Introduction Description condition of the shoulder characterized by functional loss of passive and active shoulder motion with no clear underlying cause Epidemiology demographics more common among women ages 40-60 years Pathophysiology mechanism of injury primary, idiopathic form post-traumatic (following proximal humerus fracture or immobilization for other upper extremity injury) post-surgical (following rotator cuff repair or axillary dissection for malignancy) pathoanatomy inflammatory process causing fibroblastic proliferation of joint capsule leading to thickening, fibrosis, and adherence of the capsule to itself and humerus fibroblasts/myofibroblasts with abundant Type III collagen present leads to mechanical block to motion essential lesion involves the coracohumeral ligament and rotator interval capsule Associated conditions diabetes (both types) stiffness may be first manifestation of diabetes and warrants further workup worse outcomes regardless of treatment increased risk with older age, increased duration of DM, autonomic neuropathy, history of MI thyroid disorders (autoimmune etiology) dupuytren's disease atherosclerotic disease cervical disc disease Prognosis self-limited disease worse outcomes among diabetics Anatomy Capsuloligamentous structures function contribute to stability of the glenohumeral joint act as check reins at extremes of motion in their non-pathologic state glenohumeral ligaments superior glenohumeral ligament (SGHL) middle glenohumeral ligament (MGHL) inferior glenohumeral ligament (IGHL) complex with the following components anterior band axillary fold posterior band Rotator interval a triangular region between the anterior border of supraspinatus and the superior border of subscapularis contains the SGHL and coracohumeral ligament Classification Clinical Stages Freezing/Painful Gradual onset of diffuse pain (6 wks to 9 mos) Frozen/Stiff Decreased ROM affecting activities of daily living (4 to 9 mos or more) Thawing Gradual return of motion (5 to 26 mos) Arthroscopic Stages Stage 1 Patchy, fibrinous synovitis Stage 2 Capsular contraction and fibrinous adhesions Stage 3 Increasing contraction, synovitis resolving Stage 4 Severe contraction Presentation Symptoms common symptoms often insidious onset of general shoulder pain preceding any noticeable loss of motion variable character and severity of pain, loss of motion dependent on the stage of disease at presentation freezing- insidious onset of pain at rest and with movement, difficulty sleeping frozen- pain lessens but significant motion limitations affecting ADLs thawing- pain is gone and motion improves but less than normal Physical exam inspection note any muscle atrophy or scars denoting prior surgery motion symmetric loss of active and passive ROM document all motion planes and compare to contralateral side limitations in motion may be slight, external rotation deficit most common finding tethered endpoint to motion pain throughout motion arc or at terminal motion depending on stage of disease provocative tests impingement, biceps, and SLAP maneuvers often positive rotator cuff testing may be limited given loss of motion Studies Metabolic panel and endocrine labs (TSH, A1c) Imaging Radiographs recommended views AP in neutral rotation scapular-Y axillary lateral alternate views AP in internal and external rotation findings disuse osteopenia must be obtained to evaluate for osteoarthritis, posterior dislocation, or surgical hardware MRI +/- arthrography indications not necessary for diagnosis but can evaluate for other pathology findings loss of axillary recess indicates contracture of joint capsule Treatment Nonoperative physical therapy, NSAIDs and/or intra-articular steroid injections, heat and/or cryotherapy indications first-line treatment, often effective physical therapy program of gentle, pain-free stretching and moist heat should be supervised and last for 3-6 months distension arthrography rarely performed Operative manipulation under anesthesia (MUA) indications failure to improve with non-operative modalities contraindications controversial if done during freezing/inflammatory phase diabetics- 50% failure rate following rotator cuff or labral repair arthroscopic or open capsular release indications after extensive therapy has failed (3 months) arthroscopy will spare subscapularis tendon with the advantage of releasing intra-articular and subacromial adhesions Techniques Physical therapy daily progressive stretching exercises to point of pain supervised or home-based programs successful for overwhelming majority Manipulation under anesthesia assess and document pre-procedure range of motion anesthesia complete muscle paralysis required in-dwelling catheter for regional anesthesia often used to aid in therapy manipulation steady force applied after full muscle paralysis achieved postoperative early physical therapy program initiated complications fracture, dislocation, rotator cuff and labral tears brachial plexus palsies Arthroscopic capsular release assess and document pre-procedure range of motion anesthesia in-dwelling catheter for regional anesthesia often used to aid in therapy approach standard skin incisions with portal placement slightly higher than normal given contracted and thickened capsule release intra-articular structures may be obscured by adhesions and contractures rotator interval released from anterior biceps tendon to superior edge of subscapularis coracohumeral ligament can then be visualized and released posterior capsular release will increase IR and cross-body adduction subacromial bursectomy and adhesions released as needed, no acromioplasty done manipulation MUA may be done before or after release to increase to range of motion postoperative early physical therapy program initiated Complications Residual stiffness Axillary nerve injury with capsular release perform inferior release near to glenoid rim Proximal humerus fracture, dislocation, rotator cuff tears or brachial plexopathy following overzealous manipulation with osteoporotic bone
QUESTIONS 1 of 17 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.165) The right shoulder exercise seen in Figure A will put the LEAST amount of stretch on which structure? Tested Concept QID: 4800 FIGURES: A Type & Select Correct Answer 1 Inferior glenohumeral ligament 20% (850/4271) 2 Coracohumeral ligament 2% (97/4271) 3 Anterior-superior capsule 6% (272/4271) 4 Superior glenohumeral ligament 6% (266/4271) 5 Posterior capsule 64% (2740/4271) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (OBQ12.71) Which of the following patients is most likely to have a fibroblastic proliferative process as a cause for their shoulder complaints? Tested Concept QID: 4431 Type & Select Correct Answer 1 65-year-old man with giant cell arteritis and bilateral shoulder pain and stiffness. 8% (394/5017) 2 40-year-old man with a history of podagra who now has acute shoulder pain. 2% (107/5017) 3 50-year-old woman with hypothyroidism and loss of both active and passive shoulder motion. 76% (3819/5017) 4 65-year-old woman with ulnar drift of the fingers and shoulder pain and stiffness. 5% (275/5017) 5 40-year-old woman with antinuclear antibodies with knee and shoulder pain 7% (372/5017) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ11UE.106) A 60 year-old diabetic man presents with increasing right shoulder pain and stiffness for 10 weeks. He works as a lawyer and has been treating the pain with non-steroidal anti-inflammatory drugs with little improvement. He had a previous injury to his right shoulder 15 years ago while playing hockey, but cannot recall any recent precipitants for this presentation. Physical examination shows significant reduction in right shoulder range of motion, with the greatest loss in external rotation. His MRI images are seen in Figures A-C. What would be the most appropriate treatment? Tested Concept QID: 4341 FIGURES: A B C Type & Select Correct Answer 1 Open supraspinatus cuff repair 1% (25/4168) 2 Arthroscopic supraspinatus cuff repair 4% (177/4168) 3 Reverse shoulder arthroplasty 2% (74/4168) 4 Arthroscopic posterior capsular release 2% (96/4168) 5 Physical therapy and medical management 90% (3734/4168) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (SBQ11UE.31) A 45-year-old patient with a history of diabetes presents with increasing shoulder stiffness over the course of the past several months. She has tried non-steroidal anti-inflammatory drugs, but they have not alleviated her pain. On examination she has global pain with passive range of motion, forward elevation of 100 degrees, external rotation to neutral, and internal rotation to her iliac crest. Radiographs of the shoulder are normal. An MR arthrogram is most likely to show which of the following? Tested Concept QID: 4266 Type & Select Correct Answer 1 Massive retracted rotator cuff tear 2% (141/5651) 2 Proliferative synovial process with hypertrophied synovium and extensive papillary projections 12% (679/5651) 3 Decreased intra-capsular volume 83% (4703/5651) 4 Subscapularis tear with long head of the biceps subluxation 1% (75/5651) 5 Fluid extravasation down the humerus 0% (26/5651) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ10.68) A 42-year-old female presents to your office with pain in the shoulder that has been present for 1 month, and she notes the shoulder is also becoming stiff. She has not previously sought treatment. After a full evaluation, you determine she has adhesive capsulitis, and is in the early stiffening stage. What treatment do you recommend? Tested Concept QID: 3158 Type & Select Correct Answer 1 Immediate aggressive therapy for active-assisted and passive range of motion exercises 31% (943/3021) 2 Platelet-rich plasma (PRP) injections 5% (148/3021) 3 Arthroscopic lysis of adhesions and bursectomy 1% (17/3021) 4 Reassurance and a gentle stretching program as symptoms allow 62% (1879/3021) 5 Manipulation under anesthesia 1% (23/3021) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (SBQ06BS.44) Which of the following statements is true regarding the anatomical boundaries of the rotator interval in the shoulder? Tested Concept QID: 2556 Type & Select Correct Answer 1 Superior border is defined by the biceps long head tendon 7% (52/731) 2 Inferior border is defined by anterior band of inferior glenohumeral ligament 6% (41/731) 3 Contains the axillary pouch which is a common site for intra-articular loose bodies 2% (12/731) 4 Superior border is defined by anterior edge of suprapinatus tendon 72% (529/731) 5 Inferior border is defined by middle glenohumeral ligament 7% (54/731) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ05.5) Which of the following is a known risk factor for the development of adhesive capsulitis of the shoulder? Tested Concept QID: 42 Type & Select Correct Answer 1 Menopause 1% (12/1946) 2 Steroid use 0% (7/1946) 3 Diabetes mellitus 62% (1212/1946) 4 Renal disease 1% (12/1946) 5 All of the above 36% (700/1946) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept (SBQ05UE.87) Which of the following is the most common outcome following non-operative management of adhesive capsulitis with a stretching program? Tested Concept QID: 1872 Type & Select Correct Answer 1 Functionally limiting pain 8% (78/967) 2 Decreased range of motion compared to contralateral shoulder 75% (721/967) 3 Recurrence of adhesive capsulitis 14% (133/967) 4 Need for operative intervention 1% (13/967) 5 Development of rotator cuff arthropathy 2% (18/967) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept
All Videos (4) Podcasts (1) Login to View Community Videos Login to View Community Videos 2017 Orthopaedic Summit Evolving Techniques Case Presentations with Questions and Answers - Moderator: Brian J. Cole, MD, MBA & Claude T. Moorman, III, MD Shoulder & Elbow - Adhesive Capsulitis (Frozen Shoulder) B 5/21/2018 327 views (1) Login to View Community Videos Login to View Community Videos 2017 Orthopaedic Summit Evolving Techniques My Shoulder is Stiff: I Would Rather Be Weak Than Stiff Doc, I Am Not Happy - Felix H. Buddy Savoie, III, MD Felix H. "Buddy" Savoie III Shoulder & Elbow - Adhesive Capsulitis (Frozen Shoulder) A 5/18/2018 714 views (3) Login to View Community Videos Login to View Community Videos 2017 Chicago Sports Medicine Symposium: World Series of Surgery Shoulder Capsular Release - Geoffrey S. Van Thiel, MD, MBA (CSMS #72, 2017) Shoulder & Elbow - Adhesive Capsulitis (Frozen Shoulder) B 11/16/2017 280 views (4) Shoulder & Elbow⎜Adhesive Capsulitis (Frozen Shoulder) Team Orthobullets 4 Shoulder & Elbow - Adhesive Capsulitis (Frozen Shoulder) Listen Now 14:32 min 10/21/2019 308 plays (6) See More See Less