Frozen shoulder (Adhesive capsulitis) F>M 40-60

Definition: Functional restriction of both passive and active shoulder motion greater than 50%. Primary motion lost in active and passive external rotation.

• Contracted shoulder capsule due to fibrosis. Abundance of collagen and connective tissues which build up through entire capsule causing fibrotic contractures (not adhesions)
• Complex condition with unknown causative elements, and therefore difficult to prevent

Primary: Idiopathic (unknown)

Secondary: Post surgery, Immobilization, Trauma, Stroke, Parkinson’s, Cardiovascular incident

Signs and symptoms:

• Insidious onset, gradually worse over time
• Unable to lift arm
• Loss of movement in external rotation
• Loss of active shoulder elevation
• Unable to lay on affected side
• Un remarkable radiology (exceptions are DJD, Osteopenia, fracture, calcified tendon)
• Night pain, poor sleep
• Pain is disproportionate to any recent trauma or overuse event

3 Phases: Freezing 0 – 3 months, Frozen 3 – 9 months, Thawing 9 – 18 months

Freezing phase: Inflammatory phase, Vascular synovitis

• Inflammatory stage where there is a decrease in joint volume down to as low as 3 – 4ml (normal 10-15ml)
• Development of new blood vessels (Angiogenesis) with nociceptive pain sensory capabilities, inflammatory cells (prostaglandins), Chemical mediators (Substance P)
• Axillary nerve supplying joint capsule and deltoid muscle may be affected
• Less joint volume with more blood vessels, therefore increasing the sensitivity of joint
• Thick scar tissue at rotator interval (Coracohumeral ligament)

Frozen phase:

• Synovial thickening, loss of axillary recess under arm

Thawing phase:

• Shoulder slowly improves and returns to normal or close as possible (9-18 months)

Risk factors:

• Diabetes, family history
• Genetics
• Hypothyroidism
• Cardiovascular disease
• Smoking
• Female
• Previous frozen shoulder on opposite side
• Previous damage to rotator cuff muscle (history of increased loading)

Differential Diagnosis possibilities

• Calcified tendinopathy (acute onset of pain often when waking up)
• Osteoarthritis of shoulder
• Trauma, post dislocation, FOOSH injury
• Avascular necrosis of humeral head
• Fractured clavicle (acute pain after traumatic injury)
• AC sprain / separation
• Muscle strains (deltoid, traps, supraspinatus)

Prognosis

• Long term outcomes good. However, condition becomes more challenging with severe pain, restricted range of motion, and coupled with co morbidities (Hypothyroidism, previous surgery, diabetes) May require up to 18 months to heal on its own

Conservative Treatment

Manual therapy:

• Massage to Subscapularis, Pecs, deltoid, latissimus dorsi, levator scapula, rhomboids, serratus anterior
• Articulating cervical and thoracic regions
• Capsular stretching with towel under glenohumeral joint, targeting coracohumeral ligament
• Encouraging glenohumeral joint to move inferiorly, posteriorly with passive movements
• Push glenohumeral joint posteriorly with arm externally rotated and abducted
• Circular motion to glenohumeral joint with traction, patient laying on back
• Push glenohumeral joint medially and inferiorly (their elbow will be over their face) with horizontal flexion
• Arm behind back – side lying, thumb under arm, use arm as lever and push down
• Traction of glenohumeral joint using Muscle energy technique

Rehab exercises done consistently 3 – 5 times a day

• Crawl hand up wall. Mark spot on wall and challenge them to go higher
• Pushing towel with two hands across table
• Bench press broom handle. Can also use light weights
• Use ball on bench to roll across with arms
• Lean over bench making large circles with arm while holding a weight for traction

Medical interventions

Intra articular corticosteroid injection:

• May help reduce inflammation and pain symptoms

Hydrodilatation: Mixture of cortisone, saline, and local anaesthetic.

• Fine needle placed inside the joint (posteriorly) using X – ray or Ultrasound to guide it. Normal joint has 10-15ml of synovial fluid. This injection helps distend joint up to 30ml therefore helping increase the joint space and stretch / break down the fibrotic joint capsule.

Education

• People do recover
• Good prognosis – long term outcomes
• Shoulders structures are not torn
• Ball socket joint is intact
• Be patient
• Fibrotic tissue can take months to break down
• Celebrate any improvements
• Do rehab exercises 3-5x / day
• Continue normal physical activity
• Reduce your stress levels

Gall bladder disease

Definition: Refers to any condition that affects the health of the Gall bladder.

Symptoms:

• Severe pain in right upper quadrant of stomach, epigastric region
• Pain can refer to shoulder and upper back region
• Jaundice
• Nausea and vomiting
• Fever and chills
• Dark urine, lighter stools, or both
• Increased heartbeat
• Abrupt drop in blood pressure

Caused by:

• Gall stones: hard crystalline mass deposit found in the fluid of the gall bladder
• Cholecystitis: Inflammation of Gall bladder
• Cholestasis: Flow of bile from the liver slow or stops
• Gall bladder cancer: Cancer that has developed in the gall bladder
• Fatty foods: Cause the gall bladder to contract and empty. Any inflammation, gall stones, or blockage in ducts will increase the pain when fatty foods are eaten, and the gall bladder is being contracted

Diagnosed via:

• Abdominal ultrasound
• Endoscopic ultrasound
• Endoscopic retrograde cholangio-pancreatography (ERCP) (procedure used diagnose and remove gall stones from bile duct)
• Blood tests

Treatment:

• Medications have been shown to thin the bile and allow the gallstones to dissolve
• Endoscopic retrograde cholangio-pancreatography (ERCP)
• Surgery, removal of Gall bladder

Osteoarthritis (F>M 50+)

Degeneration of joint cartilage and underlying bone

• Stiff, tender, and swollen joints
• Morning stiffness lasting up to 30 minutes
• Aches and pains in muscles
• Decreased joint range of motion
• Fatigue feeling or tiredness
• Can cause physical deformity

Caused by

• Increased weight (obesity)
• Females > Males
• Increased age
• Joint injuries
• History of fractures
• Repeated stress on joints (repetitive activities)
• Genetics
• Bone deformities
• Metabolic disorders

Diagnosed via: X – rays, observation for physical deformity

Treatment:

Condition can not be reversed. Treatment is aimed at reducing symptoms and increasing range of motion

• Manual therapy to help with surrounding soft tissue structures
• Exercise to help strengthen muscles and joints
• Medications to help reduce inflammation
• Cortisone injections into joint
• Surgery for joint replacements

Rheumatoid Arthritis

Definition: an autoimmune disease, where the body mistakes its own cells as foreign invaders.

This causes an attack of the body’s joint synovium by inflammatory chemicals. Flare ups may

last from months to a lifetime with symptoms being episodic in nature.

Symptoms: (mimics many other arthritic conditions in early stages)

• Insidious onset of pain and stiffness, swelling and warmth that begins with thesmall joints of the hands and/or feet.
• Commonly affects people aged 25-45 years old.
• More than 1 joint is affected, usually bilateral involvement
• Symmetrical involvement of the metacarpophalangeal or metatarsophalangeal joints
• Symptoms may come and go
• Morning stiffness which can last hours
• Fatigue, low-grade fever, weakness
• Soft tissue swelling
• Joint effusion and synovial swelling
• Tenderness on palpation or movement of joint
• Joint Deformities (Boutonniere, Swan Neck, Z deformity of wrist, Ulnar deviation)

Caused by:

• Genetics: gene HLA-DR1
• May be associated with poor diet (high in red meats, processed meats, refined grains, fried foods, high fat dairy and sugar can increase chances of developing RA

Examination:

• Physical examination of joints observing for swelling, warmth, redness, tenderness, decreased range of motion, palpation of joint line irregularities, and joint deformity.
• Morning stiffness lasting more than 30 minutes
• Blood tests will be looking to diagnose:
  1. Rheumatoid factor
  2. Erythrocyte sedimentation rate (ESR)
  3. Full blood count (CBC)
  4. CCP antibodies
  5. Antinuclear antibody (ANA)
  6. C – reactive protein (CRP)

Treatment:

• Disease Modifying Anti -Rheumatic Drugs (DMARDs)
• Analgesics and NSAIDs
• Education on exercises
• Hydrotherapy
• Diet – introducing omega3 and fish oils
• Acute flare ups require rest
• Rheumatologist management

Prognosis:

• Fair to poor. Depending on number of symptoms. Can last for months to a lifetime depending on flare ups and management.

Psoriatic arthritis (M=F 30-55)

Definition: chronic, autoimmune form of arthritis that causes

joint inflammation and occurs with the skin condition psoriasis

Symptoms:

• Red patches of skin topped with silvery scales
• Multiple joint pain, stiffness, and swelling
• Swollen fingers and toes
• Nails may form pits, crumble, or separate from the nail beds.
• May present similarly as Ankylosing spondylitis

Caused by:

• Genetic predisposition (HLA-B27 gene)
• May be triggered by a viral or bacterial infection when genetically predisposed
• Physical trauma to joints may predispose to Psoriatic arthritis
• Psoriasis skin condition often predisposes Psoriatic arthritis

Examination:

• Observe for signs of swelling and tenderness around joints
• Pitted fingernails
• May present unilaterally or bilaterally
• PsA should be suspected in any patient who has psoriasis and arthritis, however it may be present in both
• (Blood test to look for Rheumatoid Factor which is present in RA, but NOT PsA
• Joint fluid test. Small fluid is aspirated from affected joint and examined for uric crystals which will indicate gout rather than PsA )
• X- ray to examine for joint destruction

Treatment

• DMARDS
• NSAIDS
• Management through Rheumatologist
• UV Light therapy for skin issues
• Manual therapy to help increase joint ROM and reduce muscle HT

Prognosis

Fair to poor. Although a chronic condition with no cure, managed with Rheumatologist, medications and manual therapy

• Form of arthritis which affects people who have Psoriasis (skin)
• Autoimmune disorder, Immune system attacks healthy cells in the body by mistake causing symptoms
• Currently no cure
• Patches of redness on skin, may have silvery scales
• Anti-inflammatory medications, steroid injections, joint replacement surgery

Fibromyalgia (F>M 30-50)

Fibromyalgia: pain disorder characterized by widespread musculoskeletal pain with localized tenderness for at least 3 months. Chronic daily body aches. Overactive nerves causing pain despite lack of any physical injury. Does NOT cause joint damage.

Age ranges: F> M 30-50

Symptoms:

• Widespread muscle pain and tenderness
• Points include shoulders, low / upper back, chest, elbows, knees, and temporal region of head
• Fatigue, altered sleep, mental distress
• Lack of energy
• Morning stiffness in joints
• Cognitive difficulties
• Stress can magnify symptoms

Common causes:

• Unknown
• Genetics
• May be initiated or triggered by physical or emotional event
• Chemical receptors in the brain can become sensitised and overreact to painful and non-painful stimuli
• Central sensitisation. Blunting of inhibitory pathways and changes in neurotransmitters cause aberrant neuro-chemical processing of sensory signals in the CNS. This lowers the patient’s pain threshold and amplifies the normal sensory signals causing pain.

Diagnosed via:

• Mild to severe pain in 3 to 7 different areas of your body
• Symptoms for at least 3 months
• No other reason for your symptoms

Treatment – medicines / procedures

• Patient education on stress reduction strategies, good sleep hygiene, and assistance for anxiety or depression related symptoms
• Exercise regimen involving cardiovascular training which improves sleep and helps decrease pain levels (recommended 30 mins of aerobic exercise 3 x a week)
• Manual therapy
• Hydrotherapy
• Medications to help reduce pain levels (consult your medical doctor)

Prognosis: Fair to poor. Factors included are listed here.

• A long duration of disease
• High-stress levels
• Presence of depression or anxiety that has not been adequately treated
• Long-standing avoidance of work (unemployed)
• Alcohol or drug dependence
• Moderate to severe functional impairment

Specialist: Rheumatologist, Physiatrist, Psychiatrist

• Widespread muscle pain and tenderness
• Points include low back, upper back, chest, elbows, knees, and temporal region of head
• Does NOT cause joint damage
• Overactive nerves causing pain despite lack of any physical injury
• Accompanied with fatigue, altered sleep, mental distress

Polymyalgia Rheumatica (F>M 70-79)

Polymyalgia Rheumatica: Connective tissue inflammatory disorder characterised by bilateral pain and stiffness in the muscles

Age ranges F > M

• 70-79 years of age

Symptoms: 

• Shoulder, neck, and hip pain associated with restricted range of motion and stiffness. Pain often spreads to the arms and legs
• Pain can develop quickly or progressively over a few weeks.
• Morning stiffness that lasts more than an hour
• Commonly bilateral
• Symptoms may be worse in the morning and with inactivity
• Symptoms may resolve after a few years

Common causes:

• Suspected genetic and environmental factors

Diagnosed via:

• A combination of clinical symptoms and laboratory findings
• ESR and C reactive protein blood tests can be used to check the levels of inflammation in the body.

Treatment

• Corticosteroids are considered the treatment of choice because they often cause complete symptom resolution and reduction of the ESR to normal. 

Prognosis 

• With early diagnosis and appropriate management, the average length of disease is 3 years. Usually lasts 1-5 years. However, exacerbations may occur if steroids are tapered too rapidly.

Fracture (Humeral head)

• Immediate swelling
• Dull ache, throbbing pain
• Difficult to raise arm
• Bruising
• X – ray / MRI
• Surgery or casting required

Reflex sympathetic dystrophy (Complex regional pain syndrome)

• Chronic limb pain
• Pain is greater than expected than injury that may have caused it
• Continuous throbbing, burning, numbness and tingling
• Sensitive to touch (painful)
• Skin colour and temperature changes
• Not well understood
• May be post-surgery, injury, stroke, or heart attack
• May involve abnormal inflammation or nerve dysfunction