Glenoid Fracture = Adhesive Capsulitis?

[MrPhysio+]

Hello Adam,
PhysioBob has given you some good answers. As you do not mention any problems with the other damaged areas, you obviously have a good healing capacity!
I am interested in the hydrodilatation history. I have been involved with hydrodilatations in Melbourne (or nearby) since 1991, shortly after the original technique was described in the American Journal of Orthopaedics. It is worth noting that the majority of these procedures are now undertaken by radiologists rather than Doctors or surgeons and that results vary widely. There is only one clinic in Melbourne that seems to have consistently good results via guided injection of the saline mix. The original technique, in my experience, works much better. In fact, one Doctor that I introduced the technique to has had Orthopaedic surgeons comment that the results were the best that they had seen (and this was related to some patients that had received multiple failed guided hydrodilatations).

Having commented upon the hydrodilatation process, it remains to be seen as to whether you actually have capsular adhesions and if you do whether other problems co-exist. PhysioBob is correct to comment that the rotator cuff musculature will require retraining to ensure the scapulat moves correctly upon the rib cage and the humeral head is correctly stabilised in the glenoid.

It sounds to me that you may also have some bicep tendon sheath adherence, possible sub deltoid bursal impingement and poor scapulo-humeral rhythm.
Thanks for providing all the information as it is helpful, but examination may provide even more relevant treatment direction.
Has anyone discussed glenoid labral tears with you?

I would try to strengthen the shoulder retractors and depressors, address the bicep long head tendon sheath, check the teres muscles and sub deltoid bursa and question the type of hydrodilatation technique. Given your history, a thorough check of your Cx to rule out some nerve root involvement or Cx facet joints (lower) contribution to the shoulder range of movement control would also be in order.

I have tried to cover the obvious areas - this is not to say that any of the above is occurring or that the list is fully comprehensive. Further assessment may bring forth more important findings. I hope the above helps to generate further comments that could be of assistance to you.

One more thing. The behaviour of your symptoms during daily activity and therapy sessions can often provide clues to the cause of your problem.

MrPhysio+

[theshoulderguy]

Hi Adam, mate you have been through a lot over the last 12+ months. I must say that your case is very interesting reading.

While my clinical physiotherapy practice is solely shoulders please understand that my expertise isn't surgical although I spend a lot of time working with them in the upper limb area.

There is some research on type III glenoid fracture fixation to suggest that you potentially should have more ER than you do although this study looks at patients 2 years down the track and surgery was arthroscopic.

Now I am not a shoulder surgeon but the things that jump out at me from looking at your docs folder is the surgery performed, the location of the screws, the anatomy within close proximity of the screws and the existing pathology present.

In particular the op notes and ultrasound and CT in June this year.

The majority of surgical work has been performed in the anterior superior aspect of your shoulder, potential involving areas such as subcoracoid/subscapularis, coracohumeral ligament, glenohumeral ligaments and capsule, coracoacromial ligament, rotator interval, long head of biceps attachment.



Significant post operative scarring anterosuperiorly, mechanical impingement of long head of biceps and capsulitis in these areas, could potentially explain your ER deficit??

Moreover, the location of the screw that remains and protrudes is placed at the superior aspect of the glenoid. The long head of biceps could be involved here??

Now where does the head of humerus go when cuff control is lacking and forces across the joint are not balanced?

You guessed it...ANTEROSUPERIORLY!

Could it be that a mechanical impingement of the head of humerus and/or long head of biceps is preventing the external rotation despite an anterior capsulotomy being performed??

I agree with the other contributor that the intraoperative ER photo is not a true reflection of your ER and it looks in reality to more restricted than depicted in the photo.


Something to think about and to ask your current surgeon or a new set of eyes.


Your physiotherapist could try a simple posterior head of humerus relocation test to see if your ER range can be improved manually.


If I can also suggest a look at general upper limb neural tension test to assess mechanosensitivity to ER/ABD due to proximity of the plexus to fractured ribs.

Food for Thought?

Good Luck!

Luke

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[adamd9]

Hi Luke,

Thanks for your reply. I suspect the nature of my original surgery (open) would have contributed to the current situation. I guess the problem with surgery is that every time they go in, they create more scar tissue and more chance for adhesions and other issues.

My new surgeon (who performed the last scope) suggested we try another 3 months of manual therapy before considering open surgery to:
-remove the remaining screw (this couldn't be removed arthriscopically)
-potentially fix a device to smooth over a divit/dent in the humeral head that might lead to arthritis later in life
-potentially look at splicing a tendon (can't remember which one) to allow more ER, but this obviously has more risk.

I'm interested in your comments around the placement of the screw and the movement of the humeral head. Are you saying that weak rotator cuff control could be causing the humeral head to sit forward (or not be pulled backwards in line with the joint surface when rotating), therefore potentially interfering with the screw? What about the original surgeon saying that the screw is buried in the cartilage? The new surgeon didn't want to rule out that the screw might be playing a part, but seemed pretty non-committal about it's role.

I'll get my physio to try as you suggest and relocate the posterior head of the humerus (which I assume means basically pushing it to the back of the joint surface and then trying to rotate).

Cheers,


Adam

[adamd9]

Hi MrPhysio+,

Thanks for your insights. Yes considering that laundry list of breaks, I had essentially no complaints other than the shoulder after about 6 - 8 weeks.

The three hydrodilations I had were all very different experiences. The first I had at RMH and it was done with a local anaesthetic, then die, and then (saline?) fluid. The doctor/radiologist who applied it was relatively new to the technique, and missed the capsual a couple of times and so had to reposition, all in all taking about 40 minutes. They got about 35ml in total; the feeling of internal pressure was pretty intense and diminished over the next few hours. The second was at Melbourne Radiology Clinic and used essentially the same technique, but with a little less fuss and similar outcome. The third was done at Victoria House Medical Imaging; I believe the doctor that helped develop the technique in Victoria was the one who treated me (Frank?). This one was a little different - no anaesthetic, no die, and over in about 10 minutes!

In all cases they were able to get 30 - 35 ml in, in one of them I seem to remember a build-up of pressure and then a 'pop' sensation followed by the loss of that pressure. All three provided no gains in ER and minimal gains gains elsewhere.I think in my case they haven't been effective in the way the surgeon had hoped.

Nobody has mentioned labral tears to me, and I couldn't read the operative notes to see if this was part of the original accident (I really wish surgeons would type their notes!). Even if there is a labral tear, I doubt I've got to worry too much about stability the way this shoulder is going...It's interesting to note that the remaining screw is very close to the edge of the joint surface. When I asked my original surgeon about this, he told me it was embedded in the cartilage (so I guess the labrum?).

In terms of my symptoms during the session, there is definitely some protective reactions going on there - I have to make a point of relaxing and letting the physio take the arm through it's motion (pain tolerance is fairly good though). While it's painful during the session, the pain almost non-existant about 15 minutes after.