A discussion about Adhesive capsulitis 한상민

A discussion about Adhesive capsulitis 한상민

Adhesive capsulitis Frozen shoulder Periarthritis Irritative capsulitis Scapulohumeral periarthritis

Shoulder anatomy SC joint AC joint GH joint team ST joint

Shoulder anantomy(clavicle) Medial- convex, Lateral- concave 수평면에서약간위쪽과후방으로기움 (20도) Medial- Costal facet Lateral- Acromial facet Humuerus 30 retroversion Scapula frontal plan 35

Shoulder anatomy(scapula)

Shoulder anatomy(humerus) Humeral head Anatomical neck Greater tubercle Intertubercular groove Deltoid tuberosity Superior medial 135 도 30 도 retroversion

Shoulder anatomy(gh joint) GHJ- 섬유성관절낭에둘러싸여있다. Synovial sheath- 이두건장두를감싸고내려온다. Axillary pouch- sling Rotator cuff m GH capsular ligament Coracohumeral ligament fix Biceps tendon

Shoulder anatomy(gh joint) SGHL adduction, humeral head inferior & posterior translation -> tightness MGHL humeral head anterior translation, ER -> tightness IGHL abduction Axillary pouch 90 abduction -> tightness

GHJ Static stability primary stability: glenoid fossa position - static locking mechanism Secondary stability: supurasupinatus Biceps, triceps, detoid EMG 연구결과 - 정적안정성에크게관여하지 X Scapula position & suprasupinatus -> static stability

Shoulder anatomy Coracoacromial arch= CAL + acromial process Nomal 1cm Subacromial space - suprarspinatus tendon - subacromial bursa - biceps long head - superior capsular ligament Subacromial bursa - supurasupinatus protect Deltoid bursa - Suprasupinatus & deltoid & humural head protect

Shoulder anatomy Scapulo-humeral rhythm 2:1 ratio (GHJ:STJ) STJ 60 도 = SCJ elevation (30) + ACJ up ro (30)

Shoulder anatomy SCJ & ACJ cooperation - early 90도 GHJ 60도 abduction + STJ 30도 up ro - terminal 90도 ~180도 GHJ 60도 abduction + STJ 30도 up ro SCJ 20~25 도 elevation v ACJ 5~10 도 up ro SCJ 5 도 elevation ACJ 20~25 도 up ro v

Shoulder anatomy SCJ & ACJ cooperation (clavical posterior ro) 40 도 posterior ro CCL stretch Posterior ro

Sub-types of Adhesive Capsulitis Idiopathic (Primary) Global limitation of glenohumeral motion secondary to contracture and loss of compliance of the glenohumeral joint capsule.

Sub-types of Adhesive Capsulitis Secondary or Acquired Limitation of motion secondary to injury, low-level repetitive trauma, or part of another condition resulting in contracture of structures which contribute to shoulder motion. May be post-traumatic, post-surgical, CVD or from a known systemic illness.

Epidemiology of Adhesive Capsulitis Affects about 2% of general population and possibly as high as 3-5% Idiopathic is seen in age group of 40-60 years. (hormone) Mean age was 50 for both men and women, and IDDM and NIDDM patients Male to Female Ratio of 58:42. Diabetics: affects 10-20%. The incidence in IDDM rises to 36%. Also see bilateral involvement more frequently in DM.

Epidemiology of Adhesive Capsulitis Injuries: can develop from a minor incident, rotator cuff strain, impingement syndrome Surgical Trauma: shoulder, axillary node dissection, neck dissection Immobility: the majority of pts referred

Epidemiology of Adhesive Capsulitis Cervical Disease: Most common at C5-6 and C6-7. with DDD are more likely to develop stiffness. Thyroid: can have bilateral invovlement and will often resolve with thyroidectomy and stable thyroid levels Cardiac Disease: may be triggered by catheterization of brachial artery or post sternotomy pain Pulmonary: incidence increases with COPD and use of isoniazid Neurologic: CVA(stroke), Parkinsons

Schematic painful shoulder musculoskeletal vascular Neurologic Visceral referred vasospasm pain Muscle spasm hypoxia 2 nd vasospasm Diminished Venous return immobilization congestion Fibrous reaction disuse Functional disability

Common injury What happened? Repeated microtrauma Loss of the Elastic connective tissue Inflammatory reaction Critical zone Fibroblast damage Traction or compressive force Adhesion result ischemia blood supply degenerative

Capsule capacity Normal capsule Adhesive capsulitis

Stages of Adhesive Capsulitis Painful Phase: Freezing - high irritability (3~6 month) Progressive Stiffness Phase: Frozen - morderate irritability (3~6 month) Resolution Phase: Thawing - low irritability (6~12 month) - aggressive rehab

Painful Phase: Freezing Lasts 3-6 months. Begins with pt having the onset of achy pain. Pain often begins at night and persists through the day. Pain is enough to substantially disturb sleep and will often request meds at night.

Painful Phase: Freezing As symptoms progress, fewer arm positions are comfortable and usually is most comfortable with arm at side and internally rotated (sling position). -> Add, IR rest Usually first treatment is to immobilize the arm which only worsens stiffening process. Progresses to constant pain and worse with repetitive movement, stress, exposure to cold or vibration, change in weather. Moderate Tx pain free (mobilization, distraction, self ROM ex, PRICE)

Progressive Stiffness: Frozen Lasts 6~12 month but may be much longer. Stiffness progresses so that ROM is lost in all planes. Pain usually less than in freezing stage have inability to sleep comfortably on the affected side. ADLs severely limited: particularly with overhead and behind back motions. Pain continues to decrease, but only within a very limited ROM.

Resolution Phase: Thawing Final stage is characterized by slow gains in motion and comfort. May have persistence of symptoms for as long as 6-10 years from onset. May have persistent motion and function restrictions.(disable 20~30%) Resolution TX -> aggressive rehabilitation

Night pain?? Abnormal blood circulation Traction effect (daytime) Scapula attach muscle compression Dopamine hormone secretion (daytime) sunbeam Humeral head At translation (supine position) Rest position, Ice ~~~

Physical Examination Body condition (drug ) Grade classification - verbally PROM and AROM with solid endpoint feel to endrange motion Posture (stooped, round shoulder, shrug sign) - posture classification (neck) in the future (adjustment) - ACJ & SCJ length discrepancy - humeral head torsion (olecrenon process) - scapula (rest, motion)

Physical Examination Six directions for ROM: - Forward elevation/flexion - ER at side and in abduction, - IR in adduction and against the spine. - Cross body Adduction AROM: Flexion measured against thorax to avoid trunk tilt or increased ST contributions. PROM Assessed with pt supine to restrict ST contribution.

Physical Examination ASIS ~ greater tuberosity Greater tuberosity ~ lateral epicondyle ACJ ~ medial styloid process Olecrenon process ~ lateral styloid process

Physical Examination Olecrenon process ~ lateral styloid process Thumb check Length or angle(??) Involve side, uninvolve side check spread on the records

Rehabilitation Painful Phase: Freezing -> pain control period - Rotator cuff m, deltoid m release - GHJ distraction (oscillation) - Joint mobilization (4 shoulder joint) - pain free range -> PNF pattern (passive) - scapula setting ex, multidirection motion (pain free) - correct muscle stretch (neck area), IR, ER isometric ex (??)

Rehabilitation Progressive Stiffness Phase: Frozen -> ROM maintain - sling active motion warm up -> multidirection - PNF pattern (passive ~ active motion) end range of motion - MET (PIR) end range - Joint mobilization (4 shoulder joint) - scapula stability ex - rotator cuff passive stretch education IR,ER strengthning (eccentric focus), scaption

Rehabilitation Resolution Phase: Thawing - aggressive rehab - GHJ multiful joint mobilization (inferior, Ant, post, IR, ER) - Isotonic eccentric MET - PNF pattern (eccentric) - end range stretch (low intensity, long time) - self PA, AA stretch (T bar, pully) over end range * connective tissue -> permanent stretch

Discussion Joint capsule release technique -> application?? - PNF, MET, JM, ART, PRT Capsular pattern Tx?? - flex, abd, ER, IR (normal) - ER, abd, flex, add, IR (parker) - abd, flex, ER, IR (Hill, Bogumill) - scapula plane (flex, ER, abd), IR Strangth (isometric, isotonic- con,ecc) -> application??