Adhesive Capsulitis
Causes: |
Diabetes |
Thyroid Disease |
Pulmonary disorders - TB, carcinoma |
Cardiac Disease (MI) |
Cerebrovascular accident |
Shoulder Trauma |
Recent surgery under anaesthetic |
Impingement Syndrome
- Not a condition on it's own |
- Caused by:
Subacromial Bone spurs/bursal hypertrophy
AC Joint arthrosis/bone spurs
Rotator cuff disease
Superior labral injury
GIRD
GH Instability
biceps tendinopathy
Scapular dyskinesis
Cx radiculopathy |
- Hx: Dull, achy shoulder - worse with shoulder abduction , overhead activity/excessive use
Sudden onset of sharp pain in shoulder with tearing = rotator cuff tear |
Exam: Pain on top of shoulder = AC joint arthritis
Pain over bicipital groove = bicipital tendonitis
Pain over lateral shoulder = supraspinatus tendinopathy
AROM = pain with shoulder abduction/flexion 8-120 degrees + shoulder hiking
PROM: WNL unless tendon is involved
RROM: Muscle weakness due to pain
SMR = WNL - rule out Cx radiculopathy/neurological
+ve impingement sign
+ve neer's sign
+ve Hawkins Kennedy
+ve Drops arm, Empty Can |
DDx: Biceps tendonitis, rotator cuff injuries, Adhesive capsulitis, AC joint pathology, Glenoid Labral Tear, Subacromial Bursitis |
Management: Education + reassurance , avoidance of aggravating activity, PRICE + NSAIDs, MF release, Manipulation of SC, AC, Cx,Tx, TENs, US
Rehab: Ice and rest shoulder after
PRFROM + Pendulum arm swings, stretching then PFAROM + mild resistance exercises |
GH Instability
Types: Anterior inferior (common), Posterior, Multidirectional - congenital |
- Trauma related - direct/overuse (overhead activities), intentional, atraumatic - congenital, bilateral, joint laxity |
Hx: General shoulder pain, worse with activity/certain arm positions
Relieved by rest/heat
Hx of catching/locking with motion
Painful arc of motion (impingement) |
Exam: Sulcus sign/redness
Trigger points + myospasm of rotator cuff
AROM/PROM shows repeatable clunk/apprehension with abduction + external rotation
+ve Load and shift
Anterior/posterior apprehension sign. |
DDx: Labral Tear/GH OA
Biceps Tendinopathy
Rotator cuff tear
Shoulder Impingement
Subacromial Bursitis |
Management: Correction of faulty movement patterns - strengthening of rotator cuffs + correction of muscle imbalances (PFROM then to mild resistance exercises), if not getting better, consider referral to GP for surgery |
GH Dislocation
- Usually anterior |
- Forced abduction + external rotation |
- Severe pain, patient holds arm tightly against body |
- Shoulder appears flattened laterally + prominent anteriorly. AC more prominent too |
- X-rays in AP and Lateral scapula/axillary |
- Posterior dislocation - axial loading of adducted, internally rotated arm. Seizure should be considered! |
Management
- Rest - may need a sling for several days |
- Cryotherapy |
- NSAIDs |
- GP for corticosteroid injections |
- Can improve within 4-5 days of conservative care |
Calcific Tendinitis
- HADD = Hydroxyapatite Deposition Disease |
- Caused by trauma/overuse |
- Intense pain in the shoulder, radiates down upper arm - starts suddenly and rapidly becomes worse |
- Pain worse with ANY shoulder movements and restricted in ALL directions |
- Clinical features + X-ray (soft tissue calcifications) |
Management
- Cryotherapy |
- Sling (48-72 hours) - decreases tension on supraspinatus tendon |
- Mobility exercises |
- NSAIDs |
- Mobilisation/manipulation of GH, AC, SC and Scapular abnormalities |
Subacromial Bursitis
- Caused by inflammation of supraspintus and/or other structures around the bursa |
- Pain and swelling = impingement |
- Pain on active + passive ROM of the shoulder |
- Focal warmth, swelling |
- Pt shrugs shoulder to initiate abduction |
- Ultrasound |
Management
3 times a week (intensive) - No manipulation at initial stage |
Rest |
Pendular Exercises |
NSAID advice - pharmacists |
Cryotherapy |
US, IF |
Trigger points/bands of the shoulder girdle - upper traps |
Spencer Technique |
When acute episode is better, restore function - active exercises |
Mobilisation/manipulation |
PIR |
Resisted strengthening exercises - isometric (press against wall) in pain free range to isotonic (moving shoulders with weights) |
DOES NOT RECUR IN THE SAME SHOULDER WHEN BETTER |
Spencer: 7 stages
1. GH Flexion + elbow extension
2. GH Extension + elbow flexion
3. Circumduction + traction
4. Circumduction + compression
5. Externally rotate + adduct (combing hair)
6. Internally rotate + abduction and extension (wiping bum)
7. Milking - scoop up
4-5 repetitions on every step. Slow movements
S&S
Onset usually >40 yo, mean age 60yo |
F > M |
Unilateral (But can be bilateral - rare) |
Increasing pain and stiffness |
3 Phases: |
Painful phase: Insidious onset - shoulder pain + ache on movement in upper traps. Increasing during the night |
Adhesive: After several months - pain becomes less severe, but pain during movement remains. Shoulder movement more restricted |
Resolution: Pain less severe , restriction is worse. ROM slowly improved |
- To differentiation between rotator cuff tenditis, Adhesive capsulitis has global restriction of passive movment , traps tenderness and early movement of scapula on abduction
Causes of Shoulder Pain
- Myofascial pain syndrome |
- Cx Dysfunction with referred pain |
- Cx Radiculopathy |
- Supraspinatus Tendinosis |
- Adhesive Capsulitis |
- Subacromial impingement syndrome |
- Supraspinatus tendon tear/rupture |
- Acute Bursitis |
- Calcific Tendinitis |
- GH Arthrosis |
- TOS |
- AC joint osteoarthrosis |
- Bicep Tendinitis |
- Visceral Referred Pain |
In Elderly
- PMR |
- Supraspinatus Tear+ Persistent tendinitis |
- Other Rotator Cuff Disorder |
- Stiff Shoulder due to Adhesive Capsulitis |
- OA of AC + GH joints |
- Cx manipulable lesion with referred pain |
- AVN of the humeral Head |
In children
- Septic Arthritis/osteomyelitis |
- Swimmer's Shoulder |
Investigations
- ESR/CRP (PMR, Infection, Inflammatory) |
- RF |
- Serum Uric acid (Gout) |
- X-ray |
- Bone Scan |
- US |
- MRI |
Further Questions
Injury - even very minor when the pain started? |
Does the pain keep you up at night? |
Pain/Stiffness in neck? |
Pain/restriction when clipping/handling your bra or touching you shoulder blades (limited internal rotation) |
Trouble with combing hair? (External rotation) |
Pain on walking/some stressful activity? |
Pain worse when waking in the morning? |
Is it both sides? Do you have it in your hips too? |
Pain associated with sporting activity, housework, dressing? |
Hx
Age |
<40yo: Instability, rotator cuff tendinopathy
>40yo: Rotator Cuff tears, Adhesive Capsulitis, GH OA |
Diabetes/Thyroid disorders |
Adhesive capsulitis |
Hx of trauma |
<40 yo: Shoulder Dislocation/subluxation
>40 yo: rotator cuff tears |
Loss of ROM |
Adhesive Capsulitis, GH OA |
Night Pain |
Rotator Cuff Disorders, adhesive capsulitis |
Paraesthesia and arm pain past elbow |
Cx Spine |
Pain Location |
Anterior- Superior shoulder pain = AC joint
Diffuse shoulder pain in deltoid = rotator cuff, adhesive capsulitis, GH OA |
Pain with overhead activity |
Impingement, rotator cuff disorders |
Sports |
Instability - overhead sports and collision sports |
Weakness |
Rotator Cuff disorders, GH OA |
Hx
- Duration |
- Onset - Night pain when leaning + Hx of trauma, >65 yo = rotator cuff tear |
- Activity/mechanism at the time of onset - Overhead work = impingement syndrome (60-120 degrees) |
- Activities that relieve/exacerbate |
- Patient's age - <30 = biomechanical/inflammatory (atraumatic instability, tendinosis and arthropathies)
>45 = Complete rotator cuff tears |
- Past Hx of trauma/injury |
- Past Hx of shoulder/arm surgery |
- Treatment attempted - not getting better |
- Other medical conditions (Diabetes, Thyroid disease, Coronary Artery disease, Alcohol abuse + use of corticosteroids) |
Referral
- Persisting night pain with shoulder joint stiffness |
- Persisting supraspinatus teninitis - Rotator cuff tear/degeneration |
- Confirmed/suspected shoulder dislocation |
- Confirmed/suspected recurrent subluxation/AVN |
- Children with shoulder instability |
Pitfalls
- Referred sources of shoulder pain: Cx spondylosis, Cx arthritis, Cx disc disease, MI, CRPS, Diaphragmatic irritation, TOS, Gallbladder Disease |
- PMR ( >60 yo, bilateral, inflammatory shoulder girdle pain) |
- Posterior dislocation of the shoulder joint |
- Recurrent subluxation of shoulder joint |
- AVN of humeral head |
- Rotator cuff tear/degeneration |
Serious Disorders
- Malignancy |
- Septic Infection |
- Carcinoma of the lung |
- MI |
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