Frozen shoulder or adhesive capsulitis:>>>>>>>>>HomeSHOULDER JOINT:
The human shoulder is made up of three bones: the clavicle (collarbone), the scapula (shoulder blade), and the humerus (upper arm bone) as well as associated muscles, ligaments and tendons. The articulations between the bones of the shoulder make up the shoulder joints. “Shoulder joint” typically refers to the glenohumeral joint, which is the major joint of the “shoulder,” but can more broadly include the acromioclavicular joint. In human anatomy, the shoulder joint comprises the part of the body where the humerus attaches to the scapula, the head sitting in the glenoid fossa[disambiguation needed].[1] The shoulder is the group of structures in the region of the joint.[2]
There are two kinds of cartilage in the joint. The first type is the white cartilage on the ends of the bones (called articular cartilage) which allows the bones to glide and move on each other. When this type of cartilage starts to wear out (a process called arthritis), the joint becomes painful and stiff. The labrum is a second kind of cartilage in the shoulder which is distinctly different from the articular cartilage. This cartilage is more fibrous or rigid than the cartilage on the ends of the ball and socket. Also, this cartilage is also found only around the socket where it is attached.[3]
The shoulder must be mobile enough for the wide range actions of the arms and hands, but also stable enough to allow for actions such as lifting, pushing and pulling. The compromise between mobility and stability results in a large number of shoulder problems not faced by other joints such as the hip.
Anatomy of the shoulder joint:
The humerus, glenoid, scapula, acromion, clavicle and surrounding soft tissues make up the shoulder. There are three significant articulations: the sternoclavicular joint, the acromioclavicular joint and the glenohumeral joint. The glenohumeral joint is the most commonly dislocated major joint in the body.
Ligaments and surrounding musculature, including the rotator cuff muscles, contribute to shoulder joint stability. The rotator cuff is composed of the four muscles: supraspinatus, infraspinatus, teres minor and subscapularis. These muscles help with internal and external rotation of the shoulder and also depress the humeral head against the glenoid.1
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Epidemiology:
• Shoulder pain is the third most common cause of musculoskeletal consultation in primary care.
• 1% of adults with new shoulder pain consult their GP each year.
• Self-reported prevalence of shoulder pain is between 16% and 26%.
Risk factors:
• Physical factors related to occupation including repetitive movements and exposure to vibration from machine tools.[3][4]
• Psychosocial factors related to work may also be risk factors for shoulder pain, including stress, job pressure, social support and job satisfaction. However, in a systematic review, results were not consistent.[3]
• Athletes who are involved in throwing sports, sports that involve repetitive arm movements or high-impact contact sports, eg rugby and swimming/diving, are prone to shoulder pain.
• Occupations particularly prone to shoulder pain syndromes include: cashiers, garment makers, bricklayers/construction workers, pneumatic tool operators, welders, meat/food-processing workers, hairdressers, plasterers, assembly/production line workers, and workers using keyboards for long periods, eg IT, secretarial
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Causes of shoulder pain:
Patients presenting in primary care often have a combination of different shoulder problems.
• Intrinsic shoulder pain:
• Rotator cuff disorders: rotator cuff tendinopathy, impingement (trapping of the rotator cuff tendon, particularly the supraspinatus, in the subacromial space), subacromial bursitis, rotator cuff tears, calcific tendonitis.
• Glenohumeral disorders: adhesive capsulitis (‘frozen shoulder’), arthritis.
• Acromioclavicular disorders.
• Biceps tendonitis.
• Infection (rare).
• Shoulder instability – associated with hypermobility including subluxation or dislocation (see also separate article Shoulder Dislocation).
• Extrinsic shoulder pain:
• Referred pain: neck pain, myocardial ischaemia, referred diaphragmatic pain (eggallbladder disease, subphrenic abscess).
• Polymyalgia rheumatica.
• Malignancy: apical lung cancers, metastases.
The four most common causes of shoulder pain and disability in primary care are rotator cuff disorders, glenohumeral disorders, acromioclavicular joint disease and referred neck pain.
Rotator cuff disorders:
Impingement syndrome (or rotator cuff syndrome) is used for rotator cuff lesions, including all stages of tendon disease from early degeneration through to complete tears.
• Most often present in patients aged 35-75 years.
• Rotator cuff tendinopathy is the most common cause of shoulder pain:
• There may be a history of heavy lifting or repetitive movements, especially above shoulder level. However, it often occurs in the non-dominant arm and in non-manual workers.
• On examination there may be muscle wasting with pain on movements and a partial restriction of active movements (passive movements are full but painful). Particularly pain on abduction with thumb down, and the pain is worse against resistance.
• A painful arc (between 70 to 120° of active abduction) is not specific or sensitive but increases the likelihood of a rotator cuff disorder.
• A rotator cuff tear:
• Usually follows trauma in young people. It is usually atraumatic in elderly people and caused by attrition from bony spurs on the undersurface of the acromion or intrinsic degeneration of the cuff.
• Partial tears may be difficult to differentiate from rotator cuff tendinopathy on examination.
• The drop arm test (see ‘Examination’, below) may be used to detect a large or complete tear.
Glenohumeral disorders:
• Adhesive capsulitis most often presents between the ages of 40 to 65 years, andosteoarthritis in those aged 60 years or older.
• Adhesive capsulitis (frozen shoulder) and arthritis often present with a history of non-adhesive capsulitis symptoms, cause deep joint pain, and restrict activities such as putting on a jacket – because of impaired external rotation.
• Adhesive capsulitis is more common in people with diabetes and may also occur after prolonged immobilisation.
• There is usually generalised shoulder pain and a restriction of passive and active movements.
•
Acromioclavicular disorders:
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• They are usually caused by trauma or osteoarthritis.
• Dislocation of the joint may occur after injury. Pain and tenderness are localised to the acromioclavicular joint and there is a restriction of passive, horizontal movement of the arm across the body when the elbow is extended.
• Acromioclavicular osteoarthritis may cause subacromial impingement.
Referred neck pain:
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• Typically, this presents with pain and tenderness of the lower neck and suprascapular area, with pain referred to the shoulder and upper arm.
• There may be a restriction of shoulder movement and movement of the neck and shoulder may reproduce more generalised upper back, neck, and shoulder pain.
• There may also be upper limb paraesthesia.
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Assessment of shoulder pain:
When assessing shoulder pain, take a history and perform an examination with these questions in mind:
• Is the pain arising from the shoulder, neck or elsewhere?
• Are there any ‘red flag’ symptoms/signs? (See box ‘Red flag symptoms/signs’, below.)
• Is the pain localised to the acromioclavicular joint? If yes, there is acromioclavicular joint disease.
• Is there global pain and restriction of all active and passive movements? If yes, this suggests glenohumeral joint disorder (either ‘frozen shoulder’ or arthritis).
• Is there pain on abduction with thumb down, worse against resistance and/or is there a painful arc? If yes, this suggests a rotator cuff disorder.
History:
Points to cover in the history include:
• The nature of the pain including:
• How the pain started.
• Any specific injury.
• Whether it is acute or chronic.
• Any impact on function/activities of daily living.
• Whether the pain is on the side of the dominant hand.
• Whether there is pain at rest or on movement.
• Whether there is night pain that affects sleep.
• Any associated pain – for example, neck, chest or other upper limb or joint pain.
• Any history of shoulder pain/instability/dislocation.
• The patient’s occupation.
• The patient’s sporting activities.
• Any signs or symptoms of systemic illness.
• Past medical history (particularly any history of diabetes, ischaemic heart disease, cancer).
• Drug history and adverse drug reactions
• Pain from generalised capsulitis is felt at the outer aspect of the upper arm or deltoid region and may keep the patient awake. Anterior capsulitis usually causes well-localised pain felt anteriorly over the upper biceps insertion. Rotator cuff/supraspinatus pain is also felt in the upper aspect of the arm or deltoid region and will be accompanied by a painful arc.
• Examine the neck, axilla and chest wall.
• Examine the cervical spine and assess range of movement.
• Inspect from the front, side, and behind for muscle wasting, swelling and deformity, or bruising.
• Palpate the sternoclavicular, acromioclavicular and glenohumeral joints. Look for tenderness, swelling, warmth and crepitus.
• As an initial screening test, ask the person to place the palms of their hands at the base of the neck with elbows pointing laterally and then to put their arms down and try to put the back of the hands between the shoulder blades. However, be aware that this also involves joints other than the shoulder .
• Assess the power, stability and range of movement (active, passive and resisted) in both shoulders.
• Look for a painful arc (pain between 70 and 120° of abduction).
• Test passive external rotation (reduced in ‘frozen shoulder’). With the elbow held into the side, turn the arm outwards as far as possible.
• Perform the ‘drop arm test’: passively abduct the patient’s shoulder. Then ask the patient to lower the abducted arm slowly to the waist. This can identify a rotator cuff tear. They may be able to lower the arm slowly to 90° because this uses mostly the deltoid muscle but, below 90°, the arm will drop to the side.
• Perform the ‘cross-arm test’: this isolates the acromioclavicular joint. Ask the patient to raise the arm to 90° straight in front of them. Then ask the patient to adduct the arm across the chest. If there is an acromioclavicular joint problem, there will be pain in the area of the joint.[1
ASSESSMENT ALSO INCLUDE:
INSPECTION:
• With the patient sitting, look for atrophy in three sites; the supraspinatus fossa, the infraspinatus fossa and the deltoid. This demonstrates weakness due either to a rotator cuff tear, or a neurological deficit.
• Examination of the shoulder blades: scapular winging and thoraco-scapular dysfunction are almost universal in shoulder instability. Classically this can be due to paralysis of the long thoracic nerve either from trauma or possible tumor, but is much more common in shoulder instability. It is assessed by having the patient perform push-ups against a wall and observing the lower pole of the scapula, which will push outwards.
PALPATION:
• Assess the clavicle and the posterior joint line.
• To palpate the acromio-clavicular joint, find the “soft spot” at the back of the clavicle, anterior to that is the A-C joint.
• To palpate the rotator cuff bursa, extend the patient’s arm backwards and internally rotate it. This brings the bursa anteriorly where it can be palpated by the index finger when the hand is placed across the upper aspect of the shoulder with the thumb posteriorly and the index finger anteriorly.
RANGE OF MOTION:
Assess:
• Forward elevation:
• The motion involved in reaching forward and up to a cupboard above the head. This is measured from zero (lowest) to 180 degrees. Always supplement active motion with passive movement to obtain the patient’s full range.
• Internal rotation:
Ask the patient to rotate his arm across his back and walk the fingers as far up the back as possible, recording this by vertebral level. If the patient is very stiff this may only be a sacral level. As a guide the inferior border of the scapula is located at about T7. Compare the internal rotation of the injured side with the normal side.
• External rotation:
Ask the patient to keep the upper arms flat against his/her sides and rotate the forearms outward. The range is from zero (straight ahead) to 90 degrees.
• The lift-off test:
• This tests the subscapularis. With the arm behind the back ask the patient to lift his hand off his back.
SPECIAL TESTS FOR SPECIFIC CONDITIONS:
1. Impingement
• Jobe’s Test: The arm is held in the scapular plane, not directly in front or out to the side, but at a comfortable angle, as if pouring out a can of pop (about 30 degrees from full extension). If holding the pouring position is painful it is because the greater tuberosity is being driven up against the acromion, a positive Jobe’s test for impingement. At the same time, since this is a position of strength, push down on the arm to test for any weakness.
• Hawkin’s Test: With the arm in the throwing position and flexed forward about 30 degrees, forcibly internally rotate the humerus. Pain suggests impingement of the supraspinatus tendon against the coraco-acromial ligament. Crepitus can also often be detected at the subacromial bursa.
• Infraspinatus Strength: Ninety percent of external rotation depends on infraspinatus strength, and loss of strength in the infraspinatus correlates closely with the size of a rotator cuff tear.
• Supraspinatus Strength: The arms are held in the scapular plane as if pouring out a can of pop ask the patient to forward elevate and assess weakness, test resisted external rotation with the arm by the side.
• Subscapularis Strength: With the supraspinatus and infraspinatus tendons, the subscapularis is part of the rotator cuff. The strength of this is tested by the lift-off test. The patient is asked to hold his hand behind his back at waist level, palm facing out, and move the arm away from the body against pressure from the examiner.
• Acromio-Clavicular Joint Tests: For osteoarthritis or osteolysis, often seen in athletes who bench press weights will have tenderness over the AC joint, pain on internal rotation and on cross body adduction of the arm, and a positive
• O’Brion’s test.
• O’Brion’s Test is performed by adducting the arm across the chest, pronating the hand as if pouring out a can of pop, and then performing resisted forward elevation. A positive O’Brion’s test is demonstrated by pain reported at the top of the AC joint with this maneuver, but not if the hand is supinated.
2. Instability:
There is considerable overlap between instability and impingement, and instability can be difficult to assess.
• Sulcus Sign. The patient’s arm is held at his side in a position of rest. The arm is gently pulled downwards while the examiner looks and palpates for a depression below the shoulder.
• Load and Shift Testing. The humeral head is grasped between the thumb and fingers and with the patient supine, the degree of mobility is assessed.
• Apprehension Sign. With the patient seated or supine, externally rotate the shoulder. The patient demonstrates apprehension that the shoulder will dislocate, and will often resist the activity, informing the examiner that the shoulder will ‘go out’. To take the test one step further, apply pressure over the humeral head to prevent dislocation, extend the arm further back, and then release the joint. The patient will jump and internally rotate the shoulder – a positiverelocation sign.
Red flag symptoms/sign::
• History of malignancy or symptoms/signs consistent with neoplasia, egweight loss, deformity, mass or swelling, abdominal discomfort/swelling.
• Overlying skin erythema may suggest tumour or infection.
• Symptoms/signs of systemic illness: ask specifically about symptoms that may indicate polymyalgia rheumatica/giant cell arteritis.
• Fever can suggest malignancy or infection.
• History of trauma or recent convulsion/electric shock may suggest an unreduced dislocation.
• Change in shoulder contour with loss of rotation suggests dislocation.
• Trauma with acute disabling pain and positive ‘drop arm test’ suggest an acute rotator cuff tear.
• The presence of a significant sensory or motor deficit suggests a neurological lesion.
Investigations:
• Blood tests and radiology are generally only necessary if there are ‘red flag’ symptoms/signs.
• Plain X-rays may help diagnose massive rotator cuff tears, shoulder instability, and shoulder arthritis.
• Magnetic resonance imaging and ultrasonography are preferred for rotator cuff disorders.
• If referred neck pain is suspected then cervical spine X-rays may be helpful.
• If there are relevant ‘red flags’ to indicate systemic illness then consider blood tests including FBC, ESR/CRP and further investigations such as chest X-ray as appropriate.
Management:
Management in primary care is usually conservative, with rest, attention to any contributing factors and medication for pain relief. The evidence for steroids and physiotherapy is relatively weak. Steroid injections have only a marginal short term effect on pain. Surgery may be required when conservative measures fail.
• Corticosteroid injections may be of short-term benefit when either used alone or as an adjuvant to physiotherapy. See separate article Joint Injection and Aspiration.
• Physiotherapy may be effective for shoulder pain in some cases but further high quality trials are needed
• There is not enough evidence to say whether acupuncture works to treat shoulder pain or if it is harmful.
• Rotator cuff disorders:
• Advise relative rest of the affected arm and modification of activities, including reducing precipitating movements (eg reaching overhead).
• Offer analgesia; paracetamol with or without codeine, or an oral non-steroidal anti-inflammatory drug (NSAID).
• Refer to physiotherapy if self-care measures and analgesia are not effective.
• Consider a subacromial corticosteroid injection if the person has a poor response to initial treatment after several weeks and requires further pain relief, or has very limited function because of pain. Do not give a corticosteroid injection if:
• The person has previously received a corticosteroid injection with minimal or no benefit.
• The person has already had three or more injections in the same shoulder in the previous year.
• A rotator cuff tear is suspected.
• Corticosteroid injection is contra-indicated (eg infection, adjacentosteomyelitis).
• Evidence shows that physiotherapy and steroid injections may be equally helpful in the short-term. Injections may be repeated if the initial response is good.
• Rotator cuff tears:
• Physiotherapy and steroid injections may be helpful for minor tears. However, there is no proven harm or benefit from steroid injection if a rotator cuff tear is present so they should be avoided if there is a positive ‘drop arm test’.
• Suspected acute, severe tears of the rotator cuff tendons may benefit from early referral for orthopaedic input.
• Surgical treatment usually involves rotator cuff tendon repair ± subacromial decompression, either through open surgery or arthroscopically.
• Calcific tendonitis:
• Crystalline calcium phosphate is deposited in a tendon, most commonly in the supraspinatus tendon of the rotator cuff.
• When calcific tendonitis is symptomatic, it may present as chronic, relatively mild pain in the shoulder, with sporadic episodes of pain radiating down the arm or to the neck, or with severe acute pain due to an inflammatory response.
• Treatment for calcific tendonitis includes non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, physiotherapy, aspiration or lavage. For patients refractory to these treatments, open or arthroscopic shoulder surgery may be offered.
• Extracorporeal shock wave lithotripsy (ESWT) is recommended by the National Institute for Health and Clinical Excellence (NICE) as a non-invasive alternative to surgery.
• Glenohumeral disorders:
• Acromioclavicular disease:
• Acromioclavicular injury usually responds to rest and simple analgesia, unless there is significant disruption of the joint, in which case orthopaedic referral is necessary.
• Consider providing a sling for 5-7 days if an acromioclavicular joint sprain is suspected.
• Consider referring to physiotherapy after 4-6 weeks if the person responds poorly to rest and analgesia.
• Degeneration of the humeral head:
• The humeral head may degenerate as a result of a range of conditions, eg osteoarthritis, rheumatoid arthritis or avascular necrosis. The whole or only part of the articular surface of the humeral head may be affected.
• Conservative treatment includes physiotherapy, pain relief, topical or oral NSAIDs and corticosteroid injections.
• Patients who do not respond to conservative treatments may need surgery, which involves either shoulder arthroplasty using a stemmed humeral head prosthesis, or fusion of the joint.
• Shoulder resurfacing arthroplasty replaces only the damaged joint surfaces, with minimal bone resection, and is recommended by NICE as a surgical option.
Criteria for referral to secondary care:
Consider referral for orthopaedic or other appropriate specialist review for people who present with shoulder pain in the following circumstances:
• Pain and significant disability for >6 months, despite appropriate conservative management.
• History of joint instability.
• Acute severe post-traumatic acromioclavicular pain.
• Suspected unreduced dislocation.
• Diagnostic uncertainty.
• ‘Red flags’ indicating systemic illness or a condition requiring urgent investigation.
Prognosis:
• The prognosis of chronic shoulder pain depends on the underlying cause.
• Increasing age, female sex, symptoms of gradual onset, prolonged symptoms, severe or recurrent symptoms and associated neck pain are associated with a worse outcome.[2]
• Recovery in shoulder pain is generally slow. Studies have shown complete recovery at one month in 23% of patients, and at 18 months in 59% of patients.
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