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Tx of Stiff Shoulder
Adhesive Capsulitis/Stiff Shoulder Notes
| Question | Answer |
|---|---|
| Main difference between true adhesive capsulitis & stiff/painful shoulder | True adhesive capsulitis will have a capsular pattern; stiff/painful shoulder may not |
| Causes of Adhesive Capsulitis | Contractures of intra-articular capsule or mm-tendon units Scar tissue bt tissues that normally move against one another easily Adhesions within extra-articular humeroscapular or scapulothoracic motion interface |
| Stiff & Painful Shoulder | Painful Limited motion No true capsular pattern of restriction Motion lmited by pain/stiffness only |
| History & Physical Exam in Stiff Shoulder | Onset more acute & severe Repetitive OH activity or trauma No mechanical restriction, just pain at end range With frozen shoulder there should be a mechanical stop to capsular contracture |
| Pathology of Frozen Shoulder | Inflammatory rxn in capsule & synovium that subsequently leads to formation of adhesions, specifically in the axillary fold & attachment of capsule at anatomic neck of humerus |
| Primary (Idiopathic) Frozen Shoulder | No known precipitating event Immunologic, inflammatory, biochemical, endocrine alternations 2-3% US population; women>men; 50-70 y.o.; NOT preferential to handedness; could occur bilaterally More common in sedentary people |
| Secondary Frozen Shoulder | Associated with or attributed to other illness/events |
| Intrinsic Secondary Frozen Shoulder causes | AC joint arthritis RTC tendonitis/tear |
| Extrinsic Secondary Frozen Shoulder causes | Cardiac disease/surgery Neuro disorders with impaired consciousness/hemiplegia Pulmonary disease Shoulder trauma/humeral fx Cervical radiculitis Personality disorders |
| Which 2 disease states are frozen shoulders more common in? | Thyroid Disease Diabetes |
| Pre-Adhesive/Freezing Phase | Little/no limitation of motion Fibrinous synovial inflammatory rxn detectable by arthroscopy |
| Painful/Freezing Phase | 10-36 wks long Severe pn Disturbs sleep Diminution of articular/capsular volume Proliferative synovitis & early adhesion formation (adhesions well into dependent axillary fold & extend to humeral head) |
| Stiffening/Frozen Phase | 4-12 months long Pain usually decreases gradually but w/o appreciable improvement in ROM |
| Thawing Phase | 12 months-years long (avg. 5-26 months) Gradual return of motion May be directly related to duration of painful stage |
| What is the total course of frozen shoulder? | 1-4 years Most pts have residual s/sx years after onset S/sx rarely interfere with work/ADLs Mild loss of ER/abd ROM |
| Key Features of Diagnosis | Sub-acute onset of unilateral shoulder pn Little-no trauma/overuse Limited AROM/PROM Endpoint leathery, occurs earlier than normal Pain with rest & activity Can't sleep Pain over biceps groove (overcompensation) Pain into C5 derm at insertion of de |
| What is the reason patients usually seek medical help? | Limited ROM |
| Acute Findings | Protective of involved limb Motion guarded Arm held in add/IR Protected mm spasm ROM difficult to assess b/c of pain/guarding Substitution patterns Empty end feel due to pain |
| Sub-Acute/Chronic Findings | *Motion Restriction Substituting scapular for GH mvmt May need scapular stab Overuse of upper traps Atrophy- RTC, delts, tris, bis Tender biceps groove Ssn/reflexes normal MMT- weak/asymptomatic at end range Tight ant/inf capsule- loss of ER/abd |
| Humeroscapular Motion Interface | All GH motion accompanied by gliding of biceps in bicipital groove ST jt responsible for ~1/3 shoulder ROM Loss of scapular motion = overall decreased ROM |
| Treatment | Frozen shoulder is self-limiting No standard tx regimen universally accepted PT, Rest, analgesia, ROM ex's; Prednisone; Corticosteroid injections |
| Capsular Distention | Injection of fluid into shoulder joint to stretch out capsule Shoulder may tighten up again afterward |
| Manipulation under anesthesia | Works well ~12 wks before feeling much better, very painful procedure Risk of iatrogenic fx, GH dislocation, RTC tear, nerve injuries Surgical capsular release |
| Plastic Deformation | Microtrauma at cellular level breaking the cross-links of the peri-articular connective tissue & elongating actual collagen bundles |
| Phase I Rehab | Decrease pn & inflammation Exercise in pain-free ROM AAROM & PROM ex's Don't allo shoulder shrug (impingement) HEP done 10-12x/day (more is better) Heat application |
| Circle Concept | Round capsule surrounding shoudler; if you injure something on one side, you'll probably injure something on the other side |
| Phase 2- Transitional Phase | Decrease pn & inflammation More aggressive ROM/mobs HEP 10x/day Continue heat followed by slightly more aggressive mobs Avoid vigorous forceful ex's to limit exacerbation |
| Phase 3- Light Phase | ROM HEP 4-6x/day LLLD stretching- 60 mins total of TERT to stretch out mm/capsule |
| Phase 4- Maintenance Phase | Stretch 3-5x/day AAROM Self capsular stretches RTC program Monitor ROM progression |
| Keys to Recovery | Compliance is critical Avoid immobilization Avoid over-aggressive ex's Gradual & steady progression rather than rushed & hurried |
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