frozen shoulder with recent advances

1. FROZEN SHOULDER
PRESENTED BY:ANUBHAV VERMA
CHAIRPERSON: DR. PRAMOD BM
9th June 2015
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2. `• INTRODUCTION
• HISTORICAL PERSPECTIVE
• ANATOMY
• PHYSICAL EXAMINATION
• ETIOPATHOGENESIS
• CLINICAL FEATURES AND DIAGNOSIS
• INVESTIGATIONS
• TREATMENT
• RECENT ADVANCES
2

3. 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 men
during the 5th to 7th decade
3

4. • 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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5. 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
5

6. • 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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11. 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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12. ADDUCTION: 0 to 50 degrees
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13. ABDUCTION: 0 to 170 degrees
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14. FORWARD FLEXION: 0 to 165 degrees
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15. EXTENSION: 0 to 60 degrees
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16. INTERNAL ROTATION(in extension): 0
to 70 degrees
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17. INTERNAL ROTATION( in abduction): 0
to 70 degrees
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18. EXTERNAL ROTATION( in abduction): 0
to 100 degrees
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19. EXTERNAL ROTATION(in extension):0
to 70 degrees
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20. ETIOPATHOGENESIS
• Lundberg classified in to primary and
secondary frozen shoulder
PRIMARY FROZEN SHOULDER
No inciting event, normal plain radiographs
and no findings other than loss of motion
SECONDARY FROZEN SHOULDER
Precipitant traumatic event
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21. 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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22. 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
22

23. • 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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26. 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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27. 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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29. 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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30. 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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31. • “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)
31

32. • Limitation of passive ROM shows a CAPSULAR
pattern: external rotation> abduction>
internal rotation
• External rotation < 45 degrees
• Abduction <80 degrees
• Internal rotation <70 degrees
32

33. 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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34. 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 abduction
However, these criteria are not definitive and
presence of all 3 is not mandatory
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35. 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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36. 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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39. 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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41. 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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42. 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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43. 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
43

44. • 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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45. 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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46. PHYSIOTHERAPY
ROLE OF THE PHYSIOTHERAPIST
THERMOTHERAPY: 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 46

47. 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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49. 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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51. 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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53. • 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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55. • 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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57. 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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58. • 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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59. 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
59

60. COMPLICATIONS OF MUA
• Proximal Humeral fractures
• Shoulder Dislocations
• Fracture dislocation
• Rotator cuff ruptures
• Traction nerve injuries
Can 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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61. 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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67. • 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
67

68. 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;8:247-52
2 PM R. 2015 May 20: S1934-1482(15)
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69. • 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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71. 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
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