Shoulder Resources

Frozen shoulder (R) Frozen shoulder (R)


Frozen shoulder – Primary adhesive capsulitis

Definition
Global decrease in shoulder motion associated with inflammation of the shoulder capsule.

Epidemiology
Found in older patients, 40-60.
Affects females>males
Affects non-dominant hand more
Bilateral in 1/3

Aetiology
Unknown.
Associated with diabetes, Dupuytren's disease, hyperlipidaemia, hyper- and hypo-thyroidism, cardiac disease and hemiplegia.
Diabetics have a 10% rate, vs. 2% without diabetes.

Pathology
Reminiscent of Dupuytren's disease, with active fibroblastic proliferation in the rotator interval, anterior capsule and coraco-humeral ligament. The rotator cuff is not involved. In the early phases of primary adhesive capsulitis the synovium proliferates, but this is not a finding in secondary frozen shoulder.
Inflammatory cells are not present in any numbers .
Cytokines, growth factors and metalloproteinases are present in increased amounts.

Clinical
The condition is associated with pain first then stiffness later. The usual course of events is to start with severe pain. After a few months stiffness sets in as pain resolves. Stiffness then slowly settles. The disease may take 18 months to run its course. Some residual pain and stiffness may persist.
On examination there is a lack of active and passive movement in all directions. Warner advocates measuring passive movement with the patient supine, as this decreases the contribution of scapulothoracic motion.

Imaging
Plain XR may demonstrate some disuse osteopenia but are otherwise normal.
Shoulder arthrograms demonstrate loss of joint space and obliteration of the inferior capsular recess. An inability of the joint to accept more than 5-10 ml of contrast has been defined as indicating frozen shoulder.

Differential diagnosis
• Infection
• Post-traumatic stiffness
• The stiffness is usually maximal at onset and gradually improves
• Disuse stiffness
• CRPS
• Brachial neuritis

Treatment

Non-surgical
Range of motion exercises. More than 90% of patients will respond to physical therapy alone. The course of physical therapy should be continued for at least one year (University of Pennsylvania ). Important to warn the patient that they will intiailly have more pain with physiotherapy, as they may stop without this warning.
NSAIDS and intra-articular corticosteroids.

Surgical

Some use hydraulic arthroscopic capsular distension (brisement) to rupture the capsule; others use MUA – this may fracture the humerus if it is osteopenic.
MUA may be considered if there is no improvement after 3/12 of physical therapy. MUA should be performed with full muscular relaxation. An indwelling marcaine catheter should be utilized to allow effective post-operative therapy. External rotation is gained first. The humerus is grasped in one hand and the scapula in the other. The forearm should not be used for leverage. Full length humeral films should be taken to rule out a fracture after MUA.
MUA is not used in patients with post-traumatic stiffness as the scar tissue may be stronger than the cuff or bone.

Arthroscopic surgery is performed in selected cases where there is inadequate response to physiotherapy. The anterior capsule is released from just below the biceps tendon (which marks the upper extent of the rotator interval) to the subscapularis tendon. An attempt is then made to manipulate the shoulder into a satisfactory ROM. If this fails, the remainder of the antero-inferior capsule is divided. If stiffness persists after a full anterior release, the ports are exchanged and the posterior capsule is released, from just posterior to the biceps tendon to the postero-inferior rim of the glenoid. The incision is made just lateral to the glenoid rim.

If this doesn't free up the joint satisfactorily the subacromial space should be inspected and if necessary debrided.
Open surgery may be necessary in refractory cases. It provides an opportunity to deal with extra-articular pathology, e.g. excessively tightened anterior capsule, or malunited tuberosity fragments. A deltopectoral approach is performed. First, the deltoid is freed up from the humerus. Next, the CA ligament is excised and the subacromial space released from scar tissue. The rotator interval and coraco-humeral ligament is released next. If this does not provide enough motion the subscapularis tendon and capsule may need lengthening using a coronal Z-plasty technique. The inferior capsule is divided while the axillary nerve is protected with a finger. Lastly the posterior capsule is released. The coronal Z-plasty provides 20 degrees of external rotation for each cm of length.

The hallmarks of an adequate release are:
• Posterior translation of the humeral head by at least 1.5cm on a posterior drawer.
• 90 degrees of internal rotation on a scarecrow test
• At least 45 degrees of external rotation with the arm adducted by the side.
• Total elevation of at least 140 degrees.
Post operatively CPM (preferably using a scalene indwelling catheter) is used.

Prognosis
Pain and stiffness should settle but there may be some persistent limitation of movement, particularly ER, in up to 50% of patients.
Patients with diabetes have a poorer prognosis and bilateral disease.

Secondary shoulder stiffness
This usually has a much poorer prognosis and surgical intervention is required more often.
Arthroscopic surgery can be used in cases that are refractory to physiotherapy and MUA. It is useful in improving ROM in patients who have stiffness post shoulder surgery and post fracture, but is not as good in relieving pain as it is in frozen shoulder.

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