Frozen shoulder: A systematic review of therapeutic options

Understanding Scapulohumeral Periarthritis: A Comprehensive Systematic Review

BACKGROUND

This systematic review examines the clinical presentations and prevalence of scapulohumeral periarthritis (SP) by synthesizing the relevant literature from open-access articles from international databases (Medline, Pedro, and EBSCO).

METHODS

Keywords guiding the review included 'scapulohumeral periarthritis', 'clinical forms', 'incidence', 'impingement syndrome, 'calcifying tendinitis', 'bicipital tendonitis', 'shoulder bursitis', 'adhesive capsulitis or frozen shoulder', 'rotator cuff tears', 'functional assessment', and 'clinical trials'. Eligible studies included randomized controlled trials, nonrandomized controlled trials, cross-sectional studies, and review articles published between 1972 and 2024.

RESULTS

Our screening identified 2481 initial articles, of which 621 were further reviewed for eligibility resulting in 107 articles that met the relevance criteria. The findings highlight six distinct clinical forms of SP, such as partial rotator cuff tears and calcific tendinitis, each characterized by specific pathological features and prevalence patterns. Key factors contributing to SP include injuries, scapular instability, acromion deformities, and degenerative rotator cuff changes. Functional assessments, including the Neer, Hawkins, Pain Arc, and Yocum tests, demonstrated diagnostic value in distinguishing SP from other shoulder conditions.

CONCLUSIONS

By comprehensively analyzing the clinical forms, functional assessment methods, and prevalent lesions of SP, functional testing can improve early diagnosis and guide personalized physiotherapy protocols for optimal rehabilitation in the physiotherapist's practice.

Pathogenic Factor Analysis of Shoulder Periarthritis and Design of Virtual Reality Exercise Intervention System

Shoulder periarthritis, a prevalent musculoskeletal disorder, causes significant pain and functional impairment, severely affecting patients' quality of life. With the increasing incidence of shoulder periarthritis linked to modern lifestyle changes, effective prevention and treatment strategies remain elusive. This study explores two areas: first, identifying risk factors for shoulder periarthritis through Mendelian randomization (MR) analysis, and second, designing a motion intervention system incorporating MediaPipe and virtual reality (VR) technology. The MR analysis revealed positive causal relationships between shoulder periarthritis and body mass index (BMI), cigarettes per day, insomnia, and sedentary behavior, while higher educational attainment was inversely associated with the condition. Based on these findings, we developed a "VR Harvest" exercise system aimed at alleviating shoulder stiffness due to prolonged sitting and reducing shoulder pain. By adjusting task difficulty to increase physical activity, the system also facilitates BMI reduction, potentially lowering the risk of shoulder periarthritis. The experimental results indicate that the "VR Harvest" therapy effectively alleviates pain and, compared to traditional exercise therapy, offers greater enjoyment, thereby enhancing participant engagement. Moreover, participants across different BMI categories experienced reductions in BMI after completing the intervention. This study offers a novel approach for shoulder periarthritis prevention and treatment, leveraging VR technology to improve both symptom relief and underlying risk factors.

Exploring the link between metformin use and adhesive capsulitis of the shoulder: a retrospective cohort study in Taiwan

The risk of adhesive capsulitis of shoulder in diabetic patients taking metformin has not been evaluated. We aimed for evaluating the relative risk of adhesive capsulitis of shoulder in diabetic patients taking metformin at the level of the whole country population. We conducted a retrospective cohort study using a national health insurance database in Taiwan from 2000 to2015. We used International Classification of Diseases, Ninth Revision, to categorise the medical condition for study group and comparison group. We used Cox proportional hazard regression analyses to determined adjusted hazard ratios (aHRs) of adhesive capsulitis of shoulder between study and comparison group after adjusting for sex, age, and comorbidities.Among 30,412 diabetic patients using metformin, 3020 patients were diagnosis with adhesive capsulitis of shoulder during follow up. Of the 121,648 patients without the use of metformin, 11,375 patients developed adhesive capsulitis of shoulder. Adhesive capsulitis of shoulder risk was elevated in patients taking metformin than in non-metformin group (adjusted hazard ratio [HR] 1.179, 95% confidence interval [95% CI] 1.022 to 1.268; p = 0.039). Risk of adhesive capsulitis of shoulder among the diabetic patients taking metformin was higher than those did not taking metformin.

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.

Pharmacopuncture therapy for adhesive capsulitis: A pragmatic randomized controlled pilot study

Background

Although several studies have reported the effectiveness of acupuncture treatment for adhesive capsulitis (AC), research on pharmacopuncture therapy for AC remains limited. We compared the effectiveness and safety of pharmacopuncture and physiotherapy for AC.

Methods

This pragmatic, randomized, controlled, parallel-group pilot study enrolled patients with limitations of shoulder movement and a numeric rating scale (NRS) score for shoulder pain ≥5 randomized (1:1) to the pharmacopuncture therapy (PPT) and physiotherapy (PT) groups. Treatment sessions were administered twice weekly for 6 weeks, and the participants were followed up for 13 weeks after randomization. The primary outcome was the NRS score for shoulder pain, and the secondary outcomes were the visual analog scale (VAS), Shoulder Pain and Disability Index (SPADI), range of motion (ROM), patient global impression of change (PGIC), EuroQol 5-Dimension 5-Level (EQ-5D-5L), and Short Form 12 Health Survey (SF-12) scores. The intention-to-treat (ITT) analysis was set as the primary analysis.

Results

Among 50 participants, for the primary endpoint (week 7) the PPT group showed a significantly superior improvement in NRS, VAS, SPADI, ROM for flexion, ROM for abduction, and EQ-5D-5L scores. The ROM for extension, ROM for adduction, physical component summary, and patient global impression of change were significantly better in the PPT than in the PT group, and these effects were sustained until week 13.

Conclusion

In this pilot study, PPT showed better effects than PT, confirming the feasibility of a follow-up main study.

Trial registration

Clinicaltrials.gov (NCT05292482) and cris.nih.go.kr (KCT0007198).

Efficacy comparison of sodium hyaluronate, corticosteroids, and autologous platelet-rich plasma in the treatment of primary frozen shoulder

OBJECTIVES

Primary frozen shoulder is a shoulder joint disease that severely impacts the quality of life of patients, and intra-articular injection is a common treatment method. This study aims to evaluate and compare the therapeutic effects of sodium hyaluronate (SH), corticosteroids (CS), and autologous platelet-rich plasma (PRP) in the treatment primary frozen shoulder.

METHODS

A total of 117 patients diagnosed with primary frozen shoulder and treated with a single injection of SH, CS, or PRP into the glenohumeral joint under ultrasound guidance at the Third Xiangya Hospital of Central South University from January 1, 2020, to December 31, 2022, were included in the study. The patients were divided into a SH group, a CS group, and a PRP group. Clinical data of patients, including Visual Analogue Scale (VAS) pain score, range of motion, Constant score, and Disabilities of Arm, Shoulder, and Hand (DASH) score were collected before treatment and at 1, 3, and 6 months after treatment. The efficacy of these 3 intra-articular injection therapies for primary frozen shoulder was compared.

RESULTS

Compared with the baseline, the SH, CS, and PRP groups all showed significant improvements in shoulder VAS pain scores, range of motion, Constant scores, and DASH scores at 6 months after treatment (all P<0.05). Compared with the SH and PRP groups, the CS group showed better VAS pain score, range of motion, Constant score, and DASH score at 1 month after treatment (all P<0.05). However, the VAS pain score, range of motion, Constant score, and DASH score in the PRP group were better than those in the SH and CS groups at 6 months after treatment (all P<0.05).

CONCLUSIONS

A single ultrasound-guided injection of SH, CS, or PRP into the glenohumeral joint can significantly improve pain degree, range of motion, and function in patients with primary frozen shoulder. Among these 3 injection therapies, CS may provide better short-term efficacy, while PRP may offer better long-term outcomes.

Exploring Coracohumeral Ligament Elasticity Changes With Matrix Rhythm Therapy in Idiopathic Adhesive Capsulitis: A Case Report

Idiopathic adhesive capsulitis is a complex pathology that combines inflammation and tightness of the ligamentous and capsular structures in the shoulder joint. Using methods like mobilization, strengthening exercises, and stretching modalities, physiotherapy is still the mainstay in treating adhesive capsulitis. However, novel treatment modalities are being used in various musculoskeletal conditions. This case study investigates the effectiveness of matrix rhythm therapy (MRT) in treating a 42-year-old female patient with idiopathic adhesive capsulitis by examining the elasticity of the coracohumeral ligament (CHL). The patient received six sessions of MRT over two weeks, in addition to stretching exercises for the CHL and capsular tissues. The modality's effectiveness was recorded using a universal goniometer for measuring the range of motion, the Numeric Pain Rating Scale (NPRS) to measure pain, and elastography to measure CHL thickness. Significant improvement in pain and range of motion was noted. Additionally, ultrasonographic evaluations revealed a substantial reduction in thickness from 1.9 mm to 0.9 mm and in CHL shear ratio from 2.94 to 0.40. MRT has shown a beneficial effect on CHL elasticity, which helped in the case of idiopathic adhesive capsulitis, showing a possibility as a viable technique for addressing deeper tissue involvement in shoulder disorders.

Arthroscopic Capsular Release Versus Manipulation under Anesthesia for Refractory Frozen Shoulder: A Systematic Review with Meta-Analysis

OBJECTIVE

Frozen shoulder (FS) is a painful and debilitating condition affecting the shoulder joint. When patients fail to improve after conservative treatments, operative treatments including arthroscopic capsular release (ACR) and manipulation under anesthesia (MUA) are recommended. However, the comparison between these two interventions remains controversial. This study aimed to compare the efficacy and safety of ACR and MUA for refractory FS.

METHODS

A systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. PubMed, EMBASE, Cochrane Library, and Web of Science were searched for eligible studies until December 10, 2023. Meta-analyses were conducted using Manager V.5.3.3. Pooled effect sizes were expressed as the weighted mean difference (WMD) or odds ratio (OR) with 95% confidence intervals (CIs).

RESULTS

A total of eight comparative studies with 768 patients were included. Compared with MUA, ACR had statistically better Δ VAS (WMD, -0.44; 95% CI, -0.71 to -0.18; I2 = 6%; p = 0.001) at over 12-month follow-up, which did not reach the minimal clinically important difference (MCID). Other outcomes regarding pain relief, function, and range of motion (ROM) improvements were not statistically different between the two groups at different follow-up timepoints. Compared with the MUA group, the ACR group had a significantly higher rate of severe complications (OR, 4.14; 95% CI, 1.01 to 16.94; I2 = 0%; p = 0.05), but comparable rates of mild complications and additional intervention.

CONCLUSIONS

In treating refractory FS, ACR demonstrated comparable pain relief, functional and ROM improvements, rates of mild complications and additional intervention but a higher risk of severe complications to MUA during short-term follow-up periods. Notably, ACR exhibited statistically superior improvement in the long-term pain relief compared to the MUA group, although it did not reach the MCID.

Efficacy of Combination Therapy (Hydrodilatation and Subdeltoid Bursa Injection With Corticosteroid, Mobilization, and Physical Therapy) vs Physical Therapy Alone for Treating Frozen Shoulder: A Randomized Single-Blind Controlled Trial, Phase I

OBJECTIVE

To compare the efficacy of combination therapy (hydrodilatation and subdeltoid bursa injection with corticosteroid, mobilization, and physical therapy [PT]) with that of PT alone for treating frozen shoulder.

DESIGN

A prospective, 2-arm parallel, single-blinded, randomized controlled trial.

SETTING

Rehabilitation clinic of a private academic hospital.

PARTICIPANTS

Patients (n=70) with frozen shoulder (freezing stage).

INTERVENTIONS

Participants (n=35) in the combination group underwent hydrodilatation and subdeltoid bursa injection with corticosteroid twice, mobilization, and usual-care PT for 8 weeks; participants (n=35) in the PT group received only the usual-care PT for 8 weeks.

MAIN OUTCOME MEASURES

The Shoulder Pain and Disability Index (SPADI) was the primary outcome measure. The secondary outcome measures were pain scores on a visual analog scale, range of motion (ROM), the Shoulder Disability Questionnaire (SDQ), quality of life (evaluated using the 36-item Short-Form Health Survey [SF-36]), and self-assessment of the treatment effect.

RESULTS

Compared with the PT group, the combination group had significantly better pain (during activity), SPADI, SDQ, active and passive ROM, and self-assessment scores (all P<.001) as well as scores on some parts of the SF-36 (physical function and bodily pain, P<.05). Between-group differences were significant at the 1-, 2-, 4-, and 6-month follow-ups.

CONCLUSIONS

A combination of hydrodilatation (with corticosteroid), bursal corticosteroid injection, and joint mobilization with PT was superior to PT alone for treating frozen shoulder, and the effects persisted for at least 6 months.

The Lack of High-quality Educational Resources about Adhesive Capsulitis on YouTube

Objective  The advent of the Internet has provided new, easily accessible resources for patients seeking additional health information. Many doctors and healthcare organizations post informative videos on this platform, and nearly all patients are looking for videos online for a second opinion. Methods  The phrases "frozen shoulder," "frozen shoulder treatment," "adhesive" capsulitis, and "adhesive capsulitis treatment" were entered into YouTube's search bar for a normal inquiry. The informativeness and overall quality of the adhesive capsulitis videos were rated using three separate scales. Results  The mean and standard deviation values of the scoring systems were JAMA 1.25 ± 0.51, DISCERN 39.4 ± 13.4, GQS 2.83 ± 0.96 and ACSS 7.43 ± 4.86, respectively. Number of views, rate of views, and likes all had a positive correlation with Global Quality Score (GQS), as did DISCERN and ACSS. There was no statistically significant difference between the median JAMA, GQS score and Discern Criteria values according to the video source/uploader (p > 0.05). Conclusion  YouTube videos on adhesive capsulitis, thus, need to be of higher quality, reliability, and instructive quality. There is a need for reliable videos about adhesive capsulitis, with instructional and high-quality cited.

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.

Evidence for Combining Conservative Treatments for Adhesive Capsulitis

Background: Adhesive capsulitis, also known as frozen shoulder, is a challenge to treat clinically. Common first-line treatment options are suprascapular nerve block (SSNB), intra-articular corticosteroid (IACS) injection, hydrodilatation, and physical therapy. This literature review summarizes each of these conservative treatments and discusses the evidence base for combining treatment options for potential additive benefits to improve patient outcomes (ie, pain, range of motion [ROM], and shoulder function). Methods: The PubMed and Google Scholar databases were searched using the search terms "adhesive capsulitis," "frozen shoulder," "corticosteroids," "physical therapy," "suprascapular nerve block," "hydrodilatation," and "conservative care." Pertinent articles were identified and synthesized to provide a comprehensive review of 4 common conservative treatments for adhesive capsulitis. Results: Combining SSNB with physical therapy and/or IACS injection and combining IACS injection with physical therapy have support in the literature for improving shoulder pain, ROM, and function, while hydrodilatation and physical therapy seem to offer some additive benefits for improving shoulder ROM when used as adjunct treatments for adhesive capsulitis. Conclusion: Adhesive capsulitis remains a challenge to treat clinically with much still unknown regarding treatment optimization. For the foreseeable future, first-line conservative management will continue to be the mainstay of managing adhesive capsulitis. Thus, knowing how to best use and optimize these various options-both individually and in combination-is vital for effective treatment.

The efficacy of platelet-rich plasma injections compared to corticosteroids and physiotherapy in adhesive capsulitis: A systematic review and meta-analysis

Introduction

Adhesive Capsulitis is a common condition of the shoulder with significant morbidity and protracted disease. It is usually characterized by sudden onset with progressive symptoms of pain and loss of function. This systematic review compares platelet rich plasma (PRP) intra-articular injections with corticosteroids (CS) injections and physiotherapy.

Material and methods

A literature search was performed using online databases (Pubmed, Cochrane, EMBASE, Medline and CINAHL) including all the studies performed on humans through April 2023. Prospective comparative studies were included in this review of patients with adhesive capsulitis assessing the use of PRP injections versus corticosteroid injections or physiotherapy. The standardized mean difference (SMD) with 95 % confidence interval in VAS/DASH/SPADI and ROM scores was calculated using a random effects model, comparing PRP to corticosteroids injections and physiotherapy across studies.

Results

A total of 11 studies and 971 patients, with a mean age of 52.1, were included in this analysis with 7 being randomised trials and four cohort studies. The control group was corticosteroid injections in 8 studies and physiotherapy in the other three studies. Overall PRP lead to a statistically significant improved outcome at 3 and 6 months follow up for all outcome parameters. The outcome measures at three months includes VAS 0.73 (0.31, 1.16) SMD, DASH 0.66 (0.36, 0.96) SMD, SPADI 1.50 (0.43, 2.57) SMD, ER 1.47 (0.27, 2.66) SMD and Abduction 1.10 (0.21, 1.98) SMD. Six months assessment similarly favoured PRP with VAS 3.17 (1.26, 5.08) SMD and DASH 2.10 (1.66, 2.55) SMD scores. Furthermore, a subgroup analysis demonstrated that PRP was favourable to corticosteroids as control with significant improvement in pain (VAS) at 3 months 0.65 (0.29, 1.00) and 6 months 3.17 (1.26, 5.08) SMD.

Conclusion

This review demonstrated that intra-articular PRP injections for adhesive capsulitis produces favourable outcomes when compared to corticosteroid injections and physiotherapy. PRP produces improved pain and functional scores as well as range of motion, which is statistically significant from 3 to 6 months post intervention. PRP seems to be a safe and effective alternative non-invasive treatment modality for patients with adhesive capsulitis.

Allogenic Platelet-Rich Plasma for the Treatment of Adhesive Capsulitis

Adhesive capsulitis (AC) is a common shoulder disorder leading to pain and restricted range of motion (ROM) and affects the patient's activities of daily living (ADL) and overall quality of life (QoL). Conservative therapies are prioritized, resorting to surgical intervention only when necessary. Unfortunately, these modalities have limitations and do not address the underlying pathological cause of AC. The use of autologous biologics, such as platelet-rich plasma (PRP), has evolved and shown promise for managing musculoskeletal (MSK) injuries, including AC. However, subpar functional outcomes have led clinicians to question the long-term efficacy of autologous PRP. To circumvent this, the possibility of utilizing a standardized and well-characterized allogenic PRP for AC has been explored. In this manuscript, we qualitatively present in vitro, pre-clinical, clinical, and ongoing studies investigating the varied applications of allogenic PRP for the management of AC. The results demonstrated that allogenic PRP acts in a pleiotropic manner and decreases pro-inflammatory cytokines only in the inflammatory condition. In addition, the administration of allogenic PRP is safe and potentially efficacious, in terms of reducing pain and improving range of motion, shoulder strength, and function, in non-surgical management of AC. Nonetheless, more pre-clinical studies and adequately powered, multicenter, prospective, non-randomized, and randomized controlled trials with longer follow-up are warranted to further establish the safety and efficacy of allogenic PRP and justify its routine clinical use.

Adhesive Capsulitis Secondary to COVID-19 Vaccination - A Case Series

Introduction

Shoulder injury related to vaccine administration (SIRVA) is a group of pathologies defined by pain and stiffness after intramuscular administration of vaccine to the upper arm and has been reported after COVID-19 vaccination. We aim to discuss its pathophysiology, clinical presentation, treatment and outcomes.

Materials and methods

We retrospectively identified patients presenting with adhesive capsulitis within four weeks of administration of COVID-19 vaccine to the affected arm at our tertiary institution from March 2021 to December 2022.

Result

Based on the above criteria, we identified seven cases of adhesive capsulitis, comprising one male and six female patients, with average age of 60 years. We present initial symptoms, signs and the duration from when the vaccine was administered. We have highlighted our treatment strategies as well as the clinical and functional outcomes reported by these patients after treatment. We have reported improvement in both Visual Analogue Scale (VAS) and range of motion (ROM) in all our patients after non-surgical management which included physiotherapy and, in some cases, hydrodilatation.

Conclusion

SIRVA related adhesive capsulitis is rare and under-reported with limited information in current literature. This study highlights that adhesive capsulitis is a potential complication arising from improper COVID-19 vaccine administration and reinforces traditional wisdom of administering vaccinations on the non-dominant arm. Conservative treatment strategies appear to be effective, particularly hydrodilatation combined with physiotherapy, and patients are expected to have a good return of function.

Causal relationship between ischemic stroke and its subtypes and frozen shoulder: a two-sample Mendelian randomization analysis

Background

Previous epidemiological and other studies have shown an association between ischemic stroke (IS) and frozen shoulder (FS). However, the causal relationship between them remains unclear. Therefore, the present study aimed to investigate the causal relationship between IS and FS using a two-sample Mendelian randomization method.

Methods

Our research was divided into two stages: discovery and replication. The data were extracted from publicly available genome-wide association studies (GWAS). We selected a large sample of IS (n = 440, 328) and its subtypes (large-artery atherosclerotic stroke (LAS), cardioembolic stroke (CES), and stroke caused by small-vessel disease (SVS) and lacunar stroke (n = 254, 959) as exposure data. Additionally, we selected a large sample of FS as outcome data (n = 451, 099). Inverse variance weighting (IVW) was applied as the primary analysis method. The weighted median, MR-Egger, simple model, and weighted model were used as complementary analysis methods to assess causal effects. Moreover, heterogeneity was analyzed using Cochran's Q-test with IVW and MR-Egger. The MR-Egger intercept and MR-PRESSO analysis methods were used for pleiotropy testing. The stability of the results was also assessed using a leave-one-out analysis.

Results

In the discovery stage, the IVW approach revealed an odds ratio (OR) of 1.207 with a 95% confidence interval (CI) of 1.027-1.417 and a P-value of 0.022. This suggests a causal association between IS levels and an increased risk of FS. In the subtype studies of IS, the findings were negative. However, during the replication stage, a significant causal link was found between selected lacunar strokes and FS with an OR of 1.252, a 95% CI of 1.105-1.419, and a P-value of 0.0004. All studies had no pleiotropy or heterogeneity, and the findings were robust.

Conclusions

Our study confirmed the causal relationship between any IS level and increased risk of FS. Furthermore, the same results were obtained in the replication stage with lacunar stroke as an exposure factor. However, there was no direct causal relationship between the subtypes of IS and FS. Our study provides theoretical support for shoulder care for patients with IS.

Anti-TNF (adalimumab) injection for the treatment of adults with frozen shoulder during the pain predominant stage protocol for a multi-centre, randomised, double blind, parallel group, feasibility trial

Objectives

The Anti-Freaze-F trial will assess the feasibility of conducting a large randomised controlled trial to assess whether intra-articular injection of anti-TNF (adalimumab) can reduce pain and improve function in people with pain predominant early stage frozen shoulder.

Methods and analysis

We are conducting a multi-centre, randomised feasibility study, with an embedded qualitative sub-study. We will recruit adults ≥18 years with a new episode of shoulder pain attributable to early stage frozen shoulder, recruited from at least five UK NHS musculoskeletal and related physiotherapy services. Participants (n=84) will be randomised (centralised computer generated 1:1 allocation) to receive either: 1) intra-articular injection of anti-TNF (adalimumab 160mg) or 2) placebo injection (saline [0.9% sodium chloride]), both under ultrasound guidance. A second injection of the allocated treatment (adalimumab 80mg) or equivalent volume of placebo will be administered 2-3 weeks later. All participants will receive a physiotherapy advice leaflet providing education and advice about frozen shoulder and pain management. The primary feasibility objectives are: 1) the ability to screen and identify potential participants with pain predominant early stage frozen shoulder; 2) willingness of eligible participants to consent and be randomised to intervention; 3) practicalities of delivering the intervention, including time to first injection and number of participants receiving second injection; 4) standard deviation of the Shoulder Pain and Disability Index (SPADI) score and attrition rate at 3 months (i.e. 12 weeks) post-randomisation in order to estimate the sample size for a definitive trial. We will also assess follow up rates and viability of patient-reported outcome measures and range of shoulder motion for a definitive trial. Research Ethics Committee approval (REC 21/NE/0214).

Trial registration number

ISRCTN 27075727; EudraCT number: 2021-003509-23; ClinicalTrials.gov NCT05299242.

Suprascapular Nerve Block (SSNB) improves the outcome in exercise based management of Primary Adhesive Capsulitis (PAC): A prospective randomized comparative study

Background and Aims

Increased pain and associated stiffness hinders the advantages of exercise and process of recovery in primary adhesive capsulitis. We hypothesized that suprascapular nerve block may positively affect the outcome due to its role in pain relief of acute or chronic shoulder pain. We compared the effect of suprascapular nerve block and exercise with only exercise on the recovery of primary adhesive capsulitis.

Material and Methods

A total of 96 patients of both sexes presenting with primary adhesive capsulitis were divided by computer randomization in two equal groups (n = 48). Group A received exercise only and Group B received suprascapular nerve block followed by exercise. Oral paracetamol was given for analgesia as desired. Patients were followed up at 4, 8, 16, and 24 weeks. Pain was assessed by visual analog scale; functional outcome by Shoulder Pain and Disability Index and range of movement by goniometer.

Results

The pain scores and Shoulder Pain and Disability Index scores were significantly lower at all observation points of 4, 8,16, and 24 weeks in Group B than Group A (P < 0.05). The range of movement in all the ranges of forward flexion, extension, internal and external rotation, and abduction at all observation points was significantly higher in Group-B (P < 0.05) compared to Group A. The consumption of analgesics was significantly more in Group A than Group B at 4 and 8 weeks (P = 0.020 and P = 0.044) but comparable at 12 and 24 weeks (P = 0.145 and P = 0.237 respectively).

Conclusion

Combining SSNB with exercise is more effective in treatment of primary adhesive capsulitis than exercise alone and reduces the use of analgesics. SSNB it is effective and safe to use in primary adhesive capsulitis.

Application of Acupuncture for Shoulder Pain Over the Past 22 Years: A Bibliometric Analysis

Purpose

Acupuncture is widely used to relieve shoulder pain. A survey was conducted in order to recognize hotspots and frontiers of acupuncture for shoulder pain from the year 2000-2022.

Methods

The Web of Science Core Collection was used to collect literature related to acupuncture therapy for shoulder pain, which spanned January 2000 to August 2022. The number of publications yearly, countries/institutions, journals, and keywords was analyzed and visualized in shoulder pain with acupuncture therapy by CiteSpace v.5.7.R5.

Results

We totally analyzed 214 articles that met the inclusion criteria. The overall trend of publication volume continues to increase. The most productive authors in the field were César Fernández las Peñas and José L Arias-Buría, and the most influential author was Green S. Kyung Hee University and the People's Republic of China had the highest volume of publications, respectively. The most influential journal is Pain with high citation and impact factor. The hot keywords were "acupuncture", "shoulder pain", "dry needling", "randomized trial", and "injection". The research frontier in acupuncture for treating chronic shoulder pain was mainly "mechanism".

Conclusion

Over the last 22 years, the findings of this bibliometric analysis have provided research trends and frontiers in clinical research on acupuncture therapy for patients with shoulder pain, which identifying hot topics and exploring new directions for the future may be helpful to researchers. Studying mechanisms underlying acupuncture therapy for shoulder pain remains a focus of future research.

Evaluation of intensive rehabilitation under continuous suprascapular nerve blockade for the treatment of refractory adhesive shoulder capsulitis. Case series

INTRODUCTION

Treatment of refractory adhesive shoulder capsulitis is a challenge. This observational retrospective study evaluated the long-term effectiveness of intensive physiotherapy protocol under a continuous peripheral blockade of the suprascapular nerve (cSSNB).

METHOD

We reviewed 29 medical records of patients suffering from adhesive capsulitis and treated with intensive physiotherapy under cSSNB during 10 days. The "disabilities of the arm, shoulder and hand" outcome questionnaire (DASH score) and shoulder movements were recorded at the beginning, 10 days after local anesthetic infusion and three months after.

RESULTS

Twenty six patients significant improved shoulder movements after 10 days of treatment. Sixteen patients were followed completely until 3 months after rehabilitation program. Range of four shoulder motion compatible with a normal daily life was acquired in nine patients at three months. There is no significant difference in shoulder motion between the end of LA infusion and at three months. At the end of infusion, DASH score is significantly decreased to 59.3 (n = 26), and persists three months 42.1 (n = 16). At three months, 33% of the initial population objectively reach the 4 goals, compatible with a correct quality of life.

CONCLUSION

Rehabilitation under cSSNB is associated with a significant long term improvement in shoulder motion and quality of life in patients with adhesive capsulitis. Randomized controlled trials will be necessary to demonstrate our encouraging results.

Genome-Wide Association Study of Adhesive Capsulitis Suggests Significant Genetic Risk Factors

BACKGROUND

Adhesive capsulitis of the shoulder involves loss of passive range of motion with associated pain and can develop spontaneously, with no obvious injury or inciting event. The pathomechanism of this disorder remains to be elucidated, but known risk factors for adhesive capsulitis include diabetes, female sex, and thyroid dysfunction. Additionally, transcriptional profiling and pedigree analyses have suggested a role for genetics. Identification of elements of genetic risk for adhesive capsulitis using population-based techniques can provide the basis for guiding both the personalized treatment of patients based on their genetic profiles and the development of new treatments by identification of the pathomechanism.

METHODS

A genome-wide association study (GWAS) was conducted using the U.K. Biobank (a collection of approximately 500,000 patients with genetic data and associated ICD-10 [International Classification of Diseases, 10th Revision] codes), comparing 2,142 patients with the ICD-10 code for adhesive capsulitis (M750) to those without. Separate GWASs were conducted controlling for 2 of the known risk factors of adhesive capsulitis-hypothyroidism and diabetes. Logistic regression analysis was conducted controlling for factors including sex, thyroid dysfunction, diabetes, shoulder dislocation, smoking, and genetics.

RESULTS

Three loci of significance were identified: rs34315830 (in WNT7B; odds ratio [OR] = 1.28; 95% confidence interval [CI], 1.22 to 1.39), rs2965196 (in MAU2; OR = 1.67; 95% CI, 1.39 to 2.00), and rs1912256 (in POU1F1; OR = 1.22; 95% CI, 1.14 to 1.31). These loci retained significance when controlling for thyroid dysfunction and diabetes. The OR for total genetic risk was 5.81 (95% CI, 4.08 to 8.31), compared with 1.70 (95% CI, 1.18 to 2.36) for hypothyroidism and 4.23 (95% CI, 2.32 to 7.05) for diabetes.

CONCLUSIONS

The total genetic risk associated with adhesive capsulitis was significant and similar to the risks associated with hypothyroidism and diabetes. Identification of WNT7B, POU1F1, and MAU2 implicates the Wnt pathway and cell proliferation response in the pathomechanism of adhesive capsulitis.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

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.

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.

Factors related to initial treatment for adhesive capsulitis in the medicare population

BACKGROUND

Primary adhesive capsulitis (AC) is not well understood, and controversy remains about the most effective treatment approaches. Even less is known about the treatment of AC in the Medicare population. We aimed to fully characterize initial treatment for AC in terms of initial treatment utilization, timing of initial treatments and treatment combinations.

METHODS

Using United States Medicare claims from 2010-2012, we explored treatment utilization and patient characteristics associated with initial treatment for primary AC among 7,181 Medicare beneficiaries. Patients with primary AC were identified as patients seeking care for a new shoulder complaint in 2011, with the first visit related to shoulder referred to as the index date, an x-ray or MRI of the shoulder region, and two separate diagnoses of AC (ICD-9-CM codes: 726.00). The treatment period was defined as the 90 days immediately following the index shoulder visit. A multivariable logistic model was used to assess baseline patient factors associated with receiving surgery within the treatment period.

RESULTS

Ninety percent of beneficiaries with primary AC received treatment within 90 days of their index shoulder visit. Physical therapy (PT) alone (41%) and injection combined with PT (34%) were the most common treatment approaches. Similar patient profiles emerged across treatment groups, with higher proportions of racial minorities, socioeconomically disadvantaged and more frail patients favoring injections or watchful waiting. Black beneficiaries (OR = 0.37, [0.16, 0.86]) and those residing in the northeast (OR = 0.36, [0.18, 0.69]) had significantly lower odds of receiving surgery in the treatment period. Conversely, younger beneficiaries aged 66-69 years (OR = 6.75, [2.12, 21.52]) and 70-75 years (OR = 5.37, [1.67, 17.17]) and beneficiaries with type 2 diabetes had significantly higher odds of receiving surgery (OR = 1.41, [1.03, 1.92]).

CONCLUSIONS

Factors such as patient baseline health and socioeconomic characteristics appear to be important for physicians and Medicare beneficiaries making treatment decisions for primary AC.

Ultrasound-Guided Suprascapular Nerve Block at Spinoglenoid Notch and Glenohumeral Joint Hydrodilation

Hydrodilation of the glenohumeral joint is commonly employed as a nonsurgical intervention for the frozen shoulder. Accuracy and pain during the procedure can be regarded as difficulties in performing this procedure. Ultrasonography (USG) guided injection and suprascapular nerve block can improve the accuracy and can decrease pain during the hydrodilation procedure. We present the step-by-step method for performing USG-guided injections for suprascapular nerve block and hydrodilation.

Effect of Adding Vertical Correction to Dynamic Scapular Recognition on Scapular Dyskinesis and Shoulder Disability in Patients With Adhesive Capsulitis: A Randomized Clinical Study

OBJECTIVE

The purpose of this study was to measure the effect of adding vertical downward correction to dynamic scapular recognition exercise on scapular dyskinesis and shoulder pain and disability in people with adhesive capsulitis.

METHODS

Sixty-seven participants with adhesive capsulitis were randomized into 2 groups. The taping intervention group performed a dynamic scapular recognition exercise using a wireless biofeedback system and a continual vertical downward correction using rigid taping with 50% to 75% tension. The comparison group performed a similar dynamic scapular recognition exercise but with sham taping. The primary outcome measures were scapular dyskinesis, scapular upward rotation, and Shoulder Pain and Disability Index, and the secondary outcome measures were shoulder flexion, abduction, and external rotation.

RESULTS

After 2 weeks, there were significant differences between the taping intervention group and the comparison group in scapular dyskinesis, scapular upward rotation, shoulder flexion, abduction, and Shoulder Pain and Disability Index (P < .05), and nonsignificant differences in shoulder external rotation (P > .05). After 2 and 6 months, there were significant differences between groups in all dependent outcome measures (P < .05).

CONCLUSION

This study demonstrated that from adding taping with a vertical downward correction to dynamic scapular recognition exercises, significant short-term and long-term improvements in scapular dyskinesis and shoulder pain and disability in people with adhesive capsulitis were observed. These improvements persisted for 6 months after intervention.

Effectiveness of graded motor imagery in subjects with frozen shoulder: a pilot randomized controlled trial

Background

Subjects with frozen shoulder (FS) might not be comfortable with vigorous physical therapy. Clinical trials assessing the effect of graded motor imagery (GMI) in FS are lacking. The aim of this study was to determine the effect of GMI as an adjunct to conventional physiotherapy in individuals with painful FS.

Methods

Twenty subjects aged 40–65 years having stage I and II of FS were randomly divided into two study groups. The conventional physiotherapy group (n = 10) received electrotherapy and exercises while the GMI group (n = 10) received GMI along with the conventional physiotherapy thrice a week for 3 weeks. Pre- (Session 1) and post- (Session 9) intervention analysis for flexion, abduction, and external rotation range of motion (ROM) using a universal goniometer, fear of movement using the fear avoidance belief questionnaire (FABQ), pain with the visual analogue scale, and functional disability using the shoulder pain and disability index (SPADI) was done by a blinded assessor.

Results

Statistically significant difference was seen within both the groups for all the outcomes. In terms of increasing abduction ROM as well as reducing fear of movement, pain, and functional disability, the GMI group was significantly better than control group. However, both groups were equally effective for improving flexion and external rotation ROM.

Conclusions

Addition of GMI to the conventional physiotherapy proved to be superior to conventional physiotherapy alone in terms of reducing pain, kinesiophobia, and improving shoulder function for stage I and II of FS.

Ultrasound-Guided Treatments for the Painful Shoulder

Shoulder pain is an extremely common condition. The painful shoulder may be the result of a wide spectrum of underlying pathological conditions, including calcific tendinopathy of the rotator cuff, subacromial-subdeltoid bursitis, acromioclavicular or glenohumeral arthritis, tenosynovitis of the long biceps tendon, rotator cuff lesions, and many other less common conditions. Ultrasound imaging is an effective tool for the diagnosis and also for the image guidance of treatment of the majority of these conditions. Several ultrasound-guided procedures are effective for pain relief, such as percutaneous irrigation, intra-bursal or intra-articular drugs injection, fluid aspiration, neural block. This review article aims to summarize and discuss the most common treatment possibilities with ultrasound guidance for the painful shoulder.

Diabetes as a Prognostic Factor in Frozen Shoulder: A Systematic Review

•

People with diabetes may experience worse outcomes from frozen shoulder than those without diabetes; however, the certainty in evidence was moderate to low.

•

If high-quality studies can confirm the findings of this review, then clinicians should monitor patients with frozen shoulder with diabetes more closely and offer further treatment if pain or lack of function persists long-term.

Objective

To summarize evidence from longitudinal observational studies to determine whether diabetes (types 1 and 2) is associated with the course of symptoms in people with frozen shoulder.

Data Sources

A systematic literature search of 11 bibliographic databases (published through June 2021), reference screening, and emailing professional contacts.

Study Selection

Studies were selected if they had a longitudinal observational design that included people diagnosed with frozen shoulder at baseline and compared outcomes at follow-up (>2wk) among those with and without diabetes at baseline.

Data Extraction

Data extraction was completed by 1 reviewer using a predefined extraction sheet and was checked by another reviewer. Two reviewers independently judged risk of bias using the Quality in Prognostic Factor Studies tool.

Data Synthesis

A narrative synthesis, including inspection of forest plots and use of the prognostic factor Grading of Recommendations, Assessment, Development and Evaluations framework. Twenty-eight studies satisfied the inclusion criteria. Seven studies were judged to be at a moderate risk of bias and 21 at a high risk of bias. Diabetes was associated with worse multidimensional clinical scores (moderate certainty in evidence), worse pain (low certainty in evidence), and worse range of motion (very low certainty in evidence).

Conclusions

This review provides preliminary evidence to suggest that people with diabetes may experience worse outcomes from frozen shoulder than those without diabetes. If high-quality studies can confirm the findings of this review, then clinicians should monitor patients with frozen shoulder with diabetes more closely and offer further treatment if pain or lack of function persists long-term.

Cost-effectiveness of surgical treatments compared with early structured physiotherapy in secondary care for adults with primary frozen shoulder : an economic evaluation of the UK FROST trial

Aims

A pragmatic multicentre randomized controlled trial, UK FROzen Shoulder Trial (UK FROST), was conducted in the UK NHS comparing the cost-effectiveness of commonly used treatments for adults with primary frozen shoulder in secondary care.

Methods

A cost utility analysis from the NHS perspective was performed. Differences between manipulation under anaesthesia (MUA), arthroscopic capsular release (ACR), and early structured physiotherapy plus steroid injection (ESP) in costs (2018 GBP price base) and quality adjusted life years (QALYs) at one year were used to estimate the cost-effectiveness of the treatments using regression methods.

Results

ACR was £1,734 more costly than ESP ((95% confidence intervals (CIs) £1,529 to £1,938)) and £1,457 more costly than MUA (95% CI £1,283 to £1,632). MUA was £276 (95% CI £66 to £487) more expensive than ESP. Overall, ACR had worse QALYs compared with MUA (-0.0293; 95% CI -0.0616 to 0.0030) and MUA had better QALYs compared with ESP (0.0396; 95% CI -0.0008 to 0.0800). At a £20,000 per QALY willingness-to-pay threshold, MUA had the highest probability of being cost-effective (0.8632) then ESP (0.1366) and ACR (0.0002). The results were robust to sensitivity analyses.

Conclusion

While ESP was less costly, MUA was the most cost-effective option. ACR was not cost-effective.

Cite this article: Bone Jt Open 2021;2(8):685–695.

Collagens in primary frozen shoulder: expression of collagen mRNA isoforms in the different phases of the disease

OBJECTIVES

Primary frozen shoulder (pFS) has three phases that differ in clinical presentation. It is characterized by contracture of the joint capsule. We hypothesized that there is a general upregulation of collagens in pFS, and that this is highest in the first phase of the disease. The aims of this study were to investigate the expression of various collagens and degradation of collagens in patients with primary pFS and relate this to the three phases of the condition.

METHODS

From twenty-six patients with pFS and eight control patients with subacromial impingement, biopsies were obtained during shoulder arthroscopy from the middle glenohumeral ligament and the anterior capsule, and mRNA levels for collagens, MMP-2 and -14 and TGF-β1, - β2 and -β3 in the tissue were analysed using real-time PCR.

RESULTS

Genes for collagens type I, III, IV, V, VI and XIV, were activated in pFS, and the total mRNA for all collagens was increased (P < 0.05). This upregulation was independent of disease phases in pFS. In addition, MMP-2, MMP-14, TGF-β1 and TGF-β3 were upregulated in all phases of the disease.

CONCLUSION

There is a general upregulation and an increased degradation of collagens in pFS in all three phases of the disease. This indicates a constantly increased turnover of the fibrotic tissue in the capsule from pFS. The difference in clinical presentation of pFS observed in the three phases of the disease is not primarily a result of variations in collagen production.

A genome-wide association study identifies 5 loci associated with frozen shoulder and implicates diabetes as a causal risk factor

Frozen shoulder is a painful condition that often requires surgery and affects up to 5% of individuals aged 40-60 years. Little is known about the causes of the condition, but diabetes is a strong risk factor. To begin to understand the biological mechanisms involved, we aimed to identify genetic variants associated with frozen shoulder and to use Mendelian randomization to test the causal role of diabetes. We performed a genome-wide association study (GWAS) of frozen shoulder in the UK Biobank using data from 10,104 cases identified from inpatient, surgical and primary care codes. We used data from FinnGen for replication and meta-analysis. We used one-sample and two-sample Mendelian randomization approaches to test for a causal association of diabetes with frozen shoulder. We identified five genome-wide significant loci. The most significant locus (lead SNP rs28971325; OR = 1.20, [95% CI: 1.16-1.24], p = 5x10-29) contained WNT7B. This variant was also associated with Dupuytren's disease (OR = 2.31 [2.24, 2.39], p<1x10-300) as were a further two of the frozen shoulder associated variants. The Mendelian randomization results provided evidence that type 1 diabetes is a causal risk factor for frozen shoulder (OR = 1.03 [1.02-1.05], p = 3x10-6). There was no evidence that obesity was causally associated with frozen shoulder, suggesting that diabetes influences risk of the condition through glycemic rather than mechanical effects. We have identified genetic loci associated with frozen shoulder. There is a large overlap with Dupuytren's disease associated loci. Diabetes is a likely causal risk factor. Our results provide evidence of biological mechanisms involved in this common painful condition.

Outcome of manipulation under anesthesia with or without intra-articular steroid injection for treating frozen shoulder: A retrospective cohort study

Manipulation under anesthesia (MUA) combined with intra-articular steroid injection (ISI) is preferred in management of the refractory frozen shoulder (FS). This study aimed to evaluate the effect of MUA with ISI or not on pain severity and function of the shoulder.Data on 141 patients receiving MUA with primary FS refractory to conservative treatments for at least 1 month were retrospectively obtained from medical records. We performed propensity score matching analysis between patients receiving MUA only and those receiving MUA plus ISI, and then conducted logistic regression analysis to identify the risk factors for the need to other treatments during 6-month follow-up.More improvement in terms of the SPADI pain scores and passive ROM at 2 weeks after first intervention remained in patients receiving MUA plus ISI after matching. The need to other treatments during 6-month follow-up occurred in 10.6% patients (n = 141). Logistic regression analysis revealed that a repeat MUA 1 week after first intervention was a protective factor (OR 0.042; 95% CI 0.011-0.162; P = .000) and duration of disease was the only one risk factor (OR 1.080; 95% CI 1.020-1.144; P = .008) for the need to other treatments during follow-up.ISI immediately following MUA provided additional benefits in rapid relief of pain and disability for patients with refractory FS. Pain and disability of the shoulder may be rapidly alleviated by an earlier MUA from the onset of the symptoms and a repeat MUA 1 week after first intervention.

Arthroscopic capsular release to treat idiopathic frozen shoulder: How much release is needed?

PURPOSE

This systematic review and meta-analysis aims to provide consensus regarding the degree of optimal extended arthroscopic capsular release in addition to a standard rotator interval release in the treatment of idiopathic frozen shoulder.

MATERIALS AND METHODS

The systematic review was conducted using the Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guidelines. All articles that reported the outcomes of capsular release in idiopathic frozen shoulder were included. A total of 18 articles with 629 patients and 811 shoulders were included. Clinical outcomes analysed include differences between pre and postoperative ranges of motion (ROM), Visual Analog Score (VAS) reduction, Simple Shoulder Test (SST) scores and Constant scores. Patients were grouped by technique: anterior-inferior capsular release (Group 1), anterior-inferior-posterior capsular release (Group 2), and 360-degree capsular release (Group 3) at follow up points 3,6 and 12 months.

RESULTS

Comparing ROM, Group 1 had greater early abduction (p<0.01), early (p<0.01) and overall external rotation (p<0.01) than Group 2, as well as greater early flexion (p<0.01), early abduction (p<0.01), early (p<0.01) and overall internal rotation (p<0.01) than Group 3. Group 2 had greater early (p=0.03) and overall flexion (p<0.01) than Group 1, as well as greater early (p<0.01) and overall flexion (p<0.01), early abduction (p<0.01) and early internal rotation (p<0.01) than Group 3. Group 3 had greater overall flexion (p<0.01) than Group 1 and greater overall external rotation (p<0.01) than Group 2. Comparing VAS scores, the less extensive releases saw the greatest significant postoperative reduction. Group 2 had greater mean improvements in postoperative Constant scores than Group 1 (p<0.01) and Group 3 (p<0.01), while SST scores were significantly higher in Group 1 (p<0.01).

CONCLUSION

This systematic review and meta-analysis suggests that less extensive releases may result in better functional and pain scores. Addition of a posterior release offers increased early internal rotation, which was not sustained over time, but provides early and sustained flexion improvements. A complete 360 release may not provide any further benefit. There were no significant differences in the complication rates amongst the 3 techniques.

LEVEL OF STUDY

II; Meta-analysis and systematic review.

Current concepts of natural course and in management of frozen shoulder: A clinical overview

Frozen Shoulder (FS) by many specialists is still considered a benign, self-limiting condition, which usually resolves without intervention. This concept originated in the 70’, stating that FS will proceed from “the freezing” phase, with the predominance of inflammation and pain to “the frozen” phase with marked stiffness in the joint and “the thawing” phase, with a progressive return to the normal Range Of Motion (ROM) and function. Nevertheless, numerous authors have recently challenged this concept, arguing that most patients with FS will never fully recover, and suffer from residual pain and loss of function. Lack of early intervention, when a patient does not improve with conservative treatment, might lead to disability. We have discussed the recent concepts in the natural course of the disease and discussed both noninvasive and surgical methods in the treatment of FS.

Can manipulation under anesthesia alone provide clinical outcomes similar to arthroscopic circumferential capsular release in primary frozen shoulder (FS)?: the necessity of arthroscopic capsular release in primary FS

Background

We evaluated the need for arthroscopic capsular release (ACR) in refractory primary frozen shoulder (FS) by comparing clinical outcomes of patients treated with ACR and manipulation under anesthesia (MUA).

Methods

We assessed patients with refractory primary FS, 57 patients (group A) who were treated with MUA and 22 patients (group B) who were treated with ACR. In group A, manipulation including a backside arm-curl maneuver was performed under interscalene brachial block. In group B, manipulation was performed only to release the inferior capsule before arthroscopic circumferential capsular release, which was carried out for the unreleased capsule after manipulation. Pain, range of shoulder motion, and American Shoulder and Elbow Surgeons score were recorded at 1 week, 3 months, 6 months, and 1 year after surgery. We compared outcome variables between treatment groups and between diabetics and non-diabetics and also evaluated the numbers of patients receiving additional intra-articular steroid injection.

Results

Outcome variables at 3 months after surgery and improvements in outcome variables did not differ between groups. Group A showed significantly better results than group B in the evaluation of pain and range of motion at 1 week. Diabetics showed comparable outcomes to non-diabetics for most variables. Eleven patients required additional steroid injections between 8 to 16 weeks after surgery: 12.2% in group A, 18.2% in group B. Additional injections were given three times more often in diabetics compared to non-diabetics.

Conclusions

MUA alone can yield similar clinical outcomes to ACR in refractory FS.

Treatment of a rotator cuff tear combined with iatrogenic glenoid fracture and shoulder instability: A rare case report

BACKGROUND

The brisement manipulation is an effective treatment for refractory shoulder stiffness. Rotator cuff tears can sometimes exist in combination with adhesive capsulitis. Arthroscopic capsular release combined with rotator cuff repair has achieved good outcomes in published reports.

CASE SUMMARY

We report the case of a patient with right shoulder pain for more than 1 year that was suspected to have adhesive capsulitis and a rotator cuff tear that was treated with brisement manipulation and arthroscopic management. An iatrogenic glenoid fracture with shoulder instability occurred during the manipulation. Arthroscopic treatment for fracture fixation, capsular release, and rotator cuff repair was performed, and the functional results are reported.

CONCLUSION

Arthroscopic fixation for iatrogenic glenoid fracture and repairing coexisting rotator cuff tear can provide the stability needed for early rehabilitation.

Biomarkers associated with idiopathic frozen shoulder: a systematic review

Background: The pathophysiology of idiopathic frozen shoulder (FS) remains poorly described. There is a lack of differentiation between idiopathic and secondary cause. The aim of this systematic review was to summarize the evidence regarding the pathophysiology of idiopathic FS on a molecular level and emphasize the clinical relevance. Methods: A database search of Medline, EMBASE and Cochrane Central Register of Controlled Trials from inception to April 2018 was performed. Participants who underwent previous injections or surgeries were excluded. A thorough selection and quality assessment process using the Cochrane Risk of Bias assessment tool and the Joanna Briggs Institute Critical Appraisal Checklist was conducted by two reviewers independently. Results: A total of 15 studies analyzing 333 study subjects were included. Twelve studies evaluated capsular tissue and three studies investigated blood samples. The tissue samples revealed increased expression of various inflammatory cytokines including interleukins, cyclooxygenase and tumor necrosis factor. Several types of acid-sensing ion channels (ASIC1 and ASIC3) were associated with disturbed neurogenesis and melatonin-regulated pain mechanism. The blood samples showed prevalence of specific interleukin and metalloproteinase genotypes. A decreased matrix metalloproteinase/tissue inhibitor of metalloproteinase ratio was found both in tissue and blood. Conclusion: The findings indicate an abnormal local neurogenesis with possible regulation through melatonin. The disturbance in remodeling of the extracellular matrix and in collagen translation, together with a persistent inflammation and an impaired healing, all interact in the process that leads to persistent fibrosis. There is global fibroplasia with localized anterior capsule contracture.

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.

Management of adults with primary frozen shoulder in secondary care (UK FROST): a multicentre, pragmatic, three-arm, superiority randomised clinical trial

BACKGROUND

Manipulation under anaesthesia and arthroscopic capsular release are costly and invasive treatments for frozen shoulder, but their effectiveness remains uncertain. We compared these two surgical interventions with early structured physiotherapy plus steroid injection.

METHODS

In this multicentre, pragmatic, three-arm, superiority randomised trial, patients referred to secondary care for treatment of primary frozen shoulder were recruited from 35 hospital sites in the UK. Participants were adults (≥18 years) with unilateral frozen shoulder, characterised by restriction of passive external rotation (≥50%) in the affected shoulder. Participants were randomly assigned (2:2:1) to receive manipulation under anaesthesia, arthroscopic capsular release, or early structured physiotherapy. In manipulation under anaesthesia, the surgeon manipulated the affected shoulder to stretch and tear the tight capsule while the participant was under general anaesthesia, supplemented by a steroid injection. Arthroscopic capsular release, also done under general anaesthesia, involved surgically dividing the contracted anterior capsule in the rotator interval, followed by manipulation, with optional steroid injection. Both forms of surgery were followed by postprocedural physiotherapy. Early structured physiotherapy involved mobilisation techniques and a graduated home exercise programme supplemented by a steroid injection. Both early structured physiotherapy and postprocedural physiotherapy involved 12 sessions during up to 12 weeks. The primary outcome was the Oxford Shoulder Score (OSS; 0-48) at 12 months after randomisation, analysed by initial randomisation group. We sought a target difference of 5 OSS points between physiotherapy and either form of surgery, or 4 points between manipulation and capsular release. The trial registration is ISRCTN48804508.

FINDINGS

Between April 1, 2015, and Dec 31, 2017, we screened 914 patients, of whom 503 (55%) were randomly assigned. At 12 months, OSS data were available for 189 (94%) of 201 participants assigned to manipulation (mean estimate 38·3 points, 95% CI 36·9 to 39·7), 191 (94%) of 203 participants assigned to capsular release (40·3 points, 38·9 to 41·7), and 93 (94%) of 99 participants assigned to physiotherapy (37·2 points, 35·3 to 39·2). The mean group differences were 2·01 points (0·10 to 3·91) between the capsular release and manipulation groups, 3·06 points (0·71 to 5·41) between capsular release and physiotherapy, and 1·05 points (-1·28 to 3·39) between manipulation and physiotherapy. Eight serious adverse events were reported with capsular release and two with manipulation. At a willingness-to-pay threshold of £20 000 per quality-adjusted life-year, manipulation under anaesthesia had the highest probability of being cost-effective (0·8632, compared with 0·1366 for physiotherapy and 0·0002 for capsular release).

INTERPRETATION

All mean differences on the assessment of shoulder pain and function (OSS) at the primary endpoint of 12 months were less than the target differences. Therefore, none of the three interventions were clinically superior. Arthoscopic capsular release carried higher risks, and manipulation under anaesthesia was the most cost-effective.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

The Effectiveness of Acupuncture in the Treatment of Frozen Shoulder: A Systematic Review and Meta-Analysis

Background

Frozen shoulder (FS) is associated with pain, reduced range of motion (ROM), and shoulder function. The condition occurs in 2-5% of the population, and it is especially common around the age of 50 years. FS symptoms will recover after 1-4 years. Many patients turn to acupuncture in order to alleviate the FS symptoms.

Objective

In this review, we will investigate the efficiency of acupuncture as a FS treatment.

Methods

A literature search of acupuncture and FS-related keywords was performed in the following databases: PubMed, Cochrane Library, Embase, and Web of Science. Thirteen publications were included for a systematic review, and a meta-analysis was done using the following measurements: visual analogue scale (VAS) for pain, Constant-Murley Shoulder Outcome Score (CMS) for shoulder function, and active shoulder ROM including flexion, abduction, and external rotation. The Cochrane Collaboration's risk of bias tool and quality of evidence GRADE recommendations and STRICTA 2010 were used to grade the included publications.

Results

A meta-analysis on VAS pain score showed significant pain reduction, restoring CMS shoulder function, and flexion ROM in favor of acupuncture versus the control. In external rotation and abduction ROM, a meta-analysis was not significant. The most used acupoints are Jian Yu (LI15) and Jian Liao (TB14).

Conclusions

The results indicate that acupuncture could be safe and effective for pain reduction, restoring shoulder function, and restoring flexion ROM for FS patients in the short term and midterm. However, the level of evidence was very low. More high-quality and longer studies are needed in order to robust the evidence.

Dynamic scapular recognition exercise improves scapular upward rotation and shoulder pain and disability in patients with adhesive capsulitis: a randomized controlled trial

BACKGROUND

Examine the ability of a dynamic scapular recognition exercise to improve scapular upward rotation and decrease shoulder pain and disability in patients with adhesive capsulitis of the shoulder.

METHODS

A test-retest randomized controlled study design was used. A total of sixty-six patients with unilateral adhesive capsulitis were equally divided into two groups. The study group received a dynamic scapular recognition exercise using a wireless biofeedback system, while the control group received placebo treatment in the form of active range-of-motion (ROM) exercises of the sound upper limb. A digital inclinometer was used to measure the scapular upward rotation and ROM of the shoulder joint, and the Shoulder Pain and Disability Index (SPADI) was used to measure the shoulder pain and disability.

RESULTS

Study results showed that after two weeks, there were statistically significant differences between the study and control groups in scapular upward rotation and shoulder flexion and abduction (P < .05) and nonsignificant differences in shoulder external rotation and SPADI (P > .05). After two and six months, there were statistically significant differences between study and control groups in scapular upward rotation; shoulder flexion, abduction and external rotation; and SPADI scores (P < .05).

CONCLUSION

This study showed that a dynamic scapular recognition exercise significantly improves scapular upward rotation and the ROM of shoulder flexion and abduction after two weeks. At two and six months, this exercise improves scapular upward rotation; ROM of shoulder flexion, abduction, and external rotation; and SPADI scores. These improvements persisted for six months after the performance of this exercise.

Usefulness of intravenous contrast-enhanced MRI for diagnosis of adhesive capsulitis

OBJECTIVES

We aimed to compare the reliability and performance of MRI measures enhanced with intravenous (IV) injection of gadolinium contrast versus non-enhanced MRI measures for the diagnosis of adhesive capsulitis (AC). We also aimed to examine the association between MRI findings and clinical features in patients with AC.

METHODS

MRI of 42 patients with a clinical diagnosis of AC confirmed by arthrography and that of 42 patients in a control group were retrospectively studied by 2 blinded readers. Reliability and performance of MRI findings were compared between IV contrast-enhanced measures and non-enhanced MRI measures in T2-weighted fat-saturated and T1-weighted images. MRI findings were correlated with clinical stage, etiology, and pain.

RESULTS

Sensitivity (97.6%) and specificity (97.6%) of axillary-recess capsule signal enhancement for AC diagnosis were significantly superior (p = 0.02) to hyperintense signals on T2-weighted fat-suppressed images (sensitivity 90.5%, specificity 92.7%). Measures of the intensity signal in the area of the rotator interval were less performant for AC diagnosis but could be improved with joint capsule enhancement. Moreover, we found very high specificity (100%) of enhancement of the coracohumeral ligament signal for AC diagnosis. The early stage of adhesive capsulitis was positively correlated with joint capsule enhancement in the rotator interval. Secondary etiology of capsulitis was correlated with joint capsule hyperintensity signals of the rotator interval on T2-weighted fat-suppressed images.

CONCLUSION

IV contrast injection with MRI can be helpful for AC diagnosis in difficult cases. The stage of AC seems related to joint capsule enhancement in the rotator interval.

KEY POINTS

• IV gadolinium-enhanced MRI can improve the analysis of signal changes in the shoulder synovium and capsule of the shoulder that are related to adhesive capsulitis. • As an original finding, we observed that coracohumeral ligament enhancement had a 100% specificity for the diagnosis of adhesive capsulitis. • The intensity of enhanced signals in the rotator interval seems to be related to the early stage of frozen shoulder.

'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

Early Clinical Outcomes of Manipulation under Anesthesia for Refractory Adhesive Capsulitis: Comparison with Arthroscopic Capsular Release

Backgroud

The purpose of this study was to compare early clinical outcomes of manipulation under anesthesia (MUA) and arthroscopic capsular release (ACR) in patients with refractory adhesive capsulitis (AC).

Methods

Thirty AC patients who underwent MUA (MUA group) were included. As a control group, thirty AC patients who underwent ACR (ACR group) were matched for age and sex with the MUA group. Visual analog scale (VAS) pain score, American shoulder and Elbow Surgeons (ASES) score, and range of motion (ROM) were evaluated preoperatively and at 3, 6, and 12 months after procedure.

Results

Both groups had significant improvements in the VAS pain score, ASES score, and ROM at 12 months after procedure. VAS pain score and ASES score were significantly better in the MUA group than in the ACR group at 3 months after procedure. Mean forward flexion was significantly greater in the MUA group than in the ACR group at 3 months after procedure. Mean external rotation and internal rotation were significantly greater in the MUA group than in the ACR group at 3, 6, and 12 months after procedure. Two patients required additional steroid injections at 3 and 6 months after MUA because of recurrent stiffness with pain.

Conclusions

Compared with ACR, MUA provided equivalent clinical outcomes in the early period after procedure. Our study suggests that MUA is a useful option to be considered as treatment for refractory AC before choosing ACR.

Optimal Cut-Off Value of the Coracohumeral Ligament Area as a Morphological Parameter to Confirm Frozen Shoulder

BACKGROUND

Thickened coracohumeral ligament (CHL) is one of the important morphological changes of frozen shoulder (FS). Previous research reported that coracohumeral ligament thickness (CHLT) is correlated with anterior glenohumeral instability, rotator interval and eventually FS. However, thickness may change depending on the cutting angle, and measurement point. To reduce measurement mistakes, we devised a new imaging criteria, called the coracohumeral ligament area (CHLA).

METHODS

CHL data were collected and analyzed from 52 patients with FS, and from 51 control subjects (no evidence of FS). Shoulder magnetic resonance imaging was performed in all subjects. We investigated the CHLT and CHLA at the maximal thickened view of the CHL using our picture archiving and communications system. The CHLA was measured as the whole area of the CHL including the most hypertrophied part of the MR images on the oblique sagittal plane. The CHLT was measured at the thickest point of the CHL.

RESULTS

The average CHLA was 40.88 ± 12.53 mm² in the control group and 67.47 ± 19.88 mm² in the FS group. The mean CHLT was 2.84 ± 0.67 mm in the control group and 4.01 ± 1.11 mm in the FS group. FS patients had significantly higher CHLA (P < 0.01) and CHLT (P < 0.01) than the control group. The receiver operator characteristic analysis showed that the most suitable cut-off score of the CHLA was 50.01 mm², with 76.9% sensitivity, 76.5% specificity, and area under the curve (AUC) of 0.87. The most suitable cut-off value of the CHLT was 3.30 mm, with 71.2% sensitivity, 70.6% specificity, and AUC of 0.81.

CONCLUSION

The significantly positive correlation between the CHLA, CHLT and FS was found. We also demonstrate that the CHLA has statistically equivalent power to CHLT. Thus, for diagnosis of FS, the treating physician can refer to CHLA as well as CHLT.