Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
FROZEN SHOULDER
PRESENTED BY:ANUBHAV VERMA
CHAIRPERSON: DR. PRAMOD BM
9th June 2015
1
`• INTRODUCTION
• HISTORICAL PERSPECTIVE
• ANATOMY
• PHYSICAL EXAMINATION
• ETIOPATHOGENESIS
• CLINICAL FEATURES AND DIAGN...
INTRODUCTION
• Frozen shoulder is defined as a glenohumeral
joint with pain and stiffness that cannot be
explained on the ...
• Bilateral involvement occurs in 10 to 40 % of
cases
• Does not usually recur in the same shoulder
• However, 20 to 30 pe...
HISTORICAL PERSPECTIVE
• Duplay referred to Frozen shoulder in 1872 as
"scapulohumeral periarthritis," a disorder he
belie...
• In 1945, Neviaser introduced the concept of
adhesive capsulitis
• He discovered that the capsule was tight,
thickened, a...
7
8
9
10
MUSCLES
• FLEXION: Anterior fibers of deltoid, pectoralis
major
• EXTENSION: posterior fibers of deltoid, latissimus
dorsi...
ADDUCTION: 0 to 50 degrees
12
ABDUCTION: 0 to 170 degrees
13
FORWARD FLEXION: 0 to 165 degrees
14
EXTENSION: 0 to 60 degrees
15
INTERNAL ROTATION(in extension): 0
to 70 degrees
16
INTERNAL ROTATION( in abduction): 0
to 70 degrees
17
EXTERNAL ROTATION( in abduction): 0
to 100 degrees
18
EXTERNAL ROTATION(in extension):0
to 70 degrees
19
ETIOPATHOGENESIS
• Lundberg classified in to primary and
secondary frozen shoulder
PRIMARY FROZEN SHOULDER
No inciting eve...
PRIMARY FROZEN SHOULDER
• No inciting event but INTRINSIC AND
EXTRINSIC predisposing factors present
• INTRINSIC factors l...
PATHOLOGY
• Lundberg evaluated the shoulder capsules of
14 patients. Histology showed increase in
fibrous tissue, fibrobla...
• This suggested that frozen shoulder may have
abnormalities at a cellular level with malfunctions
of fibroblast recruitme...
24
25
SECONDARY FROZEN SHOULDER
• Rotator cuff diseases
• Fracture residuals
• Calcific tendinitis
• Previous shoulder surgery
•...
CLINICAL FEATURES
• Consists of 3 phases in case of primary frozen
shoulder
• Secondary frozen shouder may not follow the
...
28
PHASE 1 - PAIN
• Insidious / acute in onset
• Present during activity and rest unlike other
disorders
• More at night affe...
PHASE 2 - STIFFNESS
• Motion is guarded and a protective muscular
spasm is a common feature
• May prefer wearing a sling t...
• “Girdle hunching maneuver” in order to
substitute glenohumeral movements with
scapulohumeral movements
• “Empty end feel...
• Limitation of passive ROM shows a CAPSULAR
pattern: external rotation> abduction>
internal rotation
• External rotation ...
PHASE 3 - THAWING
• As motion increases, pain diminishes
• Usually occurs spontaneously over 4 to 9
months even without an...
DIAGNOSIS
• Clinical diagnosis
• Campbell decribes presence of 3 features to
diagnose frozen shoulder
1. Internal rotation...
INVESTIGATIONS
• Do not have a significant role
• PLAIN XRAY is normal. However, it can be used
to rule out other conditio...
ARTHROGRAPHY
• Can either be done fluoroscopically or with help
of MRI
• 50 % reduction in joint fluid volume and box like...
37
38
MRI
• The normal inferior glenohumeral ligament
measures <4mm and is best seen on coronal
oblique images at the mid glenoi...
40
TREATMENT
• Although Frozen shoulder is a self-limiting
condition, it imposes such morbidity and
lengthy recovery time tha...
MODALITIES
• Oral analgesics: salicylates, NSAIDS and
codeine compounds help to reduce pain and
inflammation in the early ...
INTRA-ARTICULAR STEROIDS
• Hollingworth reported
that injection of a
corticosteroid directly
into the anatomical site of
t...
• Weiser injected prednisolone into the
shoulder joints of 100 patients, then passively
mobilized the joint and gave the p...
INFILTRATION DEBRIDEMENT
• This method consists of forcibly extending the
joint capsule with the contrast material that is...
PHYSIOTHERAPY
ROLE OF THE PHYSIOTHERAPIST
THERMOTHERAPY: before resorting to passive
mobilization, the thick and contracte...
PHASE 1 PHYSIOTHERAPY
• Used when the patient has a painful joint
• A physical therapist would apply accessory movement
in...
48
PHASE 2 PHYSIOTHERAPY
• Used to treat a stiff joint
• As the condition progresses, the therapist may
detect stiffness befo...
50
ROLE OF THE PATIENT
• “patient heal thyself”
• Home treatment regimen
• pendulum exercises: in a forward stooping
position...
52
• SHOULDER ELEVATION EXERCISES: with the
normal hand supporting the affected one, the
shoulder is gradually lifted to a po...
54
• SHOULDER WHEEL EXERCISES: to be done by
the patient himself at the physiotherapy
center
• PULLEY EXERCISES: which can be...
56
MANIPULATION
• Closed manipulation of the shoulder under
General anesthesia
• Reserved for patients who have failed to gai...
• Shoulder is manipulated using a short arm
lever and a fixed scapula
• The acronym FEAR can be used as a safe
sequence fo...
POST MANIPULATION CARE
• Immediate exercises to be started, emphasizing
the need to move the arm continuously
• Circumduct...
COMPLICATIONS OF MUA
• Proximal Humeral fractures
• Shoulder Dislocations
• Fracture dislocation
• Rotator cuff ruptures
•...
ARTHROSCOPIC RELEASE
• For patients in whom closed manipulation fails
• ROTATOR INTERVAL: triangular area in
anterior and ...
62
63
64
65
66
• Selective arthroscopic releases may
accomplish the following gains in motion
(Bennett):
• Rotator interval: external rot...
RECENT ADVANCES
• Ip and Fu1 in May 2015 concluded that LLLT(Low
level laser therapy) is a viable option in the
conservati...
• Kim et al showed that hypertonic saline
solution is more effective than that using
normal saline solution in patients
wi...
70
REFERENCES
• Turek’s Orthopaedics: Principles and their
application: 6th edition
• Campbell’s operative orthopaedics: 12th...
Upcoming SlideShare
Loading in …5
×

244

Share

Download to read offline

Frozen shoulder 9.6.15

Download to read offline

frozen shoulder with recent advances

Related Books

Free with a 30 day trial from Scribd

See all

Related Audiobooks

Free with a 30 day trial from Scribd

See all

Frozen shoulder 9.6.15

  1. 1. FROZEN SHOULDER PRESENTED BY:ANUBHAV VERMA CHAIRPERSON: DR. PRAMOD BM 9th June 2015 1
  2. 2. `• INTRODUCTION • HISTORICAL PERSPECTIVE • ANATOMY • PHYSICAL EXAMINATION • ETIOPATHOGENESIS • CLINICAL FEATURES AND DIAGNOSIS • INVESTIGATIONS • TREATMENT • RECENT ADVANCES 2
  3. 3. INTRODUCTION • Frozen shoulder is defined as a glenohumeral joint with pain and stiffness that cannot be explained on the basis of joint incongruity • Also known as adhesive capsulitis as the pathology involves the capsule of the joint • Incidence is 2% • Seen in women more commonly than men during the 5th to 7th decade 3
  4. 4. • Bilateral involvement occurs in 10 to 40 % of cases • Does not usually recur in the same shoulder • However, 20 to 30 percent develop the condition in the opposite shoulder 4
  5. 5. HISTORICAL PERSPECTIVE • Duplay referred to Frozen shoulder in 1872 as "scapulohumeral periarthritis," a disorder he believed resulted from subacromial bursitis • Pasteur later referred to the same condition as "tenobursite," which he attributed to bicipital tendinitis. • In 1934, Codman coined the term "frozen shoulder" but used it in association with tendinitis of the rotator cuff 5
  6. 6. • In 1945, Neviaser introduced the concept of adhesive capsulitis • He discovered that the capsule was tight, thickened, and stuck to the humerus in such a manner that it could be peeled off like “adhesive plaster from the skin” 6
  7. 7. 7
  8. 8. 8
  9. 9. 9
  10. 10. 10
  11. 11. MUSCLES • FLEXION: Anterior fibers of deltoid, pectoralis major • EXTENSION: posterior fibers of deltoid, latissimus dorsi • ABDUCTION: Middle fibers of deltoid, supraspinatus • ADDUCTION: Pectoralis major, latissimus dorsi • LATERAL/EXTERNAL ROTATORS: infraspinatus, teres minor • MEDIAL/INTERNAL ROTATORS: subscapularis, latissimus dorsi 11
  12. 12. ADDUCTION: 0 to 50 degrees 12
  13. 13. ABDUCTION: 0 to 170 degrees 13
  14. 14. FORWARD FLEXION: 0 to 165 degrees 14
  15. 15. EXTENSION: 0 to 60 degrees 15
  16. 16. INTERNAL ROTATION(in extension): 0 to 70 degrees 16
  17. 17. INTERNAL ROTATION( in abduction): 0 to 70 degrees 17
  18. 18. EXTERNAL ROTATION( in abduction): 0 to 100 degrees 18
  19. 19. EXTERNAL ROTATION(in extension):0 to 70 degrees 19
  20. 20. ETIOPATHOGENESIS • Lundberg classified in to primary and secondary frozen shoulder PRIMARY FROZEN SHOULDER No inciting event, normal plain radiographs and no findings other than loss of motion SECONDARY FROZEN SHOULDER Precipitant traumatic event 20
  21. 21. PRIMARY FROZEN SHOULDER • No inciting event but INTRINSIC AND EXTRINSIC predisposing factors present • INTRINSIC factors like age between 40 and 60 years of age, female sex, Diabetes mellitus • EXTRINSIC factors may include immobilization and faulty body mechanics 21
  22. 22. PATHOLOGY • Lundberg evaluated the shoulder capsules of 14 patients. Histology showed increase in fibrous tissue, fibroblasts and vascularity • Hazelman reported Shoulder capsular tissue showed fibroblast and myoblast proliferation identical to that seen in dupuytren disease and vascular changes suggestive of diabetic microangiopathy 22
  23. 23. • This suggested that frozen shoulder may have abnormalities at a cellular level with malfunctions of fibroblast recruitment and cytokine growth factor production and release • Hannafin and colleagues described three phases based on capsular biopsies on 15 patients with frozen shoulder • Neviaser defined four stages of frozen shoulder based on arthroscopic changes observed 23
  24. 24. 24
  25. 25. 25
  26. 26. SECONDARY FROZEN SHOULDER • Rotator cuff diseases • Fracture residuals • Calcific tendinitis • Previous shoulder surgery • Osteoarthritis • Cervical spine lesions • Autoimmune disease • Chest wall tumors • Thyroid disorders • Parkinson's disease • CVA • Head injury • Myocardial infarction 26
  27. 27. CLINICAL FEATURES • Consists of 3 phases in case of primary frozen shoulder • Secondary frozen shouder may not follow the same chronology • The three stages are pain, stiffness and thawing also known as freezing frozen and thawing stages 27
  28. 28. 28
  29. 29. PHASE 1 - PAIN • Insidious / acute in onset • Present during activity and rest unlike other disorders • More at night affecting sleep • Distributed vaguely over the deltoid muscle area • Only point of tenderness is the bicipital groove • May radiate over C5 dermatome • Upper back ache due to compensatory use of shoulder girdle muscles 29
  30. 30. PHASE 2 - STIFFNESS • Motion is guarded and a protective muscular spasm is a common feature • May prefer wearing a sling to support the arm • Functional activities such as dressing or grooming which require reaching overhead or behind the back may be difficult • Loss of ROM is most prominent once the pain has subsided 30
  31. 31. • “Girdle hunching maneuver” in order to substitute glenohumeral movements with scapulohumeral movements • “Empty end feel” at the end of the ROM • Internal rotation is lost initially followed by loss of flexion and external rotation • HALLMARK: Terminally painful passive ROM (c.f. rotator cuff tendinitis and painful arc syndrome) 31
  32. 32. • Limitation of passive ROM shows a CAPSULAR pattern: external rotation> abduction> internal rotation • External rotation < 45 degrees • Abduction <80 degrees • Internal rotation <70 degrees 32
  33. 33. PHASE 3 - THAWING • As motion increases, pain diminishes • Usually occurs spontaneously over 4 to 9 months even without any treatment • May not regain full range of motion, but may feel normal as a result of compensatory mechanisms and adjustments in activities of daily living. 33
  34. 34. DIAGNOSIS • Clinical diagnosis • Campbell decribes presence of 3 features to diagnose frozen shoulder 1. Internal rotation restricted upto the point when the patient cannot touch beyond his sacrum 2. 50% loss of external rotation 3. < 90 degrees of abduction However, these criteria are not definitive and presence of all 3 is not mandatory 34
  35. 35. INVESTIGATIONS • Do not have a significant role • PLAIN XRAY is normal. However, it can be used to rule out other conditions. Commonly revealed conditions are osteoporosis, degenerative changes, decreased space between acromion and humeral head, calcium deposits and cystic changes. 35
  36. 36. ARTHROGRAPHY • Can either be done fluoroscopically or with help of MRI • 50 % reduction in joint fluid volume and box like appearance of the joint cavity is diagnostic • Joint volume capacity is only 5 to 10 ml (normal = 20 to 30 ml) • Tight thickened capsule,loss of the axillary recess, subcoracoid folds and subscapular bursa and absence of dye in the biceps tendon sheath. 36
  37. 37. 37
  38. 38. 38
  39. 39. MRI • The normal inferior glenohumeral ligament measures <4mm and is best seen on coronal oblique images at the mid glenoid level. In adhesive capsulitis, the axillary recess may show thickening up to 1.3 cm or more; the joint capsule is also thickened • Classical “ subcoracoid triangle sign is seen” in sagittal oblique T1 weighted images 39
  40. 40. 40
  41. 41. TREATMENT • Although Frozen shoulder is a self-limiting condition, it imposes such morbidity and lengthy recovery time that patients and clinicians alike seek treatment interventions. No standard treatment regimen, however, is accepted universally. • Conservative treatment is the mainstay of therapy and only refractory cases are subjected to operative interventions 41
  42. 42. MODALITIES • Oral analgesics: salicylates, NSAIDS and codeine compounds help to reduce pain and inflammation in the early stages • Many medical practitioners prefer the intra- articular injection of steroids, accompanied by local analgesics and gentle active motion, in the freezing stage of Frozen shoulder 42
  43. 43. INTRA-ARTICULAR STEROIDS • Hollingworth reported that injection of a corticosteroid directly into the anatomical site of the lesion produced pain relief and at least 50% improvement in ROM in 26% of the cases studied • Quigley stated that they may reduce pain if administered in conjunction with manipulation 43
  44. 44. • Weiser injected prednisolone into the shoulder joints of 100 patients, then passively mobilized the joint and gave the patients a vigorous active home exercise program; 78% obtained pain relief, and 61% regained normal function. • In summary, local corticosteroid injections have been used with various results but, generally, they produce a greater gain in motion recovery if used in combination with exercises and heat therapy 44
  45. 45. INFILTRATION DEBRIDEMENT • This method consists of forcibly extending the joint capsule with the contrast material that is used for arthrographic procedures • Local anesthetics and ROM exercises may be combined with infiltration debridement to facilitate restoration of motion. 45
  46. 46. PHYSIOTHERAPY ROLE OF THE PHYSIOTHERAPIST THERMOTHERAPY: before resorting to passive mobilization, the thick and contracted capsule must be released and made more stretchable by deep heating using ultrasonic or other suitable modalities The heating is carried out throughout the joint. • Passive physiological exercise: motion in a range that usually is achieved actively • Accessory exercise :motion between joint surfaces, which cannot be achieved actively 46
  47. 47. PHASE 1 PHYSIOTHERAPY • Used when the patient has a painful joint • A physical therapist would apply accessory movement in a comfortable joint position, with the affected arm supported in a loose-packed position • The therapist administers slow, gentle oscillatory movements in anterior-posterior and cephalad-caudad directions if they do not increase pain or induce muscle spasm • The therapist provides a mechanical block to movement short of the painful, restricted range and continues to use gentle, low-amplitude oscillations. 47
  48. 48. 48
  49. 49. PHASE 2 PHYSIOTHERAPY • Used to treat a stiff joint • As the condition progresses, the therapist may detect stiffness before or concurrently with the onset of pain • The therapist then should begin low-amplitude physiological and accessory oscillations at the limit of the restriction • To increase abduction, for example, the therapist with caudal glide performs more powerful oscillations at the end of the accessory range 49
  50. 50. 50
  51. 51. ROLE OF THE PATIENT • “patient heal thyself” • Home treatment regimen • pendulum exercises: in a forward stooping position, with one hand resting on a table or chair, the patient gradually swings the arm like a pendulum and later carries out a circumduction movement • 5 times daily in 5 to 10 minute sessions 51
  52. 52. 52
  53. 53. • SHOULDER ELEVATION EXERCISES: with the normal hand supporting the affected one, the shoulder is gradually lifted to a position of flexion abduction and external rotation • HAND TO BACK POSITION: patient carries the arm backwards with the shoulder in a position of extension, adduction 53
  54. 54. 54
  55. 55. • SHOULDER WHEEL EXERCISES: to be done by the patient himself at the physiotherapy center • PULLEY EXERCISES: which can be done by the patient himself at home 55
  56. 56. 56
  57. 57. MANIPULATION • Closed manipulation of the shoulder under General anesthesia • Reserved for patients who have failed to gain ROM after physiotherapy and local injections • Also recommended in patients who refuse to wait for long for resolution of symptoms • Significant improvement is seen in around 70% of patients 57
  58. 58. • Shoulder is manipulated using a short arm lever and a fixed scapula • The acronym FEAR can be used as a safe sequence for shoulder manipulation-flexion, extension, abduction and adduction, external and internal rotation. • Audible and palpable release of adhesions is a good prognostic sign. 58
  59. 59. POST MANIPULATION CARE • Immediate exercises to be started, emphasizing the need to move the arm continuously • Circumduction, overhead bar, pulley exercises are begun immediately(10 – 20 repetitions each hour) • Constant reassurance for 3 months • Counseling that ROM will improve immediately but pain may persist for 3 to 6 weeks. Permanent loss of 20 degrees of flexion, internal rotation and external rotation is usual • Abduction orthosis at night for 3 weeks to prevent significant axial pouch adhesions from returning in the early phase 59
  60. 60. COMPLICATIONS OF MUA • Proximal Humeral fractures • Shoulder Dislocations • Fracture dislocation • Rotator cuff ruptures • Traction nerve injuries Can be avoided by gentle, slow manipulation. If a firm end point to motion is felt, further manipulation should not be attempted 60
  61. 61. ARTHROSCOPIC RELEASE • For patients in whom closed manipulation fails • ROTATOR INTERVAL: triangular area in anterior and superior shoulder where no rotator cuff tendons are present • bounded by the supraspinatus superiorly, the subscapularis inferiorly, and the coracoid medially • Contents: The coracohumeral ligament, biceps tendon, and superior glenohumeral ligament. 61
  62. 62. 62
  63. 63. 63
  64. 64. 64
  65. 65. 65
  66. 66. 66
  67. 67. • Selective arthroscopic releases may accomplish the following gains in motion (Bennett): • Rotator interval: external rotation • Inferior capsule: external rotation, flexion, internal rotation • Posterosuperior capsule: internal rotation 67
  68. 68. RECENT ADVANCES • Ip and Fu1 in May 2015 concluded that LLLT(Low level laser therapy) is a viable option in the conservative treatment of shoulder pain arising from adhesive capsulitis of the shoulder in the elderly, with a positive clinical result of more than 90% • Lee et al2 have proven for the first time that Capsular stiffness of the glenohumeral joint significantly correlated with limitation in shoulder ROM, especially in the abduction and external rotation directions 1 J Pain Res. 2015 May 25;8:247-52 2 PM R. 2015 May 20: S1934-1482(15) 68
  69. 69. • Kim et al showed that hypertonic saline solution is more effective than that using normal saline solution in patients with adhesive capsulitis. 69
  70. 70. 70
  71. 71. REFERENCES • Turek’s Orthopaedics: Principles and their application: 6th edition • Campbell’s operative orthopaedics: 12th Edition • Mercer’s Textbook of orthopedics and trauma: 9th edition • Advanced Arthroscopy: James C. Chow: 3rd edition 71
  • Udk0710

    Sep. 16, 2021
  • SpandanaMS2

    Sep. 4, 2021
  • Archinalohana

    Aug. 29, 2021
  • AnalPatel7

    Aug. 16, 2021
  • Hashimkhan154

    Aug. 12, 2021
  • SanjanaThakur19

    Jul. 30, 2021
  • RaunakPareek3

    Jul. 14, 2021
  • SidHJayJohar

    Jul. 13, 2021
  • srabankumarsahu

    Jul. 1, 2021
  • PriyankaRanawat2

    Jun. 17, 2021
  • SonalAgrawal79

    May. 30, 2021
  • ArchanaJadeja1

    May. 20, 2021
  • SalmanFarish9

    Apr. 30, 2021
  • AnandhuBinu

    Apr. 9, 2021
  • prateekingle

    Mar. 26, 2021
  • AnirudhdhaSinh

    Mar. 14, 2021
  • JacquePelin

    Mar. 3, 2021
  • anwarullah30

    Feb. 25, 2021
  • SurajBisht39

    Feb. 16, 2021
  • ChandniPraveen

    Feb. 16, 2021

frozen shoulder with recent advances

Views

Total views

47,926

On Slideshare

0

From embeds

0

Number of embeds

41

Actions

Downloads

2,053

Shares

0

Comments

0

Likes

244

×