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7 January, 2019 00:00 00 AM

Frozen shoulder

Prof. Dr. Hafizuddin Ahmed
Frozen shoulder

Working as Head of the Dept. of Surgery of MSMCH every other day I had to see a case of Frozen Shoulder. It was a great concern for me. I could well imagine how large is the number of people suffering from this condition in our society.

Definition:

It is a painful adhesive capsulitis i.e. periarthritis occurring in the shoulder joint in the advanced age causing restriction of the movement. It is also used as a synonym for Supraspinatus tendinitis.

History:

More than 150years ago description of Frozen Shoulder appeared in the medical literatures.

Anatomical consideration:

Shoulder joint or Glenohumeral joint is a ball and socket type of synovial joint formed by the head of humerus and glenoid cavity of scapula. The head pf the humerus is four times the size of glenoid cavity which is small(1sq.inch) and shallow. This gives the joint a wide range of mobility (flexion, extension, adduction, abduction, medial rotation, lateral rotation, circumduction). The ligaments of the joint are: Fibrous capsule, Coracohumeral ligament, Glenohumeral ligament, Transverse humeral ligament and fibrocartilaginous Glenoidal labrum. There are nine bursae around the joint.

This weak joint is strengthened by coracoacromial arch, Glenoidal labrum (reflected from the margin of glenoid deepens the cavity), Musculotendinous cuff or Rotator Cuff (formed by Subscapularis infront, Supraspinatus above and behind by Infraspinatus with Teres Minor.Besides the long head of Biceps above, long head of Triceps below and atmospheric pressure(15lb in 1sq.inch of glenoid) comes in support.

The blood supply of the joint is derived from Anterior & Posterior cicumflex humeral, Suprascapular and Subscapular arteries. Nerve supply comes from Axillary, Musculocutaneous and Suprascapular nerves(supplies capsule).

Abduction movement:

Abduction of normal shoulder joint occurs through 180 degree with the effort of shoulder joint and shoulder girdle that causes forward rotation of scapula round the chest wall. For every 15 degree elevation 10 degree occurs at shoulder joint and 5 degree by the scapular movement.

Abduction is initiated by the middle fibres of Deltoid and maintained by Supraspinatus. Initial 25-30 degree abduction occurs at at Shoulder joint. Other muscles that are involved include: Serratus anterior and upper and lower fibres of Trapezius. Besides Subscapularis, Infraspinatus and Teres minor provide opposing force by exerting downward traction on the head of humerus and these with Deltoid constitute a 'couple' for abduction.

Signs and symptoms:

Sudden onset of pain around the shoulder joint which gradually lncreases. It becomes so acute that many patients can't sleep especially on the affected side and wake up at night. Pain is provoked by movement and may move to the neck as by that time accessory muscles of neck that raise the scapula are overworking. Restriction of movement especially abduction is so severe that it interferes with normal activities including eating, dressing, washing etc. Because of acute pain the patient tries to protect the shoulder by holding it still which increases more stiffness leading to more movement restrictions.

In the first 3 months pain, stiffness and movement restrictions gradually increase and reach to the height. The next 3 months the condition remains static. Then with increase movement and supportive treatment it returns to normal within 9-12 months. Sometimes it takes 3 years to become normal.

Etiology:

The cause is unknown. It occurs spontaneously or following some injury or sudden abnormal movement of the joint causing pain and stretching or rupture of the ligament or in bed ridden/plastered patient . Diabetes Mellitus, Dupuytren's, Cardiovascular disease etc make the patient more susceptible to it.

Age:

Female: 40-50 years, Male: 50-60years.

Pathology:

By lnflammatory exudate the 2 layers of synovial membrane of the shoulder joint adheres to one another. When shoulder joint is glued the loss of the movement is partly compensated by increased mobility of scapula.

Examination and Differential Diagnosis:

The patient should be stripped to the waist. The contour of the shoulder (normal rounded shape is lost in the dislocation), flattening, wasting should be inspected and range of movement should be tested by standing behind the patient. The diseases that should be excluded are:

1. Acute arthritis

2. Osteoarthritis

3. Tuberculosis

4. Charcot's disease

5. Painful Arc Syndrome (occurring between 45-160 degree).

6. Incomplete rupture of Supraspinatus tendon

7. Calcified deposits in Suprspinatus.

8. Subacromial bursitis

9. Crack fracture of greater trochanter of humerus

10. Any condition causing irritation of the diaphragm can also give risevto pain in shoulder as Phrenic nerve and Supraclavicular nerves contain fibres from cervical 3 and 4 spinal segments. Supra-acromial nerve of Supraclavicular group supplies skin half-way down to Deltoid muscle and posterior aspect of shoulder as far down as spine of scapula.

Investigations:

1. X-Ray shoulder region: to exclude other abnormalities.

2. T.C,ESR: to exclude other diseases. High T.C. indicates infective process and raised ESR hints to tuberculosis which should be excluded by further tests.

3. C-RP

Treatment:

Pain Relief

Paracetamol or Ibuprofen, Indomethacin suppository occasionally in severe pain at night.

Physiotherapy

The doctor who sees the patient first must start the first physiotherapy himself by manipulating the joint at the chamber without anaesthesia as far as bearable by the patient. However consent should be taken before such act. Then he will teach the patient certain movement of the shoulder that should be practiced daily:

a) Ask the patient to clasp fingers of one hand with the other making lock and trying to taking the arch such formed over the head to back. Initially he or she will fail to do so but later on becomes successful and stiffness will go.

b) Ask the patient to stand near a wall and raise the affected hand daily twice from lateral side climbing i.e. Finger Walk with fingers as far as possible marking the height he reached. Following day he should try to climb a little higher than the previous mark and make a new mark. Ultimately some day the person will be able to climb with the fingers making 180 degree and patient will be free from suffering.

c) Ask the patient to stand and lean over slightly allowing affected arm to hang down and swing the arm in small circle about a foot diameter 10 times once daily.

Manipulation under anaesthesia

Following such manipulation the capsule around the joint will be torn allowing the it to move freely..

Surgery

Surgical Release can be done by a key hole arthroscopic procedure cutting tightened tissues.

Hot application

Taking hot bath, pouring hot water over shoulder i.e. application of heat  gives comfort and quick recovery. Ask the patient to take warm shower or bath for 10-15 minutes daily.

Injection therapy

In stubborn cases intra-articular injection of Hydrocortisone 25 mg or Triamcinolone mixing with local anaesthetic e.g. 2/: Lidocaine 1c.c.can be given.

Conclusion

The most important thing is that analgesic should be prescribed to the patient to relieve pain The doctor should show him to try to do exercises of the limb as far as possible to keep his shoulder moving or refer him to an ideal physiotherapist. Ask the patient kindly not to use gym equipment for exercises.

 

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Editor : M. Shamsur Rahman

Published by the Editor on behalf of Independent Publications Limited at Media Printers, 446/H, Tejgaon I/A, Dhaka-1215.
Editorial, News & Commercial Offices : Beximco Media Complex, 149-150 Tejgaon I/A, Dhaka-1208, Bangladesh. GPO Box No. 934, Dhaka-1000.

Editor : M. Shamsur Rahman
Published by the Editor on behalf of Independent Publications Limited at Media Printers, 446/H, Tejgaon I/A, Dhaka-1215.
Editorial, News & Commercial Offices : Beximco Media Complex, 149-150 Tejgaon I/A, Dhaka-1208, Bangladesh. GPO Box No. 934, Dhaka-1000.

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