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Traumatic arthritis shoulder
Traumatic arthritis shoulder
a) History
On empirical grounds, the patient is usually over 45 years old (never under 40, except if there has been a fracture).
The history is typical :
a trivial onset (injury or overuse). A trauma/overuse occurs, the patient experiences some pain, disappearing at first and then, after 3-4 days, returning and increasing every day. This is the starting point of the traumatic arthritis.
Traumatic arthritis shoulder (2)
We now have approximately two weeks to stretch the capsule, while we remain in stage I. If we are too late, the lesion reaches stage II and the treatment strategy has to be adapted accordingly.
A spontaneous evolution taking 9-12 months is described :
* during the first 3-4 months the pain and the limitation get worse ; the pain is constant, even at night.
* The pain gradually eases.
* The range of motion gradually increases.
The shoulder remains in stage I for about two weeks and in stage II for another four weeks. The probable evolution of limitation of movements is as follows :
* after 10 days : lat. rot. - 20° / abd. - 5° / med. rot. not limited
* after one month : -60° / - 20° / - 10°
* after 3-4 months : -80° / -45° / -15°.
At the end of this spontaneous evolution, the normal ROM has returned, even without treatment.
b) Treatment
There is no reason whatsoever why the patient should endure this spontaneous evolution. At any phase, there is a quick, effective therapy.
* Stage I : capsular stretching
we stretch for about 10', followed by exercise therapy and some self treatment exercises. Three times a week. After each treatment session, the patient should experience 2-3 hours of post treatment soreness. If not, then the treatment procedure was not vigorous enough.
* Stage III : i.a. injection with triamcinolone (4-5x)
(a good manual alternative : distraction technique)
It is most important to give the second injection before the pain flares up again, i.e. an interval of 7 days between first and second injection (the effect of the first injection lasting about 10 days), 10 days between second and third, 14 days between third and fourth and 21 days between fourth and fifth.
What results can we expect ? The pain markedly improves from the first injection (the patient can sleep again) ; the mobility increases after the third injection.
The physiotherapist's alternative is distraction. This is a pain inhibition technique, not a mobilization. It is given for 20' per session, 4-5 times a week, without exercises or home exercises at the beginning.
* Stage II : the distraction technique is adapted to achieve the desired result :
stage II+ : it becomes more of a mobilization
stage II- : the joint is now mobilized at the end of the possible range (there exist most suitable manual therapy techniques).
It might be interesting to note that in a traumatic arthritis the same errors are met routinely :
* not prescribing mobilization in the first two weeks (stage I), when it would be most suitable.
* Prescribing mobilization after two weeks (stage II), when it becomes less suitable.
* On injection therapy : awaiting the return of the pain before giving the next injection is merely an unfortunate loss of time.
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