Effectiveness of Hydrodilatation in Adhesive Capsulitis of Shoulder: A Systematic Review and Meta-Analysis

Functional Outcome of Hydrodilation in Adhesive Capsulitis of Shoulder

Introduction

Adhesive capsulitis, or frozen shoulder, is a painful and disabling condition characterized by progressive restriction of shoulder movement. Hydrodilatation, a minimally invasive procedure involving joint capsule distension, has been proposed as an effective treatment option. This study evaluates the functional outcomes of hydrodilatation in patients with adhesive capsulitis using the Constant-Murley score (CMS) and American Shoulder and Elbow Surgeons (ASES) score, along with pre- and post-procedure range of motion (ROM) assessments.

Materials and Methods

A prospective observational study was conducted on 30 patients diagnosed with adhesive capsulitis who underwent hydrodilatation. Functional and ROM improvements were assessed at baseline, post-procedure, 1 month, 3 months, 6 months, and 1 year. Data were analyzed using paired t-tests, and P < 0.05 was considered statistically significant.

Results

The mean age of participants was 47.7 ± 9.8 years. The study population comprised 14 males (46.7%) and 16 females (53.3%), indicating a slightly higher prevalence among females. Significant improvements were observed in active and passive abduction, adduction, forward flexion, and external rotation (P < 0.001). Internal rotation restriction reduced from 59.1% to 40.9% (P < 0.001). Functional scores (ASES and CMS) showed progressive improvement, with ASES increasing from 41.1 ± 6.1 to 65.9 ± 8.4 and CMS from 44.4 ± 5.8 to 64.8 ± 9.1 at 1 year (P < 0.001).

Conclusion

Hydrodilatation is an effective and well-tolerated intervention for improving shoulder function in adhesive capsulitis, with sustained benefits up to 1 year. Future studies should focus on standardizing treatment protocols and optimizing patient selection criteria.

British Elbow and Shoulder Society patient care pathway: Frozen shoulder

Background

Current guidelines from the British Elbow and Shoulder Society (BESS) were published in 2015 for managing frozen shoulders in the primary and secondary care setting. Updated guidelines have been developed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology.

Methods

A multi-disciplinary BESS Working Group defined key management questions based on agreed outcome measures and time points. A literature search, conducted up to March 2023 following PRISMA guidelines, identified randomised controlled trials, systematic reviews, and meta-analyses. Quality assessments were performed using the GRADE Decision Framework, considering bias, imprecision, indirectness, and inconsistency. Data were extracted for meta-analysis. In the absence of high-quality trials, narrative reviews were created.

Results

Consensus opinions produced statements based on the quality and volume of evidence and the magnitude of desirable and undesirable effects. These statements form a comprehensive framework for managing frozen shoulder.

Discussion

This updated guideline provides evidence-based guidance for managing frozen shoulder and identifies key areas for future research.

Pharmacoacupuncture for the Treatment of Frozen Shoulder: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Pharmacoacupuncture (PA) is an alternative injection therapy for a broad range of conditions. This meta-analysis evaluates the effectiveness and safety of PA in treating frozen shoulder (FS) and aims to standardise PA characteristics in clinical practice.

METHODS

Randomized controlled trials (RCTs) assessing PA for FS were systematically reviewed from seven electronic databases up to August 31, 2023. Outcomes measured included the visual analogue scale (VAS) or numerical rating scale (NRS), effective rate, Constant-Murley Score (CMS), Shoulder Pain and Disability Index (SPADI), ROM, quality of life (QoL), and adverse events. Data analysis was conducted using RevMan 5.3, with the risk of bias in each trial evaluated using Cochrane's risk of bias tool. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool assessed the quality of evidence.

RESULTS

Thirteen RCTs involving 1034 patients met the inclusion criteria, with eleven RCTs and 872 patients included in the meta-analysis. PA showed low-quality evidence of improvement in VAS, effective rate, CMS Total, and CMS Pain. Moderate-quality evidence indicated improvement in CMS ADL and CMS Mobility. PA was effective in four SF-36 subscales: physical function, social role function, mental health, and emotional role function. No significant difference in CMS strength was observed. One trial reported mild anaphylaxis reaction to bee venom as an adverse event.

CONCLUSION

PA may offer potential benefits as an alternative injection therapy for FS patients. Further well-designed RCTs with rigorous methodology are required to substantiate its therapeutic efficacy and clinical utility.

REGISTRATION

PROSPERO (CRD42023445708).

Additive effect of glenohumeral joint hydrodilatation applied in addition to suprascapular nerve blockage in patients with adhesive capsulitis

BACKGROUND

We aimed to investigate the efficacy of shoulder hydrodilatation (HD) applied in addition to suprascapular nerve blockage (SSNB) on severity of pain, shoulder joint range of motion (ROM), functional status, handgrip (HG) strength in patients with adhesive capsulitis (AC).

METHODS

Forty-eight patients who were diagnosed with AC based on physical examination findings included in the study. The patients were randomized into two groups as combination of SSNB + HD and SSNB alone. Injections were performed under ultrasonography guidance. Shoulder ROM angles were measured with a goniometer. Pain intensity was evaluated with visual analog scale. Functional status was evaluated with Quick Disability of Arm, Shoulder, and Hand (QDASH). HG strength was measured by a Jamar dynometer. After the injection, a home-based exercise program was given to all patients. Patients were evaluated at baseline, 1st and 3rd month.

RESULTS

Abduction and external rotation ROM angles were statistically significantly limited in SSNB group, at baseline (p = 0.020, p = 0.018, respectively). In terms of other parameters, both groups were similar at baseline (p > 0.05). At comparison of baseline-1st month, a significant improvement was observed in VAS score, abduction and flexion ROM and QDASH score, in both groups (p < 0.05), however, there was no statistically significant difference between the groups. There is a statistically significant decrease in VAS score in both groups, at all times, but, no significant difference between the groups. At the comparison of baseline-3rd month measurements, it was observed that all of the parameters significantly improved in both groups, and there was no statistically significant difference between the groups except for abduction and external rotation ROM (p > 0.05). Abduction ROM and external rotation ROM were significantly higher in the SSNB group than SSNB + HD group at 3rd month.

CONCLUSIONS

Both SSNB + HD and SSNB alone provide significant improvement clinically especially in shoulder pain. HD added to SSNB does not seem to provide any additional benefit. SSNB is an effective treatment option for up to 3 months in patients with AC, mainly in abduction and external rotation limitation.

The S2e Guideline on Shoulder Stiffness

The clinical picture of "frozen shoulder" is still poorly understood. In order to present the current state of knowledge on aetiology, diagnosis, and treatment, and to provide recommendations for the professional groups involved, a working group was formed by the DGOU and the DVSE to create a German language, evidence-based guideline, which was published in 2022 by the AWMF. The following summarises the development and the most important results.

Pharmacoacupuncture for the Treatment of Frozen Shoulder: protocol for a systematic review and meta-analysis

Objectives

Frozen shoulder (FS) is one of the most challenging shoulder disorders for patients and clinicians. Its symptoms mainly include any combination of stiffness, nocturnal pain, and limitation of active and passive glenohumeral joint movement. Conventional treatment options for FS are physical therapy, nonsteroidal anti-inflammatory drugs, injection therapy, and arthroscopic capsular release, but adverse and limited effects continue to present problems. As a result, pharmacoacupuncture (PA) is getting attention as an alternative therapy for patients with FS. PA is a new form of acupuncture treatment in traditional Korean medicine (TKM) that is mainly used for musculoskeletal diseases. It has similarity and specificity compared to corticosteroid injection and hydrodilatation, making it a potential alternative injection therapy for FS. However, no systematic reviews investigating the utilization of PA for FS have been published. Therefore, this review aims to standardize the clinical use of PA for FS and validate its therapeutic effect.

Methods

The protocol was registered in Prospero (CRD42023445708) on 18 July 2023. Until Aug. 31, 2023, seven electronic databases will be searched for randomized controlled trials of PA for FS. Authors will be contacted, and manual searches will also be performed. Two reviewers will independently screen and collect data from retrieved articles according to predefined criteria. The primary outcome will be pain intensity, and secondary outcomes will be effective rate, Constant-Murley Score, Shoulder Pain and Disability Index, range of motion, quality of life, and adverse events. Bias and quality of the included trials will be assessed using the Cochrane handbook's risk-of-bias tool for randomized trials. Meta analyses will be conducted using Review Manager V.5.3 software. GRADE will be used to evaluate the level of evidence for each outcome.

Results

This systematic review and meta-analysis will be conducted following PRISMA statement. The results will be published in a peer-reviewed journal.

Conclusion

This review will provide scientific evidence to support health insurance policy as well as the standardization of PA in clinical practice.

Ultrasound-guided hydrodilatation for adhesive capsulitis: capsule-preserving versus capsule-rupturing technique

OBJECTIVE

To compare the clinical efficacy of capsule-rupturing versus capsule-preserving ultrasound-guided hydrodilatation in patients with shoulder adhesive capsulitis (AC). To determine potential factors affecting the outcome over a 6-month follow-up.

MATERIALS AND METHODS

Within a 2-year period, 149 consecutive patients with AC were prospectively enrolled and allocated into (i) group-CR, including 39 patients receiving hydrodilatation of the glenohumeral joint (GHJ) with capsular rupture and (ii) group-CP, including 110 patients treated with GHJ hydrodilatation with capsular preservation. Demographics, affected shoulder, and AC grade were recorded. Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and visual analog scale (VAS) were used for clinical assessment at baseline/1/3/6 months. Comparisons were performed with Mann-Whitney U test and Kolmogorov-Smirnov test. Linear regression was used to identify predictors of outcome. P value < 0.05 defined significance.

RESULTS

DASH and VAS scores in both groups improved significantly compared to baseline (P < 0.001) and were significantly lower in the CP compared to CR group at all time-points following intervention (P < 0.001). Capsule rupture was a significant predictor of DASH score at all time-points (P < 0.001). DASH scores correlated to initial DASH score at all time-points (P < 0.001). DASH/VAS scores at 1 month were correlated to the AC grade (P = 0.025/0.02).

CONCLUSION

GHJ hydrodilatation results in pain elimination and functional improvement till the mid-term in patients with AC, with improved outcome when adopting the capsule-preserving compared to the capsule-rupturing technique. Higher initial DASH score is predictive of impaired functionality in the mid-term.

A high level of scientific evidence is available to guide treatment of primary shoulder stiffness: The SIAGASCOT consensus

PURPOSE

Shoulder stiffness (SS) is a condition characterised by active and passive restricted glenohumeral range of motion, which can occur spontaneously in an idiopathic manner or be associated with a known underlying aetiology. Several treatment options are available and currently no consensus has been obtained on which treatment algorithm represents the best choice for the patient. Herein we present the results of a national consensus on the treatment of primary SS.

METHODS

The project followed the modified Delphi consensus process, involving a steering, a rating and a peer-review group. Sixteen questions were generated and subsequently answered by the steering group after a thorough literature search. A rating group composed by professionals specialised in the diagnosis and treatment of shoulder pathologies rated the question-answer sets according to the scientific evidence and their clinical experience.

RESULTS

Recommendations were rated with an average of 8.4 points out of maximum 9 points. None of the 16 answers received a rating of less than 8 and all the answers were considered as appropriate. The majority of responses were assessed as Grade A, signifying a substantial availability of scientific evidence to guide treatment and support recommendations encompassing diagnostics, physiotherapy, electrophysical agents, oral and injective medical therapies, as well as surgical interventions for primary SS.

CONCLUSIONS

A consensus regarding the conservative and surgical treatment of primary SS could be achieved at a national level. This consensus sets basis for evidence-based clinical practice in the management of primary SS and can serve as a model for similar initiatives and adaptable guidelines in other European countries and potentially on a global scale.

LEVEL OF EVIDENCE

Level I.

Long-Term Outcomes of Ultrasound-Guided Hydrodistension for Adhesive Capsulitis: A Prospective Observational Study

Ultrasound-guided hydrodistention has been established as an effective minimally invasive treatment option for glenohumeral joint adhesive capsulitis (AC). Nonetheless, the long-term outcomes of the procedure have not yet been established. A total of 202 patients with AC were prospectively recruited and followed up for a total of 2 years. Pain and functionality were assessed with the use of the visual analogue scale (VAS) and the disabilities of the arm, shoulder, and hand (DASH) score, respectively, at the beginning and the end of the follow-up period. The relapse of AC over the 2-year period and the effect of diabetes were also evaluated in the treatment cohort. The Mann-Whitney U test was used to compare mean scores at the two time points, and Cox survival analysis and χ2 test were used to assess the effect of diabetes on AC relapse. VAS and DASH scores were significantly lower at 2 years compared with the beginning of the follow-up period (p < 0.001). Diabetes was diagnosed in 38/202 patients (18.8%) and was found to be significantly associated with recurrence of the disease (p < 0.001). In conclusion, in this observational study, we have demonstrated that ultrasound-guided hydrodistention is linked to excellent long-term outcomes for the treatment of AC, which are significantly worse in patients with diabetes.

Efficacy of hydrodilatation in frozen shoulder: a systematic review and meta-analysis

INTRODUCTION

It is unclear whether hydrodilatation is beneficial in the management of frozen shoulder compared with other common conservative management modalities. This systematic review evaluates the efficacy of hydrodilatation for the management of frozen shoulder.

SOURCES OF DATA

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An extensive search of PubMed, Embase, Scopus, Cochrane Central, Web of Science and CINAHL databases using multiple keyword combinations of 'shoulder', 'rotator', 'adhesive capsulitis', 'hydrodilatat*', 'distension' since inception of the databases to June 2023 was implemented.

AREAS OF AGREEMENT

Hydrodilatation leads to at least transient more marked improvements in shoulder disability and passive external rotation compared with intra-articular corticosteroid injections.

AREAS OF CONTROVERSY

Hydrodilatation improves passive external rotation in the longer term. Moreover, hydrodilatation may be a preferable option over manipulation under anaesthesia, given its lower cost and better patient convenience.

GROWING POINTS

Intensive mobilization after hydrodilatation is a promising adjuvant treatment option for patients suffering from a frozen shoulder.

AREAS TIMELY FOR DEVELOPING RESEARCH

Although current evidence suggests that hydrodilatation provides a transient improvement in disability in patients with frozen shoulder, its clinical relevance remains unclear. Further research is necessary to establish its role in the management of the condition.

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.

Ultrasound-guided hydrodistension for adhesive capsulitis: a longitudinal study on the effect of diabetes on treatment outcomes

OBJECTIVE

The effect of diabetes on adhesive capsulitis (AC) and its impact on the outcomes of ultrasound (US)-guided hydrodistension of the glenohumeral joint are still unclear. We aimed to identify predictors of US-guided hydrodistension outcomes, while assessing the performance of the method in diabetic compared to non-diabetic patients.

MATERIALS AND METHODS

A total of 135 patients with AC who underwent US-guided hydrodistension were prospectively included. Demographics and factors linked to chronic inflammation and diabetes were recorded and patients were followed-up for 6 months. Functionality and pain were evaluated with the Disabilities of the Arm, Shoulder and Hand (DASH) and the Visual Analogue Scale (VAS) score. Statistical analysis was performed with Mann-Whitney U test, linear, and binary logistic regression.

RESULTS

Diabetes was identified in 25/135 patients (18.5%). Diabetic patients had worse DASH and VAS score at presentation (P < 0.0001) and presented with a higher grade of AC (P < 0.0001) and lower range of motion (P < 0.01) compared to non-diabetics. Higher DASH (P = 0.025) and VAS scores (P = 0.039) at presentation were linked to worse functionality at 6 months. Presence and duration of diabetes, and the number of hydrodistension repeats, correlated with worse VAS and DASH scores at 6 months. The number of procedure repeats was the only independent predictor of complete pain resolution at 6 months (OR 0.418, P = 003).

CONCLUSION

Diabetes is linked to more severe AC at presentation and worse outcomes in patients undergoing US-guided hydrodistension. In resistant cases, repeating the intervention is independently linked to worse outcomes for at least 6 months post-intervention.

Comparative Effectiveness of Corticosteroid Dosages for Ultrasound-Guided Glenohumeral Joint Hydrodilatation in Adhesive Capsulitis: A Randomized Controlled Trial

OBJECTIVE

To investigate the efficacy of hydrodilatation with 40 mg triamcinolone acetonide (TA) compared with the same procedure with 10 mg TA in patients with adhesive capsulitis (AC) of the shoulders.

DESIGN

Prospective, double-blind, randomized controlled trial with 12 weeks of follow-up.

SETTING

Tertiary care rehabilitation center.

PARTICIPANTS

Eighty-four patients diagnosed with AC (N=84).

INTERVENTIONS

Ultrasound guidance using (A) hydrodilatation with 4 mL of TA (40 mg)+4 mL 2% lidocaine hydrochloride+12 mL normal saline or (B) hydrodilatation with 1 mL of TA (10 mg)+4 mL 2% lidocaine hydrochloride+15 mL normal saline through the posterior glenohumeral recess.

MAIN OUTCOME MEASURES

Shoulder Pain and Disability Index (SPADI), visual analog scale (VAS) for pain, and range of motion (ROM) at baseline and at 6 and 12 weeks after injection.

RESULTS

Both groups experienced improvements in the SPADI score, VAS scores for pain, and ROM throughout the study period. However, group-by-time interactions were not significant for any outcome measurement at any follow-up time point. No adverse events were reported in either group.

CONCLUSION

Ultrasound-guided hydrodilatation with 40 and 10 mg TA yielded similar improvements in SPADI, VAS score, and ROM at the 12-week follow-up. Considering the potential detrimental effects of corticosteroids on the adjacent cartilage and tendons, a low dose of TA would be preferable for ultrasound-guided hydrodilatation for AC.

Current concepts in the diagnosis and treatment of adhesive capsulitis: role of diagnostic imaging and ultrasound-guided interventional procedures

Adhesive capsulitis is a common cause of painful shoulder, characterized by pain and restricted range of motion of the glenohumeral joint. With a well-known clinical presentation, and an increasing understanding of its clinical and radiologic features, early diagnosis of adhesive capsulitis is becoming a reality. Although often treated conservatively, for refractory cases arthroscopic release and open capsulotomy have been the only therapeutic option for a long time. Therefore, in the last years, a particular effort was put into the development of novel minimal-invasive techniques capable of pain relief and functional range improvement of the glenohumeral joint. The purpose of this literature review is to report the main updates on diagnosis and treatment for adhesive capsulitis with a focus on imaging diagnosis techniques and novel minimally invasive ultrasound-guided treatments. Results showed that ultrasound-guided procedures come with a high success rate in terms of pain reduction and improved range of motion, thus making the ultrasound a unique tool capable of giving the operator real-time diagnostic information confirming the clinical suspicion, and subsequently performing an interventional procedure.

Frozen shoulder

Frozen shoulder is a common debilitating disorder characterized by shoulder pain and progressive loss of shoulder movement. Frozen shoulder is frequently associated with other systemic conditions or occurs following periods of immobilization, and has a protracted clinical course, which can be frustrating for patients as well as health-care professionals. Frozen shoulder is characterized by fibroproliferative tissue fibrosis, whereby fibroblasts, producing predominantly type I and type III collagen, transform into myofibroblasts (a smooth muscle phenotype), which is accompanied by inflammation, neoangiogenesis and neoinnervation, resulting in shoulder capsular fibrotic contractures and the associated clinical stiffness. Diagnosis is heavily based on physical examination and can be difficult depending on the stage of disease or if concomitant shoulder pathology is present. Management consists of physiotherapy, therapeutic modalities such as steroid injections, anti-inflammatory medications, hydrodilation and surgical interventions; however, their effectiveness remains unclear. Facilitating translational science should aid in development of novel therapies to improve outcomes among individuals with this debilitating condition.

Manipulation under Anesthesia versus Non-Surgical Treatment for Patients with Frozen Shoulder Contracture Syndrome: A Systematic Review

Purpose: To investigate the efficacy of manipulation under anesthesia (MUA) compared to other non-surgical therapeutic strategies for patients with frozen shoulder contracture syndrome (FSCS). Methods: A systematic review of literature was conducted. A literature search was performed in MEDLINE, EMBASE, PEDro, Cochrane Central Library and Scopus. Only randomized controlled trials were included and assessed for critical appraisal through the Cochrane Collaborations tools. Results: Five randomized controlled trials were included. The overall risk of bias (RoB) was high in 4 out of 5 of the included studies. MUA was found to be not superior in terms of reduction of pain and improvement of function when compared to cortisone injections with hydrodilatation (mean regression coefficient MUA −2.77 vs. injection −2.75; 95% CI (−1.11 to 1.15)) and home exercise (mean difference 95% CI: 0.2 (−0.64 to 1.02)) in the short term (3 months), and cortisone injections with hydrodilatation (mean regression coefficient MUA 3.13 vs. injection 3.23; 95% CI (−0.90 to 1.11)) in the long term (>6 months). Moreover, if compared to structured physiotherapy, MUA highlighted a higher Oxford Shoulder Score at final 1-year follow up (mean difference 95% CI: 1.05 (−1.28 to 3.39); p = 0.38). Similar results were obtained for disability, with statistically no significant long-term (>12 months) differences between MUA and home exercise (mean difference 95% CI: 0 (−3.2 to 3.2)) or structured physiotherapy (mean difference 95% CI: −0.50 (−5.70 to 4.70); p = 0.85)). Only two trials reported adverse events. Conclusions: This review suggested that limited and inconsistent evidence currently exists on the efficacy of MUA compared to other non-surgical strategies in the management of patients with FSCS. Future research should focus on clinical trials with higher methodological quality.

Post-surgical physiotherapy in frozen shoulder: A review

Despite its prevalence, the optimal management of frozen shoulder is unclear. A range of conservative measures are often undertaken with varying degrees of success. In cases of severe and persistent symptoms, release procedures which could include any combination of manipulation under anaesthetic, arthroscopic capsular release or hydrodilatation are frequently offered, none of which has been shown to offer superior outcome over the others. When surgical release is performed a period of rehabilitation is normally recommended but no best practice guidelines exist resulting in considerable variations in practice which may or may not directly affect patient outcome. During this narrative review, we hypothesise that these differing responses to treatment (both conservative and surgical options) are potentially the result of different causal mechanisms for frozen shoulder and may also suggest that post-release rehabilitation may need to take this into account.

The role of suprascapular nerve block in hydrodilatation for frozen shoulder

Introduction: Frozen shoulder is a debilitating problem that requires comprehensive diagnosis and management. Patients usually recover, but the possibility of not reobtaining a full range of motion exists. Thus, early shoulder exercises are necessary to achieve their full range of motion. This study aims to understand the effects of suprascapular nerve block (SSNB) augmentation at the spinoglenoid notch in hydrodilatation to treat frozen shoulder to facilitate early shoulder exercises. Methods: The current study retrospectively observed 31 patients, including 40–60-year-old patients diagnosed and treated with primary frozen shoulder. The participants were divided into groups A (hydrodilatation) and B (hydrodilatation and the augmentation of an SSNB). Shoulder function and pain scores were assessed before, during, and after the intervention (at months 1 and 6). Results: The result of this study shows that suprascapular nerve block plays a role in decreasing pain in intraintervention (0.69 vs. 5.73; p < 0.05), month 1 of follow-up (3.44 vs. 6.40; p < 0.05), but not significant on month 6 of group A and B after intervention (5.88 vs. 7.20; p > 0.05). Better delta functional scores were noted in the therapy group during month 1 of the follow-up (delta American shoulder and elbow surgeons [ASES]: 19.29 vs. 34.40, p < 0.05; delta disabilities of the arm, shoulder, and hand [DASH]: 17.88 vs. 38.15, p < 0.05). The difference in functional score on month 6 between both groups was not significantly different (delta ASES: 31.97 vs. 30.31, p > 0.05; delta DASH: 36.63 vs. 38.92, p > 0.05). Discussion: One rationale for using an SSNB augmentation at spinoglenoid notch in hydrodilatation for treating frozen shoulder was to obtain pain relief immediately to facilitate early manual exercise. SSNB has positive effects on short-term evaluation of shoulder pain and function after glenohumeral hydrodilatation, but not in the long term.

Hydrodilatation with corticosteroids is the most effective conservative management for frozen shoulder

PURPOSE

The purpose of this overview is to summarise the findings of meta-analyses of randomised controlled trials that compare conservative treatment options for frozen shoulder.

METHODS

The authors conducted an electronic literature search for meta-analyses published using PubMed, Web of Science and the Cochrane Library. Two researchers independently applied selection criteria and assessed quality of meta-analyses using A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2). Short-, medium- and long-term outcomes were synthesised narratively.

RESULTS

A total of 319 studies were identified, of which 8 meta-analyses were eligible for inclusion. All included meta-analyses were judged to be low or critically low quality according to AMSTAR-2, however, their data synthesis and interpretation was considered valid. Physiotherapy, intra-articular and subacromial corticosteroid injection (CSI), and arthrographic distension/hydrodilatation with corticosteroid were reported with sufficient evidence. Intra-articular CSI and arthrographic distension/hydrodilatation with corticosteroid provide advantages over placebo in short-term pain relief, range of motion (ROM) and shoulder function, with improvements in ROM continuing into the medium and long term. Arthrographic distension/hydrodilatation with corticosteroid provides medium-term and long-term improvements in ROM over intra-articular CSI and physiotherapy. Proprioceptive neuromuscular facilitation provides advantages over conventional physiotherapy for pain improvement and external rotation in the short term.

CONCLUSIONS

Arthrographic distension/hydrodilatation with corticosteroid provides superior pain relief in the short term and improvement in range of motion across all time frames for frozen shoulder when compared to CSI or physiotherapy.

LEVEL OF EVIDENCE

Level IV.

Treatment of Primary Shoulder Stiffness: Results of a Survey on Surgeon Practice Patterns in Italy

Objectives  Shoulder stiffness is a condition of restricted glenohumeral range of motion (ROM), which can arise spontaneously or as consequence of a known cause. Several treatment options are available and currently no consensus has been obtained on which treatment algorithm represents the best choice for the patient. The aim of this study was to investigate surgeon practice patterns in Italy regarding treatment of primary shoulder stiffness.

Methods  A literature review was performed to identify randomized controlled trials reporting results of shoulder stiffness treatment. The following controversial or critical points in the treatment of primary shoulder stiffness were identified: modalities of physical therapy; indication for oral corticosteroid; indication and frequency for injective corticosteroid; technique and site of injection; and indication, timing, and technique for surgery. A survey composed by 14 questions was created and administrated to the members of a national association specialized in orthopaedics and sports traumatology (SIGASCOT at the time of survey completion, recently renamed SIAGASCOT after the fusion of the societies SIGASCOT and SIA).

Results  A total of 204 completed questionnaires were collected. Physical therapy was recommended by 98% of the interviewed. The use of oral corticosteroids was considered by 51%, and injections of corticosteroids by 72%. The posterior injection approach was the one preferred and a number of three was considered the upper limit for repeated injections. Injective therapy with local anesthetics and hyaluronic acid was considered by more than 20% of the interviewed. Thirty percent of the interviewed did not treat shoulder stiffness surgically.

Conclusion  Several approaches to shoulder stiffness have been proposed and high-level evidence is available to analyze and discuss their results. Several controversial points emerged both from a literature review and from this national survey. Treatment of shoulder stiffness should be tailored to the patient's clinical situation and the stage of its pathology and should aim at pain reduction, ROM restoration, functional regain, and shortening of symptoms duration, with conservative therapy remaining the mainstay of treatment.

Experiences and perceptions of trial participants and healthcare professionals in the UK Frozen Shoulder Trial (UK FROST): a nested qualitative study

OBJECTIVES

To explore the experiences and perceptions of trial participants and healthcare professionals in the UK Frozen Shoulder Trial (UK FROST), a multicentre randomised controlled trial that compared manipulation under anaesthesia (MUA), arthroscopic capsular release (ACR) with a 12-week early structured physiotherapy programme (ESP) in people with unilateral frozen shoulder referred to secondary care.

DESIGN

Nested qualitative study with semistructured interviews. We used constant comparison method to develop our themes.

SETTING

This qualitative study was nested within the UK FROST.

PARTICIPANTS

44 trial participants (ESP: 14; MUA: 15; ACR: 15), and 8 surgeons and 8 physiotherapists who delivered the treatments in the trial.

RESULTS

Trial participants found UK FROST treatments acceptable and satisfactory in terms of content, delivery and treatment benefits. Participants in all arms experienced improvements in pain, shoulder movements, and function. Participants said they would choose the same treatment that they received in the trial.Surgeons and physiotherapists felt that the content and delivery of UK FROST treatments was not significantly different to their routine practice except for the additional number of physiotherapy sessions offered in the trial. They had mixed feelings about the effectiveness of UK FROST treatments. Both stressed the value of including hydrodilatation as a comparator of other treatment options. Physiotherapists raised concerns about the capacity to deliver the number of UK FROST physiotherapy sessions in routine clinical settings.Shared perceptions of trial participants, surgeons and physiotherapists were: (1) Pain relief and return of shoulder movements and function are important outcomes and (2) Adherence to exercises leads to better outcomes.

CONCLUSION

In general, our findings indicated that trial participants, and surgeons and physiotherapists who delivered the treatments had positive experiences and perceptions in the UK FROST. Early qualitative investigations to explore the feasibility of delivering treatments in real-world settings are suggested in future trials in the frozen shoulder.

TRIAL REGISTRATION NUMBER

International Standard Randomised Controlled Trial Register, ID: ISRCTN48804508. Registered on 25 July 2014; Results.

Ultrasound-Guided Hydrodilatation With Triamcinolone Acetonide for Adhesive Capsulitis: A Randomized Controlled Trial Comparing the Posterior Glenohumeral Recess and the Rotator Cuff Interval Approaches

For patients with adhesive capsulitis, hydrodilatation is typically performed using corticosteroids with ultrasound guidance via the posterior glenohumeral recess. Recently, a new intervention technique via the rotator cuff interval has been described. This study aimed to compare the efficacy of hydrodilatation with triamcinolone acetonide via the posterior glenohumeral recess and the rotator cuff interval in patients with adhesive capsulitis. This prospective randomized controlled trial was conducted in a tertiary care center with a follow-up period of 12 weeks. We enrolled 64 patients diagnosed with shoulder adhesive capsulitis. The subjects were randomly assigned to two groups that received hydrodilatation with corticosteroids either through the posterior glenohumeral recess or though the rotator cuff interval. The injection contained 4 ml of triamcinolone acetonide (40 mg) mixed with 4 ml of 2% lidocaine hydrochloride and 12 ml of normal saline. The shoulder pain and disability index, visual analog scale for pain, and range of motion were analyzed before and at 6 and 12 weeks after the treatment. Both groups experienced improvements in the visual analog scale scores, shoulder pain and disability index scores, and range of motion throughout the study period. A significant group-time interaction was observed in terms of the visual analog scale for pain during motion (p = 0.019), favoring hydrodilatation through the rotator cuff interval. Thus, hydrodilatation through the rotator cuff interval might be a better treatment option than that through the posterior glenohumeral recess for patients with adhesive capsulitis, considering its superior effect in alleviating pain during shoulder movement.

Clinical Guidelines in the Management of Frozen Shoulder: An Update!

Among all the prevalent painful conditions of the shoulder, frozen shoulder remains one of the most debated and ill-understood conditions. It is a condition often associated with diabetes and thyroid dysfunction, and which should always be investigated in patients with a primary stiff shoulder. Though the duration of 'traditional clinicopathological staging' of frozen shoulder is not constant and varies with the intervention(s), the classification certainly helps the clinician in planning the treatment of frozen shoulder at various stages. Most patients respond very well to combination of conservative treatment resulting in gradual resolution of symptoms in 12-18 months. However, the most effective treatment in isolation is uncertain. Currently, resistant cases that do not respond to conservative treatment for 6-9 months could be offered surgical treatment as either arthroscopic capsular release or manipulation under anaesthesia. Though both invasive options are not clinically superior to another, but manipulation could result in unwarranted complications like fractures of humerus or rotator cuff tear.

Frozen Shoulder: A Systematic Review of Cellular, Molecular, and Metabolic Findings

BACKGROUND

Frozen shoulder is a common, poorly understood condition affecting the shoulder joint, with poor long-term outcomes in some in relation to pain and mobility. Understanding the pathophysiology of frozen shoulder at a cellular level and a molecular level may help in the development of novel treatments. The aim of this study was to perform a systematic review of studies examining the cellular, molecular, and metabolic findings in frozen shoulder.

METHODS

A literature search was conducted using Embase, CINAHL (Cumulative Index of Nursing and Allied Health Literature), and PubMed using relevant terms. Studies were included if they assessed cellular, molecular, or metabolic alterations in tissue or blood samples of patients with frozen shoulder.

RESULTS

Of 4,794 studies identified, 25 were included for analysis. Histological findings included nonspecific chronic inflammation and the proliferation of fibroblasts, adipocytes, and blood vessels. Molecular studies showed increased pro-inflammatory mediators, reduced matrix metalloproteinases (MMPs), and increased activity of factors promoting fibroblast activation and nerve growth. Metabolic alterations included an increase in blood lipids.

CONCLUSIONS

Frozen shoulder is thought to occur after a primary insult to the shoulder triggers a complex cascade and upregulation of growth factors and cytokines with an increased turnover of the extracellular matrix, activation of myofibroblasts with deposition of collagen, and reduced matrix degradation. The presence of a background pro-inflammatory state (e.g., patients with diabetes or hyperlipidemia) may exacerbate these abnormalities. Further work assessing patients in early stages of the disease and comparing the inflammatory or fibrogenic characteristics of the shoulder capsule with those of the other joints may help to determine the initiating factors and to explain the predisposition of the shoulder to stiffness.

CLINICAL RELEVANCE

Our findings may form the basis for identifying new targets for the clinical management of frozen shoulder.

Ultrasound-guided hydrodilatation for adhesive capsulitis of the hip is a safe and effective treatment

Purpose

Adhesive capsulitis of the hip (ACH) is likely that this condition had been previously encountered, but easily unrecognised. We investigated the clinical features of patients with ACH, the efficacy of ultrasound-guided intra-articular hydrodilatation, and the patients’ prognosis.

Methods

We enrolled 84 patients (93 hips) who visited the outpatient clinic from August 2018 to November 2019. ACH was diagnosed by restricted range of motion and sharp pain when turning with the affected leg fixed on the ground. We evaluated patient demographics and associated intra-articular pathologies found on magnetic resonance angiography (MRA) images. Injections were performed twice at two week intervals with a mixture of 0.5% lidocaine (25 mL) and triamcinolone (40 mg; 1 mL) with capsular distension under ultrasound guidance. Patients were assessed before and after treatment using a visual analogue scale (VAS), hip disability and osteoarthritis outcome score (HOOS), hip range of motion (ROM), and distance from floor to knee (DFK) when sitting in the cross-legged position.

Results

On MRA, 18 patients had abnormal findings (eight labral tears, seven abductor tendinosis, three primary arthrosis). The mean VAS decreased from 7.1 ± 1.1 to 0.8 ± 0.9 after the last injection, and the HOOS improved in all subsets. The mean DFK decreased from 17.9 ± 4.8 to 9.7 ± 2.8 cm, and passive ROM showed improvement, especially in flexion and rotation. In seven patients, symptom recurrence was reported a mean of 4.1 months after the latest injection, but no independent risk factor for recurrence was identified.

Conclusion

Based on these current observations, patients with ACH may receive relief from hip joint pain and experience improved function with a timely diagnosis and effective treatment.

Updates on the treatment of adhesive capsulitis with hydraulic distension

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

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.

Surgical treatments compared with early structured physiotherapy in secondary care for adults with primary frozen shoulder: the UK FROST three-arm RCT

BACKGROUND

Frozen shoulder causes pain and stiffness. It affects around 10% of people in their fifties and is slightly more common in women. Costly and invasive surgical interventions are used, without high-quality evidence that these are effective.

OBJECTIVES

To compare the clinical effectiveness and cost-effectiveness of three treatments in secondary care for adults with frozen shoulder; to qualitatively explore the acceptability of these treatments to patients and health-care professionals; and to update a systematic review to explore the trial findings in the context of existing evidence for the three treatments.

DESIGN

This was a pragmatic, parallel-group, multicentre, open-label, three-arm, randomised superiority trial with unequal allocation (2 : 2 : 1). An economic evaluation and a nested qualitative study were also carried out.

SETTING

The orthopaedic departments of 35 hospitals across the UK were recruited from April 2015, with final follow-up in December 2018.

PARTICIPANTS

Participants were adults (aged ≥ 18 years) with unilateral frozen shoulder, characterised by restriction of passive external rotation in the affected shoulder to < 50% of the opposite shoulder, and with plain radiographs excluding other pathology.

INTERVENTIONS

The inventions were early structured physiotherapy with a steroid injection, manipulation under anaesthesia with a steroid injection and arthroscopic capsular release followed by manipulation. Both of the surgical interventions were followed with post-procedural physiotherapy.

MAIN OUTCOME MEASURES

The primary outcome and end point was the Oxford Shoulder Score at 12 months post randomisation. A difference of 5 points between early structured physiotherapy and manipulation under anaesthesia or arthroscopic capsular release or of 4 points between manipulation under anaesthesia and arthroscopic capsular release was judged clinically important.

RESULTS

The mean age of the 503 participants was 54 years; 319 were female (63%) and 150 had diabetes (30%). The primary analyses comprised 473 participants (94%). At the primary end point of 12 months, participants randomised to arthroscopic capsular release had, on average, a statistically significantly higher (better) Oxford Shoulder Score than those randomised to manipulation under anaesthesia (2.01 points, 95% confidence interval 0.10 to 3.91 points; p = 0.04) or early structured physiotherapy (3.06 points, 95% confidence interval 0.71 to 5.41 points; p = 0.01). Manipulation under anaesthesia did not result in statistically significantly better Oxford Shoulder Score than early structured physiotherapy (1.05 points, 95% confidence interval -1.28 to 3.39 points; p = 0.38). No differences were deemed of clinical importance. Serious adverse events were rare but occurred in participants randomised to surgery (arthroscopic capsular release,n = 8; manipulation under anaesthesia,n = 2). There was, however, one serious adverse event in a participant who received non-trial physiotherapy. The base-case economic analysis showed that manipulation under anaesthesia was more expensive than early structured physiotherapy, with slightly better utilities. The incremental cost-effectiveness ratio for manipulation under anaesthesia was £6984 per additional quality-adjusted life-year, and this intervention was probably 86% cost-effective at the threshold of £20,000 per quality-adjusted life-year. Arthroscopic capsular release was more costly than early structured physiotherapy and manipulation under anaesthesia, with no statistically significant benefit in utilities. Participants in the qualitative study wanted early medical help and a quicker pathway to resolve their shoulder problem. Nine studies were identified from the updated systematic review, including UK FROST, of which only two could be pooled, and found that arthroscopic capsular release was more effective than physiotherapy in the long-term shoulder functioning of patients, but not to the clinically important magnitude used in UK FROST.

LIMITATIONS

Implementing physiotherapy to the trial standard in clinical practice might prove challenging but could avoid theatre use and post-procedural physiotherapy. There are potential confounding effects of waiting times in the trial.

CONCLUSIONS

None of the three interventions was clearly superior. Early structured physiotherapy with a steroid injection is an accessible and low-cost option. Manipulation under anaesthesia is the most cost-effective option. Arthroscopic capsular release carries higher risks and higher costs.

FUTURE WORK

Evaluation in a randomised controlled trial is recommended to address the increasing popularity of hydrodilatation despite the paucity of high-quality evidence.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN48804508.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 71. See the NIHR Journals Library website for further project information.

Secondary frozen shoulder after traumatic anterior shoulder instability

Background

Secondary frozen shoulder after traumatic anterior shoulder instability is rare. The therapeutic management and clinical outcome of this condition are not well known. This study aimed to investigate the characteristics of such rare cases and verify treatment outcomes.

Methods

We reviewed the cases of 12 patients with secondary frozen shoulder after anterior shoulder dislocation or subluxation between April 2007 and March 2018. All patients underwent physical therapy along with an intra-articular injection. Patients with refractory stiffness received arthroscopic mobilization. The range of motion, Rowe score, and University of California, Los Angeles score were evaluated at the first and final visits. A telephone survey was performed to determine the long-term outcomes including recurrent instability, the Oxford Shoulder Score, and the Oxford Instability Score.

Results

The mean age of patients at the first visit was 42.5 years. Two patients underwent surgical treatment, which revealed scar-like tissue of the anteroinferior capsule. The range of motion, Rowe score, and University of California, Los Angeles score significantly improved at a mean follow-up of 15 months. At a mean follow-up of 82 months, the telephone survey revealed recurrent instability in 1 patient who was conservatively treated; the average Oxford Shoulder Score and Oxford Instability Score were 46.4 and 43.2, respectively.

Conclusions

The average patient age observed in this study was higher than the known peak age of traumatic anterior shoulder instability occurrence. Less activity, loss of capsule elasticity, or scarring after a capsular tear may lead to stiffness after traumatic anterior shoulder instability. Conservative treatment can be used as the first-line therapy, followed by effective arthroscopic mobilization when conservative treatment fails.

Evaluating Correlations of Coracohumeral Ligament Thickness with Restricted Shoulder Range of Motion and Clinical Duration of Adhesive Capsulitis with Ultrasound Measurements

OBJECTIVES

The primary objective of this study is to evaluate, using ultrasound measurements, the correlation between coracohumeral ligament (CHL) thickness and restricted shoulder range of motion (ROM) in patients with adhesive capsulitis (AC). The secondary objective is to investigate the correlation between CHL thickness and disease duration.

DESIGN

Prospective cross-sectional survey.

SETTING

Clinical research of a tertiary care hospital.

METHODS

Overall, 65 patients with clinically diagnosed AC were enrolled. Ultrasound measurements of CHL thickness in the axial oblique plane were obtained under maximal external rotation of the glenohumeral joint. Both Shoulder Pain and Disability Index (SPADI) and shoulder ROM were prospectively evaluated by an experienced investigator. CHL thickness was compared with shoulder ROM and SPADI. The association between CHL thickness and disease duration was also investigated.

RESULTS

Simple linear regression analysis showed significant inverse correlation between CHL thickness and shoulder ROM including external rotation (ER) (r = -0.335, P = .006) and internal rotation (IR) (r = -0.409, P = .001). CHL thickness also correlated with disease duration (r = -0.352, P = .004). Multiple linear regression analysis demonstrated that CHL thickness was significantly associated with restricted ER (r = -0.293, P = .02) and IR (r = -0.363, P = .003) after adjusting for age and disease duration. On the other hand, CHL thickness showed no significant correlation with abduction (r = -0.210, P = .09), flexion (r = -0.170, P = .176), or total SPADI score (r = 0.176, P = .16). Moreover, CHL was significantly thicker in patients with disease duration >6 months (P = .004, difference in means: 0.55 mm, 95% confidence interval: -0.922, -0.183).

CONCLUSIONS

CHL was significantly thicker in later-stage AC. CHL thickness correlated negatively with ER and IR of the shoulder. Furthermore, CHL thickening could be observed in the early stage of the disease course. These imaging findings may assist in confirming the diagnosis of AC, leading to early intervention and treatment options.

In shoulder adhesive capsulitis, ultrasound-guided anterior hydrodilatation in rotator interval is more effective than posterior approach: a randomized controlled study

Abstract

Shoulder adhesive capsulitis, also called frozen shoulder, is a musculoskeletal disorder associated with pain and functional disability. This study aimed to compare the effectiveness of shoulder ultrasound-guided hydrodilatation with corticosteroid, via rotator interval (RI) anteriorly, versus posterior approach, in adhesive capsulitis patients. All patients received exercise program following injection.

Patients and methods

A prospective randomized controlled study among 60 consecutive adhesive capsulitis patients was randomized into two equal groups. Group I received ultrasound-guided hydrodilatation with corticosteroid, saline, and local anesthetic via posterior intra-articular approach; group II received the same ultrasound-guided hydrodilatation via anterior rotator interval approach. Both groups received guided stretching exercises for 3 months after injection. Baseline and 3 months evaluation of pain by visual analogue scale (VAS), shoulder pain and disability index (SPADI), and range of motion (ROM) had been recorded for all patients.

Results

Both groups showed significant improvement 3 months after hydrodilatation regarding VAS pain, external rotation, and SPADI. Only in group II (RI anterior approach) improvement was observed regarding flexion and abduction. There was no improvement regarding extension or internal rotation in either group. When comparing the improvement in both groups after hydrodilatation, group II (anterior approach) showed a statistically significant higher level of improvement regarding VAS pain (p = 0.003), SPADI, flexion, abduction, and external rotation, compared to group I (p < 0.001). Extension, internal rotation, and adduction were not different.

Conclusions

Ultrasound-guided anterior rotator interval hydrodilatation for adhesive capsulitis, followed by guided exercise, is clinically and functionally more effective than the conventional posterior approach.

Intra-articular steroid for adhesive capsulitis: does hydrodilatation give any additional benefit? A randomized control trial

OBJECTIVES

To assess the benefit offered by capsular hydrodilatation in addition to intra-articular steroid injections in cases of adhesive capsulitis, assess outcomes in diabetic patients with capsular hydrodilatation as compared to non-diabetics and correlate duration of symptoms with outcome based on the type of intervention given.

MATERIALS AND METHODS

This prospective double-blinded randomized control trial included patients presenting with clinical features of adhesive capsulitis with no evidence of rotator cuff pathology and randomized them into two groups-intra-articular steroid with hydrodilatation (distension group) and only intra-articular steroid (non-distension group) with intervention being performed as per the group allotted. Primary outcome measure was Shoulder Pain and Disability Index (SPADI) scores which were taken pre-intervention, at 1.5, 3 and 6 months post-intervention, which were assessed by generalized linear model statistics and Pearson correlation.

RESULTS

Although there was statistically significant drop in SPADI in both groups over time [F(1.9, 137.6) = 112.2; p < 0.001], mean difference in SPADI between the 2 groups was not statistically significant (1.53; CI:-3.7 to 6.8; p = 0.56). There was no significant difference between both groups among diabetics [F(1,38) = 0.04; p = 0.95] and no significant difference between diabetic and non-diabetic patients who received hydrodilatation [F(1.8, 60) = 2.26; p = 0.12]. There was no significant correlation between the reduction in SPADI scores and duration of symptoms in any subset of the study population.

CONCLUSION

Shoulder joint hydrodilatation offered no additional benefit compared to intra-articular steroid injections for shoulder adhesive capsulitis. Outcome for diabetics and non-diabetics were similar and there was no correlation between duration of symptoms and outcome.

'Frozen shoulder' is ill-defined. How can it be described better?

Frozen shoulder, a common and debilitating shoulder complaint, has been the subject of uncertainty within the scientific literature and clinical practice.

We performed an electronic PubMed search on all (1559) articles mentioning ‘frozen shoulder’ or ‘adhesive capsulitis’ to understand and qualify the range of naming, classification and natural history of the disease. We identified and reviewed six key thought leadership papers published in the past 10 years and all (24) systematic reviews published on frozen shoulder or adhesive capsulitis in the past five years.

This revealed that, while key thought leaders such as the ISAKOS Upper Extremity Council are unequivocal that ‘adhesive capsulitis’ is an inappropriate term, the long-term and short-term trends showed the literature (63% of systematic reviews assessed) preferred ‘adhesive capsulitis’.

The literature was divided as to whether or not to classify the complaint as primary only (9 of 24) or primary and secondary (9 of 24); six did not touch on classification.

Furthermore, despite a systematic review in 2016 showing no evidence to support a three-phase self-limiting progression of frozen shoulder, 11 of 12 (92%) systematic reviews that mentioned phasing described a three-phase progression. Eight (33%) described it as ‘self-limiting’, three (13%) described it as self-limiting in ‘nearly all’ or ‘most’ cases, and six (25%) stated that it was not self-limiting; seven (29%) did not touch on disease resolution.

We call for a data and patient-oriented approach to the classification and description of the natural history of the disease, and recommend authors and clinicians (1) use the term ‘frozen shoulder’ over ‘adhesive capsulitis’, (2) use an updated definition of the disease which recognizes the often severe pain suffered, and (3) avoid the confusing and potentially harmful repetition of the natural history of the disease as a three-phase, self-limiting condition.

Cite this article: EFORT Open Rev 2020;5:273-279.DOI: 10.1302/2058-5241.5.190032

Distension arthrogram in the treatment of adhesive capsulitis has a low rate of repeat intervention

AIMS

The primary aim of this study was to evaluate the efficacy of distension arthrography in the treatment of adhesive capsulitis of the shoulder. The secondary aim was to assess which patient and procedural factors predicted the recurrence of symptoms after the procedure.

METHODS

All patients referred to our shoulder clinic over a ten-year period, between 2008 and 2018, with a clinical diagnosis of capsulitis and symptoms persisting for more than six months, were offered treatment with a distension arthrogram. All procedures were performed by one of five musculoskeletal radiologists, with a combination of steroid, local anaesthetic, and a distention volume of 10 ml, 30 ml, or 50 ml. Patient demographics, procedural details, recurrence of symptoms, and the need for further intervention were evaluated.

RESULTS

A total of 2,432 distension arthrograms were performed during the study period. The mean time between arthrography and analysis was 5.4 years (SD 4.4; 1 to 11). Recurrent symptoms occurred in 184 cases (7.6%), all of whom had a repeat distension arthrogram at a median of nine months (interquartile range (IQR) 6.0 to 15.3). The requirement for further intervention for persistent symptoms following arthrography was significantly associated with diabetes (p < 0.001) and bilateral capsulitis (p < 0.001). The volume of distension, either with air or saline, showed a dose-dependent advantage. Distension of 50 ml versus 30 ml showed a significantly decreased odds ratio for recurrence of 2.2 (95% confidence interval (CI) 1.6 to 3.0; p < 0.001). Capsule rupture (p = 0.615) or steroid dose (p = 0.275) did not significantly affect the rate of recurrence. There were no infections or neurovascular injuries. Following the second distension arthrogram, the symptoms resolved in 137 cases (74.5%) with no further intervention being required. An arthroscopic capsular release was ultimately required in 41 cases, comprising 1.7% of the entire cohort.

CONCLUSION

We found a low rate of repeat intervention following distension arthrography in patients with adhesive capsulitis of the shoulder, at long term follow-up. Greater volumes of distension are associated with lower rates of recurrence independent of capsule rupture. Cite this article: Bone Joint J 2020;102-B(5):606-610.

Capsular Injury and Inflammation

The capsular and ligamentous structures of the glenohumeral joint are important for stability of the shoulder. These structures are best evaluated by MR imaging. Familiarity with normal and abnormal appearance of the capsular structures of the shoulder is important to ensure that important pathology is not overlooked. Injury to the capsular structures can occur in the setting of trauma and most commonly involves the inferior glenohumeral ligament and axillary pouch. Adhesive capsulitis is a common inflammatory condition with characteristic imaging features that should be considered in the absence of alternative diagnoses.

Short-Term Outcome Predictors in Patients With Primary Adhesive Capsulitis Treated With Ultrasound-Guided Hydrodilatation With Corticosteroids

OBJECTIVE

Glenohumeral joint hydrodilatation with corticosteroids has been proposed as an effective secondary therapeutic procedure for primary adhesive capsulitis. However, little is known about which subgroup of patients would benefit from this procedure. This study aimed to identify covariates associated with improved prognosis in patients receiving ultrasound-guided hydrodilatation with corticosteroid injection.

DESIGN

This was a cohort study. Data on baseline demographic characteristics, disease status, past medical conditions, and initial ultrasonographic findings were collected. Linear and logistic regression analyses were performed to determine the prognostic factors associated with better clinical outcomes.

RESULTS

Fifty-three patients (54 shoulders) were included. Linear regression analysis showed that coracohumeral ligament thickness of less than 3 mm, use of analgesics before hydrodilatation, and female sex were associated with good improvement in the Shoulder Pain and Disability Index score. Multivariate logistic regression analysis showed that coracohumeral ligament thickness of less than 3 mm on ultrasound was associated with a strong tendency (P = 0.054) of reaching the minimal detectable change. In addition, capsule rupture did not play a role in determining the clinical efficacy of hydrodilatation.

CONCLUSIONS

In patients with primary adhesive capsulitis, coracohumeral ligament thickness of less than 3 mm is correlated with greater short-term improvement in the Shoulder Pain and Disability Index score after ultrasound-guided hydrodilatation with steroid injection is performed.

Adhesive Capsulitis: Demographics and Predictive Factors for Success Following Steroid Injections and Surgical Intervention

Purpose

Examine demographic factors of all patients treated for adhesive capsulitis by a single surgeon, report the treatments and outcomes of these patients, and determine the effectiveness of various treatments, including corticosteroid injections and operative intervention in relation to risk factors for adhesive capsulitis.

Methods

All patients treated for adhesive capsulitis by a single surgeon between 2008 to 2014 with minimum 2 years' follow-up were identified via charts and operative reports and were eligible for inclusion. Demographic information including sex and medical comorbidities was documented. Preintervention and postintervention shoulder range of motion was recorded. Specific treatment information (number of corticosteroid injections, etc) was collected. Treatment outcomes were then compared as an aggregate and among varying comorbidities.

Results

Overall, 1377 patients were treated for adhesive capsulitis (946 women vs 431 men [P = .001]). For patients with adhesive capsulitis: a higher percentage of men than women had diabetes (24.8% vs 17.3% [P = .001]); nondiabetic patients had better forward flexion at initial presentation than patients with diabetes (114° vs 108° [P = .015]); more patients with diabetes required capsular release than nondiabetic patients (13% vs 7.3% [P = .003]); more nondiabetic patients resolved adhesive capsulitis without corticosteroid or surgical intervention than patients with diabetes (83.6% vs 61.7% [P = .001]); more nondiabetic patients resolved adhesive capsulitis after single corticosteroid injection than did patients with diabetes (95.9% vs 86.7% [P = .001]). Multiple intraarticular corticosteroid injections provided no added benefit over a single injection in resolving adhesive capsulitis in patients with diabetes and nondiabetic patients.

Conclusion

In shoulder adhesive capsulitis, women and patients with diabetes are more commonly affected, patients with diabetes respond less favorably to physical therapy in isolation and physical therapy plus corticosteroid injections than nondiabetic patients. No benefit from multiple intraarticular corticosteroid injections was seen compared with a single intraarticular corticosteroid injection in patients with diabetes and nondiabetic patients. Patients with diabetes and nondiabetic patients have functional improvement after capsular release and manipulation if conservative treatment for adhesive capsulitis fails.

Level of Evidence

III, case control.

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.