases based on capsular biopsies on 15 patients with frozen shoulder

• Neviaser defined four stages of frozen shoulder based on arthroscopic changes observed

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SECONDARY FROZEN SHOULDER• Rotator cuff diseases• Fracture residuals• Calcific tendinitis• Previous shoulder surgery• Osteoarthritis• Cervical spine lesions• Autoimmune disease• Chest wall tumors• Thyroid disorders• Parkinson's disease• CVA• Head injury• Myocardial infarction

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CLINICAL FEATURES

• Consists of 3 phases in case of primary frozen shoulder

• Secondary frozen shouder may not follow the same chronology

• The three stages are pain, stiffness and thawing also known as freezing frozen and thawing stages

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PHASE 1 - PAIN

• Insidious / acute in onset• Present during activity and rest unlike other

disorders• More at night affecting sleep• Distributed vaguely over the deltoid muscle area• Only point of tenderness is the bicipital groove• Upper back ache due to compensatory use of

shoulder girdle muscles

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PHASE 2 - STIFFNESS

• Protective muscular spasm is a common feature

• May prefer wearing a sling to support the arm• Functional activities such as dressing or

grooming which require reaching overhead or behind the back may be difficult

• Loss of ROM is most prominent once the pain has subsided

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• “Empty end feel” at the end of the ROM• Internal rotation is lost initially followed by

loss of flexion and external rotation• HALLMARK: Terminally painful passive ROM

(c.f. rotator cuff tendinitis and painful arc syndrome)

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• Limitation of passive ROM shows a CAPSULAR pattern: external rotation> abduction> internal rotation

• External rotation < 45 degrees• Abduction <80 degrees• Internal rotation <70 degrees

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PHASE 3 - THAWING

• As motion increases, pain diminishes• Usually occurs spontaneously over 4 to 9

months even without any treatment• May not regain full range of motion, but may

feel normal as a result of compensatory mechanisms and adjustments in activities of daily living.

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DIAGNOSIS

• Clinical diagnosis• Campbell decribes presence of 3 features to

diagnose frozen shoulder 1. Internal rotation restricted upto the point when

the patient cannot touch beyond his sacrum 2. 50% loss of external rotation 3. < 90 degrees of abductionHowever, these criteria are not definitive and

presence of all 3 is not mandatory

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INVESTIGATIONS

• Do not have a significant role

• PLAIN XRAY is normal. However, it can be used to rule out other conditions. Commonly revealed conditions are osteoporosis, degenerative changes, decreased space between acromion and humeral head, calcium deposits and cystic changes.

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ARTHROGRAPHY

• Can either be done fluoroscopically or with help of MRI

• 50 % reduction in joint fluid volume • Joint volume capacity is only 5 to 10 ml (normal

= 20 to 30 ml)• Tight thickened capsule,loss of the axillary

recess, subcoracoid folds and subscapular bursa and absence of dye in the biceps tendon sheath.

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TREATMENT

• Although Frozen shoulder is a self-limiting condition, it imposes such morbidity and lengthy recovery time that patients and clinicians alike seek treatment interventions. No standard treatment regimen, however, is accepted universally.

• Conservative treatment is the mainstay of therapy and only refractory cases are subjected to operative interventions

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MODALITIES

• Oral analgesics: salicylates, NSAIDS and codeine compounds help to reduce pain and inflammation in the early stages

• Many medical practitioners prefer the intra-articular injection of steroids, accompanied by local analgesics and gentle active motion, in the freezing stage of Frozen shoulder

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INTRA-ARTICULAR STEROIDS• Hollingworth reported that

injection of a corticosteroid directly into the anatomical site of the lesion produced pain relief and at least 50% improvement in ROM in 26% of the cases studied

• Quigley stated that they may reduce pain if administered in conjunction with manipulation

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• In summary, local corticosteroid injections have been used with various results but, generally, they produce a greater gain in motion recovery if used in combination with exercises and heat therapy

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PHYSIOTHERAPY

ROLE OF THE PHYSIOTHERAPISTTHERMOTHERAPY: before resorting to passive

mobilization, the thick and contracted capsule must be released and made more stretchable by deep heating using ultrasonic or other suitable modalities

The heating is carried out throughout the joint. • Passive physiological exercise: motion in a range

that usually is achieved actively • Accessory exercise :motion between joint surfaces,

which cannot be achieved actively

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PHASE 1 PHYSIOTHERAPY• Used when the patient has a painful joint

• A physical therapist would apply accessory movement in a comfortable joint position, with the affected arm supported in a loose-packed position

• The therapist administers slow, gentle oscillatory movements in anterior-posterior and cephalad-caudad directions if they do not increase pain or induce muscle spasm

• The therapist provides a mechanical block to movement short of the painful, restricted range and continues to use gentle, low-amplitude oscillations.

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PHASE 2 PHYSIOTHERAPY

• Used to treat a stiff joint• As the condition progresses, the therapist may detect

stiffness before or concurrently with the onset of pain• The therapist then should begin low-amplitude

physiological and accessory oscillations at the limit of the restriction

• To increase abduction, for example, the therapist with caudal glide performs more powerful oscillations at the end of the accessory range

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ROLE OF THE PATIENT

• Home treatment regimen• pendulum exercises: in a forward stooping

position, with one hand resting on a table or chair, the patient gradually swings the arm like a pendulum and later carries out a circumduction movement

• 5 times daily in 5 to 10 minute sessions

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• SHOULDER ELEVATION EXERCISES: with the normal hand supporting the affected one, the shoulder is gradually lifted to a position of flexion abduction and external rotation

• HAND TO BACK POSITION: patient carries the arm backwards with the shoulder in a position of extension, adduction

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• SHOULDER WHEEL EXERCISES: to be done by the patient himself at the physiotherapy center

• PULLEY EXERCISES: which can be done by the patient himself at home

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MANIPULATION

• Closed manipulation of the shoulder under General anesthesia

• Reserved for patients who have failed to gain ROM after physiotherapy and local injections

• Also recommended in patients who refuse to wait for long for resolution of symptoms

• Significant improvement is seen in around 70% of patients

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COMPLICATIONS OF MUA

• Proximal Humeral fractures• Shoulder Dislocations• Fracture dislocation• Rotator cuff ruptures • Traction nerve injuriesCan be avoided by gentle, slow manipulation. If

a firm end point to motion is felt, further manipulation should not be attempted

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RECENT ADVANCES

• Ip and Fu1 in May 2015 concluded that LLLT(Low level laser therapy) is a viable option in the conservative treatment of shoulder pain arising from adhesive capsulitis of the shoulder in the elderly, with a positive clinical result of more than 90%

• Lee et al2 have proven for the first time that Capsular stiffness of the glenohumeral joint significantly correlated with limitation in shoulder ROM, especially in the abduction and external rotation directions

1 J Pain Res. 2015 May 25;8:247-522 PM R. 2015 May 20: S1934-1482(15)

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• Kim et al showed that hypertonic saline solution is more effective than that using normal saline solution in patients with adhesive capsulitis.

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REFERENCES

• Turek’s Orthopaedics: Principles and their application: 6th edition

• Campbell’s operative orthopaedics: 12th Edition

• Mercer’s Textbook of orthopedics and trauma: 9th edition