Orthopedics Decury 1: Adhesive Capsulitis

Agabin, Troy Vincent

Grageda, Yna

Ong, Marie Collins

Mesina, Daniella

Uy, Sean Wesley

Villacamapa, Alessandra Joy

04/19/2013

S> AP, a 47 y/o (-) DM/Htn/Asthma ® handed ♂ pt c/o gr. 5/10 intermittent “kirot at ngalay” pain (0=no pain; 10= worst pain on SPS) on ® shoulder in simple movements but ↑ to gr. 7/10 upon movement to endrange as to reaching overhead; (L) “lumalagatok” knee c pain @ gr. 3/10, pt claims pain is relieved c ice & sometimes subsides when playing basketball. HPI: a mo. ago, pain was felt again on his ® shoulder & gradually ↑ until 2 wks ago, when he felt the pain was not tolerable anymore. He consulted a MD last April 12 & referred him to Dr. Reyes of MMC, where he was Dx c adhesive capsulitis on ® shoulder last April 17; no meds were given. X-ray was done but results were still to be read. PMHx: condition started last Jan 2012 during pt’s volleyball training, he spiked c his ® shoulder & felt something like a pulled muscle; placed ice pack right away. His coach advised him to take a 3-day rest, p resting, he exercised c a “yellowish” theratube for a wk & felt okay. Lifestyle: (-) alcoholic beverages drinker/smoker, works as an outside plant engineer, which requires driving, computer & office works. Pt still plays basketball during his spare time. Home & social environment: Pt lives c his wife & mom in a 2-storey house & claims he uses his (L) shoulder to reach their overhead cabinets; computer @ work follows proper ergonomics. Goal: “Magheal ung sugat at makalaro nang maayos.”

O> VS> BP= a: 120/80mm Hg p:140/100mmHg OI>endomorph

(-) redness of (B) UE (-) trophic skin changes on (B) UE (-) swelling & atrophy on (B) UE

Palpation> (+) gr1 tenderness on ® bicipital groove area (+) crepitations upon ® shoulder ER&IR (-) muscle spasm on ® shoulder (-) muscle guarding on ® shoulder towards all planes

ROM> All joints of (B) UE are assessed and found significance c ® shoulder:AROM PROM Endfeel

Flex 0-150 0-160 Firm c pain @ endrangeExt 0-30 0-35 Firm c pain @ endrangeAbd 0-90 0-108 Firm c pain @ endrangeER 0-90 0-95 Firm c pain @ endrangeIR 0-80 0-85 Firm c pain @ endrange

MMT> All major muscles of (B) UE are graded 5/5 except:® shoulder flexor 4/5® shoulder abductor 4/5® shoulder extensor 4/5

Sig: Weakness maybe d/t pain. Special tests> (+) Yergason’s test on ®

(+) Speed’s test on ® (-) Neer impingement test on ®

FA> Pt is indep in all aspects of ADLs, bed mob & transfers Able to reach overhead but c pain Able to don & doff shirt c mod difficulty

A> PT Dx: MD Dx of adhesive capsulitis on ® shoulder further defined by inability to do overhead activities normally 2 to pain & LOM on ® shoulder

Problem list:1. Pain2. LOM3. Functional limitation (difficulty in doing overhead activities)

LTG> Rehabilitative: Pt will be able to reach overhead, move ® shoulder towards all planes s pain& play basketball c ease p 6 PT sessions

>Preventive: Pt will adhere to HEP& apply pt education p 1 PT session to avoid further complications

STG> 1. Pt will report ↓ pain from 7/10 to 3/10 p 3 PT sessions to help him do his work better2. Pt will demonstrate ↑ AROM by ~10 on all movements of ® shoulder p 3 PT sessions to

aid in his work especially in doing overhead as to putting cables & wires.P> Pt will be seen & treated as an OP for 6 PT sessions c ff mx:

® shoulder1. US x 1MHz x 1.5 w/cm x 5’ on ® bicipital groove to ↓ pain2. HMP x 20’ on ® shoulder to ↓ pain3. TENS x 20’ on ® shoulder to ↓ pain4. Joint mobilization grade 2 of ® shoulder towards ant, post, inf gliding x 30secs oscillation

x 2 reps to ↑ ROM5. Arm pull of ® shoulder x 1 rep to relax muscles & joints6. GPS towards ® shoulder abd, flex &ext x 15secs x 3 sets each to ↑ ROM7. Overhead pulley towards shoulder flex &abd of ® shoulder x 10reps x 2 sets to ↑ ROM8. Shoulder wheel towards ® shoulder ER & IR x 10reps x 2 sets to ↑ ROM9. Finger ladder towards ® shoulder abd& flex c 6SH x 10 reps x 2 sets to ↑ ROM (L) knee(L) knee1. HMP x 20’ on ® shoulder & (L) knee to ↓ pain2. Hamstring sets x 10 reps x 2 sets c 6SH o strengthen hamstrings3. Short arc quads x 10 reps x 2 sets c 6SH to strengthen quadriceps4. SLR c ext rot x 6SH x 10 reps x 2 sets to strengthen quadriceps

HEP>1. Wand exercises2. Self-stretching3. Pt education:4. Respect fatigue5. Stretch properly prior to game & training

Basic Science/Background

We all know that muscles initiate the movement of a certain body area. In the case of the shoulder, we can divide it into three parts. First are the muscles connecting the upper limb to the thoracic wall namely the Pectoralis major which is supplied by the medial and lateral pectoral nerves from brachial plexus and its action is to adduct the arm and rotate it medially. Next is the Pectoralis minor which is supplied by medial pectoral nerve from brachial plexus and it depresses point of shoulder if scapula is fixed and it elevates the ribs of origin (third, fourth and fifth ribs). Next is the Subclavius which is supplied by the nerve to subclavius from upper trunk of the brachial plexus and it depresses the clavicle and steadies this bone during movements of the shoulder girdle. Last is the Serratus anterior which is supplied by long thoracic nerve and it draws the scapula forward around the thoracic wall and rotates the scapula.

Next are the muscles that connect the upper limb to the vertebral column. There are five, first is the Trapezius which is supplied by the spinal part of the accessory nerve (motor) and C3-C4 nerve root (sensory). The trapezius has three different parts that has different actions. It is divided into the upper fibers which elevate the scapula, middle fibers pull the scapula medially and the lower fibers pull medial border of the scapula downward. Next is the Latissimus Dorsi muscle, it is supplied by the thoracodorsal nerve and it extends, adducts and medially rotate the arm. Next is the Levator scapula which is supplied by C3-C4 nerve roots and dorsal scapular nerve. The Levator scapula also raises the medial border of the scapula. Next are the Rhomboids major and minor. They are supplied by dorsal scapular nerve and they both raise the medial border of the scapula upward and medially.

Last are the muscles that connect the scapula to the humerus. First is the Deltoid muscle which is supplied by the axillary nerve. The Deltoid muscle abducts the arm, the anterior fibers flex and medially rotate the arm while the posterior fibers extend and laterally rotate the arm. Next are the infraspinatus and supraspinatus which are both supplied by the subscapular nerve. Their actions are to abduct the arm and stabilize the shoulder joint, and laterally rotate the arm and stabilizes shoulder joint respectively. Next are the Teres major and subscapularis muscles, they are supplied by lower subscapular nerve and upper and lower subscapular nerve respectively. They both medially rotate the arm and stabilize the shoulder joint. Last is the Teres Minor which is supplied by the axillary nerve and it laterally rotates the arm and stabilizes shoulder joint.

Blood supplying these muscles are thoracoacromial trunk (pectoral branch and deltoid branch), thoracodorsal artery, subscapular artery, circumflex scapular artery and muscular branches of brachial artery.

These muscles are attached to the bones to help stabilize the shoulder girdle. We have the Scapula which is attached to the posterior thoracic wall. The spine of the scapula extends to form the acromion which will later on be attached to the clavicle to form the acromioclavicular joint. The spine of the scapula then extends to form the glenoid fossa then the head of the humerus will be articulating to the glenoid fossa to form the glenohumeral joint. Usually, the head of the upper arm is larger than the socket, and a soft tissue called labrum surrounds the socket to help stabilize the joint. The labrum also serves as an attachment site for several ligaments.

The shoulder complex is composed of five joints – two functional joints (scapulothoracic and suprahumeral joints), and three true joints (sternoclavicular, acromioclavicular and glenohumeral joints). The scapulothoracic (ST) joint is the articulation between the scapula and the thorax, while the suprahumeral (or coracoacromial) arch is formed by the coracoid process,

the acromion process, the coracoacromial ligament and the inferior surface of the acromioclavicular joint. Although not part of the true joints of the shoulder complex, these joints contribute to the normal function of the shoulder complex. Movements in the scapulothoracic joint affect movement on both the acromioclavicular (AC) joint and the sternoclavicular (SC) joint making the ST joint part of a true closed chain with the AC and SC joints and the thorax. The suprahumeral arch on the other hand protects the subacromial bursa, the rotator cuff tendons, and part of the biceps brachii (long head) tendon from direct trauma, and serves as a barrier that prevents the humeral head from dislocating superiorly.

The sternoclavicular joint is composed the articulation between the medial end of the clavicle and the notch formed by the manubrium sternum and the first costal cartilage. This articulation forms two saddle-shaped articulation surfaces. This joint is the only structural connection between shoulder complex and upper extremity, and the axial skeleton. It is reinforced by a strong fibrous capsule and the three ligament complexes – sternoclavicular, costoclavicular and interclavicular ligaments. It has three rotatory degrees of freedom (elevation/depression, protraction/retraction and anterior/posterior rotation) and three translator degrees of motion that occurs in the anterior/posterior, medial/lateral, and superior/inferior directions.

The acromioclavicular joint is a plane synovial joint that connects the scapula to the clavicle. It is supported by a relatively weak capsule, and reinforced by two ligament complexes – the acromioclavicular and coracoclavicular ligaments. Motions in the acromioclavicular joint produce three rotary motions occurring around axes oriented to the scapular plane (internal/external rotation, anterior/posterior tilting, and upward/downward rotation), and three translator motion occurring in the anterior/posterior, medial/lateral, and superior/inferior directions.

The glenohumeraljoint is a ball-and-socket joint formed by the head of the humerus and the glenoid fossa of the scapula. It has three rotational degrees of freedom – flexion/extension, abduction/adduction, and medial/lateral roration. It is reinforced by a large and loose capsule that is taut superiorly and slack anteriorly and inferiorly. Its resting position is 40-55oabduction and 30o horizontal adduction. Its closed packed-position is full abduction and external rotation, making the capsule tight. The capsular pattern of the glenohumeral joint is lateral rotation, abduction and medial rotation.

Large movements occurring in the glenohumeral joint is brought about by the joint’s relative laxity. It is therefore necessary for the joint to be supported by surrounding ligaments and muscles. Static capsular reinforcements include the superior, middle and inferior glenohumeral ligaments located inside the capsule as thickened regions, and the coracohumeral ligament. Dynamic reinforcement is provided by the rotator cuff muscles and their tendons by inserting directly and blending into the glenohumeral joint capsule.

Ranges of motion for the glenohumeral joint may vary across different individuals. According to the American Academy of Orthopaedic Surgeons, normal ranges are as follows: 180o flexion, 60o extension, 180o abduction, 70o medial rotation, and 90o lateral rotation.

The glenohumeral joint largely participates in the scapulohumeral rhythm, a coordinated series of synchronous motions that occurs during shoulder elevation. This concept demonstrates that for every 15o of motion between 30-170o of shoulder abduction, the glenohumeral joint contributes 10o of motion while the remaining 5o comes from the scapulothoracic joint, resulting in a 2:1 ratio.

Medical Background

Frozen shoulder or adhesive capsulitis is a feared sequelae of shoulder tendinitis, bursitis, partial tear and even reflex sympathetic dystrophy. It is often idiopathic but prolonged immobilization is a significant risk factor. It is a very painful condition and there will be a gradual increase in restriction of motion in all directions, especially external rotation and abduction, as the disease progresses. According to Braddom, Pathologic evaluation reveals perivascular inflammation but predominantly fibroblastic proliferation with nodular band formation. According to the American Shoulder and Elbow Society (ASES), frozen shoulder syndrome is “a condition of uncertain etiology characterized by significant restriction of both active and passive shoulder motion that occurs in the absence of a known intrinsic shoulder dislocation.” There are 3 stages of Adhesive capsulitis namely: freezing, frozen and thawing.

FREEZING FROZEN THAWING Intense pain

even at rest Pain only with movement No pain, no synovitis

LOM by 2-3 weeks after onset

Significant adhesions & limited GH motions

Significant capsular restrictions from adhesions

Lasts 10-36 weeks

Atrophy of deltoids, rotator cuffs, biceps & triceps.

Lasts 4 to 12 months

Lasts 2 to 24 months

The common impairments in frozen shoulder would be nocturnal pain & disturbed sleep during acute flares, decreased arm swing, decreased joint play and ROM, faulty postural compensation, general muscle weakness, etc.

Differential DiagnosisBicipitalTendinopathy • Bicipital tendinitis, or biceps tendinitis, is an inflammatory

process of the long head of the biceps tendon• Disorders of the biceps tendon can result from

impingement or as an isolated inflammatory injury.• (+) Speed’s Test• (+) Yergason’s• Anterior shoulder pain over the bicipital groove (with

possible radiation over Biceps)• Tenderness upon palpation over the LHB tendon• (+/-) Crepitation• Popping, audible snap c shoulder movementd/t overuse

Osteoarthritis • Osteoarthritis is mostly a result of natural aging of the joint. With aging, the water content of the cartilage increases, and the protein makeup of cartilage degenerates

• Repetitive use of the worn joints over the years can irritate and inflame the cartilage, causing joint pain and swelling.

• Pain at the joint itself (Deep, Boring)• Pain c movement• M/c c advanced age (50y/o & above)

• LOM• Insidious onset• Degeneration d/t overuse (wear & tear)

Rotator Cuff Tendinopathy • Inflammation of Rotator Cuff tendons • Most injuries occur in the supraspinatus tendon• (+)Empty Can• (+)Hawkins-Kennedy• (+)Neer’s• weakness on abduction and ER• LOM (especially c IR)• Pain c movement (especially overhead activities)• Nocturnal pain• Painful arc of shoulder abduction (70º-120º)• Tenderness over Supraspinatus mm.• d/t overuse

Reflex Sympathetic Dystrophy Syndrome

• a chronic condition characterized by severe burning pain, pathological changes in bone and skin, excessive sweating, tissue swelling, and extreme sensitivity to touch.

• a nerve disorder that occurs at the site of an injury (most often to the arms or legs).

• It occurs especially after injuries from high-velocity impacts such as those from bullets or shrapnel. However, it may occur without apparent injury.

• Tendon contractures• Muscle wasting• Loss of strength• (+) swelling and stiffness in affected joints

Brachial Plexus Injury Damage to the nerves controlling the shoulder and arm Paralyzed arm Lost muscle control in arm, hand or wrist Numbness in the arm

References: 1. Braddom, Randall L., Leighton Chan, and Mark A. Harrast.(2011).Physical

medicine and rehabilitation. 4th ed. Philadelphia, PA: Saunders/Elsevier, Print.2. Snell, Richard. (2008). Clincal Anatomy edition 8. Lippincott Williams & Wilkins:

351 West Camden Street Baltimore, MD 21201