Adult Reconstruction, 1st Edition

Section III - Shoulder Reconstruction

Part B - Evaluation and Treatment of Shoulder Disorders 

46

Frozen Shoulder

Michele T. Glasgow

Frozen shoulder is defined as “a condition characterized by functional restriction of both active and passive motion.” Zuckerman et al. further classified frozen shoulder into primary and secondary groups. Primary frozen shoulder was considered idiopathic. Secondary frozen shoulder was divided into intrinsic, extrinsic, and systemic subtypes (Table 46-1). More specific, quantitative definitions have been sought. Diagnostic criteria have included duration of symptoms, loss of motion, and radiographic evaluation. Significant variability in the diagnostic criteria has made treatment and outcome studies difficult to compare (Table 46-2).

Pathogenesis

Etiology

Primary, or idiopathic, frozen shoulder has by definition no clear cause. There are, at best, associations that link underlying disease processes to loss of soft tissue compliance. A cellular basis for disease has been speculated. Deficiencies in cellular immunity, identified in some studies, have been thought to result in an autoimmune disease resulting in capsular contracture. However, reports have not been consistent among investigators, and this proposed cause remains controversial.

Chromosomal abnormalities have been suggested, and shoulder capsule tissue culture analysis has demonstrated trisomy seven and eight in seven patients with frozen shoulder. Trisomy seven has been identified in the tissue of the Dupuytren contracture suggesting a similar common pathway. In addition, cellular mechanisms related to metalloproteinases, enzymes that control collagen remodeling, and cytokines have been implicated.

Secondary frozen shoulder may be caused by surgery, fracture, nonsurgical soft tissue trauma such as rotator cuff tear or contusion, tendonitis, and arthritis. These are considered causes of secondary frozen shoulder that are intrinsic to the shoulder joint itself. Extrinsic conditions may occur with secondary frozen shoulder. These include neurologic injuries from head trauma, brain surgery or cerebrovascular accident, cervical radiculitis, brachial plexopathy, thoracic outlet syndrome, and peripheral nerve palsy. Antiepileptic treatment with phenobarbitone has been associated with frozen shoulder. Other associated conditions include cardiac disease and cardiac surgery, thoracic tumors such as bronchogenic carcinoma and Pancoast tumor. Desmoid tumors of the shoulder girdle presenting as frozen shoulder have been recently reported. Systemic disease may also be associated with secondary frozen shoulder. These diseases include diabetes, hypothyroidism, hyperthyroidism, polymyalgia rheumatica, myositis, and many other systemic illnesses.

Systemic diseases may stimulate cellular changes within the shoulder joint capsule. Advanced glycosylation end products (AGEs) accumulate in the basement membranes of diabetics. The accumulation of AGEs results in irreversible cross-links between adjacent protein molecules. This appears related to acquired defects in vascular compliance in diabetics and may reflect a common pathway that leads to arthrofibrosis in the diabetic population. Association of frozen shoulder with diabetes, thyroid disease (both hypothyroidism and hyperthyroidism), hyperlipidemia, and other systemic illnesses is clearly seen. The exact mechanism(s) that lead to capsular restriction have yet to be delineated definitively.

Epidemiology

Frozen shoulder is noted to have a prevalence of 2% to 5% in the general population. It is generally considered more common in women than men, but this is not consistent across all studies. The age presentation is most commonly 40 to 60 years. However, it may occur earlier in long-standing insulin-dependent diabetics. Incidence of frozen shoulder in diabetics has been reported from 10% to as high as 35%. Diabetics with frozen shoulder are more likely to have additional organ involvement.

Recurrence in the same shoulder and concurrent bilateral disease are unusual in the general population, but may occur in diabetics. Both shoulders may be affected in 6% to 34% of patients across multiple studies. Diabetics appear to be more likely to develop bilateral stiffness (≤40%).

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TABLE 46-1 Primary and Secondary Frozen Shoulder

Primary frozen shoulder

  Idiopathic

Secondary frozen shoulder

  Intrinsic: Shoulder fracture, tendonitis, rotator cuff tear, degenerative joint disease

  Extrinsic: Neurologic—radiculopathy, head trauma, complex regional pain syndrome, Parkinson, cardiovascular accident, humeral fractures

  Systemic: Diabetes, thyroid disease, myositis/polymyalgia rheumatica

Pathophysiology

Pathophysiology is a final end pathway of fibrosis and decreased capsular compliance. Loss of external rotation with associated scarring and contracture of the rotator interval capsule, coracohumeral, and superior glenohumeral ligaments is pathognomic of frozen shoulder.

Idiopathic frozen shoulder is defined in three phases. These phases are the following:

  • The initial phase (“freezing phase”) is marked by insidious onset of pain of increasing severity. This lasts from a few weeks up to 9 months. It is associated with the loss of active and passive motion. Arthroscopy and histology studies demonstrate acute synovitis (Fig. 46-1).
  • The second phase (“frozen phase”) is associated with less pain. The hallmark of this phase is global shoulder stiffness. Comfort for activities of daily living is achieved within the patient's limited range. The duration of this phase may be 3 to ≥12 months. Pathologic specimens demonstrate extensive fibrosis with high cellular populations of fibroblasts and myofibroblasts.
  • The final phase(“thawing phase”) is characterized by return of motion toward normal over a period of 5 to 26 months on average. This phase, however, has been cited in the literature to extend as far as 8 to 10 years following the onset of symptoms. Outcome studies regarding the natural history of the thawing phase are clouded by lack of consistent study inclusion criteria. Methodology frequently has been retrospective and without control groups. Patient numbers have generally been small, and frequently studies have included mixed treatments and causes. Despite this, reports suggest persistent mild pain and/or stiffness in ≤50% of patients. At mean follow-up, Binder, Bulgen and colleagues reported little functional impairment in 40 out of an initial study group of 42 patients. However, 45% of patients continued to have pain and/or restricted range of motion.

TABLE 46-2 Clinical Diagnosis of Frozen Shoulder

1. Duration of symptoms: 3 weeks to >3 months

2. Range of motion (as percentage of normal side): >50% loss of passive external rotation or abduction

3. Range of motion (absolute restriction): limitation of 30 degrees or more in two or more planes

4. Normal radiographs (idiopathic frozen shoulder)

 

Figure 46-1 Joint synovitis encountered at arthroscopy.

Diagnosis

History

Idiopathic frozen shoulder is characterized by three phases of clinical presentation. The physician is challenged to identify the stage and evaluate the patient for other causes or associated disease processes. Concurrent bilateral involvement is relatively uncommon. Initial presentation of concurrent bilateral frozen shoulder may suggest systemic disease. It is incumbent on the clinician at all stages to evaluate for possible associated conditions. This necessitates a careful and thorough general medical history.

Idiopathic frozen shoulder in the initial phase is characterized by pain without history of significant trauma. Aching unrelieved by rest and worsening at night is frequent. Loss of range of motion is pathognomic. The patient may present with protective posturing of the arm in an adducted internally rotated position against the body. The physical examination is generally notable for severe pain with range of motion. X-ray films taken at this time are generally negative, though there may be slight osteopenia.

In phase II (frozen phase) the patient reports less pain. Significant motion restriction is noted with pain generally at the extremes of available motion. There is functional restriction of activities of daily living. Night pain remains common.

Phase III (thawing phase) is characterized by variable activity limitations associated with loss of range of motion. Generally over the course of observation, both range of motion and night pain demonstrate gradual improvement. Despite improvement, studies suggest that motion remains limited relative to the contralateral normal extremity in ≥50% of patients.

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Physical Examination

Global assessment of the neck and bilateral shoulder complexes as well as the upper extremity is essential. Exam of the shoulder should include the following:

  • Inspection and palpation of the neck and shoulder to include both the glenohumeral and scapulothoracic articulations
  • Cervical spine range of motion with the Spurling test
  • Assessment of range of motion according to the American Shoulder and Elbow Surgeons (ASES) standard format. Motion arcs of the affected and unaffected shoulder are recorded for the following:
  • Forward elevation in the sagittal plane
  • External rotation at the side (ERS)
  • External rotation at 90 degrees of coronal abduction if possible (ERA)
  • Internal rotation at 90 degrees of coronal abduction if possible (IRA)
  • Cross-body adduction measuring the difference from the antecubital fossa to the opposite shoulder (XBA)
  • Internal rotation/extension up the back (IRB)
  • Strength is recorded for forward elevation, abduction, and external and internal rotation. Ancillary strength testing may include belly press. The lift-off test may be difficult to assess if significant posterior capsular contracture and/or pain does not allow adequate glenohumeral internal rotation. Additional active tests may include the supraspinatus stress test and the Whipple test.

A distal upper extremity exam should be performed to assess range of motion and strength. This will assist in evaluating for secondary neurologic conditions (i.e., cervical radiculopathy, complex regional pain syndrome, brachial plexopathy, and others).

Radiography

Plain Radiography

Anterior-posterior views are suggested in internal and external rotation. Outlet and true axillary views complete the shoulder series. Radiographs are inspected for fracture, tumor, calcific tendonitis, arthritis, and subacromial spurring.

Arthrography

Presently this is not commonly used. Arthrographic findings have failed to show correlations with clinical outcome.

MRI with or Without Intra-Articular Contrast

MRI imaging may be useful in the evaluation of the rotator cuff and bony anatomy in a patient with weakness or unusual presentation. Common findings in frozen shoulder are thickening of the coracohumeral ligament and rotator interval capsule. Synovitic abnormalities at the top of the subscapularis tendon and volume loss at the axillary recess are noted.

Ancillary Diagnostic Testing

Blood Studies

Generally, blood work is not needed for the evaluation and treatment of frozen shoulder. The clinician may elect to order selective tests if an underlying systemic disease or infection is suspected.

Electromyography

Testing is indicated in selected cases where neurogenic causes of shoulder motion loss are suspected.

Treatment

Conservative, Nonsurgical Measures

Conservative, nonsurgical measures have been demonstrated to be successful.

Physical Therapy

Gentle, firm stretching has been reportedly effective in the relief of pain and restoration of motion in 90% of patients. Physical therapy may be done at home with monthly visits to the therapist and surgeon, or more extensive formal evaluation and treatment may be performed as indicated. Basic exercises include supine active assisted forward elevation, supine external rotation with a stick, cross-body adduction, and standing towel exercises for internal rotation up the back. Multiple repetitions are performed and held for firm end field stretch without pain. The hallmark of stretching in frozen shoulder is repetition of exercises multiple times throughout the day. Prospective studies suggest “supervised neglect,” described as supportive therapy and exercises within the pain limit, produced superior 24-month outcome compared with vigorous stretching. Techniques of translational manipulations or glides may also be used by the therapist. Range of motion and visual analog pain scores have been noted to improve with this technique using regional anesthesia.

Anti-Inflammatories and Analgesics

Anti-inflammatories and analgesics have been demonstrated to assist with pain relief. Patients who used analgesics and exercise were shown to have greater improvement than with exercise alone. Short-course oral prednisolone was shown to have short-term benefit over placebo with regard to pain and motion at 3-week follow-up. Benefits compared with placebo were not maintained beyond 6 weeks.

Injections

Literature with regard to the use of injection is controversial. Results of intra-articular injections are difficult to interpret because they are frequently associated with other treatment modalities. In patients with painful stiffness, a 50% improvement in pain scores associated with injection has been reported. Bulgen et al. reported early improvement in pain and range of motion with no long-term advantage in comparing patients receiving intra-articular injection with

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an untreated control group. Intra-articular glucocorticoid injection with and without joint distension was compared prospectively. Intra-articular lidocaine (19 mL volume) and 20 mg of triamcinolone hexacetonide was compared with triamcinolone hexacetonide alone. Injection was confirmed by ultrasound and repeated with an end point of a maximum of six weekly injections or no symptoms. Pain measured by visual analog scale was no different between groups, but the distension group showed improvement in range of motion. Comparison with normal controls or opposite shoulder evaluation was not provided.

Despite controversy, data suggest that intraarticular glucocorticoid injection may assist in pain relief in frozen shoulder. Thus, injection may facilitate early rehabilitation.

Operative Treatment

Manipulation Under Anesthesia

Indications for manipulations under anesthesia include 3 months of worsening symptoms despite compliance with home exercise or failure to improve motion over 6 months of treatment. Loew et al. have reported on 30 consecutive patients with primary frozen shoulder resistant to analgesics and therapy for 6 months. They noted excellent restoration of range of motion with manipulation. Manipulation was performed gently following their standard protocol. This included the following:

  • General anesthesia in a supine position
  • Measurement of premanipulation range of motion
  • Manipulation with the humerus held close to the axilla to diminish lever arm effect
  • Forward elevation and internal rotation with light traction
  • Cross-body adduction to stress and release the posterior capsular contracture
  • External rotation stretch from neutral (ERS)
  • External rotation at 90 degrees of scapular abduction

Postmanipulation arthroscopy performed by Loew et al. demonstrated capsular ruptures anteriorly (24 of 30), posteriorly (16 of 30), and superiorly (11 of 30). Four patients had acute superior labral anterior posterior (SLAP) tears. Four patients had anterior labral detachments; one of which was osteochondral. Three patients had partial tears of the subscapularis tendon, and two had middle glenohumeral ligament tears.

Manipulation may also be done under regional anesthesia or after local anesthetic intra-articular distension. Harryman and Lazarus describe a protocol for manipulation under anesthesia. Their protocol is as follows:

  • Sagittal plane elevation with observation for crepitant lysis of scar
  • Cross-body adduction
  • Abducted internal rotation followed by internal rotation with the arm adducted
  • Internal rotation up the back if the patient is awake and cooperative
  • External rotation in 90 degrees of coronal abduction followed by external rotation after carefully lowering the arm to an adducted position

Postsurgically, the use of regional anesthesia has benefit in that it allows for painless patient cooperation in the instruction and reinforcement of the postsurgical stretching program. Stretches are repeated multiple times daily following hospital discharge with emphasis on achieving forward elevation, rotation, and posterior capsular stretching. Postmanipulation intra-articular injections with steroids may be used to diminish postsurgical inflammation and pain. Injection, however, has not been shown to enhance outcome.

Disadvantages of manipulation under anesthesia include the obvious inability to visualize intra-articular pathology available with arthroscopy. A cumulative 1% complication rate has been reported. Complications include rotator cuff tear, fracture, nerve palsy, and dislocation. Insulin-dependent diabetics have poor outcomes with regard to maintenance of range of motion following manipulation. The overall recurrent stiffness rate is between 5% and 20% including diabetic and nondiabetic patients.

Open Release

Indications for open release include postsurgical stiffness with glenohumeral scarring, muscle contracture, and excessive extra-articular scarring. An open approach is indicated when lengthening of the subscapularis is required following an anterior instability procedure. Resection of spurs and heterotopic bone may also be performed efficiently via an open approach.

A limited deltopectoral exposure or deltoid-splitting incision may be used for release of the rotator interval capsule and coracohumeral ligament. This may be combined with gentle manipulation to restore motion.

Drawbacks of open release include poor accessibility to the posterior capsule from this anterior approach. If it is necessary to release the middle and inferior glenohumeral ligaments, a subscapularis take-down may be necessary. This necessitates restriction of rehabilitation postsurgically to protect the subscapularis repair. Open release followed by manipulation under anesthesia has been shown to improve range of motion and pain relief with mean follow-up approaching 7 years in some studies.

Arthroscopic Release

Arthroscopy allows visualization of the glenohumeral joint. Inflamed synovium may be resected with a shaver and capsular release performed with arthroscopic basket or cautery.

Indications for arthroscopic capsular release include the following:

  • Inability to achieve full range of motion with gentle manipulation under anesthesia
  • Consideration in insulin-dependent diabetics with resistant contractures
  • Patients with significant osteopenia in whom there is a concern of fracture with manipulation
  • Postsurgical and posttraumatic stiff shoulder where recurrent fracture or soft tissue injury may occur with manipulation

The technique for arthroscopic release may involve multiple glenohumeral portals. A high posterior portal may be

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positioned just cephalad to the standard posterior portal. Entry into the joint may be difficult secondary to scarring and contracture. The blunt trocar is advanced into the joint carefully to avoid iatrogenic articular injury. A secondary anterior portal is selected just superior to the rolled board of the subscapularis. This may be localized using a spinal needle from an outside-in technique. The cannula enters the joint slightly laterally along the upper border of the subscapularis.

Diagnostic arthroscopy is performed to record any associated pathology. If the biceps is scarred and immobile, it is tenotomized at the glenoid rim.

Harryman and Lazarus recommend synovectomy followed by posterior capsular resection first. They note that fluid extravasation posteriorly is limited by the infraspinatus muscle. They recommend using arthroscopic basket forceps to spread the muscle off the capsule. A posterior superior followed by direct posterior and posterior inferior release are performed. A rotary shaver is used to resect the edges of the capsular release.

In progressing to the inferior capsule, a 70-degree arthroscope may be used from the front or the arthroscope alternatively may be positioned in the posterior superior portal. An additional posterior portal is positioned approximately 2 cm caudal and 1 cm lateral to the high posterior portal. A spinal needle can be used to localize the best position such that the approach is parallel to the floor of the axillary pouch. The capsule is incised outside the labrum and close to the glenoid. The axillary nerve passes obliquely anteromedial to posterolateral along the inferior margin of the capsule. Authors suggest that an arthroscopic basket forceps be used to spread the extracapsular tissue off the inferior capsule prior to incising the capsule. This is preferred to avoid axillary nerve injury.

Working from the anterior portal, a rotator interval release with attention to the coracohumeral and superior glenohumeral ligament is performed. The anterior superior release is performed above the biceps and labrum. The coracoacromial ligament and conjoined tendon are visualized from the posterior intra-articular arthroscopy portal. Attention is turned to release of the middle glenohumeral ligament (Fig. 46-2) and anterior aspect of the inferior glenohumeral ligament connecting the release inferiorly. Debris may be resected with a motorized shaver. The blades of the shaver are positioned away from the axillary nerve and rotator cuff with judicious use of suction.

 

Figure 46-2 Anterior capsular release. Middle glenohumeral ligament has been incised revealing subscapularis tendon.

Other authors have used bipolar cautery to perform releases. At the inferior pouch, maintaining close apposition

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to the inferior glenoid neck protects the axillary nerve. General anesthesia is preferred. If the deltoid is stimulated, the bipolar direction is changed. Maintaining the cautery along the glenoid rim and using accessory portals for improved access in the axillary pouch is helpful.

 

Figure 46-3 Algorithm for treatment of frozen shoulder. ROM, range of motion; PE, physical examination; DJD, degenerative joint disease; MRI, magnetic resonance imaging; NSAIDs, nonsteroidal anti-inflammatory drugs; EMG, electromyogram; GH, glenohumeral; MUA, manipulation under anesthesia.

Subacromial arthroscopy for release of scar may be performed. Idiopathic frozen shoulder pathology is classically a primary intra-articular capsular fibrotic process, and subacromial findings may be limited. However, in the posttraumatic stiff shoulder, significant subacromial adhesions may be present, necessitating extensive debridement. Acromioplasty is performed if there is abrasion of the undersurface of the coracoacromial ligament or significant spurring.

The arthroscopic equipment is then withdrawn. Gentle manipulation to assess range of motion is performed. An intra-articular steroid may be used.

Postsurgical management includes physical therapy immediately. Interscalene anesthesia can be helpful, and the patient may be discharged with a home exercise program. Postsurgical admission may be beneficial if pain control or medical factors are of concern. Continuous interscalene anesthesia may also be used to facilitate early and frequent range of motion.

Results of arthroscopic release for frozen shoulder have been reported extensively throughout the literature. Studies have generally found significant increase in both Constant scores and ASES scores. Ogilvie-Harris et al. noted in a comparative series of 20 patients undergoing manipulation under anesthesia and 20 patients undergoing arthroscopic release that range of motion was similar but surgical arthroscopic release provided better function and pain relief overall at a mean follow-up of 2 to 5 years.

Potential complications of arthroscopic capsular release include risks and complications inherent to surgical procedures including infection, bleeding, and nerve injury. One report of transient axillary neurapraxia was found. Postoperative instability has not been noted. Persistent stiffness has been reported. Despite 50% of their patients demonstrating persistent stiffness in internal rotation, Segmuller et al. demonstrated 88% satisfactory outcome. Two of three patients dissatisfied with their final outcome were diabetic. In stratifying groups based on causes, patients with idiopathic frozen shoulder appear to do better than those with secondary posttraumatic or postsurgical stiffness. Diabetics have been demonstrated to do initially worse in terms of motion and pain relief with comparable final outcomes to those of patients without diabetes.

Overall, arthroscopic capsular release is a technically demanding procedure, but is generally a safe procedure with few complications noted in the literature (Fig. 46-3).

Suggested Readings

Buchbinder R, Hoving JL, Green S, et al. Short course prednisolone for adhesive capsulitis (frozen shoulder or painful stiff shoulder): a randomized, double blind, placebo controlled trial. Ann Rheum Dis. 2004; 63:1460-1469.

Binder AL, Bulgen DY, Hazelman BL, et al. Frozen shoulder: a long-term prospective study. Ann Rheum Dis 1984; 43:361-364.

Bulgen DY, Binder AI, Hazelman BL. Frozen shoulder: prospective clinical study with an evaluation of three treatment regimens. Ann Rheum Dis. 1984; 43:353-360.

Chambler AFW, Carr AJ. Aspects of current management. The role of surgery in frozen shoulder. J Bone Joint Surg Br. 2003; 85-B:789-795.

Gam AN, Schydlowsky P, Rossel I. Treatment of “frozen shoulder” with distention and glucocorticoid compared with glucocorticoid alone: a randomized controlled trial. Scand J Rheumatol. 1998; 6:425-430.

Griggs SM, Ahn A, Green A. Idiopathic adhesive capsulitis. a prospective functional outcome study of non-operative treatments. J Bone Joint Surg Am. 2000; 82:1398-1407.

Harryman DT, Lazarus MD. The stiff shoulder. In: Rockwood CA, Matsen FA, Wirth MA, et al., eds. The Shoulder. 3rd ed. Philadelphia: WB Saunders; 2004: 1121-1172.

Loew M, Heichel TO, Lehner B. Intraarticular lesions in primary frozen shoulder after manipulation under general anesthesia. J Shoulder Elbow Surg. 2005; 14:16-21.

Ogilvie-Harris DJ, Biggs DJ, Fitsialos DP, et al. The resistant frozen shoulder. Manipulation versus arthroscopic release. Clin Orthop Relat Res 1995; 319:238-248.

Placzek JD, Roubal PJ, Freeman DC, et al. Long term effectiveness of translational manipulation for adhesive capsulitis. Clin Orthop. 1998; 356:181-191.

Segmuller HE, Taylor DE, Hogan CS, et al. Arthroscopic treatment of adhesive capsulitis. J Shoulder Elbow Surg. 1995; 4:403-408.

Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder: a long-term follow-up. J Bone Joint Surg Am. 1992; 74:738-846.

Zuckerman JD, Cuomo F, Rokito F. Definition and classification of frozen shoulder: a consensus approach. J Shoulder Elbow Surg. 1994; 4:572.



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