Can adhesive capsulitis of the shoulder be a consequence of COVID-19? Case series of 12 patients

Revisiting articular syndrome in the peri-pandemic COVID-19 era

Articular syndrome is often the presentation of a person's various rheumatic or related diseases. It includes both arthralgia and arthritis, with objective signs of joint inflammation defining the latter. This syndromic approach to joint pain enables a scientific method for early diagnosis of common rheumatic conditions without compromising the recognition of uncommon conditions. This review explores common rheumatic conditions associated with articular syndrome, including osteoarthritis, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE). It supports the early differentiation of uncommon but emerging entities such as reactive arthritis (ReA). The aim of the review is to comprehensively overview various forms of articular syndrome to update rheumatologists' and allied health specialists' knowledge. Epidemiology, clinical presentations, diagnostic approaches, and therapeutic strategies are discussed in the context of articular syndrome. The challenges emerging in the peri-pandemic COVID-19 era are highlighted. The improved understanding of the spectrum of clinical conditions and disease states presenting with articular syndrome may facilitate early diagnosis, optimal management, and enhanced patient outcomes within the realm of rheumatology.

The incidence of adhesive capsulitis and COVID-19 pandemic effect

Background

There are multiple pieces of evidence in the literature that coronavirus disease 2019 (COVID-19) has a pronounced effect on physiological health. There is little existing literature that has studied the pandemic's impact on adhesive capsulitis (AC) incidence. This study aimed to compare the incidence of primary AC before and during the pandemic.

Methods

A retrospective cohort study was done to establish the incidence of primary AC during the COVID-19 pandemic, from March 2020 to March 2021, the pandemic period, and from March 2019 to March 2020, the control period. During these periods, all patients diagnosed with primary AC were included. Patients were also categorized into three different treatment groups according to corticosteroid injection status (none, 1 injection, and 2 injections). The waiting time for the appointment was calculated as a possible confounding factor. Statistical analysis used the chi-square for categorical variables and the Student t test for continuous variables.

Results

There were 69 patients diagnosed with primary AC out of 704 new referrals during the pandemic. One year earlier, a total of 73 patients were diagnosed with primary AC out of 1148 new referrals. Representing a relative increase of 3.5% (P = .086) in the incidence of primary AC. No significant differences were found between the control and the pandemic groups in regard to the distribution of patients per treatment group (P = .13), age (P = .49), sex (P = .21), laterality (P = .54), diabetic disease (P = .45), and thyroid disease (P = .62).

Conclusion

There was a nonstatistically significant increase in the incidence of primary AC during the COVID-19 pandemic. No other significant differences were found. Further research is still needed to evaluate the relationship between the COVID-19 pandemic and AC.

Ultrasound-Guided Infiltrative Treatment Associated with Early Rehabilitation in Adhesive Capsulitis Developed in Post-COVID-19 Syndrome

Background and Objectives: Post-COVID-19 syndrome is commonly used to describe signs and symptoms that continue or develop after acute COVID-19 for more than 12 weeks. The study aimed to evaluate a treatment strategy in patients with adhesive capsulitis (phase 1) developed in post-COVID-19 syndrome. Materials and Methods: The method used was an interventional pilot study in which 16 vaccinated patients presenting with the clinical and ultrasound features of adhesive capsulitis (phase 1) developed during post-COVID-19 syndrome were treated with infiltrative hydrodistension therapy under ultrasound guidance associated with early rehabilitation treatment. Results: Sixteen patients with post-COVID-19 syndrome treated with ultrasound-guided infiltration and early rehabilitation treatment showed an important improvement in active joint ROM after 10 weeks, especially in shoulder elevation and abduction movements. The VAS mean score before the treatment was 6.9 ± 1.66. After 10 weeks of treatment, the VAS score was 1 ± 0.63. Conclusions: The study demonstrated that the management of adhesive capsulitis (phase 1) developed in post-COVID-19 syndrome, as conducted by physiotherapists in a primary care setting using hydrodistension and a rehabilitation protocol, represented an effective treatment strategy.

Acute myopericarditis and left shoulder capsulitis following second dose of mRNA SARS-CoV-2 Moderna vaccination

Vaccination against mRNA SARS-CoV-2 has been administered on a very large scale and various side effects have been described. The increased risk of myopericarditis is known, and only a few cases of shoulder capsulitis have been reported after vaccination. These two pathologies have never been reported in the same patient after vaccination. Our article presents the history of a man in his 40s who presented with myopericarditis a few days after vaccination against SARS-CoV-2 with mRNA(Messenger RNA) Moderna® vaccine and who at the same time developed shoulder capsulitis. His cardiovascular symptoms resolved rapidly, and his shoulder symptoms improved/resolved within 1 year. This case should make physicians aware of the possibility of several concomitant side effects following vaccination against SARS-CoV-2.

Early shoulder-girdle MRI findings in severe COVID-19-related intensive care unit-acquired weakness: a prospective cohort study

OBJECTIVE

To describe clinical and early shoulder-girdle MR imaging findings in severe COVID-19-related intensive care unit-acquired weakness (ICU-AW) after ICU discharge.

METHODS

A single-center prospective cohort study of all consecutive patients with COVID-19-related ICU-AW from November 2020 to June 2021. All patients underwent similar clinical evaluations and shoulder-girdle MRI within the first month and then 3 months (± 1 month) after ICU discharge.

RESULTS

We included 25 patients (14 males; mean [SD] age 62.4 [12.5]). Within the first month after ICU discharge, all patients showed severe proximal predominant bilateral muscular weakness (mean Medical Research Council total score = 46.5/60 [10.1]) associated with bilateral, peripheral muscular edema-like MRI signals of the shoulder girdle in 23/25 (92%) patients. At 3 months, 21/25 (84%) patients showed complete or quasi-complete resolution of proximal muscular weakness (mean Medical Research Council total score > 48/60) and 23/25 (92%) complete resolution of MRI signals of the shoulder girdle, but 12/20 (60%) patients experienced shoulder pain and/or shoulder dysfunction.

CONCLUSIONS

Early shoulder-girdle MRI findings in COVID-19-related ICU-AW included muscular edema-like peripheral signal intensities, without fatty muscle involution or muscle necrosis, with favorable evolution at 3 months. Precocious MRI can help clinicians distinguish critical illness myopathy from alternative, more severe diagnoses and can be useful in the care of patients discharged from intensive care with ICU-AW.

KEY POINTS

• We describe the clinical and shoulder-girdle MRI findings of COVID-19-related severe intensive care unit-acquired weakness. • This information can be used by clinicians to achieve a nearly specific diagnosis, distinguish alternative diagnoses, assess functional prognosis, and select the more appropriate health care rehabilitation and shoulder impairment treatment.

Adhesive Capsulitis

Adhesive capsulitis, colloquially known as "frozen shoulder," is a relatively common disorder, affecting approximately 2% to 5% of the general population. The incidence may be higher as the condition can be relatively mild and self-limited and thus many patients who experience it may never present for treatment. It involves a pathologic process of gradual fibrosis of the glenohumeral joint that leads to limited active and passive range of motion, contracture of the joint capsule, and shoulder pain.

Incidence of adhesive capsulitis of the shoulder during the beginning of the COVID-19 pandemic

OBJECTIVE

Adhesive capsulitis is an inflammatory disease of the joint capsule, clinically manifested as pain, stiffness, and dysfunction of the shoulder. We subjectively observed an increased incidence of adhesive capsulitis, and raised the hypothesis that adhesive capsulitis was more frequent in magnetic resonance imaging examinations performed during the COVID-19 pandemic as compared with examinations prior to this period.

METHODS

Data from medical records and magnetic resonance imaging of the shoulder presenting typical imaging findings of adhesive capsulitis, performed in our organization from March to June 2020, were evaluated and compared with data and imaging from the same period of the previous year. To this end, an organizational business intelligence tool called "search reports" was used, searching for the term "adhesive capsulitis" in the radiological report, results were tabulated, and corresponding magnetic resonance imaging exams were analyzed.

RESULTS

Our search found a total of 240 and 1,373 cases of adhesive capsulitis in the 2020 and 2019 periods, respectively. The mean age of patients was 53.9 years in the 2020 group and 49.9 years in 2019 (p<0.001). Magnetic resonance imaging findings were positive for adhesive capsulitis in 40 out of 240 shoulders (16.7%) in the 2020 group versus 127 out of 1,373 shoulders (9.2%) in the 2019 group. This difference was statistically significant (p=0.001).

CONCLUSION

Our study findings suggest a relative increase in the proportion of magnetic resonance imaging findings suggestive of adhesive capsulitis cases during COVID-19 pandemics based on data from our organization.

The impact of the COVID-19 pandemic on frozen shoulder incidence rates and severity

BACKGROUND

Although there is evidence that the COVID-19 pandemic had profound physiological and psychological effects, there is no research aimed at understanding if the pandemic has had an impact on the incidence or severity of frozen shoulder (FS). The aim of this study was to compare the incidence and severity of idiopathic FS before and during the pandemic.

METHODS

A retrospective cohort study was performed to establish the incidence of FS during the pandemic, from March 2020 to January 2021 (pandemic study period), compared to the same time period 1 year earlier, before the pandemic (control group). All patients who were diagnosed with idiopathic FS were included. To assess the severity of the condition, visual analog scale (VAS) for pain score and Subjective Shoulder Value (SSV) on presentation were recorded and the patients were categorized into 5 different treatment groups (0 injections, 1 injection, 2 injections, 3 injections, or capsular release). As the pandemic and public health restrictions could have influenced the availability of appointments, the waiting time between referral and first appointment was calculated as a possible confounding factor. Statistical analysis was performed using the chi-square and Student t test for categorical and continuous variables, respectively.

RESULTS

There were 847 new patient consultations during the pandemic study period; of these, 232 were for idiopathic FS. One year earlier, there were 898 initial consultations for a new shoulder problem; of these, 176 were for idiopathic FS. This represents a relative increase of 39.8% (P < .001) in the incidence of patients with FS. The mean SSV in the control group was 50% ± 20% vs. 45% ± 18% in the pandemic group-statistically significant (P = .013) but unlikely to be clinically significant. The VAS pain score was similar in both groups: mean 6 ± 2 and 7 ± 2, respectively (P = .06). There was no significant difference between the control and the pandemic group in the distribution of patients per treatment group (P = .94). The mean waiting time from referral to appointment was not significantly different between the control and the pandemic group: 58 ± 30 days vs. 55 ± 27 days (P = .30).

CONCLUSION

During the COVID-19 pandemic, there was a significant increase in the incidence of patients with FS. No significant difference in severity was observed. Further research is needed to evaluate a causal relationship between the COVID-19 pandemic and FS.

Musculoskeletal Manifestations of COVID-19: Currently Described Clinical Symptoms and Multimodality Imaging Findings

COVID-19, the clinical syndrome produced by infection with SARS-CoV-2, can result in multisystem organ dysfunction, including respiratory failure and hypercoagulability, which can lead to critical illness and death. Musculoskeletal (MSK) manifestations of COVID-19 are common but have been relatively underreported, possibly because of the severity of manifestations in other organ systems. Additionally, patients who have undergone sedation and who are critically ill are often unable to alert clinicians of their MSK symptoms. Furthermore, some therapeutic measures such as medications and vaccinations can worsen existing MSK symptoms or cause additional symptoms. Symptoms may persist or occur months after the initial infection, known as post-COVID condition or long COVID. As the global experience with COVID-19 and the vaccination effort increases, certain patterns of MSK disease involving the bones, muscles, peripheral nerves, blood vessels, and joints have emerged, many of which are likely related to a hyperinflammatory host response, prothrombotic state, or therapeutic efforts rather than direct viral toxicity. Imaging findings for various COVID-19–related MSK pathologic conditions across a variety of modalities are being recognized, which can be helpful for diagnosis, treatment guidance, and follow-up.

The online slide presentation from the RSNA Annual Meeting is available for this article.

^©RSNA, 2022

What Do We Need to Know About Musculoskeletal Manifestations of COVID-19?: A Systematic Review

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COVID-19 is a disease that is challenging science, health-care systems, and humanity. An astonishingly wide spectrum of manifestations of multi-organ damage, including musculoskeletal, can be associated with SARS-CoV-2.

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In the acute phase of COVID-19, fatigue, myalgia, and arthralgia are the most common musculoskeletal symptoms.

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Post-COVID-19 syndrome is a group of signs and symptoms that are present for >12 weeks. The associated musculoskeletal manifestations are fatigue, arthralgia, myalgia, new-onset back pain, muscle weakness, and poor physical performance.

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Data on COVID-19 complications are growing due to large absolute numbers of cases and survivors in these 2 years of the pandemic. Additional musculoskeletal manifestations encountered are falls by the elderly, increased mortality after hip fracture, reduced bone mineral density and osteoporosis, acute sarcopenia, rhabdomyolysis, Guillain-Barré syndrome, muscle denervation atrophy, fibromyalgia, rheumatological disease triggering, septic arthritis, adhesive capsulitis, myositis, critical illness myopathy, onset of latent muscular dystrophy, osteonecrosis, soft-tissue abscess, urticarial vasculitis with musculoskeletal manifestations, and necrotizing autoimmune myositis.

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A wide range of signs and symptoms involving the musculoskeletal system that affect quality of life and can result in a decrease in disability-adjusted life years. This powerful and unpredictable disease highlights the importance of multimodality imaging, continuing education, and multidisciplinary team care to support preventive measures, diagnosis, and treatment.

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.