SHOULDER

Anatomy

The shoulder joint is the second largest and most mobile joint in the human body and can be easily understood if divided into three layers. view 

Shoulder Contusion

Trauma is the term used to describe injury. Trauma is classified by its severity depending on the amount of force used to cause the injury. view 

Shoulder Fractures

Shoulder Fractures or breaks in the shoulder can occur in the humeral bone, collar bone or the in shoulder blade.  view

Shoulder Dislocations

A shoulder dislocation is classified according to the direction of the dislocation (Anterior, posterior or multi-directional), the amount of force it took to dislocate the shoulder (Traumatic or Atraumatic), and whether it is accompanied by a fracture (fracture dislocation).  view 

Shoulder Arthiritis

Shoulder Arthritis is the loss of the cartilage cushion in the joint surfaces (blue section) that allows the smooth pain free gliding required during shoulder motion. view

Shoulder Nerve Compression Syndromes

Nerve compression syndromes are normally found in adults of all ages and it is rare to find nerve compression syndromes in patients younger than 20 years of age.  view 

Shoulder Tendon Disorders

Shoulder pain is the most common presenting shoulder complaint in an orthopedic practice.  view 

Shoulder Infection

The shoulder is one of the most well perfused areas of the human body and because of this ample blood supply to the shoulder which carries circulating white blood cells, offers excellent protection against infection, consequently making a shoulder infection a rare occurrence.  view 

Frozen Shoulder

A Frozen shoulderalso called adhesive capsulitis is a condition presenting withshoulder stiffness and severe shoulder pain when shoulder motion is initiated. view 

Shoulder Tumor

Tumors are divided into benign and malignant types.  view 

FROZEN SHOULDER

Pathology

Frozen shoulder is a condition presenting with shoulder stiffness and severe shoulder pain when shoulder motion is initiated. Also called adhesive capsulitis.

Normal Shoulder Structure

  • When the arm is down, the shoulder capsule and the corresponding ligaments are loose.
  • The capsule/ligament complex tightens at the extremes of shoulder motion to limits excessive shoulder motion. This provides passive shoulder stability.

Frozen Shoulder Structure

  • The capsule/ligament complex is excessively tight, even when the arm is down. The tight structure causes limited motion and pain when the arm is moved in any direction due to the humeral head (top of the arm bone) now being pushed in the opposite direction of motion.
  • The normally loose patulous pouch on the inferior portion of the arm is lost.

frozen_shoulder1

Types of Stiff or Frozen Shoulders

Idiopathic

  • Occurs mostly in females between the ages of 40-55 years of age.
  • It occurs most often after a minor lifting event or for no apparent reason at all.
  • 70-90% of female cases happen during the peak of menopause, suggesting hormonal changes may be a factor.

Post-traumatic

  • Occurs after an injury to the shoulder or after the shoulder has been immobilized for a prolonged period of time. Long-term immobilization leads to the shoulder capsule stiffening, as well as other shoulder interface layers adhering to each other.
  • Involves more than the capsular layer and is difficult to treat without surgical intervention due to the involved layers.

Glenohumeral Internal Rotation Deficit (GIRD) Shoulder

  • Occurs in overhead athletes from repetitive overhead throwing activities.
  • These activities cause the anterior shoulder capsule loosen, while the posterior and posterior inferior portion of the capsule tighten. This subsequently forces the shoulder to shift anteriorly and impinge on the internal fibers of the rotator cuff and posterior superior labrum.
  • Range of motion in the shoulder is limited in internal rotation, cross body adduction, and internal rotation up the back.

Conditions Increasing Chance of Developing Frozen Shoulder

  • Diabetes
  • Thyroid disorders
  • Heart disease
  • A history of frozen shoulder in one arm. The chance the opposite shoulder will subsequently develop frozen shoulder is 50%

Once a frozen shoulder is treated, the likelihood of it returning on the same side is remote.

 

Treatment

The mainstay of treatment for a frozen shoulder is shoulder capsular stretching exercises. Treatment duration is about 2 years.

Our experience at ROC is that 90% of patients with idiopathic frozen shoulders can obtain 85% of normal movement in about three months if they engage in a good supervised exercise program continued daily with a supplemental home exercise routine 95% of patients presenting with idiopathic frozen shoulder are treated by non-operative means. Non-Operative Means:

  • Use of a subacromial steroid injection
  • Pain medication taken 30 minutes prior to therapy
  • Heat used prior to stretching
  • Anti-inflammatory medication

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Shoulder Six Pack Exercise Program

 

ROC follows very specific therapy focusing on an assisted passive stretching program. This is very hands-on with a trained therapist. Due to the significant amount of pain experienced during capsular stretching, a patient cannot be expected to do the exercises alone. This is why we advise patients to take prescribed pain medication 30 minutes prior to beginning therapy and also to warm up prior to stretching.

The sequence of stretching is extremely important and involves stretching the shoulder capsule one plane at a time. Two such exercises include forward flexion stretching and cross body adduction stretching. Once these two planes of motion have been achieved, the anterior capsule and rotator interval is stretched by external rotation at the side and in abduction. The final stretch is internal rotation stretching behind the back.

Surgery for Frozen Shoulder is considered if:

  • Therapy fails because the pain is intolerable
  • The frozen shoulder has shown no improvement in spite of a good supervised therapy protocol over a 3-6 month period

Surgery is a combined closed manipulation and arthroscopic release of the shoulder capsule. A closed manipulation performed alone risks injury to the shoulder. Post-traumatic frozen shoulder is the condition most likely resulting in surgery and simple manipulation alone does not release all layers of adhesions present in the subacromial space. This is why an arthroscopic decompression must accompany the capsular release to achieve success.