Assessment and Management of Frozen Shoulder

The Arm Clinic's Mr Mike Walton presents his thoughts on assessment and management of Frozen Shoulder. Presentation for The Arm Clinic educational event #stiffshoulder at The Wilmslow Hospital, 29th April 2016.

1. The Stiff Shoulder My Thoughts on Assessment and Management of Shoulder Stiffness Mike Walton Consultant Shoulder Surgeon

2. What is Stiff? Patient - “I cant move my shoulder as well ‘cos it hurts” Us - Reduction in active and passive glenohumeral joint movement compared to the contralateral side

3. 4 N’s Neck (or neural) Near normal movement - pain inhibition Not moving - true stiffness Nasty (Infection, Malignancy)

4. Neck Radicular pain - extending below elbow, occasionally medial scapula (c3/4) Neuralgic amyotrophy - wasting, pain ++ Shoulder should be painfree to passive ROM Can occur in combination

5. Nearly Normal Movement Pain Inhibition Calcific tendinitis Cuff tendinopathy / Impingement “Cuff Muscle Stiffness” - Ginn et al

6. True Stiffness Reduction in Passive and active glenohumeral joint movement Limitation due to bony abnormality Osteoarthritis Missed Dislocation Soft tissue contracture - “Frozen Shoulder"

7. True Stiffness Reduction in Passive and active glenohumeral joint movement Limitation due to bony abnormality Osteoarthritis Missed Dislocation Soft tissue contracture - “Frozen Shoulder" Easy to Diagnose on Xray

8. Nasty Night and Unremitting pain Red flags history of malignancy unexplained weight loss

9. Nasty Night and Unremitting pain Red flags history of malignancy unexplained weight loss

10. Assessment History - speed of onset, trauma, age Examination Loss of Passive ER Xray!!

11. Atraumatic Stiffness

12. Traumatic Stiffness

13. Frozen Shoulder Capsular Contraction coracohumeral ligament Anterior / Deep pain Loss of External Rotation Hard end point Normal Xray

14. Frozen Shoulder

15. Aims of Treatment Relieve Pain Restore Movement Regain Function

16. Natural History Most cases recover within 2 years 50% mild pain at 7 years * 60% persistent stiffness * Post traumatic more resistant * Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder: a long-term follow-up. J Bone Joint Surg [Am] 1992;74-A:738–746

17. Treatment Options Physiotherapy Steroids Volume Hydrodilatation / Distention Arthrography Surgery

18. Physiotherapy Recent CSP Guidelines Passive Mobilisation Capsular Stretching Group Classes - Russell et al 2014 May be counter productive in painful phase

19. Physiotherapy Interventions Ultrasound, Interferential, TENS, pulsed electromagnetic stimulation etc Very limited scientific evidence May possibly sometimes be useful on a individual patient basis (CSP Guidelines)

20. Physiotherapy ESSENTIAL post surgical intervention

21. Steroids Commonly prescribed PO and IA Cochrane and Meta-analyses Good short to medium term benefit but doesn’t appear to be sustained May get rebound

22. Volume Hydrodilatation Small numbers of studies Case series and quasi RCTs Some conflicting data Cochrane Review (2008) Good short term relief - “Silver level” Uncertain whether better than alternatives

23. Volume Hydrodilatation Wrightington data: 76% improved ROM at 3 months 91% improved Pain at 1 year Especially primary idiopathic frozen shoulder

24. Volume Hydrodilatation

25. Surgery MUA Arthroscopic Capsular Release Open Capsular Release

26. MUA I don’t perform this in isolation Several good studies showing excellent long term outcome Short lever-arm sequential manipulation Uncontrolled technique

27. Capsular Release Arthroscopic EUA pre-op - always stiff ? Ginn et al Allows systematic evaluation of the joint Controlled release of contracted capsule and ligaments

28. Capsular Release

29. Capsular Release

30. Capsular Release Check ROM peri-op

31. Capsular Release Open More limited visualisation of capsule Difficult to address posterior capsule May lengthen subscapularis Indicated post surgery particularly to release subdeltoid adhesions

32. What I Tell Patients... It will usually get better if we do nothing Intervention will “hopefully” speed up recovery Volume hydrodilatation is less invasive but may have a higher rate of recurrence Arthroscopic capsular release more invasive but may have a better chance success

33. Arthritis Loss of articular cartilage Bone on bone articulation Pain Stiff Osteophytes

34. Arthritis Cuff Integrity Intact - Anatomic arthroplasty Hemiarthroplasty Total Shoulder Replacement Torn / Dysfunctional - Reverse Replacement

35. Cuff Function Superior Deltoid Rotator Cuff Acromion Humeral Head Glenoid

36. Cuff Function Superior Deltoid Rotator Cuff Acromion Humeral Head Glenoid

37. Cuff Dysfunction Superior Deltoid Rotator Cuff Acromion Humeral Head Glenoid

38. Cuff Dysfunction Superior Deltoid Rotator Cuff Acromion Humeral Head Glenoid

39. Cuff Dysfunction Superior Deltoid Rotator Cuff Acromion Humeral Head Glenoid

40. Cuff Dysfunction Superior Deltoid Rotator Cuff Acromion Humeral Head Glenoid

41. Cuff Dysfunction Superior Deltoid Rotator Cuff Acromion Humeral Head Glenoid

42. Cuff Dysfunction Superior Deltoid Rotator Cuff Acromion Humeral Head Glenoid

43. Reverse

44. Reverse

45. Summary Good History Assess passive ER Get an Xray Abnormal - Nasty, Calcific Tendintis, OA Normal - Frozen Shoulder