Frozen Shoulder

Adhesive Capsulitis
Defnition
Idiopathic infammatory condition characterized by progressive
shoulder pain, stifness that spontaneously resolves and estriction
o! motion movement in all planes
"pidemiology #
$%&'% years
(omen )#*
+on&dominant limb more afected
,ilateral in *%&$%-
)- o! population
**- o! diabetic population
Sedentary .or/ers
Aetiology #
0oorly understood
Autoimmune theory proposed but not proven
0redisposing !actors#
Immobility
1rauma 2o!ten trivial3
Cervical disc disease
Diabetes 4ellitus
*%&)%- compared .ith )- o! general population
,ilaterality 2$%-3
5 *% years o! IDD4 ris/
1hyroid disorders
6yperthyroidism
esolves .ith treatment o! disease
4yocardial in!arction
Intrathoracic disorders
1,
Carcinoma
"mphysema
Intracranial 0athology
6emiplegia
Cerebral 6aemorrhage
Cerebral tumours
0ersonality disorder
+ot associated .ith
7steoarthritis
Cuf 0athology
Classifcation #
89unberg5
0rimary : idiopathic condition underlying
Secondary underlying disease 2trauma, subse;uent immobilization,
D4, hypothyroid,hyperthyroid, hypoadrenalism, par/inson disease,
surgical cardiac surgery
Apley
1hree phases each lasting $&< months
Freezing
Increasing pain
Frozen
Decreasing pain
Increasing stifness
1ha.ing
Decreasing stifness
0athogenesis = 0athology #
Initial synovitis o! un/no.n cause
esults in
Capsulitis
Intra&articular adhesions
7bliteration o! in!erior a>illary !old
Subse;uent development o!
Subacromial adhesions
otator cuf contracture
1hen spontaneous resolution
Contracted, thic/ened ?oint capsule dra.n tightly around the
humeral head .ith relative lac/ o! synovial fuid
See cellular changes o! infammation .ith fbrosis = perivascular
infltration in subsynovial layer o! capsule 2+evaiser3 @ similar
appearance to DupuytrenAs disease
0oor correlation bet.een the microscopic = gross capsular changes
Capsular !olds = pouches obliterated by synovial adhesions
Coracohumeral ligament is shortened = prevents "
otator cuf bellies contracted f>ed = inelastic
Fe. adhesions in subacromial bursa
Spontaneous resolution the rule
9oo/# 7n inspection, the arm is held by the side in adduction and
internal rotationB 4ild disuse atrophy o! the deltoid and
supraspinatus may be presentB
Feel# 7n palpation, there is difuse tenderness over the
glenohumeral ?oint, and this e>tends to the trapezius and
interscapular area o.ing to attempted splinting o! the pain!ul
shoulderB
4ove# In true !rozen shoulder there is almost complete loss o!
e>ternal rotationB 1his is the pathognomonic sign o! a !rozen
shoulderB*,) .*&.C Confrming that e>ternal rotation is impossible
.ith active and passive movements is importantB For e>ample, i!
e>ternal rotation .as easily possible .ith the help o! the doctor, .e
.ould consider the diagnosis o! a large rotator cuf tear, .hich
.ould re;uire completely diferent managementB In !rozen shoulder,
all other movements o! the ?oint are reduced, and i! movement
occurs this usually comes !rom the thoracoscapular ?ointB
1hree classical stages 2Apley3 #
1hree phases o! clinical presentation
0ain!ul !reezing phase
Duration *%&C' .ee/sB 0ain and stifness around the shoulder .ith
no history o! in?uryB A nagging constant pain is .orse at night, .ith
little response to non&steroidal anti&infammatory drugs
Adhesive phase
7ccurs at $&*) monthsB 1he pain gradually subsides but stifness
remainsB 0ain is apparent only at the e>tremes o! movementB Dross
reduction o! glenohumeral movements, .ith near total obliteration
o! e>ternal rotation
esolution phase
1a/es *)&$) monthsB Follo.s the adhesive phase .ith spontaneous
improvement in the range o! movementB 4ean duration !rom onset
o! !rozen shoulder to the greatest resolution is over C% months
6istory
Insidious onset
+o history o! trauma
0ain
Initially
At site o! deltoid insertion
At e>tremes o! motion
,ecomes more
Difuse
Severe
Constant
Inter!eres .ith sleep
1hen begins to decrease
est pain disappears
0ain only on movement
Stifness
Develops a!ter onset o! pain
DiEculty reaching
7verhead
,ehind bac/
Activities modifed
1hen stifness slo.ly resolves
">amination #
4uscle atrophy
+o point tenderness
4ar/edly 74, especially
Abduction
otation
0ain on !orced movement
4ost sensitive indicator is pain on !orced e>ternal rotation
Scapulothoracic movement substituted !or glenohumeral movement
Investigations
imaging
Diagnosing adhesive capsulitis is primarily determined by history
and physical e>amination, but imaging studies can
be used to rule out underlying pathologyB adiographs are
typically normal .ith adhesive capsulitis but can identi!y
osseous abnormalities, such as glenohumeral osteoarthri&
tisB Arthrographic fndings associated .ith adhesive cap&
sulitis include a ?oint capsule capacity o! less than *% to
*) m9 and variable flling o! the a>illary and subscapular
recessBF*,<',*%G
4agnetic resonance imaging 24I3 may help .ith the di!& !erential
diagnosis by identi!ying so!t tissue and bony ab& normalitiesBH,*)<
4I has identifed abnormalities o! the capsule and rotator cuf
interval in patients .ith adhesive capsulitisB fndings in& cluded a
thic/ened coracohumeral ligament and ?oint capsule in the rotator
cuf interval and a smaller a>illary recess vol& ume, but .ithout
a>illary recess thic/eningB Ising 4I, a>& illary recess thic/ening,
?oint volume reduction, rotator cuf interval thic/ening, and
proli!erative synovitis surrounding the coracohumeral ligament have
been observed in patients .ith adhesive capsulitisB
A recent study'$ using ultrasonography .ith arthroscopic
confrmation identifed fbrovascular infammatory so!t tis& sue
changes in the rotator cuf interval in *%%- o! C% pa& tients .ith
adhesive capsulitis .ith symptoms less than *) monthsB
+evaiser suggested !our stages
Stage I @ 4ild reddened synovitis
Stage II @ Acute synovitis .ith adhesion o! dependent !olds
Stage III @ 4aturation o! adhesions
Stage IJ @ Chronic adhesions
Diferential Diagnosis
D6K 7steoarthritis
otator cuf tear
4issed 0ost&D6K Dislocation
SD
AJ+
1reatment
+onoperative
0rimary consideration is prevention
"arly 74 a!ter trauma or surgery
"ducate care&givers
Supportive care primary goal
eassurance as frst treatment
6C9A )nd line
Avoid physiotherapy as ma/es it more pain!ul = doesnLt 74
Supportive
Care!ul e>planation o!
+ature o! disease
+atural history
eassurance
Freezing 0hase
Directed to.ards pain relie!
Simple Analgesics : +SAID
Sedatives
Sling
Ice
1"+S
0hysiotherapy = e>ercises o! no beneft
Can ma/e pain .orse
Can be used to maintain strength o! cuf = periscapular musclesM
Frozen 0hase
"ncourage hand use to avoid SD
M Consider 6ydrostatic Distension at this stage i! desperate
1ha.ing 0hase
Dentle 74 = strengthening
M 4IA or Distension
7perative 1reatment
4IA = steroid in?ection
Controversial
1echni;ue 2+evaiser3
At least a!ter ':*) N late Frozen or early 1ha.ing
DA
Shoulder 4IA to regain 74 Oout & up & inP
">ternal rotation frst
1hen abduction
1hen internal rotation in abduction
1hen 6C9A
Sensation o! tearing is the a>illary !old tearing on A:S
Shoulder abduction H%Q !or ):G)
0ostoperative physiotherapy
esults
Incertain i! alters natural history
eports vary !rom
Shorter rehabilitation time
Decreased period o! stifness
+o in course o! disease
+o beneft .ith signifcant complications
Contra&Indications o! 4IA
7steopaenia
0revious !racture or surgery
0JD
6istory instability
Complications o! 4IA
6umeral !ractures = dislocations
Cuf tears
Increased infammation = scarring
adial nerve palsy
6ydrostatic Distension
Incertain at .hat stage to use # M Frozen or 1ha.ing
1echni;ue
+eedle into D6K under 9A
Koint !orce!ully distended by in?ection
Gml 9A
*ml Steroid
Ip to $%ml Saline
Distension until capsule ruptures
Sudden drop in resistance
Immediate postoperative physiotherapy
esults
Immediate resolution o! pain
+ormal !unctional 74 by $:G)
7ther
ArthroscopyR
7pen Capsulotomy
DonAt release a>illary pouch
RCapsule rent .ith 4IA usually along anterior capsule = in!eriorly
through most o! ID69
Some surgeons no. suggest controlled division o! the capsule
arthroscopically @ ie 4IA .ithout the ris/ o! !ractures = dislocations
0roblem is arthroscopic access in !rozen shoulder
0rognosis
1raditionally thought to be benign = sel!&limiting
esolves a!ter *)&C':*)
Average *< months 2Chris ,len/in says )&G years is average3
4a>imum *% years
4ost have no signifcant symptoms or !unctional restriction
,ut not as benign as previously thought
)%- have mild pain
C%&'%- have 74
Isually e>ternal rotation 2limitation o! " to less than '%- o!
opposite3
1reat aggressively to avoid 7steoarthritis
& See more at#
http#::...Bortho!racsBcom:adult:elective:shoulder:!rozen&
shoulder:!rozen&shoulderBhtmlSsthashBeAi*DTKABdpu!
& U otator cuf tears 2positive 9ag sign or drop& arm test3
& U Acromioclavicular ?oint pain 20ositive Scar! test3
& U 0ancoast tumour 2apical lung tumour3 @ hoarseness,
dyspnoea or cough
& U 7steoarthritis
& U Cervical spine nerve root irritation @ posterior shoulder
pain:.hole are pain V:&paraesthesia: anaesthesia
& U Jisceral shoulder pain
& & Angina W le!t shoulder tip pain
& & Dall bladder disease : liver W right shoulder pain
& & Subphrenic abscess W can present as severe rapid onset
shoulder tip pain V:& un.ell or abdominal symptomsB
& Subacromial impingement syndrome 2SAIS3 #
& 0resentation
& U Age $%@'%
& U 0ain anteriorly and lateral to shoulder 2o!ten over deltoid
area3
& U 0ain!ul arc
& U 0ain commonly .ith reaching or .ith overhead activity
& U +o pain radiating past elbo.
& U +octurnal pain i! rolls onto afected shoulder at night
& Assessment
& U Sub?ective assessment# pain .ith overhead activitiesX
movements o! shoulder such as pushing reaching, pulling and
li!ting
& U 7b?ective assessment#
& & pain!ul arc H%&*)% degrees shoulder fe>ion
& or abduction
& & positive impingement tests 26a./ins and Yennedy and
empty can3