Capsulite Adesiva + Tendinite calcaria

Question 1

Qual a epidemiologia da tendinite calcária?

Answer 1

Individuals who are older than 30 years old, and it afects 10% of the population. Ten percent of patients afected have bilateral deposits. Women seem to be afected more oten than men. Most individuals with deposits are asymptomatic, but pain can be intense in symptomatic patients.

Question 2

Qual a causa de tendinite calcária?

Answer 2

Its cause is unknown. Suggested causes have included a vascular etiology, with degeneration of the tendon fibers preceding calcification, and aging of the tendon, with a general diminishing of the vascularity to the supraspinatus as a normal course of events. Microangiographic studies showed an area of hypovascularity near Codman’s “critical zone” just proximal to the supraspinatus insertion into the greater tuberosity.

Question 3

Como ocorre a progressão cronológica da tendinite calcificante?

Answer 3

Three-phase chronology described by Sarkar and Uhthof is useful in planning treatment:
Phase I—precalcification stage. Fibrocartilaginous metaplasia. Asymptomatic.
Phase II—calcification stage. 3 stages. 1 = phase of formation; the cells and coalesce into larger calcium deposits; 2 = resting phase, during which the pain may be minimal, and the radiographic appearance is one of well-marginated, mature-appearing deposits. This resting phase is of variable length and ends with the beginning of the resorptive phase; 3 = resorptive phase, vascular channels appear at the periphery of the deposit and calcium resorption ensues. This stage can be exceedingly painful, and many patients seek treatment at this time. The calcium deposits at this time resemble cream or toothpaste. As the calcium is resorbed, the dead space is filled with granulation tissue.
Phase III—postcalcification phase. granulation tissue matures into mature collagen aligned along stress lines with the longitudinal axis of the tendon, reconstituting the tendon. Pain subsides markedly during this phase.

Question 4

Como é o tratamento clínico da tendinite calcificante?

Answer 4

Physical therapy, exercises, anti-inflammatory medications, and steroid injections. Corticosteroids have been suggested to abort the resorptive phase, returning the lesion to dormancy and setting into motion the factors necessary for recurrence.

Question 5

Qual o tratamento de escolha para a tendinite calcificante?

Answer 5

Essentially all patients eventually recover from calcific tendinitis and nonoperative management is the initial treatment of choice.

Question 6

Quais são as indicações para o tratamento cirurgico da tendinite calcificante?

Answer 6

Gschwend et al. listed the following as indications for operative treatment: (1) symptom progression, (2) constant pain that interferes with activities of daily living, and (3) absence of improvement after conservative therapy.

Question 7

Como é cirurgia para tratamento de tendinite calcificante?

Answer 7

An ultrasound-guided percutaneous needling technique used in conjunction with subacromial corticosteroid injection was reported to be successful in approximately 70% of patients. Extracorporeal shock wave therapy (ESWT) also has been advocated for the treatment of calciic tendinitis. Several comparative studies have reported greater pain relief with ESWT than with placebo or sham treatment, although in one study half of the patients eventually required surgery. Currently, we prefer an arthroscopic technique when surgery is warranted. Removal of calcium deposits is done with a mechanical shaver.

Question 8

Qual a taxa de bons resultados no tratamento artroscópico da tendinite calcificante?

Answer 8

Several authors have reported good results in approximately 90% of patients with arthroscopic removal of calcific deposits;

Question 9

Qual o local mais comum de ocorrencia da tendinite calcária?

Answer 9

The most common site of occurrence is within the supraspinatus tendon and at a location 1.5 to 2 cm away from the tendon insertion on the greater tuberosity.

Question 10

Como Neviaser descreveu a capsulite adesiva?

Answer 10

Neviaser coined the term adhesive capsulitis to describe a contracted, thickened joint capsule that seemed to be drawn tightly around the humeral head with a relative absence of synovial fluid and chronic inflammatory changes within the subsynovial layer of the capsule.

Question 11

Como é a fisiopatologia da capsulite adesiva?

Answer 11

Evidence suggests that the underlying pathological changes in adhesive capsulitis are synovial inflammation with subsequent reactive capsular fibrosis. Cytokines and metalloproteinases have been implicated in the process, but the initial triggering event in the cascade is unknown.

Question 12

Qual a incidencia de capsulite adesiva na população geral?

Answer 12

2%

Question 13

Quais são os fatores de risco para capsulite adesiva?

Answer 13

Female gender, age older than 49 years, diabetes mellitus (five times more), cervical disc disease, prolonged immobilization, hyperthyroidism, stroke or myocardial infarction, the presence of autoimmune diseases, and trauma.

Question 14

Qual é a epidemiologia da capsulite adesiva?

Answer 14

Individuals between the ages of 40 and 70 are more commonly afected. Approximately 70% of patients are women.

Question 15

Qual porcentagem de individuos que sofrem de capsulite adesiva em um ombro desenvolve também no ombro contralateral?

Answer 15

Twenty percent to 30% of affected individuals develop adhesive capsulitis in the opposite shoulder. The condition rarely recurs in the same shoulder.

Question 16

Qual é o fator mais significante para desenvolvimento da capsulite adesiva?

Answer 16

Common to almost all patients is a period of immobility, the causes of which are diverse; this probably is the most significant factor related to the development of the condition.

Question 17

Como Lundberg classificou a capsulite adesiva?

Answer 17

Lundberg developed a classification system of frozen shoulder based on the presence or absence of an inciting event. Frozen shoulders in patients who report no inciting event and with no abnormality on examination (other than loss of motion) or plain radiographs were designated as “primary,” and frozen shoulders in patients with precipitant traumatic injuries were designated as “secondary.” Patients with shoulder stiffness after a surgical procedure technically have a secondary frozen shoulder, but their clinical course and treatment are diferent.

Question 18

Qual o primeiro movimento perdido na capsulite adesiva?

Answer 18

We have noted that internal rotation frequently is lost initially, followed by loss of flexion and external rotation. Most often our patients can internally rotate only to the sacrum, have 50% loss of external rotation, and have less than 90 degrees of abduction.

Question 19

Qual o aspecto da artrografia na capsulite adesiva?

Answer 19

Arthrograms characteristically show a reduced joint volume with irregular margins. A volume of less than 10 mL and lack of filling of the axillary fold currently are accepted arthrographic indings indicative of a frozen shoulder.

Question 20

Como é o curso clínico da capsulite adesiva primária?

Answer 20

Three phases and may not follow the exact chronology.
Phase I—Pain. Patients usually have a gradual onset of difuse shoulder pain, which is progressive over weeks to months. The pain usually is worse at night and is exacerbated by lying on the afected side. As the patient uses the arm less, pain leading to stifness ensues.
Phase II—Stiffness. Patients seek pain relief by restricting movement. This heralds the beginning of the stiffness phase, which usually lasts 4 to 12 months. Patients describe dificulty with activities of daily living; men have trouble getting to their wallets in their back pockets, and women have trouble with fastening brassieres. As stiffness progresses, a dull ache is present nearly all the time (especially at night), and this often is accompanied by sharp pain during range of motion at or near the new end points of motion.
Phase III—Thawing. This phase lasts for weeks or months, and as motion increases, pain diminishes. Without treatment (other than benign neglect), motion return is gradual in most but may never objectively return to normal, although most patients subjectively feel near normal, perhaps as a result of compensation or adjustment in ways of performing activities of daily living.

Question 21

Qual o fator preditivo de bom resultado na capsulite adesiva?

Answer 21

Dominant shoulder involvement has been reported to be predictive of a good result, whereas occupation and treatment programs are not statistically significant. The best treatment of frozen shoulder is prevention (secondary frozen shoulder), but early intervention is paramount.

Question 22

Como é o tratamento conservador para capsulite adesiva?

Answer 22

Initial treatment is nonoperative, with emphasis placed on control of pain and inflammation. Transcutaneous electrical nerve stimulation and ultrasound may be helpful, combined with passive and active range-of-motion exercises. Abduction should be avoided initially to prevent impingement until joint motion becomes more supple. Intraarticular cortisone injections have proved beneicial in phase 1 or early phase 2 of the clinical course.

Question 23

Qual a porcentagem de bons resultados com a manipulação sob anestesia do paciente com capsulite adesiva?

Answer 23

With appropriate patient selection, significant improvement can be obtained in approximately 70% of patients. We have used closed manipulation under anesthesia with good results over many years and still believe in its eficacy.

Question 24

Quais outras modalidades de tratamento para capsulite adesiva existem?

Answer 24

For patients in whom closed manipulation fails, arthroscopic release is recommended. If arthroscopic release fails to relieve symptoms, open release of contractures has been recommended, with emphasis on release of the coracohumeral ligament and reestablishment of the interval between the supraspinatus and subscapularis.

Question 25

Qual a sequencia de movimentos deve ser realizada na manipulação fechada da capsulite adesiva?

Answer 25

The acronym FEAR can be used as a safe sequence for shoulder manipulation - flexion, extension, abduction and adduction, external and internal rotation. Audible and palpable release of adhesions is a good prognostic sign.

Question 26

Como continuar o tratamento após a manipulação fechada?

Answer 26

We perform manipulations during the earlier part of the week and initiate physical therapy the following day. Supervised physical therapy sessions are performed daily for at least 2 to 4 weeks. The goal of rehabilitation is early full range of motion. In some patients, we recommend an abduc-tion orthosis at night for 3 weeks to prevent significant axial pouch adhesions from returning in the early phase.

Question 27

Quais complicações podem ocorrer durante a manipulação fechada da capsulite adesiva?

Answer 27

The proximal humerus may be fractured during manipulation, or dislocation may occur. Manipulation should be avoided in patients with osteopenia or recently healed fractures and reserved for patients with recalcitrant stiffness unresponsive to conservative management. If dislocation occurs ater closed reduction, rehabilitation should be aggressive, but the abducted, externally rotated position should be avoided.