Shoulder patho Adhes Capsulitis

Question 1

Adhesive Capsulitis aka Frozen Shoulder

Answer 1

This is a significant decrease in AROM and PROM at the shoulder with associated pain, due to inflammation and fibrosis of the joint capsule.

Question 2

Etiology:

Answer 2

Contributing factors:

• Ages 40 to 70
• More prevalent in women then men
• High association with hyperkyphosis (explains prevalence in women)
• Current thinking is the joint capsule is primarily involved, with the surrounding structures affected secondarily
• Axillary Recess – inferior fold/pleat that stretches out during abduction. This is obliterated in frozen shoulder
• Inflammatory repair is said to be at the subsynovial layer (membranous layer) then at the synovial layer suggesting the easy tearing with AB and ER  inflammation
• Triangular area between subscapularis and biceps tendons is the initial area of adhesion; development spreads to surrounding rotator cuff muscles, glenoid rim, and coracohumeral ligament (fig.34.1 p. 458 – Rattray)

Question 3

Etiology:Old school vs New school:

Answer 3

Old school:
Arm not being used because of some painful condition (pain causes loss of motion)
Disuse
Fibrosis of joint capsule
New school:
Loss of motion is responsible for pain.
The guest will continually use the arm through pain
Restriction begins to present itself (difficulty with ADL’s)
Guests usually don’t seek medical help until the shoulder has loss about
90˚ abduction, 60˚ flex, 60˚ ER and 45˚ IR

Question 4

Primary Vs Secondary Frozen Shoulder

Answer 4

Primary Frozen Shoulder
- Idiopathic
Secondary Frozen Shoulder
- Impingement syndrome
- Subacromial bursitis
- Tendonitis or tears (rotator cuff or biceps)
- Trigger pints in the subscapularis (decrease ER and influences satellite TPR’s in surrounding muscles  decrease vascularity  inflammation  fibrosis of joint capsule
- Postural dysfunction – hyperkyphosis
- Disuse following shoulder injury or immobilization
- Extrinsic disorder: MI, hemiplegia, pulmonary disorders, breast surgery, bypass surgery, humeral fractures)
- Systemic disease (diabetes – type II higher chance and hyperthyroidism)

Question 5

Signs and Symptoms:

Answer 5

Acute:
- (1st phase) Freezing phase or painful phase
- Gradual onset of pain
- Severe pain at night and unable to lie on affected side.
- Pain on the lateral brachial region
Subacute:
- (2nd phase) Blends with acute – Frozen phase or stiffening phase
- Severe pain diminishes but stiffness becomes primary complaint
- ADL’s affected – capsular pattern
- Disuse atrophy – deltoid and rotator cuff
- Last for 4 – 12 months
Chronic:
- (3rd phase) Thawing phase or Resolution phase
- Pain begins to localize and continues to diminish
- Pain doesn’t always wake them at night
- Motion and function gradually return
- Full ROM isn’t always regained
- Supposed to spontaneously resolve over 2 years however, studies show that symptoms may last for years (5-10).
- Length of painful phase corresponds to length of recovery time
Other associated S&S:
- Muscle spasm, inflammation, stiffness
- Hyperkyphosis, head forward posture
- Decrease joint play especially with anterior and posterior glides

Question 6

ROM

Answer 6

AROM
- Decrease ROM – reverse scapulohumeral rhythm or 1:1
- Substituted movements – “cheating”
- Painful arc is available ~70˚
PROM
- Capsular pattern of restriction
RROM
Pain and strength depends on if there is a tear or tendonitis
- Strong/painless = no significant lesion
- strong/painful = minor lesion
- weak/painful = possible partial rupture or inhibition form a more serious lesion
- weak/painless = complete rupture or neural compromise

Question 7

Special tests:

Answer 7

Adhesive Capsulitis Abduction Test (PROM) This tests for restricted motion at the shoulder as a result of fibrosis and adhesions in the axillary recess

Question 8

Treatment Planning:

Answer 8

Acute:
- Help manage pain and inflammation
- Maintain available ROM
- Mobilize hypomobile joints (gr 1 and 2)
- Address muscle hypertonicity and fascial restrictions
Subacute:
- Cont to manage pain and inflammation
- Cont to address HT, fascial restrictions, and hypomobile joints (gr 3and 4)
- Maintain and begin to increase ROM
Chronic:
- Maintain and increase ROM – capsular stretch
- Maintain and increase strength
- Re-educate movement and proprioception

Question 9

CI’s and precautions:

Answer 9

Medical intervention:

• Medication – anti-inflammatories and pain-killers
• Steroid and anesthetic injections
• Saline injections to breakdown adhesions
• Manipulation under anesthesia – hematoma, fractures, dislocation
• High grades of joint play too early in the condition

Question 10

REMEX and Homecare:

Answer 10

• Passive stretching
• Self GH joint manipulation: capsule stretches
• PF AROM&raquo_space;Increase strength/stability via isometrics