Frozen Shoulder

Definition 

 

Idiopathic inflammatory condition

- characterised by progressive shoulder pain & stiffness

- due to contracture of capsuloligamentous structures

- spontaneously resolves 

 

Epidemiology

 

2% incidence

- 40 - 60 years

- Women 2:1

 

Sedentary workers

- Non-dominant limb

 

Bilateral in 10 - 40%

 

Aetiology

 

Primary

- Unknown

- ? Autoimmune theory

 

Associations 

- diabetes - 35% IDDM > 10yrs

- yhyroid disorders

- stroke

- MI

- cardiac surgery

- neurosurgery

- dupuytren's

 

Not Associated with

- OA

- Cuff Pathology

 

Secondary

 

Intrinsic

- post surgery i.e. RC

- trauma i.e. SNOH, stabilisation

- immobilisation

 

Extrinsic

- cervical radiculopathy

- axillary node clearance

- long period immobilisation

 

Classification Neviaser

 

Each lasts 4-8 months

 

1.  Freezing

- painful stage

- capillary proliferation, synovial hypertrophy

- develop capsular adhesions

 

Shoulder Arthroscopy Frozen Shoulder

 

2.  Frozen

- decreasing pain, increasing stiffness

- maturation and development capsular contractures

 

3.  Thawing

- decreasing stiffness

 

Pathology

 

Neviaser described pathology of frozen shoulder 

- contracture of capsuloligamentous structures

- inflammation followed by fibrosis

 

Cellular basis poorly understood

- a dense matrix of type 1 and II collagen

- laid down by fibroblasts and myofibroblasts

 

1° Frozen Shoulder

 

Initial synovitis of unknown cause results in

- intra-articular adhesions

- capsulitis

- obliteration of inferior axillary fold

 

Subsequent development of

- subacromial adhesions

- rotator cuff contracture

 

Eventually spontaneous resolution

 

2° Frozen Shoulder

- much less synovial inflammation

- 2° due to either intrinsic or extrinsic cause

 

Natural History

 

Traditionally thought to be benign & self-limiting

 

Grey 1978

- 24/25 resolved by 2 years 

- Maximum 10 years

 

Most have no significant symptoms or functional restriction

- But not as benign as previously thought

 

Reeves 1975

- 60 % have residual decreased ROM 

- usually limitation ER

- only 6% claimed functional disability

 

Shaffer 1992

- 50% pain or stiffness at mean 7 years

- never more than mild with little functional disability

 

History

 

Insidious onset /  No history of trauma

 

Pain

 

Initially 

- at site of deltoid insertion

- at extremes of motion

 

Becomes more

- diffuse / severe / constant

- interferes with sleep

 

Then begins to decrease

- rest pain disappears

- pain only on movement

 

Stiffness

 

Develops after onset of pain

Difficulty reaching

- overhead

- behind back

 

Examination

 

Muscle atrophy

 

No point tenderness

 

Markedly decreased ROM

- abduction

- ER classically

- limited GH movement, increased ST movement

 

Frozen Shoulder Reduced ER

 

DDx Causes of reduced ER

1. Frozen shoulder

2. OA

3. Unreduced posterior dislocation

 

Pain on forced movement

- most sensitive indicator is pain on forced ER

 

Xray

 

Normal

 

Arthrogram / MRA

 

1. Reduced volume

- <10 ml of contrast can be injected

- normal = 20-30 ml

2. Obliterated axillary capsular recess

3. Thickened capsule

 

Management

 

Goals

- Relieve pain

- Restore range

- Remove secondary cause

 

Non Operative

 

Reassurance as first treatment

 

Careful explanation of 

- nature of disease

- NHx

- reassurance

 

Algorithm

 

Freezing Phase

- directed towards pain relief

- simple Analgesics / NSAID

- sling / ice / TENS

- intra-articular HCLA

- avoid physio as makes it more painful / doesn't increase ROM

 

Frozen Phase

- encourage hand use to avoid RSD

 

Thawing Phase

- gentle ROM & strengthening 

- consider intervention if prolonged / major functional disability

 

HCLA

 

Lorbach et al J Should Elbow Surg 2010

- compared oral corticosteroids to 3 doses of intra-articular corticosteroids

- best ROM and pain relief in intra-articular group although both effective

 

Operative Options

 

1.  MUA

 

Timing

- at least after 6/12

- in late frozen or early thawing  phases

 

Contra-indications 

- osteopenia

- previous fracture or surgery

- history instability

 

Complications

- fractures & dislocations

- cuff tears

- increased inflammation & scarring

 

Technique (Neviaser)

- GA or interscalene block

- confirm diagnosis with MUA (i.e. limited ROM)

 

1.  Abduction first

- gentle, 2 fingers

- sensation of tearing is the axillary fold tearing

 

2.  Rotation second

- must avoid fracture

- IR / ER in abduction

 

3.  HCLA +/- hydrodistension

 

Post-op physio

 

Results

 

Weber Clin Rheum 1995

- average 6 months post diagnosis

- 73% full recovery

- needed 6 weeks off work

 

2.  Hydrostatic Distension

 

Technique

- needle into GHJ under LA

- joint forcefully distended by injection

- 5 ml LA

- 1 ml steroid

- up to 40 ml Saline

- distension till capsular ruptures 

- sudden drop in resistance

- immediate post-op physio

 

Results

 

Rydell Clin Orthop 1992

- 22 patients

- 15 months

- MUA + hydrodistention + steroids

- 91% no or slight pain at 6 weeks

- 83% normal or almost normal ROM

 

Jacobs J Should Elbow Surg 2009

- 53 patients randomised to either MUA or steroid hydrodistention

- 2 year follow up

- no difference in two group

 

Quraishi et al JBJS Br 2007

- randomised trial of MUA v hydrodistention

- improved ROM in both groups

- more patients satisfaction and better shoulder scores in hydrodistention

 

3.  Open Release

 

Ozaki et al 1989 JBJS Am 1989

- one of first papers

- open release CH ligament and RC interval

- mean of 10 months post diagnosis

- MUA as part of procedure

- 94% relief of pain and complete ROM

 

Segmuller et al J Should Elbow Surg 1995

- released inferior and middle GH ligaments

- 24 patients

- 88% satisfied

- 76% normal function

 

4.  Arthroscopic release

 

Diagnosis

- +++ synovitis

- very tight shoulder to arthroscope

- capsule very thick

- very limited ROM

 

Arthroscopy Frozen Shoulder Synovitis

 

Technique

 

1.  Release rotator interval

- remove all tissue in between biceps and SSC

 

Frozen Shoulder Interval Release 1Frozen Shoulder Interval Release 2

 

2.  Release anterior IGHL

- from 3 o'clock down to 5 o'oclock

- leave labrum intact / anterior to labrum

- release inferior capsule with scissors / 6 o'clock

 

Frozen Shoulder MGHL ReleaseFrozen Shoulder IGHL ReleaseFrozen Shoulder Release IGHL Complete

 

Frozen Shoulder Inferior Release with scissors

 

3.  Mobilise SSC

- release adhesions on posterior and superior aspect

- some advocate release of intra-articular tendinous portion

 

4.  Release posterior IGHL

- place camera in anterior portal

- posterior to posterior labrum

- complete inferior release

 

Frozen Shoulder Posterior Capsule ReleaseFrozen Shoulder Posterior Release CompleteFrozen Shoulder Complete Inferior Release

 

5.  MUA with abduction

- remove instruments and camera

- tears inferior aspect of capsule

 

6.  Injection of HCLA

 

Results

 

Ogilvie-Harris et al Clin Orthop 1995

- MUA v arthroscopic release in 40 patients

- better outcomes in arthroscopic release at 2 and 5 years

- excellent in 15/20 arthroscopic

- excellent in 7/18 MUA