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Adhesive capsulitis, or frozen shoulder

Adhesive capsulitis, or frozen shoulder is more common in people who have underlying arthritis but particularly chronic rotator cuff disease, diabetes. Thatís a adhesive capsulitis. Diabetics are more prone to frozen shoulder and I think that is the most common reason that Iíve seen it. Occasionally after myocardial infarction patients will get a frozen shoulder adhesive capsulitis. This is different because the patient will complain of pain in their shoulder but it is true shoulder pain. They will localize the pain over the glenohumeral joint, which is basically medial to the head of the humerus. If you examine, thatís where it will be tender. Also they will say, "I have trouble raising my arm up." Their motion is limited and when you examine them you will find that their motion is limited, sometimes such that they canít even raise their arm up to do their hair or brush their teeth and they are depending on their other arm to do everything. If you see that, you are obligated to get an x-ray. The x-ray is usually normal in these patients. You may see evidence of rotator cuff disease but they

Itís important to relieve the pain, which can be with antiinflammatory drugs. Sometimes oral corticosteroids, a short course, or intraarticular corticosteroids and get them into physical therapy to get that arm moving, the shoulder moving again. Otherwise, if itís untreated, you could end up with a very poor functioning joint. If you do all these things, unless the patient is really delayed coming to the doctor, you usually have a pretty good outcome, although it can occur. Reflex sympathetic dystrophy is basically frozen shoulder with distal edema and pain in the hands. Some people think they are essentially the same things, just to different degrees. Again, the shoulder needs to be addressed and physical therapy is really the mainstay of a therapy for frozen shoulder.

The other thing to keep in mind is that cervical radiculopathy or certain nerve entrapment syndromes can lead to shoulder pain and itís important to keep these things in mind. The pain is usually neuropathic and the pain expert can certainly tell us that this is generally of a different quality. A strong nocturnal component, burning, numbness, sometimes it feels better if you rub it a little bit. Standard pain medications donít really work. Also, if there are associated neurologic findings, thatís helpful. Lastly, the range of motion of the shoulder should be completely normal and there may be no well-localized tenderness on examination, since the pain is really being referred.

Several structures can be involved. The first is the olecranon bursa, which is right over the point of your elbow. The most common thing that I see is olecranon bursitis due to trauma. Is anybody from Philadelphia, Philadelphia area? Well, Einstein Hospital is affiliated with Moss hospital which is a big rehab hospital and a lot of the patients have had a stroke or theyíve had a hip replacement. And the nurses and therapists are telling them, "Get up, letís move, get dressed" and they use their arms a lot, especially initially to get mobilized. A lot of times they lean on their elbows and about once a month we see a patient in the hospital with olecranon bursitis due to this type of activity. The history may be that the patient doesnít even know itís there or they notice that itís swollen, doesnít bother them. Sometimes the doctors are more concerned that there is a problem. Although there can be some pain and if itís just due to trauma, not much warmth or anything else, you have to be concerned that there could be an infection there. Even in a patient with just trauma. Sometimes that can somehow "seed" it with staph, the most common bacteria. Or patients who have rheumatoid arthritis or gout can get inflammatory involvement of this bursa. In that case it will be quite red and swollen, tender. The main thing to remember though is that the range of motion of the elbow is intact. You have good rotation of the radial head, usually near normal extension. Sometimes if it is very swollen the patient wonít be able to extend it comfortably, because of the fact that you are putting pressure on the bursa. But otherwise the range of motion is normal. If you feel over the elbow joint it is pretty free of tenderness and there is no pain there.

Basically, treatment is just aspiration if itís just a non-inflammatory situation. Occasionally if the patient has a lot of symptoms I will inject some corticosteroids. Sometimes in a patient who is having repetitive trauma, such as they are recovering from a stroke and I know they are going to continue using that elbow, just have the physiatrist prescribe elbow pads to protect a little bit. If you draw this fluid out and it looks a little bit cloudy, be concerned about an infection. Iíll send it off to the lab. If the white count is more than 1,000 Iíll be concerned. And of course, gram stain and culture. Unlike a septic arthritis, this is not necessarily