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PostPosted: 22 Nov 2019 19:10 
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SHOULDER JOINT OVERVIEW
• The shoulder joint (glenohumeral joint) consists of three bones - the upper arm bone (humerus), shoulder blade (scapula), and the collarbone (clavicle).
• The head of the humerus fits into a rounded socket of the scapula. This socket is called the glenoid cavity.
• A combination of muscles and tendons ensure that the humerus stays in place within the glenoid cavity. These are called the rotator cuff.
• The rotator cuff covers the head of the humerus and attach it to the shoulder blade, and together provide joint movement and stability. Shoulder can come from any of these structures

ROTATOR CUFF
• The Rotator Cuff (RC) is the general term for the group of four distinct muscles and their tendons, which provide strength and stability to the shoulder joint. They are also referred to as the SITS muscles, with reference to the first letter of their names - Supraspinatus, Infraspinatus,Teres minor, and Subscapularis, respectively. They connect the head of the humerus to the scapula, forming a cuff around the glenohumeral (GH) joint
• As stated earlier, they keep the head of the humerus within the small glenoid fossa of the scapula and assist in increased range of motion of the shoulder joint and avoid mechanical obstruction (i.e. a possible biomechanical impingement during elevation).
• Disorders of the rotator cuff can lead to shoulder pain, reduced range of movement in the shoulder and an overall reduced quality of life

FROZEN SHOULDER OVERVIEW
• The various components of the shoulder joint including bones, ligaments and tendons are enclosed in a capsule of connective tissue. Frozen shoulder occurs when this capsule thickens and tightens around the shoulder joint, limiting its mobility. It is also termed adhesive capsulitis.
• Approximately 3% of adults may suffer from a frozen shoulder during their lifetime.
• There are two main types - primary and secondary

 Primary frozen shoulder is more common and occurs spontaneously, for example in persons with underlying health conditions including diabetes, heart disease and thyroid problems. It is seen between the ages of 40 and 60, and is more common in women.

 Secondary frozen shoulder occurs as a result of trauma or a period of immobilization for example after surgery or following other shoulder conditions such as impingement.

• In frozen shoulder, only the shoulder (and usually only one shoulder) is affected. Other joints will be normal and there should be no pain. If other joints, such as knee joint or hands show symptoms, it is not frozen shoulder and it's important to get the right diagnosis

RISK FACTORS OF FROZEN SHOULDER
• Women over 40 years of age
• Prolonged shoulder joint immobilization - trauma, rotator cuff injury, stroke, mastectomy
• Systemic diseases - diabetes, thyroid disorders, heart disease, Parkinson's disease, tuberculosis

SYMPTOMS OF FROZEN SHOULDER
Frozen shoulder typically develops gradually, and has three distinct stages. Each stage can last several months.

• Freezing or painful stage - Any movement of the shoulder causes pain, and range of movement becomes
restricted. Typically lasts up to 9 months but longer in diabetics. The pain might be worse at night and disturb sleep.
• Frozen or adhesive stage - Pain may reduce slightly, but the shoulder joint becomes stiffer, and mobility is increasingly reduced. This stage may last between 4 months to an year.
• Thawing or recovery stage - The range of motion of the shoulder joint starts to improve, and may last between one to three years.

DIAGNOSIS OF FROZEN SHOULDER
• The diagnosis of frozen shoulder is usually made by a detailed history and examination. The diagnosis may be confirmed by imaging such as an x-ray or MRI of the shoulder joint.
• The hallmark of frozen shoulder is that the joint appears normal on imaging tests

FROZEN DIAGNOSIS - DIFFERENTIAL DIAGNOSIS
• Rotator cuff injury - The shoulder is painful only when the patient moves the joint (active movement) but not when the doctor moves the arm for you (called passive movements). In frozen shoulder both active and passive movements are painful.
• Osteoarthritis of shoulder joint
• Subacromial bursitis
• Biceps tendinitis
• Rheumatoid arthritis of shoulder

TREATMENT OF FROZEN SHOULDER
Treatment of frozen shoulder involves controlling shoulder pain and preserving the range of motion of the shoulder as much as possible

MEDICATIONS
Over-the-counter pain relievers, such as paracetamol, aspirin and ibuprofen reduce pain and inflammation associated with frozen shoulder. If these are not effective, stronger pain-relieving and anti-inflammatory drugs may be prescribed.

PHYSIOTHERAPY
Many patients are referred to a physiotherapist and benefit from physiotherapy. The physiotherapist may teach some shoulder exercises and also offer measures to reduce pain such as warm or cold temperature packs and transcutaneous electrical nerve stimulation (TENS) machines.

SHOULDER EXERCISES
Shoulder exercises are often advised and are useful. They keep the shoulder from 'stiffening up' and help to preserve the range of motion. It is important to do the exercises regularly as advised by the doctor or physiotherapist.

STEROID INJECTIONS
Steroid injection into, or near to, the shoulder joint can provide symptomatic relief for several weeks in some cases. Steroids reduce inflammation, and do not cure the condition. Symptoms tend to return gradually, and many patients are happy with the relief provided by steroid injections. However, steroid injections can cause harm, by damaging the tendons inside the shoulder, causing infection and bleeding.

JOINT DISTENSION
Injecting sterile water into the joint capsule may stretch it a bit and improve mobility

SURGERY
Sometimes surgery is considered if other treatments do not help. Techniques that are used include

• Manipulation - This is a procedure under anesthesia, where the shoulder is moved around by the surgeon, and may loosen up the adhesions but carries a slight risk damaging other parts of the shoulder.
• Arthroscopic capsular release - This is a simple operation performed as 'keyhole' surgery. It is usually a day-case procedure. During the operation, the tight joint capsule is released using a special probe.

SUMMARY
• Usually affects women over 40 years
• Exact etiology unclear (check for diabetes)
• Affects only shoulder; other joint involvement r/o diagnosis
• Three clinical stages
• Imaging shows normal shoulder joint
• Treatment includes medications, physiotherapy steroid injections and surgery


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