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ADHESIVE CAPSULITIS

ADHESIVE CAPSULITIS. THANATHEP TANPOWPONG ASSISTANT PROFESSOR CHULALONGKORN UNIVERSITY. “difficult to define difficult to treat difficult to explain” Codman. Codman first define “frozen shoulder”

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ADHESIVE CAPSULITIS

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  1. ADHESIVE CAPSULITIS THANATHEP TANPOWPONG ASSISTANT PROFESSOR CHULALONGKORN UNIVERSITY

  2. “difficult to define difficult to treat difficult to explain” Codman

  3. Codman first define “frozen shoulder” • 1945 : Nevaiser describe pathological lesion of fibrosis, inflammation and capsular contracture

  4. Prevalence • 2-3% of population (Female) • 40-60 year • Non-dominant hand • 20-30% involve opposite side

  5. Etilogy • Unknown • Trauma • Inflammation (TGF-β) • Associate with diabetes, thyroid dysfunction, Dupuytrens contracture, autoimmune disease, treatment of breast cancer, cerebrovascular accident, MI

  6. Diagnosis • Primary : idiopathic process, global capsular inflammation and fibrosis • Secondary : known injury or disesase prior to adhesion

  7. 62% of idiopathic adhesive capsulitis were found to have partial thickness tear of supraspinatus Yoo et al Orthapaedics. 2009;32(1):22

  8. Staging(Neviaser et al CORR 1987)

  9. Stage 1 • Pain, stiff • Gain full ROM after GA or intra-articular anesthetic injection • Duration 3 month

  10. Stage 2 (freezing) • Progressive capsular contracture • Limit ROM (not fully recovered) • “Christmas tree appearance”

  11. Acknowledgement to Neviaser AMJ Sport 2010;38:2346

  12. Stage 3 (frozen) • Progressive loss of motion • Not improve after intraarticular anesthetic injection • Duration 9-15month

  13. Stage 4 (thawing) • Minimal pain • Gradual improve ROM • Fully mature adhesion • Difficult to identify intra-articular structure during arthroscope

  14. Natural history • No true study of natural history • Self-limiting • Grey: complete recovery in 2 years • Miller: normal function and minimal pain after home therapy 4 year after home therapy JBJS Am 1978;60(4):564 Orthopaedics 1996;19(10):849-853

  15. 94% of idiopathic frozen shoulder recover to normal level, range of motion, function without treatment Vastamaki et al CORR 2012;470(4):1133.43

  16. TREATMENT • Address underlying pathology • Treatment according to clinical stage at presentation

  17. NSAIDs • Theoretical benefit • No level I or II study to prove effectiveness • Improve pain but not improve motion • Cox-2 have comparable efficacy compare to Cox-1 ( better night pain control) Rhind Rhumatol Rehabil 1982;21(1):51-53 Duke Rhumatol Rehabil 1981;20(1):54-59 Otha et al. Mod Rhumatolol. Feb 2013

  18. Oral steroid • Provide rapid relief of pain (similar to intraarticular steroid injection) but not sustain at long term • Possible long term systemic effects • Not recommend Buchbinder Ann Rhum Dis 2004;63(11):1460-1469

  19. Intra-articular steroid injection • Rizk et al : transient (2-3 week) improvement of pain compare to placebo • Bulgen et al : improve pain and motion in 4 weeks Arch Phys Med Rehabil 1991;72(1):20-22 Ann Rheum Dis 1984;43(3):353-360

  20. Van der Windt • 109 patient • 40 mg of triamcinolone vs physical therapy 2/wks • 2.2 injection/6 weeks • Passive joint motion, exercise, ice, hot, electrotherapy • 1 year follow up • Self-assessment and functional score • 77% success in injection group vs 46% in physical therapy group BMJ 1998;317(7168):1292-1296

  21. Intraarticular steroid injection gives better result in early stage of disease • Stage 1recover in 6 weeks • Stage 2 recover in 7 months Marx HHS J 2007;3(2):202-207

  22. Physical therapy • Most consistently prescribe for latter stage • Cochrane database review • Little overall evidence (4/26) • No evidence that physiotherapy alone is of benefit in adhesive capsulitis Cochrane Database Syst Rev 2003;(2):CD004258

  23. Carette and Bulgen found no difference between physiotherapy and no treatment (control group)—level I study • Low number of participants Arthritis Rheum 2003;48(3):829-838 Ann Rhum Dis 1984;43(3):353-360

  24. Level I study by Vermeulen • Low grade mobilization have little difference compare with high grade technique • Low grade : movement with in pain free zone • High grade: movement into stiff and painful range • “reflex muscle acivity” Phys Ther 2006;86(3):355-368

  25. Surgical intervention In most series 10% of patients do not respond to non-operative treatment

  26. Surgical intervention • Suprascapular nerve blocks • Hydrodilation • Manipulation under anesthesia • Arthroscopic release • Open release

  27. Suprascapular nerve block • Unclear therapeutic mechanism • Disruption of efferent and afferent pain signaling • May normalization pathological and neurological process • Insufficient data to prove it’s efficacy

  28. Hydrodilation (Brisement) • Increase intracapsular pressure until rupture • Compare hydrodilation with MUA • No diiference in ROM • Better Constant and VAS score • Small number of trials to proof it’s efficacy Quraishi JBJS Br. 2007;89(9):1197-1200

  29. Manipulation (MUA) • MUA vs home exercise (level II) • Slight better moblility at 3 month • No difference in 6 and 12 month • MUA have effect of improve motion and pain relief for approx 23 years Kivimaki J Shoulder Elbow Surg 2007;16(6):722-726 CORR 2013;471(4):1245-50

  30. Arthroscopic release • Advantage • Accurate and complete • Ability to perform synovectomy • Improve mobility of musculotendinous unit compare with open surgery • Minimal pain • Identify intrinsic pathology • Post operative motion can be done immidiately

  31. Contraindication • Unable to cooperate postoperative program • Pateint cannot tolerate stress from fluid challenge (renal or cardiac failure)

  32. Surgical technique Release rotator interval , SGHL

  33. MGHL

  34. Posterior capsular release

  35. Release axillary pouch and IGHL (multiple perforation or direct cut)

  36. My practice • Stage 3 or 4 • No intraarticular steroid are injected • Jackin’s exercise (low grade) • Nsaids prior and ice after • If 3-6 month not improve MUA or scope release

  37. Jackin’s exercise program Each 4 position are perform 10 times/round 5 round/day

  38. Post operative protocol • Regional nerve block ( interscalene, SSN, brachial) • Immediate post-op : pendulum exercise • Passive stretching ( Forward flexion, IR, ER, ABD) • 2 times/day, 15 minutes/session • Follow up: post-op week 1,2,4,6,8

  39. Thank you

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