TUGAS Frozen Shoulder Syndrome in Patient With Pulmonary Tuberculosis

8/18/2019 TUGAS Frozen Shoulder Syndrome in Patient With Pulmonary Tuberculosis

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F rozen-Sh oulder S yndrom e in P atien ts w ith

P u lm onary T ub ercu losis

B Y J. T . H . JO H N SO N , M .D ., B AL T IM O R E , M AR YL AN D

’ ’o m IIme DCJ)am’( 10 C 0 t of 8 m m rg cry , l)it’i.. ion of O m ’( Imop ac(lu’SO rgcry,

JoIm its IIo /)k i?m .s’ I osjn l (ii, Ba it o nL(’(

A s com m sult.aim t iim ortim Ol)aediC surgery to several tuberculosis sam m itaria,I imavelong n oted tim e lm iglm nm ci(lence of tim e so-called frozen-slm ould er syIm ( m OiIm e aiim om m g tim e

patients ilm these im ospit.als. A itim ougim it isveil km m ow n that tim is syndronm e is oftenassocia ted w ’itim car iac an( otim er dei)iiit-a ting illnesses tim e litera ture is quite

5l)it15C concerim im mg its re la tiolm sim ii) w ith i)ulilm Om maiY t-uim erculos is .Franklin alm ( Nem m m cik noted a lm igim im m cli ence of slm OU i(ler conm plaints of a iy-

im m g degree im m tuberculous pat-ie im tsat F itzsim im ons Arm m m y Hospital. T im ese patien ts

w .ci.e not follow ed for am m y iengtlm of tim e, but tim e autim ors w ere discouraged by the

l)00 i results obtained by aim y m mm etlm od of treatim ment.Einaudi recently reported aim igim im m ci(lence of l)eriartlm ritis of tim e sim oulder in tuberculous patien ts in Italy, but

im e too ( id not im ave any lolm g-term )m follow-up of tim ese cases.

In ord er to clarify im ot oim iy tim e im m cidence but tim e clin ical course and eventual

result of this colm d ition, I decid ed to fo llow all cases seen in one im ospital in a given

l)eiiOd o f tim mm e. 1\Ioim mm t \Vilso im StateHospital w as selectedl-a m m m o( e rn, effic ientinsti t imtiomm I1C11 ’ B altnm m ore-in wim icli patiem its of all ages witim all degrees of tuber-

etm losis are t.i’e ted . T im e c ale nda r year of 1956 wa s cim osen, am m d all i)atients w ’itim

tim e frozen-sim oulder syndronm e w im o w eme seen by m e in tim at period were included

im mtllC SeI d’S. rFimis obviously m m m eant, in a( mrOImie colm (h tion SU (im its tim is, tim at som m m e

l)L tiem m tS first had d istress w it-im their shoulders in 1955, otim ers colm tinue( to have(Iiffictm it-y om i im m to 1957 , but all im ad been afflictedto soim m e degree im m 1956.

T im e m mext PI’oblem mm“itS to clarify w im at wa s to be im melU( e( U n(lem ’ tim e term im

f IOZCFi S/lOl4l(le1 \lany patieim ts im ad paim m and soim m e d egree of stiffim ess w itim out real

“freezim m g” ever developing. T im erefore, an arb itram y nm im m im m ium m mof 50 pei cent lm m ita-t.iom m of scapuloim uim m eral nm otion was set ; tim is w its furtim er (lefined asinability to

iti)i Uct tim e sim oim ltler eitim er actively or passively beyond90 degrees . T im e grad ingof pemTclmtage o f s tif fn es s wa s necessarily rough because factors lik e a pp re im em m sio n

and iaim m cOU l(1 im ot be excluded , i)ut w ith l)ractice a fairly accurate estim ate could

i)e m mm ade.

In (l(lI1’fl CC

Tvem m tv-m mim m e im atiem m tsvitim at least 50 i)(’1 cent hinm ita tiom m of sim oulder m otion

\ e1.e seem m im m 1 956; isevelmimad bilateral lim mm itatiom m. Tim erew as tim us a total of thirty-

six sim oul(lers. M ost renm arkable of all, and a trii)ute to tim e advantages of study in

it tul)erculosis sam m itaniunm , all patiem m ts were follow ed for at leasts ix m mm ontim s, om

ummt- i l l(COVd’VV.

1m m 1 956, tim e average d aily cem m sus ofthe im osl)ital 408 patients, so tim e

i)i’OI)iti)ilit.v of frozen sim otii( ler 7. 1 per cen t. per patient. year. T im e averageim O sl)it-ttl s tay w as 277 days, so om m iv 904 patieim ts were in tim e im ospital during tim e

e r, sotmme fo r s little as a (i y, soim m efor tim e entire year. Countim m g tota l Patiem m ts

for 1956, tim e ilm ci(le lm ce of frozen sim oul(ler 3. 2 ier cent.

. lqc

‘T ’im e I)tttid’m mtsvitlm frozem m sim otliders 1 m m ged in age from m m t-im irt.y-sevem m to sixty-

eight ve l om m lv om m e va s under fort , and only tim ree over sixty years old , w itim

t ime a ve ra ge b e i ng 50.8 years. In tim e hospital at large tim e average censuswa s 17 0

V O l.. 4i-A . N O . 5. JUL Y 1959 87 7


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87 8 J . T. H . JO H N SO N

i)atientS in tim e group of patients forty to sixty yearsOld . A s our series sim ow edtw enty-five iat-ients in tim is age group , tim e average incidem m ce per im osi)it-al year

in the forty to sixty-year group w as 14.7 pe r cent (nearly one case in six . T im tim e

group under forty, tim e ilm cidenCew as a im m im m ute 0.55 i)er cent, am m ( im m tim e group over

six ty yeai , on ly 3. 7 l)e1 cent.

ex

In tim is sei es tim ere w ere tw enty nm en and nine w onm eim , show ing w im at. seem m m edi to

i) e it i)rel)olmderance of m en. Hovever, tim e im ospital averaged 67 ier cem m t m m m eim am m dl

33 pe cem m t w onm em m , so tim e final ra tio w as 7.3 per cem m t m m m en and 6.6 ier cem m t wom m m en.

Side of B od y u’ith Sh ould er L esion

It w as believed tim at tim e side of tim e bodywith sim oulder stiffness m m m igim t be of

significance. H ow ever, in this series tim ere w ere seven patients affected i)ilaterally,

ten patients w itim tim e lesion on tim e righ t side, and tw elve with tim e lesion on tim e left

sid e, g iving seven teen (47 per cent) rig lm t sim oulders and nineteen (53 pcI’ cent) left

simoulders.

A ” - de o f B ody w ith P ulm oiw ry L esionrFler are num erous tim eories that l)eriartim ritis of tim e shoulder is related to

reflex neurological c im anges stim ulated by a tim O logica1 changes elsew im ere. Follow -

i:m g tim is line of thought, it w ould be logical to expect the patim ological c im anges to

predonm inate in an area w ith the sam e general reflex arc as tim e affected sim oulderandit wa s anticipated that tim ere would be som e correla tion of tim e side of tim e body

w itim tim e lung lesion w ith tim e side of tim e body with the affected shoulder. Instead,

it was’ foun d that tim e m ajor lu ng les ion s w ere on tim e sam eside as tim e frozen sim oul-

tier in only 13 per cent and were on tim e opposite side in 27 per ceim t, w im ereas tim e

luim gs w ere equally affected or botim sim oulders were involved iim 60 per ceim t of tim e

Patients. T im e a parent predilection for the opposite side was m m ot considered to bestatistically significant in this sm all series, and it w as felt tim at tim e figures slm owonly tim at. tim eSidle of tim e body w ’itlm the lung lesion is not im portant.

S cverittj of Lung Lesion

Tim ere ’as, Im ow ever, a definite correlation between frozen shoulders am m d sever-

ity of tim e I)uhlm onary tuberculosis. In13 pei cent of our patients the tuberculosis

w as m ild ; in 35 per cent, im m oderate ; and in 52 per cent, severe .

I)ura tion of H o spita liza tion

Sinm ilarly, tim ere seem m m ed tobe a definite connection between tim e lengtim of im os-

Pita lization and tim e onset of sim oulder sym ptonm s. Only 21 per eem m t of tim e l)a t-ientsim ad onset of sim oulder sym ptom s in tim e first tlm ree nm ontim s of im ospitalizatio lm ,58 per

cent in tim e tim ree to s ix-m onth period, and 21er cent after six m nontim s. It is inter-

esting to note tlm at none of the patien ts, except two tram m sfers froim m aim otim er s m m i-

tariuimm , Im ad frozen sim ould ers before adnm ission.

It is tim e gem m eral policy of tim isand other tuberculosis im osp itals to put i)atielm ts,

especially tim ose witim severe or nm od crately severe lesions, on relative h)e(rest fo rat leas t tim ree to six im m ontim s. Excessive exercise is discouraged,alm dl so im met-u mm es o ver-

em phasis oim rest and d ire predic tiom m s of tim e consequences of activity i nee(le(l

to restrain recalc itrant patients.

A ll patients’ w ere receiving an tituberculosis drugs, and m any w ere receiviim g a

com im i)ination of drugs. Therefore , an accurate correla tion betw een any oim ed rug

an d frozen sim oulder w as im m m possible .

Froni tim e figures, it seenm s t-im at tim e debilita ted person of from forty to sixty

years of age, after three m nontim s ofi)ed rest, is tim e ideal candlidate for a frozen

shoulder.

T H E JO U R N A L O F B O N E A N D JO IN T S U R G E R Y


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I-’ItozI:x-smn)ULI)F:It SYNI)RUME 87 9

( ‘llfltC (tl ( o urs e

I v s eager to fohlow t-im (’sep ti(Im ts to see im ow ’ their (inm icai course aim d (11(1

1(’S tm lt.s (onhi) r(’d vitim tim ose Pitt iem m tsvit.im frozen sim oulder seem m eisevim ere. Fort.u-

Im teiV, :tll of timd’Se pa t ielmtm 1e((’ i ed P1it(t i ( i tl l t l ie sa imme t I ’tt im m eim t- for tim eir sim otm i-

(1(15. ‘F im is treat.im meim t wam essem mti ilv l s. e faire o r W ’ tc im ft1 l \\‘a itilm g-J tis t- sylmip-

t-O IIitt iC Iii( iie t-io im li( I occ siom m :tl iti)i)hicitt iom m of im e t-5 () t i m at. t i m e im tiim ’a1 c()l1 eof tim e (olm (iitio lm (0111(1 i)(Oi)S(1V(’d. Fim( i ) 1 ’ l I l i i t I l ’ i)i)ro cim \\‘ 5 to r( 5St1 l’C tim e

i) t i(1mt audi to eX pl ifl tim at ait.im otm gim tim e com m ditioim m m m igiit\\ 1m ieIm i)efore iI1mJ)1()VIIi(1(1it-I1 l 1’(’(O\’(’1 ’ \V.tS i)1 t(t I(ill ly (( 1 ttilm . I t. W ’itS (‘V eIm 11101C V tltlitl)i( t0 1 ’(’f(1 t i1(Iim

t ( 1 5 O I I1 ( (f li ( oim t im (’i1 W 1( I oi lIst. ( lov im t I ie I m al 1, v imo iiit( I 1 ’o\ d froum tim e sanm e

o lm lit i on .

1 t\’Si(iti tI m(’l’t Y \\‘as im ot a \‘iti la i i’ at. fi 1s t :tli I ‘ S imot 1 e( 1 t1 (’ St e( I t iiCI(’it f t e r,its t m e Patiem m ts seenm e(l to i)e ( onm g w ell. Cortisone\\5 (lecided gaiim st fo r t im(’se

I )tt ielm t S \V it ii itC t 1\’( t i i i ) (‘ 1 t 1 lO S i S . A.l 1 i)tt ieimt 5 r im t im e (t.1V(’ im m f1 iim tm m t-o ri’ i ) iiits eof meriart ii lit IS \\‘(‘1 ’ t(I\’is(’ I t o liSP t I 1(11 1 I1m S S 111t1(Im S i)O SSii)le iimimmot ions t hat

l i l i m o t i m u rt - , i ) t I t im ot .t o t r y i i n ft s t r et eh ii mg . 1 t i en ts i i m ti me im ea li im g i ) il ase \ \‘ m e

( 1\’is((l to (to, m m (1 sim ow ]m im o to (10 , \V hl eiilm m i)nm g. m ’O l)e uilim m g, l 1( ut-her (‘X(’F-(iS(’S, i)tlt. t imel(’ \\‘ s little (olm t 101 d)\’(i imO’tV \\‘eil tim ese (Xer(iS (S \v(’l.e ( O m m (

( )i )j( ‘C t i \’ e e\’:tit1 t ion w’ s )111ii 11 ly ( olm e( rlm e( \Vit ii t lit lum mit a t-io im of niot.iom m

i tS5O(lit t (‘( I i t 1m t Im t frozem m -’.l m olm l( 1(15V11( I 1 1ii( . .-c(or(Inmg to IIt (Vititlitt iOu , iiit.w (’Im tv-six sim oul(lers (72 i)er cent of those ilm \’OlV edI tim erewas, at vorst , 50 to 65

l)(1 ((Im t hinm it :ttid)Im of glem m oim unm er l im m ot i on; in four sim oul( te l’s ( I I i ‘i (‘elm t t t 1\ its ( to 80 per cent liinita tiom m ;and im mfive sim oul(iers I 6 per cem m tt there w:ts over

80 m ( 1i t. I oss o I ’I I m o t iomm

I im t-il( itve ritge frozeim mOlli( l(1 t ii(’rC 1 ( t W ’() silii )i( am m (l( list ilm (t- (iilm ical

I )i l 5(5----O1ie of ilm (lC:tsiIig I) 111 1n I st i f I ll(’ss, 1i( I om m e of gra(h tlaily tl((r(’ siIm g pitinitmm( stil’flmems. .A . l t i i o tmu imt ime ilividing line is m m ot- i)rup t., n io st. i)at-ien ts ar e itl)lC to

F((O glm iZ (, \ it im iim \\-( .5 w’hm(’lm t ime t-i(l( tu rlm e(l um d i1 im pro\ lim e1it stitF te(l.

Jim t his 5(1’1e5. ilmel’d’itsilmg I ) i1m itiid s t i ff ll (5 5 hitste(1 1(55 than tb ree m ouths im mO lm i\’ foil I’ Ett.ieflt 5 t 1 4 l)(1 ((lit t ; OV(I foti mit m oim t im s in om m lv tlm ree i)itt ieim t5 1 1 0 er(‘(‘lit- t ; lm d tim ree to four im m oim t his iimtw en ty-tw o i)atiem m t-s ( 76 ler cem m tt

‘lime ( htii tt iom m of ( 1(’ere silm g sti ulim ess s iUtI( l(’l’ to evaluate as sonme patients

\ ‘s ’O tl l( si lO \\ ’ s li gi m t.i l imi )1OVeI lmeImt . . (‘S ((iitily ri m r i t lmge o f nmot io im, f o r n m ny nm oim t i i s

it f ter good ftm lm ctioliiti reeov(’rv Iut I i)eem m t t:tiIle( I. Event tm aiiy . a )O ilm t \\ se -

i((td’( I t . \vim i(im tI m e )itt i(I it was fl() l oim gt’ r S ig lm ific flt iv hot iRre( liv t im e llii um( l

t15(( it. freely. lim is tm SlU thl\’ (oincide(i vitim t ie st 80 per ((‘m m t ofim ornm al rium ge of

miiot-iomm.

I mm fi ye i)tt i emm t5 ( I 7 i (cut. tI IC ( 1iii t lou of (I((re si1m g sti lllm (’ss to relative

r(’(OV(IV \\‘ S 1(55 t Im im t I mee i m m o im t h i m .I Im s e\ m utt iem m ts (24 l er (‘elm t t it. was greater

tim aim four n mo im t i ms . ; : t n m. lm o ev e r . f o r t ime 1im JOrity. s e m m t e e m m i) tieIits (59 i)(’m

(elmt.) . tim (’ (lllF ittiO li W ’ 5 tim le( tofour nm oim tim s.

ri m l1s tim e to t iti (lii rat iom m oft im ( ’ ( O li di ti O lm \ itS um m(Ier six nm oim tim siii fou r p t ieimts

( I 4 pe r (‘(‘l it-) , six t o eigl m.I mm oim tim s in t. w’e im ty -o im e i tient 5 1 72 )(‘1 ed it t {149}lm ( I OV(’Ieight. l m m ol m t ii s i l m four l) tielm ts 14 pe r cc imt t

Iii( V l t1 t iO1m of t ime f1 li i Iem ”m tlit is im ’m omoi imevim a t. iim ccu r:tt-e s SO 1iiC J) ti(m m tS

\\‘(‘1 iitSt 5(’(’Ii O Im iV SiX to (‘igi I t. m m m olm tiS after ()lis(t. of tim eil’ syl1i tO lim s. 1 im tii(’Se a

f i i md i l mg o f 80 i ) ’ 1 ‘ l i t - of 1m OI ’1 im i lml ot io li \ t’ Ot li l 1 i ) i) ly , u m a f 1 i i ’ I i i o l m t i m s .

(1 m am m ge tti 90 01 I 00 )(‘I ((‘lit . :\. few . ot im er I)a t ie lm tS \\‘ere fohiow’ed closely for m m m c

Ii mommt- imm-t0 Ve t 1 1)(iOl t Im ev m it tai 1i(( I Sat isf ct orv nm ot iou ; t.im e\\‘(l’e t I m em ( h is -

(im rg(’(1 110111 1 1 1 1t i m 1 O i ) S ’l i t t iO 1 m .

I (litSslfi(( tim e fiim :tl r itng (’ 0 1 Iim otio lm in s iX t(’(’I i sim O lIi(i(’ls (4 4 pc i c’liti to he 95

- 1 Ut) i ‘l (elm t. of noi’nm :ti ; fo ti it ((‘Ii si m l Ii( 1(15 t 39 1 ‘ l’ ( ‘( ‘l it ) t ( I e 90 t i 95 i 1’ (elit (

I1o1’Il m:t1; bit 1 I I i e1 (‘(‘lit t t o i )(‘ ) ) (‘ l’ ( ‘( ‘l it : t11( 1 t \V d) si m ( i tI l( 1 ( 15 I 6 1(1 (‘(‘lm t t to I fl

70 i e 1 (‘(‘lit . Ti i(’S( htst- t vo si m olll( 1(1’s\V (1 ’( (‘011 1 )i i(’itte( I I v 51 1 lgery ; one Pitt ant I m a I

it. i)fl)lm (im O (’tlt.ttIleO tlS f1stUl vimiclm il ( I ( ‘O lmmi )i(t ( l ’ S(’ 1 ’l’((l ( OW ’Im his scapula, lm (I

oim e l)ttt-ie lit- im ad tim oracoj)lastv oim tim e affected side .

V O L . 4m -A. NO . 5. JU LY 1939


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88 0 J . T . H . JO H N SO N

Sub jective C lin ica l C o urse

The second m ajor clin ical c im aracteris tic of the frozen-shoulder syndrom e is

tim e purely subjective one of pain . T im is isvery hard to evaluate accurate ly but

m ost patients can be classified ra tim er easily as having m ild, m oderate , or severe

pain . A lm ost a ll patients w ill have pain on stre tc im ing or strenuous use of tim e in-

volved arm . M ost patients have fairly com fortable use of tim eirarm s during ligimt

activity, w ith the elbow near the side . Therefore , pain at rest-particularly at

nigh t-was felt to be a m ore accurate gu ide of tim e degree of severity .

A ll patients were asked about nigim t pain. If tim ey rare ly lost m m m ore t im an an

hour’s sleep because of pain, the painw as classified as m ild. If tim ey lost one to

three hours’ sleep for one to three weeks, pain w as considered m oderate . A nytim ing

worse than this w as classified as severe .

When this criterion w as used, fifteen cases (52 per cent) w ere considered nm ildl;

five cases (17 per cent), m oderate ; and nine cases (31 per cent), severe.

L ocaliza tion of P ain

A ll patients w ere asked to localize tim e areas of greatest pain andteimderness.

Alm ost all sa id that the pain m oved about, som etim es w orse on top of tim e sim ould er,

som etim es over the la tera l part of the sim oulder and upper part of tim e arm m m , and,

occasionally , in the forearm . The m ost com m on area was the la teral portion of

the upper part of the arm , near the delto id insertion. Tim is also seem ed to be tim e

area of m axim um tenderness in m any patients, altim ough m ost, especia lly tim ose

whose pain w as in the acute phase, had tenderness in m any areas. T im e bicipita l

groove w as frequently tender but rarely m ore so tim an other areas, including the

nearby coracoid process . B iceps-tendon tests gave no m ore positive results tim an

other tests that put s tra in on an acute ly inflam ed shoulder.

Psychological Reaction

M ost authors have noted a high corre la tion betw een nervous and em otionally

unstable persons and frozen shoulder. C oventry even w ent so far as to describe a

“periarthritic personality”. To evaluate th is aspect I exam ined the patien ts’ chm arts

for a history of neurotic or unstable beim avior either before or during im ospita liza-tion. In addition, the patients w ere asked to evaluate their own nervous beim avior

-whether they were im igh-strung, tense, or subject to frequen t m m m alad ies. It was

realized tim at hospita liza tion for tuberculosiswa s an unsettling experience, how -

ever, a ll of these patients w ere hospita lized and m any actually were re lieved of

anxie ty by having som ebody else look after them .

W hen both the m edical evaluation and tim e patien t’s ow n in terpretation w ere

used, fourteen patients (48 per cent) w ere class ified as im aving stable personalities,

seven patients (24 per cent) as being m oderate ly stable , and eiglm t patients (28 per

cent) as hm aving basically unstable personalities . I fe lt tim at in thm is series there

w as no such thing as a periarthritic personality , and t.im at tim e m m m alady could develop

in anyone, w im ether em otionally stable or unstable.

There was, how ever, as m ight he expected, a definite corre la tion betw eem m i)r(

vious em m iotional instab ility and the patients’ nervous reactions to tim e frozen sim oul-

(her. Of tim e eigim t patients c lassified as em otionally unstable ,five im ad severe

nervous reaction s totheir shoulder sym ptom s, and three im ad im m oderately severe

reactions.

A lso, as nm ight be expected, therewa s considerable corre la tion between degree

of pain and nervous reaction. Of tim e nine patients w hose pain was class ified as

severe, six h m ad severe nervou s reaction s ; one, m oderate ; and two, im m iid . The ques-

tion alw ays arises w hetim er it is the pain that causes the nervous reaction or tim e

psycim ic elem ent that increases tim e apparent pain. T im is is, of course, im possible toanswer, but it can be noted that of tim ose patients com lam ning of severe pain, only

tw o had severe objective s tiffness; thm ree,im m oderate stiffness; and four, m ild

stiffness.

T H E JO U R N A L O F BO N EA ND JO iNT S U R G E RY


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FR O Z E N -S H O U LD ER SY N D R O M E 88 1

It is m y opinion that even tim ough the incidence and objective sym ptom s of

the frozen-s im oulder syndrom e are not directly connected to tim e patient’s tem pera-

nm ent, tim e sub jective sym ptom s are . Sin ce im ervous people, com plain ing of great

I)a in, m ake the greatest noise and fuss, the erroneous im m m l)ressm on im as been created

that t.im ey form the great m ajority of sufferers.

P reviou s S hou lder P ro blem s

A ll patients w ere questioned ai)outprevious shoulder problem s in an effort to

see if tim ese could be initiating or predlisposing factors. A relm iarkab le feature that

evolve( from mm tim is s tudy was tim e rela tivelack of shoulder difficulty in tim e m onths

O r years reced in g tim e onset of tim e frozen sim ould er . O f twenty-nine cases only one

1)atient hiadi a clear-cut im is torv of 1)um -sitisw ith calcium dieposit. O ne im ad had areceim t vrist fractu re v itim pro i)ai)le sinm ultaneous contusion of tim e shm ouider. Tvo

i)atients im ad tim oracopiasty ; one sim ortly after tim e onset of sim oulder syim m ptonm s, andone w im eim tim ( frozen shm oulder seem mm edto he ilm m 1’oving. In botim i)atients tim e sim oul-

dci’s becalm m e coim siderably w orse for several m m m ont-im s ; one im ad ttiberculous osteo-

im m vehit.is of tim e tll)l)e m m m etaphysis of tim e hunm erus of the involved shoulder.

I w as inm pressed i)y tim e lack of anyhistory of cim ronic disability of tim e shoul-

der as w ell as tim e lack of recent disease or injum ’y tim at could im ave triggered the

onset of tim e frozen sim oulder. Som e of tim e patients oim w im onm pulnm onary operations

w ere perfornm ed (luring tim e course of tim e active inflanm m m m ation w erem ade worse,

just as sonic patien ts are m ade w orse byill advised m anipulation or too vigorous

pim ysical tim erapy.

R oentgenogram s w ere m m m ade in a nunm her of cases and in general show ed only

im m ild osteoporosis and tim e so-called im igim sim oulder witim tim e im unm erusrid ing a little

im igim in tim e glenoid, and tim e space betw een tim e acrom m m ion and the head of the

hunierus sh ig im tly dim in ished.

A ssocia ted S tiffness in O th er Join ts

Soim m e diffuse stiffness in tim e fingers developedin six patients, in the sam e side

as tim e sim oulder invo lvem ent.. In tim ree tim e stiffnessw as quite severe; these cases

could he classed as ty m cal of tim e shm oulder-im and syn(lrolm m e. A s usual in these

cases, tim e im ands lim i)ered up nm ucim im m ore slowly aim d less com m m pletely than tim e

slmoui(lem’s.

Tw o patiem m ts 1111(1 i m iild sveh iing and st.iffim ess of tim e knees and tw o im ad cim ronic

back Pain . One m m m aim im ad synm ptom m m s of m m m ild gener:tiz(’(I rim eulim at.oidl artim ritis w ithm

occas ion al sw ollen joints . O n e Patiem m t im a( hu iater:’i 1)up uytren’.s contrac ture an d

one, a trigger-tim uim m i). In general, im ow ever, tim e frozen shoulder seem ed to be a local

condition ratim er tim an part of a systenm ic rim eum m m at-ic reaction.

Other J)iseases

Al l of tim e patiem m ts w it.im frozen sim oulder oi)viously im a(l Pulm onarY tuberculos is

of greater or lesser d egree. Several im ad pullm m on ry conm phications such as em -

im ysenm a or enm pyem m m a. A fewim ad nm inor car(Iiac conditiom m s. In general, how ever,

there w ere few other colm m piicating diseases an(1 no evidencetim at any influenced tim e

shoulder condition, except in tim ose few I)atielm ts, j)revioU sly m m m entioned, w im oha d

t.im oracic surgery and infection in tim e sim oulder-girdle area .

m Subfrozen Shoulders

1\-Iany patients colm m l)laine( of ach ing and frequeim tly of som m e stiffness ; im ow -

ever, their shm ouiders coim ld not i)eincluded in this series because 50 per cent him ita-

tion of m otion was never r eac imed . A lso, of t ime tw en ty-tw o p atien ts in tim is ser ies

w ith only one frozen shoulder recorded as such, six im a( som e (legree of pain and

stiffness in the opposite sim oulder.

It is apparen t t h a t no t on ly 10 we no t know tim e cause oft h i s con(lit-ion, bu t

V O L . 41-A . NO . 5. JU LY 1959


6/6

88 2 T. II. JOH NSO N

‘ e calilm ot l)rd (liC t hm ov SCVCi’( tim e coim ditm om m will i)eco im m e or w ’im etim er it. ih l d eVd’lOl)

at all.

C O N C L I.’sI()N 4

1Tim is stt1( IV 1)rilm gs out. S(\’(l l com m vnm cnm g st atist al t’oim eiusiom m m ’ of )Ositi\’d’

lma t U cc

I . F im e im ig ii im m ci(IeIm (’e of frozem m sim otilderi m m a t ti l) el ’( ’U i d) Si s S 1mit. I i tm1im.

2 . Time great. m m m aorm ty of p tiem m ts were im m tim e itgeg lolli) fol’ty to sixty yciti’s.

3. Flit o im set is gelm erm tiiy t imlee to six l imolmtlms after dlm m ission to im osl)ititi am m (after r o io Imged l i)d’(I lest.

4. Fi l (’ l ii it 0 1’ it V of (‘ S(’S d)(’(’U 1l’e(I in ) t i(’lm ts it I m f i il s(’VeI’(’ ii mi mg lis ea se Im d gelm er l (Iei)m hity.

5. T im e (‘iilii(’tti (‘O tII’S ( is f irlv ioim g, hut 1ehtt ively m m m m i(.

6. ‘Ii m e eta I 1’(’sults ttl goo( ( lespite am m im m im m al t im el l

Ilm(’I’e 1 ’ itlso S(’V(i1 l (‘olmvnmcilmg d’ommclus iomis of a m m eg tive 1m tlm l’(’. lT im el’e is:

I . N t) sgimif icammt v ri tiom m c(’or(hiIm g to sex .

2 . N si gim i fleant- pr(’( m led’tiom m for shm oul( Icr lesiona(’eoI’( lnm g to a at it i(’tll al-il( ( d )f tim e b o d y.

3, N o sig lm i fic:um t correlation vi t 1i pt1h1lmolm l lesioim (’(’Ol’( hu g t o :t I it It ieiihtm’S1(Id of tue bod y .

4. s iglm ific Im t. d’orrela tiolm m t im previous s im otlid(l’ s lIm pto1m m s.

.5 . No sigm m ifiem tnt (‘0rrel t iom m \\‘it ii i)itt m em m ts Im (’l’\’OtisI’( (’t m o m m()1’ t I l (’ ) (‘ 1’ i l ’-

t iIl’iti(’ p ’ r s o n a i i t .

( ‘OMMEN’l’

1 i 1’tim litis of tim e sim otihier iim tim e 1) tiem m ts. seem liv lim e. 15 l)l i)itI)lY ( tI(’ to

I ) . I l’est alm( I reiittive (lisuse iim a ( e i)i lit at e(1i)(’lSOIm v imo is itt. t lie ag e w ’h me im m m orm m ia l

( egemmerative (‘imanges I’ ( O (’ (’ Ul ’I ’i im g jim tim e sim ouh dem ’ cufi’ am md otim er stru(’t-ures. Tlmere

l lm:tV I)e aim eim docrnm e factor asth is is tim e o-(’ lied m m m em m oi)umsal p(’rio( , m tim d t im e

( Iei)ihit. t(( patm (’m mt l)I’O l)iti)iY hats, iim a(I(IitR )Im , a(Irem moco1’t-ie l iim sufficieim cv. _A .m mt-i-

t.lm i)(’m ’(’U lO sis m m m e(Ii(’atiom m (‘0111(1 he afac tor, bu t- m m o evi(Ieim(’e for timis fouimd.

Pi’evem m t i \.e tre t ii m e m m t, ( ‘ om m s m s t m1 m g1I Iegti I r a I’lil exer(’m ses for tim e l)at.iem mtS forty

to sixty \‘(‘ l’5 01(1 v lmo i ’e om m bed rest, should be com m si(Ier(’(l.

R EF ER E N C ES

1 . ( VEN’r l (Y, \I . B . : Pm oi)l(’m mm of P mm inful Sim olm l(l(’m ’.J. .A .m mm \I(’m l. 15 1 : 177-155. 1953.2. 1 )F -m.tm . - ‘ . . . I” . : S tim ’ger(’ (m f t Ia’ S lm otm ldem ’. 1 m ilm mdeli im mm mJ. B . I p (m n(’m )t-t, C o., 19 50.3 . iI N .1_I)I . ( ‘ . : I m l i m e m ’m m mm ’t-i t (‘ (lellmm s m m m i lm te 1 m m s m n (l m ’o m m m e s m m m l lm t -m n m m m m om l c om ’somI i t n i ) (‘ m m’ lm l os m

l m o ll m m o m lm m m ’ (’ . R ( ’t m m m 1 m m tm s mo. 8: 71-81 . 1956.4 . FRAN K i.I N . i . c’.. mln(l NF: m 1K , I. J . : m o1m l(l(’m - I ) vsfunctioim in im mm lm mmm mm mm -yFim i )(‘m m’lm iosm s.

. ii. J . M (’(l. ‘1(’11(’(’5. 227: 601-608. 1954.5. 11 Ii.Kl-.R, .\ - . : ‘lim e Shouldei’-H m m n(l Svndm ’om m m e : A (‘o mm m mlim ’m m to n o f( ‘ mi-mmnmm m-v. m t ‘i-v I )mse:mse.

.m mm m. Im mt. I’l., 31 : 303 -311 , 1949.

T H E JO U R N A L O F BO N E A N DJOINT S U R G E RY

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