FROZEN SHOULDER

FROZEN SHOULDER

DEFINITION

            Frozen shoulder is a common chronic affectation of the shoulder characterized by the development of dense adhesion and capsular restriction. Especially in the dependent fold of the capsule rather than arthritic changes in the cartilage and bone. There is limitation in all direction particularly internal and external rotation and abduction, gradually progressing over a period of 3-12 months. Then follows a course to normal or near normal state.

Other name for frozen shoulder are:

- periarthritis

- Obliterative bursitis

- diffuse rotator cuff tendinitis

- adhesive capsulitis

- Duplay’s disease

- stiff shoulder

The classic pattern of frozen shoulder is divided into:

1.            freezing – characterized by the pain at rest and LOM by 2-3 weeks following onset. These acute symptoms may last 10-36 weeks

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2.            frozen – characterized by pain only with movement, significant adhesions and limited glenohumeral motion with substitute motion in the scapula. Atrophy of the rotator cuff, biceps, and triceps brachii muscle occur. This stage last 4-12 months.

3.            thawing – characterized by no pain and no synovitis but significant capsular restriction from adhesion. This stage last 2-24 months or longer. Some pt. never regain normal ROM.

ETIOLOGY

·                     unknown

·                     direct/indirect local trauma

·                     RA/OA

·                     Subacromial bursitis

·                     Supraspinatus tendonitis

·                     Surgery

·                     Confiment to bed

·                     May follow CVA or MI

·                     Hemiplegia

·                     Biceps tendinitis

·                     Immobilization

·                     Reffered shoulder pain from cardiac or nerve root affectation

·                     Sequel to injury on distal part of limb

·                     Acromioclavicular tendinitis

·                     Long period of activities

EPIDEMIOLOGY

            It mainly affects females 40-70 years old and may be bilateral in 10% of the population.

Predisposing factors to the development of frozen shoulder include:

·                     Immobility

·                     Diabetes

·                     Thyroid disease

·                     Humeral lesion

·                     Personality disorders

PATHOPHYSIOLOGY

-                      changes in the joint capsule including edema, fibrosis and round cell infiltration, indicating low-grade inflammatory process

-                      synovial recesses may become adherent, such adhesion obliterate parts of the joint cavity and sharply limit joint motion.

-                      Inelastic shortened and fibrotic periarticular tissue fixes the humeral head in the glenoid cavity

-                      Muscle atrophy

-                      Failure of the capsule and the biceps tendon

-                      Obliteration of the inferior axillary fold

-                      Impingement of the greater tuberosity, acromion and coracoacromial ligament

-                      Osteoarthritic spurring of the distal processes of the acromion

-                      Subsequent development of subacromial adhesions

-                      Rotator cuff contracture

-                      Spontaneous resolution

-                      After periods of pain and dysfunction, the inflammatory process subsides with resolution of adhesion and restoration of muscle activity

CLINICAL MANIFESTATION

-                      no history of major trauma or recent shoulder immobilization

-                      insidious onset of diffuse, dull or aching shoulder pain that begins as the nagging shoulder discomfort occasionally causing difficulty in sleeping

-                      stiffness

-                      most prominent feature is decrease passive and active mobility in the scapulohumeral joint particularly abduction, rotation and extension

-                      affected shoulder held at the side

-                      x-rays result show noabnormality but later stages has presence of osteopenia

-                      arthrogram shows shrunken capsule

-                      pain may radiate to the anterolateral aspect of the shoulder, the biceps muscle muscle belly, flexor surface of the forearm, and the inferior angle of the scapula

-                      tenderness over the intertubercular sulcus, the biceps tendon and the joint capsule

-                      signs of limitation:

1.            shrugging with excessive scapular rotation and limited glenohumeral abduction

2.            limited arm overhead elevation ( arm away from head and ear )

3.            hands fails to reach normal interscapular distance of reach

4.            limited external rotation with elbow flexed

5.            limited arm overhead elevation in posterior direction

6.            with hands behind head failure of the arm to fully flexed posteriorly

DIFFERENTIAL DIAGNOSIS

-                      bursitis

-                      rotator cuff tear

-                      bicipital tendinitis and rupture

-                      glenohumeral arthritis

-                      neglected shoulder dislocation

-                      reflex sympathetic dystrophy

-                      impingement syndrome

-                      hemarthrosis

-                      aseptic necrosis of the humeral head

-                      infection

Diagnosis and Special tests:

Patient History and Physical examination

-                      LOM particularly external and internal rotation

-                      Hx of insidious onset of stiff painful shoulder

-                      Bilaterality suggests systemic diserders

-                      Excessive compensatory scapular rotation to overcome restricted glenohumeral motion

-                      Presence of muscle atrophy and stiffness ( deltoid, supraspinatus and infraspinatus area )

Plain Radiograph

-                      degenerative changes of the glenohumeral and acromialclavicular joint and osteoponia

Arthrogram

-                      shows loss of loose dependent fold of the joint

-                      decrease joint volume from 25-35 ml to 10 ml

-                      incomplete filling of the axillary fold, subacromial bursa and biceps tendon sheath seen

PROGNOSIS

-                      resolve after 12-36 months

-                      most have no significant symptoms or functional restrictions

-                      20% have mild pain

-                      Inappropriate aggressive therapy at he wrong time prolong  symptoms

MANAGMENT AND RATIONALE

Medical and surgical management:

1.            pain management

-                      NSAID’s

-                      Analgesic

-                      Steroid injection

2.            distention arthrophy or infiltration brisement

-                      injecton of anesthetic and saline solution to the glenohumeral joint to produce hydraulic distention of capsule and lysis of adhesions

3.            manipulation under anesthesia

-                      if patient has poor progress with therapy program

-                      performed with forced abduction of the humerus on a fixed scapula

PT modalities:

hot moist packs

-                      to relieve pian

-                      to reduced edema

-                      to improve circulation

ultrasound

-                      to loosen adhesion

infrared radiation

-                      to increase circulation

-                      to decrease skin resistance prior to ES

massage

-                      to assist various return

-                      to free adhesion

overhead pulley

-                      to strengthen rotator cuff muscle

-                      to increase muscle power

-                      to increase ROM

finger ladder

-                      to increase ROM of fingers

-                      to strengthen flexors and extensors

shoulder wheel

            -uses effect of gravity to distract the humerus from the glenoid fossa

            -helps to relieve pain through gentle traction and oscillating movements

moderate stretching

            -to increase soft tissue and muscle mobility

ROM exercises

            -to increase ROM

            -to increase joint mobility

Patient  Rehabilitation and treatment:

Acute stage (freezing)

1.            to control pain, edema, guarding

-                      immobilization in sling

-                      grade 1 gentle joint oscillation techniques

1.            to maintain soft tissue and joint mobility and integrity

-PROM on all ranges of pain free motion

-Passive joint traction and glides (grades 1 & 2) in pain free motion

-gentle muscle setting on the shoulder, scapula and elbow

      3. to maintain integrity and function of associated areas

            -ROM on elbow, forearm, wrist and fingers

            -elevation of hand to avoid edema

Subacute and chronic stages (frozen and thawing)

      1. to control pain edema and joint effusion

            - increase acute treatment

      2. to increase ROM, decrease contracture formation and increase joint tissue mobility

            - grades 2 & 3 passive joint mobilization techniques

            - pendulum exercise:

                        1. Codman’s- patient is standing with trunk forward flexed and the arm freely hanging to provide slight distraction force. The patient moves the trunk forward, backward or sideward to produce a pendulum motion on the shoulder in sagittal or coronal plane.

                        2. Sperry’s- the same with Codman but with 5lbs. weight is added to the arm.

                        3. Chandler’s- the patient lies prone on the plinth with the arm hanging loosely on the side. The therapist assist the patient to the pendulum exercise on th suspended hand.

            - ROM up to the point of pain including shoulder and scapular motions

            - use of shoulder wheel, overhead pulleys and wand exercises

            - closed chain exercises with protected weight bearing

–        self-stretching exercises( body is moved in relation to the stabilize arm)

2.    Management: post manipulation under anesthesia

            - arm is kept elevated overhead in abduction

            - ROM with emphasis on internal and external rotation in abducted position

            - Caudal glides of shoulder to prevent readherence of inferior capsule

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REFERENCES:

1. Physical Medicine And Rehabilitation 3^rd edition ; Randall L. Braddom

2.Physical Rehabilitation (5^th Edition); Susan B.O’ Sullivan, Thomas J. Schmitz