Lessons learnt from the painful shoulder; a case series of malignant shoulder girdle tumours misdiagnosed as frozen shoulder
© Quan et al; licensee BioMed Central Ltd. 2005
Received: 01 November 2004
Accepted: 12 January 2005
Published: 12 January 2005
Adhesive capsulitis or frozen shoulder is a common condition characterized by shoulder pain and stiffness. In patients in whom conservative measures have failed, more invasive interventions such as arthrographic or arthroscopic distension can be very effective in relieving symptoms and improving range of movement. However, absolute contraindications to these procedures include the presence of neoplasia around the shoulder girdle. We present five cases referred to our institution where the diagnosis of shoulder joint malignancy was delayed, following prolonged, ineffective treatment for frozen shoulder. These cases highlight the importance of careful review of the radiology and the need for reconsideration of the diagnosis in refractory "frozen shoulder".
KeywordsFrozen shoulder adhesive capsulitis hydrodilatation distension tumour
Frozen shoulder was first described by Codman in 1934, as an idiopathic painful restriction in the range of shoulder joint movement, in the presence of normal plain radiographs . It is also known as "adhesive capsulitis", based on the presence of chronic synovitis and a contracted, thickened joint capsule seen during open surgery of the shoulder joint . It is usually a self-limiting condition, with a mean duration of one to three years . The natural clinical course involves an initial painful phase, followed by progressive stiffness, with a gradual return of functional range of motion . However, between 15 – 50% of patients have persisting severe refractory pain that is unresponsive to conservative management involving physiotherapy, non-steroidal anti-inflammatories and subacromial corticosteroid injections [5, 6]. More aggressive treatment options for these patients include manipulation under anaesthesia, arthrographic capsular distension (hydrodilatation), and arthroscopic or open capsular release [7, 8]. Hydrodilatation is commonly performed as treatment for frozen shoulder as it is minimally invasive, inexpensive, does not require an anaesthetic, and is effective [9–12]. The procedure involves insertion of a needle into the glenohumeral joint under radiologic guidance, followed by gradual distension of the capsule with a combination of local anaesthetic, corticosteroid and normal saline, until lysis of adhesions and capsular rupture are achieved . Arthrography performed at the beginning of the procedure by injecting radio-opaque contrast material into the shoulder joint is the definitive diagnostic investigation for frozen shoulder, and is associated with decreased joint volume and obliteration of the axillary fold and subscapular bursa.
Tumours around the shoulder girdle are uncommon causes of shoulder pain and stiffness, but often present with symptoms and a clinical history identical to that of a frozen shoulder. A strict contraindication to arthrographic or arthroscopic distension of the shoulder is the presence of a local oncological process. Such procedures may change the surgical management from being a limb-preserving resection to a forequarter amputation. In the past month, five patients have been referred to us with malignant tumours around the shoulder joint, all previously diagnosed as having a frozen shoulder. All patients had undergone prolonged conservative management and hydrodilatation, with persistence of symptoms. Two of the patients had also undergone arthroscopic surgery. The following cases illustrate the importance of reconsidering the diagnosis in refractory frozen shoulder and the value of a detailed clinical history and examination and careful consideration of radiologic imaging in assessing recalcitrant "frozen shoulder".
Adhesive capsulitis or frozen shoulder is a common condition that may affect up to 5% of the general population in their lifetime. Although the aetiology of frozen shoulder is unknown, it has been associated with diabetes mellitus, thyroid disease, ischaemic heart disease and various autoimmune conditions . Other causes of shoulder pain and stiffness that need to be excluded include rotator cuff pathology, arthritis, fractures, infection and local tumours [15, 16]. Arthrographic or arthroscopic distension with shoulder capsular rupture are effective treatment modalities in well-selected patients with refractory frozen shoulder symptoms despite intensive conservative management [5–7]. In a recent randomised, double blinded study, Buchbinder et al.  demonstrated a significant improvement in both pain and range of motion in patients treated with hydrodilation compared with arthrogram alone. However, absolute contraindications to surgical intervention for frozen shoulder include neurological abnormalities originating from the cervical spine, presence of infection, and an ongoing oncological process.
Tumours of the shoulder girdle are uncommon causes of shoulder pain and restricted movement. In most cases, they are diagnosed based on the presence of a soft tissue mass on clinical examination, as well as characteristic radiographic changes. Robinson et al.  suggested that younger patients with bony tenderness elicited by gentle tapping are more likely to have a shoulder neoplasm. However, in up to 10% of shoulder neoplasms, plain x-rays are normal, and these patients may present with painful limitation of shoulder motion that can be difficult to distinguish from primary frozen shoulder. Indeed, in one series of 140 patients with frozen shoulder referred for manipulation, 2% had a primary chest wall tumour . Misdiagnosis, inappropriate surgery and delayed therapy for shoulder symptoms due to malignancy may potentially have grave consequences. Our five patients had locally invasive malignant tumours, and received prolonged conservative and interventional treatment for "frozen shoulder" before the definitive diagnosis of tumour was made. In all cases of recalcitrant frozen shoulder resistant to conventional treatment, less common causes for shoulder pain and stiffness such as an ongoing oncological process must be considered. A detailed clinical history and examination is critical in the assessment of a painful, stiff shoulder. Plain antero-posterior and axillary lateral radiographs of the shoulder should be performed as a routine, and these films then require careful review by an experienced radiologist prior to undertaking any invasive procedures. More sensitive radiological investigations such as radionucleotide scanning and CT scanning or MRI should be considered when shoulder symptoms are atypical or progress despite invasive management, if there is suspicion of malignancy, or if there are any bony abnormalities evident on plain radiographs.
magnetic resonance imaging, CT: computed tomography, TSE: turbo spin echo, STIR: short tau inversion recovery.
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