FROZEN SHOULDER

PRESENTED BY : Dr.Akash
Kazmi
HO , FGPC
orthopedics department

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 INTRODUCTION
`
HISTORICAL PERSPECTIVE
ANATOMY
PHYSICAL EXAMINATION
ETIOPATHOGENESIS
CLINICAL FEATURES AND DIAGNOSIS
INVESTIGATIONS
TREATMENT
RECENT ADVANCES

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 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
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 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

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 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
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ADDUCTION: 0 to 50
degrees

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ABDUCTION: 0 to 170
degrees

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FORWARD FLEXION: 0 to 165
degrees

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EXTENSION: 0 to 60 degrees

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INTERNAL ROTATION(in extension):
0 to 70 degrees

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INTERNAL ROTATION( in abduction): 0
to 70 degrees

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EXTERNAL ROTATION( in abduction):
0 to 100 degrees

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 EXTERNAL ROTATION(in
extension):0 to 70 degrees

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 ETIOPATHOGENESIS
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

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 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
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 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

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 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

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 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

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 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 26
 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)

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 Limitation of passive ROM shows a
CAPSULAR pattern: external
rotation> abduction> internal
rotation
External rotation < 45 degrees
Abduction <80 degrees
Internal rotation <70 degrees

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 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.
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 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
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 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 31
 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.
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 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 35
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 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
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 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 38
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

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 .

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
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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.
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 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 42
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 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 44
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 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

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 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 48
 .
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.

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 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
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 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
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 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.

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 .
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

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 REFERENCES
Tureks Orthopaedics: Principles and
their application: 6th edition
Campbells operative orthopaedics:
12th Edition
Mercers Textbook of orthopedics and
trauma: 9th edition
Advanced Arthroscopy: James C.
Chow: 3rd edition

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