Frozen shoulder: prospective clinical study with an evaluation of three treatment regimens

AAOS 2024 best paper in the shoulder and elbow classification: watchful waiting provides higher value with similar functional outcomes to physical therapy for frozen shoulder: a prospective randomized controlled trial

BACKGROUND

Physical therapy remains a ubiquitous treatment modality for the management of frozen shoulder (adhesive capsulitis) despite limited high-level evidence supporting its use. Leveraging patient-reported outcome measures (PROMs) and healthcare costs, this study compared patient outcomes and value achieved through watchful waiting (WW) vs. physical therapy (PT) for conservative management of frozen shoulder.

METHODS

Patients in this prospective, parallel randomized controlled trial who were diagnosed with frozen shoulder were randomized 1:1 to WW or PT. All patients were offered therapeutic, intra-articular corticosteroid injections (CSIs). The primary outcome was the American Shoulder and Elbow Surgeons Score. Secondary outcomes included patient value (ie, 12-month American Shoulder and Elbow Surgeons score divided by healthcare costs), the Disabilities of the Arm, Shoulder, and Hand questionnaire, and Visual Analog Scale pain. Due to the confidentiality of internal hospital data, all economic outcomes were divided by an undisclosed constant to set the normalized study mean for direct costs to 1000; similarly, patient value was normalized to set the study mean to 100. Outcomes were assessed at baseline, 6 weeks, 3 months, 6 months, and 12 months using mixed-effects models, with sensitivity analyses adjusting for nonlinear improvement trajectories and CSIs.

RESULTS

Between November 2014 and November 2022, 175 patients were screened, 61 of whom (34.9%) were randomized to WW (31 patients) or PT (30 patients). Forty-seven patients (96%) received at least one CSI, with no significant difference in CSI administration between cohorts (P = .29). Relative to baseline scores, patients from both cohorts improved significantly at each time point for all PROMs (P < .05 for all), with no significant differences in PROMs between groups at any time point (P > .05 for all). However, compared to those assigned WW, patients randomized to PT incurred 10.0× higher costs (normalized mean difference: 1636; 95% CI: 967, 2304; P < .001) and achieved only 16.9% of the patient value (normalized mean difference: -147.0; 95% CI: -207.5, -86.5; P < .001). These results held across all sensitivity analyses.

CONCLUSION

Relative to WW, patients randomized to PT reported similar PROMs but incurred significantly higher direct costs (10.0×) and imposed a greater economic burden on the healthcare system (3.4-6.0×). Accordingly, WW resulted in significantly higher (5.9×) patient value than PT. Although additional high-level, multicenter studies are needed to corroborate these findings, the present study may support physicians and patients in pursuing the most appropriate treatment plan for each patient based on their individualized needs and preferences.

Sonographically-navigated frozen shoulder release (S-FSR): A modified technique for sonographically-navigated, in-office hydrodilatation of adhesive capsulitis

We describe a new technique for hydrodilatation of the frozen shoulder, which we coined 'Sonographically-Navigated Frozen Shoulder Release (S-FSR)' or 'Dr Gonzalez's technique.' Traditional treatments include a combination of conservative and surgical modalities, such as non-steroidal anti-inflammatories, physical therapy, and open capsular release. We describe a modification to hydrodilatation of the frozen shoulder. Our technique describes the gradual dilation of the glenohumeral (GH) capsule with the goal of seeing a gentle release of the frozen shoulder. Furthermore, we outline our protocol for patient preparation with preprocedural diazepam 5 mg and Hydrocodone 5 mg-Acetaminophen 325 mg, one tablet each. During the procedure, we inject a solution of 10 mL lidocaine mixed with 2 mL of 40 mg/mL triamcinolone acetonide injection (80 mg total) through an anterior approach at the level of the rotator interval for pain control. Following this injection, we proceed to fenestrate the superior glenohumeral ligament (SGHL) in the process. We conclude the procedure with hydrodilatation of the GH joint (GHJ) through the posterior approach with approximately 50 mL of 0.9% normal saline, or until an expansion and release of the GH joint is visualized under ultrasound visualization. A full instruction video can be found at: https://www.youtube.com/watch?v = ZNB0R0hkeok&ab_channel = DrJorgeA.Gonzalez.

Comparative outcome of ultrasound guided vs. fluoroscopy guided hydrodilatation in adhesive capsulitis: a prospective study

BACKGROUND

The incidence of adhesive capsulitis varies from 2-5% in the general population to 20% in people with diabetes. One of the most effective treatment methods is hydrodilatation, which can be done under US-guidance or Fluoroscopic guidance. However, the clinical effectiveness of US-guided injections in comparison to fluoroscopy-guided injections is still debatable. The possibility of severe side effects, the expense, and the time required to carry out this minimally invasive procedure highlight how crucial it is for patients to have a precise intra-articular injection. This study aims to compare the effectiveness of Ultrasound-guided vs. Fluoroscopic guided hydrodilatation for patients with adhesive capsulitis.

METHODS

Sixty-four patients were randomly selected for hydrodilatation using any one of the techniques. The patients were evaluated for clinical improvements using the visual analog scale (VAS), oxford shoulder score (OSS), and range of motion (ROM).

RESULTS

The US-guided group experienced more pain reduction than the fluoroscopy group within the first four weeks (P < 0.001). The increase in ROM was much more significant in the US-guided group for the first 8 weeks. Improvement in Abduction and External rotation was much more significant (P < 0.001) in the first 4 weeks after hydrodilatation in the US-guided group. The improvement in ROM was maintained on long-term follow-up (mean 24 months), with 45 out of 64 (70.3%) reporting a normal or near normal ROM. On assessing the Oxford shoulder score improvements, the US-guided group's score significantly increased after the first week (P = 0.003), but the fluoroscopy-guided group's score increased after the second week. On comparison between the two groups, the amount of score improvement was more significant in the US-guided group than in the fluoroscopy-guided group in the first 4 weeks (P < 0.001).

CONCLUSION

US-guided technique for intra-articular injection for patients with adhesive capsulitis provided a quicker pain reduction and a larger improvement in range of motion and overall shoulder functions.

Study of Functional Outcome of Intra-articular Steroid Injection and Manipulation of Shoulder Joints in Frozen Shoulder

INTRODUCTION

Frozen shoulder, also known as adhesive capsulitis, is characterized by the insidious onset of pain and progressive loss of global active and passive mobility of the glenohumeral joint, which can be treated by non-surgical or surgical methods. This study was done to evaluate the functional outcome of intra-articular (I/A) steroid injection and manipulation of the shoulder joint manipulation under anesthesia (MUA) in frozen shoulder.

METHODS

A cross-sectional study was done in a tertiary care hospital in Pokhara, Nepal. A total of 35 patients over 40 years were included in the study. All the patients underwent I/A steroid injection and MUA. The functional outcome was evaluated using a Constant-Murley shoulder score (CSS) and a visual analogue scale (VAS) scoring system.

RESULT

The mean age was 53.46±7.524 years. Twenty-two were female, while 13 were male. Twelve patients were associated with diabetes. Minor complications were noted in 15 patients (14 with transient pain and one with facial flushing). At 12 weeks, the mean VAS score was 2.16±1.33 cm, and the mean CSS score was 82.66±7.008. At 24 weeks, the mean VAS was 1.534±1.195 cm, and the mean CSS score was 85.77±6.998.

CONCLUSION

This study shows that patients with frozen shoulder treated with I/A steroid injection and MUA give excellent functional outcomes in most patients.

Effects of humeral head stabilization intervention during aggressive manual passive stretching exercises in patients with painful stiff shoulder: a prospective, comparative study

BACKGROUND

No reports have been published verifying the effects of manual interventions such as humeral head stabilization on improving function and reducing pain when applying aggressive manual passive stretching in patients with painful stiff shoulders. The purpose of this study was to compare clinical outcomes, such as range of motion, pain, and disability scores, in patients with painful stiff shoulders with and without humeral head stabilization intervention while applying aggressive manual passive stretching.

METHODS

Fifty-six patients with painful stiff shoulders were recruited (31 with humeral head stabilization intervention and 25 without such intervention). Clinical outcomes such as active range of motion (A-ROM), pain, and disability scores were evaluated using a goniometer; measurement of activity visual analog scale (A-VAS); and Disabilities of the Arm, Shoulder and Hand (DASH) and Shoulder Pain and Disability Index (SPADI), respectively.

RESULTS

All the parameters, A-ROM, A-VAS, and disability scores (DASH and SPADI) were not significantly different between the 2 groups (P > .05) before the intervention. However, after the intervention, the mean difference in A-ROM for flexion, abduction, and external and internal rotation was 18 (95% confidence interval [CI], 14.1-21.7), 31 (95% CI, 24.9-37.4), 17 (95% CI, 13.4-21.4), and 16 (95% CI, 11.6-20.9), respectively. The mean difference in A-VAS and disability scores for DASH and SPADI was -1 (95% CI, -1.5 to -0.8), -27 (95% CI, 32.3 to -22.6), and -23 (95% CI, -27.8 to -18.3), respectively. All of these measurements favored humeral head stabilization.

CONCLUSION

During aggressive manual passive stretching in patients with painful stiff shoulders, humeral head stabilization intervention may be more beneficial in improving clinical outcomes such as A-ROM, A-VAS pain levels, and disability scores.

Ultrasound-Guided Glenohumeral Corticosteroid Injection for the Treatment of Adhesive Capsulitis of the Shoulder: The Role of Clinical Stage in Response to Treatment

BACKGROUND

Treatment for idiopathic adhesive capsulitis of the shoulder remains controversial. Stages 1 to 2 reflect an inflammatory process supporting a rationale for intra-articular glenohumeral joint corticosteroid injection to treat synovial inflammation and prevent progression to capsular fibrosis.

HYPOTHESIS

We hypothesize that an intra-articular ultrasound-guided glenohumeral injection (USGI) of corticosteroid in patients diagnosed with Stage 1 or 2 idiopathic adhesive capsulitis will result in timely functional recovery and resolution of pain and stiffness.

STUDY DESIGN

Case series.

LEVEL OF EVIDENCE

Level 4.

METHODS

Patients with Stage 1 or 2 idiopathic adhesive capsulitis treated with an intra-articular corticosteroid injection were included. Patients were seen by a single physician and diagnosed using history and physical examination with careful attention to measurement of glenohumeral range of motion (ROM). A total of 61 patients met inclusion criteria. ROM measurements documented in the patient charts were recorded in forward flexion, abduction, internal rotation, and external rotation in neutral abduction. All ROM measurements were performed pre- and postinjection. All patients were treated with an USGI of local anesthetic and depomedrol. Recovery criteria were defined as forward flexion, abduction, and external rotation within 15° of the contralateral side and internal rotation within 3 spinous process levels of the contralateral side.

RESULTS

A total of 11 patients with Stage 1 and 50 patients with Stage 2 adhesive capsulitis comprised the final study cohort. Within the Stage 1 cohort, all 11 patients met recovery criteria for forward flexion and internal rotation (100%), 10 met recovery criteria for abduction (91%), and 8 met recovery criteria for external rotation (73%). Within the Stage 2 cohort, 31 patients met recovery criteria for forward flexion (62%), 30 met recovery criteria for abduction (60%), 36 met recovery criteria for internal rotation (72%), and 25 met recovery criteria for external rotation (50%). The difference in time to recovery in days was statistically significant in all ROM planes and was within 2 to 6 weeks for patients in Stage 1 and 7 to 10 weeks for Stage 2.

CONCLUSION

USGI for early adhesive capsulitis allows patients to recover ROM more rapidly if performed early after onset of pain and stiffness.

CLINICAL RELEVANCE

These results stress the importance of recognition of idiopathic adhesive capsulitis in its early stages and subsequent intervention with an intra-articular glenohumeral corticosteroid injection.

Corticosteroid Injection Methods for Frozen Shoulder: A Network Meta-analysis

OBJECTIVE

To investigate the efficacy of corticosteroid (CS) injection methods for frozen shoulder.

DATA SOURCES

PubMed, Embase, and Cochrane Library were searched up to May 6, 2023.

STUDY SELECTION

Randomized controlled trials (RCTs) that investigated CS injection methods for frozen shoulder were included.

DATA EXTRACTION

Data were extracted independently by 2 authors. Risk of bias was assessed using the RoB 2 tool.

DATA SYNTHESIS

A random-effects network meta-analysis was performed within a frequentist framework. The certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations approach. A total of 66 RCTs involving 4491 patients were included. For short-term outcomes, 4-site injection (vs placebo [PLA]: standardized mean difference [SMD]=-2.20, 95% confidence interval [CI], -2.81 to -1.59 in pain; SMD=2.02; 95% CI, 1.39-2.65 in global function) was the most effective (low certainty). Rotator interval injection was the optimal treatment with moderate to high certainty (vs PLA: SMD=-1.07, 95% CI, -1.51 to -0.64 in pain; SMD=0.94, 95% CI, 0.49-1.40 in global function). For midterm outcomes, 4-site injection was most effective (vs PLA: SMD=-1.71, 95% CI, -2.41 to -1.01 in pain; SMD=2.22, 95% CI, 1.34-3.09 in global function; low certainty). Distension via rotator interval (D-RI) was the optimal treatment with moderate to high certainty (vs PLA: SMD=-1.10, 95% CI, -1.69 to -0.51 in pain; SMD=1.46, 95% CI, 0.73-2.20 in global function). Distension and intra-articular injection via anterior or posterior approaches produced effects equivalent to those of rotator interval injection and D-RI.

CONCLUSIONS

Rotator interval injection, distension, and intra-articular injection had equivalent effects on symptom relief. More RCTs are required to validate the superiority of multisite injections.

Manual therapy and exercise for adhesive capsulitis: a systematic review with meta-analysis

BACKGROUND

Adhesive capsulitis (AC) affects approximately 1% of the general population. Current research lacks clear guidance on the dosage of manual therapy and exercise interventions.

OBJECTIVE

The purpose of this systematic review was to assess the effectiveness of manual therapy and exercise in the management of AC, with a secondary aim of describing the available literature present on the dosage of interventions.

METHODS

Eligible studies were randomized clinical/quasi-experimental trials with complete data analysis and no limits on date of publication, published in English, recruited participants >18 years of age with primary adhesive capsulitis, that had at least two groups with one group receiving manual therapy (MT) alone, exercise alone, or MT and exercise, that included at least one outcome measure of pain, disability, or external rotation range of motion, and that had dosage of visits clearly defined. An electronic search was conducted using PubMed, Embase, Cochrane, Pedro, and clinicaltrials.gov. Risk of bias was assessed using the Cochrane Collaboration Risk of Bias 2 Tool. The Grading of Recommendations Assessment, Development, and Evaluation was used to provide an overall assessment of the quality of evidence. Meta-analyses were conducted when possible, and dosage was discussed in narrative form.

RESULTS

Sixteen studies were included. All meta-analyses revealed non-significant effects of pain, disability, and external rotation range of motion at short- and long-term follow-up, with an overall level of evidence ranging from very low to low.

CONCLUSION

Non-significant findings with low-to-very-low-quality of evidence were found across meta-analyses, preventing seamless transition of research evidence to clinical practice. Lack of consistency in study designs, manual therapy techniques, dosing parameters, and duration of care impedes the ability to make strong recommendations regarding optimal dosage of physical therapy for individuals with AC.

Relationship between pain and range of motion in frozen shoulder

Background

A frozen shoulder (FS) is characterized by pain and limited range of motion (ROM). Although physical assessment of ROM is important for diagnosing and staging FS, ROM cannot be accurately assessed in clinical practice because of pain and muscle contraction. This study aimed to measure changes in shoulder joint ROM before and after anesthesia (ΔROM) in patients with FS and investigate the factors affecting these changes.

Methods

This study included 54 patients (age, 55.6 ± 9.4 years; 17 males; disease duration, 6.6 ± 3.4 months) with FS before manipulation under transmission anesthesia. FS was defined as having a ROM in external rotation (ER) that was less than 50% of that in the unaffected shoulder. Pain at night and during motion was assessed using a numerical rating scale. Before anesthesia, the passive ROM of forward flexion (FF), abduction (AD), and ER were measured in the supine position. After confirming that the anesthesia was effective, passive ROM was measured again.

Results

The ROM in the FF, AD, and ER after anesthesia was significantly higher than that before anesthesia (P < .001). ΔROM in the FF, AD, and ER was significantly correlated with pain at night (r = 0.51, P < .001; r = 0.45, P < .001; and r = 0.39, P = .004, respectively). Furthermore, ΔROM in the ER was significantly correlated with pain during motion (r = 0.31, P = .023) and disease duration (r = -0.31, P = .021).

Conclusion

The ROM of the FS is susceptible to pain and muscle contraction. Interventions, such as physical therapy, may be recommended after pain relief.

Vitamin C as a Potential Prophylactic Measure Against Frozen Shoulder in an In Vivo Shoulder Contracture Animal Model

BACKGROUND

Frozen shoulder is a common, painful, and movement-restricting condition. Although primary frozen shoulder is idiopathic, secondary frozen shoulder can occur after trauma or surgery. Prophylactic and therapeutic options are often unsatisfactory. Vitamin C (ascorbic acid) is a potent physiological antioxidant and likely inhibits the activation of nuclear factor κB, which plays a decisive role in inflammatory reactions.

HYPOTHESIS

Because of its anti-inflammatory effects, vitamin C may be valuable in the prevention of secondary frozen shoulder.

STUDY DESIGN

Controlled laboratory study.

METHODS

An in vivo shoulder contracture model was conducted by fixation of the right proximal limb of Sprague-Dawley rats. A treatment group (n = 8) receiving vitamin C orally was compared with a control group (n = 9) without vitamin C. The primary outcome was capsular thickness at the shoulder joint measured on magnetic resonance imaging (MRI) examination. Further histological examination was performed but was not statistically analyzed because of variability of the cutting plane through the glenoid.

RESULTS

Vitamin C treatment resulted in less thickening of the axillary fold of the operated shoulder at 2 of the 3 locations measured on MRI compared with untreated controls (insertion to the glenoid, P = .074; insertion to the humerus, P = .006; middle of the axillary recess, P = .008). The observed structural changes in histological examination corroborated the significant changes obtained from the MRI measurements.

CONCLUSION

Prophylactic vitamin C seemed to reduce the thickening of the axillary recess in secondary frozen shoulder in this preclinical study.

CLINICAL RELEVANCE

Vitamin C may be helpful as a noninvasive therapeutic measure to prevent secondary frozen shoulder (eg, within the context of surgery in the shoulder region or immobilization) or to treat primary frozen shoulder at an early stage. Further studies are required to evaluate the effect of this treatment in humans and the necessary dosage in humans.

Predictive Factors for Failure of Intraarticular Injection in Management of Adhesive Capsulitis of the Shoulder

Intraarticular (IA) corticosteroid injections have been demonstrated to be an effective management for adhesive capsulitis in both the short- and mid-term. Yet, certain patients fail to improve both subjectively and clinically. This study aims to identify predictive factors for treatment failure of IA injections in management of adhesive capsulitis. A retrospective review found 533 patients undergoing IA corticosteroid or IA NSAID injection for adhesive capsulitis between June 2015 and May 2020 at a single healthcare institution. Patient demographics characteristics, comorbidities, pain scores, and range of motion were compared. Treatment failure was defined as need for subsequent IA injection within 6 months or progression to surgical management within 12 months. 152 patients (28.52%) experienced treatment failure of IA corticosteroid injection. Pre-injection pain scores were greater for those who experienced treatment failure (5.40 vs. 4.21, p < 0.05). Post-injection pain scores were greater for those who experienced treatment failure (3.77 vs. 2.17, p < 0.01). Reduced post-injection external rotation in abduction also predicted treatment failure (56.88° vs. 70.22°, p < 0.01). IA corticosteroid injections are associated with increased rates of failure and progression to surgical management when patients present with increased pain levels as well as with less improvement in pain levels and ROM following injection.

Adhesive Capsulitis of the Hip: A Case Presentation and Review

There remains a paucity of literature addressing adhesive capsulitis of the hip (ACH), making the diagnosis and treatment a continued challenge for healthcare providers. ACH encompasses restricted hip range-of-motion and pain that progresses through analogous Stages (1-4) to adhesive capsulitis of the shoulder. We report a case presentation of a middle-aged man that illustrates the significance of certain patient factors and provide a review of current literature to aid in the diagnostic evaluation and treatment for addressing ACH. Initial conservative treatment of ACH includes the appropriate management of associated comorbidities, oral and/or injectable pharmacologics, and physical therapy. While frequently resolving with time, refractory cases of ACH may require more aggressive approaches including pressure dilation, manipulation under anesthesia, synovectomy, capsular release and, for select patients, total hip arthroplasty. Given the limited available literature addressing ACH, healthcare providers may be forced to rely on a small number of published case reports and outdated review articles to guide their diagnostic evaluation and treatment approaches. Thus, this case presentation and review provides an updated approach to better diagnose and manage patients with ACH.

Non-Surgical and Rehabilitative Interventions in Patients with Frozen Shoulder: Umbrella Review of Systematic Reviews

Background

Frozen shoulder (FS) is a painful condition characterized by progressive loss of shoulder function with passive and active range of motion reduction. To date, there is still no consensus regarding its rehabilitative treatment for pain management.

Purpose

The aim of this umbrella review of systematic reviews was to analyze the literature, investigating the effects of non-surgical and rehabilitative interventions in patients suffering from FS.

Patients and Methods

A review of the scientific literature was carried out from 2010 until April 2020 using the following search databases: PubMed, Medline, PEDro, Scopus and Cochrane Library of Systematic Reviews. A combination of terms was used for the search: frozen shoulder OR adhesive capsulitis AND systematic review OR meta-analysis AND rehabilitation NOT surgery NOT surgical intervention. We included systematic reviews that specifically dealt with adults with FS, treated with non-surgical approaches. All the systematic reviews and meta-analyses included in the study that met the inclusion criteria were assessed using the Assessment of Multiple Systematic Reviews as a quality assessment tool.

Results

Out of 49 studies, only 14 systematic reviews respected the eligibility criteria and were included in this study. Their results showed an important heterogeneity of the studies and all of them agree on the lack of high-quality scientific work to prove unequivocally which rehabilitative treatment is better than the other. Due to this lack of gold standard criteria, there may be also a heterogeneity in the diagnosis of the reviews analyzed.

Conclusion

Non-surgical and rehabilitative interventions are undoubtedly effective in treating FS, but there is no evidence that one approach is more effective than the other regarding the methods reported. Future high-quality RCTs are needed to standardize the treatment modalities of each physiotherapy intervention to provide strong recommendations in favor.

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.

Role of suprascapular nerve block in idiopathic frozen shoulder treatment: a clinical trial survey

Background

Several therapeutic methods have been proposed for frozen shoulder syndrome. These include suprascapular nerve block, a simple and cost-effective technique that eliminates the need for nonsteroidal anti-inflammatory drug therapy.

Methods

This was a clinical trial that included patients with unilateral shoulder joint stiffness. Patients were divided into three groups: those treated with isolated physiotherapy for 12 weeks (PT group), those treated with a single dose intra-articular injection of corticosteroid together with physiotherapy (IACI group), and those treated with a suprascapular nerve block performed with a single indirect injection of 8-mL lidocaine HCL 1% and 2 mL (80 mg) methylprednisolone acetate together with physiotherapy (SSNB group). The variables assessed were age, sex, side of involvement, dominant limb, presence of diabetes, physical examination findings including erythema, swelling, and muscle wasting; palpation and movement findings; shoulder pain and disability index (SPADI) score; and the visual analog scale (VAS) score pre-intervention and at 2-, 4-, 6-, and 12-week post-intervention.

Results

Ninety-seven patients were included in this survey (34 cases in the PT group, 32 cases in the IACI group, and 31 cases in the SSNB group). Mean age was 48.55±11.06 years. Fifty-seven cases were female (58.8%) and 40 were male (41.2%). Sixty-eight patients had a history of diabetes (70.1%). VAS and SPADI scores and range of mototion degrees dramatically improved in all cases (p<0.001). Results were best in the SSNB group (p<0.001), and the IACI group showed better results than the PT group (p<0.001).

Conclusions

Suprascapular nerve block is an effective therapy with long-term pain relief and increased mobility of the shoulder joint in patients with adhesive capsulitis.

Evaluation of the tissue thickness of the supraspinatus and biceps long head tendons using ultrasound among elderly patients with unilateral adhesive capsulitis in the freezing phase

[Purpose] This study aimed to clarify the changes in the tissue thickness of the abnormal supraspinatus and biceps long-head tendons among elderly patients to select the treatment targets and evaluate the treatment effects in the freezing phase of adhesive capsulitis. [Participants and Methods] Thirty-two elderly patients with unilateral shoulder pain underwent ultrasound of the supraspinatus and biceps long-head tendons, pain evaluation, and orthopedic testing. Both the supraspinatus and biceps long-head tendons were classified as normal, abnormal, and other groups. Participants with negative orthopedic test results were assigned the “normal group”. Participants with positive orthopedic test results and resting and night pain were assigned the “abnormal group”. Differences in tissue thickness were calculated from the differences between the symptomatic and non-symptomatic sides. [Results] The thickness of the supraspinatus and biceps long-head tendons was significantly higher in the abnormal than in the normal group. [Conclusion] This study clarified the changes in tissue thickness of the abnormal supraspinatus and biceps long-head tendons among elderly patients to select the treatment targets and assess the treatment effects in the freezing phase of adhesive capsulitis. The study results suggest the usefulness of ultrasound for selecting the treatment targets for analgesia and assessing the treatment efficacy in cases of adhesive-capsulitis freezing phase.

Effectiveness of acromioclavicular joint mobilization and physical therapy vs physical therapy alone in patients with frozen shoulder: A randomized clinical trial

OBJECTIVES

The objective of this trial was to compare the efficacy of acromioclavicular joint mobilization and standard physical-therapy versus physical-therapy alone in the treatment of the frozen shoulder.

DESIGN

Single-blind randomized clinical trial.

SETTING

Outpatient setting.

SUBJECTS

Patients with frozen shoulder.

INTERVENTION

Participants were randomly allocated into mobilization + physical-therapy (n = 28), and physical-therapy alone (n = 28) groups for one month.

MAIN MEASURES

The primary outcomes were the shoulder pain and disability index and the shoulder range of motion. The secondary outcome was the visual analogue scale. Measures were performed at the baseline, immediately and one month after the beginning of the treatment.

RESULTS

Visual analogue scale and the shoulder pain and disability index improved more significantly in the mobilization group compared to the physical-therapy group immediately [-4.63 (-5.58--3.67) vs. -2.22 (-2.96--1.47), P < 0.001 and -23.08 (-28.63--17.53) vs. -13.04 (-17.93--8.16), P = 0.008, respectively] and one month after the beginning of the treatment [-5.58 (-6.45--4.72) vs. -3.61 (-4.60--2.62), P < 0.001 and -33.43 (-40.85--26.01) vs. -20.03 (-26.00--14.07), P = 0.001, respectively]. Active abduction range of motion was also improved more significantly immediately after the treatment in the mobilization group compared to the physical-therapy group [25.83 (11.45-40.13) vs. 10.17 (1.02-19.15), P = 0.025], however there were no significant differences between two groups concerning other measured range of motions.

CONCLUSIONS

Adding acromioclavicular mobilization to standard physical-therapy was more efficient in decreasing pain and disability and improving active abduction range of motion compared to standard physical-therapy in frozen shoulder patients.

Comparative analysis of intra-articular injection of steroid and/or sodium hyaluronate in adhesive capsulitis: prospective, double-blind, randomized, placebo-controlled study

Background

Few studies have reported the effects of simultaneous injections of corticosteroid (CS) and hyaluronic acid (HA) on adhesive capsulitis (AC) of the shoulder. This study investigated the synergistic effects of simultaneous intra-articular injections of CS and compared them to those of CS or HA alone.

Method

Sixty patients with AC were enrolled in this randomized, placebo-controlled trial. The participants were divided into 4 groups: saline, CS, HA, and CS with HA groups. The primary outcome measure was changes in the Shoulder Pain and Disability Index (SPADI) scores at one month. The secondary outcome measures included changes in pain, range of motion, muscle strength, and additional shoulder functional scores at 1 day, 1 week, and 1, 3, and 6 months after injection.

Results

After 1 month, changes of the SPADI scores were significantly higher in the CS with HA group (−58.4%) than those in the saline (−7.7%) and HA (−14.4%) groups. The score changed more in the CS with HA group than that in the CS group (−43.7%), but there was no significant difference. In the changes in pain, the CS with HA group showed significantly better and faster effects than the saline and HA groups. In the changes of range of motion, functional scores, the CS with HA group showed better results than the saline and HA groups.

Conclusion

In the treatment of AC, the simultaneous injection of CS and HA was more effective in improving SPADI scores at one month after injection than a single injection of CS or HA.

Arthroscopic release in adhesive capsulitis of the shoulder: a retrospective study with 2 to 6 years of follow-up

Background

This study aimed to evaluate the response rate to arthroscopic release treatment in adhesive capsulitis of the shoulder (ACS) for patients with refractory to conservative treatment.

Methods

In this retrospective study, 51 patients (age mean, 49.1±5.6 years) with unilateral adherent capsule underwent arthroscopic releasing surgery for the shoulder capsule. Etiologies of the ACS in 30 patients were idiopathic: 10 patients were affected after surgery and 11 patients following trauma. The patients were evaluated in terms of shoulder function, satisfaction rate, pain intensity, and joint range of motion (ROM) based on a Constant score, a Simple Shoulder Test, the visual analog scale, and four movements, respectively.

Results

The mean Constant score before surgery was 48.2±3.5 and reached 74.4±6 and 77.0±6.3 at 6 months and the final follow-up, respectively (p<0.001). The mean scores of pain intensity, a Simple Shoulder Test, and ROM showed significant improvement at all follow-ups (p<0.001). Sex, age, and diabetes did not have any significant effect on patient recovery. However, patients who experienced ACS after surgery had poorer results than others at all follow-up points.

Conclusions

Arthroscopic releasing surgery of the shoulder in patients with ACS refractory to conservative treatment produces rare complications and an effective injury response. It seems that patients suffering ACS following surgery have a weaker response to the treatment.

Comparison of Treatments for Frozen Shoulder: A Systematic Review and Meta-analysis

IMPORTANCE

There are a myriad of available treatment options for patients with frozen shoulder, which can be overwhelming to the treating health care professional.

OBJECTIVE

To assess and compare the effectiveness of available treatment options for frozen shoulder to guide musculoskeletal practitioners and inform guidelines.

DATA SOURCES

Medline, EMBASE, Scopus, and CINHAL were searched in February 2020.

STUDY SELECTION

Studies with a randomized design of any type that compared treatment modalities for frozen shoulder with other modalities, placebo, or no treatment were included.

DATA EXTRACTION AND SYNTHESIS

Data were independently extracted by 2 individuals. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Random-effects models were used.

MAIN OUTCOMES AND MEASURES

Pain and function were the primary outcomes, and external rotation range of movement (ER ROM) was the secondary outcome. Results of pairwise meta-analyses were presented as mean differences (MDs) for pain and ER ROM and standardized mean differences (SMDs) for function. Length of follow-up was divided into short-term (≤12 weeks), mid-term (>12 weeks to ≤12 months), and long-term (>12 months) follow-up.

RESULTS

From a total of 65 eligible studies with 4097 participants that were included in the systematic review, 34 studies with 2402 participants were included in pairwise meta-analyses and 39 studies with 2736 participants in network meta-analyses. Despite several statistically significant results in pairwise meta-analyses, only the administration of intra-articular (IA) corticosteroid was associated with statistical and clinical superiority compared with other interventions in the short-term for pain (vs no treatment or placebo: MD, -1.0 visual analog scale [VAS] point; 95% CI, -1.5 to -0.5 VAS points; P < .001; vs physiotherapy: MD, -1.1 VAS points; 95% CI, -1.7 to -0.5 VAS points; P < .001) and function (vs no treatment or placebo: SMD, 0.6; 95% CI, 0.3 to 0.9; P < .001; vs physiotherapy: SMD 0.5; 95% CI, 0.2 to 0.7; P < .001). Subgroup analyses and the network meta-analysis demonstrated that the addition of a home exercise program with simple exercises and stretches and physiotherapy (electrotherapy and/or mobilizations) to IA corticosteroid may be associated with added benefits in the mid-term (eg, pain for IA coritocosteriod with home exercise vs no treatment or placebo: MD, -1.4 VAS points; 95% CI, -1.8 to -1.1 VAS points; P < .001).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that the early use of IA corticosteroid in patients with frozen shoulder of less than 1-year duration is associated with better outcomes. This treatment should be accompanied by a home exercise program to maximize the chance of recovery.

Frozen shoulder: overview of clinical presentation and review of the current evidence base for management strategies

Adhesive capsulitis of the shoulder (ACS) is a condition with significant clinical and economic implications. The etiology of adhesive capsulitis is not clearly understood and there remains lack of consensus in clinical management for this condition. It can occur as a primary idiopathic condition or secondary to medical conditions or trauma. The hallmarks of ACS are pain and stiffness, caused by formation of adhesive or scar tissue in the glenohumeral joint. Management strategies vary depending on stage of presentation, patient factors and clinician preferences, and can range from conservative options to surgical intervention. The aim of this review is to summarize the pathophysiology and clinical presentation of ACS and to discuss the evidence base for various management strategies employed today.

Frozen shoulder (FS) is a relatively common condition characterized by pain and stiffness of the shoulder joint. The exact cause of primary FS is unknown and in some patients the condition can persist for several years. Treatment strategies vary depending on stage of presentation, patient factors and clinician preferences. This review gives a summary of the clinical presentation of FS and an overview of the current evidence for both surgical and conservative treatment options for the condition.

A Comprehensive Update of Adhesive Capsulitis and Minimally Invasive Treatment Options

Background

Adhesive capsulitis of the shoulder (AC) is characterized by fibrosis and contracture of the glenohumeral joint capsule, resulting in progressive stiffness, pain, and restriction of motion of the shoulder. The prevalence of AC is estimated to be 2-5% of the general population. Patients with AC typically have an insidious onset of pain and can progress to severe limitation of the shoulder leading to significant disability and decreased quality of life.

Objectives

The objective of this manuscript is to provide a comprehensive review of AC with a focus on clinical presentation, natural history, pathophysiology, and various treatment modalities.

Study Design

A review article.

Setting

A review of literature.

Methods

A search was made on the Pubmed database using the keywords of adhesive capsulitis, frozen shoulder, shoulder capsulitis, arthrofibrosis, shoulder pain, shoulder stiffness.

Results

Our search identified numerous studies in order to provide a comprehensive review of the current understanding of the treatment and management of AC.

Limitations

There remains limited evidence in literature about the understanding of AC and optimal treatment.

Conclusion

AC is an important cause of chronic pain and disability. There is currently no consensus on treatment. Initial treatment modalities revolve around conservative measures as well as aggressive physical therapy. Further treatment options include intraarticular injections, hydro-dilation, nerve blocks, and for more refractory cases, surgical interventions such as arthroscopic capsulotomy.

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.

Evaluating the Outcome of Two Different Regimes in Adhesive Capsulitis: A Prospective Clinical Study

OBJECTIVE

Adhesive capsulitis or frozen shoulder is a painful condition affecting up to 5% of the general population. We conducted this study with the aim of evaluating the results of physiotherapy plus intra-articular methylprednisolone injection versus physiotherapy alone in idiopathic frozen shoulder.

METHODS

This prospective clinical study was conducted in a tertiary care center between August 2016 and August 2018. Patients who were diagnosed with idiopathic frozen shoulder were included in the study, and each patient was randomly allocated to one of two groups: physiotherapy alone (group A) and physiotherapy plus intra-articular steroid injection (group B).

RESULTS

A total of 52 cases diagnosed with idiopathic frozen shoulder were included and treated with the two modalities. There was a significant improvement in group B compared to group A at 6 weeks and 3 months in the range of flexion, abduction, and external rotation. The Shoulder Pain and Disability Index showed improvement in both pain and disability score in group B -compared to group A, and improvement was significant at 6 weeks and 3 months.

CONCLUSION

The results demonstrate the advantages of physiotherapy plus intra-articular steroid injection in idiopathic frozen shoulder. The predictability of results with physiotherapy plus intra-articular steroid injection in selected patients is excellent, and it is a better modality of treatment compared to physiotherapy alone.

Treatment Strategy for Frozen Shoulder

Frozen shoulder (FS) is a common shoulder disorder characterized by a gradual increase of pain of spontaneous onset and limitation in range of motion of the glenohumeral joint. The pathophysiology of FS is relatively well understood as a pathological process of synovial inflammation followed by capsular fibrosis, but the cause of FS is still unknown. Treatment modalities for FS include medication, local steroid injection, physiotherapy, hydrodistension, manipulation under anesthesia, arthroscopic capsular release, and open capsular release. Conservative management leads to improvement in most cases. Failure to obtain symptomatic improvement and continued functional disability after 3 to 6 months of conservative treatment are general indications for surgical management. However, there is no consensus as to the most efficacious treatments for this condition. In this review article, we provide an overview of current treatment methods for FS.

The relationship between joint hypermobility and subacromial impingement syndrome and adhesive capsulitis of the shoulder

OBJECTIVE:

Joint hypermobility (JH) is a clinical condition in which the joints move beyond the expected physiological range of motion. JH can be accompanied by many musculoskeletal complaints. One of the common causes of musculoskeletal pain is shoulder pain. The aim of this study was to investigate the relationship between subacromial impingement syndrome (SAIS), shoulder adhesive capsulitis (AC), and JH in patients with shoulder pain.

METHODS:

Patients aged between 18 and 70 years who presented at the physical medicine and rehabilitation outpatient clinic and who were diagnosed with SAIS or AC in a clinical and physical examination were included in the study. Patients in the same age group without musculoskeletal system pain were included in a control group. All of the cases were assessed for hypermobility using the Beighton score for generalized joint hypermobility (GJH), and the revised 1998 Brighton criteria for benign joint hypermobility syndrome (BJHS).

RESULTS:

Of the 124 cases included in the study, 71 (57.3%) were female and 53 (42.7%) were male. There was no case of GJH in the AC group. There were 2 (4.50%) cases in the SAIS group and 3 (7.5%) in the control group. BJHS was found in 4 (10%) cases in the AC group, 6 (13.63%) in the SAIS group, and 2 (5%) cases in the control group. There was no statistically significant difference between groups in terms of JH (p>0.05). The Beighton scores of the AC group were statistically lower those of the control group (p<0.05).

CONCLUSION:

The results of this study indicated no significant difference between the SAIS group, the AC group, and the control group in terms of GJH and BJHS. The fact that Beighton scores were lower in the AC group than in the control group suggests that the probability of developing AC in those with JH may be lower.

Arthrofibrosis and large joint scarring

Large joint arthrofibrosis and scarring, involving the shoulder, elbow, hip, and knee, can result in the loss of function and immobility. The pathway of joint contracture formation is still being elucidated and is due to aberrations in collagen synthesis and misorientation of collagen fibrils. Novel antibodies are being developed to prevent arthrofibrosis, and current treatment methods for arthrofibrosis include medical, physical, and surgical treatments. This article describes the biology of joint contracture formation, along with current and future pharmacologic, biologic, and medical interventions.

Effectiveness of Nonsurgical Interventions for Managing Adhesive Capsulitis in Patients With Diabetes: A Systematic Review

OBJECTIVE

This systematic review evaluated the effectiveness of nonsurgical interventions for managing adhesive capsulitis (AC) in patients with diabetes on pain, function, and range of motion.

DATA SOURCES

MEDLINE and other databases were searched for studies published in the last 20 years.

STUDY SELECTION

Randomized controlled trials (RCTs) that assessed AC in people with diabetes and implemented 1 or a combination of physiotherapeutic interventions, corticosteroids, and manipulation under anesthesia (MUA) were eligible for inclusion.

DATA EXTRACTION

The Cochrane Risk of Bias was used by 2 independent raters who met to achieve consensus. The quality of trials was assessed using Grading of Recommendations, Assessment, Development and Evaluations. Data extracted from the eligible studies included study design, participant characteristics and duration of symptoms, type of intervention, outcome measures, follow-up intervals, and research findings.

DATA SYNTHESIS

Because of the lack of similar interventions, a narrative synthesis was conducted, and meta-analyses were not performed. The effect sizes or between-group differences of the interventions were reported. A total of 8 RCTs met the inclusion criteria: 4 addressed physiotherapeutic interventions, 3 corticosteroid injections, and 1 MUA. The effect sizes for physiotherapeutic interventions were 0.8-2.0, 0.9-2.0, and 1.0 for ROM, function, and pain, respectively, with the largest effect size (2.0) being reported for joint mobilization plus exercises. The effect sizes for corticosteroids were 0.2-0.5 and 0.1 for ROM and pain. The between-group improvement for MUA was 5.6 points on Constant Shoulder Score.

CONCLUSION

Low-quality evidence suggests large effects of joint mobilization plus exercises on AC in people with diabetes, although confidence in this conclusion is limited due to the high risk of bias. Even weaker support was available for corticosteroid and MUA. Future high-quality RCTs are needed to determine the best intervention for managing AC in patients with diabetes.

The effectiveness of conservative and surgical treatment for shoulder stiffness: a systematic review of current literature

INTRODUCTION

Currently, no therapeutic intervention is universally accepted, and the most effective management for restoring motion and diminishing pain in patients with shoulder stiffness has yet to be defined. This systematic review analyses outcomes of conservative and surgical interventions to treat shoulder stiffness.

SOURCE OF DATA

A systematic review of literature according to the PRISMA guidelines was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, Ovid and Google Scholar databases using various combinations of the keywords 'shoulder', 'shoulder stiffness', 'stiff shoulder', 'conservative', since inception of databases to June 2018 was performed.

AREAS OF AGREEMENT

Shoulder stiffness could be treated with conservative means including nonsteroidal anti-inflammatory medications, corticosteroid injections, or transcutaneous electrical nerve stimulation, manipulation under anaesthesia, and arthroscopic capsular release.

AREAS OF CONTROVERSY

No therapeutic intervention is universally accepted, and the most effective management to restore motion and diminish pain in patients with shoulder stiffness has yet to be defined.

GROWING POINTS

The rate of failure after treatment for stiff shoulder is higher in the surgical group than in the conservative group.

AREAS TIMELY FOR DEVELOPING RESEARCH

There is insufficient evidence to establish whether surgical or conservative management is the best choice to manage shoulder stiffness. Prospective, randomized studies are needed to establish whether surgical or conservative management produce a clinically relevant difference in functional outcome.

A NOVEL APPROACH TO TREATMENT UTILIZING BREATHING AND A TOTAL MOTION RELEASE® EXERCISE PROGRAM IN A HIGH SCHOOL CHEERLEADER WITH A DIAGNOSIS OF FROZEN SHOULDER: A CASE REPORT

BACKGROUND AND PURPOSE

Frozen shoulder (FS) is a condition of the shoulder that is characterized by gradual loss of passive and active range of motion of the glenohumeral joint. Current treatment recommendations remain unclear due to the elusive etiology of FS and absence of nomenclature in the literature. The purpose of this case report is to describe the effects of treatment guided by the assessment and treatment of a breathing pattern disorder (BPD) coupled with Total Motion Release® on a 17-year high school cheerleader with a diagnosis of frozen shoulder.

CASE DESCRIPTION

A 17-year-old female cheerleader reported left anterolateral chest pain after running during cheer practice. The subject continued to experience additional episodes of chest pain and sought out medical care at an emergency department where she was diagnosed with a FS. Clinical findings upon examination included soft tissue muscular irritability, glenohumeral internal and external rotation active range of motion (AROM) loss, and a dysfunctional breathing pattern. Intervention consisted of two types of breathing interventions and a Total Motion Release® (TMR) exercise program. The Numeric Rating Scale (NRS), inclinometer measurements to measure AROM, and breathing assessment outcomes were used to identify patient-reported outcomes and determine treatment effects.

OUTCOMES

The use of the coupled treatment resulted in a resolution of the patient's primary complaint, an increase in AROM, and an improvement in breathing assessment outcomes. After the first treatment, internal rotation (IR) improved by 27° exceeding a minimal detectable change (MDC) of 8°, and after the second treatment, external rotation (ER) improved by 21° exceeding a MDC of 9°. Equally important, there were improvements in flexion (11°) and abduction (45°) exceeding the MDC of 8° and 4° respectively over the course of treatment. The minimal clinically important difference (MCID) on the NRS was exceeded when the patient returned to activity.

DISCUSSION

In this case report, breathing treatments, coupled with a TMR® exercise program, were beneficial treatments for this patient and provided a clinically meaningful resolution of her condition. Clinicians treating patients who display a similar presentation of frozen shoulder can consider this a possible treatment option.

LEVELS OF EVIDENCE

Level 4; single case report.

Outcomes From Conservative Treatment of Shoulder Idiopathic Adhesive Capsulitis and Factors Associated With Developing Contralateral Disease

Background:

Idiopathic adhesive capsulitis is a common condition resulting in painful multidirectional restriction of motion without other identifiable shoulder abnormality. First-line therapies for this condition are nonoperative, but limited data are available regarding which treatments are most effective. Factors associated with contralateral disease are not well established.

Hypothesis:

Younger patients will have a better response to treatments, and older patients and patients with diabetes will be more likely to develop contralateral disease.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients diagnosed with idiopathic adhesive capsulitis were treated with a single intra-articular glenohumeral injection of local anesthetic and corticosteroid as well as 4 weeks of supervised physical therapy (PT). Patients were re-evaluated monthly and received additional conservative treatment based on failure to restore normal motion. Patient-reported outcome scores and range of motion were used to assess treatment efficacy.

Results:

Minimum 2-year follow-up data (mean, 3.4 years) were available for 60 of 75 eligible patients (80%). Patients who did not attend supervised PT as prescribed were more likely to undergo repeat injection due to a lack of adequate range of motion at follow-up (P = .003). Conservative therapy failed in 2 patients (3.3%), and they underwent arthroscopic release and manipulation under anesthesia. Twenty-two patients (36.7%) were subsequently diagnosed with contralateral idiopathic adhesive capsulitis, with a higher incidence in patients with diabetes (P = .009) and patients younger than 50 years (P = .005). American Shoulder and Elbow Surgeons score improved from 41.2 (95% CI, 33.0-49.4) at baseline to 92.0 (95% CI, 88.4-95.6) at final follow-up (P < .0001). Patients with diabetes had a decrease in Shoulder Activity Scale score at final follow-up (P = .049).

Conclusion:

Conservative treatment for idiopathic adhesive capsulitis resulted in good clinical outcomes with a low incidence of surgical intervention. Physical therapy reduced the use of a second injection as part of treatment in this treatment algorithm. Young patients and patients with diabetes may be more likely to develop contralateral disease.

Effectiveness of translational manipulation under interscalene block for the treatment of adhesive capsulitis of the shoulder: A nonrandomized clinical trial

Study Design: Nonrandomized controlled trial. Objective: To determine whether translational manipulation under anesthesia/local block (TMUA) adds to the benefit of mobilization and range of motion exercise for improving pain and functional status among patients with adhesive capsulitis of the shoulder (AC). Background: TMUA has been shown to improve pain and dysfunction in patients with AC. This intervention has not been directly compared to physical therapy treatment without TMUA in a prospective trial. Methods: Sixteen consecutive patients with a primary diagnosis of AC were divided into two groups. Patients in the first (TMUA) group received a session of translational manipulation under interscalene block, followed by six sessions of manipulation and exercise. Patients in the comparison group received seven sessions of manipulation and exercise. Outcome measures taken at baseline and 3, 6, 12 months and 4 years included Shoulder Pain and Disability Index (SPADI) scores. Four-year outcomes included percent of normal ratings, medication use, and activity limitations. Results: Both groups showed improved SPADI scores across all follow-up times compared to baseline. The TMUA group showed a greater improvement in SPADI scores than the comparison group at 3 weeks, with no significant differences in SPADI scores at other time points. However, at 4 years, significantly more subjects in the comparison group (5 of 8) had activity limitations versus subjects in the TMUA group (1 of 8). No subject experienced a complication from either intervention protocol. Conclusion: Physical therapy consisting of manual therapy and exercise provides benefit for patients with AC. Translational manipulation under local block may be a useful adjunct to manual therapy and exercise for patients with AC.

Analysis of the Clinical Outcome of Arthrographic Steroid Injection for the Treatment of Adhesive Capsulitis

BACKGROUND

Idiopathic adhesive capsulitis is a condition of uncertain etiology characterized by pain and decreased shoulder range of motion (ROM) that occurs without a known intrinsic disorder. Many treatments have been advocated, yet the best option remains unclear. The purpose of this study was to determine if arthrographic injection of the shoulder joint with steroid and local anesthetic results in decreased pain and increased shoulder function in a cohort of patients with idiopathic adhesive capsulitis.

METHODS

This is a retrospective case series of patients who were treated with an arthrographic steroid and local anesthetic injection for adhesive capsulitis. The injections were all given by the same musculoskeletal radiologist using image guidance, and the patients were all from the same surgeon's practice. Patients were evaluated with the Shoulder Pain and Disability Questionnaire (SPADI) and Constant Shoulder Score and their shoulder ROM was tested. Descriptive statistics in the form of counts, percentages, means and standard deviations were used, as well as parametric and non-parametric tests.

RESULTS

Thirty-three shoulders in 25 patients were examined. The average length of follow-up was 17 months. Sixty-nine percent of the cohort continued to complain of some shoulder pain in the post-injection follow-up clinic, however, their pain had improved from 8.8/10 pre-injection to 2.2/10 post-injection (p=0.01). The average score of the SPADI Pain, SPADI Disability and Constant Score were 36, 31 and 64, respectively.

CONCLUSION

All patients who received an arthrographic injection using steroid and local anesthetic reported improved pain and mobility. In addition, those who had tried other treatment modalities felt that the injection had been the most beneficial.

Intra-articular Steroid Injection for Frozen Shoulder: A Systematic Review and Meta-analysis of Randomized Controlled Trials With Trial Sequential Analysis

BACKGROUND

Intra-articular steroid injection is a common intervention for frozen shoulder (FS).

PURPOSE

This review aimed to illustrate the effects of intra-articular steroid injection for FS.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

PubMed, Embase, and the Cochrane Library were searched for randomized controlled trials (RCTs) comparing intra-articular steroid injection with no injection or sham injections for FS. Visual analog scale (VAS) pain scores were the primary outcome measure. Secondary outcome measures included passive external rotation, abduction, flexion, internal rotation, and functional scores. Complication rates were the safety outcome measure. Comparisons were performed with mean differences (MDs) and 95% confidence intervals (95% CIs). Three time intervals were analyzed: 4 to 6 weeks, 12 to 16 weeks, and 24 to 26 weeks postintervention. Trial sequential analysis was used to verify the pooled results. Line charts were drawn to view the recovery trend in both the intervention and control groups.

RESULTS

Eight RCTs with 416 patients were included. Compared with controls, patients who received intra-articular steroid injection had significantly reduced VAS pain scores at 4 to 6 weeks (MD, 1.28 cm [95% CI, 0.75 to 1.82]), 12 to 16 weeks (MD, 1.00 cm [95% CI, 0.47 to 1.52]), and 24 to 26 weeks (MD, 0.65 cm [95% CI, 0.19 to 1.10]) postinjection. Trial sequential analysis confirmed the pooled results at 4 to 6 weeks and 12 to 16 weeks but not at 24 to 26 weeks. Patients who received intra-articular steroid injection had improved passive external rotation, abduction, and flexion and Shoulder Pain and Disability Index (SPADI) scores at all 3 time intervals, as well as improved American Shoulder and Elbow Surgeons (ASES) scores at 12 to 16 weeks (MD, 12.20 [95% CI, 2.55 to 21.85]). No difference was noticed in Constant scores (MD, 5.70 [95% CI, -0.59 to 11.99]) or internal rotation except at 12 to 16 weeks (MD, 0.81° [95% CI, 0.18° to 1.44°]) and 24 to 26 weeks (MD, 3.88° [95% CI, 0.51° to 7.25°]) between steroid injection and placebo. Complication rates were 1.78% for facial flushing, 0.71% for dizziness owing to vasovagal reactions during injection, 1.07% for chest or shoulder pain, and 0.36% for nausea. Line charts improved in both groups.

CONCLUSION

Intra-articular steroid injection is effective and safe for FS and relieves pain, improves functional performance, and increases range of motion. The effects are significant at 4 to 6 and 12 to 16 weeks postintervention and may last as long as 24 to 26 weeks.

Effectiveness of corticosteroid injections in adhesive capsulitis of shoulder: A meta-analysis

BACKGROUND

Primary adhesive capsulitis is mainly characterized by spontaneous chronic shoulder pain and the gradual loss of shoulder motion. The main treatment for adhesive capsulitis is a trial of conservative therapies, including analgesia, exercise, physiotherapy, oral nonsteroidal anti-inflammation drugs, and intra-articular corticosteroid injections. Previously, it was reported that intra-articular corticosteroid lead to fast pain relief and improvement of range of motion (ROM). The objective of this study was to determine whether corticosteroid injections would lead to better pain relief and greater improvement in ROM.

METHODS

We searched PubMed, Medline, and the Cochrane library. We included 5 articles of the 1166 articles identified. Totally injection group included 115 patients and placebo group included 110 patients. We calculated the weighted mean differences to evaluate the pain relief as the primary outcome. We determined the ROM as the secondary outcome. Study quality was evaluated using the 12-item scale. We also used the criteria of the Grading of Recommendations Assessment, Development and Evaluation to evaluate the quality of evidence.

RESULTS

In total, 5 studies were included, 4 of which were randomized clinical trials, with a sample size of 225 patients with adhesive capsulitis of the shoulders. The overall pooled data demonstrated that, compared with placebo as control treatment, intra-articular corticosteroid injections were more effective in reducing the pain score at 0 to 8 weeks, but there was no difference between the injection group and the control group at 9 to 24 weeks. Improvement of ROM in the injection group was greater than that of the control group both at 0 to 8 and 9 to 24 weeks.

CONCLUSIONS

Intra-articular corticosteroid injections were more effective in pain relief in the short term, but this pain relief did not sustain in the long term. Intra-articular corticosteroid injection resulted in greater improvement in passive ROM both in the short and the long terms.

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.

Randomized controlled trial of supervised physiotherapy versus a home exercise program after hydrodilatation for the management of primary frozen shoulder

HYPOTHESIS AND BACKGROUND

Hydrodilatation and physiotherapy are commonly used treatments for primary frozen shoulder. Little is known about the optimal form of physiotherapy. This study reports a randomized controlled trial comparing 2 forms of physiotherapy after hydrodilatation. The null hypothesis was that there would be no difference between the 2 groups at 1 year as measured by the Oxford Shoulder Score (OSS).

METHODS

We randomized 41 patients undergoing hydrodilatation for primary frozen shoulder into 2 treatment groups: group 1 (n = 20) underwent supervised physiotherapy in addition to a home exercise program, and group 2 (n = 21) followed a self-directed home exercise program in isolation. Assessment was carried out by a blinded research nurse at baseline, 4 weeks, 3 months, 6 months, and 1 year. The primary outcome measure was the OSS. Other measures were range of movement, visual analog scale pain score, and EQ-5D index.

RESULTS

There was no significant difference between the treatment groups at any time point as measured by the OSS or EQ-5D index. In group 1, the OSS improved significantly from 25.00 (95% confidence interval [CI], 21.92-28.08) at baseline to 38.29 (95% CI, 34.01-42.58; P < .0001) at 4 weeks and 43.71 (95% CI, 41.61-45.80; P < .0001) at 1 year. In group 2, the OSS improved significantly from 26.60 at baseline (95% CI, 22.50-30.70) to 40.07 (95% CI, 36.77-43.36; P < .0001) at 4 weeks and 43.00 (95% CI, 39.69-46.31; P < .0001) at 1 year. All outcome measures improved significantly from baseline to 4 weeks.

CONCLUSION

In this group of patients, after a hydrodilatation procedure for the treatment of primary frozen shoulder, there was no significant difference in clinical outcomes between supervised physiotherapy in addition to a home exercise program and a self-directed home exercise program in isolation.

Adhesive capsulitis of the shoulder: review of pathophysiology and current clinical treatments

Adhesive shoulder capsulitis, or arthrofibrosis, describes a pathological process in which the body forms excessive scar tissue or adhesions across the glenohumeral joint, leading to pain, stiffness and dysfunction. It is a debilitating condition that can occur spontaneously (primary or idiopathic adhesive capsulitis) or following shoulder surgery or trauma (secondary adhesive capsulitis). Here, we review the pathophysiology of adhesive shoulder capsulitis, highlighting its clinical presentation, natural history, risk factors, pathoanatomy and pathogenesis. Both current non-operative and operative treatments for adhesive capsulitis are described, and evidence-based studies are presented in support for or against each corresponding treatment. Finally, the review also provides an update on the gene expression profile of adhesive capsulitis and how this new understanding can help facilitate development of novel pharmacological therapies.

A Review of Systematic Reviews of the Effectiveness of Conservative Interventions for Rotator Cuff Tendinopathy

Background

Rotator cuff tendinopathy is common and a wide range of conservative interventions are currently used to treat this problem. The purpose of this review is to systematically review the systematic reviews that evaluate the effectiveness of conservative interventions for rotator cuff tendinopathy.

Methods

An electronic search of PEDro, MEDLINE and the Cochrane Library was undertaken and supplemented by hand and citation searching. The AMSTAR checklist was adopted for quality appraisal and a narrative synthesis was undertaken.

Results

Twenty-six systematic reviews were retrieved. Methodological quality was variable. Exercise and multimodal physiotherapy appear to confer superior outcomes over no treatment or placebo, although the clinical significance of these results remains unclear. Surgery does not confer an additional benefit over exercise alone or multimodal physiotherapy. Combining manual therapy with exercise is not currently supported, neither is the use of corticosteroid injections or acupuncture. Other commonly prescribed interventions lack evidence of effectiveness.

Conclusions

Exercise and multimodal physiotherapy might be effective interventions for rotator cuff tendinopathy, although the clinical significance of this effect is unclear. This interpretation is drawn from systematic reviews comprising mainly small randomized controlled trials that frequently measure outcome in a heterogeneous manner, limiting the strength of any conclusions.

Is there a short-term benefit from an intra-articular steroid injection in female patients with adhesive capsulitis of the shoulder treated with physiotherapy?

INTRODUCTION

The purpose of this retrospective study was to investigate the possible short-term benefit of a single intra-articular corticosteroid injection in those patients treated with physiotherapy when compared to a group of patients undergoing physiotherapy only (PT only).

METHODS

A retrospective chart review was conducted to identify eligible patients treated over a 4-year period. All female patients between 40 years and 60 years with a confirmed clinical diagnosis of idiopathic adhesive capsulitis who completed a prescribed physiotherapy program were considered eligible. Sixty-three patients fulfilled the inclusion criteria, but 22 were excluded because of missing data in the medical record. The remaining 41 patients comprise the study cohort; an experienced musculoskeletal physiotherapist assessed these patients both at initial presentation and at 12 weeks. Twenty patients with a mean age of 55.1 years underwent PT only and 21 patients with a mean age of 52.4 years received a single intra-articular dose of 40 mg methylprednisolone followed by physiotherapy. Outcome measures included the visual analogue scale (VAS) and measurement of range of motion.

RESULTS

At final assessment (12 weeks), significant between-group differences were identified for the 'PT only' group for flexion ( p = 0.01) and abduction ( p = 0.008). When comparing the mean change from the initial assessment, a significant between-group difference was observed for abduction ( p = 0.03).

CONCLUSIONS

The results of this study suggest that the intra-articular injection of a single dose of cortisone has no significant short-term benefit in female patients with idiopathic adhesive capsulitis managed with physiotherapy.

Effects of two different mobilization techniques on pain, range of motion and functional disability in patients with adhesive capsulitis: a comparative study

[Purpose] This study aimed to compare the effects of two different mobilization techniques in the management of patients with adhesive capsulitis. [Subjects and Methods] Thirty non-diabetic men and women with adhesive capsulitis were randomly allocated to the reverse distraction group (n=15) or Kaltenborn group (n=15). The reverse distraction technique and Kaltenborn’s caudal and posterior glides (grades III and IV) were applied 10–15 times along with conventional physical therapy for 18 treatment sessions in 6 weeks. Pain was measured with a visual analog scale, abduction and external rotation range of motion with goniometry, hand behind back reach with inch tape, and functional disability with the Flexilevel scale of shoulder function before and after the treatment. [Results] Although all the variables improved significantly in both groups after 18 intervention sessions, reverse distraction was significantly better than Kaltenborn’s caudal and posterior glides in decreasing pain and improving abduction range of motion and functional scores. [Conclusion] This study supports the clinical use of reverse distraction as an alternative to conventional mobilization techniques to decrease pain and improve range of motion and functional scores in patients with adhesive capsulitis.

Clinical efficacy of hydrodistention with joint manipulation under interscalene block compared with intra-articular corticosteroid injection for frozen shoulder: a prospective randomized controlled study

BACKGROUND

Hydrodistention is known to be an effective method of treatment for frozen shoulder. However, hydrodistention is accompanied by severe pain during the procedure. An interscalene block may relieve the severe pain associated with the procedure of hydrodistention. This study compared the clinical efficacy of hydrodistention with joint manipulation under an interscalene block with that of intra-articular corticosteroid injection.

METHODS

This prospective randomized controlled study included 121 patients presenting with frozen shoulder. Patients were randomized into 2 groups; those in group A (60 patients) were treated by hydrodistention with joint manipulation under an interscalene block, and those in group B (61 patients) were managed with intra-articular corticosteroid injection. Pain intensity and patient satisfaction were assessed by the visual analog scale. Functional outcomes were assessed by the Constant score and the range of shoulder motion.

RESULTS

Group A demonstrated better patient satisfaction and earlier restoration of range of motion than group B at 6 weeks (P ≤ .001). At 12 weeks, the pain score was lower and the Constant score was better in group A than in group B. However, at 12 months after treatment, pain score (P = .717), patient satisfaction (P = .832), range of motion (P > .05), and Constant score (P = .480) were similar in the 2 groups.

CONCLUSION

Hydrodistention combined with joint manipulation under an interscalene block provided earlier pain relief and restoration of shoulder range of motion and function compared with single intra-articular corticosteroid injection in patients with primary frozen shoulder.

Intelligent framework for diagnosis of frozen shoulder using cross sectional survey and case studies

OBJECTIVES

Frozen shoulder is a disease in which shoulder becomes stiff. Accurate diagnosis of frozen shoulder is helpful in providing economical and effective treatment for patients. This research provides the classification of unstructured data using data mining techniques. Prediction results are validated by K-fold cross-validation method. It also provides accurate diagnosis of frozen shoulder using Naïve Bayesian and Random Forest models. At the end results are presented by performance measure techniques.

METHODS

In this research, 145 respondents (patients) with a severe finding of frozen shoulder are included. They are selected on premise of (clinical) assessment confirmed after by MRI. This data is taken from the department of Orthopedics (Pakistan Institute of Medical Sciences Islamabad and Railway Hospital Rawalpindi) between September 2014 to November 2015. Frozen shoulder is categorized on the basis of MRI result. The predictor variables are taken from patient survey and patient reports, which consisted of 35+ variables. The outcome variable is coded into numeric system of "intact" and "no-intact". The outcome variable is assigned into numeric code, 1 for "intact" and 0 for "no-intact". "Intact" group is used as an indication that tissue is damaged badly and "no-intact" is classified as normal. Distribution of result is 110 patients for "Intact" group and 35 patients for "No-Intact" group (false positive rate was 24 %). In this research we have utilized two methods i.e. Naive Bayes and Random Forest. A statistics regression model (Logistic regression) to categorize frozen shoulder finding into "intact" and "no-intact" classes. In the end, we validated our results by Bayesian theorem. This gives a rough estimate about the probability of frozen shoulder.

RESULTS

In this research, our anticipated and predictive procedures gave better outcome as compared to statistical techniques. The specificity and sensitivity ratio of predicting a frozen shoulder are better in the Naïve Bayes as compared to Random Forest. In end the likelihood ratio results are used with Bayesian theorem for final evaluation of the results, from this we conclude predictive model is valid model for classification of frozen shoulder.

CONCLUSIONS

We have used three predictive models in our study to classify frozen shoulder. Then we validated our predictive results by Bayesian theorem to give a rough estimate about the probability of occurrence of disease or not. This enhances the clinical decision making regarding frozen shoulder.

Short-term outcomes after arthroscopic capsular release for adhesive capsulitis

BACKGROUND

Little is known about the short-term temporal outcomes of an arthroscopic capsular release for adhesive capsulitis (frozen shoulder). Specifically, it is not known how immediate the improvements are and how quickly patients return to normal function after an arthroscopic release.

METHODS

The study included 140 shoulders in 133 patients with idiopathic adhesive capsulitis who underwent a complete arthroscopic release of the shoulder capsule, performed by a single surgeon in a day surgery setting. Patient-reported pain and shoulder function were evaluated with the use of Likert scales, and an independent examiner assessed shoulder strength and range of motion preoperatively and at 1 week, 6 weeks, 12 weeks, and 24 weeks postoperatively.

RESULTS

Arthroscopic capsular release resulted in immediate improvements in pain, functional outcomes, and range of motion (P < .0001). External rotation increased from 21° ± 17° (mean ±  standard deviation) to 76° ± 17° at 1 week. Passive range of shoulder motion improved at 1 week, deteriorated slightly at 6 weeks, and then continued to improve at 12 and 24 weeks. Before surgery, 38% of patients reported that they "always" experienced extreme pain. This proportion reduced to 30% (P < .0001) at 1 week postoperatively and 2% (P < .0001) at 24 weeks postoperatively. There were no complications.

CONCLUSIONS

Patients who underwent an arthroscopic capsular release for idiopathic adhesive capsulitis experienced significant reductions in pain, improvements in range of motion, and improvements in overall shoulder function in the first postoperative week. These immediate improvements in pain and function continue to improve at 6, 12, and 24 weeks postoperatively.

Corticosteroid injection for adhesive capsulitis in primary care: a systematic review of randomised clinical trials

Adhesive capsulitis is a common cause of shoulder pain and limited movement. The objectives of this review were to assess the efficacy and safety of corticosteroid injections for adhesive capsulitis and to evaluate the optimum dose and anatomical site of injections. PubMed and CENTRAL databases were searched for randomised trials and a total of ten trials were included. Results revealed that corticosteroid injection is superior to placebo and physiotherapy in the short-term (up to 12 weeks). There was no difference in outcomes between corticosteroid injection and oral nonsteroidal anti-inflammatory drugs at 24 weeks. Dosages of intra-articular triamcinolone 20 mg and 40 mg showed identical outcomes, while subacromial and glenohumeral corticosteroid injections had similar efficacy. The use of corticosteroid injections is also generally safe, with infrequent and minor side effects. Physicians may consider corticosteroid injection to treat adhesive capsulitis, especially in the early stages when pain is the predominant presentation.

Does chondrolysis occur after corticosteroid-analgesic injections? An analysis of patients treated for adhesive capsulitis of the shoulder

BACKGROUND

Clinical studies using continuous infusions of local anesthetics and basic science studies that model injections of local anesthetics have shown chondrotoxicity. However, clinical studies do not exist that have assessed for the risk of chondrolysis in nonarthritic joints exposed to single or intermittent corticosteroid or analgesic injections. Currently, there are no data available to guide the clinician on the safety of using these injections in clinical practice.

MATERIALS AND METHODS

A retrospective review of patients treated for adhesive capsulitis of the shoulder with at least 1 intra-articular injection of a corticosteroid and anesthetic was performed. The inclusion criteria were a diagnosis of adhesive capsulitis and a minimum 2-year follow-up. Prospective follow-up was performed to obtain patient-determined outcome scores, range of motion, and radiographs to determine the presence of chondrolysis.

RESULTS

Fifty-six patients with a mean age of 52.5 ± 7.2 years were enrolled at a mean follow-up of 54 months. The mean number of injections performed was 1.5 ± 0.7 (range, 1-4). At final follow-up, the mean Western Ontario Osteoarthritis of the Shoulder score was 91.4% ± 14.2%; Disabilities of the Arm, Shoulder and Hand score, 6.7 ± 9.6; Shoulder Pain and Disability Index score, 7.4 ± 11.4; and Single Assessment Numeric Evaluation score, 92.7% ± 10.1%. The Shoulder Activity Score was 8.3 ± 4.7. Passive and active forward elevation, external rotation, internal rotation, and cross-body adduction showed no significant differences compared with the unaffected contralateral shoulder. There was no radiographic evidence of chondrolysis in any patient.

CONCLUSIONS

This study did not show chondrolysis in patients treated with an intra-articular corticosteroid and local anesthetic for adhesive capsulitis. The findings of this study do not support the cessation of using intra-articular analgesic-corticosteroid injections for the treatment of adhesive capsulitis.

LEVEL OF EVIDENCE

Level IV; Case Series; Treatment Study.

Steroid Injection Versus Physiotherapy for Patients With Adhesive Capsulitis of the Shoulder: A PRIMSA Systematic Review and Meta-Analysis of Randomized Controlled Trials

To compare the effect of steroid injection and physiotherapy for patients with adhesive capsulitis of the shoulder (ACS).An electronic search was performed on Pubmed, Embase, and Cochrane library, and reference lists were also reviewed for randomized controlled trials (RCTs) comparing steroid injection and physiotherapy for patients with ACS. The quality of included studies were assessed using PEDro scale. Standardized mean differences (SMDs) and 95% confidence interval (CI) were used for comparisons. The primary outcome was functional improvement.Nine RCTs including 453 patients were identified. From 6-7 weeks to 24-26 weeks postintervention, no superiority was noted in favor of either steroid injection or physiotherapy for functional improvement (SMD 0.28; 95% CI -0.01-0.58; P = 0.06) or pain relief (SMD -0.10; 95% CI -0.70-0.50; P = 0.75). Steroid injection provided more improvement in passive external rotation at 24 to 26 weeks (3 studies, SMD 0.42; 95% CI 0.11-0.72; P = 0.007) but not at 6 to 7 weeks (4 studies, SMD 0.63; 95% CI 0.36-0.89; P = 0.32) or 12 to 16 weeks (3 studies, SMD -0.07; 95% CI -0.79-0.65; P = 0.85). Steroid injection was as safe as physiotherapy for patients with ACS (risk ratio 0.94; 95% CI 0.67-1.31).Both steroid injection and physiotherapy are equally effective for patients with ACS. One steroid injection might be the 1st choice for ACS. Results should be interpreted with caution due to the heterogeneity among the studies.