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The Stiff Shoulder
My Thoughts on Assessment and
Management of Shoulder Stiffness
Mike Walton
Consultant Shoulder Surgeon
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
• 4 N’s
• Neck (or neural)
• Near normal movement - pain
inhibition
• Not moving - true stiffness
• Nasty (Infection, Malignancy)
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
Nearly Normal
Movement
• Pain Inhibition
• Calcific tendinitis
• Cuff tendinopathy /
Impingement
• “Cuff Muscle Stiffness” -
Ginn et al
True Stiffness
• Reduction in Passive and active
glenohumeral joint movement
• Limitation due to bony abnormality
• Osteoarthritis
• Missed Dislocation
• Soft tissue contracture - “Frozen
Shoulder"
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
Nasty
• Night and Unremitting pain
• Red flags
• history of malignancy
• unexplained weight loss
Nasty
• Night and Unremitting pain
• Red flags
• history of malignancy
• unexplained weight loss
Assessment
• History - speed of onset, trauma, age
• Examination
• Loss of Passive ER
• Xray!!
Atraumatic Stiffness
Traumatic Stiffness
Frozen Shoulder
• Capsular Contraction
• coracohumeral
ligament
• Anterior / Deep pain
• Loss of External Rotation
• Hard end point
• Normal Xray
Frozen Shoulder
Aims of Treatment
• Relieve Pain
• Restore Movement
• Regain Function
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
Treatment Options
• Physiotherapy
• Steroids
• Volume Hydrodilatation / Distention
Arthrography
• Surgery
Physiotherapy
• Recent CSP Guidelines
• Passive Mobilisation
• Capsular Stretching
• Group Classes - Russell et al
2014
• May be counter
productive in painful
phase
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)
Physiotherapy
• ESSENTIAL post surgical intervention
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
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
Volume
Hydrodilatation
• Wrightington data:
• 76% improved ROM at 3 months
• 91% improved Pain at 1 year
• Especially primary idiopathic frozen
shoulder
Volume
Hydrodilatation
•
Surgery
• MUA
• Arthroscopic
Capsular Release
• Open Capsular
Release
MUA
• I don’t perform this in isolation
• Several good studies showing
excellent long term outcome
• Short lever-arm sequential
manipulation
• Uncontrolled technique
Capsular Release
• Arthroscopic
• EUA pre-op - always stiff ? Ginn et al
• Allows systematic evaluation of the
joint
• Controlled release of contracted
capsule and ligaments
Capsular Release
Capsular Release
Capsular Release
• Check ROM peri-
op
Capsular Release
• Open
• More limited visualisation of capsule
• Difficult to address posterior capsule
• May lengthen subscapularis
• Indicated post surgery particularly to
release subdeltoid adhesions
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
Arthritis
• Loss of articular cartilage
• Bone on bone articulation
• Pain
• Stiff
• Osteophytes
Arthritis
• Cuff Integrity
• Intact - Anatomic arthroplasty
• Hemiarthroplasty
• Total Shoulder Replacement
• Torn / Dysfunctional - Reverse
Replacement
Cuff Function
Superior
Deltoid
Rotator Cuff
Acromion
Humeral
Head
Glenoid
Cuff Function
Superior
Deltoid
Rotator Cuff
Acromion
Humeral
Head
Glenoid
Cuff Dysfunction
Superior
Deltoid
Rotator Cuff
Acromion
Humeral
Head
Glenoid
Cuff Dysfunction
Superior
Deltoid
Rotator Cuff
Acromion
Humeral
Head Glenoid
Cuff Dysfunction
Superior
Deltoid
Rotator Cuff
Acromion
Humeral
Head
Glenoid
Cuff Dysfunction
Superior
Deltoid
Rotator Cuff
Acromion
Humeral
Head Glenoid
Cuff Dysfunction
Superior
Deltoid
Rotator Cuff
Acromion
Humeral
Head
Glenoid
Cuff Dysfunction
Superior
Deltoid
Rotator Cuff
Acromion
Humeral
Head
Glenoid
Reverse
Reverse
Summary
• Good History
• Assess passive ER
• Get an Xray
• Abnormal - Nasty, Calcific Tendintis,
OA
• Normal - Frozen Shoulder

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