Loss of Scapulohumeral Motion (Frozen Shoulder)

Duplay (1896) was the first investigator to recognize pathologic disorders of extra-articular tissues as possible factors responsible for stiff and painful shoulders. It was his belief that an inflammatory process of the subacromial bursa was the causative agent producing this syndrome. He designated the entity “scapulohumeral periarthritis.” Soon this term came to include a host of heterogeneous cases which presented similar clinical features, namely, all had pain and stiffness in the shoulder region. Since the original work of Duplay many workers have succeeded in extracting from the all-inclusive term “scapulo-periarthritis” many unequivocal entities. Notably among these observers were Painter, Baer, King and Holmes, Mumford and Martin, Codman, Meyer, Pasteur, Gilcreest, and more recently Lippmann, Abbott, Saunders and Hitchcock and Bechtol. Meyer [11] was the first observer to focus our attention on the tendon of the long head of the biceps brachii muscle as a possible source of disorders about the shoulder. He noted in anatomical specimens advanced degenerative abnormalities comprising fraying, shredding, fasciculations and tearing of the fibers of the biceps tendon. Some specimens exhibited partial or complete dislocation of the tendon out of the bicipital groove and several specimens revealed absence of the intrascapular portion of the tendon while the extracapsular portion had attained a bony attachment on the shaft of the humerus in the region of the lesser tuberosity. It was Meyer's belief that the aforementioned changes were the products of several causes: (1) contact of the tendon with a supratubercular ridge when present, (2) irregularities and excrescences in the floor of the intertubercular groove, and (3) contact of the tendon with raised cartilagenous margins of the head of the humerus or with the lesser tuberosity. He further believed that these alterations were the result of using the upper extremity in a position of abduction and external rotation. His observations were made on the shoulder joints of cadavers in whom no clinical data were available prior to death; therefore it was impossible to evaluate the clinical significance of these alterations. Meyer's observations were confirmed by the author together with J. B. White and G. Callery in an investigation conducted on shoulder joints which were obtained postmortem from individuals on whom clinical data were available prior to death. It was interesting to note that many of the degenerative and attritional changes described by Meyer were compatible with good, painless function of the shoulder joint. In 1932 Pasteur [13] described a new clinical syndrome “tenobursite” which he believed was responsible for frozen shoulder. He was the first to correlate bicipital tenosynovitis with frozen shoulder. This was followed by the work of Schrager who, for the first time in American literature, described tenosynovitis as an unequivocal entity. Many other workers soon began to recognize the significant role that the tendon of the long head of the biceps brachii muscle played in stiff and painful shoulders. Lippmann [9] in 1943 described adhesive tenosynovitis as the causative agent of frozen shoulder, a concept with which the author is not in total agreement. On the other hand, Codman [3], one of the greatest authorities on lesions of the shoulder joint, wrote “Personally, I believe that the sheath of the biceps tendon is less apt to be involved than are other structures. I have never proved its involvement in a single case. I think that the substance of the tendon of the supraspinatus is the most often involved.” Codman was of the opinion that tendinitis of the rotator tendons was the underlying pathologic disorder responsible for frozen shoulder. In the following study an attempt will be made to show that frozen shoulder is a diffuse inflammatory process implicating all the soft tissue components of the scapulohumeral joint including the biceps tendon and not any one component or an isolated region of the joint; also, that bicipital tenosynovitis is a concomitant finding in all frozen shoulder, that it may be primary or secondary in origin, and that it is responsible for the pain factor which is the most distressing feature of this syndrome. Furthermore, it will be pointed out that once the pain element in frozen shoulders is eliminated, restoration of function can begin and continues until optimum function is regained and all tissues are returned to normal. The observations herein recorded were made on a clinical study of 38 cases, of which 32 were investigated surgically. Correlation of these pathologic findings with those recorded in a previously reported investigation on degenerative lesions of the shoulder joint allows one to reach some logical conclusions concerning the causes and pathogenesis of frozen shoulders. Clinical Characteristics Frozen shoulder is a malady usually encountered in individuals past 40 years of age; in this series only one case was under 40. The greatest incidence is found between 50 and 60 years and women are more frequently affected than men (68.3 per cent of the cases in this study were in women). It is a relatively common disorder in patients afflicted with cardiovascular, pulmonary, or metabolic disorders. The syndrome exhibits a characteristic cycle of events. It may be initiated by trauma to the region of the shoulder; on the other hand its onset may be insidious without injury. Early in the disease pain and stiffness in the shoulder are the outstanding symptoms. Pain is accentuated by activity and specific motions at the scapulohumeral joint such as abduction and external rotation or dorsal flexion and internal rotation. Also, in most instances the pain is projected to the anterolateral aspect of the shoulder and to the anterior aspect and middle of the upper arm, occasionally to the flexor surface of the forearm. Pain during the night is often severe and interferes with sleep. Pressure over the intertubercular sulcus and rolling the biceps tendon under the examiner's thumb elicits tenderness in all instances. The severity of the symptoms slowly and steadily increase while the arcs of painless motion at the scapulohumeral joint become progressively smaller until little or no motion is demonstrable in the joint (Fig. 1). At this stage of the disease the extremity is held at the side in a position of internal rotation. All shoulder motions are guarded and painful and atrophy of deltoid and spinatii muscles is discernible. As a rule, a few degrees of painless motion are demonstrable in the antero-posterior plane. Occasionally, all the cardinal signs and symptoms of a scalenus anticus syndrome may confuse the clinical picture.Fig. 1: This is a typical patient with a frozen right shoulder. Note the angle that the shaft of the humerus makes with the vertebral border of the scapula. All motion is in the scapulothoracic joint. This patient has completely lost all scapulohumeral motion. The scapula and the humerus move as one unit when abduction is attempted. This patient shows the maximum range of abduction that she is able to carry out with a frozen shoulder.At all times during the course of the disease pain is the most significant clinical manifestation. Although the range of motion of the affected extremity is severely impaired, the pain factor outshadows the loss of motion. The clinical course of frozen shoulders is unpredictable; it may terminate spontaneously at any stage of the disease or it may remain static for many months before regression begins. As a rule, after a variable period of time the pain becomes less intense and function is progressively restored. It is erroneous to believe that in all instances complete restoration of function is attained. In many instances some residual loss of motion, particularly abduction and external rotation, and some weakness of the extremity are demonstrable. Moreover, in the literature the thought is repeatedly conveyed that spontaneous recovery occurs in all instances in six to 36 months. Three individuals in this investigation disclosed frozen shoulders five, six, and eight years respectively after the onset of the disease, with no indication of regression or improvement. Etiology and Pathogenesis This study emphasizes that muscular inactivity is the causative agent responsible for frozen shoulders. Any cause which restricts scapulohumeral movements favors muscular inactivity; bicipital tenosynovitis was noted to be the most common factor. Other causes producing restriction or loss of scapulohumeral movements were calcareous tendinitis, sprains, contusions, and fractures in the region of the shoulder joint. Also, lesions at a distance from the shoulder joint, such as fractures of the forearm and wrist which are treated with the arm in the sling position, may produce muscular inactivity about the shoulder. In the face of muscular inactivity, regardless of the cause, muscle atrophy ensues. This is followed by disturbance in the metabolic processes of all the soft tissues about the shoulder joint, and there follows a slowing down of the circulation and venous and lymphatic stasis. All tissues comprising the musculotendinous cuff and those adjacent to the cuff are implicated in this process. The tissues become saturated with serofibrinous exudates which provide fibrin responsible for the formation of capsular, synovial, fascial, intermuscular and intramuscular adhesions. It must be emphasized that the low grade inflammatory process involves all the normal tissues simultaneously. Microscopic study of sections made from different areas in the musculotendinous cuff, synovial membrane, subacromial bursa and biceps tendon revealed, in all instances of frozen shoulders, findings consistent with a chronic inflammatory process (Fig. 2 A, B, C, D, E). It is common knowledge that functional activity reverses the above process and restores normal circulation, joint function, and normality of the affected tissues.Fig. 2A-E: The degenerative and inflammatory changes of all the soft tissue components of the scapulohumeral joint of an individual with a frozen shoulder are shown. Note that all these specimens reveal marked edema of the tissues, degeneration of the collagenous fibers, pronounced round cell infiltration of the tissues, increased vascularity, marked thickening of the synovial membrane, and evidence of increased fibrosis. These findings are consistent with a low grade chronic inflammatory process, reparative in nature. (A) A microscopic section (×140) through the coracohumeral ligament. (Again note the marked hypertrophy and increased vascularity of the synovial membrane.) (B) A microscopic section (×140) through the supra sinatus tendon. (C) A microscopic section through the bursal wall. (D) A microscopic section (×140) through the musculotendinous area of the subscapularis muscle. (E) A microscopic section (×140) (through the biceps tendon. (Note the marked thickening of the synovial membrane and increased cellular elements in this tissue).The anatomy of the shoulder joint lends itself to changes which produce stiffness. Its fibrous capsule is loose and redundant, and with the arm at the side the capsule forms nictitating folds on the inferior and anterior aspects of the scapulohumeral joint. In addition, the short rotator muscles provide large surface areas on which serofibrinous fluid may accumulate. Large surface areas also exist between the outer and inner muscular sleeves (the outer muscular sleeve consists of the deltoid muscle, the inner sleeve of the spinatii and subscapularis muscles). Moreover, the subscapularis recesses (often referred to as and the subacromial are for of It was interesting to that frozen shoulders only when muscular inactivity initiated the aforementioned in shoulder joints of individuals past 40 years of or in that period of when degenerative alterations in the musculotendinous cuff, and biceps tendons were demonstrable and In a previously recorded study these lesions were first in the and increased in in are alterations from and and (Fig. In the of these abnormalities the inflammatory process, in most until of the scapulohumeral joint by and term is to in the nictitating folds of the fibrous capsule and in the anterior and inferior aspects of the scapulohumeral joint the synovial side of the capsule to the inferior surface of the head of the All tissues implicated in this process and become particularly those on the anterior aspect of the This the degenerative changes noted in a previously recorded study made on shoulder joints in Note the in in of the degenerative lesions implicating the biceps and musculotendinous note that after the there is a in the severity of the degenerative coracohumeral in these cases revealed significant alterations. It is a of fibrous tissue the between the process and the of the humerus (Fig. together with the subscapularis muscle, as to external rotation while the and muscles the range of internal Note the anatomy of the coracohumeral as it from the process to the humerus the intertubercular This is and in a frozen shoulder becomes or in a position and as a to external this series all cases disclosed of the of the biceps its involvement may be primary or The of the inflammatory process the biceps tendon and its sheath In some instances the tendon was in a of while in some it was to the of the capsule in the region of the intertubercular and reported similar In cases the tendon was to the floor of the groove and only be by In instances advanced degeneration of the extracapsular portion of the tendon The tendons were and to the floor of the bicipital It as was to the by the extracapsular portion of the biceps tendon to the shaft of the It that once bicipital tenosynovitis was it played a significant role in the and course by frozen shoulders. In the of the observations noted it is to that in a large it was responsible for the pain factor in this particularly when the extremity was through specific arcs of motion which a range of of the head of the humerus on the tendon. together with the to motion by between the tendon and favors muscular inactivity, a which of the soft tissues and formation of more adhesions. bicipital tenosynovitis is the responsible agent for pain in the and of frozen shoulder was out by the that in all instances over the intertubercular sulcus and rolling the biceps tendon under the examiner's thumb also of the by and of pain It is common knowledge that in many cases of frozen shoulders, after of pain and of the shoulder, pain and restoration of function In these it is to that the inflammatory process described above of and muscular activity is which of normal circulation to the affected In other instances the process continues until there is complete of the this by the extracapsular portion of the biceps tendon to the shaft of the usually in the region of the lesser tuberosity. this the pain factor is and restoration of function can The clinical course of the case a of this clinical This individual was prior to death. clinical of shoulder was demonstrable and the patient was of any in he a that to years prior to this he had severe pain and of motion, first in the right and in the shoulder joint. an period of time to pain and function returned in shoulders. the and of restriction of motion it was to that a frozen shoulder had in At scapulohumeral joints with the musculotendinous were and The of the biceps tendons were while the extracapsular had attained a bony the lesser In some to completely the biceps tendon spontaneous recovery not and pain and stiffness In this investigation disclosed that the clinical course following muscular inactivity of the shoulder, regardless of the cause, is the of degenerative alterations in the comprising the scapulohumeral joint. frozen shoulders muscular inactivity in individuals under 40 years of in whom only degenerative changes in the musculotendinous cuff are discernible. In individuals are in frozen shoulders may spontaneous recovery occurs in most of On the other hand, in individuals past the of and are afflicted by some disease which to the severity of degenerative particularly those in the tissues of the scapulohumeral joint, of a frozen shoulder following muscular inactivity is the In the of the aforementioned it becomes that the of is not the for all cases of frozen shoulders. the causative factor producing the syndrome be and In many instances of this causative agent will to of pain and muscle and restoration of muscular activity and This is in cases of calcareous tendinitis of long which have frozen shoulders. In such of the calcareous will the of to bicipital tenosynovitis is the factor of the of this may pain and restoration of function in the scapulohumeral joint. Early of the of motion in the scapulohumeral joint, in the of the disease, is the result of pain and muscle It has many times on the when the patient is under that with muscular of motion is that pain and muscle are responsible for the loss of motion. The of in these individuals is complete to to the shoulder region and in the All are the painless arcs of motion. to pain and muscle is the with to of per cent of a is for to The arm is in the sling position are are to times and the painless arcs of motion. a few the sling is and and are The of this of the of the patient and the and of the A such as described will result in a large of eight to Some patients will a period of In of the may a to the described is or for to In of a of many cases to to these and to the of the of the In to pain and muscle formation of and extracapsular and of the rotator and muscles of the shoulder joint the range of motion. Moreover, as previously in all instances of frozen shoulders, particularly in the of the disease, the biceps tendon degrees of In this series it has repeatedly that the pain factor is by of the of the biceps restoration of function ensues. This is by the biceps tendon at the and it to the process. Hitchcock and were the first observers to of the portion of the tendon. the of the tendon to the shaft of the humerus in the floor of the bicipital The described by Hitchcock and is to the anterior aspect of the deltoid muscle (Fig. the anterior fibers of the deltoid are and the subacromial musculotendinous cuff and intertubercular The extracapsular portion of the biceps tendon is by the and the capsule the intertubercular This is through the fibers of the coracohumeral for a distance of This of the portion of the biceps tendon. The biceps tendon is with a long to the and from the joint (A) This the subacromial region after the deltoid muscle has (B) This the long head of the biceps tendon at the and from the joint also a has made in the process. (C) This shows the tendon in its new position, the of the musculotendinous cuff by and the to the is made over the process through the tendon fibers of the and short head of the biceps muscle. The process is by and with a a bony is made in its substance (Fig. The biceps tendon is in the bony by and by the by the tendon. of the of the biceps tendon is with to the tendon of the and short head of the biceps tendon. are to the of the fibrous capsule and ligament. At this it must be emphasized that at no time or after the must the arm be through its normal arcs of movements at the joint. It has found to the and coracohumeral in all instances of frozen shoulder in which the biceps tendon was to the process. In frozen shoulders the forms a to the head of the humerus when the extremity is of this the head to the with the is the of be to its the As previously recorded the coracohumeral in frozen shoulders is a from the of the process to the fibrous capsule as as It as a to external rotation and of this restoration of scapulohumeral motion. the the arm is in a are on the or These are a times or on the the sling is Although the range of motion is progressively it is at all times the of the and are restoration of function is attained in to months. In all cases in this series in which the above was pain was and restoration of muscular activity was for Frozen of frozen shoulders is a and this is was confirmed by the observations noted in cases which were under The affected shoulders of these patients were through an anterior deltoid In all instances when the arm was regardless of the was of degrees were noted in the subscapularis tendon and in its muscle fibers the shaft of the In individuals the of the subscapularis muscle was completely from the lesser and the the musculotendinous cuff for one and of the arm in all cases in the fibrous capsule the inferior aspect of the of the In instances the surface of the head came through in the In instances of the biceps tendon at the of the intertubercular sulcus was and in of the observations out the of such a is to that the cases that are by may be those in which the tendon of the long head of the biceps brachii muscles was the is and pain may be As previously often to this by the tendon to the shaft of the of cases of frozen shoulder were In this series there were per and (68.3 per the shoulder was implicated in cases per and the right in per The of symptoms from to in cases symptoms had for and months In instances shoulders were The from to only one individual was under 40 years of inactivity was the common factor in all instances. In cases per a bicipital tenosynovitis was responsible for the muscular of the cases were followed from the onset of the malady which began as a bicipital tenosynovitis to the stage of the disease, when a frozen shoulder was demonstrable. In the of the cases, a of the onset of the disease one to that the bicipital tenosynovitis was the In per cases, muscular inactivity of the shoulder was by such as calcareous tendinitis on the shoulder, of the arm in the sling position following fractures of the humerus or of the and in following a It must be emphasized that in all individuals after the degrees of degenerative changes exist in the musculotendinous This was in a previously reported in the of these alterations will muscular inactivity produce a frozen shoulder. The cardinal clinical (1) loss of the normal scapulohumeral (2) of the extremity at the side in a position of internal rotation, (3) loss of scapulohumeral motion for a few degrees of motion in the tenderness over the intertubercular groove and rolling the biceps tendon under the examiner's thumb cases to while 32 were treated surgically. In all instances in to the and microscopic evidence of a low grade chronic inflammatory process implicating the musculotendinous cuff and fibrous involvement of the of the biceps tendon in was discernible. In some cases the biceps tendon in a of while in the tendon was by to the groove and to the of the fibrous In instances was in to the tendon from the in the subacromial bursa from the formation of a few the bursal to complete of the bursa by fibrous The coracohumeral in all instances was found to be and frozen in a In the 32 cases which were treated by pain was following the The time to maximum restoration of painless function in the scapulohumeral joint from eight to and Frozen shoulder is a clinical entity which is by muscular inactivity of the shoulder in individuals past 40 years of tenosynovitis is the most common factor producing muscular initiated the syndrome in per cent of the cases in this Pain is the outstanding clinical feature of frozen shoulder; once pain is restoration of function can in cases may the syndrome. In cases of the tendon of the long head of the biceps brachii muscle to the process will the pain factor and painless motion in the shoulder. In this series optimum restoration of function was obtained in eight to