FROZEN

SHOULDER
Lady Saerang, dr
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Data Base (January, 8th 2018)

 Name : Mr. S
 Sex : Male
 Age : 37 years old
 Address : Surabaya
 Occupation : “Ojek”
 Religion : Islam
 Ethnic group : Javanese
 Marital status : Married
Was referred from Neurologic out patient Clinic with
Tendinitis Dextra
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Chief complain : Nyeri bahu kanan

History of Present Illness

 Pain on left shoulder since 1 months ago, gradually worsened
 The pain was dull with vas 5, continuous, worsened by
movement of shoulder to upright, front, left side and rotate
 There were no muscle weakness, numbness, nor tingling
sensation at both side of her shoulder or arm
 He had difficulty to do some activity such as dressing,
bathing, eating, driving motorcycle and can not help his wife
to pick the groceries
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History of Past illness

 Hypertension (-)
 History of DM (-)
 No history of trauma on her shoulder

Occupational hystory
 He work as “ojek” since 2 years
 Sometimes he help his wife to carried the groceries from
market with put the groceries at his right shoulder
(±40kg) or pick it with right hand
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GENERAL STATUS
CM, independent ambulation, normal gait, right handed
domination
Body Weight : 65 Kg. Body Height : 163 cm. BMI : 24,5 (normal)
BP : 100/70 mmHg, HR : 88 x/minute , RR : 20 x/minute
Head & Neck : no anemia, icterus, cyanosis & dyspneu
Thorax : Cor : S1–S2 sound, murmur -, gallops -
Pulmo : vesiculer, wheezing -/-, ronchi -/-
Abdomen : Meteorismus -,vLiver/spleen : unpalpable
Extremities : warm acral +/+ , edema -/-
Physiatric examination 6

Musculoskeletal examination
Cervical ROM MMT
Flexion F (0-400) 5
Extension F (0-400) 5
Lateral Flexion F/F (0-450) 5/5
Rotation F/F (0-500) 5/5

Trunk ROM MMT

Flexion F (0-850) 5
Extension F (0-350) 5
Lateral Flexion F/F (0-300) 5/5
Rotation F/F (0-450) 5/5
Shoulder ROM 7
MMT

Flexion active (0-1000) / F (0-1800) 5/4 (pain)

passive (0-1000)
Extension F/F (0-45 0) 5/4 (pain)
Abduction active (0-600) / F (0-1800) 5/4 (pain)
passive(0-700)
Adduction active (0-300) / F (0-45 0) 5/4 (pain)
passive (0-300)
Ext. Rotation active (0-150) / F (0-90 0) 5/4 (pain)
passive (0-300)
Int. Rotation active (0-600)/F (0-90 0) 5/4 (pain)
passive (0-700)
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Elbow ROM MMT

Flexion F/F (0-1350) 5/5
Extension F/F (135-00) 5/5
Forearm supination F/F (0-900) 5/5
Forearm pronation F/F (0-900) 5/5

Wrist ROM MMT

Flexion F/F (0-800) 5/5
Extension F/F (0-700) 5/5
Radial deviation F/F (0-200) 5/5
Ulnar deviation F/F (0-300) 5/5
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Fingers ROM MMT

Flexion
MCP F/F (0-900) 5/5
PIP F/F (0-1000) 5/5
DIP F/F (0-900) 5/5
Extension F/F (0-300) 5/5
Abduction F/F (0-200) 5/5
Adduction F/F (200-0) 5/5

Thumb ROM MMT

Flexion
MCP F/F (0-500) 5/5
IP F/F (0-900) 5/5
Extension F/F (0-300) 5/5
Abduction F/F (0-700) 5/5
Adduction F/F (700-0) 5/5
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Hip ROM MMT

Flexion F/F (0-1200) 5/5
Extension F/F (0-300) 5/5
Abduction F/F (0-450) 5/5
Adduction F/F (0-200) 5/5
Ext. Rotation F/F (0-450) 5/5
Int. Rotation F/F (0-450) 5/5

Knee ROM MMT

Extension-Flexion F/F (0-1350) 5/5

Ankle ROM MMT

Plantar Flexion F/F (0-500) 5/5
Dorsi Flexion F/F (0-200) 5/5
Inversion F/F (0-350) 5/5
Eversion F/F (0-150) 5/5
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Toes ROM MMT

Flexion
MTP F/F (0-300) 5/5
IP F/F (0-500) 5/5
Extension F/F (0-800) 5/5

Big Toe ROM MMT

Flexion
MTP F/F (0-250) 5/5
IP F/F (0-250) 5/5
Extension F/F (0-800) 5/5
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Neurological examination
 N. Cranialis I–XII : Normal impression
 Physiological Reflex: BPR ++/++ TPR ++/++
KPR ++/++ APR ++/++
 Pathological Reflex : Babinski -/-, Hofmann -/-,
Tromnerr -/-
 Sensory deficit : -/-

Local Status : Shoulder

 I : swelling (-/-), redness (-/-), deformity (-/-), redness (-/-)
 P : Tenderness (+/-) at anterior aspect of right shoulder and
upper arm , muscle spasm (+/-) upper trapezius D, atrophy
(-/-), subluxation (-/-)
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Special Test :

 Compression test : -/-

 Distraction test : -/-
 Spurling test : -/-
 TOS : -/-
 Empty can test : +/-
 Neer test : +/-
 Hawkins test : +/-
 Belly test : -/-
 Lift off test : dte/-
 Infraspinatus test : -/-

* dte = difficult to evaluate

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Special Test :

 Drop arm test : -/-

 Infraspinatus test : -/-
 Belly test : -/-
 Yergason test : -/-
 Painfull arch : 600 shoulder D
 Appley scratch test (shoulder D)
• Adduksi + internal rotasi : full
• Abduksi +external rotasi : VTh1
• Adduksi +internal rotasi : Sacrum
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Diagnosis : Frozen Shoulder D

Functional diagnosis :
 Impairment : pain and stiffness shoulder D
 Disability : difficulty in ADL (dressing, bathing,
eating, grooming)
 Handicapped : couldn’t work properly
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Problem list :
 Surgical : -
 Medical : Frozen Shoulder D
Rehabilitation Medicine:
 R1 (Ambulation) :-
 R2 (ADL) : Difficulty in dressing, bathing,
eating, grooming
 R3 (Communication) : -
 R4 (Psychological) : worried about her disease
 R5 (Sosioeconomic) :-
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 R6 (Vocational) : decreasing income

 R7 (Others) :
- Pain on shoulder S (VAS = 5)
- ROM Limitation of shoulder S
- upper trapezius S spasm
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Planning :
1. Surgical : -
2. Medical : Natrium diclofenac 2x50 mg
3. Rehabilitation Medicine :
P. Dx : -
P. Tx :
Modalities
- USD 1 MHz 2 watt/cm2 for 10 minutes continuous on
supraspinatus regio
- High TENS on tenderpoint shoulder dextra, frequency 100
Hz, for 30 minutes
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Therapeutic Exercise
- Finger ladder exercise shoulder D
- AAROM exercise shoulder D as patient tolerance

P.Mx : Clinical signs, VAS, ROM shoulder D

P.Ed : Health Education & Home Exercise Program

- Education about patient’s condition
- Icing on shoulder D for 15-20 minutes every
2-3 hours
- continue exercise at home
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GOAL
 Short term
 Reduce pain
 Long term
 Achieve functional ROM Shoulder D
 Return patient to normal ADL and work
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Summary
Mr. D, 37 yo has complained right shoulder pain since 1
months ago, a dull pain with vas 5, continuous, worsened by
movement There were no muscle weakness, numbness, nor
tingling sensation at both side of her shoulder or arm.
He had difficulty to do some activity such as dressing,
bathing, eating, driving motorcycle and can not help his wife
to pick the groceries.
At physical examination we found ROM limitation shoulder
D, Neer, hawkin and empty can was positif for right
shoulder and painfull arch 600. and appley scratch test has
limitated for adduction and internal rotation also abduction
and external rotation
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We diagnosed this patient with Frozen Shoulder D.

Planning therapy consist of modalities USD and High TENS,
and therapeutic exercise with finger ladder exercise
shoulder D, AAROM exercise shoulder D as patient
tolerance. We monitoring Clinical signs, VAS, and ROM and
educated to Icing and continue exercise at home
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THANK YOU
SUPPORTING SLIDE

SHOULDER
Anatomy of shoulder girdle
1. Gleno – Humeral joint
2. Suprahumeral joint
3. Acromio–Clavicular joint
4. Scapulo – Costal joint
5. Sternal – Claviculo joint
6. Costo – Sternal joint
7. Costo – Vertebral joint
8. Biceps mechanism
SHOULDER PAIN
 DD :
 1. Adhesive capsulitis (Frozen shoulder)
 2. Rotator cuff tear
 3. impingement syndrome
 4. Bursitis
 5. calcified tendonitis
 6. bicipital tendonitis
Adhesive capsulitis

 Definisi: nyeri dan limitasi ROM shoulder

pada pasien dengan gambaran radiologi
normal
 Etiologi : - tdk diketahui
- autoimmune, trauma, inflamasi
Pathologic concept
1. Adhesions between layers of the subdeltoid
bursa
2. Extra-articular and intracapsular adhesions
3. Contracture of the subscapularis and biceps
tendon
4. Adherence of the anterior-inferior folds of the
joint capsule
5. Obliterative bursitis
6. Myostatic contracture
stage durasi klinis
Painfull stage 0-8 bln Progresif pain
Stiffening stage 8-16 bln penurunan ROM
Thawing stage > 16 bln peningkatan ROM dan
berkurangnya nyeri
Sara cucurullo

braddom
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Provocative Tests
 Neer’s impingement sign : pemeriksa menstabilisasi
scapula penderita dengan memberi tekanan ke
bawah secara pasif melakukan fleksi maksimal
humerus.
 Nyeri menunjukkan kompresi tendon supraspinatus
antara acromion dan tuberositas mayor
 Tes (+) nyeri pada bahu atas.
 Hawkins Impingement
Sign pemeriksa
memfleksikan humerus
dan siku 90° selanjutnya
internal rotasi shoulder
secara pasif
 Nyeri menunjukkan
kompresi tendon
supraspinatus oleh
ligamen coracoacromial
 Tes (+)nyeri pada
bagian atas shoulder

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drop arm test

Drop arm test

• The arm is passively abducted to 90° and internally rotated
• The patient is unable to maintain the arm in abduction with
or without a
force applied
• This indicates a complete tear of the cuff
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Subscapularis test

Procedure: This test has the opposite

effect with respect to the infraspinatus.
With the patient’s elbow alongside but
not quite touching the trunk, the
examiner comparatively assesses
passive external rotation in both arms
and active internal rotation of the
shoulder against resistance.

Assessment: Increased painless passive external rotation in comparison with

the contralateral side and weakness of the active internal rotation suggests
an isolated tear of the subscapularis. A tear of the subscapularis manifests it
self as pain and weakness in internal rotation. Where pain is slight, this
reduced strength suggests a tear. Where pain is more severe, it is non usually
possible to distinguish between a tear and tendinopathy.
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Assessment: Pain or weakness in external rotation indicates a

disorder
of the infraspinatus (external rotator). As infraspinatus tears are
usually
painless, weakness in rotation strongly suggests a tear in this muscle.
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BURSITIS

 Bursa pada bahu : subscapular , subcoracoid,

subdeltoid dan subacromial
 Struktur ini saling berhub. antara b.subscapular &
b.subcoracoid, b.subdeltoid & perluasan
b.subacromial
 Penyebab: seringkali tidak diketahui. Dpt disebabkan
krn trauma, rheumatoid disesae, deposit kristal pada
Gout
 Klinis: nyeri lokal, edema, limitasi ROM
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CALCIFIC TENDONITIS OF THE

SUPRASPINATUS TENDON
General
• Calcium deposits most commonly involving the
supraspinatus tendon
• Size of the deposit has no correlation to the
symptoms
Clinical
• A sharp pain in the shoulder
Imaging
• AP X-ray of the shoulder will show calcium deposits
usually at the site of tendon insertion
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Bicipital Tendonitis
 Activation of the biceps muscle is noted with elbow
flexion
and supination of the forearm.
 There is also some activity with abduction of the arm in
an externally rotated position.
 Inflammation of the long head of the biceps tendon at
the insertion on the greater tuberosity
 The tendon may be impinged between the head of the
humerus, acromion and coracoclavicular
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Provocative Tests
• Biceps tendonitis
– Yergason’s test (Figure 4–28)—This test determines
the stability of the long head of the biceps
tendon in the bicipital groove
Pain at the anterior shoulder with flexion of the
elbow to 90° and supination of the wrist against
resistance

Imaging
• None specific
Apley Scratch test
To
test the Active
ROM of the Shoulder
a. Add-Endo
b. Abd-Exo
c. Add-Exo

Efek Thermal USD
Meningkatkan sirkulasi darah perifer.
 Meningkatkan metabolisme jaringan.
 Meningkatkan permeabilitas membran sel.
 Modulasi nyeri.
 Mengurangi spasme otot.
 Mengurangi kekakuan sendi.
 Meningkatkan aliran darah.
 Meningkatkan ekstensibilitas serabut kolagen
pada tendon dan kapsul sendi.
PERESEPAN
 Frekuensi 0,8 – 1,1 MHz
 Intensitas 0,5 – 2,0 W/cm² (WHO 2008),
maksimal 3,0 W/cm².
 Durasi 5 - 10 menit
 Pendulum (Codman’s) exercises are techniques
that use the effects of gravity to distract the
humerus from the glenoid fossa. They help relieve
pain through gentle traction and oscillating
movements (grade II) and provide early motion
of joint structures and synovial fluid.
 No weight is used during this phase of treatment