Frozen Shoulder - Alistair Jepson 31/7/2001

BACKGROUND

Frozen shoulder coined by Codman (1934), who said of it that: ‘It is difficult to define, difficult to treat and difficult to explain from point of view of pathology’

Now acknowledged as fibrous contracture of the coraco-humeral ligament and rotator interval of the capsule – check-rein (Bunker & Anthony 1995 & Ozaki et al 1989 )

• highly cellular tissue with dense matrix Type III collagen, fibroblasts & contractile myofibroblasts

• like Dupuytren’s contracture (Bunker, 1995)

N.B.

Term ‘adhesive capsulitis’ coined by Nevaiser (1945) – however neither adhesions nor inflammation present. Further Nevaiser (1983 & 1987) papers have advocated staging adhesive capsulitis – Stage 1, Stage 2 ‘Freezing Stage’, Stage 3 ‘Frozen stage’, Stage 4 ‘Thawing Phase’ (felt pathology different in each phase)

Also the term ‘periarthritis’ has previously been used (Duplay 1872)

Features:

1. ‘a slow onset … of pain felt near insertion of Deltoid, inability to sleep on affected side, painful and restricted elevation and external rotation, with normal radiological appearance’ (Codman)

2. ‘condition of uncertain aetiology characterised by substntial restriction of both active and passive shoulder motion that occurs in the absence of a known shoulder disorder’ (Zuckerman & Cuomo 1993)

Patient typically in 50’s, R=L, M=F

Associated with:

• Diabetes mellitus

• Dupuytren’s disease

• Hyperlipidaemia (Bunker & Elser 1995)

• Thyroid disease & autoimmune disease

• Stroke & Myocardial infarction

• Trauma inc. distant e.g. Colles   #

Natural Hx:

Codman stated that ‘even the most protracted cases recover with or without treatment in about 2 years’ (highly qualified statement)

Grey’s paper (1978) of quoted by those who say condition resolves (SWT)

• only 5 paragraphs long!

• 25 frozen shoulders in 21 pts (aged 47-74, 8M:13F) –24 had returned to work within 2 yrs of onset. States that only 1 shoulder still slighly painful with loss of 20 ° glenohumeral abduction

Schaffer et al (1992): evaluated 62 pts objectively & subjectively for an ave f/u of 7 yrs

• 50% still had mild pain or stiffness or both

• 60% still demonstrated some ¯ ROM (ER mainly)

Reeves (1975 – see below): prospective study of 41 pts with frozen shoulder (f/u 5-10 yrs) found:

• painful phase lasted 10-36 months, stiffening phase 4-12 months, recovery 12-42 months (i.e. 2- 7 yrs; ave 30.1 months)

• 25/41 pts had permanent ¯ ROM (functional loss only in 3, and in these protracted total duration of symptoms)

Treatment:

Aim is to stretch, soften or excise the rotator interval (physio, steroid injection, MUA, and arthroscopic release). Approx 10% will never recover.

physio good in late phase but early on it has been suggested to cause micro-trauma

• interscalene blocks

• injections

MUA

• Good for early restoration of function (Dodenhoff 2000)

• Flexion/extension, then abduction/adduction, and finally ext rotation.

• Rupture of anterior capsular structures (inc. subscapularis, ant middle GHL & IGHL & inferior capsule