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

Type 2 diabetes, metabolic health, and the development of frozen shoulder: a cohort study in UK electronic health records

OBJECTIVE

Estimate the effect of type 2 diabetes on the development of frozen shoulder and investigate whether the effect is mediated by other metabolic factors.

METHODS

Primary care medical record-based cohort study containing 43,977 people newly diagnosed with type 2 diabetes and 43,977 without diabetes. Variables were identified using established Read codes. A weighting approach with Cox regression was used to decompose the total effect into the direct effect and indirect effect, mediated by metabolic health (which was defined as the number of metabolic factors developed during follow-up). Estimates were expressed as hazard ratios (HR). Confounders were identified using a DAG. Sensitivity to unmeasured confounding, extreme weights, and missing data were tested.

RESULTS

The total effect of type 2 diabetes on the development of frozen shoulder was HR = 4.38 (95% CI: 3.70-5.21), the natural indirect effect (mediated through metabolic health) was HR = 0.98 (95% CI: 0.93-1.03) and the natural direct effect was HR = 4.46 (95% CI: 3.68-5.41). Results were robust to unmeasured confounding, extreme weights, and missing data.

CONCLUSIONS

This study suggests that type 2 diabetes may be a cause of frozen shoulder but does not support the hypothesis that the effect is mediated by metabolic health. Clinicians should remain alert that shoulder pain in people with diabetes could be indicative of a frozen shoulder. This study should raise awareness that, despite often being overlooked, musculoskeletal conditions can be complications of diabetes and should be considered during clinical conversations with patients.

ISAC PROTOCOL REGISTRATION NUMBER

19_219R.

Higher body mass index increases the risk of shoulder adhesive capsulitis in young adults: a nationwide cohort study

BACKGROUND

The impact of overweight on the incidence of shoulder adhesive capsulitis (AC) has not been clearly proven. This study aimed to investigate the association between overweight and AC by age using a large-scale nationwide population-based cohort in Korea.

METHODS

We analyzed clinical data from 3,517,066 individuals older than 20 years who had undergone a National Health Insurance Service health checkup in 2009. Patients who visited a hospital or private clinic to treat shoulder pain at least three times in 1 year and were assigned a diagnostic code for AC (International Classification of Diseases,10th Revision code M75.00) were identified using claims data during a median follow-up duration of 8.3 years. Hazard ratios (HRs) and 95% confidence intervals for AC were calculated using the Cox proportional hazards model.

RESULTS

The adjusted HR for AC in the < 40 year group started to increase in overweight status and was associated with the severity of obesity (body mass index (BMI) < 18.5; 0.654 (0.613-0.697), <23; 1, <25; 1.272 (1.231-1.315), <30; 1.322 (1.281-1.364), ≥30; 1.332 (1.253-1.416)). But in the 40-64 year group and the ≥ 65 year group, there was no significant increasing trend of HR for AC according to BMI level. We conducted a subgroup analysis based on the BMI 23 for defining overweight and presence of comorbidities including diabetes and hyperlipidemia. The adjusted HR for AC was highest with overweight and comorbidities of diabetes and hyperlipidemia (diabetes; 1.528 (1.508-1.549), hyperlipidemia; 1.212 (1.199-1.226)).

CONCLUSIONS

In the young age group (20-40 years), a higher BMI level increased the HR for AC. Overweight along with diabetes or hyperlipidemia significantly increased the risk of AC.

A comprehensive scoring system for the diagnosis and staging of adhesive capsulitis: development, application, and implications

INTRODUCTION

Adhesive capsulitis (AC), often referred to as frozen shoulder, presents a diagnostic challenge due to its insidious onset and progressive nature. The condition is characterized by pain and restricted motion in the shoulder, with a predilection for individuals between 40 and 60 years of age. A novel scoring system was developed to enhance the accuracy of diagnosing AC and distinguishing between its stages, aiming to streamline clinical decision-making and treatment planning.

METHODS

A cohort of patients with symptoms suggestive of AC was assessed using the new scoring system, which integrates clinical, radiological, and patient history factors. Parameters included comorbidities like diabetes mellitus, recent immobility, rotator cuff tears, and specific ultrasound findings. Patients were scored and categorized into definitive AC, uncertain diagnosis, or exclusion from AC, with scores > 7, 6-2, and < 2, respectively.

RESULTS

The scoring system effectively categorized patients, with those scoring > 7 demonstrating pronounced symptoms and ultrasound changes consistent with Phase 2 AC. Patients with scores between 6 and 2 were classified into uncertain Phase 1 or Phase 3, necessitating further observation. Scores < 2 effectively excluded AC, indicating a need to explore alternative diagnoses.

CONCLUSION

The structured scoring system demonstrated potential as a comprehensive tool for diagnosing AC. By quantitatively assessing a range of contributory factors, it allowed for the stratification of the disease into distinct stages. This system is anticipated to improve early diagnosis and the precision of treatment interventions, although further validation in larger cohorts is warranted.

LEVEL OF EVIDENCE

II-III.

Sub-Acromioclavicular Decompression Increases the Risk of Postoperative Shoulder Stiffness after Arthroscopic Rotator Cuff Repair

OBJECTIVE

The sub-acromioclavicular (SAC) decompression is often performed during arthroscopic rotator cuff repair. However, the impact of SAC decompression on patients with postoperative shoulder stiffness (POSS) are controversial and unclear. This study is aim to evaluate the impact of additional sub-acromioclavicular (SAC) decompression during arthroscopic rotator cuff repair on the postoperative shoulder stiffness (POSS) in patients.

METHODS

This retrospective study examined digital data from patients with full-thickness rotator cuff tears who underwent arthroscopic rotator cuff repair at a local institution. Patient-reported outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) Score, the University of California-Los Angeles (UCLA) score, and visual analog scale (VAS) scores. Restricted shoulder mobility occurring within 6 months postoperatively, lasting more than 12 weeks, characterized by a passive forward flexion angle of <120° or an external rotation angle of <30°, with or without associated shoulder pain was identified as POSS. Factors affecting POSS were analyzed by binary logistic regression analysis. The patient-reported outcomes scores were analyzed by generalized estimating equations to examine the impact of SAC decompression.

RESULTS

A total of 155 patients met the set criteria and were included in the study. The analysis of binary logistic regression showed that diabetes (p = 0.001) and SAC decompression (p = 0.003) were independent factors for POSS. In the analysis of each follow-up point, only at the 3-month follow-up, the ASES scores (p = 0.003), UCLA scores (p = 0.045), and VAS scores (p = 0.005) showed significant differences between the SAC decompression group and the non-decompression group. For the intergroup comparison, the results showed a significant difference in the ASES scores (β = -4.971, p = 0.008), UCLA scores (β = -1.524, p = 0.019), and VAS scores (β = 0.654, p = 0.010) throughout the study duration between the SAC decompression group and the non-decompression group.

CONCLUSION

The findings of this study suggested that SAC decompression during arthroscopic rotator cuff repair increase the risk of POSS compared with those without the decompression, which indicate surgeons do not perform SAC decompression unless necessary.

A Narrative Review of Adhesive Capsulitis with Diabetes

Background/Objectives: To update the perspectives of the association between diabetes (DM) and adhesive capsulitis (AC). Methods: Our findings were summarized in a narrative review. We searched PubMed, Embase, and Consensus databases, using keywords such as "diabetes", "adhesive capsulitis", and "frozen shoulder", for articles published from January 2015 to June 2024, covering both type 1 and type 2 DM. Results: After compiling relevant articles on DM-related AC published since 2015, we found that most studies show an increased prevalence of AC in DM patients, ranging from 3 to 10 times. A longer duration of DM is a risk factor for AC. Whether T1DM or prolonged insulin use will increase the risk of AC is still controversial. Poor blood sugar control seems to increase the risk of AC. Recent studies also show a correlation between blood sugar levels and the prevalence of AC. Cytokines, such as IL-6, IL-8, TNF-α, VEGF, and AGEs, related to inflammation and fibrosis may contribute to the pathophysiological processes of AC. Conclusions: Recent research findings have revealed new perspectives divergent from past notions, while also presenting some topics worthy of exploration. Due the close relationship between DM and AC, clinicians need to be alert to the presence of AC, especially early stage, in DM cases, and control the blood glucose level to reduce the risk of AC. Further research is still needed to provide better prevention and management for DM patients with AC.

Effects of moderate physical activity on diabetic adhesive capsulitis: a randomized clinical trial

Background

Moderate physical activity (MPA) has proven advantages for glycemic control, cardiovascular health, and functional independence. However, physical activity is not part of routine conventional physical therapy (CPT) in managing diabetic adhesive capsulitis patients.

Objective

To determine the effects of moderate MPA on diabetic adhesive capsulitis (AC).

Methodology

A randomized control trial was conducted at the Combined Military Hospital (CMH), Muzaffarabad, Pakistan from March 2022 to October 2022. A total of n = 44 patients with diabetic AC, aged 40 to 65 years, HbA1c > 6.5% were enrolled. Group A received MPA and CPT, while Group B only received CPT for six weeks. The upper extremity function, pain, and range of motion were assessed at baseline, third week, and sixth week through the disability of arm, shoulder, and hand (DASH) questionnaire, numeric pain rating scale (NPRSS), and goniometer respectively.

Results

The NPRS score and ROMs showed significant improvement (p < 0.05) in group A compared to group B with a large effect size. When comparing the mean difference of the DASH score (73 + 7.21 vs. 57.9 + 12.64, p < 0.001, Cohen's d = 1.46) was significantly improved with large effect size in group A as compared to group B.

Conclusion

MPA along with CPT has positive effects on patient pain, range of motion, and disability in patients with diabetic adhesive capsulitis.

Impacts of preoperative anxiety and depression on pain and range of motion after arthroscopic frozen shoulder release: a cohort study

PURPOSE

We aimed to evaluate the impact of preoperative anxiety and depression levels on baseline and postoperative pain in patients who underwent arthroscopic frozen shoulder release.

METHODS

The study included 59 patients with more than three months of idiopathic frozen shoulder. All patients had arthroscopic frozen shoulder release. Two patients were excluded from statistical analysis. Therefore, the statistical analysis was performed on the remaining 57 patients. The patients were divided into two groups according to HADS scores: group 1 which included 28 patients with a healthy psychological status (anxiety ≤ 7 and depression ≤ 7), and Group 2, which included 29 patients with psychological distress ( anxiety ≥ 8 or depression ≥ 8).

RESULTS

The hallmark finding of this study is that patients complaining of frozen shoulder symptoms and having psychological distress (HADS ≥ 8) experienced higher pain scores preoperatively and at one-year follow-up after arthroscopic release. All patients showed significant improvement between the preoperative period and the one year follow-up regarding the abduction, forward flexion, external rotation at the side and the VAS pain score with a P value of 0.001.

CONCLUSIONS

Arthroscopic frozen shoulder release significantly lowers the VAS pain score over the 12-month.

[Comparison of mid-term effectiveness between diabetic secondary stiff shoulder and primary frozen shoulder after arthroscopic shoulder capsular release combined with acromiohumeral distance restoration]

Objective

To compare the mid-term effectiveness of arthroscopic shoulder capsular release combined with acromiohumeral distance (AHD) restoration in the treatment of diabetic secondary stiff shoulder and primary frozen shoulder.

Methods

A retrospective analysis was conducted on clinical data of 22 patients with diabetic secondary stiff shoulder (group A) and 33 patients with primary frozen shoulder (group B), who underwent arthroscopic 270° capsular release combined with AHD restoration treatment. There was no significant difference between the two groups in gender, age, affected side, disease duration, and preoperative AHD, shoulder flexion range of motion, abduction range of motion, American Shoulder and Elbow Surgeons (ASES) score, visual analogue scale (VAS) score, and Constant score ( P>0.05). Only the difference in the internal rotation cone rank and external rotation range of motion between the two groups showed significant differences ( P<0.05). The improvement in shoulder pain and function was evaluated by using VAS score, ASES score, and Constant score before operation and at last follow-up. Active flexion, abduction, external rotation range of motion, and internal rotation cone rank were recorded and compared. AHD was measured on X-ray films.

Results

All patients were followed up 24-92 months (median, 57 months). There was no significant difference in follow-up time between group A and group B ( P>0.05). No fractures or glenoid labrum tears occurred during operation, all incisions healed by first intention, and no complication such as wound infection or nerve injury was observed during the follow-up. At last follow-up, there were significant improvements in active flexion, abduction, external rotation range of motion, internal rotation cone rank, AHD, VAS score, ASES score, and Constant score when compared with preoperative ones in both groups ( P<0.05). Except for the difference in change in external rotation range of motion, which had significant difference between the two groups ( P<0.05), there was no significant difference in other indicators between the two groups ( P>0.05).

Conclusion

Arthroscopic capsular release combined with AHD restoration can achieve good mid-term effectiveness in the treatment of diabetic secondary stiff shoulder and primary frozen shoulder. However, the improvement in external rotation range of motion is more significant in the patients with diabetic secondary stiff shoulder.

Subdiaphragmatic phrenic nerve supply: A systematic review

OBJECTIVE

The aim of this systematic review is to study the subdiaphragmatic anatomy of the phrenic nerve.

MATERIALS AND METHODS

A computerised systematic search of the Web of Science database was conducted. The key terms used were phrenic nerve, subdiaphragmat*, esophag*, liver, stomach, pancre*, duoden*, intestin*, bowel, gangli*, biliar*, Oddi, gallbladder, peritone*, spleen, splenic, hepat*, Glisson, falciform, coronary ligament, kidney, suprarenal, and adrenal. The 'cited-by' articles were also reviewed to ensure that all appropriate studies were included.

RESULTS

A total of one thousand three hundred and thirty articles were found, of which eighteen met the inclusion and exclusion criteria. The Quality Appraisal for Cadaveric Studies scale revealed substantial to excellent methodological quality of human studies, while a modified version of the Systematic Review Centre for Laboratory Animal Experimentation Risk of Bias Tool denoted poor methodological quality of animal studies. According to human studies, phrenic supply has been demonstrated for the gastro-esophageal junction, stomach, celiac ganglia, liver and its coronary ligament, inferior vena cava, gallbladder and adrenal glands, with half of the human samples studied presenting phrenic nerve connections with any subdiaphragmatic structure.

CONCLUSIONS

This review provides the first systematic evidence of subdiaphragmatic phrenic nerve supply and connections. This is of interest to professionals who care for people suffering from neck and shoulder pain, as well as patients with peridiaphragmatic disorders or hiccups. However, there are controversies about the autonomic or sensory nature of this supply.