MasterclassFrozen shoulder contracture syndrome – Aetiology, diagnosis and management
Section snippets
History and nomenclature
Duplay (1896) described the disabling combination of shoulder pain and restricted movement as péri-arthrite scapulo-humérale, attributing the condition to inflammation of the subacromial bursa. The term periarthritis of the shoulder has been used by others, both as a diagnosis and to explain the pathology (Dickson and Crosby, 1932, Wright and Haq, 1976). With the advent of radiographs, calcific deposits were observed, and for a period of time, the pain and stiffness was attributed by some to
Pathoaetiology
The normal intra-articular volume of the glenohumeral joint has been reported to be between 15 and 35 cc and in FSCS the volume may reduce to 5–6 cc (Lundberg, 1969). Neviaser (1945) described an inflammatory (hence capsulitis) process, Lundberg (1969) did not report significant numbers of inflammatory cells, a finding supported by others (Bunker, 1997, Bunker, 2009). However, others have suggested that the pathology associated with FSCS involves a chronic inflammatory response with
Epidemiology and natural history
Although published data suggest FSCS occurs in 2%–5% of the population (Neviaser and Hannafin, 2010), the actual lifetime prevalence and annual incidence of FSCS remains uncertain. Different diagnostic criteria used in epidemiological analyses is one reason for this. Risk factors for FSCS appear to include; diabetes, family history and possibly hypothyroidism (Smith et al., 2012, Wang et al., 2013), genetic predispostion (Hirschhorn and Schmidt, 2000, Hakim et al., 2003, Smith et al., 2012) and
Diagnosis
There is no definitive gold standard test to diagnose FSCS and diagnosis is based upon; (i) clinical examination, (ii) exclusion of other pathologies and (iii) normal glenohumeral radiographs. What constitutes a positive clinical examination is equivocal. Cyriax and Cyriax (1993) recommended a pattern of progressively restricted joint movement attributed to capsular restriction to diagnose FSCS. A consensus recommendation involved restriction of active and passive shoulder movements with normal
Management
As described FSCS is typically classified into three or four stages (Reeves, 1975, Neviaser and Neviaser, 1987). It is the authors preference that following diagnosis to divide the condition clinically into two stages; (i) more pain than stiff, and (ii) more stiff than pain.
Once the diagnosis is established the first stage in management involves patient education. People suffering from FSCS typically want to know; what is the problem?, what has caused the problem?, why them?, how long will it
Conclusions
The pain and movement restriction that is the hallmark of FSCS is typically associated with substantial morbidity. Although the condition improves over time, full pain free range of movement, may not be restored in everyone. Additionally, it is likely that most people suffering from FSCS would prefer resolution if possible, more quickly than the average 30.1 months. Physiotherapists in the United Kingdom have set up dedicated care pathways that provide; assessment, referral for imaging,
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