Clinical Notes : Orthopedics and Trauma

72. Frozen Shoulder

If the presenting shoulder pain is not referred from the neck then consider :

  1. Frozen shoulder

  2. Acromioclavicular joint pain

    • AC disruption

    • AC osteoarthritis

  3. Rotator cuff pain

    • Impingement

    • Tear

    • Calcific tendonitis

  4. Shoulder instability

    • SLAP tear

    • Dislocation

  5. Glenohumeral arthritis

 

Video : True shoulder pain vs referred neck pain (5:01)

Shoulder pain mapping :

 

Urgent referral if shoulder pain in the presence of :

  • History of trauma with acute pain & weakness

    • AC joint tear or displacement

    • Rotator cuff tear

  • History of trauma or epileptic fit leading to loss of rotation

    • SLAP tear

  • History of instability or subluxation

    • Dislocation

  • Mass/swelling/erythema

    • Infective process

Video : Complete shoulder examination for the GP (3:39)

 

Frozen Shoulder

 

In frozen shoulder (adhesive capsulitis)  the capsule of the shoulder joint becomes inflamed, thickened and scarred, causing pain and stiffness of the shoulder.

  • occurs in about 2-5% of the population

  • most commonly in those aged 40 to 60 years old

  • more often in postmenopausal women

 

Etiology

  • often unidentifiable

  • after injury

  • after surgery

  • after prolonged immobility

  • more common in diabetes and hyperthyroidism

 
 

Diagnosis :

There are usually three phases of a frozen shoulder:

  • Freezing:

    • This phase lasts for between 6 weeks to several months.

    • The shoulder also gradually gets very stiff and loses most of its range of motion

    • Pain

      • gradual onset that becomes progressively worse

      • usually aching in nature and felt over the back and outer shoulder area and down the arm.

      • aggravated by trying to move the shoulder

      • can be extremely severe and cause sleepless nights.

  • Frozen:

    • This phase lasts for approximately 6 months.

    • Pain itself may get better but the stiffness remains.

  • Thawing:

    • The stiffness slowly improves.

    • Complete recovery back to normal, or near normal strength and range of motion takes up to a further 2 years.

Xray to exclude arthritis

MRI to demonstrate fluid or synovitis

Video : Frozen shoulder examination (1:26)

 

Management :

Although frozen shoulder usually gets better by itself over the course of 3 years, the symptoms are often severe enough to require treatment.

The main aim of treatment is to relieve the pain and maintain and restore the range of motion

  • Non-surgical

    • NSAIDs

    • stretching excercises

    • physio, including Transcutaneous Electrical Nerve Stimulation (TENS)

    • steroid injection

  • Surgical

    • Capsule stretching under anaesthesia

    • arthroscopic release

 

Video : Frozen shoulder stretch excercises (4:08)

 
 
journals.png

The pathology of frozen shoulder.

Hand GC, Athanasou NA, Matthews T, Carr AJ. J Bone Joint Surg Br. 2007;89:928–932

Access

 

Adhesive capsulitis: a review of current treatment.

Neviaser AS, Hannafin JA: Am J Sports Med, 2010, 38: 2346–2356.

Access

 

Frozen shoulder—a stiff problem that requires a flexible approach.

Guyver PM, Bruce DJ, Rees JL: Maturitas, 2014,78: 11–16

Access

 

The natural history of idiopathic frozen shoulder: a 2- to 27-year followup study.

Vastamäki H, Kettunen J, Vastamäki M: Clin Orthop Relat Res, 2012, 470: 1133–1143

Access

 

Effectiveness of sustained stretching of the inferior capsule in the management of a frozen shoulder.

Paul A, Rajkumar JS, Peter S, et al. : Clin Orthop Relat Res, 2014, 472: 2262–2268.

Access

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