a POWER POINT PRESENTATION ON

   Periarthritis shoulder

Introduction

ÒPA is a condition characterized by pain & progressive limitation of GH movements.

ÒIt is the initial manifestation of ongoing pathology which usually culminates in frozen shoulder.

ÒDuplay in 1872 referred the condition as humerocapsular Periarthritis.

ÒCodman in 1934 coined the term ‘Frozen shoulder’ – painful loss of motion with normal radiographic studies.

ÒIn 1946, Naviaser ,named the condition ‘adhesive capsulitis’ based on his work & radiographic appearance.

ÒIn 1949, Simmonds, proposed that rotator cuff inflammation preceds PA shoulder.

ÒIn 1973, Macnab illustrated that degenerative changes in supraspinatus, leads to an autoimmune reaction, produces diffuse capsulitis.    

ÒPA shoulder/ frozen shoulder –

ÉPrimary adhesive capsulitis

ÉSecondary adhesive capsulitis / acquired shoulder stiffness.

ÒUncommon in athletes, may occur due to prolonged immobilization.

 

Etiology
ÒExact cause is unknown.
ÒCertain factors considered to contribute to development of PA are:

ÉPain

ÉDisuse / immobilization

É& periarthritic personality.

Pathoanatomy
ÒThickening & contracture of joint capsule with obliteration of inferior recess.
Òcollagen band bridging across recesses, random collagen production.
ÒAcquired cases reflects the underlying causes :

ÉSurgery

ÉTrauma

ÉOther pathological conditions like insulin dependent diabetes, reflex sympathetic dystrophy, etc.

Clinical presentation:

PRIMARY ADHESIVE CAPSULITIS

ÒInsidious and idiopathic

ÒUsually older than 40 yr. of age.

ÒHigher incidence in females.

ÒHistory of progressive shoulder stiffness associated with diffuse pain

Òadhesive capsulitis is classically characterized by three stages:

ÉInitial/ freezing phase

ÉSecond / frozen phase

ÉFinal/ thawing phase

( Reeves B:The natural history of the frozen shoulder syndrome. Scand J Rheumatol 4;193,1975) 

ÒInitial/ freezing phase

ÉOnset of diffuse, aching pain in the shoulder.

ÉPhase can last for 2 to 9 months.

ÉPatient position the arm in abduction & internal rotation.

ÉAssociated with acute inflammatory synovitis.

ÒSecond / frozen phase

ÉPain at rest usually diminishes .

ÉADLs becomes severely restricted according to capsular pattern.

ÉSevere pain occurs attempted motion.

ÉThis stiffening phase can last for 4 to 12 months.

ÉGH motion lost under anesthesia.

ÉHypervascular proliferative synovitis & Capsular fibrosis

ÒFinal/ thawing phase

ÉOccurs with slow recovery of motion.

ÉGradual resumption of ADLs

ÉThis phase can last for 6 months to 2 years.

ÉThe capsule is now very scarred, thick, fibrotic, & hypovascular.

SECONDARY OR ACQUIRED SHOULDER STIFFNESS

ÒThis condition is associated with a known predisposing condition of the shoulder

ÒPatient with acquired stiff shoulder have much clearer & concise history.

ÒLoss of external rotation, abduction & flexion.

ÒRadiographs are helpful in acquired cases.

Differential diagnosis

ÒPartial rupture of supraspinatus tendon.

ÒSupraspinatus tendinitis.

ÒBrachial neuritis.

ÒOA of the AC joint.

ÒTuberculous arthritis of shoulder

Treatment : 

PHYSIOTHERAPY  Treatment

ÒPhase 1: weeks 0-8

ÉRelieve pain

ÉRestore motion

ÐExercises

×AROM

×AAROM

×PROM

ÉHome exercise program should be instituted from beginning.

ÒPhase 2: Weeks 8-16

ÉContinue the treatment program of phase 1 &

ÉExercises for strengthening of rotator cuff & scapular stabilizers.

ÐClosed chain isometric strengthening

ÐOpen chain strengthening

ÐLight isotonic dumbbell exercise

ÒPhase 3: Months 4 & beyond

ÉThere should be resolution of pain & significant functional recovery of shoulder motion.

ÉHome exercise program should be continued.

ÒMaximum improvement may be achieved 6-9 months after treatment initiation.

Surgical treatment

ÒSurgical intervention may be indicated, if no improvement is seen after 3 months of management:

ÉClosed manipulation under anesthesia

ÉArthroscopic capsular release.

ÉOpen release.

Postop. management

ÒShould begin on the day of surgery.
ÒTherapy should begun with ROM exercises.
ÒTherapy should consist a stretching program in all planes.
ÒOnce pain free arc is regained, a strengthening
program may be added.

references:

ÒHunter James M: Rehabilitation of the hand & upper extremity. 5th Ed.

ÒBrotzman S Brent: Clinical orthopedic rehabilitation.2nd Ed.

ÒDonatelli Robert A: Physical Therapy of Shoulder.2nd Ed.

ÒCyriax J: text book of orthopedic medicine volume 1. 8th Ed.

ÒSolomon L: Apley’s system of orthopedics & fractures. 8th Ed

ÒReid David C: Sports injury Assessment & rehabilition

ÒMaitland GD: Peripheral Manipulation. 2nd Ed.

ÒSimonds FA: SHOULDER PAIN With Particular Reference to the “ Frozen” Shoulder . The Journal Of Bone And Joint Surgery 31B:426,1949

ÒNEVIASER JS: ADHESIVE CAPSULITIS OF THE SHOULDER: A Study Pathological Findings in Periarthritis of the Shoulder. J Bone Joint Surg Am. 1945;27:211-222.

ÒManske Robert C: Diagnosis and management of adhesive capsulitis. Curr Rev Musculoskelet Med (2008) 1:180–189

ÒCharnley J: Periarthritis of shoulder