Frozen shoulder

Question 1

What are some causes of shoulder pain and stiffness?

Answer 1

Rotator cuff injury 
Adhesive capsulitis
PMR
Mechanical injury
Osteoarthritis

Question 2

What is a key risk factor for adhesive capsulitis?

Answer 2

Diabetes

Middle aged people most commonly affected

Question 3

Pathophysiology of adhesive capsulitis?

Answer 3

Inflammation and fibrosis in the joint capsule lead to adhesions - these bind the capsule and cause it to tighten around the joint, restricting movement

Question 4

Presentation of adhesive capsulitis

Answer 4

Has three phases typically:

• Painful phase - pain often first symptom and worse at night
• Stiff phase - stiffness on both active and passive movement (external rotation most affected), pain settles
• Thawing phase - gradual improvement in stiffness

Entire illness takes 1-3 years to resolve but many have persistent Sx

Question 5

Differential diagnoses

Answer 5

Not preceded by trauma or acute injury:

• Supraspinatus tendinopathy
• Acromioclavicular joint arthritis
• Glenohumeral joint arthritis

Preceded by trauma/injury:

• Shoulder dislocation
• Fractures (e.g., proximal humerus, clavicle or rarely the scapula)
• Rotator cuff tear

Also important to consider septic arthritis, inflammatory arthritis and malignancy (e.g., osteosarcoma or bony metastasis)

Question 6

What is supraspinatus tendinopathy?

Answer 6

Shoulder impingement

Involves inflammation and irritation of the supraspinatus tendon, due to impingement where it passes between the humeral head and the acromion

Question 7

How can you assess for supraspinatus tendinopathy?

Answer 7

The empty can test (AKA Jobe test)

Positive if there is pain or arm gives way

Question 8

Examination findings in AC joint arthritis

Answer 8

Tenderness to palpation of AC joint

Pain is worse at extremes of shoulder abduction (around 170 degrees onwards)

Positive scarf test – pain caused by wrapping the arm across the chest and opposite shoulder

Question 9

Adhesive capsulitis investigations

Answer 9

None needed usually

Clinical diagnosis

Imaging not needed

Question 10

Management of adhesive capsulitis?

Answer 10

Non-surgical options for improving symptoms and quickening recovery:

• Continue using the arm but don’t exacerbate the pain
• Analgesia (e.g., NSAIDs)
• Physiotherapy
• Intra-articular steroid injections
• Hydrodilation (injecting fluid into the joint to stretch the capsule)

Surgery may be used in resistant or severe cases, options are:

• Manipulation under anaesthesia – forcefully stretching the capsule to improve the range of motion
• Arthroscopy – keyhole surgery on the shoulder to cut the adhesions and release the shoulder