Frozen shoulder The end of the Ice Age? Andy Forester Parkside Hospital, Wimbledon Imperial College Healthcare NHS Trust
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1 Frozen shoulder The end of the Ice Age? Andy Forester Parkside Hospital, Wimbledon Imperial College Healthcare NHS Trust
2 Enigma Latin aenigma, from Greek ainigma, from ainissesthai To speak in riddles.. Cambridge English Dictionary : Something that is mysterious and seems impossible to understand completely.
3 S***happens.
4 Frozen Shoulder Aetiology (why does this shit happen?) Unknown!! 2 5% of population 60% female: 40% male 5x more common in diabetes Slightly more common in Dupuytren s 15 20% patients affected both sides More common on year olds May follow shoulder trauma/surgery or breast reconstruction
5 Disease progression Symptoms last an average of 30 months Three phases (four??): (Pre-freezing 0-1 week) Freezing 1 8 months Frozen Thawing 9 16 months months
6 Symptoms Pain may be severe, other symptoms include: Night pain, especially lying on affected side Difficulty dressing, especially bra straps, coats Pain radiating down the arm Inability to brush/wash hair Problems with personal hygiene Difficulty driving
7 Consequences Inflammation starts in rotator interval Spreads to other structures Results in capsular pattern movement Muscle wasting Decreased ROM
8 History Most important!! Duration of symptoms Any history of trauma/surgery Effect on activities of daily living Localisation of pain Night pain Co-morbidities Effect of NSAIDs or other analgesics
9 Clinical examination Examination should be with the patient stripped to the waist so that both shoulders may be visualised Preferable to use a standing position over sitting to observe trick movements Should confirm your clinical suspicion and localise the pathology prior to any imaging A painful shoulder can result in loss of range of movement and that this may not be frozen shoulder
10 Beware of tigers...or leopards... Calcific tendinitis Acute supraspinatus tendinitis Septic arthritis Cuff tear Cervical/peripheral neuropathy Major trauma OA
11 If the shoulder is stiff With the patient standing identify their range of active elevation and check passive mobility Elevation may be limited to 120º or 130º with a hard end point External rotation with the arm at neutral may be slightly reduced Internal rotation with the hand behind the back is limited and painful
12 If the shoulder is not stiff In this situation a more complete and thorough examination can be performed Special tests can be used to identify the underlying pathology
13 If the shoulder is not stiff.
14 Imaging Two types of imaging: First type obtained with patient at first consultation (usually plain radiographs) Specialist investigations (ultrasound, MRI) useful following standard imaging when a more precise diagnosis of the affected part is required. Relying on the imaging for diagnosis is potentially hazardous.
15 Primary imaging To be any use the standard views need to be obtained reliably and should include: A humeral head view showing the joint space in neutral rotation (plus internal and external rotation if required) Rotator cuff profile Axillary view Glenoid view
16 Specialist imaging May include the following!! Acromioclavicular joint views Ultrasound MRI Arthrography +/- MRI CT scan
17 Treatment of frozen shoulder Do nothing and reassure NSAIDs Physiotherapy/osteopathy Oral steroids (probably not) Steroid injections (up to 3?) Hydrodilation Manipulation under anaesthetic (avoid!!) Arthroscopic capsular release Suprascapular nerve blocks
18 Hydrodistension
19 Hydrodistension Capsule is stretched by injecting joint to it s limit with local anaesthetic and saline. May be painful/poorly tolerated. Concomitant use of steroid? Joint just stretched? or torn? Improvement maintained over a 2 yr period
20 Manipulation under anaesthetic
21 Manipulation under anaesthetic Manipulation in Forward Elevation, Abduction and finally Rotation with muscle relaxation. Tissues stretched under anaesthetic can be painful post procedure. Risk of fracture, nerve traction injury, torn tendons, bleeding etc.. Acronym is not FEAR for no reason! Probably should be consigned to history books.
22 Arthroscopic capsular release Pathology is a tight rotator interval and contracted coracohumeral ligament. Division of scar tissue under direct vision. Post-op physio essential for success
23 Thank you for your attention
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