The Stiff Shoulder My Thoughts on Assessment and Management of Shoulder Stiffness

The Stiff ShoulderMy Thoughts on Assessment and Management of Shoulder StiffnessMike WaltonConsultant Shoulder Surgeon

What is Stiff?Patient - I cant move my shoulder as well cos it hurtsUs - Reduction in active and passive glenohumeral joint movement compared to the contralateral side

4 NsNeck (or neural)Near normal movement - pain inhibition Not moving - true stiffness Nasty (Infection, Malignancy)

NeckRadicular pain - extending below elbow, occasionally medial scapula (c3/4)Neuralgic amyotrophy - wasting, pain ++Shoulder should be painfree to passive ROMCan occur in combination

Nearly Normal MovementPain Inhibition Calcific tendinitis Cuff tendinopathy / ImpingementCuff Muscle Stiffness - Ginn et al

True StiffnessReduction in Passive and active glenohumeral joint movementLimitation due to bony abnormalityOsteoarthritisMissed DislocationSoft tissue contracture - Frozen Shoulder"

True StiffnessReduction in Passive and active glenohumeral joint movementLimitation due to bony abnormalityOsteoarthritisMissed DislocationSoft tissue contracture - Frozen Shoulder"Easy to Diagnose on Xray

NastyNight and Unremitting painRed flagshistory of malignancyunexplained weight loss

NastyNight and Unremitting painRed flagshistory of malignancyunexplained weight loss

AssessmentHistory - speed of onset, trauma, ageExaminationLoss of Passive ERXray!!

Atraumatic Stiffness

Traumatic Stiffness

Frozen ShoulderCapsular Contractioncoracohumeral ligamentAnterior / Deep painLoss of External RotationHard end point Normal Xray

Frozen Shoulder

Aims of Treatment

Relieve PainRestore MovementRegain Function

Natural HistoryMost cases recover within 2 years50% 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 BoneJoint Surg [Am] 1992;74-A:738746

Treatment OptionsPhysiotherapySteroidsVolume Hydrodilatation / Distention ArthrographySurgery

PhysiotherapyRecent CSP Guidelines Passive Mobilisation Capsular StretchingGroup Classes - Russell et al 2014May be counter productive in painful phase

PhysiotherapyInterventionsUltrasound, Interferential, TENS, pulsed electromagnetic stimulation etcVery limited scientific evidenceMay possibly sometimes be useful on a individual patient basis (CSP Guidelines)

PhysiotherapyESSENTIAL post surgical intervention

SteroidsCommonly prescribed PO and IACochrane and Meta-analysesGood short to medium term benefit but doesnt appear to be sustainedMay get rebound

Volume HydrodilatationSmall numbers of studiesCase series and quasi RCTsSome conflicting dataCochrane Review (2008)Good short term relief - Silver levelUncertain whether better than alternatives

Volume HydrodilatationWrightington data:76% improved ROM at 3 months91% improved Pain at 1 year

Especially primary idiopathic frozen shoulder

Volume Hydrodilatation

SurgeryMUAArthroscopic Capsular ReleaseOpen Capsular Release

MUAI dont perform this in isolationSeveral good studies showing excellent long term outcomeShort lever-arm sequential manipulationUncontrolled technique

Capsular ReleaseArthroscopicEUA pre-op - always stiff ? Ginn et alAllows systematic evaluation of the jointControlled release of contracted capsule and ligaments

Capsular Release

Capsular Release

Capsular ReleaseCheck ROM peri-op

Capsular ReleaseOpenMore limited visualisation of capsuleDifficult to address posterior capsuleMay lengthen subscapularisIndicated post surgery particularly to release subdeltoid adhesions

What I Tell Patients...It will usually get better if we do nothingIntervention will hopefully speed up recoveryVolume hydrodilatation is less invasive but may have a higher rate of recurrence Arthroscopic capsular release more invasive but may have a better chance success

ArthritisLoss of articular cartilageBone on bone articulationPainStiffOsteophytes

ArthritisCuff IntegrityIntact - Anatomic arthroplastyHemiarthroplastyTotal Shoulder ReplacementTorn / Dysfunctional - Reverse Replacement

Cuff Function

SuperiorDeltoidRotator CuffAcromionHumeral HeadGlenoid

Cuff Function

SuperiorDeltoidRotator CuffAcromionHumeral HeadGlenoid

Cuff Dysfunction

SuperiorDeltoidRotator CuffAcromionHumeral HeadGlenoid

Cuff Dysfunction

SuperiorDeltoidRotator CuffAcromionHumeral HeadGlenoid

Cuff Dysfunction

SuperiorDeltoidRotator CuffAcromionHumeral HeadGlenoid

Cuff Dysfunction

SuperiorDeltoidRotator CuffAcromionHumeral HeadGlenoid

Cuff Dysfunction

SuperiorDeltoidRotator CuffAcromionHumeral HeadGlenoid

Cuff Dysfunction

SuperiorDeltoidRotator CuffAcromionHumeral HeadGlenoid

Reverse

Reverse

SummaryGood HistoryAssess passive ERGet an XrayAbnormal - Nasty, Calcific Tendintis, OANormal - Frozen Shoulder