THE STIFF SHOULDER: CURRENT CONCEPTS Felix H. Savoie III, MD Ray J. Haddad Professor & Chairman Department of Orthopaedic Surgery Tulane University New Orleans, LA Tulane Orthopaedic Surgery
COI Royalties: Exactech • Stock: none • Consultant: S&N, Mitek, Zimmer-Biomet, Exactech, Rotation Medical • Research/Fellowship support S&N The picture can't be displayed. Tulane Orthopaedic Surgery
ADHESIVE CAPSULITIS • Nevaiser, JS: JBJS 1945: Adhesive Capsulitis of the shoulder: A study in peri-arthritis of the shoulder (coined the term) • Reeves: Scand J Rheum, 1975: Frozen shoulder is a condition of uncertain cause, characterized by spontaneous onset of pain with significant restriction of both active and passive range of motion of the shoulder Tulane Orthopaedic Surgery
ANKYLOSIS • Ankylosis (Anchylosis) is stiffness of a joint due to abnormal adhesions, scar and rigidity …..due to inflammation/scarring of the tendinous, muscular and ligamentous structures outside and inside the joint Tulane Orthopaedic Surgery
AC : CLASSIFICATION Primary (Idiopathic – • means we don’t know) • Secondary Systemic (DM, • Thyroid) Extrinsic : heart, breast, • neck, stroke Intrinsic: RC ,biceps, calcific • tendonitis • Tertiary (Ankylosis) Post • op (SLAP), fracture, RC Tulane Orthopaedic Surgery
AC : PATHOLOGY • Thickened, contracted capsule with peri- articular hypertrophic synovitis ( Bateman) • • Neer: starts at CHL • • Duplay(1896) starts @subdeltoid bursa • • Myer, Pasteur, DePalma: starts @ Biceps Tulane Orthopaedic Surgery
AC: PATHOLOGY: TREATMENT • Initial structures involved are the PIGHL and CHL, which is what we need to treat • • Progressively involves more of the interval structures , Capsule and biceps as stages progress Tulane Orthopaedic Surgery
AC: HISTORY Gradual onset of vague • pain • Pt will usually relate • some minor injury • Often first noticed with • a sudden movement or extreme (putting on coat) motion • May have numbness • radiating down the arm, spasm in scapula, trapezius and cervical area Tulane Orthopaedic Surgery
PHYSICAL EXAMINATION • Inspection unremarkable except for mild dyskinesia • • Palpation: tenderness over the rotator interval • • PROM may not be limited early • • Often impingement and slap signs + Tulane Orthopaedic Surgery
AC EXAM: INFERIOR GLIDE TEST (how to not get fooled) • Tests main structures(CHL/IGHL) involved in early capsulitis Arm slightly abducted • to 40 degrees, cup the elbow and do a gentle inferior shift into pighl, IGHL, and AIGHL with a pulling type move 100% sensitivity for AC • Tulane Orthopaedic Surgery
AC EXAM: INFERIOR GLIDE TEST (how to not get fooled) • 280 new shoulder patients • Independent exam by attending( FHS) and resident (KF) • 35 + IGT by both examiners, all developed AC • 245 neg IGT : variety of pathology but no capsulitis Tulane Orthopaedic Surgery
AC EXAM: IMAGING • Radiographs typically normal • • MRI often read as SLAP/ tendonosis early, will show increased signal at rotator interval area if you look closely • • Later will show contracted inferior capsule Tulane Orthopaedic Surgery
AC PHASES (NEVAISER) • Phase 1: pre-adhesive Phase 2: Acute • Phase 3L Chronic • Phase 4: Mature • Tulane Orthopaedic Surgery
AC PHASES (NEVAISER) • Phase 1: pre-adhesive Phase 2: Acute • Phase 3L Chronic • Phase 4: Matur e • Tulane Orthopaedic Surgery
AC PHASES (NEVAISER) • Phase 1: pre-adhesive Phase 2: Acute • Phase 3L Chronic • Phase 4: Mature • Tulane Orthopaedic Surgery
AC PHASES (NEVAISER) • Phase 1: pre-adhesive Phase 2: Acute • Phase 3L Chronic • Phase 4: Mature • Tulane Orthopaedic Surgery
AC INITIAL TREATMENT • Steroid injection – Intra-articular – PIGHL/CHL Physical therapy • Meds • – NSAID ineffective – Oral steroids some efficacy Tulane Orthopaedic Surgery
AC: TREATMENT EVIDENCE Song, Higgins Neuromuscular J Paye et al: 2014 Cochrane data systemic review base review • 25 studies , 7 RCT 32 trials with 1836 patients • Steroid injection definitely • 92% of patients improved with • effective in decreasing injections pain (VAS scale) and • @ 2 years all patients showed motion increased motion and Manual therapy was not • decreased pain regardless of better than home exercise treatment NSAID had no effect • Oral steroids had • subjective effectiveness in improving “well being” Tulane Orthopaedic Surgery
AC: MANIPULATION Indication: failure to • improve after 3-6 months of PT Contra-indication: • Diabetes ( 50% failure rate), – Post Surgical (especially RC & SLAP: retear) Risks: XRAY! • – fracture ( 10%) – plexopathy (2%), – dislocation (rare but devastating) Tulane Orthopaedic Surgery
ANKYLOSIS: MANIPULATION • This is not AC but a joint surrounded by thick scar • Post RC : the weakest part of the shoulder is our repair • Post fracture: the weakest part is the bone Tulane Orthopaedic Surgery
ARTHROSCOPIC RELEASE • Answers • Questions: – Manipulate first or after – Either-I prefer after surgical release release: not an option in ankylosed – Risks of entry shoulder: always release – Order of release and – Blunt trocar, keep it high what do we release to avoid chondral injury – Acromioplasty – Interval, then 360 – Injection when capsule CHL in bursa and in completed or wait until ankyloses will remove all scar follow up between deltoid and rc – CPM/PT post op Yes plus steroid injection and oral Tulane Orthopaedic Surgery
AC: ARTHROSCOPIC RELEASE INTIAL EVALUATION RELEASE ROTATOR INTERVAL Tulane Orthopaedic Surgery
AC: ARTHROSCOPIC RELEASE ANTERIOR RELEASE TO 5 POSTERIOR RELEASE Tulane Orthopaedic Surgery
AC: ARTHROSCOPIC RELEASE INFERIOR RELEASE: ADD PORTAL CHL RELEASE IN BURSA Tulane Orthopaedic Surgery
AC: ARTHROSCOPIC RELEASE: RESULTS • Esch, Gartsman & Recommended Reading: Harryman credited with • Warner: JBJS 79: 1997 1808- development 1816: Arth rel for chronic AC Berndt et al: Oper ortho • Warner: J Am Acad Ortho traum 2014: 27/37 • improved with full rom Surg: 1997: 5: 130-140 Ad. Cap at 3.6 months Warner : treatment of the stiff • Mehta et al JBJS 2014 : shoulder after RCR: JBJS 79, • 90% of non diabetics 1997 and 70% of diabetics obtained full motion Tulane Orthopaedic Surgery
ANKLYOSIS: RESULTS • Minimal data available • Bhatia ( Rush group) • Field/Savoie released Indian J Ortho: 29 post 1/283 stiff RC had a RCR stiff patients with release and it was arthroscopic release successful • F 105 improved to 159 • Blended with stiff shoulder of any kind • ER 25 improved to 59 • Surgical results generally • No complications or re- good tears Tulane Orthopaedic Surgery
CONCLUSIONS: AC • Etiology of adhesive • Manipulation under capsulitis remains anesthesia can work for poorly understood non diabetic, non ankylosis cases Diagnosis by inferior • • Arthroscopic release glide test is effective provides best results in Steroid injections and • diabetics and meds are mainstay of postoperative cases non operative treatment Tulane Orthopaedic Surgery
THANK YOU Tulane Orthopaedic Surgery
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