Frozen Shoulder Flashcards
Shoulder Pain Prevalence
20-30 % in Elderly, > 70 % Rotator cuff disease
Primary Care 5-10% of visits, 20% female, 7% male 10/yr
What are the 4 shoulder joints?
Glenohumeral, Acromioclavicular, Sternoclavicular
‘Scapulothoracic-not really a joint’
What is the Glenohumeral joint? What is its ROM? What actions are possible?
True synovial joint between the head of humerus and glenoid (a Shallow articular surface Deepened by glenoid labrum Ratio 3:1)
Multi axial, least stable, Lax capsule to allow rotation and elevation, Most ROM-120°
Long head of biceps can indicate whats wrong with capsule.
What are the Glenohumeral ligaments?
Superior, Middle and Inferior reinforce the capsule. Joint capsule thicker anteriorly as this is where its most lax to allow extension
What is the Acromioclavicular joint? What actions are possible?
Fibrous, Little movement, full abduction adduction+flex.
Interacts with subacromial space
Ligaments: acromioclavicular + coracoclavicular
What is the Sternoclavicular joint? What actions are possible?
Sternoclavicular rotates with elevation 30-40 °
What is the Scapulothoracic joint?
Scapulothoracic not a true joint -lies against posteriorlateralthoracic wall
Origin for rotator cuff muscles, deltoid and trapezius
What affects joint stability?
Static: Capsule: Labrum-Ligaments(Glenohumeral and Coracohumeral)
What affects dynamic stability?
The rotator cuff muscles and Long head biceps
What Muscles allow abduction?
First 30° by supraspinatus, 30-90° by middle body deltoid, 90-180° by trapezius.
Rotation by supraspinatus (avoids impingement)
Deep muscles depress humeral head preventing unopposed deltoid action (toward acromion) = “force couple” Subscapularis prevents head subluxation in later abduction, Requires 30-40° clavicle rotation (SCJ, some ACJ) Requires lateral slide of scapula on thorax
What is the role of the joints in abduction?
GHJ (120) and STJ (60) movement must be synchronous
Ratio of movement increases with higher abduction (ST >GH) Initially GH movement then scapula takes over. If imbalance of muscle strength/ hypermobility- higher risk of impingement (of cuff and bursa) or tendonopathy
What muscles are involved in Adduction? Normal ranges?
Pec major and lat dorsi 45°
What muscles are involved in Flexion?Normal ranges?
Pec major and ant. Deltoid 180°
What muscles are involved in Extension?Normal ranges?
Lat dorsi, teres major and post deltoid 50°
What muscles are involved in Lateral rotation?Normal ranges?
Infraspinatus 90°
What muscles are involved in Medial rotation?Normal ranges?
Pec major, lat dorsi and ant deltoid 90°
What are Subacromial bursa?
Subacromial bursa-between supraspinatus tendon and acromion. Provide lubrication. Blends into acromion and rotator cuff. Only communicates with jt if rotator cuff tear. Can be inflamed via impingement.
What does the Suprascapular nerve innervate?
Derived from upper trunk of brachial plexus Innervates Superior and posterior parts of joint and capsule and Supra and infraspinatus
What does the Axillary nerve innervate?
Deltoid, teres minor
Sensory: upper lateral cutaneous surface, Anterior aspect of jt and capsule
What muscle is the primary GH mover
Deltoid
What is the capulohumeral rhythm?
Synchronous movement b/t GH and STH (120°:60°)
Scapular movement increases > 90 ° important in impingement
Where is ACJ and STJ pain felt?
ACJ and STJ well localised to joint
Where is Rotator cuff pain felt?
Rotator cuff-outer upper arm/deltoid
Where is Adhesive capsulitis pain felt?
Adhesive capsulitis-deep aching-back of shoulder hard to sleep at night
Where is C spine-referred pain felt?
C spine-referred neck/back/m of arm pain depending on nerve affected
What is Active movement? what does it indicate?
Movement performed by the patient. Tests “joint/capsule” and “muscles/tendons”
What is passive movement? what does it indicate?
Movement performed by the examiner
- Tests “joint/capsule”
What does reduced active & passive movement indicate?
GH or capsule problem
What does Reduced active & normal” passive movement indicate?
“muscle/tendon” problem
What is Resisted movement? what does it indicate?
Try to move against resistance, Tests tendons by isolating them:
Abd 90 °, flex 30 ° int rot (thumb down) to align shoulder with scapula making sure its muscles your testing.
Abd → Supraspinatus is the only abductor
Internal rotation → subscapularus
Ext. rot→ Infraspin. & Teres minor
Abduction from neutral
Shoulder flexion with elbow extended and Supination with elbow flexed tests the biceps.
What is Impingement movement? what does it indicate
Reproduce movements that cause greater tuberosity to ‘squash’ cuffagainst acromion, ACJ or coracoacromial ligament Rotator cuff (passive ) Stabilise scapula: Abduct 90, forward flex30 → int. rot. & elevate, Stabilise scapula, Full flexion=pain?
Differential Diagnosis for Joint/Capsule problems
arthritis, capsulitis ‘frozen shoulder’
Differential Diagnosis for Tendons problems
Rotator cuff tendinopathy, Bicipital tendinopathy, Calcific tendinopathy
What is Adhesive Capsulitis?
Frozen Shoulder-“This is a condition of unknown aetiology in which there is a painful global restriction of GH movements in all planes, both active and passive, in the absence of joint degeneration (Xray/tests are normal) sufficient to explain this restriction” can be 1° or 2°
Frozen Shoulder: Epidemiology
Prevalence: 2-3% in non-diabetics (10-20%in diabetics)
Rare <40 Usually In 60’s+ (diabetics may get it younger)
Slight female preponderance 1.4:1, younger
Contralateral 6-15% in 5yrs
May be precipitated by trauma, M.I, C.V.A
Associated with: thyroid disease, lung disease (TB, Ca.) cardiac disease/surgery
3 Stages of Frozen Shoulder-
Painful (3-8/12): ache, night pain, spasm (initially not restricted so may be confused with RC problems)
Adhesive (4-6/12): pain, stiffness, ↑ restriction
Resolution (1-3yrs: less pain, gradual resolution (naturally occurs can’t get to this stage quicker)
Frozen Shoulder- Clinical Features
Early diff to d/w RCD, Tender trapezius, Global↓ROM (active & passive), Scapulohumeral rhythm, Disuse atrophy
Frozen Shoulder- Pathophysiology
Increased incidence in DM may implicate microvascular disease: abnormal collagen repair predisposition to infection
Histology: ↑fibrous tissue, fibroblasts, type III collgen, vascularity, no↑in inflammatory, synovial cells
No HCA or immunologic disturbance
Genetic increase Trisomy 7 and 8 in fibroblasts of those with chronic disease
Early phase more like neuropathic pain with allodynia
Later phase similar to dupytrens in histology (but outcome different)
Frozen Shoulder: Neurogenic mechanism ?
Evidence of sympathetic dysfunction (hyper reactivity) in the upper limbs of many with ‘adhesive capsulitis’. (This can also potentially explain the increased association between hyperthyroidism and capsulitis.)
Hypersensitivity of peripheral alpha adrenoreceptors and increased vasomotor tone (response to pain), may reduce blood supply to the capsule and lead to increased fibroblasts and collagen deposition and pain
Frozen Shoulder: Recovery
Recovery: 1-2/3 have↓ROM, 10-15% have↓function
No link b/t duration and outcome
Corticosteroid reduce symptoms but not duration of disease,
Frozen Shoulder: Investigations
Usually doesn’t require further investigation
Radiography r/out: GH disease, calcific tendinopathy neoplasm
Ultrasonograph: r/out RCD
What is Arthroscopy?
Laser to treat frozen shoulder -release of thickened capsule
Frozen Shoulder: Management
Early emphasis for pain reduction and to minimise restriction
Physiotherapy: interferential, heat, acupuncture
Corticosteroids: improve pain/ROM not duration
Capsular distension: end of adhesive phase arthrography, US or blind
Arthroscopic capsular release: arthroscopy with release of thickened capsule
Manipulation under anaestheticrisk of rupture inf. capsule, SSC,elderly risk of fracture, RC rupture
Immediate rehab NB++
What is Rotator Cuff Tendonopathy?
Common cause of shoulder pain where degeneration of tendon leads to dysfunction and impingement
What are Rotator Cuff Tendonopathy signs/symptioms?
Painful arc (catching on lowering), deltoid, trauma Night-time pain, reduced function. Reduced active, better passive movements, pain on restricted Impingement test. If tender ++ consider calcific tendinopathy. If positive drop off or weakness ++ on external rotation consider complete rupture
Rotator Cuff Tendonopathy classification?
Structural-Acromion, CA ligament, ACJ
Functional- Fatigue, tendinopathy, instability
Avascular zone
Rotator Cuff Tendonopathy pathophysiology:
3 stages:
1) Oedema and hemorrhage,
2) Fibrosis and tendonitis,
3) Tendon degeneration, bony change, tendon rupture
Rotator Cuff Tendonopathyr: Management
Outcome is poor in elderly, cuff arthropathy
Emphasis on cuff strengthening, reducing instability
Corticosteroids reduce pain, & improve external rotation
Surgical decompression depending on: Pain, Age, occupation, Structural abnormality
Biceps Tendon problems?
Nearly always with rotator cuff pathology Check Anterior stability, depress’s humeral head, Subluxation, Rupture biceps retraction
ACJ problems
Trauma, OA, instability, Localised swelling/ pain, Tender
Use Provocation tests
