Clinical Notes : Orthopedics and Trauma
72. Frozen Shoulder

If the presenting shoulder pain is not referred from the neck then consider :
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Frozen shoulder
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Acromioclavicular joint pain
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AC disruption
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AC osteoarthritis
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Rotator cuff pain
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Impingement
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Tear
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Calcific tendonitis
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Shoulder instability
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SLAP tear
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Dislocation
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Glenohumeral arthritis
Video : True shoulder pain vs referred neck pain (5:01)
Shoulder pain mapping :

Urgent referral if shoulder pain in the presence of :
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History of trauma with acute pain & weakness
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AC joint tear or displacement
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Rotator cuff tear
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History of trauma or epileptic fit leading to loss of rotation
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SLAP tear
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History of instability or subluxation
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Dislocation
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Mass/swelling/erythema
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Infective process
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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.
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occurs in about 2-5% of the population
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most commonly in those aged 40 to 60 years old
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more often in postmenopausal women
Etiology
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often unidentifiable
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after injury
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after surgery
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after prolonged immobility
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more common in diabetes and hyperthyroidism


Diagnosis :
There are usually three phases of a frozen shoulder:
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Freezing:
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This phase lasts for between 6 weeks to several months.
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The shoulder also gradually gets very stiff and loses most of its range of motion
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Pain
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gradual onset that becomes progressively worse
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usually aching in nature and felt over the back and outer shoulder area and down the arm.
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aggravated by trying to move the shoulder
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can be extremely severe and cause sleepless nights.
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Frozen:
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This phase lasts for approximately 6 months.
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Pain itself may get better but the stiffness remains.
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Thawing:
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The stiffness slowly improves.
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Complete recovery back to normal, or near normal strength and range of motion takes up to a further 2 years.
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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
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Non-surgical
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NSAIDs
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stretching excercises
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physio, including Transcutaneous Electrical Nerve Stimulation (TENS)
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steroid injection
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Surgical
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Capsule stretching under anaesthesia
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arthroscopic release
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Video : Frozen shoulder stretch excercises (4:08)

The pathology of frozen shoulder.
Hand GC, Athanasou NA, Matthews T, Carr AJ. J Bone Joint Surg Br. 2007;89:928–932
Adhesive capsulitis: a review of current treatment.
Neviaser AS, Hannafin JA: Am J Sports Med, 2010, 38: 2346–2356.
Frozen shoulder—a stiff problem that requires a flexible approach.
Guyver PM, Bruce DJ, Rees JL: Maturitas, 2014,78: 11–16
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
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.

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