8/12/2019 WEEK Orthopedics Dr John

1/16

FROZEN SHOULDER

Oleh

Noorgiani Lestari

8/12/2019 WEEK Orthopedics Dr John

2/16

Adhesive capsulitis

Definition :

Idiopathic inflammatory condition

characterized by progressive shoulder pain,

stiffness that spontaneously resolves and

Restriction of motion movement in all planes

8/12/2019 WEEK Orthopedics Dr John

3/16

8/12/2019 WEEK Orthopedics Dr John

4/16

Etiology classification

Primary / idiopathic : underlying condition

Secondary underlying disease (trauma,

subsequent immobilization, DM,hypothyroid,hyperthyroid, hypoadrenalism,

parkinson disease, surgical cardiac surgery

8/12/2019 WEEK Orthopedics Dr John

5/16

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 lackof 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

8/12/2019 WEEK Orthopedics Dr John

6/16

Clinical manifestation

Look: On inspection, the arm is held by the side in adduction and internalrotation. Mild disuse atrophy of the deltoid and supraspinatus may bepresent.

Feel: On palpation, there is diffuse tenderness over the glenohumeraljoint, and this extends to the trapezius and interscapular area owing toattempted splinting of the painful shoulder.

Move: In true frozen shoulder there is almost complete loss of externalrotation. This is the pathognomonic sign of a frozen shoulder. Confirmingthat external rotation is impossible with active and passive movements isimportant. For example, if external rotation was easily possible with thehelp of the doctor, we would consider the diagnosis of a large rotator cufftear, which would require completely different management. In frozenshoulder, all other movements of the joint are reduced, and if movementoccurs this usually comes from the thoracoscapular joint.

8/12/2019 WEEK Orthopedics Dr John

7/16

Three classical stages (Apley) : Three

phases of clinical presentation

1. Painful freezing phase

Duration 10-36 weeks. Pain and stiffness around the shoulder with nohistory of injury. A nagging constant pain is worse at night, with littleresponse to non-steroidal anti-inflammatory drugs

2. 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 ofglenohumeral movements, with near total obliteration of external rotation

3. Resolution phase

Takes 12-42 months. Follows the adhesive phase with spontaneousimprovement in the range of movement. Mean duration from onset offrozen shoulder to the greatest resolution is over 30 months History

8/12/2019 WEEK Orthopedics Dr John

8/16

IMAGING

Diagnosing adhesive capsulitis is primarily determined by history and physical examination, but imagingstudies can be used to rule out underlying pathology.

Radiographs are typically normal with adhesive capsulitis but can identify osseous abnormalities, such asglenohumeral osteoarthritis. Arthrographic findings associated with adhesive capsulitis include a jointcapsule capacity of less than 10 to12 mL and variable filling of the axillary and subscapular recess.

Magnetic resonance imaging (MRI) may help with the differential diagnosis by identifying soft tissue and

bony abnormalities. MRI has identified abnormalities of the capsule and rotator cuff interval in patientswith adhesive capsulitis. findings in- cluded a thickened coracohumeral ligament and joint capsule in therotator cuff interval and a smaller axillary recess vol- ume, but without axillary recess thickening. UsingMRI, axillary recess thickening, joint volume reduction, rotator cuff interval thickening, and proliferativesynovitis surrounding the coracohumeral ligament have been observed in patients with adhesive capsulitis.

A recent study64 using ultrasonography with arthroscopic confirmation identified fibrovascularinflammatory soft tis- sue changes in the rotator cuff interval in 100% of 30 pa- tients with adhesivecapsulitis with symptoms less than 12 months.

8/12/2019 WEEK Orthopedics Dr John

9/16

Nevaiser suggested four stages

Stage IMild reddened synovitis

Stage IIAcute synovitis with adhesion of dependent

folds

Stage IIIMaturation of adhesions

Stage IVChronic adhesions

8/12/2019 WEEK Orthopedics Dr John

10/16

Treatment

INTERVENTIONSCORTICOSTEROID INJECTIONS

Intra-articular corticosteroid injections combined withshoulder mobility and stretching exercises are moreeffective in providing short-term (4-6 weeks) pain reliefand improved function compared to shoulder mobilityand stretching exercises alone.

INTERVENTIONSJOINT MOBILIZATION

Clinicians may utilize joint mobilization proceduresprimarily directed to the glenohumeral joint to reducepain and increase motion and function in patients withadhesive capsulitis.

8/12/2019 WEEK Orthopedics Dr John

11/16

INTERVENTIONSTRANSLATIONAL MANIPULATION

Clinicians may utilize translational manipulation

under anesthesia di- rected to the glenohumeraljoint in patients with adhesive capsulitis who arenot responding to conservative interventions.

INTERVENTIONSSTRETCHING EXERCISES

Clinicians should instruct patients with adhesivecapsulitis in stretch- ing exercises. The intensity of

the exercises should be determined by thepatients tissue irritability level.

8/12/2019 WEEK Orthopedics Dr John

12/16

Differential Diagnosis

- 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 : radiographic exclude

- Cervical spine nerve root irritation posterior shoulder pain/whole arepain +/-paraesthesia/ anaesthesia

- Visceral shoulder pain ( refered 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.

8/12/2019 WEEK Orthopedics Dr John

13/16

- 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 suchas pushing reaching, pulling and lifting

-

Objective assessment:- - painful arc 90-120 degrees shoulder flexion

- or abduction

8/12/2019 WEEK Orthopedics Dr John

14/16

8/12/2019 WEEK Orthopedics Dr John

15/16

8/12/2019 WEEK Orthopedics Dr John

16/16