9/20 - Adhesive Capsulitis Flashcards
what is frozen shoulder a general term for
any shoulder condition consisting of pain and limited ROM
what is characteristic of frozen shoulder syndrome as a pathology or dx
self limiting
what is adhesive capsulitis
inflammatory reaction of the capsule and/or synovium that subsequently leads to formation of adhesions in the axillary fold of attachment of inferior capsule to anatomic neck
how does adhesive capsulitis impacts the arthrokinemetics of the shoulder joint
stops humerus from rolling inferiorly like it normally does
- the inferior/anterior capsule isn’t lax like it is supposed to
what is frozen shoulder characterized by
functional restriction of both AROM and PROM shoulder motion
radiographs of GH joint unremarkable other than possible presence of:
- osteopenia
- calcific tendinitis
how can adhesive capsulitis be classified
primary - insidious onset, no significant event or associated condition
secondary - identifiable event or associated condition which led to it
what are 3 causes of secondary frozen shoulder
intrinsic - at or in the shoulder
extrinsic - identifiable abnormality remote to shoulder itself
systemic - associated w systemic disorders
what are intrinsic causes of secondary frozen shoulder (3)
rotator cuff disorders
biceps tendinitis
calcific tendinitis
what are extrinsic causes of secondary frozen shoulder (7)
mastectomy
heart surgery
cervical radiculopathy
CVA
MI
humeral fx
AC arthritis
what are systemic causes for secondary frozen shoulder (3)
DM
hyper/hypothyroidism
hypoadrenalism
what stage of a frozen shoulder is marked by pain
stage 2 - acute adhesive, freezing
what causes the pain experienced in stage 2 frozen shoulder? describe the pain
angry red synovitis is what causes pain
bad a rest, worse w movement
- causes an empty end feel (can’t move to point of restriction d/t pain)
what is an important component of pt education when it comes to frozen shoulder
telling them its a long road
what are the 2 biggest risks/causes of frozen shoulder
insidious
DM
why is DM a commonly associated risk factor w adhesive capsulitis
hyperglycemia leads to inc in intermolecular cross-linkages in collagen
collagen is more resistant to degeneration and more likely to accumulate
collagen cross-links may also inc the stiffness of connective tissue
describe the pathology of adhesive capsulitis (7 steps)
- chronic capsular inflammation
- capsular fibrosis
- constrictive capsulitis
- adhesion of synovial folds and axillary recess
- obliteration of joint cavity
- formation of scar tissue where adhesions are
- thickened and contracted capsule becomes fixed to bone
what would a capsular pattern present as
ER > ABD > IR
what is diagnostic criteria (4)
capsular pattern
insidious onset, night pain
painful & limited A-PROM
normal radiographs
what is the key indicator for diagnosing adhesive capsulitis
ALL motion is limited
how does a pt present (not including pain) - 3
insidious onset
difficulty sleeping
motion restriction continues
acute vs frozen/thawing stage primary presentation
acute - pain primary complaint
frozen/thawing - significant limitations in mobility
how does a pt’s pain typically present
pain predominant early
- new n. growth in capsuloligamentous complex
- vague in deltoid area
- C5 distribution along lateral arm
pain on palpation (bicipital groove)
pain at rest subsides w progression
pain resolves spontaneously
what are the two biggest things seen in a physical exam for someone in the acute stage
high reactivity
empty end feel
why is ROM restricted in sub-acute/chronic stages
scarred adhesions
how is joint play limited in sub-acute and chronic stages
limited throughout
- inferior most limited
- then anterior
what is the predominant feature noticed in a physical exam of sub-acute and chronic stages
motion restriction
how do the end feels vary in early freezing vs frozen/thawing
early freezing - empty end feel
frozen/thawing - capsule/hard
what stage would a pt likely be in if they complain they can’t sleep thru the night
acute freezing
if someone is in the freezing stage, what is an important education piece to provide about their sx
its going to get worse before it gets better
how are radiographs utilized in adhesive capsulitis
typically normal
can r/o other path
what other path can radiographs r/o (5)
OA
osteoporosis
degenerative changes
calcium deposits
dec subacromial space
what are 7 differential dx to consider if suspect adhesive capsulitis
impingement syndrome
rotator cuff lesion
biceps tendinitis
OA
cervical radiculopathy
neural tension
medical complications
how can you differentiate between adhesive cap and impingement syndrome
impingement syndrome will have normal accessory glide at GH joint
how can you differentiate between a RC lesion and adhesive cap
RC lesion will have normal PROM and accessory glide at GH joint
RC lesion will have pain w AROM w arm at side
how can you differentiate between biceps tendinitis and adhesive cap
biceps tendinitis will have normal accessory glide at GH joint
what differential dx is closely related to adhesive cap
biceps tendinitis
- pain is present w both dx
how can you differentiate b/w OA and adhesive cap
OA will have (+) radiograph findings of spurring and dec joint space
what similarities do you see between OA and adhesive cap
pain and capsular pattern
how do you differentiate b/w cervical radiculopathy and adhesive cap
cervical radiculopathy will have sx reproducible w a cervical exam
what similarities do you see in the presentation of cervical radiculopathy and adhesive cap
similar pain in C5 distribution
how do you differentiate b/w neural tension and adhesive cap
neural tension is typically seen w trauma or repetitive stress
what medical complications could be presenting similar to adhesive cap (5)
heart
lungs
spleen
gall bladder
thyroid
how do you differentiate b/w adhesive cap and any other medical complications
medical complications will have an absence of mechanical findings
what is an important component in optimizing treatment
depends on recognition of clinical stage at presentation
- condition will progress thru a predictable sequence
what are the 4 overall goals of treatment
dec pain
dec inflammation
education - how long healing can take
restore capsular mobility
use of modalities in treatment
lack of evidence for efficacy
- if anything might be helpful acutely
- but rarely in your tx plan
what direction are mobilizations in typically
posterior and inferior
- people already leaning forward and putting pressure on anterior capsule
why would mobilization of the posterior capsule be beneficial
posterior capsule restrictions prevent anterior movement of humeral head w ER
what are some mobilization techniques that can be utilized in treatment
distraction
anterior
posterior
inferior
combined movements
- anterior and inferior
- posterior and inferior
what patient would benefit to a combined motion of anterior-inferior mobilization
if pt has limited ER
- can add ER to take up slack
what patient would benefit from a combined motion of posterior-inferior mobilization
if pt has limited IR
- can add IR to take up slack
when is it ideal for interventions to be more aggressive
in frozen and thawing stages
- aggressive interventions would make condition worse in freezing stage
what are benefits to a corticosteroid injection (3)
reduce pain and ms guarding
faster initial relief of sx
improved pain and ROM in initial 4wks
what plays a role in the efficacy of a corticosteroid injection
the earlier the better
- more significant improvements in acute stage (2-6wks in studies)
studies showing no difference at 12wks
what is the method to doing a manipulation under GA/brachial plexus block
short lever arm force into ABD while stabilizing scap followed by manip into ER and IR
what are complications to performing a manipulation under GA/brachial plexus block (5)
fx: glenoid, scap, humeral
dislocation
RC/labral tear
hemarthrosis
brachial plexus traction injury
who is a good candidate for a corticosteroid injection
high irritability cases
what pathology is characteristic of stage 1
synovial inflammation
minimal or no loss of mobility
what pathology is characteristic of stage 2
synovitis
early adhesions
what pathology is characteristic of stage 3
loss of axillary fold
dec synovitis
what pathology is characteristic of stage 4
mature adhesions and motion restriction
capsular end feel
what is the role of PT post-op an arthroscopic capsular release
daily pt
- prevent scarring from coming back in
where do you see the arthroscopic capsular release anatomically
typically RC interval and coracohumeral ligament
can release other shoulder ligaments and posterior capsule
