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Yan Y, Li X, Chen C, Cui D, Wang Z, Li M, Long Y, Zhang J, Li C, Wang Z, Zhou C, Yao Z, Wang D, Hou J, Yang R. A mussel-inspired, antibacterial, antioxidant, injectable composite hydrogel for the sustain delivery of salvianolic acid B for the treatment of frozen shoulder. Bioact Mater 2024; 40:396-416. [PMID: 39022185 PMCID: PMC11252718 DOI: 10.1016/j.bioactmat.2024.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 05/02/2024] [Accepted: 06/06/2024] [Indexed: 07/20/2024] Open
Abstract
Frozen shoulder (FS) manifests as progressively worsening pain and a reduction in shoulder range of motion (ROM). Salvianolic acid B (SaB) is recently expected to be used in the treatment of fibrosis diseases including FS. We firstly demonstrate that SaB can effectively hinder the progression of oxidative stress, inflammation, and pathological fibrosis within the synovial tissue in FS, potentially leading to the reduction or reversal of capsule fibrosis and joint stiffness. For further clinical application, we design and synthesize a novel, superior, antioxidant and antibacterial CSMA-PBA/OD-DA (CPDA) hydrogel for the delivery of SaB. In vitro experiments demonstrate that the CPDA hydrogel exhibits excellent biocompatibility and rheological properties, rendering it suitable for intra-articular injections. Upon injection into the contracted joint cavity of FS model rat, the SaB-CPDA hydrogel accelerate the recovery of ROM and exhibit superior anti-fibrosis effect, presenting the promise for the treatment of FS in vivo.
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Affiliation(s)
- Yan Yan
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510000, China
| | - Xinhao Li
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510000, China
| | - Chen Chen
- Department of Geriatric Dentistry, NMPA Key Laboratory for Dental Materials National Engineering Laboratory for Digital and Material Technology of Stomatology, Peking University School and Hospital of Stomatology, Beijing, 100081, China
| | - Dedong Cui
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510000, China
| | - Zhuo Wang
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510000, China
| | - Ming Li
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510000, China
| | - Yi Long
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510000, China
| | - Jinming Zhang
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510000, China
| | - Cheng Li
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510000, China
| | - Zhiling Wang
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510000, China
| | - Chuanhai Zhou
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510000, China
| | - Zeyu Yao
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510000, China
| | - Dan Wang
- School of Biomedical Science, The Chinese University of Hong Kong, Hong Kong, 999077, China
| | - Jingyi Hou
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510000, China
| | - Rui Yang
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510000, China
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Zhang J, Song Y, Zhu L, You Y, Hu J, Xu X, Wang C, Lu J, Shen Q, Xu X, Teng C, Du Y. An injectable thermosensitive hyaluronic acid/pluronic F-127 hydrogel for deep penetration and combination therapy of frozen shoulder. Int J Biol Macromol 2024; 263:130342. [PMID: 38395289 DOI: 10.1016/j.ijbiomac.2024.130342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/31/2024] [Accepted: 02/19/2024] [Indexed: 02/25/2024]
Abstract
Frozen shoulder (FS) is a common and progressive shoulder disorder that causes glenohumeral joint stiffness, characterized by inflammation and fibrosis. The treatment options are quite limited, and the therapeutic response is hindered by the fibrous membrane formed by excessive collagen and the rapid removal by synovial fluid. To address these challenges, we designed a hyaluronic acid/Pluronic F-127 (HP)-based injectable thermosensitive hydrogel as a drug carrier loaded with dexamethasone and collagenase (HPDC). We screened for an optimal HP hydrogel that can sustain drug release for approximately 10 days both in vitro and in vivo. In the meanwhile, we found that HP hydrogel could inhibit the proliferation and diminish the adhesion capacity of rat synovial cells induced by transforming growth factor-β1. Furthermore, using an established immobilization rat model of FS, intra-articular injection of HPDC significantly improved joint range of motion compared to medication alone. Relying on sustained drug release, the accumulated collagen fibers were degraded by collagenase to promote the deep delivery of dexamethasone. These findings showed a positive combined treatment effect of HPDC, providing a novel idea for the comprehensive treatment of FS.
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Affiliation(s)
- Jucong Zhang
- Institute of Pharmaceutics, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Yanling Song
- Institute of Pharmaceutics, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Luwen Zhu
- Institute of Pharmaceutics, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Yuchan You
- Institute of Pharmaceutics, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Jiahao Hu
- Institute of Pharmaceutics, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Xinyi Xu
- Institute of Pharmaceutics, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Chen Wang
- Institute of Pharmaceutics, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Jingyi Lu
- Institute of Pharmaceutics, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Qiying Shen
- Institute of Pharmaceutics, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Xiaoling Xu
- Shulan International Medical College, Zhejiang Shuren University, Hangzhou 310015, China.
| | - Chong Teng
- Department of Orthopedic Surgery, The Fourth Affiliated Hospital, School of Medicine, Zhejiang University, Yiwu 32200, China.
| | - Yongzhong Du
- Institute of Pharmaceutics, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China; Collaborative Innovation Center of Yangtza River Delta Region Green Pharmaceuticals, Zhejiang University of Technology, 18 Chaowang Road, Hangzhou, Zhejiang 310014, China; Innovation Center of Translational Pharmacy, Jinhua Institute of Zhejiang University, Jinhua 321299, China.
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Kraal T, de Wit Y, The B, van Boekel L, Oost IKV, Boer R, Borne MV, Goossens P, Koenraadt K, Eygendaal D. Improved range of motion after manipulation under anesthesia versus physiotherapy for stage two frozen shoulder: a randomized controlled trial. JSES Int 2024; 8:293-298. [PMID: 38464443 PMCID: PMC10920131 DOI: 10.1016/j.jseint.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024] Open
Abstract
Background Frozen shoulder (FS) is a common cause of shoulder pain and stiffness. Conservative treatment is sufficient for the majority of patients with long-term recovery of shoulder function. Manipulation under anesthesia (MUA) is known as a well-established treatment option if conservative treatment fails. It is unknown whether MUA does indeed shorten the duration of symptoms or leads to a superior outcome compared to conservative treatment. The objective of the current trial is to evaluate the effectiveness of MUA followed by a physiotherapy (PT) program compared to a PT program alone in patients with stage 2 FS. Methods A prospective, single-center randomized controlled trial was performed. Patients between 18 and 70 years old with stage 2 FS were deemed eligible if an initial course of conservative treatment consisting of PT and intra-articular corticosteroid infiltration was considered unsatisfactory. Patients were randomized, and data was collected with an online data management platform (CASTOR). MUA was performed by a single surgeon under interscalene block, and intensive PT treatment protocol was started within 4 hours after MUA. In the PT group, patients were referred to instructed physiotherapist, and treatment was guided by tissue irritability. The primary outcome was the Shoulder Pain and Disability Index (SPADI) score. Secondary outcomes were pain, range of motion (ROM), Oxford Shoulder Score, quality of life, and ability to work. Results In total, 82 patients were included, 42 in the PT group and 40 in the MUA group. There was a significant improvement in SPADI, Oxford Shoulder Score, pain, ROM, and quality of life in both groups at 1-year follow-up. SPADI scores at three months were significantly improved in favor of MUA. MUA showed a significantly bigger increase in anteflexion and abduction compared to PT at all points of follow-up. No significant differences between both groups were found for all other parameters. No fractures, dislocations, or brachial plexus injuries occurred in this trial. Conclusion MUA in stage 2 FS can be considered safe and results in a faster recovery of ROM and improved functional outcome, measured with SPADI scores, compared to PT alone in the short term. After 1 year, except for slightly better ROM scores for MUA, the result of MUA is equal to PT.
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Affiliation(s)
- Tim Kraal
- Department of Orthopedic Surgery, Flevo Hospital, Almere, the Netherlands
| | - Yordi de Wit
- Department of Orthopedic Surgery, Amphia Hospital, Breda, the Netherlands
- Foundation for Orthopedic Research, Care & Education, Amphia Hospital, Breda, the Netherlands
| | - Bertram The
- Department of Orthopedic Surgery, Amphia Hospital, Breda, the Netherlands
- Foundation for Orthopedic Research, Care & Education, Amphia Hospital, Breda, the Netherlands
| | - Leonieke van Boekel
- Department of Orthopedic Surgery, Amphia Hospital, Breda, the Netherlands
- Foundation for Orthopedic Research, Care & Education, Amphia Hospital, Breda, the Netherlands
| | - Iris Koenraadt-van Oost
- Department of Orthopedic Surgery, Amphia Hospital, Breda, the Netherlands
- Foundation for Orthopedic Research, Care & Education, Amphia Hospital, Breda, the Netherlands
| | - Ronald Boer
- Department of Orthopedic Surgery, Amphia Hospital, Breda, the Netherlands
| | - Maaike vd Borne
- Department of Orthopedic Surgery, Amphia Hospital, Breda, the Netherlands
| | - Pjotr Goossens
- Department of Orthopedic Surgery, Amphia Hospital, Breda, the Netherlands
| | - Koen Koenraadt
- Foundation for Orthopedic Research, Care & Education, Amphia Hospital, Breda, the Netherlands
| | - Denise Eygendaal
- Department of Orthopedic Surgery, Erasmus MC, Rotterdam, the Netherlands
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Huang J, Zhu H, Liu S, Li M, Li Y, Luo H, Zuo X. Protein profiling in systemic sclerosis patients with different pulmonary complications using proteomic antibody microarray. Arthritis Res Ther 2024; 26:29. [PMID: 38233947 PMCID: PMC10792928 DOI: 10.1186/s13075-024-03267-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/10/2024] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) and interstitial lung disease (ILD) are leading causes of systemic sclerosis (SSc)-related death. In this study, we aimed to identify biomarkers for detecting SSc pulmonary complications that are mild and in the early stages to improve the prognosis. METHODS We screened for serum biomarkers using a proteomic antibody microarray that simultaneously assessed 1000 proteins. Differentially expressed proteins were further verified using ELISA. Finally, we performed a correlation analysis using clinical data. RESULTS We identified 125 differentially expressed proteins, of which calcitonin, sclerostin (SOST), CD40, and fibronectin were selected for further verification. Serum calcitonin and SOST levels were significantly elevated in all SSc pulmonary complication subgroups, whereas serum calcitonin levels were higher in the SSc with PAH subgroup than in the SSc without PAH and ILD subgroup. Serum SOST levels were possibly associated with the presence of ILD and positively related to the presence of cardiac and gastrointestinal involvement. Serum CD40 and calcitonin levels appeared to be positively related to the presence of renal involvement, and serum calcitonin was also positively related to the presence of gastrointestinal involvement. CONCLUSIONS This study indicated that serum calcitonin and SOST levels may be promising biomarkers for SSc-related PAH and ILD, respectively. Further research is needed to verify this result and understand the underlying mechanisms.
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Affiliation(s)
- Jing Huang
- Department of Rheumatology, Xiangya Hospital, Central South University, Provincial Clinical Research Center for Rheumatic and Immunologic Diseases, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, China
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, State Key Laboratory of Complex Severe and Rare Diseases, No.1 Shuaifuyuan, Beijing, 100730, China
| | - Honglin Zhu
- Department of Rheumatology, Xiangya Hospital, Central South University, Provincial Clinical Research Center for Rheumatic and Immunologic Diseases, Changsha, China
| | - Sijia Liu
- Department of Rheumatology, Xiangya Hospital, Central South University, Provincial Clinical Research Center for Rheumatic and Immunologic Diseases, Changsha, China.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, China.
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, State Key Laboratory of Complex Severe and Rare Diseases, No.1 Shuaifuyuan, Beijing, 100730, China.
| | - Yisha Li
- Department of Rheumatology, Xiangya Hospital, Central South University, Provincial Clinical Research Center for Rheumatic and Immunologic Diseases, Changsha, China
| | - Hui Luo
- Department of Rheumatology, Xiangya Hospital, Central South University, Provincial Clinical Research Center for Rheumatic and Immunologic Diseases, Changsha, China
| | - Xiaoxia Zuo
- Department of Rheumatology, Xiangya Hospital, Central South University, Provincial Clinical Research Center for Rheumatic and Immunologic Diseases, Changsha, China
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Ouyang Y, Chen S, Tu Y, Wan T, Fan H, Sun G. Exploring the potential relationship between frozen shoulder and Dupuytren's disease through bioinformatics analysis and machine learning. Front Immunol 2023; 14:1230027. [PMID: 37720213 PMCID: PMC10500125 DOI: 10.3389/fimmu.2023.1230027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 08/02/2023] [Indexed: 09/19/2023] Open
Abstract
Background Frozen shoulder (FS) and Dupuytren's disease (DD) are two closely related diseases, but the mechanism of their interaction is unknown. Our study sought to elucidate the molecular mechanism of these two diseases through shared gene and protein interactions. Methods GSE75152 and GSE140731 data were downloaded from the Gene Expression Omnibus (GEO) database, and shared genes between FS and DD were selected by using R packages. Then, we used Cytoscape software and the STRING database to produce a protein-protein interaction (PPI) network. Important interaction networks and hub genes were selected through MCODE and cytoHubba algorithms. To explore the potential mechanisms of the development of the two diseases, the hub genes were further enriched by GO and KEGG analyses. We predicted the transcription factors (TFs) of hub genes with Transcriptional Regulatory Relationships Unraveled by Sentence-based Text mining (TRRUST). Moreover, we identified candidate genes for FS with DD with cytoHubba and machine learning algorithms. Finally, we analyzed the role of immunocyte infiltration in FS and constructed the relationship between candidate genes and immunocytes in FS. Results We identified a total of 321 shared genes. The results of GO and KEGG enrichment of shared genes showed that extracellular matrix and collagen fibril tissue play a certain role in the occurrence and development of disease. According to the importance of genes, we constructed the key PPI network of shared genes and the top 15 hub genes for FS with DD. Then, we predicted that five TFs are related to the hub genes and are highly expressed in the FS group. Machine learning results show that the candidate genes POSTN and COL11A1 may be key for FS with DD. Finally, immune cell infiltration revealed the disorder of immunocytes in FS patients, and expression of candidate genes can affect immunocyte infiltration. Conclusion We identified a PPI network, 15 hub genes, and two immune-related candidate genes (POSTN and COL11A1) using bioinformatics analysis and machine learning algorithms. These genes have the potential to serve as diagnostic genes for FS in DD patients. Furthermore, our study reveals disorder of immunocytes in FS.
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Affiliation(s)
- Yulong Ouyang
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- The First Clinical Medical College, Nanchang University, Nanchang, Jiangxi, China
| | - Shuilin Chen
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- The First Clinical Medical College, Nanchang University, Nanchang, Jiangxi, China
| | - Yuanqing Tu
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- The First Clinical Medical College, Nanchang University, Nanchang, Jiangxi, China
| | - Ting Wan
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- The First Clinical Medical College, Nanchang University, Nanchang, Jiangxi, China
| | - Hao Fan
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- The First Clinical Medical College, Nanchang University, Nanchang, Jiangxi, China
| | - Guicai Sun
- Department of Orthopedics, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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Yan Y, Zhou M, Meng K, Zhou C, Jia X, Li X, Cui D, Yu M, Tang Y, Li M, Zhang J, Wang Z, Hou J, Yang R. Salvianolic acid B attenuates inflammation and prevent pathologic fibrosis by inhibiting CD36-mediated activation of the PI3K-Akt signaling pathway in frozen shoulder. Front Pharmacol 2023; 14:1230174. [PMID: 37593175 PMCID: PMC10427508 DOI: 10.3389/fphar.2023.1230174] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/18/2023] [Indexed: 08/19/2023] Open
Abstract
Frozen shoulder (FS) is characterized by pain and limited range of motion (ROM). Inflammation and fibrosis are accepted as main pathologic processes associated with the development of FS. However, the intrinsic mechanisms underlying pathologic fibrosis remain unclear. We aimed to elucidate the key molecules involved in pathologic fibrosis and explore new therapeutic targets for FS. Synovial fibroblasts isolated from patient biopsies were identified using immunofluorescence. Western blotting, RT-qPCR, cell adhesion tests, and would-healing assays were used to evaluate the fibrosis-related functions of synovial fibroblasts. Elevated cluster of differentiation 36 (CD36) expression was detected in FS using Western blotting and immunohistochemistry. Salvianolic acid b (SaB) inhibited CD36, blocking synovial fibroblast-induced inflammation and fibrosis. Our RNA-seq data showed that knocking down CD36 dramatically impaired the capacity of synovial fibroblasts for cell adhesion and that the PI3K-Akt signaling pathway may be crucial to the fibrotic process of FS. By up-regulating CD36 and inhibiting the phosphorylation of Akt, we demonstrated that CD36 promotes pathologic fibrosis by activating the PI3k-Akt pathway. Finally, rats treated with SaB had improved ROM and less collagen fiber deposition than the FS model group. Conclusion: SaB attenuates inflammation and inhibited the CD36-mediated activation of the PI3K-Akt signaling pathway to block pathologic fibrosis of FS in vitro and in vivo models.
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Affiliation(s)
- Yan Yan
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Min Zhou
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ke Meng
- Department of Orthopedics, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Chuanhai Zhou
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaoyu Jia
- Sun Yat-sen University, Guangzhou, China
| | - Xinhao Li
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dedong Cui
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Menglei Yu
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yiyong Tang
- Department of Orthopedics, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Ming Li
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | | | - Zhuo Wang
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jingyi Hou
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Rui Yang
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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Alghamdi A, Alyami AH, Althaqafi RMM, Alzeyadi A, Alrubaei FS, Alyami AA, Singer MS, Saati AA, Alotaibi WT, Alsharif MO. Cytokines' Role in the Pathogenesis and Their Targeting for the Prevention of Frozen Shoulder: A Narrative Review. Cureus 2023; 15:e36070. [PMID: 37056530 PMCID: PMC10092900 DOI: 10.7759/cureus.36070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2023] [Indexed: 03/14/2023] Open
Abstract
Frozen shoulder (FS) is a common name for shoulder movement limitation with different degrees of shoulder rigidity and pain. It is characterized by varying developmental courses, different levels of shoulder movement limitation, and background ambiguity due to the multiplicity of its causative factors. Systemic inflammatory cytokines monitoring and restraining is easy to apply, fast to conduct, and needs lower costs compared to invasive methods for frozen shoulder stage evaluation and early controlling of its progress to the stage that necessitates surgical intervention. The aim of this review was to assess the recent findings concerning the role of cytokines in FS pathogenesis and the possibility of preventing or controlling their progress through targeting these cytokines by the new drugs candidates, such as hyaluronan (HA), botulinum toxin type A (BoNT A), Tetrandrine, tumor necrosis factor-stimulated gene-6 (TSG-6), and cannabidiol. Searching the PubMed site, we encountered out of 1608 records, from which 16 original studies were included for the quantitative construction of this systematic review screening of the recent studies to investigate the different FS pathogenic pathways. Most of the scenarios are centered around the inflammatory and fibrotic process triggered by synovial and capsular fibroblast stimulation. This mechanism depends mainly on alarmins cytokines, including thymic stromal lymphopoietin (TSLP), interleukin-33 (IL-33), and interleukin-25 (IL-25), with the stimulation of interleukin-1 α (IL-1α), interleukin-1 β (IL-1β), tumor necrosis alpha (TNF-α), cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) in a joint capsule. Different pathways of transforming growth factor- β (TGF-β) stimulation, resulting in overexpression of the fibrotic factors as tenascin C (TNC), fibronectin 1, collagen I (COL 1) and collagen III (COL III), and matrix metalloproteinases (MMPs) in the capsular or synovial/capsular fibroblasts. The overall investigation of these studies led us to conclude that the new drug candidates proved their efficiency in controlling the common pathogenesis of the inflammatory and fibrotic pathways of frozen shoulder and therefore represent a prospect for easy and early controlling and efficiently treating this serious disease.
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Papalexis N, Parmeggiani A, Facchini G, Miceli M, Carbone G, Cavallo M, Spinnato P. Current concepts in the diagnosis and treatment of adhesive capsulitis: role of diagnostic imaging and ultrasound-guided interventional procedures. LA RADIOLOGIA MEDICA 2022; 127:1390-1399. [PMID: 36376543 DOI: 10.1007/s11547-022-01566-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/30/2022] [Indexed: 11/16/2022]
Abstract
Adhesive capsulitis is a common cause of painful shoulder, characterized by pain and restricted range of motion of the glenohumeral joint. With a well-known clinical presentation, and an increasing understanding of its clinical and radiologic features, early diagnosis of adhesive capsulitis is becoming a reality. Although often treated conservatively, for refractory cases arthroscopic release and open capsulotomy have been the only therapeutic option for a long time. Therefore, in the last years, a particular effort was put into the development of novel minimal-invasive techniques capable of pain relief and functional range improvement of the glenohumeral joint. The purpose of this literature review is to report the main updates on diagnosis and treatment for adhesive capsulitis with a focus on imaging diagnosis techniques and novel minimally invasive ultrasound-guided treatments. Results showed that ultrasound-guided procedures come with a high success rate in terms of pain reduction and improved range of motion, thus making the ultrasound a unique tool capable of giving the operator real-time diagnostic information confirming the clinical suspicion, and subsequently performing an interventional procedure.
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Affiliation(s)
- Nicolas Papalexis
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via GC Pupilli 1, 40136, Bologna, Italy
| | - Anna Parmeggiani
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via GC Pupilli 1, 40136, Bologna, Italy
| | - Giancarlo Facchini
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via GC Pupilli 1, 40136, Bologna, Italy
| | - Marco Miceli
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via GC Pupilli 1, 40136, Bologna, Italy
| | - Giuseppe Carbone
- Shoulder and Elbow Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marco Cavallo
- Shoulder and Elbow Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Paolo Spinnato
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via GC Pupilli 1, 40136, Bologna, Italy.
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Abstract
Frozen shoulder is a common debilitating disorder characterized by shoulder pain and progressive loss of shoulder movement. Frozen shoulder is frequently associated with other systemic conditions or occurs following periods of immobilization, and has a protracted clinical course, which can be frustrating for patients as well as health-care professionals. Frozen shoulder is characterized by fibroproliferative tissue fibrosis, whereby fibroblasts, producing predominantly type I and type III collagen, transform into myofibroblasts (a smooth muscle phenotype), which is accompanied by inflammation, neoangiogenesis and neoinnervation, resulting in shoulder capsular fibrotic contractures and the associated clinical stiffness. Diagnosis is heavily based on physical examination and can be difficult depending on the stage of disease or if concomitant shoulder pathology is present. Management consists of physiotherapy, therapeutic modalities such as steroid injections, anti-inflammatory medications, hydrodilation and surgical interventions; however, their effectiveness remains unclear. Facilitating translational science should aid in development of novel therapies to improve outcomes among individuals with this debilitating condition.
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Sun Y, Luo Z, Chen Y, Lin J, Zhang Y, Qi B, Chen J. si-Tgfbr1-loading liposomes inhibit shoulder capsule fibrosis via mimicking the protective function of exosomes from patients with adhesive capsulitis. Biomater Res 2022; 26:39. [PMID: 35986376 PMCID: PMC9389696 DOI: 10.1186/s40824-022-00286-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 08/09/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Adhesive capsulitis is a common shoulder disorder inducing joint capsule fibrosis and pain. When combined with rotator cuff tear (RCT), treatments can be more complex. Currently, targeted therapy is lacking. Since adhesive capsulitis is reported to be related to circulating materials, we analyzed the contents and biology of circulating exosomes from RCT patients with and without adhesive capsulitis, in an attempt to developing a targeting treatment. METHODS Samples from a consecutive cohort of patients with RCT for surgery were collected. Circulating exosomal miRNAs sequencing were used to detect differentially expressed miRNAs in patients with and without adhesive capsulitis. For experiments in vitro, Brdu staining, CCK-8 assay, wound healing test, collagen contraction test, real-time quantitative polymerase chain reaction, and western blot were conducted. Histological and immunofluorescent staining, and biomechanical analysis were applied in a mouse model of shoulder stiffness. The characteristics of liposomes loaded with siRNA were measured via dynamic light scattering or electron microscopy. RESULTS Circulating exosomal miRNAs sequencing showed that, compared to exosomes from patients without adhesive capsulitis, miR-142 was significantly up-regulated in exosomes from adhesive capsulitis (Exo-S). Both Exo-S and miR-142 could inhibit fibrogenesis, and the anti-fibrotic effect of Exo-S relied on miR-142. The target of miR-142 was proven to be transforming growth factor β receptor 1 (Tgfbr1). Then, liposomes were developed and loaded with si-Tgfbr1. The si-Tgfbr1-loading liposomes exhibited promising therapeutic effect against shoulder stiffness in mouse model with no evidence toxicity. CONCLUSION This study showed that, in RCT patients with adhesive capsulitis, circulating exosomes are protective and have anti-fibrotic potential. This effect is related to the contained miR-142, which targets Tgfbr1. By mimicking this biological function, liposomes loaded with si-Tgfbr1 can mitigate shoulder stiffness pre-clinically.
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Affiliation(s)
- Yaying Sun
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhiwen Luo
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yisheng Chen
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Jinrong Lin
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yuhan Zhang
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Beijie Qi
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Jiwu Chen
- Department of Sports Medicine, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai, China.
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11
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Surgical versus Nonsurgical Multimodality Treatment in an Idiopathic Frozen Shoulder: A Retrospective Study of Clinical and Functional Outcomes. J Clin Med 2021; 10:jcm10215185. [PMID: 34768705 PMCID: PMC8584489 DOI: 10.3390/jcm10215185] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/23/2021] [Accepted: 11/02/2021] [Indexed: 11/16/2022] Open
Abstract
This retrospective study compared the clinical and functional outcomes of patients diagnosed with an idiopathic frozen shoulder with symptom onset of a maximum of six months, treated by arthroscopic capsular release followed by corticosteroid injection and physiotherapy to patients who received only corticosteroid injection followed by physiotherapy. The patients who underwent arthroscopic capsular release, intraoperative corticosteroid injection, and physiotherapy (Group I, n = 30) or received only corticosteroids injection and physiotherapy (Group II, n = 29) were examined in terms of shoulder range of motion (ROM), pain intensity, and function before a given treatment and three, six, and twelve months later. The groups were comparable pre-treatment in terms of ROM, pain, and functional outcome. Group I had statistically and clinically significantly better ROM and function at three and six months post-treatment than Group II. Despite being statistically significant, the between-group differences at twelve-month follow-up in ROM and function were too small to be considered clinically notable. The between-group comparison of pain revealed no significant differences at any post-treatment point of time. The early arthroscopic capsular release preceding corticosteroid injection and physiotherapy seemed more effective at three- and six-month follow-up; however, it brought a comparable result to corticosteroid injection and subsequent physiotherapy at twelve months follow-up.
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12
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Zhao H, Kong L, Shen J, Ma Y, Wu Z, Li H, He Y. Tetrandrine inhibits the occurrence and development of frozen shoulder by inhibiting inflammation, angiogenesis, and fibrosis. Biomed Pharmacother 2021; 140:111700. [PMID: 34044279 DOI: 10.1016/j.biopha.2021.111700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Frozen shoulders (FS) is a major clinical concern, where chronic synovial inflammation, abnormal angiogenesis, and fibrosis represent the critical pathologies in the glenohumeral capsule. However, no pharmacotherapy has been introduced to treat this pathology. Tetrandrine (TET) has been proposed as a treatment for many diseases due to its strong anti-inflammatory, anti-angiogenic, and anti-fibrotic effects. PURPOSE To study the anti-inflammatory, anti-angiogenic, and anti-fibrotic effects of TET on FS, and identify whether TET can prevent the development of FS in rats. STUDY DESIGN A controlled laboratory study. METHODS Forty-eight male Sprague-Dawley (SD) rats were randomly divided into control, TET, and FS groups. The TET group was intraperitoneally injected with TET every 2 days. TET and saline treatment were started on the day of FS surgery. After 8 weeks, the animals were sacrificed, and samples were collected for X-ray examination, glenohumeral range of motion (ROM) evaluation, histology and immunohistochemistry analysis, transmission electron microscopy (TEM) observation, and profibrogenic factors as well as proinflammatory cytokines measurements. RESULTS No significant difference in shoulder ROM was observed between the TET and control groups, but a significant difference was noted between these groups and the FS group (P < 0.01). Immunohistochemical staining showed no abnormal angiogenesis or fibrosis in the TET group or the control group. However, significant angiogenesis, collagen remodeling, and fibrosis were observed in the FS group, and the expression and proportion of type I and type III collagen in the FS group were significantly higher than those in the TET group or the control group (P < 0.01). TEM observation showed that TET protected the ultrastructure of collagen fibrous reticular arrangement of the articular capsule and prevented the formation of scar-like fibrotic structures, which are unique to FS. The significantly increased expression of Smad7 and the suppressed expression of Smad 2 in the TET group compared with that of the FS group indicated that TET also significantly inhibited the TGF-β1 intracellular signal pathway. The expression of profibrogenic factors and proinflammatory cytokines in the TET group and the control group was significantly lower than that in the TET group (P < 0.01). CONCLUSION The results demonstrated that TET protected the normal reticular structure of the capsule during the freezing period and prevented the development of FS by inhibiting inflammation, angiogenesis, and fibrosis in a rat FS model. CLINICAL RELEVANCE TET may be a safe and effective clinical medication for preventing and treating FS.
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Affiliation(s)
- Huakun Zhao
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai 200233, China
| | - Lingzhi Kong
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai 200233, China
| | - Ji Shen
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai 200233, China
| | - Yanhong Ma
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai 200233, China
| | - Zhi Wu
- Shanghai Jiao Tong University Affiliated Sixth People's Hospital, School of Biomedical Engineering and School of Biomedical Engineering, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai 200030, China
| | - Haiyan Li
- Shanghai Jiao Tong University Affiliated Sixth People's Hospital, School of Biomedical Engineering and School of Biomedical Engineering, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai 200030, China; Chemical and Environmental Engineering, School of Engineering, RMIT University, 124 La Trobe St, Melbourne, VIC 3000, Australia.
| | - Yaohua He
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai 200233, China.
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13
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Zhang L, Xing R, Huang Z, Ding L, Zhang L, Li M, Li X, Wang P, Mao J. Synovial Fibrosis Involvement in Osteoarthritis. Front Med (Lausanne) 2021; 8:684389. [PMID: 34124114 PMCID: PMC8187615 DOI: 10.3389/fmed.2021.684389] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/03/2021] [Indexed: 12/14/2022] Open
Abstract
Bone changes have always been the focus of research on osteoarthritis, but the number of studies on synovitis has increased only over the last 10 years. Our current understanding is that the mechanism of osteoarthritis involves all the tissues that make up the joints, including nerve sprouting, pannus formation, and extracellular matrix environmental changes in the synovium. These factors together determine synovial fibrosis and may be closely associated with the clinical symptoms of pain, hyperalgesia, and stiffness in osteoarthritis. In this review, we summarize the consensus of clinical work, the potential pathological mechanisms, the possible therapeutic targets, and the available therapeutic strategies for synovial fibrosis in osteoarthritis to gain insight and provide a foundation for further study.
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Affiliation(s)
- Li Zhang
- Departments of Orthopedics, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Runlin Xing
- Departments of Orthopedics, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Zhengquan Huang
- Departments of Orthopedics, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Liang Ding
- Departments of Orthopedics, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Li Zhang
- Departments of Orthopedics, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Mingchao Li
- Departments of Orthopedics, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Xiaochen Li
- Departments of Orthopedics, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Peimin Wang
- Departments of Orthopedics, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Jun Mao
- Departments of Orthopedics, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
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14
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Abstract
Among all the prevalent painful conditions of the shoulder, frozen shoulder remains one of the most debated and ill-understood conditions. It is a condition often associated with diabetes and thyroid dysfunction, and which should always be investigated in patients with a primary stiff shoulder. Though the duration of 'traditional clinicopathological staging' of frozen shoulder is not constant and varies with the intervention(s), the classification certainly helps the clinician in planning the treatment of frozen shoulder at various stages. Most patients respond very well to combination of conservative treatment resulting in gradual resolution of symptoms in 12-18 months. However, the most effective treatment in isolation is uncertain. Currently, resistant cases that do not respond to conservative treatment for 6-9 months could be offered surgical treatment as either arthroscopic capsular release or manipulation under anaesthesia. Though both invasive options are not clinically superior to another, but manipulation could result in unwarranted complications like fractures of humerus or rotator cuff tear.
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15
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Sun Y, Lin J, Luo Z, Zhang Y, Chen J. The Serum from Patients with Secondary Frozen Shoulder Following Rotator Cuff Repair Induces Shoulder Capsule Fibrosis and Promotes Macrophage Polarization and Fibroblast Activation. J Inflamm Res 2021; 14:1055-1068. [PMID: 33790620 PMCID: PMC8001608 DOI: 10.2147/jir.s304555] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/10/2021] [Indexed: 02/05/2023] Open
Abstract
PURPOSE Disorders with systematic inflammation were prognostic for secondary frozen shoulder (sFS) following rotator cuff repair (RCR); however, how systematic inflammation affects sFS remains unclear. The aim of this study was to observe the effect of pre-operative serum from patients with sFS and the serum from those without on shoulder capsule in mice, and on macrophages and fibroblasts in vitro. METHODS Serum samples of a consecutive cohort of patients for RCR were collected pre-operatively. Three months after RCR, patients who developed sFS (Group S) were identified. Serum samples from gender- and age-matched controls without sFS (group NS) were also picked out. Firstly, the effect of serum on shoulder capsule fibrosis was observed histologically and biomechanically in a mouse model of RCR. Secondly, the roles of the serum on macrophage polarization and fibroblast activation were investigated, and the potentially involved signaling pathways were identified. Finally, inflammation and fibrosis-related cytokines in serum were quantified. RESULTS In our cohort, all patients had free pre-operative shoulder range of motion. Seven patients developed sFS at 3 months after surgery. Seven matched patients without sFS were selected as control. The inter-group difference of basic characteristics was not significant. Compared to the serum of group NS, the serum of group S significantly induced hypercellularity, capsular thickening, and range of motion deficiency in mice shoulders after RCR. Compared to the serum of group NS, samples of group S significantly promoted M2 polarization of THP-1 human macrophages and the activation of human capsule-derived fibroblasts. Meanwhile, Smad3 and p-Smad3 in macrophages and fibroblasts were significantly up-regulated. On the other hand, levels of inflammation and fibrosis-related cytokines were not significantly different between serum in group S and group NS. CONCLUSION Although all patients in this cohort had free range of motion pre-operatively, the pre-operative serum from patients with sFS at 3 months after RCR could act as a trigger of shoulder capsule fibrosis post-operatively. This effect may be related to its promotion on macrophage polarization to M2 phenotype and fibroblast activation.
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Affiliation(s)
- Yaying Sun
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Jinrong Lin
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Zhiwen Luo
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Yuhan Zhang
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Jiwu Chen
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, People’s Republic of China
- Correspondence: Jiwu Chen Department of Sports Medicine, Huashan Hospital, Fudan University, 12# Middle Wulumuqi Road, Jing’an District, Shanghai, 200040, People’s Republic of ChinaFax +86 21 52888255 Email
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16
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Kraal T, Lübbers J, van den Bekerom MPJ, Alessie J, van Kooyk Y, Eygendaal D, Koorevaar RCT. The puzzling pathophysiology of frozen shoulders - a scoping review. J Exp Orthop 2020; 7:91. [PMID: 33205235 PMCID: PMC7672132 DOI: 10.1186/s40634-020-00307-w] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/02/2020] [Indexed: 02/06/2023] Open
Abstract
Purpose The pathophysiology of frozen shoulders is a complex and multifactorial process. The purpose of this review is to scope the currently available knowledge of the pathophysiology of frozen shoulders. Methods A systematic search was conducted in Medline, Embase and the Cochrane library. Original articles published between 1994 and October 2020 with a substantial focus on the pathophysiology of frozen shoulders were included. Results Out of 827 records, 48 original articles were included for the qualitative synthesis of this review. Glenohumeral capsular biopsies were reported in 30 studies. Fifteen studies investigated were classified as association studies. Three studies investigated the pathophysiology in an animal studies. A state of low grade inflammation, as is associated with diabetes, cardiovascular disease and thyroid disorders, predisposes for the development of frozen shoulder. An early immune response with elevated levels of alarmins and binding to the receptor of advance glycation end products is present at the start of the cascade. Inflammatory cytokines, of which transforming growth factor-β1 has a prominent role, together with mechanical stress stimulates Fibroblast proliferation and differentiation into myofibroblasts. This leads to an imbalance of extracellular matrix turnover resulting in a stiff and thickened glenohumeral capsule with abundance of type III collagen. Conclusion This scoping review outlines the complexity of the pathophysiology of frozen shoulder. A comprehensive overview with background information on pathophysiologic mechanisms is given. Leads are provided to progress with research for clinically important prognostic markers and in search for future interventions. Level of evidence Level V.
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Affiliation(s)
- T Kraal
- Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp, the Netherlands. .,, Haarlem, The Netherlands.
| | - J Lübbers
- Department of Molecular cell biology and Immunology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | | | - J Alessie
- Avans University of Applied Science, Breda, The Netherlands
| | - Y van Kooyk
- Department of Molecular cell biology and Immunology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - D Eygendaal
- Department of Orthopaedic Surgery, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - R C T Koorevaar
- Department of Orthopaedic Surgery, Deventer Hospital, Deventer, the Netherlands
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