Frozen Shoulder Adhesive Capsulitis - Everything You Need To Know

Frozen Shoulder Adhesive Capsulitis - Everything You Need To Know

https://www.youtube.com/watch?v=VhfaPe8f7g0 

Frozen shoulder (adhesive capsulitis)

The frozen shoulder can be associated with diabetes or thyroid disease.  It may be the initial presenting symptom for these conditions.  The exact details of this relationship remain poorly understood.  Ever patient with a frozen shoulder should have the HbA1c and TSH levels tested.  Also, check for arthritis, rheumatoid factors and antinuclear antibodies.  Most patients with frozen shoulder are female between the ages of 40 and 60 years old.  And frozen shoulder, the patient will lose both the active and the passive range of motion of the shoulder.  The patient develops pain, which means that there is inflammation with early fibrosis of the joint capsule, leading to joint stiffness.  The active and passive global motion, especially external rotation, will be reduced compared to the other side.  The shoulder pain and motion loss is usually not related to trauma.  It is an idiopathic process that results in shoulder pain and loss of motion due to contracture of the capsule.  The essential lesion involves the coracohumeral ligament and the rotator interval.  The synovial inflammation and capsular fibrosis results in pain and joint volume loss.  Check for previous trauma or fractures.  Rule out shoulder joint arthritis and rule out posterior dislocation of the shoulder.  It can also occur post-surgery from a rotator cuff tear.  It may also be associated with dupuytren disease and cervical disc disease.  Check for medical comorbidities such as stroke or cardiac diseases.  The x-ray will exclude trauma, malignancy, arthritis, calcific tendinitis, impingement, and AC joint arthritis.  And frozen shoulder, the humeral head will remain in its normal location.

 

MRI

There is a space reduction in the axillary recess.  Rotator cuff strength is normal by exam and on the MRI.  The pain and stiffness lasts beyond 6 months, then you can do manipulation of the shoulder under anesthesia.  There is a 50% failure rate in diabetics.  The diabetes is associated with a much worse prognosis and poor outcome for surgical and nonsurgical treatment.

 

Treatment

·         Nonoperative

o   This should be done for at least 3 to 6 months.

o   Supervised or home-based capsular stretching program +/-intra-articular steroid joint injection.

o   Nonsteroidal anti-inflammatory medication

·         Surgery

o   Capsular release (arthroscopic or open) and release the intra-articular and subacromial adhesions.

o   The axillary nerve may be injured during release of the capsule.

o   Utilize surgery in patients that have failure of initial conservative treatment for 3 months, and the patient remains functionally limited.

Shoulder Dislocation, Posterior

Shoulder Dislocation, Posterior

The usual story is that the patient visits the emergency room and comes back to see the doctor because the patient is having constant shoulder pain and is unable to move the shoulder. When examining the patient, the patient will have limitation of external rotation of the shoulder. You may be shown an x-ray, an AP view of the shoulder, and the interpretation of the x-ray is that the shoulder appears normal. You need to get two x-ray views (orthogonal views): AP view and axillary view. An AP view x-ray alone will not diagnose posterior shoulder dislocation. When you have posterior dislocation of the shoulder, the AP x-ray view will show the classic “lightbulb” humeral head due to internal rotation of the shoulder.

The humeral head takes on a rounded appearance. The axillary view x-ray will show dislocation of the shoulder posteriorly. It is the best view to show the posterior shoulder dislocation. After reduction, always get an axillary view and check concentric reduction. Locate the coracoid (anteriorly) and outline it. Locate the acromion (posteriorly). Then locate the glenoid and determine whether the dislocation is posterior or anterior. In posterior dislocation of the shoulder, the axillary view will show the humeral head going posteriorly away from the coracoid and in the direction of the acromion. With posterior shoulder dislocation, the shoulder is locked in the internal rotation position with prominence of the posterior shoulder, prominence of the coracoid process, and flattening of the anterior shoulder. Posterior shoulder dislocation may be associated with fracture of the lesser tuberosity. 50% of posterior shoulder dislocations will have a Reverse Hill-sachs lesion or impaction fracture next to the lesser tuberosity. When you examine the patient and you see limitation of the range of motion, especially external rotation of the shoulder, you may think it is adhesive capsulitis (frozen shoulder). Frozen shoulder can start by limiting the external rotation, however it is usually a global restriction of the range of motion.

Posterior dislocation of the shoulder is rare (about 5%) and it is usually stable after reduction if no fracture is present. Posterior dislocation of the shoulder usually occurs after seizures or electric shock. Why is it that dislocation of the shoulder most commonly occurs as a posterior shoulder dislocation with seizures and electric shock? This is a controversial subject. Some physicians believe that this is due to the fact that the shoulder internal rotator muscles (pectoralis major, latissimus dorsi, and subscapularis) are stronger than the external rotator muscles. Up to 50% of posterior dislocations of the shoulder can go undiagnosed when the patient is examined in the emergency room, especially if dislocation results from seizures. If posterior dislocation of the shoulder occurs due to seizures, the patient should be examined carefully and neurology consult should be done to control the patient’s seizures. Any future treatment of posterior dislocation of the shoulder may fail due to lack of controlling seizures. Closed reduction is not difficult in the acute setting and can be done up to 3 months. Instability is rare with absence of fracture. Immobilize the arm in neutral rotation with the elbow at the side and posterior to the plane of the body. Impaction less than 20%, do closed reduction and immobilize in external rotation. Open reduction is done when posterior dislocation is chronic or locked. In locked posterior dislocation, the deltopectoral approach to the shoulder is usually used. If the defect is between 20%-40%, transpose the lesser tuberosity or the subscapularis tendon into the defect. More than 45% defect or if the dislocation is more than 6 months, do arthroplasty and place the prosthesis in less retroversion.

Cervical Radiculopathy

Cervical Radiculopathy

Cervical radiculopathy is caused by cervical nerve root compression. The patient will have pain and/or progressive neurological deficit that results from conditions such as disc herniation that irritates a nerve in the cervical spine. Cervical radiculopathy is an irritation of the cervical nerve root. Cervical spine and shoulder problems overlap. The condition is of cervical spine etiology if the patient’s symptoms are relieved by shoulder abduction, by placing the hand over the head. The relief of the symptoms occurs due to decreased tension on the nerve roots. In cervical disc problems, be aware of false positive MRIs especially if the patient is above the age of 40 years old. Nerve conduction studies are not useful; they have a high false negative rate. EMG and nerve studies may differentiate radiculopathy from peripheral nerve entrapment. Cervical disc problems usually affect the lower numbered nerve root.

When you see the middle finger numbness, then this is C7. When compression of the C7 nerve root, there will be middle finger numbness, triceps weakness, and the triceps reflex will be affected. The cervical nerve roots are horizontal in orientation. It does not matter if cervical disc herniation is central or foraminal, it will compress the same nerve root. C7 nerve root runs above the pedicle of the C7 vertebra. C5-C6 is the most commonly affected disc and that will compress the C6 nerve root. The patient will come to the doctor with unilateral arm pain that is relieved by arm elevation. The numbness and paresthesia will occur in specific dermatomes. The patient may also have upper trapezius pain or interscapular pain. The patient may complain of occipital headache. When you examine the patient, do provocative tests such as the spurling’s test and the shoulder abduction test. The Spurling’s test is done by extending and rotating the neck towards the involved side. It reproduces the symptoms by narrowing the neuroforamen. The Spurling’s test differentiates cervical radiculopathy from peripheral nerve entrapment. Lifting the arm above the head relieves the symptoms if the cervical nerve roots are irritated. The Shoulder Abduction test differentiates cervical pathology from other causes of painful shoulder etiology. Make sure that you do not have a double crush syndrome, one in the neck and one in the peripheral nerve. Make sure that you differentiate radiculopathy from myelopathy. Make sure that you exclude a coexisting myelopathy. Examine the patient for upper motor neuron signs or cervical

myelopathy. Test the patient for gait instability. Test the patient for Hoffman’s sign. Test the patient for Babinski reflex. Test the patient for ankle Clonus. Check to see if the patient has hyperflexia in the upper and lower extremities (triceps/quadriceps). Even if there is a bad cervical spine disc problem on the MRI, treat it conservatively for about 3 months. Give the patient therapy and nonsteroidal anti-inflammatory medication (NSAIDS). 75% of the patients will improve with nonoperative treatment. Cervical radiculopathy is generally treated nonoperatively, in contrast to cervical myelopathy. Do surgery when there is persistent, severe pain for 6-12 weeks and/or progressive neurological deficit such as weakness or numbness. The procedure to treat cervical radiculopathy surgically is usually done anteriorly with direct removal of the lesion that causes the radiculopathy such as a herniated disc or spurs. When you place the anterior bone graft or the allograft in the disc space, you open the nueroforamen, and that will indirectly relieve the nerve. Then you will add the anterior plate. Some surgeons prefer to do a posterior approach.

Adhesive Capsulitis, Frozen Shoulder

Adhesive Capsulitis, or frozen shoulder, is a painful progressive loss of shoulder motion. It affects both active and passive movement of the shoulder joint. The shoulder will be stiff and painful and occurs due to inflammation, fibrosis, scarring, and contraction of the capsule. A normal shoulder joint capsule is elastic and allows great range of motion. Inflammation and thickening of the shoulder capsule and may lead to adhesive capsulitis. Frozen shoulder may occur without any specific cause, however it may be triggered by a mild trauma to the shoulder.

This condition develops slowly and goes through three phases:

1. Pain and freezing
2. Stiffness or frozen
3. Resolution

During the pain and freezing phase, the pain is worse at night and increases with any movement. This phase will last several months. During the second phase, range of motion is limited as pain is diminishing. This may last up to one year. The resolution phase may begin overtime and may last up to three years.

Conditions associated with frozen shoulder include:

• Diabetes
• Thyroid problems
• Auto immune disease
• Stroke
• Rheumatoid arthritis
• Trauma or post-surgery

A patient with frozen shoulder will have loss of both active (movement without assistance) and passive (movement with assistance) motion. External rotation of the shoulder is very limited and the condition is self-limiting and may resolve on its own. X-rays are needed to rule out degenerative arthritis.  An MRI or arthrogram will show small fluid in joint cavity. Rotator cuff may be normal and synovitis and narrowing of the rotator cuff interval is usually seen.

Treatment consists of anti-inflammatory medications, physical therapy, injections, and manipulation under anesthesia. Surgery will be done in the form of a release of the capsule when nonoperative methods fail. The physician should always check the patient for diabetes.