Shoulder Disorders

Discussion of Shoulder Disorders

Rotator Cuff Injuries

Shoulder impingement is a progressive disorder that results in chronic degeneration of the tendons of the rotator cuff. It is an injury that affects the muscles of the rotator cuff, rotator cuff strength, and range of motion, but does not necessarily require surgical intervention. Individuals with surface or partial thickness tears of the rotator cuff clinically may be included in this category. This condition may progress to partial full thickness or complete full thickness rotator cuff tear.

Rotator cuff injuries are also associated with overhead activities and highly repetitive motions,35,36 and can be thought of that is progressive wear and tear of the cuff and accentuated by those activities that require repetitive overhead use of the arm and/or repeated gripping and grasping.37 It is also promoted by anatomic impingement morphology, certain medical conditions such as diabetes, and the habit of smoking. Specifically, an actual rotator cuff tear is generally caused by an unambiguous traumatic event and with surgery most individuals successfully recover. Less than optimal outcomes are related to a variety of premorbid conditions and failure to return to work becomes more likely at age greater than 55 years and is often associated with the possibility of retirement.38 Rotator cuff injuries are common in the workers’ compensation system and patients benefit greatly from treatment and surgical repair of these tears. However, disparities exist between workers’ compensation patients and their non-workers’ compensation counterparts.39

A full-thickness or complete tear involves disruption of the rotator cuff muscle with retraction. A partial tear does not involve muscle retraction and is clinically similar to impingement. There are important differentiations between the condition of impingement and a partial rotator cuff tear. The prevalence of partial tears is anywhere from 13-32% and is age-related; usually occurring after the fifth decade of life and more often requires surgical intervention.40

Diagnostic Studies
Baseline x-rays may be beneficial initially to determine evidence of arthritis or chronic calcific tendinitis in the shoulder. Sometimes impingement morphology may be visualized on plain x-rays. MRI scan remains the gold standard for determining complete rotator cuff tear.41,42 However, ultrasound in the hands of an experienced operator is as sensitive and specific.43,44 Magnetic imaging indicates about 4% of individuals under age 40 have an asymptomatic rotator cuff tear with the figure increasing to greater than 50% in individuals over age 60. Partial rotator cuff tears do not involve complete cuff disruption and so are some-times difficult to visualize by either scan. The most sensitive test for this condition is an MRI arthrogram.40,41

Physical Exam Findings
A variety of shoulder tests are available, many of which are familiar to any examiner. Literature cannot fully recommend a specific set of tests that have a high degree of sensitivity. Based on a 2008 data review and original data, the use of any single test to make a pathognomonic diagnosis cannot be universally recommended.45,46,47 Studies have noted that there was insufficient evidence to base a selection of physical tests for rotator cuff impingement as local lesions of the bursa tendon or labrum may also accompany impingement.

Treatment
Surgical treatment of a rotator cuff tear can provide good clinical results especially in patients who are operated on within the first 3 weeks after the injury. After surgery, 95% of patients have no limitations in activities of daily living and are satisfied with their treatment.48,49

Active physical therapy remains a cornerstone and rehabilitative care post-surgery. For rotator cuff repair, a staged recovery of range of motion over a 6-month period, and strengthening progression beginning at post-operative week 6; in a functional progression for returned athletic or demanding work activities between post-operative months 4 and 6. No evidence was found that immobilization after arthroscopic rotator cuff repair proved superior to early motion rehabilitation in terms of tendon healing and outcome. Clinical outcomes also suggest that early passive range-of-motion exercises are helpful, but not mandatory after rotator cuff repair of small- to medium-sized full-thickness tears. Early mobilization does allow quicker range-of-motion recovery.50,51

Prevention and Post-Rehabilitation Care
Most individuals have a successful outcome with return of preinjury physical abilities. Persons left with a defect post-arthroscopic repair (incomplete rotator cuff repair) will maintain these defects which in time generally increase in size. The affected shoulders are often asymptomatic, but there is usually strength loss. In one study, after 7.9 years, patients with recurrent defects after rotator cuff repair still had improvement in pain, function, and satisfaction.52 These findings suggest patients with current defects can remain asymptomatic over the long term, but will predictably lose strength in the involved extremity.

In addition to the required physical therapy, there is evidence to suggest that specific physical therapy training for dynamic stabilizer muscles enhances rotator cuff muscle strength, core stability, throwing distance, and flexibility.53 These results suggest that full-training activities can be useful in preventing shoulder injuries.53

Acromioclavicular (AC) Joint Injury
The AC joint is subject to complex motion of rotation to the shoulder; it moves in various planes. It is also subject to compressive loads, especially in certain weightlifting activities. Due to exposed position, the AC joint has a high risk for direct injury from falls or blows. The most common injury to the AC joint results from a direct impact.

AC Separation
There are 6 types of injury to be considered54:

• Type I – AC ligaments are sprained, but the joint is intact.
• Type II – The AC joint is torn, but the CC ligaments (coracoclavicular ligament complex) are intact.
• Type III – Both the AC and CC ligaments are torn.
• Type IV – There is complete dislocation with posterior displacement of the distal clavicle into or through the fascia of the trapezius.
• Type V – Greater degree of soft tissue damage.
• Type VI – Inferior AC joint dislocations into subacromial or subcoracoid position.

Diagnosis
Diagnostics for the AC joint primarily involve x-ray testing. Stress x-rays can determine the degree of separation. Stability of the AC joint can be assessed with the cross-body adduction stress test, and acromial clavicular resistant extension test, and active compression test. Assessment of physical tests for isolated AC joint lesion have not shown that any one specific test to be significantly reliable. Therefore, a combination of a variety of tests is recommended.55,56

Treatment
Conservative treatment for acromioclavicular separation type I is recommended. Surgical treatments for Type III acromioclavicular injuries have not changed significantly since the 1990s with the exception of increased preference for distal clavicle resection. Management of Type II AC separation is still controversial; however, 80% of patients are treated conservatively without surgery.57,58

Rehabilitation
Conservative treatment and some physical therapy to increase strength and tone of the stabilizing muscles of the shoulder girdle may allow individuals to return to regular duty. Type III joint separations remain the most problematic and controversial, due to differing opinions about treatment options. As discussed, surgery is generally recommended. However, there is evidence describing conservative treatment of Type III separations with physical therapy and successful return to full activity within 12 weeks.59

Clavicle Fracture

Treatment
Clavicle fractures are treated non-surgically using splinting with progressive motion and indication for surgery with displacement and shortening. A retrospective study looking at all clavicle fractures managed surgically over 5 years, noted that the primary indication for surgery was displacement and shortening. Radiological union was achieved in all patients at an average of 13 weeks, ranging up to 24 weeks without major complications.22 All patients returned to work on average of 2.6 months having a good Oxford shoulder score.22

Labral Tears

The glenohumeral joint is the main shoulder joint and consists of a spherical head which sits in a shallow socket known as the glenoid fossa. The shoulder is made more stable by a ring of firm tissue, called the labrum that helps stabilize the humerus. The long head of the biceps runs through the grove between the greater and lesser tuberosity entering the shoulder deep to the rotator cuff inserting into the superior glenolabrum. The labrum can be torn by mechanisms that include both acute and chronic degeneration. In addition, the biceps tendon at its insertion when damaged may also cause dysfunction of the biceps muscle and shoulder. This can be caused either by acute or chronic trauma.60,61

Slap Tears
A superior labrum, anterior to posterior (SLAP) tear is a type of labral injury. A SLAP tear may occur with a fall onto an outstretched arm, anterior traction as in water skiing, superior traction as the result of attempting to break a fall from heights, and inferior traction as a result of a sudden pull when losing hold of a heavy object. Traction injuries also occur in sports involving overhead activities such as throwing (as in baseball) and exert chronic stress on the biceps at labral attachment resulting in tears. An analogous activity in law enforcement would be baton training. A direct blow to the glenohumeral joint has been also recognized as a mechanism of injury as well.61,62

A labral injury can occur with or without biceps injury in activities that cause anterior, superior, or posterior traction of the arm with direct trauma or while the arm is in a fixed position. These injuries may occur with activities that involve forceful motion of the upper extremity such as utilization of the baton and in defensive combat tactics as well as training exercises. Many of these activities are analogous to the throwing motion in the shoulder.63

Diagnosis
There are 10 types of labral tears. Types 1 through 4 are the most commonly encountered.60,63

• Type I lesion. The peripheral labral edge remains firmly attached to the glenoid with intact attachment of the bicep tendon. The lesion is a degenerative process common in middle-aged and older patients.
• Type II lesions: The most common tears are Type II (41%). There is usually fraying of the edge of the labrum similar to Type I. The significant finding is a detached biceps anchor, either anterior or posterior.
• Type III lesions constitute 33% of the population studied and consist of a bucket handle tear of the meniscoid superior labrum with a normal biceps attachment. Often, locking symptoms develop as a result of the mobile fragment similar to the bucket handle tear of the meniscus in the knee.
• Type IV is similar to Type III with an extension of the tear into the biceps tendon.

Diagnostics
There is no diagnostic gold standard to identify a SLAP lesion. Both MRI and MRI arthrograms may be utilized. Evidence supports a significant improvement in sensitivity accuracy with MRI arthrogram.63,64 However, it should be recognized that there is a relatively high incidence of asymptomatic labral tears in persons aged 45-60 years, and this may be a normal age-related finding.65

There are a variety of clinical diagnostic tests (O’Brien, crank, clunk, anterior slide, compression rotation, and active compression) that can be performed to help make the determination of a labral injury. Speed’s test is an accurate test for determining the biceps injury. The O’Brien test has good correlation for a Type II SLAP lesion.60 Most tests are fairly nonspecific. Clinical history and examination remain essential with a focused review for symptoms such as locking or a clunk or click in the shoulder. The literature suggests the use of a combination of tests to assist in diagnosis.66,67,68

Treatment
Type I lesions are treated conservatively with progressive range-of-motion and strength training. In some individuals, surgical debridement of the frayed labrum is required. Most labral injuries classified as Type II or above generally require surgical intervention.60,63 Several studies discuss the long-term outcome of arthroscopic surgical repair of Type II SLAP lesions. A study of 55 patients (mean age 39.7 years) revealed that 87% had a good or excellent functional outcome from arthroscopic SLAP repair.69 However, variables included age >40, and whether or not it was a workers’ compensation case.69,70

A retrospective study described successful outcome of SLAP repair in a military group in which 76.9% reached activity level equal to or greater than pre-operative level and 96% were able to stay at active duty. A case series focused on elite athletes revealed an 88% return to pre-injury levels.71,72

However, additional studies revealed less optimistic results. A prospective analysis of 225 patients with Type II SLAP tears concluded that arthroscopic SLAP repair provides a clinically and statistically significant improvement in shoulder outcomes although this was not associated with a reliable return to work in individuals age 36 or older.73A 2012 analysis that focused on the elite athletes found that only 63% were able to return to the same level of competition.74

Risk factors for a less than optimal outcome include age, concomitant medical problems, existence of a workers’ compensation claim, and concomitant shoulder injuries. Due to the complexity of this condition, prolonged physical therapy is often required and a detailed re-evaluation of the LEO before return to duty may be needed.

Scapular Fractures

Scapular fractures are uncommon and usually associated with high-energy injuries. They are often (up to 50% of the time) associated with pulmonary contusion and injuries to other body parts. Between 80-90% of scapular fractures are nondisplaced and successfully heal with conservative treatment in 6-8 weeks. Displaced scapular fractures, with or without surgery, may require up to 6 months for recovery. If the injury involves the glenoid fossa or the ipsilateral clavicle, and with greater displacement or multisystem trauma, a considerably longer period of treatment and rehabilitation may be required.2,19,20,21,75

Proximal Humeral Fractures

Proximal humeral fractures are more common in the elderly, but can occur in LEOs. Nondisplaced proximal fractures of the humerus may be treated non-operatively with an initial period of immobilization followed by early range-of-motion exercises. Initial immobilization may be achieved with a sling, shoulder immobilizer, or sling with an accompanying swathe. These devices provide varying degrees of constraint. If the fracture is stable, gentle range-of-motion exercises may begin after 7-10 days. Physical therapy may be initiated after 3 weeks and may allow a more expeditious return of upper-extremity function. Fractures that require closed reduction and percutaneous pinning for open reduction and internal fixation entail considerably longer periods of recovery. There is some ambiguity present in the literature as to when surgical treatment is required.16,17,18

Biceps Tendinitis and Tears

The proximal biceps involve 2 separate heads and is one of the primary flexors of the forearm and assist with abduction of the shoulder. The long head of the biceps arises from the supraglenoid tubercle and inserts in the radial tuberosity on the medial part of the forearm. Ninety percent (90%) of all biceps tears occur in the proximal long head of the biceps, while a tear to the short head occurs least of all. Initial symptoms may include a cracking or popping feeling in the shoulder resulting in some strength loss and cosmetic deformity “Popeye” muscle. The injury is more common in middle-aged men with concomitant risk factors associated with chronic biceps tendinitis as well as chronic shoulder impingement. In addition, utilization of anabolic steroids has been identified as a risk factor for tears.

Diagnostics
MRI is not the most accurate tool for diagnosing a tear to the long head of the biceps. It may reveal thickening of the biceps tendon and assist in the diagnosis of tendinitis. The only precise diagnostic tool for a ruptured long head of the biceps is an arthroscope. Specialized physical examination tests, such as Speed’s and Yergason’s, are helpful in determining the presence of bicipital tendinitis and may assist in the diagnosis of a biceps tear.2,76

Recovery
Persons with biceps tendinitis generally recover in 3-4 weeks and individuals with partial biceps tears generally recover in 6-8 weeks and may return to unrestricted work. Individuals requiring surgery need 4-6 months to recover before returning to unrestricted work.

Shoulder Arthroplasty

Shoulder replacement surgery has been used to treat severe shoulder fractures since the 1950s. Over the years, shoulder joint replacement has significantly improved and is now used to treat many painful shoulder conditions, most commonly arthritis. Individuals with higher BMIs tend to have poorer outcomes.

There are 5 types of shoulder arthroplasty: 1) total shoulder arthroplasty (TSA); 2) hemiarthroplasty (HA); 3) humeral resurfacing (HS); 4) total shoulder resurfacing (TSR); and 5) reverse total shoulder arthroplasty (RTSA). As with other types of arthroplasty, the primary purpose is pain relief. The goal of treatment is to improve activities of daily activities and most people eventually regain about two-thirds of normal shoulder motion after surgery. In general, surgeons restrict patients from doing things that put stress on the joint, and as shoulder arthroplasty has been primarily performed in the elderly population, this seemed reasonable. More recently, studies have noted that individuals under age 65 seem to do as well with similar activity levels as older patients, suggesting that the concern that younger patients might be placing excessive demands on the prosthesis may not be as significant as initially thought.77,78

It is important to consider the type of arthroplasty performed when considering post-surgical ability to return to normal activity level or return to duty. TSA has been shown to be associated with a higher rate of return-to-sport or preinjury activity than either RTSA or HA.79

An additional study noted that resurfacing allowed the highest recommended rate of return-to-sports activities.80 However, in reviewing the performance outcomes, no contact activities were included in the return-to-sport assessment.

An additional study assessed surgeon preferences for return-to-sports activities.80 The study found that most surgeons allowed return to some sports post-arthroplasty, but recommended activities that did not involve high demands of the shoulder with respect to contact, high loads, risk of fall, or collision.

Studies have revealed varying outcomes based on the type of arthroplasty used. Many individuals were able to return to much higher activity levels than previously noted. There are presently two studies on shoulder arthroplasty applicable to LEOs’ level of return-to-duty fitness requirement.81,82 These studies measured arthroplasty outcome in the United States military, and found that about 50% of patients were able to return to preinjury level or return to military duty post arthroplasty. However, both studies were small (n = 19,81 n = 2682) and the subjects predominantly male.

At the present, shoulder arthroplasty is successful in relieving pain and allowing the individual to return to a variety of light sporting activities, but it does not restore the shoulder to a point where the LEO can safely return to high-demand contact activities.

Shoulder Instability
The term “shoulder instability” refers to primary shoulder dislocations, recurrent dislocations, and subluxations. Instability is the risk factor that predicts further shoulder recurrent dislocation, pain, loss of strength and subluxation, or any combination of these factors.2 The shoulder joint is the most frequently dislocated joint of the body and accounts for almost 50% of all joint dislocations. Most commonly, these dislocations are anterior (90-98%) and occur because of trauma. Posterior dislocations are less common (2-10%) and inferior dislocations the least common. A variety of complications often occur with these injuries – rotator cuff and axillary nerve injury being the most common.83 The prevalence of traumatic shoulder dislocation, expressed in terms of cumulative incident rate, was found to be 0.7% for men and 0.3% for women up to age 70.84

Anterior Shoulder Instability and Dislocation
The most common shoulder dislocation is anterior, accounting for more than 90% of dislocations. The highest incidents rates comprised men age 21-30, and women age 61-80.84 These populations have different mechanism of injury, as the young generally injured their shoulder from direct trauma such as in a field sport, while the injury in the elderly was usually a from fall on an outstretched arm. Concomitant injuries of the shoulder include rotator cuff tear and injury to the axillary nerve.

Physical exam. Initial exam findings include pain and the inability to move the arm. Often the shoulder is visibly displaced.

Diagnostic testing. X-rays are helpful in confirming a diagnosis and an MRI may be useful to assess soft tissue damage. If there is suspicion of a labral injury, an MRI arthrogram is considered to have higher sensitivity.

Treatment
Treatment of an acute first-time shoulder dislocation has long been controversial. For many years, this condition was treated conservatively with 3-4 weeks of immobilization and recommendations for physical therapy.85 However, in post-injury individuals treated conservatively high rates of recurrent shoulder instability with subluxation and/or dislocation as well as other sub-optimal outcomes were noted with multiple studies assessing the long-term complications of recurrent instability, glenohumeral arthritis, pain, and loss of motion.86,87

• Risk of instability and recurrent dislocation. In individuals age ≤40, post-dislocation, the shoulder is less stable and more susceptible to recurrent instability with an increased risk of re-dislocation. For individuals treated with closed reduction, the rate of recurrent dislocation is high: 5% a year over 25 years7; 95% of recurrent dislocations occur within 5 years3; 13.3% a year for individuals less than 22 years of age 5; and 56% recurrence in 2 years.6 By age 40, the rates flatten out to 1-1.1% a year.3,4 Additional studies and reviews echo these findings, emphasizing age at the time the dislocation occurs as a prime determinant. There are additional risks for delaying surgical treatment as recurrent dislocation increases bone loss and leads to early arthrosis as well as making surgical repair more technically difficult.5,11,88,89,90
• Occupational risk post-dislocation. Individuals that are at the highest risk for recurrent instability were those less than 25 years of age, who participate in contact or collision sports or activities, and those who will use their arm at or above chest level in their occupation.
• Factors that increase the risk of recurrent instability. Individuals with acute glenoid rim fracture of >5% (Bankart Lesion) are at increased risk of recurrent dislocation. Individuals with a type IV SLAP injury at the time of dislocation are at an increased risk (22%) for recurrent shoulder dislocation.91 The presence of a positive anterior apprehension test is indicative of an increased risk of re-dislocation.
• Surgical vs. non-surgical treatment. Recent studies evaluating the effectiveness of arthroscopic and conservative treatment for dislocation have concluded that early arthroscopic stabilization is more predictable with lower recurrence rates in young athletic individuals. In young individuals, post-operative dislocation rates remain high for up to 2 years with recurrent dislocations diminishing thereafter. However, this is affected by the type of dislocation divided among Baker Category 1-3. Individuals with a Baker 1 dislocation have an excellent prognosis and with less likelihood of dislocation. Baker Category 2 and 3 is associated with higher rates of dislocation and those individuals require restrictions for a longer period of time before their shoulder becomes stable.92 Individuals over age 40 with anterior shoulder dislocation may be treated with closed reduction primarily. However, for those who have persistent symptoms of instability, surgery is indicated. In individuals over age 40, recovery is generally good with a low rate of recurrence. Additional studies have evaluated different operative techniques including open stabilization for glenohumeral instability versus arthroscopic treatment. With recent advances, arthroscopic technique is now usually recommended; however, open surgery remains an acceptable option in selected individuals.

Posterior Shoulder Instability and Dislocation
Posterior dislocation of the shoulder accounts for 2-10% of all reported cases of shoulder dislocation. It is important to differentiate between traumatic dislocation and atraumatic instability as the outcomes differ. The most common mechanism of traumatic posterior dislocation is blunt force trauma when axial load is applied to the adducted and internally rotated arm (e.g., being thrown headfirst from a bicycle). Atraumatic instability results from microtrauma such as repetitive overhead work, weightlifting, etc. Atraumatic dislocations result in recurrent instability and subluxation is more common. Both conditions are acutely disabling.

Physical Exam
Physical findings include skin dimple posterior medial deltoid, Jerk test, Kemp test, and posterior drawer test. Specific physical examination tests include posterior load and shift and Jerk test and posterior apprehension test.

Diagnostic Testing
There is no one best diagnostic image, but diagnosis is generally made by x-ray view. Diagnostic x-rays usually include 3 views with an axillary or West Point and/or supraspinatus outlet view. An MRI is helpful for evaluation of soft tissue findings or cartilaginous abnormalities especially with instability. CAT scans provide better imaging for any bony injuries such as reverse Hill-Sachs lesion.

Treatment
Traumatic Posterior Shoulder Dislocation. The frequency of recurrent dislocation or instability from a traumatic posterior shoulder dislocation is 20.6% within 5 years (17.7% in the first year), Because of this, surgical treatment is preferred. This is especially true for individuals less than 40 years old. There are important factors that should be considered that help to determine the treatment recommendations:

1. Traumatic posterior dislocations that result from a seizure (all causes) require surgery.
2. Traumatic posterior dislocation from a fall or related to an MVA may be treated conservatively. Factors that increase the risk of recurrent dislocation include age <40 are a large reverse Hill-Sachs lesion >1.5cm3 and should be considered high risk for recurrent dislocation and require surgery.10 A traumatic posterior shoulder dislocation may be treated with conservative therapy consisting of 4 weeks of immobilization, followed by 4-6 weeks of physical therapy and rehabilitative exercise. Contact activity is precluded until 18-24 weeks.10 LEOs who experience recurrent shoulder pain, instability or functional limitations after a course of conservative treatment over 3-6 months may be considered candidates for surgery. Both arthroscopic and open procedures are used.13
3. Recurrent posterior shoulder dislocation – individuals with recurrent posterior shoulder dislocation are very likely to require surgery. For certain individuals who can be identified as low risk (age >40, and small Hill-Sachs lesion <1.5cm3), a trial of physical therapy may be considered appropriate.10

Recovery post-surgery generally requires 6-9 months and is reasonably assessed with findings of painless range of motion without symptoms of instability and suitable strength of at least 80% compared to the contralateral shoulder.12

Atraumatic Posterior Shoulder Instability
Individuals with atraumatic instability have a much higher (80%) success rate with physical therapy. LEOs with atraumatic posterior shoulder instability can be treated conservatively. Those with adequate active range of motion can return to duty in 6 months following a successful return to full-training activities. Those with atraumatic multidirectional instability that does not respond to conservative care generally require surgery.12

Inferior Shoulder Dislocation
This is a rare shoulder dislocation with an incidence of about 1 in 200 dislocations. The mechanism of injury is usually blunt trauma or a fall from heights. The primary complications are axillary nerve palsy and rotator cuff tear. This dislocation can be treated non-surgically if reduction is easily obtained. However, in failed reduction, surgical treatment is required. Recovery can be prolonged, requiring up to 1-2 years.

Chronic Shoulder Instability
Chronic shoulder instability is generally the result of recurrent dislocation, multiple shoulder injuries, genetics, or repetitive trauma. Instability may be anterior, posterior or multidirectional. Chronic shoulder instability can be divided into two general categories: traumatic and atraumatic, with very different causes. Traumatic shoulder dislocation(s) may lead to instability, but many individuals have never had frank dislocation. There can be increased laxity secondary to trauma or as the result of repetitive overhead sport or occupational activities. Swimming, tennis, and volleyball are among the sports requiring repetitive overhead motion that can stretch out the shoulder ligaments and result in a painful unstable shoulder. Atraumatic shoulder instability is usually multidirectional and commonly occurs in individuals with generalized hyperlaxity due to connective tissue disorders, weak rotator cuff muscles, small or flat glenoid fossa, and several other diagnoses.

Adhesive Capsulitis (Frozen Shoulder)
Adhesive capsulitis is a painful and disabling disorder related to immobilization/disuse. It can also occur spontaneously in some persons (notably diabetics) and involves the gradual onset of shoulder stiffness and pain caused by tightening of the joint capsule that occurs as the area around the shoulder joint contracts and thickens. The condition is thought to be caused by injury or trauma to the shoulder or may have an autoimmune component and can be bilateral. Risk factors include hypothyroidism, connective tissue disease, cerebrovascular accident, and cardiac and lung disease. Signs and symptoms typically begin gradually and progressively worsen with time and then resolve, usually within 1-3 years from onset. This condition is more prevalent in individuals aged 40-60 and males more so than females.

Adhesive capsulitis generally occurs in 3 stages:

1. Freezing stage. Any movement of the shoulder causes pain, and the shoulder’s range of motion starts to become limited.
2. Frozen stage. Pain may begin to diminish during this stage. However, the shoulder becomes stiffer, and using it becomes more difficult.
3. Thawing stage. The range of motion in the shoulder begins to improve. Pain is usually constant, worse at night, as well as with cold weather.

Diagnostics
Adhesive capsulitis is primarily a clinical diagnosis, although imaging may be used to exclude other causes of shoulder pain (e.g., fracture, dislocation, rotator cuff tear) and depict findings that increase confidence in clinical diagnosis. Arthrography is usually regarded as the gold standard for imaging diagnosis.

Treatment
Non-surgical treatment for frozen shoulder includes range-of-motion exercises, oral and injected medications, and manipulation under anesthesia. Surgical treatment for patients who do not respond adequately to non-surgical measures involves lysis of adhesions.23,93