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Tx of Stiff Shoulder

Adhesive Capsulitis/Stiff Shoulder Notes

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
Created by: 1190550002
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