Frozen shoulder Korapuk Lerswanichwattana,MD

Advisor Asst.Prof. Chanakarn Phornphutkul

Asst.Prof. Prasit Wongtriratanachai
Dr. Puwapong nimkingrata
Outline

• Introduction
• Pathology
• Classification
• History and Symptoms
• Diagnostic Imaging
• Treatment
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1 Introduction
Frozen shoulder
§ Adhesive capsulitis or frozen shoulder
Active and passive ROM are limited secondary to formation
of adhesions of the glenohumeral joint capsule
§ Primarily involves contracture of joint capsule and rotator interval

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Frozen shoulder
§ Incident 2% in general population
§ Age 40-60 years old
§ Female > male (F : 70%)
§ 30% in contralateral shoulder
§ Most idiopathic
§ Usually resolves in 12 to 18 months
§ Rarely recurs in same shoulder

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2 Pathology
Pathology
§ Pathophysiology of AC is often idiopathic

§ Main pathology involves inflammatory

contracture of shoulder capsule with
recruitment of inflammatory cytokines

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Pathology
§ Inflammatory process >> fibroblastic proliferation of joint capsule
leading to thickening, fibrosis and adherence of the capsule
§ Leading to mechanical block to motion

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§ These photos taken through an arthroscope show
a normal shoulder joint lining (left)
and an inflamed joint lining affected by frozen shoulder 9
3 Classification
Arthroscopic stages
§ Classified into 4 stages on arthroscopic and histologic appearance
§ Stage 1 : the pre-adhesive stage
§ Proliferation of the fibroblasts without formation of adhesions
§ Full ROM but pain
§ Stage 2 : acute adhesive synovitis
§ Hypertrophy of synovium and early formation of adhesions
§ mild loss of ROM with pain

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Arthroscopic stages
§ Stage 3 : the maturation stage
§ Transition of synovitis to fibrosis
§ The axillary fold is often adhered to capsule
§ ROM markedly reduced less pain than in earlier stages
§ Stage 4 : the chronic stage
§ Severe loss of ROM and dense fibrotic adhesions
§ Minimal pain, except when ROM is forcefully moved past
restraints of fibrotic capsule

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Clinical stages
§ Stage I : Freezing (painful) 4 months
§ Pain any shoulder movement (Gradual onset, worse at night)
§ Begin stiffness
§ Stage II : Frozen (Stiff) 4-12 months
§ Pain begins to subside
§ ROM is significant limited
§ Trouble in getting wallet in back pocket/fasten brassieres
§ Stage III : Thawing (resolving) 5-26 months
§ ROM begin improve
§ Pain diminishes
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Clinical stages

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4 History and Symptoms
History
§ Poor localized pain at shoulder
§ Progressive gradual onset pain
§ Severe pain at end point of motion

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Physical examination
§ Inspection
§ Palpation
§ Rotator cuff power
§ Range of Motion
§ Loss of active and passive ROM
§ Internal rotation is lost initially
§ followed by flexion and external rotation

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5 Diagnostic Imaging
Diagnostic Imaging
§ Plain radiographs >> classically normal
§ MRI :
§ Contracted inferior capsule with increase blood flow to the
synovium
§ Thickening of joint capsule and synovial membrane > 4 mm

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6 Treatment
Treatment option
§ Nonsurgical Management
§ Oral anti-inflammatories, either nonsteroidal (NSAIDs)
§ Short tapered course of corticosteroids
§ Physical therapy : Jackins exercise

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Treatment option
§ Nonsurgical Management
§ Corticosteroid Injections : most effective in early

§ Role of intraarticular corticosteroid injection

§ Reduce inflammation & synovitis
that shortening natural history of the disease

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High VS Low dose corticosteroid injection
§ Triamcinolone acetonide long-acting corticosteroids

§ Triamcinolone acetonide 20 mg VS 40 mg
§ No clinical significant difference between high and low dose
corticosteroid injection
§ Initial use of low dose encouraged to minimize potential local and
systemic complication

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Ultrasound guide corticosteroid injection

Blind injection (anatomic landmarks)

VS Ultrasound guide injection

§ Ultrasound-guided intra-articular injection

§ more accurate & effective than blind injections
§ Improve in pain, function of patients
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Treatment option
§ Nonsurgical Management
§ Extracorporeal Shock Wave Therapy
§ Alternative to corticosteroids
§ no adverse events
§ Calcitonin
§ Decrease systemic inflammatory response
§ low adverse effect

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Treatment option
§ Nonsurgical Management
§ Ultrasonography–guided
Hydro distention
§ effective in short term

§ Hyaluronic Acid Injections

§ Combination with corticosteroid injections and PT

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Manipulation under anesthesia
§ Indication
§ Failure (decrease motion) 4-6 month of exercise
§ Failure pain relief, intraarticular steroid injection
§ Contraindication
§ Inflammatory phase [Freezing stage]
§ Fail previous MUA
§ Severe osteopenia
§ Recently healed fracture

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Manipulation under anesthesia
§ Closed Manipulation
§ Safe sequence (FEAR) for shoulder manipulation
§ Flexion, Extension, Abduction and Adduction,
external and internal Rotation

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Arthroscopic capsular release
§ Indication
§ Fail conservation treatment
§ Fail close manipulation
§ Contraindication for MUA
§ Recurrence of stiffness after MUA

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Arthroscopic capsular release

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Arthroscopic capsular release

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Arthroscopic capsular release

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Open release
§ Indication
§ For release extracapsular adhesion
§ Lysis subdeltoid adhesion
§ Release rotator interval
§ Release or lengthening of subscapularis

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Manipulation Under Anesthesia Alone
Versus Arthroscopic Capsular Release

§ Prospective study
§ 26 - Patients randomized to surgical group underwent
arthroscopic capsular release and MUA
§ No statistically significant difference existed
§ Systematic review of 22 studies
§ Compared outcomes between patients treated with MUA,
capsular release, or a combination of both
§ Little benefit may be there for capsular release
instead of, or in addition to, an MUA
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Reference

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THANK YOU