Evaluation of the Stiff Shoulder

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Last Updated: Monday, February 4, 2013

Evaluation of the Stiff Shoulder

 The normal shoulder is the most moveable joint in the body. It enables us to put our hand in a wide range of positions for example reaching over head reaching cross the body reaching up the back and rotating out to the side. These motions are accomplished by motion between the humerus (arm bone) and scapula (shoulder blade) as well as between the scapula and the chest wall. These motions are called humeroscapular and scapulothoracic motions.

Average shoulder motions

Forward flexion: 170 degrees
External rotation: 80 degrees
Internal rotation: T5 segment
Cross body: 14 cm

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Figure 1 - Forward flexion
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Figure 2 - External rotation
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Figure 3 - Internal rotation
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Figure 4 - Cross body

Most of the common causes of shoulder stiffness are related to problems between the humerus and scapula.

Many causes

The normally supple capsule around the joint can become stiff--a condition known as frozen shoulder. Frozen shoulders can come on after a period of disuse of the arm. A frozen shoulder can also come on for no apparent reason at all. Frozen shoulders can be particularly severe in individuals with diabetes.

Shoulder stiffness can also result when the normal gliding surfaces of the shoulder become scarred after injury or surgery--a condition known as post-traumatic stiff shoulder.

The shoulder can become stiff because the joint surfaces have lost their normal smoothness--as in arthritis.

Finally shoulder motion can be restricted by limited scapulothoracic motion (motion between the shoulder blade and the chest wall). Scapulothoracic range of motion can be limited by such factors as sternoclavicular arthritis acromioclavicular arthritis contracture rib or scapular fracture post-traumatic scarring tumor dislocation or other factors disrupting the scapulothoracic motion interface.

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About the Mechanics of Shoulder Stability: The capsule

In evaluating stiff shoulders it is essential to establish the circumstances surrounding the onset of stiffness the duration of the condition any tendency toward worsening or improvement and the possible existence of risk factors such as a period of immobilization metabolic disease (such as diabetes) or referred pain from the neck chest or abdomen.

The importance of the history

In post-traumatic stiff shoulders the relationship of loss of motion to previous surgery or injury becomes evident from the history.

The age of patients with idiopathic frozen shoulders presenting to our service is typically between 43 and 63 years.

Patients with frozen shoulders may have substantial functional losses. Patients with frozen shoulders had greatest difficulty sleeping comfortably on the affected side putting their hands behind their heads with the elbow out to the side lifting 8 pounds to the level of the top of their head without bending their elbow and throwing overhand.

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Figure 5 - Age of patients with idiopathic
frozen shoulders presenting to our service
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Figure 6 - Patients with frozen shoulders
may have substantial functional losses

Steps in examination

First obtain a quick assessment of the overall shoulder motion by examining the maximal ranges of elevation external rotation internal rotation and cross body adduction.

Then proceed to determine the humeroscapular range by stabilizing the scapula with one hand and putting the humerus through a passive range of motion with the other. The patient should remain relaxed during this examination to assure that muscle contraction is not limiting motion. Specific ranges of humeroscapular elevation and rotation can be measured by determining the positions that the humerus can attain in relation to the four palpable scapular reference points. Humeroscapular elevation of less than 90 degrees indicates stiffness especially if it is less than the contralateral normal shoulder.

Localized areas of capsular tightness or adhesions are identified by the pattern of motion restriction. For example a shoulder with limited humeral elevation in anterior scapular planes limited cross body adduction and limited internal rotation is likely to have tightness of the posterior capsule. A post-operative shoulder with isolated limitation of external rotation with the arm at the side is likely to have some combination of the following problems: scarring at the humeroscapular motion interface between the coracoid muscles and the subscapularis excessive tightness of the subscapularis and anterior capsule or contracture of the rotator interval capsule. Finally a shoulder with limited elevation after a previous acromioplasty is likely to have scarring at the humeroscapular motion interface between the acromion deltoid and rotator cuff.

The definition of a frozen shoulder requires a normal joint space and normal joint relationships.

Order certain views

Thus in the evaluation of a shoulder with restricted humeroscapular motion an axillary view and an anteroposterior radiograph in the plane of the scapula should be ordered to exclude the presence of narrowing of the radiographic joint space glenohumeral dislocation or joint surface fracture. When scapulothoracic range is limited a tangential (lateral) radiographic view of the scapula and a chest film are included to seek displaced fractures of the ribs or scapula scapulothoracic dislocation or osteochondroma on the anterior aspect of the scapula.

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Figure 7 - Axillary view and an anteroposterior
radiograph in the plane of the scapula

Shoulder & Elbow Articles

  1. About the Mechanics of Shoulder Stability.
  2. Anterior glenoid reconstruction for unstable dislocating shoulders. Surgery to restore lost anterior glenoid bone and deep the socket with a bone graft can restore shoulder anatomy and lessen pain and improve function.
  3. Arthroplasty in Cuff Tear Arthropathy: Surgery for shoulders with a rotator cuff tear and arthritis can lessen shoulder pain and improve function with joint replacement.
  4. Atraumatic Shoulder Instability.
  5. Bankart repair for unstable dislocating shoulders: Surgery to anatomically and securely repair the torn anterior glenoid labrum and capsule without arthroscopy can lessen pain and improve function for active individuals.
  6. Basics of failed shoulder surgery, complications of shoulder surgery and revision shoulder surgery
  7. Chondrolysis
  8. Clinical Presentation and Evaluation of Glenohumeral Arthritis.
  9. Clinical Presentation of Glenohumeral Instability.
  10. Compartmental Syndromes.
  11. Diagnosis of Capsulorraphy Arthropathy.
  12. Diagnosis of the Frozen Shoulder.
  13. Evaluation of Recurrent Instability.
  14. Evaluation of the Rough Shoulder.
  15. Evaluation of the Stiff Shoulder.
  16. Evaluation of the Weak Shoulder.
  17. Examination Under Anesthesia.
  18. Failed Shoulder Replacement and Revision.
  19. Glenohumeral Arthritis References.
  20. Home Exercises for the Rough Shoulder.
  21. Home Exercises for Stiff Shoulder
  22. Home Exercises for the Unstable Shoulder.
  23. Home Exercises for the Weak Shoulder.
  24. Humeroscapular Positions and Motion.
  25. Humerothoracic Positions and Motion.
  26. Injuries Associated with Anterior Dislocations.
  27. Intermediate Shoulder Instability.
  28. Management of Glenohumeral Arthritis.
  29. Mechanics of Glenohumeral Arthritis.
  30. Mechanics of Glenohumeral Arthroplasty.
  31. Mechanics of Glenohumeral Instability.
  32. Mechanics of Shoulder Strength.
  33. More Information on Rotator Cuff Surgery.
  34. Posterior glenoid osteoplasty for unstable dislocating shoulders. Surgery to build up the back of the glenoid socket using an osteotomy and graft can restore shoulder anatomy and lessen pain and improve function.
  35. Ream and Run for Shoulder Arthritis: Conservative Reconstructive Surgery for Selected Individuals Desiring Higher Levels of Activity than Recommended for Traditional Total Shoulder Joint Replacement
  36. Ream and Run non-prosthetic glenoid arthroplasty for shoulder arthritis: Regenerative cementless surgery designed for individuals desiring higher levels of activity than recommended for traditional total joint replacement.
  37. Rehabilitation after Shoulder Arthroplasty.
  38. Rehabilitation following shoulder joint replacement arthroplasty
  39. Relevant Anatomy of Glenohumeral Instability.
  40. Repair of Rotator Cuff Tears: Surgery for shoulders with torn rotator cuff tendons can lessen shoulder pain and improve function without acromioplasty.
  41. Reverse Shoulder Replacement (Delta joint replacement) for arthritis: Surgery with a reverse prosthesis can lessen shoulder pain and improve function in shoulders with failed surgery or combined arthritis, rotator cuff tears and instability.
  42. Reverse Total Shoulder or Delta Shoulder for Shoulder Arthritis Combined with Massive Rotator Cuff Tear and for Failed Conventional Total Shoulder Replacement
  43. Rotator Cuff Clinical Presentation.
  44. Rotator Cuff Differential Diagnosis.
  45. Rotator Cuff Failure.
  46. Rotator Cuff Historical Review.
  47. Rotator Cuff Imaging Techniques.
  48. Rotator Cuff Relevant Anatomy and Mechanics.
  49. Rotator Cuff Tear: When to Repair and When to Smooth and Move the Shoulder
  50. Rotator Cuff Treatment.
  51. SF 36 and Health Status.
  52. Scapulothoracic Positions and Motion.
  53. Shoulder Arthritis
  54. Shoulder Arthritis Book
  55. Shoulder and Elbow Cases to Consider.
  56. Shoulder arthritis and rotator cuff tears: The combination of arthritis and rotator cuff tears is called rotator cuff tear arthropathy. The management of this condition requires thought and experience.
  57. Shoulder arthritis: Osteoarthritis, Chondrolysis, Rheumatoid Arthritis, Degenerative joint disease, and arthritis after shoulder surgery.
  58. Shoulder joint replacement arthroplasty for shoulder arthritis pain and stiffness: two options: total shoulder and ream and run
  59. Shoulder osteoarthritis, chondrolysis, rheumatoid arthritis, degenerative joint disease, and arthritis after shoulder arthroscopy and open surgery
  60. Simple Shoulder Test.
  61. Subacromial Smoothing.
  62. Surface replacement for shoulder arthritis: Surgery with a CAP, a special type of conservative resurfacing joint replacement that resurfaces the ball of the ball and socket joint, can lessen pain and improve function.
  63. Surgery for Atraumatic Instability of the Shoulder.
  64. Surgical release for stiff frozen shoulders: Surgery to remove scar tissue and release contractures can lessen pain and improve function for stiff shoulders that have not responded to rehabilitation or physical therapy.
  65. Total Shoulder Replacement Arthroplasty for Shoulder Arthritis
  66. Total elbow joint replacement for elbow arthritis: Surgery with a dependable, time-tested prosthesis can lessen pain and improve function in elbows, especially in rheumatoid arthritis of the elbow
  67. Total shoulder joint replacement for shoulder arthritis: Surgery with a dependable, time-tested conservative prosthesis and accelerated rehabilitation can lessen pain and improve function in shoulders with arthritis.
  68. Traumatic Shoulder Instability.
  69. Treating Shoulder Dislocation / Subluxation (Instability) and Associated Pain with Minimally Invasive Arthroscopy
  70. Treatment of Recurrent Instability.
  71. Types of Glenohumeral Instability.