Diabetes mellitus and accompanying hyperlipidemia are independent risk factors for adhesive capsulitis: a nationwide population-based cohort study (version 2)

Impact of open bursectomy and biceps tendon release with closed manipulation in frozen shoulder

This retrospective observational study evaluated the efficacy of 2 different surgical approaches for the treatment of frozen shoulder (adhesive capsulitis). This study aimed to compare the efficacy, safety, and recovery times of the 2 treatment modalities. Fifty patients diagnosed with frozen shoulder and treated at Seyhan State Hospital were included in the study. The patients were retrospectively divided into 2 groups based on the treatment received. Group 1 consisted of 25 patients who underwent standard closed manipulation under anesthesia, a technique involving passive movements of the shoulder joint to tear the tight capsule and expand the range of motion (ROM). Group 2, which included 25 patients, underwent closed manipulation in addition to open bursectomy and biceps tendon capsule release. Open bursectomy involves surgical removal of the bursa to alleviate inflammation, while biceps tendon capsule release addresses chronic biceps tendonitis by partially removing the capsule of the tendon. Data on demographic information, operative details, preoperative and postoperative conditions, and patient-reported outcomes were collected and analyzed. Data analysis revealed that the combination of closed manipulation with open bursectomy and biceps tendon capsule release was more effective in reducing pain, increasing ROM, and improving quality of life than closed manipulation alone. The discussion would typically elaborate on how the results compare with existing literature, the clinical implications, and any potential limitations of the study. The results showed that the method that combined closed manipulation with open bursectomy and biceps tendon capsule release was better than closed manipulation alone in terms of reducing pain, increasing ROM, and improving quality of life.

Type 2 diabetes and fasting glycemic traits are causal factors of frozen shoulder: a 2-sample Mendelian randomization analysis

BACKGROUND

The causal relationship between type 2 diabetes (T2D) and frozen shoulder is unclear. This study aims to explore the genetic causal association between T2D and glycemic traits (fasting glucose [FG], fasting insulin [FI], glycated hemoglobin [HbA1c], and 2-hour postprandial glucose [2hGlu]) on frozen shoulder.

METHODS

Using 2-sample Mendelian randomization (MR), we analyzed nonconfounded estimates of the effects of T2D and glycemic traits on frozen shoulder. Single-nucleotide polymorphisms (SNPs) strongly associated (P < 5 × 10-8) with exposures from genome-wide association studies (GWAS) were identified. We employed fixed effect mode inverse variance weighting (IVW-FE), random effect mode IVW (IVW-MRE), MR-Egger, and weighted median to assess the association of exposures and outcome. Sensitivity analysis was conducted to test for heterogeneity and multidirectionality bias in MR.

RESULTS

We found a significant genetic causal correlation between T2D (IVW-MRE P = .007, odds ratio [OR] 1.093, 95% confidence interval [CI] 1.03-1.16), FG (IVW-FE P < .001, OR 1.455, 95% CI 1.173-1.806), and frozen shoulder, but no evidence for causal correlation between FI, HbA1c, and 2hGlu and frozen shoulder. Although there was certain heterogeneity, sensitivity analysis reveals no deviation from the MR assumptions.

CONCLUSION

This study supports a genetic causal relationship between T2D and FG and frozen shoulder.

The Risk of Shoulder Adhesive Capsulitis in Individuals with Prediabetes and Type 2 Diabetes Mellitus: A Longitudinal Nationwide Population-Based Study

BACKGRUOUND

This study aimed to investigate the association between type 2 diabetes mellitus (T2DM) and shoulder adhesive capsulitis (AC) using a large-scale, nationwide, population-based cohort in the Republic of Korea.

METHODS

A total of 3,471,745 subjects aged over 20 years who underwent a National Health Insurance Service medical checkup between 2009 and 2010 were included in this study, and followed from the date of their medical checkup to the end of 2018. Subjects were classified into the following four groups based on the presence of dysglycemia and history of diabetes medication: normal, prediabetes, newly diagnosed T2DM (new-T2DM), and T2DM (claim history for antidiabetic medication). The endpoint was new-onset AC during follow-up. The incidence rates (IRs) in 1,000 person-years and hazard ratios (HRs) of AC for each group were analyzed using Cox proportional hazard regression models.

RESULTS

The IRs of AC were 9.453 (normal), 11.912 (prediabetes), 14.933 (new-T2DM), and 24.3761 (T2DM). The adjusted HRs of AC in the prediabetes, new-T2DM, and T2DM groups were 1.084 (95% confidence interval [CI], 1.075 to 1.094), 1.312 (95% CI, 1.287 to 1.337), and 1.473 (95% CI, 1.452 to 1.494) compared to the normal group, respectively. This secular trend of the HRs of AC according to T2DM status was statistically significant (P<0.0001).

CONCLUSION

This large-scale, longitudinal, nationwide, population-based cohort study of 3,471,745 subjects confirmed that the risk of AC increases in prediabetic subjects and is associated with T2DM status.

Prognostic factors associated with improvements in patient-reported outcomes in idiopathic adhesive capsulitis

Background

The purpose of this study was to identify prognostic factors that are associated with improvements in patient-reported outcomes measures (PROMs) related to upper extremity function and pain in those suffering from idiopathic adhesive capsulitis.

Methods

All patients treated conservatively for primary idiopathic adhesive capsulitis were identified from our institutional database between 2019 and 2021. Exclusion criteria included any patients treated surgically, follow-up less than one year, or incomplete survey results. PROMs including Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Computer Adaptive Test Version 2.0 (P-UE), Pain Interference (P-Interference), Pain Intensity (P-Intensity), and visual analog scale (VAS) pain scores. They were obtained at initial consultation and at one year to assess patient-perceived impact of their condition. Multiple linear and multivariable logistic regressions were performed to identify factors associated with improvement in patient-perceived pain and shoulder function using final PROM scores and difference in PROM scores from initial consultation. An independent t-test was used to compare baseline and one-year minimum follow-up PROMs. Odds ratios and their 95% confidence intervals were calculated for each factor; a P value of < .05 was considered statistically significant.

Results

A total of 56 patients (40 females and 16 males) were enrolled in the study with an average age of 54.7 ± 7.7 years. A significant improvement (P < .001) was demonstrated at one-year minimum outcomes for P-UE, P-Interference, P-Intensity, and VAS scores. With respect to comorbid conditions, hypothyroidism [P-UE (β: 9.57, P = .006)] was associated with greater improvements in PROMs, while hyperlipidemia [P-UE (β: -4.13, P = .01) and P-Intensity (β: 2.40, P = .02)] and anxiety [P-UE (β: -4.13, P = .03)] were associated with poorer reported changes in PROMs. Female sex [P-UE (β: 4.03, P = .007) and P-Interference (β: -2.65, P = .04)] and employment in manual labor professions [P-Interference (β: -3.07, P = .01), P-Intensity (β: -2.92, P = .006), and VAS (β: -0.66, P = .03)] were associated with significantly better patient-perceived outcomes. Hispanic heritage was associated with higher reported changes of P-Intensity (β: 8.45, P = .004) and VAS (β: 2.65, P = .002).

Conclusion

Patient-perceived improvements in PROMIS score during the natural history of adhesive capsulitis are likely multifactorial, with anxiety, hyperlipidemia, increased body mass index, and Hispanic heritage associated with reduced improvement in PROMIS scores.

Diabetes as a risk factor for the onset of frozen shoulder: a systematic review and meta-analysis

OBJECTIVE

Summarise longitudinal observational studies to determine whether diabetes (types 1 and 2) is a risk factor for frozen shoulder.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, Embase, AMED, PsycINFO, Web of Science Core Collection, CINAHL, Epistemonikos, Trip, PEDro, OpenGrey and The Grey Literature Report were searched on January 2019 and updated in June 2021. Reference screening and emailing professional contacts were also used.

ELIGIBILITY CRITERIA

Longitudinal observational studies that estimated the association between diabetes and developing frozen shoulder.

DATA EXTRACTION AND SYNTHESIS

Data extraction was completed by one reviewer and independently checked by another using a predefined extraction sheet. Risk of bias was judged using the Quality In Prognosis Studies tool. For studies providing sufficient data, random-effects meta-analysis was used to derive summary estimates of the association between diabetes and the onset of frozen shoulder.

RESULTS

A meta-analysis of six case-control studies including 5388 people estimated the odds of developing frozen shoulder for people with diabetes to be 3.69 (95% CI 2.99 to 4.56) times the odds for people without diabetes. Two cohort studies were identified, both suggesting diabetes was associated with frozen shoulder, with HRs of 1.32 (95% CI 1.22 to 1.42) and 1.67 (95% CI 1.46 to 1.91). Risk of bias was judged as high in seven studies and moderate in one study.

CONCLUSION

People with diabetes are more likely to develop frozen shoulder. Risk of unmeasured confounding was the main limitation of this systematic review. High-quality studies are needed to confirm the strength of, and understand reasons for, the association.

PROSPERO REGISTRATION NUMBER

CRD42019122963.

Influence of diabetes on response to ultrasound guided hydrodistension treatment of adhesive capsulitis: a retrospective study

BACKGROUND

Diabetes is associated with microvascular and macrovascular complications. Although it is less recognized, diabetes also has an important role in the development of musculoskeletal disorders. Our objective was to evaluate the effect of type 2 diabetes (T2D) on the severity of adhesive capsulitis of the shoulder (AC) and on the efficacy of ultrasound guided hydrodistension treatment.

METHODS

We conducted a retrospective longitudinal observational study, of patients with AC who underwent ultrasound guided hydrodistension at our Centre. Severity was measured with DASH (Disabilities of Arm, Shoulder and Hand) score and pain was evaluated with a score between 0 and 10. The association of T2D with baseline characteristics of AC, and with outcomes at 6-12 months was analyzed using linear and logistic regression models.

RESULTS

We evaluated 120 ultrasound guided hydrodistension treatments of AC, 85 in patients without diabetes and 35 in patients with T2D. Patients with diabetes had a higher prevalence of dyslipidemia, hypertension and higher HbA1c values. The average duration of diabetes was 4.8 years (2.0, 7.9). The baseline characteristics of AC were not significantly different between patients with and without diabetes. Patients with T2D relapsed more frequently and required more reinterventions than patients without diabetes (20.0% vs 4.7%, p = 0.008), had higher post-intervention pain scale values [4.0 (0.0-5.0) vs 0.0 (0.0-5.0), p = 0.022] and higher post-intervention DASH score [0.8 (0.0-1.8) vs 0.0 (0.0-0.8), p = 0.038].

CONCLUSION

Although baseline characteristics of AC in patients with diabetes were similar to those without diabetes, patients with diabetes had a worse response to treatment, more frequent relapses and a greater need for new interventions.

Usefulness of combined handheld ultrasound and fluoroscopy-guided injection in adhesive capsulitis of the shoulder: A prospective, randomized single blind-pilot study

BACKGROUND

Ultrasound is increasingly being utilized in the diagnosis and treatment of adhesive capsulitis.

OBJECTIVE

To compare the therapeutic effects and advantages of combined handheld ultrasound and fluoroscopy-guided intra-articular corticosteroid injection with those of conventional ultrasound-guided corticosteroid injection in adhesive capsulitis of the shoulder.

METHODS

A total of 39 patients diagnosed with adhesive capsulitis of the shoulder were randomly assigned into two groups. Group A patients (n= 19) underwent combined handheld ultrasound and fluoroscopy-guided corticosteroid injection and group B patients (n= 20) underwent conventional ultrasound-guided corticosteroid injection to the intra-articular space of the shoulder twice. Treatment efficacy was assessed at 2 and 6 weeks after the final injection, based on the verbal numeric pain scale, Shoulder Pain and Disability Index, and range of motion. Secondary outcome measures were the accuracy and procedure time.

RESULTS

Both injection methods were effective in the treatment of adhesive capsulitis. No significant differences in treatment efficacy and injection accuracy were observed between the two groups (p> 0.05).

CONCLUSIONS

This study showed no statistical differences in treatment efficacy between 2 groups. However, the combined use of ultrasound and fluoroscopy can increase the accuracy of injection compared with conventional ultrasound alone.

The Patient Acceptable Symptom State as a Predictor of the Sports Activity Available State After Arthroscopic Rotator Cuff Repair

Background

The patient acceptable symptom state (PASS) has emerged as a metric for evaluating patient satisfaction after treatment. There is little research on the relationship between sports activity and PASS values after arthroscopic rotator cuff repair (ARCR).

Purpose

To (1) introduce the sports activity available state (SAAS) as an indicator of whether sports activities are possible based on patient symptoms after ARCR, (2) investigate the correlation between the SAAS and PASS, (3) predict the SAAS using derived PASS values, and (4) identify factors for achieving the PASS and SAAS.

Study Design

Case-control study; Level of evidence, 3.

Methods

Included were 201 patients who underwent ARCR between January 2015 and December 2016. At a mean follow-up of 38.7 ± 7.0 months, anchor questions were used to classify patients as SAAS+ (sports group) or SAAS- (nonsports group) and derive the PASS values for the pain visual analog scale (pVAS), American Shoulder and Elbow Surgeons (ASES), and Single Assessment Numeric Evaluation (SANE). The authors analyzed the correlation and difference between PASS and SAAS acquisition, and univariate and multivariate logistic regression analyses were performed to determine factors for PASS and SAAS achievement.

Results

The final PASS values for the pVAS, ASES, and SANE were 0.5, 93.5, and 82.5, respectively. A significant correlation existed between PASS and SAAS acquisition (phi correlation coefficient, 0.647; P < .001). Sensitivity and specificity were >0.7 for all outcome scores when predicting SAAS using PASS values. A higher preoperative ASES score was significantly associated with achieving both the SAAS (OR, 1.032 [95% CI, 1.005-1.059]; P = .018) and PASS (OR, 2.556 [95% CI, 1.753-3.726]; P < .001). Diabetes (OR, 0.348 [95% CI, 0.130-0.931], P = .036) and a large to massive tear (OR, 0.378 [95% CI, 0.162-0.884]; P = .025) were significantly negatively associated with achieving the SAAS.

Conclusion

The authors found the SAAS to be significantly correlated with the PASS. Also, SAAS was able to be predicted using the PASS value. Patients with higher preoperative ASES scores had higher odds of achieving both the PASS and SAAS, and patients with diabetes and those with large to massive tears had lower odds of achieving the SAAS.

Evaluating whole-genome expression differences in idiopathic and diabetic adhesive capsulitis

BACKGROUND

Diabetic patients have a greater incidence of adhesive capsulitis (AC) and a more protracted disease course than patients with idiopathic AC. The purpose of this study was to compare gene expression differences between AC with diabetes mellitus and AC without diabetes mellitus.

METHODS

Shoulder capsule samples were prospectively obtained from diabetic or nondiabetic patients who presented with shoulder dysfunction and underwent arthroscopy (N = 16). Shoulder samples of AC with and without diabetes (n = 8) were compared with normal shoulder samples with and without diabetes as the control group (n = 8). Shoulder capsule samples were subjected to whole-transcriptome RNA sequencing, and differential expression was analyzed with EdgeR. Only genes with a false discovery rate < 5% were included for further functional enrichment analysis.

RESULTS

The sample population had a mean age of 47 years (range, 24-62 years), and the mean hemoglobin A_1c level for nondiabetic and diabetic patients was 5.18% and 8.71%, respectively. RNA-sequencing analysis revealed that 66 genes were differentially expressed between diabetic patients and nondiabetic patients with AC whereas only 3 genes were differentially expressed when control patients with and without diabetes were compared. Furthermore, 286 genes were differentially expressed in idiopathic AC patients, and 61 genes were differentially expressed in diabetic AC patients. On gene clustering analysis, idiopathic AC was enriched with multiple structural and muscle-related pathways, such as muscle filament sliding, whereas diabetic AC included a greater number of hormonal and inflammatory signaling pathways, such as cellular response to corticotropin-releasing factor.

CONCLUSIONS

Whole-transcriptome expression profiles demonstrate a fundamentally different underlying pathophysiology when comparing diabetic AC with idiopathic AC, suggesting that these conditions are distinct clinical entities. The new genes expressed explain the differences in the disease course and suggest new therapeutic targets that may lead to different treatment paradigms in these 2 subsets.

The epidemiology and etiology of adhesive capsulitis in the U.S. Medicare population

Background

Adhesive capsulitis (AC) of the shoulder, also known as frozen shoulder, causes substantial pain and disability. In cases of secondary AC, the inflammation and fibrosis of the synovial joint can be triggered by trauma or surgery to the joint followed by extended immobility. However, for primary AC the inciting trigger is unknown. The burden of the disorder among the elderly is also unknown leading to this age group being left out of therapeutic research studies, potentially receiving delayed diagnoses, and unknown financial costs to the Medicare system. The purpose of this analysis was to describe the epidemiology of AC in individuals over the age of 65, an age group little studied for this disorder. The second purpose was to investigate whether specific medications, co-morbidities, infections, and traumas are risk factors or triggers for primary AC in this population.

Methods

We used Medicare claims data from 2010–2012 to investigate the prevalence of AC and assess comorbid risk factors and seasonality. Selected medications, distal trauma, and classes of infections as potential inflammatory triggers for primary AC were investigated using a case–control study design with patients with rotator cuff tears as the comparison group. Medications were identified from National Drug codes and translated to World Health Organization ATC codes for analysis. Health conditions were identified using ICD9-CM codes.

Results

We found a one-year prevalence rate of AC of approximately 0.35% among adults aged 65 years and older which translates to approximately 142,000 older adults in the United States having frozen shoulder syndrome. Diabetes and Parkinson’s disease were significantly associated with the diagnosis of AC in the elderly. Cases were somewhat more common from August through December, although a clear seasonal trend was not observed. Medications, traumas, and infections were similar for cases and controls.

Conclusions

This investigation identified the burden of AC in the US elderly population and applied case–control methodology to identify triggers for its onset in this population. Efforts to reduce chronic health conditions such as diabetes may reduce seemingly unrelated conditions such as AC. The inciting trigger for this idiopathic condition remains elusive.

Hyperlipidemia Is a Risk Factor of Adhesive Capsulitis: Real-World Evidence Using the Taiwanese National Health Insurance Research Database

Background:

Patients with adhesive capsulitis are evaluated for pain and progressive contracture of the glenohumeral joint. Whether endocrine, immune, or inflammatory processes are involved in its definite pathogenesis is still under debate. Some cross-sectional studies with a small sample size have noted that hyperlipidemia is a possible risk factor for frozen shoulders.

Purpose/Hypothesis:

The purpose was to conduct a longitudinal population-based study to investigate the risk of adhesive capsulitis among patients with hyperlipidemia. It was hypothesized that patients with hyperlipidemia would have a higher risk of adhesive capsulitis and that the use of statin drugs could reduce the rate.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Using data from the National Health Insurance Research Database (NHIRD) of Taiwan, the authors obtained the records of patients with hyperlipidemia who received a diagnosis between 2004 and 2005 and were followed up until the end of 2010. The control cohort comprised age- and sex-matched patients without hyperlipidemia. Propensity score matching was performed for the other comorbidities. A Cox multivariate proportional hazards model was applied to analyze the risk factors of adhesive capsulitis. The hazard ratio (HR) and adjusted HR were estimated between the study and control cohorts after adjustment for confounders. The effects of statin use on adhesive capsulitis risk were also analyzed.

Results:

The NHIRD records of 28,748 patients and 114,992 propensity score–matched controls were evaluated. A higher incidence rate of adhesive capsulitis was revealed in the hyperlipidemia cohort, with a crude HR of 1.70 (95% CI, 1.61-1.79; P < .001) and adjusted HR of 1.50 (95% CI, 1.41-1.59; P < .001). Patients with hyperlipidemia who used a statin still had higher crude and adjusted HRs compared with controls. Statin use did not exert protective effects on patients with hyperlipidemia.

Conclusion:

Patients with hyperlipidemia had a 1.5-fold higher risk of adhesive capsulitis than did healthy controls. Statin use did not provide protection against adhesive capsulitis in patients with hyperlipidemia.

Updates on the treatment of adhesive capsulitis with hydraulic distension

Adhesive capsulitis of the shoulder joint is a common disease characterized by pain at the insertional area of the deltoid muscle and decreased range of motion. The pathophysiological process involves fibrous inflammation of the capsule and intraarticular adhesion of synovial folds leading to capsular thickening and contracture. Regarding the multidirectional limitation of motion, a limitation in external rotation is especially prominent, which is related to not only global fibrosis but also to a localized tightness of the anterior capsule. Ultrasound and magnetic resonance imaging studies can be applied to rule out other structural lesions in the diagnosis of adhesive capsulitis. Hydraulic distension of the shoulder joint capsule provides pain relief and an immediate improvement in range of motion by directly expanding the capsule along with the infusion of steroids. However, the optimal technique for hydraulic distension is still a matter of controversy, with regards to the infusion volume and rupture of the capsule. By monitoring the real-time pressure-volume profile during hydraulic distension, the largest possible fluid volume can be infused without rupturing the capsule. The improvement in clinical outcomes is shown to be greater in capsule-preserved hydraulic distension than in capsule-ruptured distension. Moreover, repeated distension is possible, which provides additional clinical improvement. Capsule-preserved hydraulic distension with maximal volume is suggested to be an efficacious treatment option for persistent adhesive capsulitis.

Prevention of adhesive capsulitis following pacemaker implantation: A randomized controlled study

INTRODUCTION

Gradual painful loss of active and passive range of motion in shoulder joint was introduced as adhesive capsulitis (AC). Disabilities in patients with AC are absenteeism from work, loss to leisure time, and recurrent seeking to health care services. The aim of this study was to evaluate the incidence of AC following pacemaker implementation. The effect of physical therapy and exercise education was also evaluated to prevent AC following pacemaker implementation.

METHODS

This study is a randomized clinical controlled trial. It was conducted on 62 pacemaker candidates. Patients with no shoulder pain and without any motion limits were enrolled in the study consecutively. The patients randomly were divided into two groups after pacemaker implementation. One group was treated with physical therapy (group A, n = 28) and the other group did not (group B, n = 34). The incidence of AC was assessed in both groups after 4 months.

RESULTS

A total of 62 patients were enrolled in the study. The mean age was 63.2 ± 12.1 years in the group A and 67.1 ± 17.6 years in the group B. Age was not significantly different between groups. A total of 11 patients (17.7%) had AC 16 weeks after the initial visit (two patients in group A and nine patients in group B; P = .004).

CONCLUSIONS

Incidence of AC is 17.7% following device implantation. Exercise education and physical therapy significantly reduces AC incidence following pacemaker implantation.

Is frozen shoulder completely resolved at 2 years after the onset of disease?

BACKGROUND

Although numerous studies have suggested that frozen shoulder (FS) is a self-limiting disease with most patients recovering within 2 years, its long-term outcome is still controversial. The aims of this study were to evaluate the clinical outcomes after conservative treatment for FS and to determine the predictors of its clinical outcome.

METHODS

This study included 234 shoulders of 215 patients who received conservative treatment for FS. The mean follow-up period was 41.8 months (range 27-117 months). Initial evaluation included demographics, detailed medical history, and clinical assessments of shoulder status. Questionnaires, which included the Visual Analogue Scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV) and satisfaction grading for the current shoulder status were assessed at the final follow-up.

RESULTS

The mean VAS pain score, ASES score, and SSV significantly improved from 6.7, 37.0, and 40.1% at the time of initial evaluation to 1.5, 87.6, and 85.0% at the final follow-up evaluation (all p < 0.001). According to satisfaction grading, the shoulder status at the final follow-up was very satisfied in 101 shoulders (43.2%), satisfied in 68 (29.1%), fair in 37 (15.8%), unsatisfied in 20 (8.5%), and very unsatisfied in 8 (3.4%). Univariate analysis revealed that gender, diabetes, simultaneous bilateral involvement, overall bilateral involvement and duration of symptoms were associated with clinical outcomes at the final follow-up. Multivariate analysis revealed that duration of symptoms (p = 0.002) was an independent risk factor for unsuccessful outcome.

CONCLUSIONS

At the mean follow-up period of 41.8 months, 72.3% of patients revealed subjective satisfaction for the current shoulder status. Duration of symptoms was an independent risk factor for poor prognosis.

Outcomes of arthroscopic capsular release for the diabetic frozen shoulder in Asian patients

INTRODUCTION

Diabetic patients have been known to have a higher incidence of frozen shoulder. Arthroscopic capsular release has been described for diabetic frozen shoulder refractory to non-surgical treatment. We describe our single-surgeon experience of this procedure done in Asian patients presenting with diabetic frozen shoulder.

RESULTS

Data were prospectively collected from 25 patients from 2007 to 2008, who underwent arthroscopic capsular release for frozen shoulder with diabetes mellitus. This included the University of California-Los Angeles (UCLA) Shoulder Score by an independent observer. Mean follow-up duration was 44.3 ± 22 months with the age of 57.3 ± 10.9 years at the time of surgery. Mean duration of symptoms prior to surgery was 8.9 ± 7.5 months. Ten right shoulders and 15 left shoulders were operated on. Arthroscopic capsular release was performed in the beach chair position with the aid of a 90° electrocautery hook, from the rotator interval to posterior capsule. Significant improvement was observed in the UCLA scores post-operatively (preoperative total score 15.8 ± 3.6 vs. post-operative 33.3 ± 2.5, p < 0.00), including all domains of pain (3.9 ± 1.8 vs. 9.4 ± 0.9, p < 0.00), function (4.8 ± 1.7 vs. 9.4 ± 1.4, p < 0.00), active forward flexion (2.6 ± 0.7 vs. 4.6 ± 0.6, p < 0.00) and satisfaction (0.0 ± 0.0 vs. 5.0 ± 0.0, p < 0.00). No significant correlation between duration of symptoms and UCLA scores. Significant improvement was observed in forward flexion (preoperative 100.4 ± 18.8° vs. post-operative 157.6 ± 15.9°, p < 0.00) and external rotation (preoperative 14.4 ± 6.34° vs. post-operative 63.8 ± 8.3°, p < 0.00). Although the duration of symptoms correlated significantly with preoperative forward flexion ( r = 0.443 and p < 0.027), there was no significant correlation with post-operative forward flexion ( r = 0.023 and p < 0.91). No axillary nerve palsy observed.

CONCLUSION

The diabetic frozen shoulder can be treated favourably with arthroscopic capsular release and the duration of symptoms prior to surgery does not affect the outcomes.

Defining subgroups of patients with a stiff and painful shoulder: an analytical model using cluster analysis

PURPOSE

The primary purpose of this research was to develop a classification system for patients with stiff and painful shoulders using hierarchical cluster analysis.

METHODS

Medical charts of 52 patients treated for stiff and painful shoulders were reviewed for descriptive and clinical data after completion of their rehabilitation. A clinician-reported outcome was derived from ratings of three members of the American Society of Shoulder and Elbow Therapists. Data were subjected to cluster analysis using the hierarchical method. Analysis of difference tests was performed to determine if differences between clusters could be found with either initial examination or outcome data.

RESULTS

Two clusters emerged from the clustering process: a healthy, strong, and mobile group of 32 patients, and an unhealthy, weak, and immobile groups consisting of 20 patients. Significant differences in initial examination measures between clusters were found for the presence of co-morbidities, range of motion for shoulder flexion, abduction, external rotation, and internal rotation, and strength of the shoulder external rotators and in the empty can position. Significant differences between clusters were found for shoulder flexion, abduction, and external rotation range of motion, and clinician-reported outcome at the time of patient discharge.

CONCLUSION

Patients with stiff and painful shoulders in this study were classified into two distinct subgroups using hierarchical cluster analysis based on demographic attributes and initial examination findings. The findings from this study also suggest that patients who may be at risk for a poorer outcome can be identified based on initial examination measures. By identifying these patients early in rehabilitation who have a poorer prognosis, improved patient education, alternative interventions or diagnostic tests may be utilized on their behalf.Implications for rehabilitationPatients with stiff and painful shoulders were classified into two subgroups using hierarchical cluster analysis based on demographic attributes and initial examination findings.Significant differences in mean clinician-reported outcome was also noted between clusters, with the patients who were healthier, stronger, and more mobile having a significantly better outcome than those patients who were more unhealthy, weak, and immobile.The findings from this study suggest that patients can be identified on initial examination who may be at risk for a poorer outcome.By identifying these patients early in rehabilitation who have a poorer prognosis, improved patient education, alternative interventions, or diagnostic tests may be utilized on their behalf sooner in the course of care.

Genetic variants involved in extracellular matrix homeostasis play a role in the susceptibility to frozen shoulder: A case-control study

Frozen shoulder is a condition of loss of active and passive motion as result of inflammatory contracture and fibrosis of the joint capsule. We hypothesize that genetic variants in genes involved in these processes such as genes that play a role in extracellular matrix homeostasis (collagens, glycoproteins, genes involved in TGFβ signaling, and metalloproteinases and its inhibitors) may contribute to the susceptibility to frozen shoulder. We evaluated eighteen SNPs of genes involved in extracellular matrix homeostasis in 186 cases (N_females  = 114; N_males  = 72) of frozen shoulder and 600 age-matched controls (N_females  = 308; N_males  = 292). Multivariate logistic regressions were carried out with age, gender, genetic ancestry, and common comorbidities as covariates. Carriers of the C allele of MMP13 rs2252070 and G/G MMP9 (rs17576 A>G/rs17577 G>A) haplotype may have an increased risk of frozen shoulder (p = 0.002, OR = 1.64, 95%CI = 1.20-2.26, and p = 0.046, OR = 1.40, 95%CI = 1.01-1.95, respectively), especially in females (p = 0.005, OR = 1.91, 95%CI = 1.22-2.99, and p = 0.046, OR = 1.59, 95%CI = 1.01-2.51, respectively). In females, the G allele of MMP9 rs17576 tended to contribute to the susceptibility to the studied disease (p = 0.05, OR = 1.51, 95%CI = 0.97-2.33). In contrast, the presence of the C allele of TGFB1 rs1800470 seems to be associated with a reduced risk (p = 0.04, OR = 0.47, 95%CI = 0.23-0.96) while the GG-genotype of TGFBR1 rs1590 was associated with increased risk (p = 0.027, OR = 4.11, 95%CI = 1.17-14.38) to frozen shoulder development in males. Thus, we identified genetic variants that were independent risk factors that can aid in the risk assessment of frozen shoulder reinforcing the involvement of MMP and TGFβ signaling in disease development. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

What Serum Lipid Abnormalities Are Associated with Adhesive Capsulitis Accompanied by Diabetes?

BACKGROUND

Adhesive capsulitis is common and can cause stiffness and pain. Diabetes and dyslipidemia are known to be associated with adhesive capsulitis. However, there is no report of any association between serum lipid profiles and adhesive capsulitis accompanied by diabetes.

QUESTION/PURPOSE

Which serum lipid abnormalities are associated with adhesive capsulitis accompanied by diabetes?

METHODS

This is a case-control study with two control groups. Our case group included 37 patients with newly diagnosed adhesive capsulitis accompanied by newly diagnosed diabetes who had no other diagnosed systemic diseases or rotator cuff tears. The two control groups each had 111 age- and sex-matched individuals with normal shoulder function (bilaterally pain-free, with full range of motion and no shoulder muscle weakness), no thyroid dysfunction, and no previously diagnosed systemic diseases. Individuals in the first control group had neither adhesive capsulitis nor diabetes. Individuals in the second control group had newly diagnosed diabetes without adhesive capsulitis. We evaluated any association between adhesive capsulitis accompanied by diabetes and serum lipid profile, including total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglycerides, and nonhigh-density lipoprotein (nonHDL). Conditional logistic regression analysis was used to evaluate the strengths of associations between serum lipid levels and adhesive capsulitis accompanied by diabetes, as determined by odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Low-density lipoprotein and nonHDL were associated with adhesive capsulitis accompanied by diabetes. Specifically, patients with adhesive capsulitis and diabetes had greater odds ratios of hyperlow-density lipoproteinemia when compared with individuals with neither adhesive capsulitis nor diabetes (OR, 3.19; 95% CI, 1.21-8.38; p = 0.019) and when compared with individuals without adhesive capsulitis but with newly diagnosed diabetes (OR, 5.76; 95% CI, 1.67-19.83; p = 0.005). Similarly, patients with adhesive capsulitis accompanied by diabetes had greater odds ratios of hypernonhigh-density lipoproteinemia when compared with individuals with neither adhesive capsulitis nor diabetes (OR, 7.39; 95% CI, 2.72-20.09; p < 0.001) and when compared with individuals without adhesive capsulitis but with newly diagnosed diabetes (OR, 3.26; 95% CI, 1.40-7.61; p = 0.006).

CONCLUSIONS

Inflammatory lipoproteinemias, particularly hyperlow-density lipoproteinemia and hypernonhigh-density lipoproteinemia, are associated with adhesive capsulitis accompanied by diabetes. Further research is needed to evaluate whether inflammatory lipoproteinemias are a cause, a related cofactor, or an aggravating factor in the development of adhesive capsulitis in people who have diabetes.

LEVEL OF EVIDENCE

Level III, prognostic study.

Asian ethnicity: a risk factor for adhesive capsulitis?

Objective

The aim of this study was to evaluate whether Asian ethnicity is a risk factor for the development of adhesive capsulitis. The secondary aim was to describe the distribution of cases of capsulitis by age group.

Methods

A cross-sectional study comparing the rate of adhesive capsulitis in individuals of Asian ethnicity with that of other ethnicities. We excluded patients with fractures and those with symptoms not involving the shoulder. The odds ratio was adjusted for confounding factors by binary logistic regression.

Results

A total of 1331 patient records were evaluated and after applying the selection criteria, 814 patients remained. We found 134 cases of adhesive capsulitis (15.6%). The peak of incidence was at 60-64 years in the patients of Asian ethnicity and at 55-59 years in the other patients. The unadjusted odds ratio was 4.2 (CI 95%, 2.4-7.4), while the odds ratio adjusted for sex and diabetes mellitus was 3.6 (CI 95%, 2.0-6.5).

Conclusion

Patients of Asian ethnicity showed an independent risk factor for the development of adhesive capsulitis, with an adjusted odds ratio of 3.6. Adhesive capsulitis was more common between 55 and 64 years.

Molecular biology of frozen shoulder-induced limitation of shoulder joint movements

Frozen shoulder is a chronic condition characterized by pain in the shoulder and restriction of movements in all directions. Some patients are left with long-term limitation of shoulder joint activity with various severities, which results in reduced quality of life. Currently, there is a paucity of literature on the molecular biology of frozen shoulder, and the molecular biological mechanism for periarthritis-induced limitation of shoulder joint movements remains unclear. Research in this field is focused on inflammation and cytokines associated with fibrosis. Repeated investigations confirmed alterations of specified inflammatory mediators and fibrosis-associated cytokines, which might be involved in the pathogenesis of frozen shoulder by causing structural changes of the shoulder joint and eventually the limitation of shoulder movements. The aim of this article is to review studies on molecular biology of frozen shoulder and provide a reference for subsequent research, treatment, and development of new drugs.

Corticosteroid Injections for Adhesive Capsulitis: A Review

OBJECTIVE

Adhesive capsulitis is a self-limiting condition in a majority of patients and is often treated nonoperatively. However, symptoms may take 2 to 3 years to resolve fully. A small, but significant, portion of patients require surgical intervention. The purpose of this systematic review is to evaluate the efficacy of corticosteroid injections for the treatment of adhesive capsulitis (AC).

DATA SOURCES

A review of articles indexed by the United States National Library of Medicine was conducted by querying the PubMed database for studies involving participants with AC, frozen shoulder, stiff shoulder, or painful shoulder. Articles that included corticosteroids, glucocorticoids, steroids, and injections were included.

MAIN RESULTS

Corticosteroid injections provide significant symptom relief for 2 to 24 weeks. Injections can be performed intra-articularly or into the subacromial space. Evidence suggests that a 20 mg dose of triamcinolone may be as effective as a 40 mg injection. It remains unclear whether image-guided injections produce a clinically significant difference in outcomes when compared with landmark-guided (blind) injections. Corticosteroids may be less beneficial for diabetic patients. Patients using protease inhibitors (antiretroviral therapy) should not receive triamcinolone because the drug-drug interaction may result in iatrogenic Cushing syndrome.

CONCLUSIONS

Corticosteroid injections for AC demonstrate short-term efficacy, but may not provide a long-term benefit. More high quality, prospective studies are needed to determine whether corticosteroid injections using ultrasound guidance significantly improve outcomes.