Manual therapy for frozen shoulder syndrome
Yang JI, Jan MH, Chang C, Lin J. Effectiveness of the end-range mobilization and scapular mobilization approach in a subgroup of subjects with frozen shoulder syndrome: A randomized control trial. Manual Therapy 2012:17:47-52
A randomized controlled trial has been conducted in Taiwan to look at the effect of manual therapy on the secondary kinematic aspects of frozen shoulder syndrome (FSS). Such kinematics include poor humeral rotation, scapular tipping and downward scapular rotation. These factors are hypothesized to worsen the experience of FSS by contributing to additional sub-acromial impingement, rotator cuff tendonitis & degenerative changes. Yang et al. (2012) expected that whilst manual therapy has been found to have minimal effect on the pathology of FSS, improving the mobility of the shoulder complex might help shorten the overall course of symptoms. They conducted a randomized controlled trial on 34 subjects diagnosed with FSS, where they were assigned to a control group (usual physiotherapy care: mobilization, ultrasound, active + passive exercises) or an intervention group (usual physiotherapy + end range glenohumeral + scapular mobilization). The intervention group had significantly better range of motion and functional ability at a 4 and 8 week follow up when compared with the control group. The control group showed no improvement over 8 weeks. It is important to note that the patients recruited were in the stiffness phase of primary FSS. Certainly heavy manual therapy in the inflammatory or “freezing” phase of FSS is widely seen to be detrimental both clinically and in the literature. However, it seems there may a role for manual therapy techniques in the later stages of FSS.
Shoulder dislocation in patients older than 60 - prognostic factors
Rapariz JM, Martin-Martin S, Pareja-Bezares, A, Ortega-Klein J. Shoulder dislocation in patients older than 60 years of age. International Journal of Shoulder Surgery. 2010:4:88-92
A retrospective study has examined the outcomes of shoulder dislocation in patients over 60 years. Shoulder dislocation in younger patients is often associated with frequent recurrence (>70%), whereas in patients older than 40 recurrence is much less common (0-16%). Spanish researchers have examined factors related to prognosis in 29 patients who presented to emergency with a shoulder dislocation and were over the age of 60 years. In this study the recurrence rate was 31%. All of the patients who suffered from recurrence had an injury to the anterior support structures i.e. the glenoid rim. If the rotator cuff was spared in the injury, functional recovery was much better. Injury to the rotator cuff significantly affected functional recovery but did not affect recurrence rate. In particular, recovery of function was disrupted if the subscapularis tendon was involved. It is these patients that may have to consider a repair of the tendon. Damage to the remainder of the cuff doesn’t appear to affect prognosis as much.
Structures involved in subacromial impingement
Hughes PC, Green RA, Taylor NF. Measurement of subacromial impingement of the rotator cuff. Journal of science and medicine in sport, 2012:15(1):2-7
One of the most common shoulder impingement tests used in clinical practice is the Hawkins-Kennedy test. This involves moving the patients shoulder into 90 degrees forward flexion and full internal rotation. The rationale behind the maneuver is that it causes impingement of the supraspinatus tendon under the subacromial arch, and will provoke symptoms in patients suffering from an impingement syndrome. A study from La Trobe university has shed more light on what occurs in the subacromial space during the test. Subacromial pressures in cadaveric shoulders were measured during a series of passive movements. They found that in the HK test position, most of the pressure was anterior to the SST i.e. involving the rotator interval. The authors propose a more accurate method of testing SST specifically would be abduction + internal rotation, which produced the high pressure on SST. During passive flexion and internal or external rotation of the shoulder, subacromial impingement occurs between the subscapularis tendon and the coracoacromial ligament. These maneuvers may help diagnose rotator cuff pathology more accurately, when combined with other, more established orthopaedic tests.
Prospective study on shoulder pain: imaging and diagnosis
Cadogan A, Laslett M, Hing WA, McNair PJ, Coates MH. A prospective study of shoulder pain in primary care: Prevalence of imaged pathology and response to guided diagnostic blocks. BMC Musculoskeletal Disorders 2011:12:119-136
The specificity of common imaging techniques for shoulder pain is notoriously poor. So much so, that the term non-specific shoulder pain is beginning to come into the physiotherapy vernacular. Fortunately, a recent high quality trial from researchers in New Zealand has shed a bit of light on how prevalent pathologic findings are with imaging, and whether these findings correspond to the patient’s symptoms. 208 subjects were recruited consecutively as they presented to medical care for shoulder pain. All patients had an ultrasound and x-ray, followed by diagnostic injections into the subacromial bursa (SAB) and the acromioclavicular joint (ACJ). If the symptoms did not improve >80%, patients were then referred for a magnetic resonance arthrogram (MRA) and a diagnostic block of the glenohumeral joint. Authors concluded that supraspinatus pathology on ultrasound was associated with a positive response to a subacromial injection. Ultrasound findings of an intact rotator cuff but a biceps tendon sheath effusion were associated with a positive response to an intra-articular anaesthetic block. These findings when combined with the clinical picture may help develop a more specific diagnosis for patients presenting with shoulder pain.
Injection of intra-articular hyaluronate for adhesive capsulitis
Harris JD, Griesser MJ, Copelan A, Jones GL. Treatment of adhesive capsulitis with intra-articular hyaluronate: A systematic review. International Journal of Shoulder Surgery 2011:5(2):31-37
A recent review of the literature has found positive short-term outcomes following an injection of hyaluronate into shoulders diagnosed with adhesive capsulitis. The review compiled four level 1 studies, and a total of 297 shoulders. They found significant differences between experimental and control groups in shoulder range of motion and pain levels a short-term (10week) follow-up. The results were equivalent to previous studies on intra-articular cortisone injections.
Improvements were in the range of 20-40 degrees in forward flexion over a 10 week period. Injections of hyaluronate appear to be a safe and effective treatment for adhesive capsulitis in the short term. Longer term follow-ups would be useful in the future to ascertain the full clinical benefit of hyaluronate injections for adhesive capsulitis.