Adhesive Capsulitis/Stiff Shoulder Notes
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| Main difference between true adhesive capsulitis & stiff/painful shoulder | True adhesive capsulitis will have a capsular pattern; stiff/painful shoulder may not
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| Causes of Adhesive Capsulitis | Contractures of intra-articular capsule or mm-tendon units
Scar tissue bt tissues that normally move against one another easily
Adhesions within extra-articular humeroscapular or scapulothoracic motion interface
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| Stiff & Painful Shoulder | Painful
Limited motion
No true capsular pattern of restriction
Motion lmited by pain/stiffness only
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| History & Physical Exam in Stiff Shoulder | Onset more acute & severe
Repetitive OH activity or trauma
No mechanical restriction, just pain at end range
With frozen shoulder there should be a mechanical stop to capsular contracture
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| Pathology of Frozen Shoulder | Inflammatory rxn in capsule & synovium that subsequently leads to formation of adhesions, specifically in the axillary fold & attachment of capsule at anatomic neck of humerus
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| Primary (Idiopathic) Frozen Shoulder | No known precipitating event
Immunologic, inflammatory, biochemical, endocrine alternations
2-3% US population; women>men; 50-70 y.o.; NOT preferential to handedness; could occur bilaterally
More common in sedentary people
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| Secondary Frozen Shoulder | Associated with or attributed to other illness/events
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| Intrinsic Secondary Frozen Shoulder causes | AC joint arthritis
RTC tendonitis/tear
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| Extrinsic Secondary Frozen Shoulder causes | Cardiac disease/surgery
Neuro disorders with impaired consciousness/hemiplegia
Pulmonary disease
Shoulder trauma/humeral fx
Cervical radiculitis
Personality disorders
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| Which 2 disease states are frozen shoulders more common in? | Thyroid Disease
Diabetes
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| Pre-Adhesive/Freezing Phase | Little/no limitation of motion
Fibrinous synovial inflammatory rxn detectable by arthroscopy
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| Painful/Freezing Phase | 10-36 wks long
Severe pn
Disturbs sleep
Diminution of articular/capsular volume
Proliferative synovitis & early adhesion formation (adhesions well into dependent axillary fold & extend to humeral head)
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| Stiffening/Frozen Phase | 4-12 months long
Pain usually decreases gradually but w/o appreciable improvement in ROM
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| Thawing Phase | 12 months-years long (avg. 5-26 months)
Gradual return of motion
May be directly related to duration of painful stage
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| What is the total course of frozen shoulder? | 1-4 years
Most pts have residual s/sx years after onset
S/sx rarely interfere with work/ADLs
Mild loss of ER/abd ROM
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| Key Features of Diagnosis | Sub-acute onset of unilateral shoulder pn
Little-no trauma/overuse
Limited AROM/PROM
Endpoint leathery, occurs earlier than normal
Pain with rest & activity
Can't sleep
Pain over biceps groove (overcompensation)
Pain into C5 derm at insertion of de
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| What is the reason patients usually seek medical help? | Limited ROM
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| Acute Findings | Protective of involved limb
Motion guarded
Arm held in add/IR
Protected mm spasm
ROM difficult to assess b/c of pain/guarding
Substitution patterns
Empty end feel due to pain
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| Sub-Acute/Chronic Findings | *Motion Restriction
Substituting scapular for GH mvmt
May need scapular stab
Overuse of upper traps
Atrophy- RTC, delts, tris, bis
Tender biceps groove
Ssn/reflexes normal
MMT- weak/asymptomatic at end range
Tight ant/inf capsule- loss of ER/abd
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| Humeroscapular Motion Interface | All GH motion accompanied by gliding of biceps in bicipital groove
ST jt responsible for ~1/3 shoulder ROM
Loss of scapular motion = overall decreased ROM
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| Treatment | Frozen shoulder is self-limiting
No standard tx regimen universally accepted
PT, Rest, analgesia, ROM ex's; Prednisone; Corticosteroid injections
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| Capsular Distention | Injection of fluid into shoulder joint to stretch out capsule
Shoulder may tighten up again afterward
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| Manipulation under anesthesia | Works well
~12 wks before feeling much better, very painful procedure
Risk of iatrogenic fx, GH dislocation, RTC tear, nerve injuries
Surgical capsular release
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| Plastic Deformation | Microtrauma at cellular level breaking the cross-links of the peri-articular connective tissue & elongating actual collagen bundles
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| Phase I Rehab | Decrease pn & inflammation
Exercise in pain-free ROM
AAROM & PROM ex's
Don't allo shoulder shrug (impingement)
HEP done 10-12x/day (more is better)
Heat application
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| Circle Concept | Round capsule surrounding shoudler; if you injure something on one side, you'll probably injure something on the other side
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| Phase 2- Transitional Phase | Decrease pn & inflammation
More aggressive ROM/mobs
HEP 10x/day
Continue heat followed by slightly more aggressive mobs
Avoid vigorous forceful ex's to limit exacerbation
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| Phase 3- Light Phase | ROM HEP 4-6x/day
LLLD stretching- 60 mins total of TERT to stretch out mm/capsule
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| Phase 4- Maintenance Phase | Stretch 3-5x/day
AAROM
Self capsular stretches
RTC program
Monitor ROM progression
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| Keys to Recovery | Compliance is critical
Avoid immobilization
Avoid over-aggressive ex's
Gradual & steady progression rather than rushed & hurried
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