Frozen Shoulder

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Definition

  The term was coined in 1934 by Codman

 “Frozen shoulder was characterised by slow onset, pain near the insertion of the deltoid, inability to sleep on the affected side, painful and restricted elevation and external rotation, and a normal radiological appearance.”

Codman's 12 Criteria:

  1. The condition comes on slowly

  2. Pain is felt near the insertion of deltoid

  3. Inability to sleep on the affected side

  4. Painful & incomplete shoulder elevation

  5.  plus external rotation

  6. restriction of both spasmodic

  7. and adherent type

  8. Atrophy of the spinatii

  9. Little local tenderness

  10. X-rays negative except for bony atrophy

  11. The pain was very trying to every one of them

  12. but they were all able to continue their daily habits & routines.

The stiff painful shoulder can be classified into two groups.

  •  Patients with primary frozen shoulders are those who fit Codman's criteria and in whom all other pathology is excluded

  • Patients with secondary frozen shoulders are those who fit Codman's criteria but in whom the condition is secondary to soft-tissue injury, fracture, arthritis, hemiplegia, or any other known cause.


 Incidence

  Quite rare, 5% (70/1,324) of consecutive new patients attending a shoulder clinic (Bunker et al)


Clinical Presentation

  •  Age (Mean 56 years) presents with an insidious onset of true shoulder pain. and difficulty sleeping on the affected side

  • Male = Female

  • L = R

 On examination

  1. Patient may suffer from depression because of the relentless night pain

  2. There is usually no wasting

  3. Deltoid may be wasted as a result of disuse

  4.  May be tenderness lateral to the coracoid process (not consistent)

  5.  Active and passive movements are markedly restricted Combined elevation is less than 100 degrees (combined elevation 83.2 º)

  6.  External rotation (passive) should be less than 50% of the unaffected side

  7. Reduction of passive external rotation is the pathognomonic sign of frozen shoulder

  8. Gross limitation of passive external rotation is present only in three conditions: arthritis, locked posterior dislocation, and frozen shoulder. (average ER 9.4 º)

  9. Internal rotation is similarly restricted both actively and passively.  Patient can just reach buttock level

 


Associated Conditions

 1. Diabetes (incidence of frozen shoulder)

  • NIDDM 10% – 20%

  • IDDM 36%

  • 42% of patients with bilateral frozen shoulder are diabetic.

2. Dupuytren’s Disease

  • Bunker examined the hands of 50 patients. 29 of 50 patients had a pit, nodule, or band of Dupuytren's contracture

 3. Elevated serum lipids

  • In one study, fasting serum lipid levels were tested and a significant elevation of cholesterol and triglyceride was found in patients with frozen shoulder.

  • Elevated serum lipid levels are found in patients with Dupuytren's contracture, cardiac disease and diabetes.

 4. Minor trauma

  • e.g. following a Colles' fracture

5. Anti-epileptics

  1. Frozen shoulder has been recorded in patients recovering from neurosurgery

  2. Phenytoin is associated with Dupuytren's disease

  3. Phenobarbitone is associated with frozen shoulder

6. Metallomatrix Proteinase Inhibitors (MMPI)

  • Patients developed bilateral frozen shoulder following administration of MMPI for gastric carcinoma.


 Diagnostic Tests

  •  FBC/ESR and HLA-B27 normal

  • X-rays, by definition, must be normal, although some disuse osteopenia is allowed.

Neviaser (1962) using arthrography, showed that there was a characteristic reduction in joint volume in frozen shoulder, with a lack of filling of the axillary fold and the subscapular recess (the rotator interval)

Emig et al examined nine patients with frozen shoulder using MRI and found that the capsule was thickened, averaging 5.2 mm thick in the frozen shoulder group against 2.9 mm thick in the control group (p < 0.01)

 

Arthroscopy

  • Joint volume reduced

  • Subscapularis recess is obliterated

  • Rotator interval is often obliterated with scar tissue covered in a highly vasculitic synovium with papillary infolding

  • Axillary recess is tight and of reduced volume

  • There are no adhesions

 

Surgical Exploration (Bunker et al)

  •  Coracoacromial ligament is always normal

  • Abnormal thickening in the rotator interval area with the rotator interval area distorted by scarring and contracture of the coracohumeral ligament

  • Superior edge of the subscapularis tendon and anterior edge of the supraspinatus tendon is highly abnormal

  • If the arm is externally rotated, this scarred area tightens and can be seen to be acting as a checkrein to external rotation

  • Division of this scarred area allows immediate and complete external rotation in the majority of patients

  • The scarred area is highly vascular and when divided bleeds forcefully  


Pathology (Fibromatosis)

  •  Frozen shoulder is a disease characterised by fibrosis of the shoulder joint capsule histologically similar to Dupuytren's contracture
  • Contracture of the coracohumeral ligament that acts as a checkrein to passive glenohumeral movement and external rotation

 

Histology of the thickened rotator interval tissues

  • The tissue showed nodules and laminae of collagen with a high cell population of fibroblasts and myofibroblasts as identified by immunocytochemistry

  • These findings were identical both histologically and by immunocytochemistry with six control cases of palmar Dupuytren's tissue


Natural History of Frozen Shoulder

 The classic understanding that frozen shoulder is a disease with three phases of pain, stiffening, and thawing leading to resolution in 2 years may be optimistic.

 Do patients improve by 2 years?

  • Shaffer (1992) showed that they did not in a detailed long-term study of the natural history of frozen shoulder

  • 50% of patients had either mild  pain or stiffness or both at an average of  7 years after the onset of the disease

  • None of the patients reported the pain as more than mild and the stiffness was mainly in external rotation

  • Functional restriction was small.

 


Treatment

 

Conservative: Physiotherapy

Steroid Injection

  • Steroid injections have been given empirically in frozen shoulder

  • Some studies show a beneficial effect from the use of intra-articular steroids

 

Manipulation Under Anaesthesia

  • Charnley (1959) manipulated the frozen shoulders of 35 patients

  • Pain relief was the most important result of manipulation

  • Duration of symptoms after manipulation lasted for an average of 10 weeks, no matter how long the symptoms had been present before the manipulation

  • Charnley insisted on one matter of technique: that external rotation should be released before abduction was attempted or dislocation could occur.

  •  In a carefully controlled study, it was shown that:

    • 75% of patients obtained a near-normal range of motion

    • 79% were relieved of their pain

    • 75% returned to work within 9 weeks of manipulation.

Diabetics have a poor response to manipulation – Janda and Hawkins showed that any improvement in movement and diminution in pain disappeared by 4 weeks after manipulation and suggested that manipulation should not be attempted in these patients.

 

Open Surgical Release 

  • Ozaki Release: Gridiron incision (coracoid -> clavicle)- spread deltoid- divide CHL & clear RCI w/ ronguer/ duckbill (inside out)- Beware LHB under CHL; = simple, safe, effective.

Arthroscopic Surgical Release 

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