1. Adhesive Capsulitis
(Frozen Shoulder)

2. Definition
• A disorder in which the shoulder capsule becomes
inflamed and stiff, greatly restricting motion and causing
pain.
• The etiology is unknown (injury or trauma, autoimmune).
• Characterized by progressive pain and stiffness which
usually resolves spontaneously after 18 months.
• Movement of the shoulder is severely restricted, pain is
worse at night.

3. Clinical Features
– Age 40-60, more in females
– Slight wasting, some tenderness.
– Pain (gradual onset)
– Stiffness or decrease in motion.
• External rotation (most severely inhibited)
• Internal rotation.
• Abduction.

4. Radiology
– X-ray:
• Osteoporosis of the proximal humerus (decreased bone density)
– Arthrography:
• Shows a contracted joint
• Dramatic decrease in the injected contrast material.
• Loss of normally loose dependent folds of the capsule.

5. Differential Diagnosis
• Post-traumatic stiffness (maximal at the start, gradually
lessens)
• Disuse stiffness
• Regional pain syndrome (associated with MI, stroke)
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6. Treatment
self-limiting: it usually resolves over time without
surgery. Movement is regained gradually but may
not return to normal
 Conservative:
– Analgesics
– Heat therapy and exercise(physiotherapy)
– Corticosteroid injection.
– Manipulation under anesthesia hastens recovery.
 Operative Treatment
– Arthroscopic division of the interval between
supraspinatous and infraspinatous (improve the range
of movement).

7. Shoulder Instability
(Dislocation)

8. Occurs when the
humerus separates from
the scapula at the
glenohumeral joint.
The glenoid socket is very
shallow and the joint is
held secure by the
fibrocartilaginous glenoid
(labrum) and the
surrounding ligaments and
muscles.

9. Types
3. Anterior instability.
4. Posterior instability.
5. Multidirectional instability.

10. Anterior Instability
• Most common. (~95%)
• 50% under 25 yrs, 50% develop recurrency (the
labrum and capsule are detached from the anterior rim
of the glenoid)
• Occurs as a sequel to acute anterior dislocation of
the shoulder, with detachment or stretching of the
glenoid labrum and capsule.
• Mechanism:
– abduction, external rotation, and extension.
– falling on outstretched hand, forcing the arm into abduction
and external rotation
• It can result in damage to the axillary artery.
• Recurrent dislocation 
– trivial trauma.
– Between episodes shoulder looks normal.

11. Approach
– Hx: severe pain, limitation of movement, anterior bulging, Hx of
trauma. This pathology limits many activities, including
overhead arm motions, external rotation, and, thus, physical or
athletic activities.

12. Examination
shoulder drawer sign
• the examiner manually assesses translation of the humeral head in the
glenoid fossa. The humeral head is grasped in one hand, and the
clavicle and scapula are stabilized in the other as the examiner pushes
anteriorly and posteriorly.
• Compared with the unaffected shoulder, the affected shoulder often
demonstrates increased laxity.
Apprehension test
• The arm is placed in abduction, extension, and external rotation while
stressing it in anterior translation. If the patient becomes apprehensive
and reports pain, this is considered a positive finding.

13. X-ray findings
– Humeral head anteriorly.
– Axial view is diagnostic. (even for sublaxation).It shows the
humeral head riding on the anterior lip of the glenoid.
– AP view with the upper arm internally rotated may show Hill-
Sachs lesion if recurrent.
– Rule out associated humeral neck fracture.
Hill-Sachs lesion :
• Depression in the posteriolateral part of the humeral head.
• Caused by recurrent forcing of the head of humerus against the anterior
glenoid rim (damage to the bone)

14. MRI :
• The Bankart lesion (detached glenoid labrum)
• Deformity of the humeral head
• MRI of anterior inferior
labral tear

16. • Hill-Sachs Lesion

17. Treatment
Reduction:
• Most techniques are facilitated by the following 2 maneuvers:
– Flexion of the elbow 90° to relax the biceps tendon
– External rotation of the humerus, which releases the superior glenohumeral
ligament and presents the favorable side of the humeral head to the glenoid
fossa
• Signs of a successful reduction include the following:
– Palpable or audible clunk
– Return of rounded shoulder contour
– Relief of pain
– Increase in range of motion
• Stimson Maneuver, Scapular Manipulation, External rotation method, Traction and
counter traction

18. Surgery
• Indications:
– Frequent dislocations, esp if painful
– A fear of recurrent dislocation sufficient to prevent participation
in everyday activities.
• Types of operation:
– Re-attachment of the glenoid labrum (Bankart)
– Shoretening and tightening of the anterior capsule and muscles
(Putti-Plat)
– Reinforcement of the antero-inferior capsule using adjacent
muscles (Bristow)

19. Posterior Instability

20. • Rare (5%)
• Due to violent jerk in an unusual position
• If recurrent, it is almost always a sublaxation, with the
humeral head riding back on the posterior lip of the
glenoid.
• Mechanism:
– Abduction, flexion, and internal rotation.
• Etiology:
– Direct trauma.
– Epileptic seizure, Electric shock.

21. • Pathology is the same as the anterior one but the capsule
is torn posteriorly.
• Approach same as anterior dislocation.

22. • Diagnosis:
– X-rays
– CT scans
• Treatment:
– Reduction
(Apply gentle, prolonged axial traction on the humerus. Then add gentle
anterior pressure while coaxing the humeral head over the glenoid rim. Slow
external rotation may be needed)
– Conservative
muscle strengthening exercises and voluntary control of the joint
– Surgery
indicated only if disability is marked and there is no gross joint laxity.

24. Multidirectional Instability

25. • Associated with capsular and ligamentous laxity, and
sometimes with weakness of the shoulder muscles.
• The patient complains of the shoulder going out of the
shoulder with remarkable ease.
• Alternating episodes of anterior and posterior sublaxation
or dislocation.
• Muscle strengthening exercises and training in joint control
are helpful.

26. Thank you!
Good luck tomorrow!
Done by:
Athar shibli