Idiopathic adhesive capsulitis. A prospective functional outcome study of nonoperative treatment

Effectiveness of corticosteroid injection in adhesive capsulitis

OBJECTIVE

To assess whether intraarticular corticosteroids improve the outcome of a comprehensive home exercise programme in patients with adhesive capsulitis.

SETTING

The study was undertaken in the Physical Therapy and Rehabilitation Department of a Ministry of Health hospital in Turkey.

SUBJECTS

Eighty patients with adhesive capsulitis were enrolled in the study.

INTERVENTIONS

The patients were randomly assigned to two groups: Group 1 patients were given intraarticular corticosteroid (1 mL, 40 mg methylprednisolone acetate) followed by a 12-week comprehensive home exercise programme. Group 2 patients were given intraarticular serum physiologic (1 mL solution of 0.9% sodium chloride) followed by a 12-week comprehensive home exercise programme.

MAIN MEASURES

The outcome parameters were Shoulder Pain and Disability Index and University of California-Los Angeles end-result scores, night pain and shoulder passive range of motion.

RESULTS

Mean actual changes in abduction range of motion, Shoulder Pain and Disability Index-total score and Shoulder Pain and Disability Index-pain score were statistically different between the two groups at the second week, with the better scores determined in group 1. However, there were no significant differences between the groups at the 12th week. Medians of University of California-Los Angeles scores in the second week were significantly different between the two groups (P = 0.02), with better scores in group 1; however, the difference in 12th week scores was insignificant.

CONCLUSIONS

Intraarticular corticosteroids have the additive effect of providing rapid pain relief, mainly in the first weeks of the exercise treatment period. In patients with adhesive capsulitis who have pain symptom predominantly, intraarticular corticosteroid therapy could be advised concomitantly with exercise.

Magnetic resonance imaging of adhesive capsulitis: correlation with clinical staging

The purpose of this study was to evaluate non-contrast magnetic resonance imaging (MRI) findings of adhesive capsulitis and correlate them with clinical stages of adhesive capsulitis. This will hopefully define a role for shoulder MR imaging in the diagnosis of adhesive capsulitis as well as in potentially directing appropriate treatment. Forty-seven consecutive non-contrast magnetic resonance imaging examinations of 46 patients with a clinical diagnosis of adhesive capsulitis were retrospectively reviewed and correlated with clinical staging. Specific MRI criteria correlated with the clinical stage of adhesive capsulitis, including the thickness and signal intensity of the joint capsule and synovium as well as the presence and severity of scarring in the rotator interval. Routine MRI of the shoulder without intraarticular administration of gadolinium can be used to diagnose all stages of adhesive capsulitis, including stage 1, where findings may be subtle on clinical examination. We believe that future studies assessing the role of MRI in guiding the initiation of appropriate treatment should be undertaken.

Shoulder stiffness

Shoulder stiffness is commonly encountered in clinical practice but varies greatly in severity and etiology. Loss of shoulder range of motion can be a patient's primary complaint or may be a secondary finding. Possible causes of stiffness include guarding due to pain or secondary gain issues (nonanatomic), true mechanical blockage due to acute or chronic trauma, adhesive capsulitis, rotator cuff disease, or surgery on or near the shoulder. This review includes a more detailed discussion of these causes as well as the appropriate history and physical and diagnostic testing recommended for each. Finally, treatment strategies for each group of patients will be presented.

The prevalence of a diabetic condition and adhesive capsulitis of the shoulder

OBJECTIVES

Adhesive capsulitis is characterized by a progressive and painful loss of shoulder motion of unknown etiology. Previous studies have found the prevalence of adhesive capsulitis to be slightly greater than 2% in the general population. However, the relationship between adhesive capsulitis and diabetes mellitus (DM) is well documented, with the incidence of adhesive capsulitis being two to four times higher in diabetics than in the general population. It affects about 20% of people with diabetes and has been described as the most disabling of the common musculoskeletal manifestations of diabetes.

METHODS

Consented patients presenting with adhesive capsulitis reporting no history of DM had blood testing for diabetes and prediabetes. An anonymous database was analyzed for a diabetic condition.

RESULTS

The prevalence of diabetes in patients with adhesive capsulitis was 38.6% (34 of 88). The prevalence of prediabetes was 32.95% (29 of 88). The total prevalence of a diabetic condition in patients with adhesive capsulitis was 71.5% (63 of 88). Previous literature fails to reveal the incidence of newly diagnosed diabetes, 2 of 88 (2%), and prediabetes, 25 of 88 (28.4%) in patients presenting with adhesive capsulitis. Early diagnosis and effective management of DM reduces the risk of microvascular complications. DM is believed to play a role in the development of musculoskeletal complications.

CONCLUSIONS

Awareness of these findings alerts the practitioner to the risk of diabetes and prediabetes in patients presenting with adhesive capsulitis of the shoulder.

Interventional microadhesiolysis: a new nonsurgical release technique for adhesive capsulitis of the shoulder

BACKGROUND

A nonsurgical intervention, interventional microadhesiolysis, was developed to release adhesions in joints and soft tissues. This paper introduces the procedure and evaluates the efficacy of the intervention for adhesive capsulitis of the shoulder.

METHODS

Ten patients (five men and five women) with primary adhesive capsulitis of the shoulder were treated at a chronic pain management center in Korea. Three specially made needles are used in interventional microadhesiolysis: the Round, Flexed Round, and Ahn's needles. A Round Needle is inserted on the skin over middle of supraspinatus and advanced under the acromion and acromioclavicular joint (subacromial release). A Flexed Round Needle is inserted two-fingers caudal to the inferior border of the scapular spine and advanced over the capsule sliding on the surface of infraspinatus muscle-tendon fascia. The capsule is released while an assistant simultaneously passively abducts the shoulder to full abduction (posteroinferior capsule release). An Ahn's Needle is inserted on the skin over the lesser tubercle and advanced under the coracoid process sliding on the surface of the subscapularis muscle (subcoracoid release).

RESULTS

After the patients underwent interventional microadhesiolysis, the self-rated pain score or severity declined significantly (p < .01), the shoulder range of motion increased significantly (p < .01), and joint effusion in the affected shoulder decreased or disappeared in nine of ten patients on magnetic resonance imaging compared to their initial status.

CONCLUSION

Our findings suggest that interventional microadhesiolysis is effective for managing adhesive capsulitis of the shoulder.

Adhesive capsulitis

Adhesive capsulitis is a common problem seen in the general population by orthopedic surgeons. It is a problem that causes patients pain and disability, and symptoms can last up to 2 years and longer. The questions of when and how to treat the frozen shoulder can present challenges. Most treatments are conservative; however, indications for surgery do exist. Arthroscopic capsular release has gained popularity over the years and offers a predictably good treatment in patients with adhesive capsulitis. The purpose of this paper is to review the orthopedic literature on adhesive capsulitis, to provide background information on this topic, and to describe our technique in arthroscopic capsular release.

Long-term outcome of frozen shoulder

Two-hundred and sixty-nine shoulders in 223 patients with a diagnosis of primary frozen shoulder were studied. The main outcome measure was the Oxford shoulder score. The mean follow-up from symptom onset was 4.4 years (range, 2-20 years). The mean age at symptom onset was 53.4 years; with women affected more commonly than men (1.6:1.0). Twenty percent of patients reported bilateral symptoms, but there were no recurrent cases. In the long term, 59% of patients had normal or near normal shoulders and 41% reported some ongoing symptoms. The majority of these persistent symptoms were mild (94%), with pain being the most common complaint. Only 6% had severe symptoms with pain and functional loss. Those with the most severe symptoms at condition onset had the worst long-term prognosis, P < .001.

Mobilization techniques in subjects with frozen shoulder syndrome: randomized multiple-treatment trial

BACKGROUND AND PURPOSE

The purpose of this study was to compare the use of 3 mobilization techniques--end-range mobilization (ERM), mid-range mobilization (MRM), and mobilization with movement (MWM)--in the management of subjects with frozen shoulder syndrome (FSS).

SUBJECTS

Twenty-eight subjects with FSS were recruited.

METHODS

A multiple-treatment trial on 2 groups (A-B-A-C and A-C-A-B, where A=MRM, B=ERM, and C=MWM) was carried out. The duration of each treatment was 3 weeks, for a total of 12 weeks. Outcome measures included the functional score and shoulder kinematics.

RESULTS

Overall, subjects in both groups improved over the 12 weeks. Statistically significant improvements were found in ERM and MWM. Additionally, MWM corrected scapulohumeral rhythm significantly better than ERM did.

DISCUSSION AND CONCLUSION

In subjects with FSS, ERM and MWM were more effective than MRM in increasing mobility and functional ability. Movement strategies in terms of scapulohumeral rhythm improved after 3 weeks of MWM.

Idiopathic adhesive capsulitis of the shoulder: a review

Many terms have been used to describe what has been called idiopathic adhesive capsulitis of the shoulder. This pathology is defined as a self-limiting condition of unknown etiology. The natural history is 18-30 months even though a high-percentage of patient present impaired range of movement even at long-term follow-up. The diagnosis is mainly clinical and no significant changes are normally present at MRI or CT scan. Several treatment options have been tried over the years with different approaches and results.

Patient outcome following rehabilitation for rotator cuff repair surgery: the impact of selected medical comorbidities

STUDY DESIGN

Prospective, multicenter research design.

OBJECTIVES

To assess functional and health status outcomes in patients following a physical therapy program after rotator cuff repair surgery, and to determine the impact of selected patient medical comorbidities on rehabilitation outcomes.

BACKGROUND

While authors have studied the influence of multiple factors on patient outcomes after rotator cuff repair surgery, little research has been done on the impact of comorbidities, particularly as it relates to establishing an accurate patient prognosis. eighteen patients who had recently undergone a rotator cuff repair surgical procedure were recruited at 1 of 30 Physiotherapy Associates, Inc outpatient clinics located in 13 states. A rehabilitation protocol was implemented and included the following interventions, as indicated: therapeutic exercise, manual therapy, electrotherapeutic modalities, and physical agents. Patient health history factors were documented during the initial examination, including age, race, body mass index, smoking, rotator cuff tear size, type of surgical procedure, and selected medications and comorbidities. The Disabilities of the Arm, Shoulder, and Hand (DASH) and the Short-Form-36 (SF-36) were completed prior to rehabilitation, at discharge, and at 6 months postdischarg

RESULTS

DASH andmost SF-36 domain mean scores obtained postrehabilitation were significantly improved from pretherapy scores. Most health status outcomes were maintained at 6-month follow-up, with slight further improvement noted in SF-36 physical dimensions and DASH scores. Having a greater number of comorbidities was associated with worse postrehabilitation SF-36 scores, but not with the DASH shoulder function scores. The mean change scores (difference between prerehabilitation and postrehabilitation status) for the DASH and SF-36 were not significantly different for patients with 0 to 1, 2, or at least 3 or more comorbidities (except for emotional role). In regression analyses a model with baseline physical function score (P = .0001), age (P = .03), and number of comorbidities (P = .003) fitted the data well and explained 38% of the variance in the physical function score at discharge.

CONCLUSIONS

A higher number of comorbidities had a negative effect on general health status outcomes but not on shoulder function outcomes at the time of patient discharge following rehabilitation. Despite a negative effect of more comorbidities on health status outcomes, the specific number of medical comorbidities did not affect the overall level of improvement prerehabilitation to postrehabilitation in function and health status. The findings describing the influence of comorbidities on rehabilitation outcomes may assist therapists in establishing accurate patient prognosis.

Nonoperative management of idiopathic adhesive capsulitis

Adhesive capsulitis of the shoulder is a common disorder, yet literature on its natural history is limited. This study examined patient characteristics, treatment patterns, and response to treatment of the disease in a large series of patients with this condition. Charts of 234 patients treated at our institution for adhesive capsulitis were reviewed retrospectively. The end points for the study were defined as resolution of symptoms with nonoperative treatment or operative treatment. A total of 105 shoulders in 98 patients were identified with follow-up to end point. Of these, 89.5% resolved with nonoperative treatment, including 17 (89.5%) of 19 diabetic shoulders. The average age of patients who went on to surgery was 51 years, whereas the average age of patients treated nonoperatively was significantly higher at 56. No significant difference was found for success of nonoperative treatment versus operative treatment or patient gender. All patients received nonsteroidal antiinflammatory medications, 52.4% received physical therapy without cortisone injection, and 37.1% received therapy with at least 1 corticosteroid injection. Duration of treatment in successfully nonoperatively treated patients averaged 3.8 +/- 3.6 months. Patients who required surgery were treated with an average of 12.4 +/- 12.1 months of nonoperative treatment. Initial forward elevation averaged 118 degrees +/- 22 degrees with average forward elevation at resolution of 164 degrees +/- 17 degrees. External rotation improved from an average of 26 degrees +/- 16 degrees pretreatment to 59 degrees +/- 18 degrees posttreatment. With supervised treatment, most patients with adhesive capsulitis will experience resolution with nonoperative measures in a relatively short period. Only a small percentage of patients eventually require operative treatment.

Comparative responsiveness of Japanese versions of the DASH and SF-36 questionnaires and physical measurement to clinical changes after carpal tunnel release

The purpose of the present study was to test the responsiveness of the Japanese Society for Surgery of the Hand version of the Disability of the Arm, Shoulder and Hand questionnaire (DASH-JSSH) by evaluating effect size (ES) and standardised response mean (SRM) in patients undergoing carpal tunnel release. Subjects comprised 25 patients with carpal tunnel syndrome. All subjects completed the DASH-JSSH, medical outcomes 36-item short-form health survey (SF-36) and visual analogue scale (VAS) for pain and underwent objective assessment of grip strength, pinch strength and static two-point discrimination before and three months after surgery. DASH-JSSH displayed the highest sensitivity to changes at three months, followed by VAS. All subscales of SF-36 were much less sensitive and both grip and pinch strength were unchanged over the three-month period. DASH-JSSH demonstrated more responsiveness to changes after carpal tunnel release than SF-36, VAS and physical measurements, and displayed correlations with subscales of SF-36.

The rotator interval: anatomy, pathology, and strategies for treatment

Over the past two decades, it has become accepted that the rotator interval is a distinct anatomic entity that plays an important role in affecting the proper function of the glenohumeral joint. The rotator interval is an anatomic region in the anterosuperior aspect of the glenohumeral joint that represents a complex interaction of the fibers of the coracohumeral ligament, the superior glenohumeral ligament, the glenohumeral joint capsule, and the supraspinatus and subscapularis tendons. As basic science and clinical studies continue to elucidate the precise role of the rotator interval, understanding of and therapeutic interventions for rotator interval pathology also continue to evolve. Lesions of the rotator interval may result in glenohumeral joint contractures, shoulder instability, or in lesions to the long head of the biceps tendon. Long-term clinical trials may clarify the results of current surgical interventions and further enhance understanding of the rotator interval.

Long-term results after primary microsurgical repair of ulnar and median nerve injuries

OBJECTIVE

The aim of this retrospective study was to analyze the long-term results of primary repair of median and ulnar nerve lesions. Clinical influence factors for nerve reconstruction were investigated. Furthermore, current score systems were inquired and evaluated on their effectiveness to illustrate the success of repair.

PATIENTS AND METHOD

Sixty-five patients with 71 lesions of the median and ulnar nerve were assessed on average 8.2 years after reconstruction. The results were classified according to the DASH (disability of arm, shoulder, and hand) Score, the Rosen's hand protocol and the Highet Scale.

RESULTS

On average the patients regained 70% of their original hand function (evaluated by Rosen Score: median nerve 2.2/for ulnar nerve 1.92 out of 3.0). Although we noticed inferior motor recovery in ulnar nerve lesions, no significant differences between the overall results of both nerves were observed. Neither accompanying artery and flexor tendon injuries nor the suture technique influenced the recovery. The age of the patient was confirmed as an important influence factor. The results of the DASH Score, Rosen Score and Highet Score correlated significantly.

CONCLUSION

For a sufficient outcome measurement we underline the importance of evaluation of patient's estimation of their impact on their activities of daily living. For this a combination of the functional Rosen Score and the DASH Score is suggested.

The effect of anterior versus posterior glide joint mobilization on external rotation range of motion in patients with shoulder adhesive capsulitis

STUDY DESIGN

Randomized clinical trial.

OBJECTIVE

To compare the effectiveness of anterior versus posterior glide mobilization techniques for improving shoulder external rotation range of motion (ROM) in patients with adhesive capsulitis.

BACKGROUND

Physical therapists use joint mobilization techniques to treat motion impairments in patients with adhesive capsulitis. However, opinions of the value of anterior versus posterior mobilization procedures to improve external rotation ROM differ.

METHODS AND MEASURES

Twenty consecutive subjects with a primary diagnosis of shoulder adhesive capsulitis and exhibiting a specific external rotation ROM deficit were randomly assigned to 1 of 2 treatment groups. All subjects received 6 therapy sessions consisting of application of therapeutic ultrasound, joint mobilization, and upper-body ergometer exercise. Treatment differed between groups in the direction of the mobilization technique performed. Shoulder external rotation ROM measured initially and after each treatment session was compared within and between groups and analyzed using a 2-way ANOVA, followed by paired and independent t tests.

RESULTS

There was no significant difference in shoulder external rotation ROM between groups prior to initiating the treatment program. A significant difference between groups (P = .001) was present by the third treatment. The individuals in the anterior mobilization group had a mean improvement in external rotation ROM of 3.0 degrees (SD, 10.8 degrees; P = .40), whereas the individuals in the posterior mobilization group had a mean improvement of 31.3 degrees (SD, 7.4 degrees; P < .001).

CONCLUSIONS

A posteriorly directed joint mobilization technique was more effective than an anteriorly directed mobilization technique for improving external rotation ROM in subjects with adhesive capsulitis. Both groups had a significant decrease in pain.

Surgical Results in Rotator Cuff Tears with Shoulder Stiffness

BACKGROUND/PURPOSE

Little has been mentioned about the treatment of rotator cuff tears and associated shoulder stiffness. We prospectively treated a series of patients with rotator cuff tears associated with shoulder stiffness concomitantly and reported the outcomes.

METHODS

A combined procedure of manipulation, lysis of adhesions, anterior acromioplasty and repair of rotator cuff was performed on 43 patients (47 shoulders) who were available for follow-up for a minimum of 2 years. Ten patients (11 shoulders) had diabetes mellitus and 33 patients (36 shoulders) were non-diabetic. Partial tear of the rotator cuff was noted in 27 shoulders, complete tears in 15 shoulders and massive tears in five shoulders. A functional score of Constant and Murley was used to evaluate the overall outcomes, the results between patients with and without diabetes mellitus and the results among different types of rotator cuff tears.

RESULTS

At a mean (+/- SD) of 48.61 +/- 18.0 months (range, 24-85 months) after the operation, each patient showed a significant improvement in subjective score, objective score and strength score as well as in the total score of Constant and Murley. There was no statistical difference in postoperative total Constant scores between patients with and without diabetes mellitus (p = 0.123). Comparison of the scores among the three types of rotator cuff tears revealed that all had a significant improvement in the total scores of Constant and Murley (44.6 +/- 7.7 vs. 91.7 +/- 4.9, p < 0.001 for a partial cuff tear; 42.9 +/- 11.3 vs. 86.0 +/- 9.6, p = 0.001 for a complete tear; and 44.2 +/- 4.8 vs. 82.0 +/- 12.1, p = 0.043 for a large tear), but patients with partial tears of the rotator cuff had significantly better total scores than did those with complete tears (92.6 +/- 4.8 vs. 82.0 +/- 12.1, p = 0.018) or large tears (92.6 +/- 4.8 vs. 86.1 +/- 9.7, p = 0.041).

CONCLUSION

A combined procedure of manipulation, lysis of adhesions, acromioplasty and repair of rotator cuff is a satisfactory procedure for patients with rotator cuff tears and associated shoulder stiffness.

Upper extremity: emphasis on frozen shoulder

Adhesive capsulitis, or frozen shoulder syndrome, is a condition characterized by gradual loss of active and passive glenohumeral motion. The etiology of adhesive capsulitis is unknown. Treatment methods include supervised benign neglect, physical therapy, intra-articular corticosteroid injections, closed manipulation under anesthesia, arthroscopic capsular release, and open surgical release. Approximately 70% of patients presenting with adhesive capsulitis are women; however, the role of sex in the etiology, development, and outcome of treatment for adhesive capsulitis remains unclear. Individualized treatment is necessary following thorough evaluation of patient symptoms and stage of the disease.

Reliability of function-related tests in patients with shoulder pathologies

STUDY DESIGN

Nonexperimental.

OBJECTIVE

To investigate the intertester and intratester reliability of a battery of function-related tests in patients with shoulder pathologies and associated reduced range of motion.

BACKGROUND

A battery of function-related tests has the potential to complement assessment of functional limitation in patients who have shoulder pathologies.

METHODS AND MEASURES

Three function-related tests (hand to neck, hand to scapula, and hand to opposite scapula) were conducted on 46 patients with shoulder pathologies, and 46 age- and gender-matched control subjects. The tests were performed by 2 independent physiotherapists to test intertester reliability. Intratester reliability was examined by investigating the reproducibility of the tests performed twice, with 3 to 5 days between tests, by the same physiotherapist. Comparison of the scores on the function-related tests between patients and controls was evaluated. A correlation matrix was calculated to test the level of association among the tests.

RESULTS

Intratester and intertester reliability on the 3 tests (weighted K) varied from 0.83 to 0.90. The patient's test performances were decreased in comparison to the control group. The correlation matrix demonstrated a level of associations among the 3 tests varying from r = 0.64 to r = 0.66.

CONCLUSION

The results of this study indicate that function-related tests are reliable and could be used in clinical practice to document reduced function of the shoulder. The level of association among the tests indicates that each test measured different aspects of shoulder function.

Functional outcomes and general health status after ulnohumeral arthroplasty for primary degenerative arthritis of the elbow

Ulnohumeral arthroplasty (UHA) is considered a satisfactory surgical treatment option for patients with primary degenerative arthritis of the elbow. Most series have used categoric elbow scoring systems to evaluate the outcome of this procedure. The purpose of our study was to evaluate the outcome of UHA with patient-derived functional and general health status outcome instruments. We evaluated 17 patients (18 elbows) with primary degenerative arthritis of the elbow at a mean of 85 months after UHA. The mean age at the time of surgery was 42 years (range, 26 to 58 years). At the follow-up evaluation, the patients were assessed with a physical examination, outcome assessment tools, and plain radiographs. The mean elbow flexion arc improved by 16 degrees (range, -15 degrees to 60 degrees ; P = .012), and the mean forearm rotation arc (supination/pronation) improved by 35 degrees (range, -20 degrees to 90 degrees ; P < .001). Of the elbows, 11 were painless, 4 were painful with motion, and 3 were painful at rest and with motion. The mean Hospital for Special Surgery elbow score was 70 (range, 40 to 99), and the mean Mayo Elbow Performance Score was 83 (range, 50 to 100). The mean Disabilities of the Arm, Shoulder and Hand score was 9.75 (range, 0 to 43.48). The Short Form-36 scores were better than the mean age- and sex-adjusted normal values. Patient self-assessed outcomes and general health status after UHA for primary degenerative elbow arthritis appear to be better than those determined by some categoric scoring systems. Consequently, the clinical utility of UHA may be underrepresented if physician-derived categoric scoring systems are the only measures of outcome assessment.

Reliability and validity of shoulder tightness measurement in patients with stiff shoulders

The purposes of this study were (1) to examine intratester and intertester reliability of measurement of anterior and posterior shoulder tightness in patients with stiff shoulders (SS), and (2) to assess construct validity by determining the relations between shoulder tightness, shoulder range of motion (ROM), and self-report measures of functional limitation. Anterior and posterior shoulder tightness were measured by two testers in below-chest abduction and cross-chest adduction tests with an inclinometer, respectively, in 16 patients with SS. Both the intratester and intertester reliability for shoulder tightness measurements were good (intratester ICC=0.84 and 0.91; intertester ICC=0.82 and 0.89). The limit of intra-tester and inter-tester agreement (mean, -0.3+/-4.4 degrees ) was acceptable as compared to the standard deviations of the measurements (range, 6.2-7.4 degrees ). Significant relationships between internal rotation and posterior shoulder tightness (R2=0.448, P=0.002), external rotation and anterior shoulder tightness (R2=0.499, P=0.003), and functional disabilities and posterior shoulder tightness (R2=0.432, P=0.006) were found. Significant correlations between shoulder internal rotation and cross-chest adduction, shoulder external rotation and below-chest abduction were observed, indicating that internal and external rotations might be related to posterior and anterior shoulder stiffness. The study also revealed significant relationship between functional disabilities and cross-chest adduction. Below-chest abduction and cross-chest adduction were found to provide reliable data. The construct validity of the abduction and adduction tests is supported by the relationship among these measurements, shoulder ROM, and functional disabilities in patients with SS.

Eight predictive factors associated with response patterns during physiotherapy for soft tissue shoulder disorders were identified

BACKGROUND AND OBJECTIVE

Combining information on initial and final state with information on speed of response may reflect the clinical reality of the course of recovery from soft tissue shoulder disorders. The purpose was to identify baseline factors that predict patterns of response to physiotherapy.

STUDY DESIGN AND SETTING

Prospective cohort of consecutive clients (n=361) with soft tissue shoulder disorders attending physiotherapy. A previous study identified four typical patterns of response such that each individual was assigned to one of four clusters (dependent outcome). Independent predictors (n=28) included demographics, disorder-related and disability measures, treatment factors, clinical findings, and expectations for recovery. Multivariable multinomial logistic regression techniques were used.

RESULTS

Predictors differentiating patterns of response were: Age (by decade), duration of current shoulder problem, worker's compensation claim, client's global rating of problem, Physical Component Score (SF-36), Mental Component Score (SF-36), over the counter medication use, and therapist prediction of client to return to usual activity.

CONCLUSION

Using a clinically sensible outcome, we have identified several predictors that can be used by clinicians in clinical decision making.

Deficits in shoulder function and general health associated with sixteen common shoulder diagnoses: a study of 2674 patients

The purpose of this study is to define the self-assessed deficits in function and general health perceived by a large cohort of patients with common shoulder diagnoses. For a 10-year period, all new shoulder patients presenting to the senior author were characterized by diagnosis, age, gender, and self-assessed shoulder function and general health status. This report concerns the 2674 patients having 1 of the 16 most prevalent diagnoses. The deficits in shoulder function and health status were correlated with diagnosis, age, and gender, as well as with each other. Patient self-assessment provided a standardized method for collecting data on shoulder function and health status. These assessments revealed substantial deficits; for example, 81% of patients were unable to sleep on the affected side, and 71% were unable to wash the back of the opposite shoulder. The magnitude of these deficits correlated significantly with gender and diagnosis but not with age.

Impact of adhesive capsulitis and economic evaluation of high-grade and low-grade mobilisation techniques

The purpose of this study was to estimate the impact of adhesive capsulitis on costs and health and to compare the cost-utility of high-grade and low-grade mobilisation techniques. In a randomised controlled trial, 92 patients with adhesive capsulitis received either high-grade mobilisation techniques or low-grade mobilisation techniques and were followed for one year. Outcome measures were quality adjusted life years (QALYs) according to the Short Form 6D (SF-6D) and societal costs estimated from cost questionnaires. Estimated costs and QALYs in both randomisation groups were similar, except for the number of treatment sessions (18.6 for high-grade mobilisation techniques versus 21.5 for low-grade mobilisation techniques), with an estimated cost difference of 105 euros in favour of high-grade mobilisation techniques (p = 0.001, 95% CI 43 euros to 158 euros). In the entire sample, the average valuation of health improved from 0.597 at baseline to 0.745 after a year. The burden due to adhesive capsulitis was estimated at 0.048 QALY and 4,521 euros per patient. About half these costs were due to absenteeism which, during the first quarter, amounted to 38% of the total working hours. In conclusion, the cost-utility analysis does not allow for an evidence-based recommendation on the preferred treatment. Based on the clinical outcome measures, high-grade mobilisation techniques are still preferred to low-grade mobilisation techniques. The estimated substantial burden, both to the patient and to society, suggests that effective early treatment of adhesive capsulitis is warranted to attempt to accelerate recovery.

Total shoulder arthroplasty: long-term survivorship, functional outcome, and quality of life

This study examines long-term outcomes of total shoulder arthroplasty (TSA) via survivorship analysis, patient questionnaires, and minimum 10-year physical examinations. The study group consisted of 320 consecutive TSAs performed in 267 patients between 1974 and 1988. Diagnoses included rheumatoid arthritis (69%), osteoarthritis (22%), and juvenile rheumatoid arthritis (4.7%). Minimum 10-year physical examination follow-up was obtained on a subset of 72 TSAs at a mean (+/- SD) of 14.0 +/- 2.7 years. A Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was obtained from 80 patients with 103 TSAs at a mean of 15.4 +/- 3.4 years after the index procedure (range, 10.4-23.2 years). Kaplan-Meier survivorship rates with revision as the endpoint at 5, 10, 15, and 20 years were 98%, 93%, 88%, and 85%, respectively. Of the shoulders, 22 (6.9%) required a revision, most commonly for loosening of one or both components (15 shoulders). Dislocation occurred earlier than other causes of revision or complication (P < .05, analysis of variance). Minimum 10-year physical examination follow-up revealed lasting, significant improvements in range of motion and strength. The patients' subjective assessments of TSA were favorable in that 92% felt that their shoulder was "much better" or "better" after TSA. The mean DASH score was 49 +/- 25; no significant differences were found among diagnoses. Long-term analysis of the Neer-type TSA revealed survivorship rates comparable to other joint replacements. The significant improvements in relief of pain, shoulder range of motion, and strength are associated with a high degree of patient satisfaction.

Is intraarticular sodium hyaluronate injection an alternative treatment in patients with adhesive capsulitis?

The aim of this study was to compare the efficacy of sodium hyaluronate (SH) injection with the most common treatment methods, intraarticular steroid injection and physical therapy modalities in patients with adhesive capsulitis (AC). A total of 95 shoulders of 90 patients were included in the study and were randomized in four groups. The patients were treated with SH injection (group 1), triamsinolone acetonide (group 2) or physical therapy modalities (group 3). Group 4 patients were served as controls. Pain severity, passive ranges of motion and functional considerations were measured before, and 15 days and 3 months after the treatments. In all treatment groups, there were significant improvements at both the 15th day and third month in all parameters (for each, p<0.001). The passive abduction values on the 15th day was found significantly higher in group 3 when compared with group 1 and controls (for each, p<0.001). At the third month, the passive abduction values of the groups 2 and 3 were improved when compared with the control group (p<0.001). Constant score was higher in group 3 on 15th day when compared with group 1. At the third month, all treatment groups were improved significantly compared with control group (p<0.001). We provided the best results in physical therapy modalities applied group for AC treatment. However, we think that SH injection may be administered as an alternative treatment method.

Trapezius muscle imbalance in individuals suffering from frozen shoulder syndrome

This aim of this study was to characterize upper and lower trapezius muscle activity for patients experiencing frozen shoulder syndrome (FSS) compared to asymptomatic subjects. Fifteen patients suffering from unilateral FSS and 15 asymptomatic subjects voluntarily participated in this study. Data were gathered on electromyographic (EMG) activity obtained from the upper and lower trapezius muscles during maximal static arm elevations at six different testing positions: 60 and 120 degrees of flexion, abduction in the frontal plane, and abduction in the scapular plane. The group with FSS revealed increased upper trapezius EMG activity at the 60 degrees (mean difference = 12%, p < 0.003) and 120 degrees (mean difference = 24%, p < 0.004) testing positions, and increased lower trapezius EMG activity at the 120 degrees testing positions (mean difference = 6%, p < 0.002), compared to asymptomatic subjects. Higher ratios of the upper trapezius to lower trapezius EMG activity were also found in the patient group (p < 0.0005) compared to asymptomatic subjects. The results of this study indicate that the increased trapezius muscle activity may contribute to scapular substitution movement in compensation for impaired glenohumeral motion in patients with FSS. The insufficiency of the increased lower trapezius muscle activity should be an important consideration in the rehabilitation of patients experiencing FSS.

Intraarticular lesions in primary frozen shoulder after manipulation under general anesthesia

The aim of this study was to find intraarticular lesions after manipulation under general anesthesia in patients with primary frozen shoulder. In a prospective trial conducted between 2001 and 2003 in 30 patients with primary frozen shoulder, the affected shoulders were manipulated while the patients were under general anesthetia. Exclusion criteria were secondary stiffness caused by rotator cuff tears and glenohumeral arthritis. After manipulation, each patient was examined by arthroscopy, and any intraarticular lesions were documented. In all patients, during manipulation, a significant improvement in the range of motion was achieved. Under anesthesia, flexion improved on average from 70 degrees +/- 33 degrees to 180 degrees +/- 15 degrees, abduction from 50 degrees +/- 20 degrees to 170 degrees +/- 25 degrees, and external rotation from -5 degrees +/- 10 degrees to +40 degrees +/- 20 degrees. Arthroscopy revealed hemarthrosis in all patients after manipulation. In 22 patients, localized synovitis was detected in the area of the rotator interval, whereas in 8 patients, disseminated synovitis was observed as a feature of adhesive capsulitis. After manipulation, the capsule was seen to be ruptured superiorly in 11 patients, the anterior capsule was ruptured up to the infraglenoid pole in 24 patients, and 16 patients each had a capsular lesion located posteriorly. In 18 patients no additional joint damage was found after manipulation. In 4 patients, iatrogenic superior labrum anterior-posterior lesions were observed. Further injuries detected were 3 fresh partial tears of the subscapularis tendon, 4 anterior labral detachments (1 with a small osteochondral defect), and 2 tears of the middle glenohumeral ligament. Even though manipulation under anesthesia is effective in terms of joint mobilization, the method can cause iatrogenic intraarticular damage.

Prevention of shoulder stiffness after rotator cuff repair

Predisposing factors for shoulder stiffness after rotator cuff repair have yet to be determined. The potential for recovery of range of motion and amelioration of pain in patients with this complication also remains unclear. Accordingly, data collected prospectively for 209 patients with a primary rotator cuff repair were retrospectively reviewed. Two groups, Group A (early motion recovery) and Group B (shoulder stiffness), were selected according to passive shoulder range of motion outcomes 6 weeks postoperatively. Both groups were compared for 10 descriptive and clinical characteristics, and for passive range of motion, muscle force, and functional outcomes obtained 0, 6, 12, 24, and 76 weeks postoperatively. Of the potential prognostic factors examined, restriction of range of motion for the preoperative hand behind the back best predicted shoulder stiffness at 6 weeks postoperatively. For patients with postoperative shoulder stiffness, pain had subsided by 24 weeks postoperatively, whereas range of motion steadily improved between 6 weeks and 76 weeks postoperatively. Results of the current study support a predictive role for restriction of range of motion for the preoperative hand behind the back, and affirms the potential for nearly complete recovery of range of motion and amelioration of pain in patients who have shoulder stiffness after rotator cuff repair.

LEVEL OF EVIDENCE

Prognostic study, Level I-1 (prospective study).

Therapy interventions for improving joint range of motion: A systematic review

The authors conducted a systematic review of the published evidence on conservative interventions for loss of upper extremity joint range of motion following selected musculoskeletal conditions. Several databases (Medline, CINAHL, PEDRO, PubMed, and Cochrane) were searched for articles that met inclusion criteria. Two reviewers determined abstract selection; two reviews performed critical appraisal of 26 articles. Level of evidence and quality on a 24-item quantitative critical appraisal form were determined for all articles meeting selection criteria. The primary outcome considered was range-of-motion measurement. Overall, the quantity and quality of evidence were moderate to low. Sackett's levels 2b, 3, and 4 evidence has shown that joint mobilization, a supervised exercise program, and splinting can all increase joint range of motion. There were no studies found in the literature that examined techniques of physical agent or electrotherapeutic modalities. Future studies are needed to delineate selection of appropriate candidates for these techniques and effective dosage.

The stiff shoulder

Shoulder stiffness is a common but poorly understood disorder of the glenohumeral joint. Many terms are used to describe a stiff shoulder, including frozen shoulder and adhesive capsulitis. This article reviews the terminology, classification, diagnostic options, and management options of shoulder stiffness. Conservative measures,emphasizing a four-quadrant stretching program, typically produce effective treatment outcomes. Operative interventions, which may be required for the small percentage of patients who fail conservative therapy, are also presented.

Manipulation and arthroscopy under general anesthesia and early rehabilitative treatment for frozen shoulders11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated

OBJECTIVE

To evaluate the efficacy of manipulation followed by arthroscopic release of the glenohumeral joint in conjunction with an immediate and intensive rehabilitation program.

DESIGN

Retrospective, descriptive study.

SETTING

A free-standing, university-affiliated orthopedics and rehabilitation hospital.

PARTICIPANTS

Forty patients with a clinical diagnosis of adhesive capsulitis resistant to pharmacologic and physical therapy (PT).

INTERVENTIONS

Patients underwent manipulation and arthroscopic release of the capsular joint and were given an intensive PT program on the first postoperative day.

MAIN OUTCOME MEASURES

All patients were evaluated pre- and postoperatively at follow-up at an average of 42 months by using the Simple Shoulder Test (SST), the Constant-Murley system score, and passive (PROM) and active (AROM) range of motion.

RESULTS

The SST, which showed a mean preoperative score of 2.2+/-0.7, was 10.8+/-0.7 (P<.001) after surgery. Preoperatively, the mean Constant-Murley score was 33.2%+/-1.9%; postoperatively, the mean score was 91.7%+/-2.9% (P<.001). PROM increased from 90 degrees to 165 degrees for anterior elevation, from 85 degrees to 160 degrees for abduction, from 20 degrees to 60 degrees for external rotation, and from 10 degrees to 40 degrees for internal rotation. AROM improved for anterior elevation from 82 degrees to 155 degrees; for abduction from 77 degrees to 143 degrees, and for external rotation, with the arm along the patient's side, from 5 degrees to 50 degrees.

CONCLUSIONS

Results support the efficacy of manipulation follow by arthroscopic release and rehabilitative treatment for patients with resistant adhesive capsulitis of the shoulder.

The effect of comorbidity on self-assessed function in patients with a chronic rotator cuff tear

BACKGROUND

The results of preoperative assessment of factors that might affect the outcome of orthopaedic surgery have rarely been studied. In this study, we evaluated the relationship between the number of medical comorbidities and the preoperative performance on outcome assessment tools in patients with a chronic rotator cuff tear.

METHODS

One-hundred and ninety-nine patients (206 shoulders) with a chronic rotator cuff tear who were treated with surgery were evaluated preoperatively with a detailed history (including medical comorbidities), physical examination, and the following outcome instruments: (1) the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, (2) the Simple Shoulder Test, (3) visual analog scales (pain, function, and quality of life), and (4) the Short Form-36 (SF-36).

RESULTS

The patients had a mean of 2.07 comorbidities (range, zero to seven comorbidities). With use of univariate regression analysis, a greater number of comorbidities was associated with worse function (DASH [p = 0.0064], Simple Shoulder Test [p = 0.0001 for the best-case scenario and p = 0.0009 for the worst-case scenario], and visual analog scale for function [p = 0.0003] and increased pain [p = 0.05]) and with worse general health status (physical function [p < 0.0001], role-physical [p = 0.0286], general health [p < 0.0001], vitality [p = 0.0014], social function [p = 0.0004], role-emotional [p = 0.0003], and visual analog scale for quality of life [p = 0.0102]). These results were confirmed with significant associations (p < 0.05) between the number of comorbidities and the scores on the Simple Shoulder Test; DASH questionnaire; visual analog scales for function, pain, and quality of life; and seven of the eight items (all but mental health) on the SF-36 in a multivariate regression analysis, which included age, gender, Workers' Compensation status, number of previous operations, smoking history, size of the tear, duration of symptoms, and average patient expectations as possible confounding variables.

CONCLUSIONS

Medical comorbidities have a negative impact on patient-reported preoperative baseline pain, function, and general health status associated with chronic rotator cuff tears. We postulate that this effect may ultimately influence the evaluation of the results of surgical treatment of rotator cuff tears and should be considered when treating patients and analyzing outcomes.

Physician referrals to physical therapy for the treatment of musculoskeletal conditions

OBJECTIVES

To identify factors associated with orthopedic surgeons' and primary care physicians' referrals to physical therapy (PT) for musculoskeletal conditions.

DESIGN

Cross-sectional analysis of National Ambulatory Medical Care Survey data.

SETTING

US office-based physician practices.

PARTICIPANTS

Visits to primary care physicians (N=4911) or orthopedic surgeons (N=4201) for musculoskeletal conditions.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Whether a PT referral was made.

RESULTS

After controlling for diagnosis, illness severity, and PT supply, insurance status and physician characteristics remained strong predictors of PT referral. Primary care visits covered by Medicaid or a managed care plan were less likely to result in PT referral than were visits covered by private insurance or a nonmanaged care plan. Orthopedic surgeon visits covered by workers' compensation or managed care were more likely to result in PT referral than were visits not covered by workers' compensation or not covered by managed care. Osteopathic primary care visits were more likely than allopathic primary care visits to result in PT referral. Given identical visit characteristics, orthopedic surgeon visits were more likely than primary care visits to result in PT referral.

CONCLUSIONS

Significant differences exist in orthopedic surgeons' and primary care physicians' referrals to PT, both within and across specialties. Variation in PT referral may be indicative of problems with access and/or inappropriate referral.

Comparative responsiveness of the disabilities of the arm, shoulder, and hand, the carpal tunnel questionnaire, and the SF-36 to clinical change after carpal tunnel release

PURPOSE

The objective of this study was to compare the responsiveness (ability to accurately detect change) of 3 self-administered questionnaires to changes produced by carpal tunnel release.

METHOD

The Disabilities of the Arm, Shoulder and Hand (DASH), the Brigham and Women's Carpal Tunnel Questionnaire, and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) were completed by 34 subjects before surgery and at 6 and 12 weeks after carpal tunnel release.

RESULTS

The instrument most sensitive to clinical change at 12 weeks as judged by effect size and standardized response means was the Carpal Tunnel Questionnaire (effect size/standardized response means, 1.71/1.66) followed by the DASH (1.01/1.13) and the Medical Outcomes Study 36-Item Short-Form Health Survey bodily pain (0.57/0.52) and role physical (0.39/0.39) subscales. There was good correlation between DASH and Carpal Tunnel Questionnaire change scores (Spearman correlation coefficient 0.87).

CONCLUSIONS

The Carpal Tunnel Questionnaire is the most sensitive to clinical change, but the DASH is sufficiently responsive for use in outcome studies of carpal tunnel syndrome done 12 or more weeks after surgery.

Effect of selective capsulorrhaphy on the passive range of motion of the glenohumeral joint

BACKGROUND

Capsulorrhaphy of the glenohumeral joint is a common surgical procedure for the treatment of instability caused by increased capsular laxity. The effect of capsulorrhaphy on the range of motion of the shoulder is poorly understood.

METHODS

We simulated localized capsular contractures by selective capsular plications in eight human cadaveric shoulders and studied the effect of such plications on the passive range of glenohumeral abduction, flexion, and external and internal rotation in different degrees of abduction. A 0.5 or 1-N-m torque was applied to the humerus, and the range of glenohumeral motion was measured with electronic goniometers in three planes and compared with those of the intact shoulder.

RESULTS

Anterosuperior capsular plication most markedly affected external rotation of the adducted arm, decreasing it by a mean of 30.1 degrees (p < 0.0001). Anteroinferior plication significantly reduced abduction by a mean of 19.4 degrees (p < 0.0001) and external rotation by a mean of 20.6 degrees (p = 0.0046). Posterosuperior plication mostly limited internal rotation of the adducted arm (mean decrease, 16.1 degrees, p = 0.0045). On the average, total anterior and total posterior plication each limited flexion by approximately 20 degrees (p = 0.005) and abduction by >or=15 degrees (p < 0.005), whereas total anterior plication limited external rotation by >30 degrees (p <or= 0.0002) and total posterior plication limited internal rotation by >20 degrees (p < 0.0001). Total inferior capsular plication restricted abduction (by a mean of 27.7 degrees, p = 0.0001), flexion, and rotation. Total superior plication restricted external rotation and flexion.

CONCLUSIONS AND CLINICAL RELEVANCE

Localized plications of the glenohumeral joint capsule lead to predictable patterns of loss of glenohumeral mobility. If plication is planned, losses of movement can be anticipated. The findings of this study may assist surgeons in identifying the parts of the capsule that are contracted and that may need lengthening.

Operative management of the frozen shoulder in patients with diabetes

Forty-three patients with diabetes (47 shoulders) who had a manipulation under anesthesia only (24 shoulders), a manipulation under anesthesia followed by an arthroscopy (12 shoulders), or an arthroscopic release (11 shoulders) for a frozen shoulder were followed-up for a mean period of 35 months. The mean Constant score improved from 20.3 to 63.7 points (P <.001). The mean improvement in forward flexion was 71.7 degrees, in abduction 78.5 degrees, in external rotation with the arm at the side 36.3 degrees, and in internal rotation from the buttock to the first lumbar vertebra (P <.001 for all). When gentle manipulation with the patient under anesthesia was possible, the outcome was satisfactory in 13 of 15 shoulders (86.7%) in patients with non-insulin-dependent diabetes and in 17 of 21 shoulders (81%) in patients with insulin-dependent diabetes (P >.5). Insulin-dependent patients with diabetes were more likely to require an arthroscopic release than patients with non-insulin-dependent diabetes (P <.05). Most of our patients obtained their maximum relief of pain and functional recovery within 3 months of surgery. We recommend manipulation under anesthesia for the resistant frozen shoulder in patients with diabetes. Arthroscopic release is required when mobilization under anesthesia is not possible.

Arthroscopic treatment of shoulder stiffness

The optimal treatment of shoulder stiffness remains controversial. The current authors reviewed the results of arthroscopic capsular release of 45 stiff shoulders in 45 patients that was done after the patients did not respond to conservative treatment. There were nine idiopathic frozen shoulders, 21 that had postoperative stiffness, and 15 shoulders with stiffness after trauma. At a mean followup of 26 months (minimum, 12 months), arthroscopic capsular release improved the subjective shoulder value from 25% to 68% and the age- and gender-adjusted Constant-Murley score from 41% to 75%. Pain improved from 4.7 to 10.9 of 15 points. Active, pain-free anterior elevation increased from 90 degrees to 128 degrees and external rotation increased from 14 degrees to 31 degrees. The quality of sleep improved from 0.5 to 1.6 on a two-point scale. The only improvement that did not reach statistical significance was the improvement in the ability to work. A retrospective analysis of the results stratified according to the etiology of stiffness showed that the outcome after treatment of idiopathic stiffness was better than after postoperative stiffness and that the results of treatment for posttraumatic stiffness were least favorable. The difference between preoperative state and followup, however, was not statistically significantly different from one group to another. All groups improved significantly and to a similar degree but the final outcome was related to the initial degree of disability. Arthroscopic release is an effective method for treatment of shoulder stiffness; however, the ultimate outcome is related directly to the severity of stiffness regardless of the etiology.