Adhesive Capsulitis

(Frozen Shoulder)

Definition

• A disorder in which the shoulder capsule becomes inflamed and stiff, greatly restricting motion and causing pain.

• The etiology is unknown (injury or trauma, autoimmune).

• Characterized by progressive pain and stiffness which usually resolves spontaneously after 18 months.

• Movement of the shoulder is severely restricted, pain is worse at night.

Clinical Features

– Age 40-60, more in females– Slight wasting, some tenderness.– Pain (gradual onset)– Stiffness or decrease in motion.

• External rotation (most severely inhibited)• Internal rotation.• Abduction.

Radiology

– X-ray:• Osteoporosis of the proximal humerus (decreased bone density)

– Arthrography:• Shows a contracted joint• Dramatic decrease in the injected contrast material.• Loss of normally loose dependent folds of the capsule.

Differential Diagnosis

• Post-traumatic stiffness (maximal at the start, gradually lessens)

• Disuse stiffness• Regional pain syndrome (associated with MI, stroke)

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Treatment

self-limiting: it usually resolves over time without surgery. Movement is regained gradually but may not return to normal

Conservative: – Analgesics– Heat therapy and exercise(physiotherapy)– Corticosteroid injection.– Manipulation under anesthesia hastens recovery.

Operative Treatment– Arthroscopic division of the interval between

supraspinatous and infraspinatous (improve the range of movement).

Shoulder Instability Shoulder Instability

(Dislocation)(Dislocation)

Occurs when the humerus separates from the scapula at the glenohumeral joint.

The glenoid socket is very shallow and the joint is held secure by the fibrocartilaginous glenoid (labrum) and the surrounding ligaments and muscles.

Types

1. Anterior instability.

2. Posterior instability.

3. Multidirectional instability.

Anterior Instability• Most common. (~95%)

• 50% under 25 yrs, 50% develop recurrency (the labrum and capsule are detached from the anterior rim of the glenoid)

• Occurs as a sequel to acute anterior dislocation of the shoulder, with detachment or stretching of the glenoid labrum and capsule.

• Mechanism:– abduction, external rotation, and extension.– falling on outstretched hand, forcing the arm into abduction and

external rotation

• It can result in damage to the axillary artery.

• Recurrent dislocation – trivial trauma.– Between episodes shoulder looks normal.

Approach

– Hx: severe pain, limitation of movement, anterior bulging, Hx of trauma. This pathology limits many activities, including overhead arm motions, external rotation, and, thus, physical or athletic activities.

Examination

shoulder drawer sign• the examiner manually assesses translation of the humeral head in the

glenoid fossa. The humeral head is grasped in one hand, and the clavicle and scapula are stabilized in the other as the examiner pushes anteriorly and posteriorly.

• Compared with the unaffected shoulder, the affected shoulder often demonstrates increased laxity.

Apprehension test• The arm is placed in abduction, extension, and external rotation while

stressing it in anterior translation. If the patient becomes apprehensive and reports pain, this is considered a positive finding.

X-ray findings

– Humeral head anteriorly.

– Axial view is diagnostic. (even for sublaxation).It shows the humeral head riding on the anterior lip of the glenoid.

– AP view with the upper arm internally rotated may show Hill-Sachs lesion if recurrent.

– Rule out associated humeral neck fracture.

Hill-Sachs lesion :• Depression in the posteriolateral part of the humeral head.• Caused by recurrent forcing of the head of humerus against the anterior

glenoid rim (damage to the bone)

MRI :

• The Bankart lesion (detached glenoid labrum) • Deformity of the humeral head

• MRI of anterior inferior

labral tear

• Hill-Sachs LesionHill-Sachs Lesion

TreatmentTreatment

Reduction:• Most techniques are facilitated by the following 2 maneuvers:

– Flexion of the elbow 90° to relax the biceps tendon

– External rotation of the humerus, which releases the superior glenohumeral ligament and presents the favorable side of the humeral head to the glenoid fossa

• Signs of a successful reduction include the following:

– Palpable or audible clunk

– Return of rounded shoulder contour

– Relief of pain

– Increase in range of motion

• Stimson Maneuver, Scapular Manipulation, External rotation method, Traction and counter traction

Surgery

• Indications:– Frequent dislocations, esp if painful

– A fear of recurrent dislocation sufficient to prevent participation in everyday activities.

• Types of operation:– Re-attachment of the glenoid labrum (Bankart)

– Shoretening and tightening of the anterior capsule and muscles (Putti-Plat)

– Reinforcement of the antero-inferior capsule using adjacent muscles (Bristow)

Posterior InstabilityPosterior Instability

• Rare (5%)

• Due to violent jerk in an unusual position

• If recurrent, it is almost always a sublaxation, with the humeral head riding back on the posterior lip of the glenoid.

• Mechanism:– Abduction, flexion, and internal rotation.

• Etiology:– Direct trauma.

– Epileptic seizure, Electric shock.

• Pathology is the same as the anterior one but the capsule is torn posteriorly.

• Approach same as anterior dislocation.

• Diagnosis:– X-rays

– CT scans

• Treatment:– Reduction

(Apply gentle, prolonged axial traction on the humerus. Then add gentle anterior pressure while coaxing the humeral head over the glenoid rim. Slow external rotation may be needed)

– Conservative muscle strengthening exercises and voluntary control of the joint

– Surgery indicated only if disability is marked and there is no gross joint laxity.

Multidirectional InstabilityMultidirectional Instability

• Associated with capsular and ligamentous laxity, and sometimes with weakness of the shoulder muscles.

• The patient complains of the shoulder going out of the shoulder with remarkable ease.

• Alternating episodes of anterior and posterior sublaxation or dislocation.

• Muscle strengthening exercises and training in joint control are helpful.

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Good luck tomorrow!Good luck tomorrow!

Done by:

Athar shibli