Loco PBL 1: Frozen Shoulder

Question 1

Which muscle is responsible for extension of the shoulder joint?

Answer 1

Deltoid

Question 2

Which muscle is responsible for flexion of the shoulder joint?

Answer 2

Biceps

Question 3

Which muscle is responsible for the first 15 degrees of abduction of the shoulder joint?

Answer 3

Supraspinatus

Question 4

Which muscles are responsible for 15-90 degrees of shoulder abduction?

Answer 4

Middle deltoid alongside trapezius and serrates anterior to rotate the scapula

Question 5

Which muscles are responsible for adduction of the shoulder joint?

Answer 5

Pec major, teres major and latissimus dorsi

Question 6

Which muscles are responsible for medial rotation of the shoulder joint?

Answer 6

Subscapularis, pec major and anterior deltoid

Question 7

Which muscles are responsible for lateral rotation of the shoulder joint?

Answer 7

Infraspinatus and teres minor

Question 8

What factors contribute to the motility of the shoulder joint?

Answer 8

Ball and socket, shallow glen cavity and a large humeral cavity in addition to the laxity of the joint capsule

Question 9

What are the rotator cuff muscles?

Answer 9

Subscapularis, infraspinatus, supraspinatus and teres minor

Question 10

How does the rotator cuff work to stabilise the shoulder joint?

Answer 10

Attach to the tubercles of the humerus and joint capsule to pull the humerus into the cavity

Question 11

How does the glenoid labrum work to stabilise the shoulder joint?

Answer 11

The glenoid labrum is a fibrocartilaginous ring that surrounds the glenoid cavity to deep it and reduce the chance of dislocation

Question 12

What is frozen shoulder (adhesive capsulitis)?

Answer 12

Slow, chronic condition of fibrosis that reduces the range of movement of the shoulder in the absence of any known intrinsic disorder of the shoulder

Question 13

What is the epidemiology of frozen shoulder?

Answer 13

Aged 40-70, affecting 2-5% of the population

Question 14

What are the risk factors for frozen shoulder?

Answer 14

Previous shoulder surgery, hyper or hypothyroidism, diabetes, stroke, heart disease, rotator cuff tear or calcific tendonitis

Question 15

What are the stages of frozen shoulder?

Answer 15

Freezing phase, frozen phase and thawing phase

Question 16

Explain the pathophysiology of frozen shoulder.

Answer 16

Scar tissue forms inside the joint capsule which causes the capsule to thicken and tighten, reducing the space for the humerus to fit in, and subsequently restarts the movement possible at the glenohumeral joint.

Question 17

What are the different types of frozen shoulder?

Answer 17

Primary (idiopathic), or secondary (due to hyper/hypothyroidism, diabetes, trauma etc.)

Question 18

Outline the freezing phase of frozen shoulder

Answer 18

Shoulder begins to ache; pain is worse at night and gradually reduces the possible ROM. This lasts between 6 weeks to 9 months.

Question 19

Outline the frozen phase of frozen shoulder

Answer 19

Joint stiffness with greatly reduced ROM, and some muscle wasting, but slightly improved pain. This lasts between 4-9 months.

Question 20

Outline the thawing phase of frozen shoulder

Answer 20

Shoulder ROM slowly returns to normal. This lasts between 5-26 months.

Question 21

How is frozen shoulder diagnosed?

Answer 21

On clinical examination; pain is felt on abduction and on adduction with external rotation of the flexed elbow. On MRI there is a decreased capsule size and capsular thickening.

Question 22

How would rotator cuff injury present on clinical examination?

Answer 22

Pain in active ‘overhead’ motions, not passive, but fine in adduction with external rotation (which would be indicative of frozen shoulder)

Question 23

How would a posterior glenohumeral dislocation present?

Answer 23

Onset of pain is acute

Question 24

How is frozen shoulder treated/managed?

Answer 24

Avoid problematic activities, physiotherapy, anti-inflammatory drugs, intra-articular steroid injections, manipulation under anaesthesia (MUA), hydroxylation (distention of joint with saline and corticosteroid) and arthroscopic capsular release

Question 25

Outline the use of intra-articular steroid injections in the treatment of frozen shoulder

Answer 25

Triamcinolone acetonide with local anaesthetic

Question 26

Outline the use of manipulation under anaesthesia in the treatment of frozen shoulder

Answer 26

Pharmacological relaxation with general anaesthesia can free adhesive and fibrotic tissue