Shoulder Case Study 2:

Frozen shoulder following humeral fracture

Margaret Stevens is a fit, healthy 62 year old, retired school teacher who
suffered an injury to her right shoulder 10 weeks ago. She fell off her cycle
onto her shoulder which was immediately painful; an x-ray at the time
revealed a fractured neck of humerus. She was treated with a collar and cuff
followed by mobilisation. The shoulder is stiff with pain over the area of the
right deltoid radiating down the arm to the elbow. Although the pain and
stiffness are easing, shoulder movements are restricted in a capsular pattern.
Mrs Steven’s GP has referred Ms Stevens to physiotherapy for assessment and
management. She takes NSAIDs which help to control of her symptoms.

Anatomy and Pathology

Anatomy

Explain local anatomy of shoulder and humerus - focusing more finally on the
aspects of the glenoid cavity and proximal humerus relevant to this case study:

Demonstrate these where appropriate on your model.

bony parts:

clavicle, coracoid process, spine of scapula,acromium process, medial border

of scapula, acromium process, inferior border of scapula,bicipital groove,
greater tuberosity (lateral of bicipital groove ) & lesser tuberosity ( medial to
bicipital groove ) of humerus surgical and anatomical neck of humerus

Muscles - origin/insertion - action - demonstrate these on your model

Trapezius - occiput,C7,T1-T12/lateral clavicular

1/3rd,acromium,scapularspine -
elevates,retracts,depresses scapula
Levator Scapulae - C1-C4/upper medial scapular border - elevates scapula
Rhomboid Minor and Major - C7-T1/medial scapular border - retracts scapula

Serratus Anterior - upper 8,9 ribs/anterior scapular fossa - protracts scapula

Pectoralis Major - clavicular & sternal heads - adducts & medially rotates
shoulder
Teres Major- inferior lateral border scapula/bicipital groove - medially rotates
adducts shoulder
Teres Minor- lateral border scapula/posterior of greater tubercle of humerus
Deltoid- clavicle,acromium,scapula/deltoidtuberosity-
flex,extend,medial,lateral abduct shoulder
Supraspinatus - hollow above sacpular spine/greater tubercle - initiates
abduction
Infraspinatus - below scapular spine/greater tubercle - laterally rotates
shoulder

Joints : Shoulder Joint - ball and socket

Acromioclavicular joint - gliding joint
Sternoclavicular joint - double arthroidal joint

focus on : humeral fracture / capsular patterns

Humeral fractures - more common at surgical rather than anatomical neck -

introduce idea of displacement - in fracture the broken bits can moved away
and twist form their original positions

Capsular pattern "Dr. James Cyriax was the first to extensively study soft
tissue lesions. When inflammation of a joint is present (known as synovitis or
capsulitis), not only does passive stretching of the capsule cause pain but a
limitation of range of motion of the involved joint is always found to be in a
specific pattern; this pattern is always similar for that particular joint,
although each joint has a different and instantly recognizable capsular
pattern"

Capsular pattern for shoulder is lateral rotation abduction and medial

rotation.

Pathology

Humeral Fracture: - fracture of the proximal humerus is common in elderly

patients. Most fractures don't show displacement and can be treated without
surgical fixation. Resetting tends to occur if displacement is >1cm or 45
degrees. Normal diagnosis is by x-ray. Patients typically have severe pain -
swelling and bruising. Pain is usually worse with any movement - loss of
feeling indicates neural injury. With minimal displacement such as Ms
Stevens appears to have suffered - a sling is usually enough and can begin an
exercise program consisting of pendulum and circumduction exercises from as
little as the first week. Isometric exercises of the deltoid and the rotator cuff
can be encouraged within the first 2 weeks and after 3 weeks the sling can be
worn part time or removed completely if pain is minimal. Patients often report
a subsequent pain and loss of range of motion in the shoulder

Adhesive Capsulitis :- Inflammation of joint capsule which makes the joint

stick - restricts motion - both active and passive - by 50% in a capsular pattern
- with pain at range's limit. Typically Patients experience and early "freezing
phase" followed by a "thawing phase" which can take between 6 months to 2
years to resolve. Patients also complain of pain and diffuse tenderness at the
deltoid insertion. The shoulder joint is a c5 structure and this are is the
dermatome for the auxiliary nerve which may be restricted by the
inflammation at the glenoid cavity. Common between 40 and 60 years of age
and diabetes is a risk factor. Minimal long term functional deficit - although
some loss of motion may remain. X rays should be taken to ensure joint
surfaces are smooth and to rule out any other abnormality such as oseophytes
and tumours. Condition m ay be bilateral - affect both shoulders.

Subjective Examination
Symptoms

Where - she reports : decreasing stiffness in a capsular pattern and pain at

deltoid insertion -
you expect - pain at limit of capsular motion & pain in subscapularis is
common
- so you ask her about this

When - reports : <>Concerns/Red Flags & Differential diagnosis - oseophtyes

from humeral malunion can affect the joint. Adhesive capsulitis should be
distinguished from the pain which occurs with rotator cuff tear and
impingement syndrome - neither of these conditions do not show passive loss
of ROM

Patient's Primary Outcome

ask this what this is for Ms Stevens - you can expect possibly a request to
increase range and/ or decrease pain.

Working Hypothesis for Objective Examination - Patients is

experiencing frozen shoulder - rule out rotator cuff tear and impingement
syndrome - check for malunion of humerus.

Main Outcome
ask this - you can expect possibly an a request to increase range and/ or
decrease pain

Objective Examination

Consent - before beginning objective examination explain procedure :

observations - assessed movements - palpation and possibly measurements -
then obtain consent

Observations

Skin Colour - expect bruising from fracture to have gone

Swelling - expect none - inflammation is internal
Posture - some imbalance across shoulder may appear
Muscle Bulk - possibly some due to rest and underuse
Deformity - none

Active Movements - ask patient to perform the following on both shoulders

-on affected shoulder - the capsular pattern (*) should show 50% loss of
movement in normal range
abduction (*) - main loss of rom
adduction
medial rotation (*) - some loss of rom
lateral rotation (*) - main loss of rom
flexion
extension

Passive Movements - perform the following on both shoulders - on affected

shoulder restriction in range will distinguish the condition from rotator cuff
tear and impingement syndrome. Stiffness should limit the (*) movements -
where possible "listen" with you hands for any grinding or grating which may
indicate humeral malunion. Expect pain to come as the joint reaches its
maximum range.

Abduction - (*) - main stiffness

adduction
medial rotation - (*) - main stiffness
lateral rotation - (*) - some stiffness
flexion
extension
Restricted Movements - perform the following - expect some muscle
weakness compared with opposite shoulder - particularly in the (*)
movements which not have been so active.

abduction - (*) - possible main loss

adduction
medial rotation - (*) - possible main loss
lateral rotation - (*) - some possible loss
flexion
extension

Special Tests

Loss of capsular rom is the key feature of frozen shoulder. No other tests are
necessary. Hawkins and empty can test for shoulder impingement which we
would expect has already been ruled out. They effect medial rotation - so since
they might produce pain for the patient as well as possibly being impaired by
loss of rom - they should be avoided.

Similarly the drop arm test - for rotator cuff tear should have been
demonstrated to be unnecessary - it effects abduction - which again might
produce unnecessary pain for the patient.

Palpation
expect to elicit pain while palpating the deltoid insertion and also down the
arm

Concluding advice and expected treatment

Tell patients symptoms might be worse following exam.

NSAID, nonnarcotic analgesics, and moist heat are indicated followed by a

gentle stretching program. Often ice is used after stretching to control
swelling. TENS units may help control pain. Home stretching program should
be done over a gentle range - advise it may take 1 to 2 years for complete
recovery.

external rotation in an adducted position tends to be the most restricted -

home exercise program should include stretching into external rotation with
the arm at no greater than 30 to 45 degrees of abduction - therapy which is too
aggressive may aggravate symptoms and/or cause fracture of the humerus

failure to show significant improvement in pain and motion after 3 months of

constant rehabilitation require further evaluation. Frozen shoulder is common
after trauma. If the fracture of the humerus was more complicated than
thought at first it could knit badly and cause permanent disturbance to the
joint capsule.