Periarthritis shoulder & painful arc

PERIARTHRITIS
SHOULDER
Dr Venkatesh V
Assistant Professor
Dept Of Orthopaedics
Ssmc

INTRODUCTION
 The periarthritis of shoulder also called as
adhesive capsulitis or Frozen shoulder, is
a chronic, inflammatory disorder of the
shoulder and surrounding soft tissues.
 This condition is frequently caused by injury,
leading to pain and lack of use.
As the joint becomes progressively tighter
and stiffer, simple movements, such as raising
the arm, become difficult.

DEFINITION
 Peri arthritis Shoulder
is a condition in
which there is
inflammation of
tissues around the
joint capsule. The
Gleno- humeral joint
(that is the shoulder
joint) becomes
painful and stiff.

SIGNS
Inspection
1)Patient holds arm protectively at side
2)Deltoid and Supraspinatus atrophy
 Palpation
1)Generalized pain at rotator cuff
and biceps tendon.

Limited range of motion
1)Loss of both active and passive Shoulder Range of
Motion
2)Loss of motion in all planes

SYMPTOMS
Painful shoulder
Stiffness in shoulder
Difficulty to reach overhead
at all times and all the movements of shoulder are
severely limited.

According to CYRIAX, there are 3 stages of
symptoms
Stage 1:
Pain persists in shoulder
It does not spread beyond elbow.
Person can sleep on the affected
side. Pain remains only in
movement.
Stage 2:
This stage is not clear but any symptom exceeding
beyond stage 1, is considered to be stage 2.

Stage 3:
Pain extends till wrist.
Person can’t sleep on the affected side.
Vague chill pain on movement.
In early stages, the pain is worse in night.
Later pain is present

FROZEN SHOULDER IS CLASSICALLY
CHARACTERIZED BY THREE STAGES
 Stage 1 – The painful/freezing stage. There is
usually a dull, aching pain onset of
predominantly nocturnal pain, usually without a
precipitating factor.
 The pain is not related to activity, although the
end range of motion can increase the pain.
 As the disease progresses, patients have pain
at rest which lasts 2-9 months, ROM is not
restricted.

 Stage 2 – This is known as the
adhesive/frozen stage.
 The shoulder typically becomes increasingly
stiff, daily activities such as grooming one’s
hair, reaching for a seatbelt, ove becomes
difficult.
 Although the pain does not normally get worse,
the muscles may start to waste slightly as they
are not being used.

 Stage3 - This is the recovery/thawing stage in
which you gradually regain movement of the
shoulder.
 The pain also fades, although it may recur from
time to time as the stiffness eases.
 Although it is possible that you may not regain full
movement of your shoulder, you will be able to do
many more tasks than previous stage.
 This stage can last any period of time from five
months to 3-4 years.

CAUSES/ETIOPATHOGENESIS
Periarthritis Shoulder is usually a disease of unknown
cause.
In some cases there is a history of previous trauma or
injury to the joint before the onset of condition.
This condition occurs when a person is not using the
shoulder
joint, keeping it in a guarded way with less movement, due to
pain.
This reduces the flexibility of the joint. Which in-turn causes
reduction in the movements of shoulder like flexion (forward
movement), extension (backward movement), abduction
(sideways movement) and rotational movements.

Age and Sex
People 40 and older are more likely to
experience frozen shoulder
More common in women
(especially in postmenopausal
women) than men

Prolonged Immobility
 In period of immobility your arm and shoulder
remains immobile (still) for long periods of time
while you recover which may cause your shoulder
capsule to tighten up from lack of its use. For
Example:
In rotator cuff injury, brachial plexus injury,
cervical spinal cord injury
Stroke
Fracture at or around shoulder.
Recovery from surgery (chest or breast surgery)

Endocrine abnormalities such as:
Diabetes
Hyperthyroidism
Systemic diseases
Heart disease
Parkinson’s disease

Frozen Shoulder Facts
 2-5% of the population.
 It is more common in women (60%)
 It is at least five times more common in diabetics
 It is slightly more common in patients with
Dupytren’s contracture and shares some of the
same pathology
 About 15% of people get it on both sides

It may have a genetic component i.e./ it can
run in the family
It may well have an hyper responsive
auto- immune component
It seems to affect 40-70 year olds (in
Japan it is known as 50’s shoulder)
About 15% of people get it on both sides

This reduces the flexibility of the joint. Which
in- turn causes reduction in the movements of
shoulder like flexion (forward movement),
extension (backward movement), abduction
(sideways movement) and rotational
movements.

DIAGNOSIS
• X-rays—a test that uses radiation to take
pictures of structures inside the body, to rule
out other possible causes of the stiffness
• MRI scan—a test that uses magnetic
radiation waves to make pictures of the
tissues in the body, used to examine the soft
tissues around the shoulder
• Arthrograms—x-ray pictures taken after dye
is injected into the shoulder area. This test
is difficult to perform with this shoulder
condition.

MANAGMENT
• Medical Treatment
• Anti-inflammatory Medications
Anti-inflammatory medications have not been shown
to significantly alter the course of a frozen shoulder,
but these medications can be helpful in offering relief
from the painful symptoms.
• Cortisone Injections
Cortisone injections are also commonly used to
decrease the inflammation in the frozen shoulder joint.
It is unclear the extent of the benefit of a cortisone
injection, but it can help to decrease pain, and in turn
allow for more stretching and physical therapy. What is
known, is the cortisone is only effective when used in
conjunction with physical therapy for the management
of a frozen shoulder.

Surgery
Surgery is an option if there is no improvement after 4
to 6
months of intensive therapy. Surgeries include:
Closed manipulation:-
This involves forceful movement of the arm at the
shoulder joint to loosen the stiffness. This is performed
under anesthesia and followed by intensive physical
therapy.

Arthroscopic surgery
An arthroscope, which is a long,
thin, fiberoptic tube with a light on
the end, is inserted through a
small incision in the shoulder.
Using this tube and other small
instruments, the tightened tissues are
released and the shoulder is
manipulated. Physical therapy must be
done after this surgery

Prevention
To help prevent frozen shoulder:
Do regular strength training and range of
motion exercises. This will help maintain a
strong and flexible shoulder joint.
After any injury to the upper extremity
(hand, wrist, elbow, etc), always move the
shoulder through a full range of motion
several times a day.

PAINFULARC
SYNDROME
DR VENKATESHV
ASSISTANTPROFESSOR
DEPT OF ORTHOPAEDICS
SSMC

Also Known As
Impingement Syndrome
Subacromial Impingement
Supraspinitus Syndrome
Swimmer’sShoulder
Thrower’sShoulder

• 1867fIrst jarjavay’
sDescribed
As Subacromial Bursitis
• 1931 Codman Noted That
Patients With Inability To
Abduct The Arm Had
Incomplete Or Complete
Ruptures Of The
Supraspinatus Tendon

• 1972 Neer Characterized It By Ridge Of
Proliferative Spurs And Excrescences On The
Undersurface Of The Anterior Process Of Acromion
Apparently Caused By Repeated Impingement Of
Rotatory Cuff And Humeral Head With Traction Of
The Coracoacromial Ligament.
• Later Neer Introduced Impingement Syndrome
The Supraspinitus Insertion Into Greater Tubirosity
That Passes Beneath The Coracoacromial Arch
During Forward Flexion Of Shoulder Is Susceptible
To Impingement.

• Neer Impingement
Sign
With The Patient
Seated, The Examiner
Raises The Affected
Arm In Forced
Forward Elevation
While Stabilizing The
Scapula, Causing The
Greater Tuberosity To
Impinge Against The
Acromion.
• Neer Impingement Test
• Subacromial Injection
Of 10 Ml Of 1%
Xylocaine. Pain
Caused By
Impingement
Usually Is
Significantly
Reduced Or
Eliminated, But Pain
Caused By Other
Conditions (With The
Exception Perhaps Of
Calcific Tendinitis) Is
Not Relieved

Periarthritis shoulder & painful arc

• Acromial morphology has been
implicated as contributing to
impingement.

• Age-related Degenerative Changes, Including
Decreased Cellularity, Fascicular Thinning And
Disruption, Accumulation Of Granulation Tissue,
And Dystrophic Calcification, All Have Been Noted
And Are Likely Irreversible
• Some Have Suggested That The Rotator Cuff
Tendons May Fail In Tension As A Result Of
Throwing A Baseball Or Other Overhead Sports.

There Are Four Types
• Primary Impingement
• Secondary
Impingement
• Subcorochoid
Impingement
• Internal Impingement

• Primary
It Is Classic Version And Occurs Without Any Other
Contributing Pathology
Divided Into
Intrinsic
Extrinsic

• Secondary
It Occurs When There Is
Instability Of The Glenohumeral Joint Allowing
Translation Of Humeral Head Typically Anteriorly
Resulting In Contact Of Rotatory Cuff Against
Coracoacromial Arch Inrinsic Extrinsic

• Intrinsic
Structures Passing Beneath The Coracoacromial
Arch Become Enlarged Resulting In Abutment
Against The Arch
1. Thickining Of Rotator Cuff
2. Calcium Deposits
Within Rotator Cuff
3. Thickening Of
Subacromial Bursa

• Extrinsic
When The Space Available For The Rotator Cuff Is
Diminished Subacromial Spurring
1. Acromial Fracture
2. Osteophytes Off
Acromioclavicular Joint
3. Exostoses Of Greater
Tuberosity

SUBCORACOID
IMPINGEMENT
Pain Caused By
Contact Between The
Rotator Cuff And The
Coracoid Process
Mainly Due To
Prominent Coracoid
Which May Be
Idiopathic (Most
Common) Iatrogenic

INTERNALIMPINGEMENT
• Internal Contact Of The
Rotator Cuff Occurs With
The Posterosuperior
Aspect Of Glenoid
When The Arm Is
Abducted, Extended And
Externally RotatedAs In
The Cocked Position Of
The Throwing Motion

• Often Seen In Throwers Who Have Lost Internal
Rotation Of Shoulder
• This Loss Causes The Center Of Rotation Of
Humeral Head To Move Upward So That The
Contact Between Rotatory Cuff And Biceps Tendon
Attachments Increases

ARTHROSCOPIC
FINDINGS
• Partial Rotatory Cuff Tear
• Posterior And Superior
Labral Tears
• Anterior Shoulder Laxity

DIFFERENTIAL
DIAGNOSIS
• Acromioclavicular Arthritis
• Glenohumeral Arthritis
• Shoulder Instability In Throwing
Athletes
• Adhesive Capsulitis
• Fibromyalgia
• Cervical Spondylosis
• Suprascapular Nerve Injury

TREATMEN
T
•Non Operative Regimen
Antiinflammatory Medication
½ Subacromial Cortisone
Injection
Physiotherapy On Strengthning The
Rotatory Cuff & Full Range Of
Movements

• Operative
Arthroscopic Or
Anterior
Acromioplasty

Periarthritis shoulder & painful arc

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