Assessment and Management of Frozen Shoulder
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The Arm Clinic's Mr Mike Walton presents his thoughts on assessment and management of Frozen Shoulder. Presentation for The Arm Clinic educational event #stiffshoulder at The Wilmslow Hospital, 29th April 2016.
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Assessment and Management of Frozen Shoulder
- 1. The Stiff Shoulder My Thoughts on Assessment and Management of Shoulder Stiffness Mike Walton Consultant Shoulder Surgeon
- 2. What is Stiff? • Patient - “I cant move my shoulder as well ‘cos it hurts” • Us - Reduction in active and passive glenohumeral joint movement compared to the contralateral side
- 3. • 4 N’s • Neck (or neural) • Near normal movement - pain inhibition • Not moving - true stiffness • Nasty (Infection, Malignancy)
- 4. Neck • Radicular pain - extending below elbow, occasionally medial scapula (c3/4) • Neuralgic amyotrophy - wasting, pain ++ • Shoulder should be painfree to passive ROM • Can occur in combination
- 5. Nearly Normal Movement • Pain Inhibition • Calcific tendinitis • Cuff tendinopathy / Impingement • “Cuff Muscle Stiffness” - Ginn et al
- 6. True Stiffness • Reduction in Passive and active glenohumeral joint movement • Limitation due to bony abnormality • Osteoarthritis • Missed Dislocation • Soft tissue contracture - “Frozen Shoulder"
- 7. True Stiffness • Reduction in Passive and active glenohumeral joint movement • Limitation due to bony abnormality • Osteoarthritis • Missed Dislocation • Soft tissue contracture - “Frozen Shoulder" Easy to Diagnose on Xray
- 8. Nasty • Night and Unremitting pain • Red flags • history of malignancy • unexplained weight loss
- 9. Nasty • Night and Unremitting pain • Red flags • history of malignancy • unexplained weight loss
- 10. Assessment • History - speed of onset, trauma, age • Examination • Loss of Passive ER • Xray!!
- 13. Frozen Shoulder • Capsular Contraction • coracohumeral ligament • Anterior / Deep pain • Loss of External Rotation • Hard end point • Normal Xray
- 14. Frozen Shoulder
- 15. Aims of Treatment • Relieve Pain • Restore Movement • Regain Function
- 16. Natural History • Most cases recover within 2 years • 50% mild pain at 7 years * • 60% persistent stiffness * • Post traumatic more resistant * Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder: a long-term follow-up. J Bone Joint Surg [Am] 1992;74-A:738–746
- 17. Treatment Options • Physiotherapy • Steroids • Volume Hydrodilatation / Distention Arthrography • Surgery
- 18. Physiotherapy • Recent CSP Guidelines • Passive Mobilisation • Capsular Stretching • Group Classes - Russell et al 2014 • May be counter productive in painful phase
- 19. Physiotherapy • Interventions • Ultrasound, Interferential, TENS, pulsed electromagnetic stimulation etc • Very limited scientific evidence • May possibly sometimes be useful on a individual patient basis (CSP Guidelines)
- 20. Physiotherapy • ESSENTIAL post surgical intervention
- 21. Steroids • Commonly prescribed PO and IA • Cochrane and Meta-analyses • Good short to medium term benefit but doesn’t appear to be sustained • May get rebound
- 22. Volume Hydrodilatation• Small numbers of studies • Case series and quasi RCTs • Some conflicting data • Cochrane Review (2008) • Good short term relief - “Silver level” • Uncertain whether better than alternatives
- 23. Volume Hydrodilatation • Wrightington data: • 76% improved ROM at 3 months • 91% improved Pain at 1 year • Especially primary idiopathic frozen shoulder
- 25. Surgery • MUA • Arthroscopic Capsular Release • Open Capsular Release
- 26. MUA • I don’t perform this in isolation • Several good studies showing excellent long term outcome • Short lever-arm sequential manipulation • Uncontrolled technique
- 27. Capsular Release • Arthroscopic • EUA pre-op - always stiff ? Ginn et al • Allows systematic evaluation of the joint • Controlled release of contracted capsule and ligaments
- 28. Capsular Release
- 29. Capsular Release
- 30. Capsular Release • Check ROM peri- op
- 31. Capsular Release • Open • More limited visualisation of capsule • Difficult to address posterior capsule • May lengthen subscapularis • Indicated post surgery particularly to release subdeltoid adhesions
- 32. What I Tell Patients... • It will usually get better if we do nothing • Intervention will “hopefully” speed up recovery • Volume hydrodilatation is less invasive but may have a higher rate of recurrence • Arthroscopic capsular release more invasive but may have a better chance success
- 33. Arthritis • Loss of articular cartilage • Bone on bone articulation • Pain • Stiff • Osteophytes
- 34. Arthritis • Cuff Integrity • Intact - Anatomic arthroplasty • Hemiarthroplasty • Total Shoulder Replacement • Torn / Dysfunctional - Reverse Replacement
- 43. Reverse
- 44. Reverse
- 45. Summary • Good History • Assess passive ER • Get an Xray • Abnormal - Nasty, Calcific Tendintis, OA • Normal - Frozen Shoulder