Contents
Definition
- The functionally limited pattern is a result of a protective activation of involuntary muscular spasms which limits movement in order to restricts further damage of the inflamed joint, and in this way avoids overstretching
- As a result of lack of movement, the intracapsular tissue adheres and the movements become fixated
- Long lasting inflammation of the capsule leads to fibrosis and thickening of the fibrous capsule.
Development
The conditions are divided into different stages with varying degree of functional limitation and pain. Understanding that the functional presentation of the patient will vary depending on which stage they are in is important
Stage 1
- Difficulty with getting a clear diagnosis due to symptoms not being clear in this phase
- No pain at rest
- Pain is limited to the upper arm
- Patient can sleep on the affected shoulder at night
- During lateral rotation of the shoulder, the end-feel is normal or slightly hard
- Pain at end-feel of passive movements
- Lateral rotation the most painful, with abnormal end-feel
- Later limitation sets in with lateral rotation being limited first, followed by the abduction and medial rotation
Stage 2
- Mixed results
Stage 3
- Large degree of limitation of movement of the shoulder
- Pain during rest
- Patient is unable to sleep on affected shoulder
- Pain spreads beyond the upper arm and into the lower arm
- Muscle spasm during end-feel of capsular pattern
Various conditions with shoulder joint lesions
Traumatic arthritis
Definition
- An injury which is the result of an injury or trauma to the shoulder
- Very rare for patient under 40 years of age, risk is virtually zero
Development
- May develop after glenohumeral joint luxations, contusions or surgery of the shoulder
- Injury may not necessarily have been severe, and the development may start a few days after an direct or indirect injury towards the shoulder
- In some cases the patient may have forgotten the incident or root cause, because of the time it takes until the pain increases to a degree where they seek help
- Heals by itself within 1 year
- There are 3 stages are observed within this period
Stage 1
- Painful phase
- Increasing pain and limitation of movement is seen over time
- First 2 weeks
- There is pain during activity which involves the shoulder
- After about 2 weeks, pain is increasing
- May cause problems with sleep
- Pain may spread into the lower arm
- After 2 months, highest amount of inflammation of the glenohumeral joint
- Pain is at it’s worst, continuous pain day and night
- Pain is spreading into the lower arm
- Clear limitation of movement of the shoulder
Stage 2
- Increasing stiffness phase
- Pain is decreasing
- Pain at night and result gradually fades out
- Pain is reverted back into the upper arm
- Limitation of movement remains the same
- Inflammation decreasing
Stage 3
- Resolution phase
- Limitation is gradually improved, usually fully restored by 1 year
- Rare examples, the limitation may last up to 6 years
- Sometimes, the limitation of elevation and lateral rotation may permanently be slightly restricted
Examination
Stage 1
- Early stage 1:
- Capsular pattern not necessarily present
- If slight, lateral rotation and abduction is barely limited
- Pain during end-range of all 3 movements (lateral rotation, abduction and medial rotation)
- End off stage 1. Limitation may be:
- 80 degree of lateral rotation
- 60 degree of abduction
- 20 degree of medial rotation
- Hard and spastic end-feel
Stage 2
- Limitation the same as end of stage 1
- End-feel may somewhat soften (but still hard), from spastic to hard
Stage 3
- Limitation of range of motion is gradually decreasing
- At the end of the period, range of motion is back to normal
- In rare cases, elevation and lateral rotation may be permanently affected to a lesser degree
Patient recommendations
- The patient should be encouraged to use the arm as much as possible within the pain limits, preferably up to full range at least 2 times per day to avoid further adhesions
- If there is too much pain, consider various treatment procedures including mobilization techniques
Considerations
- Even though mobilization is recommended, too aggressive mobilization may lead to more pain and increased inflammation
- If mobilization and stretching is done during a high inflammation stage it may worsen the condition
Immobilization arthritis
Definition
- Pathology which occurs in patients over 60 years old, due to immobilization of the shoulder
Causes
- Immobilization of shoulder, e.g. due to
- Hemiplegia
- Resulting after subarachnoid bleeding of the capsule
- Parkinson’s
- Previous fracture of humerus or elbow
- Heart disease
- May develop as a result of immobilization after an infarction or surgery
Development
Stage 1
- Painful phase
- Increasing pain and limitation of movement is seen over time
- First 2 weeks
- There is pain during activity which involves the shoulder
- After about 2 weeks, pain is increasing
- May cause problems with sleep
- Pain may spread into the lower arm
- After 2 months, highest amount of inflammation of the glenohumeral joint
- Pain is at it’s worst, continuous pain day and night
- Pain is spreading into the lower arm
- Clear limitation of movement of the shoulder
Stage 2
- Increasing stiffness phase
- Pain is decreasing
- Pain at night and result gradually fades out
- Pain is reverted back into the upper arm
- Limitation of movement remains the same
- Inflammation decreasing
Stage 3
- Resolution phase
- Limitation is gradually improved, usually fully restored by 1 year
- Rare examples, the limitation may last up to 6 years
- Sometimes, the limitation of elevation and lateral rotation may permanently be slightly restricted
Examination
Stage 1
- Early stage 1:
- Capsular pattern not necessarily present
- If slight, lateral rotation and abduction is barely limited
- Pain during end-range of all 3 movements (lateral rotation, abduction and medial rotation)
- End off stage 1. Limitation may be:
- 80 degree of lateral rotation
- 60 degree of abduction
- 20 degree of medial rotation
- Hard and spastic end-feel
Stage 2
- Limitation the same as end of stage 1
- End-feel may somewhat soften (but still hard), from spastic to hard
Stage 3
- Limitation of range of motion is gradually decreasing
- At the end of the period, range of motion is back to normal
- In rare cases, elevation and lateral rotation may be permanently affected to a lesser degree
Treatment
Mobilize the shoulder daily to avoid further adhesions and arthritis
Frozen shoulder
Definition
- An inflammatory condition which causes fibrosis of the glenohumeral joint and is accompanied by gradual progressive stiffness and significant restriction of range of motion of the shoulder
- In most cases the condition lasts for 1-2 years
- Also called adhesive capsulitis or monoarticular steroid-sensitive arthritis
- Develops without any clear underlying cause
- General population has a 2-3% chance of developing frozen shoulder
- 5 times more likely to develop in people with diabetes (13%)1
- Hyper- and hypothyroid patients have an increased risk of frozen shoulder than that of patients without these condition 2, 3
Development
- Can develop at any age
- But mainly seen in people between 45-60 years of age
- Only affects one shoulder at a time, but other shoulder could get involved within 5 years
- Is divided into 4 periods with each period lasting normally from 6-9 months
Phase 1
- Patient starts to complain about shoulder pain without any obvious cause
- Over time, the pain increases and becomes continuous
- Pain will start to expand into the lower arm
- Pain becomes often worst at nighttime, giving the patient problem with sleep
Phase 2
- Pain remains stable, but high for another 6 months
Phase 3
- Pain starts to diminish, usually after about 1 years, but sometimes later
- Pain usually disappears fully within the last part of this phase
- Movement is still restricted throughout the phase
Phase 4
- Movement gradually improves
- But still somewhat restricted
- Still some discomfort, but relatively low
- Movement is returned to full range of motion by end of phase
Examination
- In the beginning of first phase, there is only pain at the end of all passive movements
- Passive lateral rotation is the most painful
- The limitation increases along with the increasing pain
- The capsular pattern is clear during the end of the first phase, with a clear feeling of spastic end-range
- Both pain and movement limitation remains stable and clear (limited and painful) during the whole of the second phase
- During the third stage the end-feel of testing softens from spastic to hard
Haemaarthrosis
Definition
- Bleeding into the joint, which may occur after an injury
Causes
- Usually a fall or injury towards the shoulder joint
- But, can also develop spontaneously
Examination
- Clear capsular pattern during testing should suspect condition if connected to a recent injury
- Limitation of passive lateral rotation
- Limitation of passive abduction
- Limitation of passive medial rotation
Treatment
- If there is blood, it is important that it is aspired quickly
- Blood is a irritant of the capsule and may lead to destruction of the joint over a few years