Frozen Shoulder (Adhesive Capsulitis) Lecture PDF

Frozen shoulder (Adhesive Capsulitis) Prof.Dr. NASR AWAD Assistant professor, Sinai University sinaiuniversity.net ADHESIVE CAPSULITIS (FROZEN SHOULDER) Definition: Frozen shoulder or adhesive capsulitis is an ambiguo...

Frozen shoulder (Adhesive Capsulitis) Prof.Dr. NASR AWAD Assistant professor, Sinai University sinaiuniversity.net ADHESIVE CAPSULITIS (FROZEN SHOULDER) Definition: Frozen shoulder or adhesive capsulitis is an ambiguous condition characterized by painful, progressive, and disabling loss of active and passive glenohumeral joint range of motion in multiple planes. Epidemiology Predominant age: 40 to 70 years Predominant sex: female > male  Prevalence General population: 2-5% Diabetics type 1 and type 2: 10-20%  Etiology and pathophysiology: The etiology of FS remains unknown, however, there is a relationship to elevated serum cytokine levels and FS. Cytokines and other growth factors facilitate tissue repair and remodeling as part of the inflammatory process. In the presence of elevated cytokine levels, a minor insult could initiate an inflammatory healing response that could result in an exaggerated and sustained inflammation and fibrosis response.  The patient initially experiences pain an limited motion due to synovial inflammation. Eventually the GH joint capsuloligamentous complex (CLC) becomes fibrotic resulting in contractu and severely restricted motion.  Contracture of the rotator cuff interval (RCI) is prevalent in patients with FS. The RCI forms the triangular shaped tissue between the anterior supraspinatus tendon edge and upper subscapularis border and includes THE SUPERIOR GH LIGAMENT THE CORACOHUMERAL LIGAMENT. The rotator interval describes the anatomic space bounded by the subscapularis, supraspinatus, and coracoid. This space contains the coracohumeral and superior glenohumeral ligament, the biceps tendon, and anterior joint capsule. The coracohumeral (CH) ligament acts as the roof of this space. Both the coracohumeral ligament and the glenohumeral ligament have a complex relationship with the long head of biceps tendon.  The interval acts as an anterior-superior hammock restricting ER with the arm at the side and preventing inferior translation. tightens of the RCI resulted in a 50% loss of ER with the arm side and RCI release in patients with FS leads to an immediate and dramatic increase in ER.  Others have noted significant subacromial scarring. Loss of the subscapular recess. Inflammation of the long head of the biceps tendon and its synovial sheath, and musculotendinous contracture in patients with FS.  Adhesive capsulitis is not directly associated with full-thickness rotator cuff tears; however, partial-thickness tears may be present in some cases. Clinicians attempting to regain ER should perform stretching and joint mobilization techniques to target the RCI as well as the anterior CLC.  Classification ❑primary ❑ secondary adhesive capsulitis  Primary ❑Occurs independent of other pathologies ❑No history of injuries  Secondary Systemic: Associates with 1. Diabetes 2. Thyroid disease  Extrinsic to GH joint Mid-humeral fracture CVA COPD Myocardial infarction Chronic liver disease Cervical disc disease  Intrinsic to GH joint Associated with rotator cuff tear Biceps tendonopathy Calcified tendinitis Acromioclavicular or glenohumeral joint arthropathy Proximal humeral or scapular fracture).  Stages of frozen shoulder Stage 1: painful (pre-adhesive stage) 0-3 months Mild erythematous synovitis Sharp pain at end ranges of ROM. Achy pain at rest, and sleep disturbance. There may be mild decrease in ROM  Patients are often misdiagnosed as rotator cuff impingement during this stage. To avoid misdiagnosis as “rotator cuff impingement”, the skilled health care provider must recognize the loss of ER with an intact rotator cuff during the pre- adhesive stage. Arthroscopic studies indicate that the synovial pathology is usually most severe in the antero-superior capsule. The presence of multiple nerve cells in tissue samples may explain why adhesive capsulitis can be so painful. Stage 2: The acute adhesive or “freezing” stage 3-9 months: Thickened red synovitis Patients frequently have acute discomfort and very painful end ranges of all motions in this stage. ROM loss becomes more profound and sustained with or without anesthesia as a result of dense fibrotic scar formation. Even though this phase is represented by pain, examination under anesthesia (EUA) reveals connective tissue changes resulting in loss of motion.  Stage 3: The fibrotic or “frozen” stage 9 to 15 months: Patients will now demonstrate less synovitis More mature capsuloligamentous fibrosis results in significant stiffness with less pain. The result is marked glenohumeral joint ROM loss, although pain during this stage tends to plateau or diminish somewhat.  These patients have motion limited by established contracture versus pain since EUA reveals equal passive motion compared to when awake. Severe capsular restriction without apparent synovitis The glenohumeral contracture is most severe in the anterior aspect of the capsule, particularly around the rotator interval and coracohumeral ligament. The histologic appearance of the contracted glenohumeral capsule is somewhat similar to that observed with Dupuytren’s disease of the palm, suggesting that the molecular biology of these disorders is similar.  Stage 4 “thawing” or Recovery stage stage 15-24 MONTH During the “thawing” or “recovery” stage glenohumeral motion and shoulder function begin to improve. Painless stiffness and progressive improvement in ROM are characteristic. Typically improves by remodeling from 15 to 24 months since onset.  Although FS initially considered a 12- to 18-month self-limited process, mild symptoms may persist for years depending on the degree of fibroplasia and subsequent resorption. Mild symptoms and loss of motion have been found up to 7 years post onset of symptoms. Generally, ROM loss of greater than 25% in at least 2 planes and passive ER loss that is great than 50% of the uninvolved shoulder or less than 30° of ER have been used to define adhesive capsulitis History Diagnosis Insidious onset of progressive, diffuse shoulder pain and stiffness. Pain predominates early in the course of the disease Night pain often interrupts sleep. Debilitating pain: achy at rest, sharper with movement, and poorly localized. Muscle spasm/pain in the neck, shoulder, acromioclavicular joint, and posterior thorax due to scapular overcompensation. Stiffness predominates as pain begins to wane in later stages of disease. Difficulties with activities of daily living (ADLs) (grooming, dressing). Inability to reach overhead or into back pocket Weakness Preceding injury, illness, or immobilization (secondary FS)  “Physical Exam” In the painful/freezing phase: There is guarded motion and protective muscle spasm during ROM testing (An empty end feel).  In the frozen adhesive phase Limited active and passive shoulder range of motion (ROM) in >1 plane of motion(capsular end feel) Diffuse shoulder tenderness with deep palpation Loss of natural arm swing with gait Accessory motions are also limited especially anterior and inferior glide of the glenohumeral joint. Also lateral distraction which stress the entire capsule are limited.  Adaptive muscle shortening due to the pattern of restricted motion which includes the shoulder held in “adduction and internal rotation” Tightness of 1. pectoralis major 2. Latissimus dorsi 3. Teres major Apley scratch test is positive-QUIK TEST Quick-test Reaching across the body to the other shoulder to determinerRa nge of motion. Reaching behind the back to palpate the highest spinous process to determine Range of motion.  Stretch weakness: due to protracted shoulder: 1. The middle and lower trapezius 2. Rhomboids This muscle imbalance adds additional stress to the capsule and associated structures such as rotator cuff muscles and the subacromial bursa. Special tests (Neer, Hawkins, etc.) are not diagnostic. No neurovascular deficits. Examine:  Differential Diagnosis ❑Rotator cuff strain/tear/impingement syndrome ❑GH or acromioclavicular joint osteoarthritis (OA) ❑Cervical strain/radiculopathy/OA ❑Myofascial pain syndrome ❑Calcific tendonitis ❑Fracture, dislocation ❑Bony neoplasm/metastases  Investigation No lab is diagnostic for primary (idiopathic) FS. Labs may help rule out underlying systemic diseases associated with secondary FS: Hbg A1C. TSH. ESR. Plain X-Ray to rule out ✓ OA ✓Calcific tendinitis  Avascular necrosis Osteomyelitis Fracture, dislocation, and tumor Radiographs are typically normal but may demonstrate disuse osteopenia of the proximal humerus in late FS. In secondary FS, MRI demonstrates characteristic thickening of the axillary pouch and helps to rule out other shoulder disorders. Treatment of Frozen shoulder  Treatment of frozen shoulder ❑Treatment is guided by the stage of FS at presentation. ❑Conservative therapy is recommended initially (the first 4 to 6 months). ❑Therapy includes combination of physical therapy, oral medications, and joint/bursal injections ❑Structured physical therapy is superior to home exercises  Patient education should include the following: ▪Expectations for a protracted recovery (months to years) characterized by resolution of pain prior to the return of function ▪Full ROM may never be recovered; however, functional limitations are uncomon  Subacromial (SA) corticosteroid injection: At any stage, SA injection in conjunction with physical therapy provides short-term (16 weeks) benefit in pain and ROM. Intra-articular (IA) corticosteroid injection>>>>>>>>>>>>>>>> short- term (16 weeks) improvement in pain and ROM if used in conjunction with physical therapy  Manipulation under anesthesia(MUA) can be used in certain cases Surgical intervention in form of Arthroscopic capsular release (most common surgical method for treating resistant FS)  Painful/freezing phase Goals/Treatment Relieve pain; achieved by Medical treatment: NSAIDs, oral cortisone Therapeutic Modalities 1. TENS 2. Iontophoresis 3. US and Phonophoresis 4. Ice, ultrasound, HVGS. 5. Low power laser therapy. 6. Moist heat before therapy, ice at end of session. 7. Mobilization Grade I and II.  Restore Shoulder motion; achieved by ▪Controlled, aggressive ROM exercises. ▪Focus is on stretching at ROM limits. ▪No restrictions on range, but therapist and patient have to communicate to avoid injuries. Glenohumeral Distraction: Testing; initial treatment (sustained grade II); pain control (grade I or II oscillations); general mobility (sustained grade III). Glenohumeral Caudal Glide in Resting Position Increase Abduction Glenohumeral Caudal Glide increase Abduction >>>>>> progression abduction Glenohumeral Elevation Progression To increase elevation beyond 90° of abduction. Glenohumeral Anterior Glide, Resting Position To increase extension; to increase external rotation. Glenohumeral External Rotation Progressions to increase ER Glenohumeral joint: distraction for external rotation progression. Note that the humerus is positioned in the resting position with maximum external rotation prior to the application of distraction stretch force. Glenohumeral Posterior Glide, Resting Position increase internal rot. Flexion  Exercises ❑Initially focus on forward flexion and external and internal rotation with the arm at the side and the elbow at 90 degrees. ❑Active ROM exercises. ❑Active-assisted ROM exercises ❑Passive ROM exercises ❑A home exercise program should be instituted from the beginning. ❑Patients should perform ROM exercises three to five times per day. ❑A sustained stretch, of 15 to 30 seconds, at the end ROMs should be part of all ROM routines.  Frozen (fibrotic) phase: Goals/treatment 1. Pain Control; reduction of pain and discomfort is essential for recovery and this achieved via Medications NSAIDs—first-line medications for pain control. GH joint injection: corticosteroid/local anesthetic combination. Oral steroid taper—for patients with refractive or symptomatic frozen shoulder. Therapeutic Modalities Ice, Ultrasound, HVGS. Moist heat before therapy, ice at end of session. Inferior Glide With the Arm at the Side and in External Rotation  Inferior Glide in Adduction and Extension to Target Posterior- superior Capsuloligam entous- complex 2. Improve shoulder motion in all planes, improve strength and endurance of rotator cuff and scapular stabilizers>>>>>>>>>>>This is achieved through -Inferior and posterior glide of GH joint. -Self-mobilization  ““Stretching exercises”” Short wave diathermy in conjunction with stretching was found to have greater improvement compared to stretching alone or the use of superficial heat and stretching. Transcutaneous electrical nerve stimulation (TENS) together with a prolonged low load stretch resulted in less pain and improved motion in patients with FS. Combining mobility and stretching exercises with modalities, such as shortwave diathermy, US, or electric stimulation, may help reduce pain and improve ROM.  Self- stretching PASSIVE IR EXTERNAL ROTATION STRETCH IN ELEVATION Chair stretch Stretchi ng of rotator cuff interval Self-stretch of rotator cuff interval ROM EXERCISES PEDULUM FORWARD FLEXION EXTERNAL ROTATION EXTENSION INTERNAL ROTATION HORIZONTAL ADDUCTION Stick for Prolonged Elevation with External Rotation A-supine active assisted range of motion in elevation ELEVATION GRADUATION B-supine single arm elevation C-SITTING BALL ROLL BALL ROLL-ON WALL STERNGTHENING ISOMETRIC STRENGTH FOR ABDUCTORS AND ER Wall clock exercises Progress to light isotonic dumbbell exercises. Strengthening of scapular stabilizers. CLOSED CHAIN EXERCISES  Closed chain strengthening exercises of the scapula stabilizers. A, Scapular protraction. B and C, Scapular retraction Standing Quadruped Tripod Opposite knee and arm On a BAPS board On a BOSU Balance Trainer. On a stability ball D2 proprioceptive neuromuscular facilitation pattern in a tripod to produce stabilization in the contralateral support limb Rhythmic stabilization for the scapular muscles Pushups done on a Plyoball Pushups done on a stability ball Wall pushups Press-ups SLIDE BOARD STRENGTHENING EXERCISE Progress to open chain strengthening PNF Plyometric ball toss: lying supine, two-hand chest toss with “plyo” or weighted ball. Progress to unstable surface to increase level of difficulty. For example, lying on Bosu ball PROPRICEPTIVE TRAINING OF OF SHOULDER THANK YOU Prof. Dr. Nasr Awad Assistant professor, faculty of physical therapy, Sinai University