intra articular injection shoulder

How to diagnose a shoulder arthritis?

What to do about a "frozen" shoulder? Is it really "frozen"?

A "frozen" shoulder seems to have kind of a spontanous evolution, which can last, in worst case scenario, 2-3 years.  Anyhow, it is a self limiting scenario.  Different types of arthritis demonstrate a spontaneous evolution.

>>> What about tendinosis, bursitis,...click here for more shoulder clinical reasoning and therapy strategy

 When a shoulder patient is suffering from an arthritis, it is so important to determine the stage in which the arthritis is. 

Depending on the stage (how irritated is the shoulder), the treatment strategy can be completely different. 

Performing e.g. intensive capsular stretching in case of a severe arthritis is not the best idea :)

How to determine the stage of a shoulder arthritis? Does this affect your treatment strategy?

We will discover a number of elements from the history and the clinical examination to will help us to determine the stage of an arthritis.  

The first thing is to establish whether or not there is a capsular pattern in the clinical image..  In this film I illustrate how to interpret the clinical image?

Traumatic arthritis 

We don’t expect a traumatic arthritis under the age of 40-45 years old (except if there has been a fracture). This is an empirical finding. 

The patient describes a typical history : There was a trauma or some overuse followed by some pain, which disappears at first and then, after 3-4 days, the pain returns and increases every day. 

This is the starting point of the traumatic arthritis. Some weeks later we already reach a stage II arthritis. In the absence of treatment there is a spontaneous evolution which takes about 9-12 months. 

During the first 3-4 months the pain and the limitation get worse ; the pain is constant, even at night. The pain gradually eases.  At the end of this evolution, the normal range has returned, even without treatment.

Treatment stage I 

In a stage I the shoulder is slightly irritated. The treatment consists of intensive capsular stretch, about 15’ per session, 3x/week, active end range mobilization shoulder – shoulder girdle and home exercise.

The “correct” dosis of capsular stretch is rather empirical : it is the purpose that the patient has 1 or 2 hours of post treatment pain. 

Because of the structural changes occuring in the mobilized tissue, a low grade inflammatory response may be produced. 

In order to maintain the elongation achieved the patient must be given an appropriate exercise program to maintain the range achieved. 

If the patient didn’t experience any discomfort after the first treatment, increase the intensity of the capsular stretch ; if, however, he suffered pain too long after the treatment, next time decrease the intensity. 

Capsular stretch has proven effective in the relief of pain and recovery of ROM in up to 90% of patients with capsular stiffness. 

Treatment stage III 

The shoulder is highly irritated . This is a acute arthritis. Exercise and active mobilization are contraindicated. There are two treatment options : or, manual distraction technique (it is not the purpose to mobilize, it is merely a pain reducing technique), about 25’ per session, 5x/week, no exercise, no active mobilization 

or, a series of intra-articular injections with triamcinolone acetonide. 

The pain markedly improves as from the first injection (no more pain at night) ; the mobility increases after the third injection. 

Effect of the distraction technique : This inhibits nociceptive reflexes which result from the long-standing stimulation of the nocisensors. These reflexes would be responsible for increased sympathetic activity giving rise to vasoconstriction of the vessels around the joint. 

Treatment stage II 

Now we may focus more on passive mobilization techniques and , if possible, we can already try to mobilize in end range direction. 

The patient already may do some home exercise in order to mobilize the shoulder 

Frequently made errors 

A patient is seen in a stage I phase, not too much pain, not too much limitation of movement : just medication is prescribed. A few weeks later he is in a stage II, more pain and more limitation, then mobilization is prescribed… Wrong : if the patient is in a stage I, mobilization should be prescribed as soon as possible in order not to loose time. 

In a stage III the patient receives an injection together with the message “come back for a second one, once you have more pain again” o Wrong : it is more interesting to keep the joint a certain amount of time under the influence of the corticosteroid, therefore several injections are needed with a specific interval  First injection : today  2 nd : 7 days later  3 rd : 10 days later, to count from the date the 2nd one was given  4 th : 14 days later, to count from the date the 3rd one was given 

Immobilizational arthritis 

This occurs frequently after shoulder or elbow surgery and is a situation which needs to be avoided. The treatment strategy is the same as the one for the traumatic arthritis. 

Steroid-sensitive arthritis versus “Frozen shoulder” 

The steroid sensitive arthritis is an arthritis that appeared spontaneously, apparently without a cause (no injury, no immobilization, no overuse). 

Initially, Cyriax had two different disorders in mind : 

a monarticular rheumatoid arthritis, if his treatment with i.a. injections of hydro- cortisone proved effective.

A frozen shoulder in which injection didn’t give any results. . In 1970, however, when he started to use the new steroids (triamcinolone), almost every arthritis, which had appeared spontaneously, now responded to treatment. Hence the new name : steroid-sensitive arthritis. This is about half of all the cases of shoulder arthritis. A steroid sensitive arthritis also has a spontaneous evolution which could take up to 2 years, but, unfortunately with some permanent loss of lateral rotation ROM.

 Therefore, it doesn”t make any sense to await the spontaneous evolution and treatment should be given regardless of the stage of the arthritis. On empirical grounds we have the impression that this type of arthritis reacts better on injections than on manual distraction techniques. The reason for that is unknown to us. 

What’s the difference with a frozen shoulder ? 

Could be idiopathic, post traumatic or related to Parkinson or diabetes resulting in a chronic fibrosis of the capsule. If the patient is insuline dependant, injections cannot be given and the prognosis is rather worse. Anyhow, the situation is also self limiting, but it can take up to 42 months before the patient is recovered. 

The sooner the pathology is detected, the sooner an efficient treatment has been started, the better the prognosis. End range mobilization and scapular mobilisation seems to be more efficient than standard physical therapy (i.e. P mid range mobilisation, flex-abd stretching, A exercises, electro). 

Rheumatoid-type arthritis 

Related to a number of system diseases such as psoriasis, lupus erythematosus, Reiter’s disease, ankylosing spondylitis, gout, etc.

 In most of those cases injection can be given, if necessary. Active mobilization therapy is of course also important in those cases. 

Osteoarthrosis 

We find a capsular pattern with a harder end-feel. The patient may have hardly any pain. There is, however, an increased tendency for a traumatic or an immobilizational arthritis.  

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