Periarthritis shoulder

DR. NIRAJ KUMAR , PT BPT, MPT (ORTHO), MHA, Ph.D. physiotherapy* ASSOCIATE PROFESSOR PHYSIOTHERAPY DEPT. shri guru rai institute of paramedical sciences , dehradun

1. DR. NIRAJ KUMAR , PT BPT, MPT (ORTHO), MHA, Ph.D. physiotherapy* ASSOCIATE PROFESSOR PHYSIOTHERAPY DEPT. shri guru rai institute of paramedical sciences , dehradun PERIARTHRITIS SHOULDER & ADHESIVE CAPSULITIS/FROZEN SHOULDER

2. Your shoulder is a ball-and-socket joint made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collar bone (clavicle). The head of HUMERUS fits into a shallow socket in your shoulder blade (SCAPULA). Strong connective tissue, called the capsule, GL, surrounds the joint. To help your shoulder move more easily, synovial fluid lubricates the shoulder capsule and the joint Anatomy

3. Anatomy of shoulder joint

4. Anatomy of shoulder joint

5. Introduction:- In 1872 Dupley 1 st Described And Called Humeroscapular Peri-arthritis . In 1934 Codman Coined The Term Frozen Shoulder. In 1945 Neviaser Gave The Term Named Adhesive Capsulitis . Frozen Shoulder Occurs In About 2% Of The General Population. It Most Commonly Affects People Between The Ages Of 40 And 60, And Occurs In Women More Common Than Men. Age:- 40 to 60 yrs old age. Sex:- F>M Peri-arthritis Shoulder / Frozen Shoulder

6. Definition:- 1. Peri-arthritis Is A Common Condition Characterised By Pain And Progressive Limitation Of Abduction & External Rotation Movement Of Shoulder Joint 2.Frozen shoulder, also called adhesive capsulitis, causes pain and stiffness in the shoulder. Over time, the shoulder becomes very hard to move. 3. Frozen shoulder or adhesive capsulitis describes the common shoulder condition characterized by painful and limited BOTH active and passive range of motion IN ALL PLAINS WITH RADIOGRAPHIC APPEARANCE.

7. Fig: frozen shoulder/PA DR. NIRAJ KUMAR

8. 1.Immobilisation Dueto Fracture & Dislocation Around The Shoulder Jt. 2. Bicipital Tendinitis 3. Rotator Cuff Tendinitis 4. Stroke, 5. Lung Disease, 6. RSD 7. Thyroid Disease ---- Hyperthyroidism 8. Heart Disease (CVS) -- Ischemic Heart Diseases 9. Diabetes Mellitus- insulin dependent diabetes 10. Tonic Seizures 11. Strain and Strain and Surgical trauma. Risk factors for frozen shoulder/PA include:-

9. You should be able to move your shoulder in all directions without pain. To test yourself, do these things: Shoulder stiffness Inability to raise arm Limited shoulder mobility Shoulder pain Shoulder immobility Radiating pain down arm Shoulder pain; usually a dull, aching pain Limited movement of the shoulder Difficulty with activities such as brushing hair, putting on shirts/bras Pain when trying to sleep on the affected shoulder 1. IN PA LIMITATION OF ABD. & ER OF GH JOINT. 2.Pain from frozen shoulder & pa is usually dull or aching. It is typically worse early in the course of the disease and when you move your arm. The pain is usually located over the outer shoulder area and sometimes the upper arm. 3. tenderness front of sh. Jt. Clinical Feature

10. CLASSIFICATION OF F.A/A.C Adhesive capsulitis is classically characterised by three stage:- 1) first stage (stage of pain) ---- ( 3 to 6 month) 2) second stage (stage of stiffness) ---(3 to 18 month) 3) third stage (stage of recovery )-----(6 MONTH to 2 YRS.) 1) first stage (stage of pain) – is the freezing stage is characterised by— *aching pain in shoulder *pain more severe at night with activities. *pain may radiates down the arm * patients adept the adduction + internal rotation. * discomfort shoulder. NOTE:- ( When it is treated by mobilisation then symptom become worsen the freezing process).

11. 2) second stage (stage of stiffness) – it is also called frozen or progressive stiffness phase * pain ↓ during rest. * adl severely restricted. * shoulder motion restricted in all plain. *patient complain:- 1 inability to reach in to back pockets. 2 fasten the bra. 3 comb the hair. 4 WASH THE OPPOSIT SHOULDER. 5 PAI AT NIGHT. STAGE CAN BE LAST FROM 3 TO 18 MONTH ( NOT:- EASILY TREATED WITH MEDICINE AND PHYSICAL THERAPY.)

12. 3) third stage (stage of recovery )---- FINAL STAGE IS THROWING OR RESOLUTION PHASE. IT IS CHARACTERISED BY NO PAIN WITH SLOW RECOVERY OF MOTION. LOSS OF EXTERNAL ROTATION WITH ARM AT SIDE OF THE PT. IS HALLMARK OF THIS CONDITION. (NOTE:- AGGRESSIVE TREATMENT WITH PHYSICAL THERAPY AS CLOSE MANIPULATION AS MAITLAND & MULLIGAN ETC. IF CONSERVATIVE MANAGEMENT IS FAILED THAN SURGICAL RELEASE IS REQUIRED ).

13. Diagnosing Osteoarthritis:- 1. X – RAY AP & LATERAL VIEW SHOULDER . 2. MRI SHOULDER 3. ORTHROSCOPY OF SHOULDER 4.Elevated erythrocyte sedimentation rate [ESR] 5. C-reactive protein [CRP] level) – Increase 6. Anti–cyclic citrullinated peptide [anti-CCP] 7. Inflammatory joint fluid with a predominance of ....polymorphonuclear leukocytes (PMNs) 8. TLC & DLC , Elevated white blood cell (WBC) count

14. MANAGEMENT OF PA/FS DRUG MANAGEMENT 1.NSAID:- Aspirin, Celecoxib (Celebrex), Diclofenac potassium (Cataflam), Diclofenac sodium (Voltaren, Voltaren XR), Diclofenac sodium with misoprostol (Arthrotec), Ibuprofen, Indomethacin (Indocin, Indocin SR), Oxaprozin (Daypro), Piroxicam (Feldene), Rofecoxib (Vioxx) Mefenamic acid (Ponstel), Meloxicam (Mobic), Nabumetone (Relafen), Naproxen (Naprosyn, Naprelan), Naproxen sodium, Ketoprofen

15. nsaid

16. 2. ANTACIDS:- pantoprazole and rabeprazole table Alamag, Alamag Suspension, Aluminum and Magnesium Hydroxide Oral Suspension (Alamag Suspension,   Maalox Suspension, Magnalox Suspension, Magnox Suspension, Mintox Suspension),   Aluminum and Magnesium Hydroxide (Alamag, AludroxGel,  Maalox, Magnalox, Mylanta,  Rulox ),  Aluminum Hydroxide Oral Liquid (AlternaGEL Liquid, Amphojel Suspension), Aluminum Hydroxide (AlternaGEL,  Alu -Cap,  Alu -Tab, Amphojel, Dialume), Calcium Carbonate Tablets (Amitone, Caltrate 600, Dicarbosil, Equilet, Mallamint, Titralac, Tums), Lansoprazole, Magnesium Hydroxide, Omeprazole, Prevacid , Prilosec , Ranitidine , Zantac , Zoton

17. ANTACIDS:-

18. antacidS

19. 3. Calcium therapy with vitamin d3

20. Management :- The basic aim of frozen shoulder exercises are: To reduce pain. To increase extensibility of the thickened and contracted capsule of the joint. To improve mobility of the shoulder. To improve strength of the muscle. However it may be remembered that strengthening of muscle is secondary to mobilization.

21. Management of pa/f. s. classified Into three stage :- 1) first stage (stage of pain) ---- ( 3 to 6 month) 2) second stage (stage of stiffness) ---(3 to 18 month) 3) third stage (stage of recovery )-----(6 MONTH to 2 YRS.) 1) first stage (stage of pain) ---- ( 3 to 6 month):- 1. NSAIDS- first line medication for pain control associated with antacid. 2. GH joint injection: corticosteroid/local anesthetic combination. 3. Oral steroid taper- for patients with refractive or symptomatic frozen shoulder. 4. Therapeutic modalities Ice for 20 min, ultrasound 0.8 to 1.2 wtts . for 5 to 7 mins , HVGS for 25 mins . Apply moist heat before therapy and ice pack at the end of session.

22. 5. Initially focus on  forward flexion and internal and external rotation with the arm at the side, and the elbow at 90 degrees . 6. Active ROM exercises. 7. Active assisted ROM exercises. 8. Passive ROM exercises. 9. A sustained stretch, of 15-30 seconds, at the end ROMs should be part of all ROM routines. 10. In home these Frozen Shoulder Exercises should be performed 3-5 times per day. 2) second & THIRD stage (stage of stiffness & STAGE OF RECOVERY ) --- Criteria for progression to stage - 2 Improvement in shoulder discomfort. Improvement in shoulder motion. Satisfactory physical examination.

23. Goals * Pain Control by same means as used in 1st 8 weeks. * Improve shoulder motion in all plane * Improve strength and endurance of rotator cuff and scapular stabilizers. Motion: Frozen Shoulder Exercises * active assisted exercises. * passive range of motion exercises to obtain around 140 degree of forward flexion, 45 degree of external rotation and internal rotation.

24. 1. Thermotherapy deep heating modalities such as swd , ust , lwd etc. using before passive mobilization for proper relaxation of muscle & ligament. 2. General mobilization technique:- *passive gliding with longitudinal traction :- supine, full abduction and neutral rot. With elbow in 90°fl. Therapist apply longitudinal traction along the axis of the humerus , he carries out ap glide & abd .& add glide in a slow rhythmic manner. ) * forward stooping positing:- stabilized the sh. jt. By one hand & other grasp the wrist then slow curcumduction movement is carried out up to limit of pain.

25. passive gliding with longitudinal traction :-

26. Passive mobilization of sh. In a forward stooping positing

27. Muscle strengthening 1. Start with rotator cuff strengthening exercises 3 times/ week, 8-12 repetitions for three sets. 2. Closed chain isometric strengthening with the elbow flexed to 90 degrees and the arm at the side. Perform internal rotation, external rotation, abduction and forward flexion. 3. Progress to open chain strengthening exercises with theraband for same group of muscles. 4. Progress to light weight dumbbell exercises for internal rotators, external rotators, abductors and forward flexors. 5. strengthening of scapular stabilizers. 6. Deltoid strengthening .

28. 1. Lying Dumbbell Presses pt. Lie on supine lying holding a light dumbbell in each hand. Extend your arms vertically with palms facing inwards. Next, push your arms further upwards keeping them parallel to each other such that your shoulders blades separate. perform between 10 and 20 repetitions of the exercise. Increase the number of repetitions with practice.

29. 2. Push-Up Plus Hold yourself in a push-up position: here, your body is horizontal, facing downwards, arms extended with your shoulders wide apart. Keep your head in a straight line with your spine. Extend your shoulders to the front and squeeze your shoulder blades to bring yourself up. Keeping your arms extended, let gravity bring you back to the original position. Repeat the workout 10-20 times daily.

30. 3. Rhomboids Stretch Rhomboideus major and minor are two important muscles to keep the shoulder girdle in a functional state. First place your right arm under your left shoulder and then place your left arm over your right shoulder and feel the stretch. Hold this position in 10 seconds and then relax. Perform 10 repetitions for each arm twice each day.

31. 7. Pendulum exercise The pendulum exercise is a part of scapular stabilization exerciseis great for working a large number of muscles like the deltoids, subscapularis , rotator cuffs and supraspinatus and infraspinatus muscles. Lean on a table placing one of your hands on the table for support. Swing the other hand 10-12 times both in the backward-forwards direction and laterally. Also swing the arm clockwise and anti-clockwise.

32. Posterior capsule stretching

33. anterior capsule stretching

34. Hand to back position: To decrease shoulder stiffness:- Grab your affected hand behind your back as far as possible. Push the hand downwards into the opposite hand and hold for 6 seconds. Relax and slowly bring the hand back up. Repeat 2 to 3 times. Hand to back Sh. Exe.

35. Other exercises : 1. wall & ladder exercises exercise. 2. Shoulder & wheel exercise 3. finger ladder exercise. Wall & ladder exe.

36. THANK YOU