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FROZEN SHOULDER

PRESENTED BY:ANUBHAV VERMA CHAIRPERSON: DR. PRAMOD BM

9th June 2015

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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

• Incidence is 2%

• 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

• Duplay referred to Frozen shoulder in 1872 as "scapulohumeral periarthritis," a disorder he believed resulted from subacromial bursitis

• Pasteur later referred to the same condition as "tenobursite," which he attributed to bicipital tendinitis.

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

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• In 1945, Neviaser introduced the concept of adhesive capsulitis

• He discovered that the capsule was tight, thickened, and stuck to the humerus in such a manner that it could be peeled off like “adhesive plaster from the skin”

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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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EXTERNAL ROTATION(in extension):0 to 70 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, female sex, Diabetes mellitus

• EXTRINSIC factors may include immobilization and faulty body mechanics

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PATHOLOGY

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

• Hazelman reported Shoulder capsular tissue showed fibroblast and myoblast proliferation identical to that seen in dupuytren disease and vascular changes suggestive of diabetic microangiopathy

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• This suggested that frozen shoulder may have abnormalities at a cellular level with malfunctions of fibroblast recruitment and cytokine growth factor production and release

• 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• May radiate over C5 dermatome• Upper back ache due to compensatory use of

shoulder girdle muscles

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PHASE 2 - STIFFNESS

• Motion is guarded and a 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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• “Girdle hunching maneuver” in order to substitute glenohumeral movements with scapulohumeral movements

• “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 and box like appearance of the joint cavity is diagnostic

• 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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MRI

• The normal inferior glenohumeral ligament measures <4mm and is best seen on coronal oblique images at the mid glenoid level. In adhesive capsulitis, the axillary recess may show thickening up to 1.3 cm or more; the joint capsule is also thickened

• Classical “ subcoracoid triangle sign is seen” in sagittal oblique T1 weighted images

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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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• Weiser injected prednisolone into the shoulder joints of 100 patients, then passively mobilized the joint and gave the patients a vigorous active home exercise program; 78% obtained pain relief, and 61% regained normal function.

• 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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INFILTRATION DEBRIDEMENT

• This method consists of forcibly extending the joint capsule with the contrast material that is used for arthrographic procedures

• Local anesthetics and ROM exercises may be combined with infiltration debridement to facilitate restoration of motion.

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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

• “patient heal thyself”• 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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• Shoulder is manipulated using a short arm lever and a fixed scapula

• The acronym FEAR can be used as a safe sequence for shoulder manipulation-flexion, extension, abduction and adduction, external and internal rotation.

• Audible and palpable release of adhesions is a good prognostic sign.

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POST MANIPULATION CARE• Immediate exercises to be started, emphasizing the

need to move the arm continuously• Circumduction, overhead bar, pulley exercises are

begun immediately(10 – 20 repetitions each hour)• Constant reassurance for 3 months• Counseling that ROM will improve immediately but

pain may persist for 3 to 6 weeks. Permanent loss of 20 degrees of flexion, internal rotation and external rotation is usual

• Abduction orthosis at night for 3 weeks to prevent significant axial pouch adhesions from returning in the early phase

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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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ARTHROSCOPIC RELEASE

• For patients in whom closed manipulation fails• ROTATOR INTERVAL: triangular area in anterior

and superior shoulder where no rotator cuff tendons are present

• bounded by the supraspinatus superiorly, the subscapularis inferiorly, and the coracoid medially

• Contents: The coracohumeral ligament, biceps tendon, and superior glenohumeral ligament.

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• Selective arthroscopic releases may accomplish the following gains in motion (Bennett):

• Rotator interval: external rotation• Inferior capsule: external rotation, flexion,

internal rotation• Posterosuperior capsule: internal rotation

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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

• Advanced Arthroscopy: James C. Chow: 3rd edition