THE STIFF SHOULDER: CURRENT CONCEPTS Felix H. Savoie III, MD Ray - - PowerPoint PPT Presentation

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Felix H. Savoie III, MD Ray J. Haddad Professor & Chairman Department of Orthopaedic Surgery Tulane University New Orleans, LA

THE STIFF SHOULDER: CURRENT CONCEPTS

COI

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ADHESIVE CAPSULITIS

• Nevaiser, JS: JBJS 1945: Adhesive Capsulitis of

the shoulder: A study in peri-arthritis of the shoulder (coined the term)

• Reeves: Scand J Rheum, 1975: Frozen

shoulder is a condition of uncertain cause, characterized by spontaneous onset of pain with significant restriction of both active and passive range of motion of the shoulder

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ANKYLOSIS

• Ankylosis (Anchylosis) is stiffness of a

joint due to abnormal adhesions, scar and rigidity …..due to inflammation/scarring of the tendinous, muscular and ligamentous structures

• utside and inside the joint

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AC : CLASSIFICATION

• Primary (Idiopathic –

means we don’t know)

• Secondary Systemic (DM,

Thyroid)

• Extrinsic : heart, breast,

neck, stroke

• Intrinsic: RC ,biceps, calcific

tendonitis

• Tertiary (Ankylosis) Post
• p (SLAP), fracture, RC

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AC : PATHOLOGY

• Thickened, contracted

capsule with peri- articular hypertrophic synovitis ( Bateman)

• • Neer: starts at CHL
• • Duplay(1896) starts

@subdeltoid bursa

• • Myer, Pasteur,

DePalma: starts @ Biceps

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AC: PATHOLOGY: TREATMENT

• Initial structures

involved are the PIGHL and CHL, which is what we need to treat

• • Progressively

involves more of the interval structures , Capsule and biceps as stages progress

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AC: HISTORY

• Gradual onset of vague

pain

• Pt will usually relate

some minor injury

• Often first noticed with

a sudden movement or extreme (putting on coat) motion

• May have numbness

radiating down the arm, spasm in scapula, trapezius and cervical area

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PHYSICAL EXAMINATION

• Inspection

unremarkable except for mild dyskinesia

• • Palpation:

tenderness over the rotator interval

• • PROM may not be

limited early

• • Often impingement

and slap signs +

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AC EXAM: INFERIOR GLIDE TEST (how to not get fooled)

• Tests main

structures(CHL/IGHL) involved in early capsulitis

• Arm slightly abducted

to 40 degrees, cup the elbow and do a gentle inferior shift into pighl, IGHL, and AIGHL with a pulling type move

• 100% sensitivity for AC

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AC EXAM: INFERIOR GLIDE TEST (how to not get fooled)

• 280 new shoulder patients
• Independent exam by attending( FHS)

and resident (KF)

• 35 + IGT by both examiners, all

developed AC

• 245 neg IGT : variety of pathology but

no capsulitis

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AC EXAM: IMAGING

• Radiographs typically

normal

• • MRI often read as

SLAP/ tendonosis early, will show increased signal at rotator interval area if you look closely

• • Later will show

contracted inferior capsule

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AC PHASES (NEVAISER)

• Phase 1: pre-adhesive
• Phase 2: Acute
• Phase 3L Chronic
• Phase 4: Mature

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AC PHASES (NEVAISER)

• Phase 1: pre-adhesive
• Phase 2: Acute
• Phase 3L Chronic
• Phase 4: Mature

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AC PHASES (NEVAISER)

• Phase 1: pre-adhesive
• Phase 2: Acute
• Phase 3L Chronic
• Phase 4: Mature

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AC PHASES (NEVAISER)

• Phase 1: pre-adhesive
• Phase 2: Acute
• Phase 3L Chronic
• Phase 4: Mature

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AC INITIAL TREATMENT

• Steroid injection

– Intra-articular – PIGHL/CHL

• Physical therapy
• Meds

– NSAID ineffective – Oral steroids some efficacy

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AC: TREATMENT EVIDENCE

• 32 trials with 1836 patients
• Steroid injection definitely

effective in decreasing pain (VAS scale) and motion

• Manual therapy was not

better than home exercise

• NSAID had no effect
• Oral steroids had

subjective effectiveness in improving “well being”

Paye et al: 2014 Cochrane data base review

• 25 studies , 7 RCT
• 92% of patients improved with

injections

• @ 2 years all patients showed

increased motion and decreased pain regardless of treatment

Song, Higgins Neuromuscular J systemic review

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AC: MANIPULATION

• Indication: failure to

improve after 3-6 months

• f PT
• Contra-indication:

Diabetes ( 50% failure rate), – Post Surgical (especially RC & SLAP: retear)

• Risks: XRAY!

– fracture ( 10%) – plexopathy (2%), – dislocation (rare but devastating)

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ANKYLOSIS: MANIPULATION

• This is not AC but a joint

surrounded by thick scar

• Post RC : the weakest

part of the shoulder is

• ur repair
• Post fracture: the

weakest part is the bone

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ARTHROSCOPIC RELEASE

– Manipulate first or after release – Risks of entry – Order of release and what do we release – Acromioplasty – Injection when completed or wait until follow up – CPM/PT post op

• Questions:

– Either-I prefer after surgical

release: not an option in ankylosed shoulder: always release – Blunt trocar, keep it high to avoid chondral injury – Interval, then 360 capsule CHL in bursa and in ankyloses will remove all scar between deltoid and rc Yes plus steroid injection and oral

• Answers

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AC: ARTHROSCOPIC RELEASE

INTIAL EVALUATION RELEASE ROTATOR INTERVAL

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AC: ARTHROSCOPIC RELEASE

ANTERIOR RELEASE TO 5 POSTERIOR RELEASE

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AC: ARTHROSCOPIC RELEASE

INFERIOR RELEASE: ADD PORTAL CHL RELEASE IN BURSA

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AC: ARTHROSCOPIC RELEASE: RESULTS

• Esch, Gartsman &

Harryman credited with development

• Berndt et al: Oper ortho

traum 2014: 27/37 improved with full rom at 3.6 months

• Mehta et al JBJS 2014 :

90% of non diabetics and 70% of diabetics

• btained full motion

Recommended Reading:

• Warner: JBJS 79: 1997 1808-

1816: Arth rel for chronic AC

• Warner: J Am Acad Ortho

Surg: 1997: 5: 130-140 Ad. Cap

• Warner : treatment of the stiff

shoulder after RCR: JBJS 79, 1997

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ANKLYOSIS: RESULTS

• Minimal data available
• Field/Savoie released

1/283 stiff RC had a release and it was successful

• Blended with stiff

shoulder of any kind

• Surgical results generally

good

• Bhatia ( Rush group)

Indian J Ortho: 29 post RCR stiff patients with arthroscopic release

• F 105 improved to 159
• ER 25 improved to 59
• No complications or re-

tears

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CONCLUSIONS: AC

• Etiology of adhesive

capsulitis remains poorly understood

• Diagnosis by inferior

glide test is effective

• Steroid injections and

meds are mainstay of non operative treatment

• Manipulation under

anesthesia can work for non diabetic, non ankylosis cases

• Arthroscopic release

provides best results in diabetics and postoperative cases

THANK YOU

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