frozen shoulder

definition

· syn. adhesive capsulitis

· condition characterised by progressive shoulder pain and stiffness that resolves spontaneously

epidemiology

· occurs between 40 and 60 yrs of age

· more common in women (2:1)

· more common in sedentary workers

· more commonly affects nondominant limb

· bilateral in 10%

aetiology

· unknown

· autoimmune theory but not proven

· reported increased incidence with

· diabetes

· thyroid disorders

· may be preceded by period of immobilisation

· surgery

· confinement to bed

· emotional tension

· similar condition may be precipitated by

· myocardial infarction

· hemiplegia

· not associated with

· osteoarthritis

· rotator cuff pathology

pathogenesis

· initial synovitis of unknown cause

· results in

· intra-articular adhesions

· capsulitis

· obliteration of inferior axillary fold

· subsequent development of

· subacromial adhesions

· rotator cuff contracture

· then spontaneous resolution

clinical features

History

· insidious onset

· no history of trauma

Pain

· initially

· at site of deltoid insertion

· at extremes of motion

· becomes more

· diffuse

· severe

· constant

· interferes with sleep

· then begins to decrease

· rest pain disappears

· pain only on movement

Stiffness

· develops after onset of pain

· difficulty reaching

· overhead

· behind back

· activities modified

· then stiffness slowly resolves

Examination

· muscle atrophy

· no point tenderness

· markedly decreased ROM, esp.

· abduction

· rotation

· pain on forced movement

· most sensitive indicator is pain on forced external rotation

· scapulothoracic movement substituted for glenohumeral movement

Stages

· each lasts 4-8 months

Freezing

· increasing pain

Frozen

· decreasing pain

· increasing stiffness

Thawing

· decreasing stiffness

radiology

Plain x-ray

· normal

Arthrogram

· confirms diagnosis

· only 5-10 ml of contrast can be injected

· normally can inject 20-30 ml

· shows

· obliteration of inferior capsular recess

· tight glenohumeral joint space

differential diagnosis

· glenohumeral arthritis

· rotator cuff tear

· neglected shoulder dislocation

· reflex sympathetic dystrophy

treatment

Supportive

· careful explanation of

· nature of disease

· natural history

· reassurance

Freezing phase

· directed towards pain relief

· analgesics

· NSAIDs

· sedatives

· sling

· ice and other local measures

· TENS

· exercises of no benefit

Frozen phase

· encourage use of hand

· to avoid RSD

Thawing phase

· gentle ROM and strengthening exercises

Manipulation

· controversial

Technique

· usually performed later in disease

· at least after 6 months

· in late frozen or early thawing stage

· general anaesthetic

· shoulder manipulated to regain ROM

· sensation of tearing of capsule felt

· local anaesthetic and steroid injected into joint

· immediate postoperative physiotherapy

Results

· some report

· shorter rehabilitation time

· others report

· decreased period of stiffness

· no decrease in course of disease

· others report

· no benefit

· significant complications

Complications

· humeral fractures and dislocations

· rotator cuff tears

· increased inflammation and scarring

· radial nerve palsy

Hydrostatic distension

Technique

· needle introduced into shoulder joint under local anaesthetic

· joint forcefully distended by injection

· 5 ml local anaesthetic

· 1 ml steroid

· up to 40 ml saline

· distension continued until capsular rupture occurs

· characterised by sudden drop in resistance

· immediate postprocedure physiotherapy

Results

· immediate resolution of pain

· normal functional ROM by 4 weeks

Other

· arthroscopy

· open release

prognosis

· traditionally thought to be benign and self-limiting

· resolves after 12-36 mths (av. 18 mths)

· most have no significant symptoms or functional restriction but

· 20% have mild pain

· 30% have decreased measured ROM (usually ER)