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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

II-III.

Similar outcomes between arthroscopic capsular release and manipulation under anesthesia for frozen shoulder: A meta-analysis

To compared the arthroscopic capsular release (ACR) with manipulation under anaesthesia (MUA) for the surgical treatment of frozen shoulder (FS) based on postoperative outcomes and complications. PubMed, Cochrane Library, Embase, and Web of Science were searched on October 2, 2023 to retrieve eligible studies that compared ACR with MUA in terms of clinical outcomes (pain visual analogue scale, external rotation, forward flexion and adverse events) for patients with FS. Mean differences (MD) were calculated for continuous outcomes and odds ratios (OR) were calculated for dichotomous outcomes. Six papers, including 5 clinical studies (a total of 690 shoulders), were included in the final meta-analysis. The forward flexion was found to be larger in the ACR group at 3 months (MD, 2.73; 95%CI, 0.42-5.04; I2 = 44%; P = 0.02) and 6 months (MD, 2.36; 95%CI, 1.29-3.44; I2 = 0%; P < 0.0001). Except for this, ACR was comparable with MUA in terms of pain visual analogue scale at 3, 6 and 12 months (p = 0.25, p = 0.11, p = 0.28, respectively), external rotation at 3, 6 and 12 months (p = 0.15, p = 0.52, p = 0.23, respectively), and forward flexion at 12 months (p = 0.08). There were no differences in complication rates between the two groups (OR, 0.82; 95%CI, 0.47-1.44; I2 = 0%; P = 0.50). In comparison with MUA, ACR demonstrated better outcomes for forward flexion at 3 and 6 months, while there were no significant differences between ACR and MUA in terms of pain visual analogue scale, external rotation and adverse events.

A Narrative Review of Adhesive Capsulitis with Diabetes

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

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

Background

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

Objective

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

Methodology

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

Results

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

Conclusion

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

Causal associations of hypothyroidism with frozen shoulder: a two-sample bidirectional Mendelian randomization study

BACKGROUND

Many studies have investigated the association between hypothyroidism and frozen shoulder, but their findings have been inconsistent. Furthermore, earlier research has been primarily observational, which may introduce bias and does not establish a cause-and-effect relationship. To ascertain the causal association, we performed a two-sample bidirectional Mendelian randomization (MR) analysis.

METHODS

We obtained data on "Hypothyroidism" and "Frozen Shoulder" from Summary-level Genome-Wide Association Studies (GWAS) datasets that have been published. The information came from European population samples. The primary analysis utilized the inverse-variance weighted (IVW) method. Additionally, a sensitivity analysis was conducted to assess the robustness of the results.

RESULTS

We ultimately chose 39 SNPs as IVs for the final analysis. The results of the two MR methods we utilized in the investigation indicated that a possible causal relationship between hypothyroidism and frozen shoulder. The most significant analytical outcome demonstrated an odds ratio (OR) of 1.0577 (95% Confidence Interval (CI):1.0057-1.1123), P = 0.029, using the IVW approach. Furthermore, using the MR Egger method as a supplementary analytical outcome showed an OR of 1.1608 (95% CI:1.0318-1.3060), P = 0.017. Furthermore, the results of our sensitivity analysis indicate that there is no heterogeneity or pleiotropy in our MR analysis. In the reverse Mendelian analysis, no causal relationship was found between frozen shoulders and hypothyroidism.

CONCLUSION

Our MR analysis suggests that there may be a causal relationship between hypothyroidism and frozen shoulder.

Arthroscopic Arthrolysis for Recalcitrant Frozen Shoulder: Double Posterior Approach

Arthroscopic capsular release is required in some patients with frozen shoulder (FS). In some cases of recalcitrant FS, arthroscopic capsular release is difficult because of the abnormal narrowing of the joint space. The aim of this article is to introduce an arthroscopic double posterior approach combined with lateral and anterior approaches that is used to complete release of the glenohumeral joint capsule at 360°, subacromial debridement, and long head of biceps tenotomy. This article shows that this double posterior technique is a safe and highly effective totally intra-arthroscopic release technique for recalcitrant FS.

Adhesive capsulitis: the importance of early diagnosis and treatment

BACKGROUND

Adhesive capsulitis (AC), more commonly known as "frozen shoulder", is a painful shoulder condition. The illness progresses through three phases: freezing, frozen and thawing. A gold standard treatment for adhesive capsulitis is not defined. The goal of any treatment is to reduce pain and restore shoulder movement.

OBJECTIVE

Objective of the present study is to evaluate the efficacy of gleno-humeral hydrodistension associated with physical therapy in patients with diagnosed adhesive capsulitis comparing the outcomes in term of pain and range of motion in patients with a phase 1 and a phase 2 disease.

METHOD

Between January 2022 and April 2023, We evaluated 87 patients with adhesive capsulitis, 47 were excluded for others concomitant pathologies, finally 40 patients were enrolled for the study, of whom 23 had capsulitis in stage 1 and 17 in stage 2. Patients were evaluated at baseline and at 2, 4 and 6 months after infiltration recording range of motion in all planes, pain and functionality scores.

RESULTS

A significant improvement was recorded in shoulder range of motion in all planes with the except of extension in both groups. Phase 2 patients were able to regain shoulder range of motion in all planes except internal rotation which was recovered with more difficulty. Pain and functionality scores improved significantly between baseline and follow-up visits.

CONCLUSION

Ultrasound-assisted hydrodistention of the glenohumeral joint combined with targeted exercise has been successful in improving pain relief, reducing disability, and increasing range of motion in subjects with stage 1 and 2 adhesive capsulitis, especially if diagnosed before phase 2 (when the range of motion is completely reduced).

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Factors associated with frozen shoulder in adults: a retrospective study

OBJECTIVE

This study aims to explore the risk factors associated with frozen shoulder patients and further analyze the relationship between gender and diabetes with frozen shoulder.

METHOD

We have reviewed the data of 1205 frozen shoulder patients in China's Xinjiang region from 2018 to 2023. The collected information included patients' gender, occupation, place of origin, marital status, age, the season of disease onset, duration of illness, etiology, surgical history, hypertension, diabetes, respiratory diseases, knee joint disease, hyperlipidemia, cardiovascular diseases, cervical spondylosis, lumbar disc herniation, rheumatoid arthritis, hyperuricemia, sleep quality, smoking and alcohol consumption, and constipation. We have used multifactor logistic regression analysis to identify the risk factors for a frozen shoulder.

RESULTS

Single-factor logistic regression analysis showed that the number of females, patients with diabetes, knee joint disease, constipation, and patients with poor sleep quality in the observation group are higher than in the control group (P < 0.05). There were no statistically significant differences between the two groups in terms of occupation, place of origin, marital status, age, season of disease onset, duration of illness, etiology, surgical history, hypertension, respiratory diseases, hyperlipidemia, cardiovascular diseases, cervical spondylosis, lumbar disc herniation, rheumatoid arthritis, hyperuricemia, smoking, and alcohol consumption history (P > 0.05). Multivariate analysis showed that the final model included four variables: gender, diabetes history, sleep, and constipation. Among them, the OR values of gender and diabetes history were more significant than 1, indicating that they were independent risk factors for frozen shoulder, while the OR values of sleep and constipation were less than 1, suggesting that they were negatively associated with the occurrence of frozen shoulder.

CONCLUSION

The results of this study suggest that gender and diabetes are independent risk factors for frozen shoulder. Additionally, poor sleep quality and constipation also can be correlated with the occurrence of a frozen shoulder.

The Feasibility and Efficacy of Remote App-Guided Home Exercises for Frozen Shoulder: A Pilot Study

Home exercise programs are beneficial in managing frozen shoulder (FS), yet adherence remains challenging. This pilot study introduces the remote app, Defrozen, designed for home exercises and assesses its feasibility and clinical outcomes in FS patients undergoing intra-articular and sub-acromial corticosteroid treatment. Over a four-week period, patients used the Defrozen-app, engaging in guided exercises. The feasibility of the intervention was assessed through several measurement scales, including adherence, the Technology Acceptance Model 2 (TAM2), the System Usability Scale (SUS), and User Satisfaction and Engagement (USE). Clinical outcomes included pain scale, Oxford Shoulder Score (OSS), Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) Score, and passive range of motion. The TAM2 results indicated high perceived usefulness (4.5/5), ease of use (4.8/5), and intention to use (4.4/5); the SUS score was high at 81.7/100, complemented by USE scores reflecting ease of learning (4.9/5) and satisfaction (4.3/5). Clinical outcomes showed significant pain reduction, improved shoulder function, reduced shoulder-related disability, and increased shoulder range of motion. These findings suggest the Defrozen-app as a promising solution for FS, significantly improving adherence and showing potential to enhance clinical outcomes. However, these clinical outcome results are preliminary and necessitate further validation through a large-scale randomized controlled trial to definitively confirm efficacy and assess long-term benefits.

Additional Effect of Extracorporeal Shockwave Therapy with Lidocaine Injection on Clinical and MRI Findings in Frozen Shoulder: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Trial

INTRODUCTION

Frozen shoulder is a very common musculoskeletal condition and the evidence related to the additional effects of extracorporeal shockwave therapy (ESWT) with intra-articular (IA) lidocaine injection in individuals with frozen shoulder is rare. Therefore, this study aims to compare and investigate the additional effects of extracorporeal shockwave therapy (ESWT) with intra-articular (IA) lidocaine injection in a frozen shoulder.

METHODS

Sixty eligible participants with frozen shoulder were included and the active group (n = 30, age 52.12 ± 5.2 years) received a lidocaine injection (1% lidocaine (Xylocaine) and 2cc (80 mg) methylprednisolone acetate) with active ESWT (3.5 bar air pressure and 2000 pulses with an energy flux density (EFD) ¼ 0.16 mJ/mm2) three sessions a week for 4 weeks. The placebo group (n = 30, age 53.56 ± 5.5 years) received lidocaine injection with placebo treatment (a special head that blocked the shock waves) three sessions a week for 4 weeks. Both groups received progressive resistance exercises (PRE) to the shoulder muscles. The primary outcome was pain intensity, measured with the visual analogue scale. The other outcome measures were the thickness of the coracohumeral ligament (CHL) measured by magnetic resonance imaging (MRI), abduction, and lateral rotation range of motion (ROM), functional disability, kinesiophobia, depression status, and quality of life. Participants were assessed at baseline, after 4 weeks, 8 weeks, and at 6-month follow-up.

RESULTS

The post-intervention at 4 weeks showed an improvement of 2.0 (CI 95% 1.71-2.28) in the active group compared to the placebo group. Similar effects were noted after 8 weeks (2.2) (CI 95% 1.91-2.48) and at the 6-month (1.9) (CI 95% 1.61-2.18) follow-up. Similar improvements were also found in the thickness of the CHL ligament (0.6) (CI 95% 0.46-0.73), abduction and lateral rotation (ROM) (- 23.6) (CI 95% - 27.47 to -19.72), (- 18.10) (CI 95% - 19.72 to - 16.47), functional disability (16.2) (CI 95% 14.85-17.54), kinesiophobia (11.0 (CI 95% 10.21-11.98), depression status (4.4) (CI 95% 4.03-4.76) and quality of life (0.9) (CI 95% 0.79-1.00) (p = 0.001) at the 6-month follow-up period, where mean estimates and their confidence intervals all included worthwhile effects. There were no adverse reactions or side effects noted in either the active or placebo groups during and after the treatment.

CONCLUSIONS

The study concluded that the addition of extracorporeal shockwave therapy after intra-articular lidocaine injection improves pain, functional disability, range of motion, kinesiophobia, depression status, and quality of life in people with frozen shoulder.

TRIAL REGISTRATION

https://ctri.nic.in , identifier; CTRI/2020/04/024834 prospectively registered on 24/04/2020.

Rotator Interval vs Posterior Approach Ultrasound-guided Corticosteroid Injections in Primary Frozen Shoulder: A Meta-analysis of Randomized Controlled Trials

OBJECTIVE

To compare the efficacy of rotator interval (RI) vs posterior approach (PA) ultrasound (US) guided corticosteroid injections into the glenohumeral (GH) joint in primary frozen shoulder (PFS).

DATA SOURCES

A systematic literature search for all relevant studies on Medline, Scopus, Embase, Web of Science, and Cochrane Central, up to January 2023 was conducted.

STUDY SELECTION

Randomized controlled trials that directly compared the US-guided corticosteroid injection into the RI and GH joint using PA in patients clinically and radiographically diagnosed with PFS.

DATA EXTRACTION

The primary outcome was pain, and the secondary outcomes were function, and range of motion (ROM). Two authors independently assessed the risk of bias using the Cochrane risk-of-bias tool version 2. A random-effects model and generic inverse variance method were performed. Effect sizes were estimated using mean difference (MD) and standardized mean difference (SMD).

DATA SYNTHESIS

A total of 5 clinical trials involving 323 subjects were included for the meta-analysis. US-guided corticosteroid injections into the RI revealed significant pain relief (MD 1.33 [95% confidence interval (CI) 0.20 to 2.46]; P=.02) and significant functional improvement (SMD 1.31 [95% CI 0.11 to 2.51]; P=.03) compared with the PA after 12 weeks.

CONCLUSION

The results suggest the injection of corticosteroid into RI space is more effective than PA after 12 weeks in improving both pain and functional scores in patients with PFS.

Corticosteroid Injection Methods for Frozen Shoulder: A Network Meta-analysis

OBJECTIVE

To investigate the efficacy of corticosteroid (CS) injection methods for frozen shoulder.

DATA SOURCES

PubMed, Embase, and Cochrane Library were searched up to May 6, 2023.

STUDY SELECTION

Randomized controlled trials (RCTs) that investigated CS injection methods for frozen shoulder were included.

DATA EXTRACTION

Data were extracted independently by 2 authors. Risk of bias was assessed using the RoB 2 tool.

DATA SYNTHESIS

A random-effects network meta-analysis was performed within a frequentist framework. The certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations approach. A total of 66 RCTs involving 4491 patients were included. For short-term outcomes, 4-site injection (vs placebo [PLA]: standardized mean difference [SMD]=-2.20, 95% confidence interval [CI], -2.81 to -1.59 in pain; SMD=2.02; 95% CI, 1.39-2.65 in global function) was the most effective (low certainty). Rotator interval injection was the optimal treatment with moderate to high certainty (vs PLA: SMD=-1.07, 95% CI, -1.51 to -0.64 in pain; SMD=0.94, 95% CI, 0.49-1.40 in global function). For midterm outcomes, 4-site injection was most effective (vs PLA: SMD=-1.71, 95% CI, -2.41 to -1.01 in pain; SMD=2.22, 95% CI, 1.34-3.09 in global function; low certainty). Distension via rotator interval (D-RI) was the optimal treatment with moderate to high certainty (vs PLA: SMD=-1.10, 95% CI, -1.69 to -0.51 in pain; SMD=1.46, 95% CI, 0.73-2.20 in global function). Distension and intra-articular injection via anterior or posterior approaches produced effects equivalent to those of rotator interval injection and D-RI.

CONCLUSIONS

Rotator interval injection, distension, and intra-articular injection had equivalent effects on symptom relief. More RCTs are required to validate the superiority of multisite injections.

Adhesive Capsulitis Following Improper Tetanus-Diphtheria (Td) Booster Administration

Adhesive capsulitis following vaccination is a rare complication secondary to improper intramuscular (IM) deltoid vaccine administration. It is considered a subset of the broad category known as shoulder injury related to vaccine administration (SIRVA). SIRVA typically results from improper shoulder anatomic localization prior to injection, leading to erroneous placement of the needle into the glenohumeral joint capsule or subacromial space. This can trigger a wide array of pathologies, including adhesive capsulitis. We present the first known case of adhesive capsulitis following improper tetanus-diphtheria (Td) vaccine administration. The patient, a previously healthy middle-aged female, began experiencing significant anterior left shoulder pain the day following a Td booster vaccination. She remarked receiving the injection "higher up" in the shoulder than normal. Over the next two weeks, she began noting significant shoulder stiffness, which was followed by a progressive loss of shoulder range of motion. Her symptoms persisted for four months without definitive diagnosis or treatment. After four months of symptoms, the patient visited an outpatient sports medicine clinic where the diagnosis of adhesive capsulitis was made. Although the patient was referred for physical therapy, focusing on gentle range of motion (ROM) and stretches, followed by a planned isometric strengthening program once ROM improved, she was eventually lost to follow-up, and her recovery is unclear. Given the rarity of the diagnosis, it is unclear if adhesive capsulitis, secondary to improper IM vaccination, follows the same temporal course as "classic" adhesive capsulitis or results in a different timeframe of recovery. Further studies are needed on this subject.

Evidence for Combining Conservative Treatments for Adhesive Capsulitis

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

Prevalence of prediabetes in patients with idiopathic frozen shoulder: a prospective study

Background

The association between diabetes and frozen shoulder is well established. However, the data regarding prediabetes and primary frozen shoulder (PFS) are still lacking.

Methods

In a prospective study, 158 patients with PFS were included. The prediabetes status was ascertained by estimating serum hemoglobin A1c (HbA1c) levels in patients with PFS. According to the level of HbA1c, patients were classified into normoglycemic, prediabetic, and diabetic. In addition, random blood sugar (RBS) was also performed.

Results

Out of 158 participants, 84 (53.2%) were male and 74 (46.8%) were female. Nine patients had bilateral shoulder involvement, and all were diabetics; 47.5% (n = 75) of the patients were in the age group of 51-60 years, 16.5% (n = 26) of the participants were normoglycemic, 37.3% (n = 59) were prediabetics, and 46.2% (n = 73) were diabetics. The difference in mean HbA1c values between the 3 groups was statistically significant (P < .001). However, there was no statistical difference in various age groups (P = .86) or gender (P = .68) between normoglycemics, prediabetics, and diabetics. The difference in mean RBS values between diabetic-nondiabetic and diabetic-prediabetic groups were statistically significant (P < .001), whereas no significant difference was detected between nondiabetic and prediabetic (P = .355).

Conclusion

The prevalence of prediabetes is 37.5% in patients with PFS. Single-point HbA1c estimation is an acceptable tool to detect prediabetes, whereas RBS estimation should not be used to detect prediabetes.

Revisiting articular syndrome in the peri-pandemic COVID-19 era

Articular syndrome is often the presentation of a person's various rheumatic or related diseases. It includes both arthralgia and arthritis, with objective signs of joint inflammation defining the latter. This syndromic approach to joint pain enables a scientific method for early diagnosis of common rheumatic conditions without compromising the recognition of uncommon conditions. This review explores common rheumatic conditions associated with articular syndrome, including osteoarthritis, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE). It supports the early differentiation of uncommon but emerging entities such as reactive arthritis (ReA). The aim of the review is to comprehensively overview various forms of articular syndrome to update rheumatologists' and allied health specialists' knowledge. Epidemiology, clinical presentations, diagnostic approaches, and therapeutic strategies are discussed in the context of articular syndrome. The challenges emerging in the peri-pandemic COVID-19 era are highlighted. The improved understanding of the spectrum of clinical conditions and disease states presenting with articular syndrome may facilitate early diagnosis, optimal management, and enhanced patient outcomes within the realm of rheumatology.

Effectiveness of high-intensity laser therapy in the treatment of patients with frozen shoulder: a systematic review and meta-analysis

The purpose of this study is to evaluate the effects of high-intensity laser therapy (HILT) in patients with frozen shoulder. PRISMA guidelines were adhered to, and a systematic search was conducted in the PubMed, Web of Science, Scopus, CINAHL, Science Direct, and PEDro databases (last update: September 4, 2023; search period: December 2022-September 2023). The inclusion criteria encompassed RCTs comparing HILT with other physical therapy interventions in frozen patients with frozen shoulders, with or without sham HILT, assessing pain intensity, shoulder ROM, and disability outcomes. The quality of the RCTs was assessed with the Cochrane Risk of Bias tool, and evidence was assessed using the GRADE approach. Five trials met the eligibility criteria and were included in the review and meta-analysis, which pooled results from the visual analog scale (VAS), goniometry, and the shoulder pain and disability index (SPADI). Mean differences (MDs) for pain intensity and disability show a pooled effect in favor of HILT both for VAS (MD =  - 2.23 cm, 95% CI: - 3.25, - 1.22) and SPADI (MD =  - 10.1% (95% CI =  - 16.5, - 3.7), changes that are statistical (p < 0.01) and clinical. The MD for flexion (MD = 9.0°; 95% CI: - 2.36°, 20.3°; p = 0.12), abduction (MD = 3.4°; 95% CI: - 6.9°, 13.7°; p = 0.51), and external rotation (MD =  - 0.95°; 95% CI: - 5.36°, 3.5°; p = 0.67) does not show statistical and clinical differences between groups after treatment. PI and disability changes were graded as important due to their clinical and statistical results. HILT into a physical therapy plan reduce pain and disability, but it does not outperform conventional physical therapy in improving shoulder ROM. It is suggested that future RCTs compare the effects of HILT and LLLT to assess their possible differences in their analgesic effects.

Magnetic resonance imaging could precisely define the mean value of tendon thickness in partial rotator cuff tears

PURPOSE

Rotator Cuff (RC) lesions are classified in full-thickness and partial-thickness tears (PTRCTs). To our knowledge, no studies investigated the mean size of shoulder tendons in healthy and PTRCT patients using MRI scans. The aim of the study was to provide data to obtain and compare the mean value of tendon sizes in healthy and PTRCTs groups.

METHODS

From 2014 to 2020, 500 were included in the study. They were divided into two groups: Group 1 (100 subjects) was composed of people positive for partial-thickness rotator cuff tears (PTRCTs), while the 400 subjects in Group 2 were negative for PTRCTs.

RESULTS

Overall, of the patients included in the study, 231 were females and 269 were males. The mean age of the patients was 49 ± 12.7 years. The mean thickness of the supraspinatus tendon (SSP) was 5.7 ± 0.6 mm in Group 1, 5.9 ± 0.6 mm in Group 2 (p < 0.001). The mean length of the ISP tendon was 27.4 ± 3.2 mm in Group 1, 28.3 ± 3.8 mm in Group 2 (p = 0.004). The mean width of the SSP tendon was 17 ± 1.6 mm in Group 1, 17.6 ± 2 mm in Group 2 (p = 0.004). The mean width of the infraspinatus tendon (ISP) tendon was 17.7 ± 1.4 mm in Group 1, 18.3 ± 2.1 mm in Group 2 (p = 0.02).

CONCLUSION

The anatomical data present in this paper may serve as a tool for surgeons to properly manage PTRCTs. The findings of the present study aimed to set the first step towards reaching unanimity to establish international cut-off values to perform surgery. Additionally, they could widely increase diagnostic accuracy, improving both conservative and surgical approaches. Lastly, further clinical trials using more accurate diagnostic MRI tools are required to better define the anatomical differences between PTRCT and healthy patients.

LEVEL OF EVIDENCE

Level II, Retrospective Comparative Trial.

Frozen Shoulder: Diagnosis and Management

ABSTRACT

Frozen shoulder is a common condition that causes pain and restriction of movement of the shoulder unrelated to secondary causes. It has three classic phases (freezing, frozen, and thawing), and is resolved in most cases within 1 to 2 years. Diagnosis is clinical based on global motion restriction and pain. Imaging plays an ancillary role to narrow the differential diagnosis. Physical therapy, nonsteroidal anti-inflammatories, and injection therapies are standard treatments, although none have been shown to alter the long-term course of the condition. Ultrasound guidance is recommended for injection-based therapy, although not required. Further study should focus on long-term outcomes and treatments that significantly alter the natural course of the disease.

Shoulder Injury Related to Vaccine Administration (SIRVA) Is Real: A Case Report

This study presents a case of SIRVA-induced adhesive capsulitis and the subsequent physiotherapy intervention. It details the patient's journey using CARE guidelines. The main symptoms included persistent pain and a reduced range of motion for flexion, abduction, and internal and external rotation of the shoulder. Interventions included active and passive mobilisation via capsular stretching, and home exercise programs. At more than two years post-injury, the patient has ongoing pain, restricted shoulder movement, and disability. This highlights the importance of healthcare practitioners' knowledge of SIRVA. Vaccinating practitioners should be aware of the mechanism of injury of SIRVA for preventing such injuries. First-contact practitioners should be aware of SIRVA-induced conditions to ensure timely and correct diagnosis and management of SIRVA-induced conditions.

The Value of Percutaneous Ultrasound-Guided Subacromial Bursography for Rotator Cuff Tear in Elderly Patients with Shoulder Pain

Objective

Based on the analysis of the images of acromial slide, we explored the application of percutaneous ultrasound-guided subacromial bursography (PUSB) on rotator cuff tear (RCT) in diagnosing elderly patients with shoulder pain.

Methods

Eighty-five patients who were clinically diagnosed with RCT and underwent PUSB examination in the department of ultrasound in our hospital were enrolled as the subjects. Independent samples t-test was used to analyze the general characteristics. Based on the gold standard of shoulder arthroscopy, the diagnostic efficacy of ultrasound, magnetic resonance imaging (MRI), and PUSB was evaluated. The sensitivity, specificity, positive and negative predictive values, and accuracy were calculated as well. The consistency of these techniques with shoulder arthroscopy in diagnosing the RCT stage was additionally compared using Kappa test.

Results

In patients with large full-thickness RCT, the 100% detection rate was achieved by the techniques of ultrasound, MRI, and PUSB. For patients with small full-thickness RCT, the detection rate of PUSB (100%) was evidently higher than those of ultrasound and MRI. Similar results were shown in the detection rates of patients with bursal-side partial-thickness RCT (90.5%) and articular-side partial-thickness RCT (86.9%). More importantly, the sensitivity, specificity, and accuracy of PUSB in patients with both full-thickness RCT and partial-thickness RCT were significantly better than those of ultrasound and MRI.

Conclusion

PUSB has a better efficacy in the detection of RCT than ultrasound and MRI, showing its feasibility as an important imaging method to evaluate the degree of RCT.

Comparing the Efficacy of Intra-articular Platelet-Rich Plasma and Corticosteroid Injections in the Management of Frozen Shoulder: A Randomized Controlled Trial

Introduction Periarthritis of the shoulder, or frozen shoulder (FS), is a common, painful, and disabling condition with varied treatment strategies. Intra-articular (IA) corticosteroid (CS) injections are a popular treatment option, but their efficacy is often temporary. Platelet-rich plasma (PRP) has emerged as an alternative therapy for adhesive capsulitis, but the literature on its effectiveness is limited. This study aimed to compare the efficacy of IA PRP and CS injections in managing FS. Methods In this prospective, randomized study, 68 patients who met the inclusion criteria were enrolled and randomized using a computer-generated table into two groups: Group 1 (IA PRP) received 4 ml PRP, and Group 2 (IA CS) received 2 ml (80 mg) of methylprednisolone acetate mixed with 2 ml normal saline (for a total of 4 ml) as a CS injection in the IA area of the shoulder. Outcome measures included pain; shoulder range of motion (ROM); the condensed version of the disabling conditions of the arm, shoulder, and hand (QuickDASH) score; and the shoulder pain and disability index (SPADI) score. Participants were monitored via follow-up for 24 weeks, with pain and function assessed at each evaluation using the visual analog scale (VAS) score, the SPADI score, and the QuickDASH score. Results The IA PRP injections demonstrated better long-term outcomes than the IA CS injections, significantly improving pain, shoulder ROM, and daily activity performance. After 24 weeks, the mean VAS score in the PRP and methylprednisolone acetate groups was 1.00 (1.0 to 1.0) and 2.00 (2.0 to 2.0), respectively (P≤0.001). The mean QuickDASH score was 41.83 ± 6.33 in the PRP group and 48.76 ± 5.08 in the methylprednisolone acetate group (P≤0.001). The mean SPADI score was 53.32 ± 7.49 in the PRP group and 59.24 ± 5.80 in the methylprednisolone acetate group (P≤0.001), indicating a significant improvement in the PRP group's pain and disability scores after 24 weeks. The rate of complications was similar between the two groups. Conclusions Our findings suggest that IA PRP injections provide better long-term results than IA CS injections for managing FS. Platelet-rich plasma can be used as a treatment modality for better outcomes, particularly when the patient is contraindicated or refuses CS treatment. Further research is needed to evaluate the efficacy of these treatment modalities at different stages of FS and explore the potential benefits of ultrasound-guided injections.

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

Background and Aims

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

Material and Methods

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

Results

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

Conclusion

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

Effect of Functional Scapular Stabilization Training on Function and Pain in Frozen Shoulder Syndrome: A Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to determine the effect of functional scapular stabilization training compared with the standard physical therapy on function and pain in people with frozen shoulder syndrome (FSS).

METHODS

In a single-blind randomized controlled trial, 86 people with FSS were randomly allocated into the intervention group (functional stabilization training [n = 43]) and control group (standard physical therapy [n = 43]) using block randomization for 12 weeks. The primary outcome measures were the Shoulder Pain and Disability Index and the numeric pain rating scale. The secondary outcome measures were range of motion (ROM), range of passive abduction, and coracoid pain test. All the outcome measures were carried out by an independent blind outcome assessor at baseline and at the end of 12 weeks.

RESULTS

A significant group × time interaction effect was observed for the Shoulder Pain and Disability Index (95% CI, 2.95-16.74; P < .01) and the numeric pain rating scale (95% CI, 0.67-2.07; P < .01) at the end of 12 weeks. The external rotation ROM showed a statistical significance with a mean change of 7.8° and P value of <.01.

CONCLUSION

The present findings show that scapular functional stabilization training resulted in improvement of function, reduction in pain, and greater improvement in external rotation ROM in patients with FSS. Also, our study findings suggest the involvement of rotator interval and inferior soft-tissue structures as indicated by the coracoid pain test and range of passive abduction.

A Case Series: Effect of Comorbidities on the Outcomes of Prolotherapy Injection for Frozen Shoulder Patients

Frozen shoulder (FS) is a disease caused by an inflammatory condition that causes severe pain and decreased range of motion by loss of glenohumeral mobility. Frozen Shoulder restricts daily life's functional aspect, increasing morbidity. Hypertension and diabetes mellitus are risk factors that make an FS poor prognosis during treatment because of the diabetes glycation process and hypertension-enhanced vascularization. Prolotherapy injects an irritant solution into the tendon, joints, ligaments, and joint spaces to release growth factors and collagen deposition, reducing pain, restoring joint stability, and increasing the quality of life. We report 3 cases of patients with confirmed FS. Patient A with no comorbidity, patient B with diabetes mellitus, and patient C with hypertension, with all patient's chief complaints of shoulder pain and limited ROM, and symptoms affected the general quality of daily life. This patient was provided injection with Prolotherapy treatment combined with physical therapy intervention. Patient A had significantly improved ROM to maximum after 6 weeks with relieved pain and improved shoulder function. Patients B and C showed increased ROM, still tiny, decreased pain, and improved shoulder function. In conclusion, prolotherapy demonstrated a beneficial effect in a patient with FS with comorbidities, although not to the maximum extent in patients without comorbidity.

Role of Platelet-Rich Plasma in the Treatment of Adhesive Capsulitis: A Prospective Cohort Study

Background

A glenohumeral (GH) joint disease, such as adhesive capsulitis, causes the shoulder capsule's fibrosis and adhesion to restrict mobility. Collagen and growth factors can be produced by platelet-rich plasma (PRP), which promotes stem cells and, as a result, improves the healing process. This study was done to determine the role of PRP injection in the treatment of adhesive capsulitis in terms of improvement in pain.

Methodology

This prospective cohort study was conducted at the Department of Orthopedics, Mayo Hospital, Lahore, Pakistan, from February 2022 to July 2022. A total of 305 patients were enrolled through the outpatient department. Basic demographic and clinical details, including the visual analog scale (VAS) pain score, were noted. First, 20 ml of the patient’s blood was drawn from the superficial saphenous vein by double syringe. After processing, the PRP was collected and injected in the subacromial bursa and intra-articular space adopting the anatomical approach. Then, the process was repeated at weekly intervals for four weeks. In this phase, PRP was injected only in the joint. The pain was assessed before and after six weeks of treatment and improvement in pain as per VAS was noted.

Results

In a total of 305 cases, the mean age was 60.47±11.55 years. There were 164 (53.8%) male and 141 (46.2%) female cases. The mean pain VAS scores before and after treatment were 6.56±1.79 and 2.42±1.71, respectively, and the mean reduction in pain after treatment was 64.57±19.40%. In 267 (87.5%) cases, an improvement of ≥ 50% was observed while 38 (12.5%) cases had an improvement of <50%.

Conclusion

The PRP can be used for the treatment of adhesive capsulitis to reduce pain. This non-operative method of treatment may help reduce the hospital burden of patients suffering from adhesive capsulitis.

A retrospective study of ultrasound-guided intervention for frozen shoulder in the frozen stage

Background

To investigate the clinical value of ultrasound (US)-guided intervention for frozen shoulder (FS) in the frozen stage.

Methods

This study included 40 patients who had primary FS in the frozen stage and were evaluated by US. These 40 patients have all received conservative treatment elsewhere, and no satisfactory results have been achieved, with no improvement in active and passive movement angles, and no improvement in scores within 3 months. Therefore, their previous treatment was set as comparison. All patients underwent US-guided shoulder joint capsule distension by injection of sterilized water. Of these participants, 22 patients with scapulohumeral periarthritis received a compound betamethasone injection, and 14 patients with thickened coracohumeral ligaments (CHLs) underwent acupotomy lysis, and the remaining 4 patients had no extra treatments. The Constant-Murley score (CMS) was evaluated before and after the operation and analysed for each patient.

Results

Before treatment, the indices for the thickening of the subaxillary joint capsule, subacromial bursa (with or without effusion), long head of the biceps brachii tendon (LHBBT) and CHL were 40, 22, 16 and 14, respectively. After treatment, all the indices were significantly decreased (all P < 0.010) except for that of the LHBBT (P = 0.123). The patients' CMSs improved, with the median total CMS increasing from 59 points (interquartile range: 53–64 points) to 86 points (interquartile range: 78–90 points) (P < 0.010). While the internal rotation (Ir) of the shoulder joint did not improve (FDRs < 0.50), abduction, forward flexion (Ff) and external rotation (Er) improved significantly (all FDRs = 1.00).

Conclusion

Compared with conservative treatment, US-guided intervention for FS in the frozen stage is highly effective and of great clinical value.

Trends in Practice Among Shoulder Specialists in the Management of Frozen Shoulder: A Consensus Survey

Background:

The management of frozen shoulder (FS) differs depending on experience level and variation between scientific guidelines and actual practice.

Purpose:

To determine the current trends and practices in the management of FS among shoulder specialists and compare them with senior shoulder specialists.

Study Design:

Consensus statement.

Methods:

A team of 15 senior shoulder specialists (faculty group) prepared a questionnaire comprising 26 questions regarding the definition, terminology, clinical signs, investigations, management, and prognosis of FS. The questionnaire was mailed to all the registered shoulder specialists of Shoulder and Elbow Society, India (SESI) (specialist group; n = 230), as well as to the faculty group (n = 15). The responses of the 2 groups were compared, and levels of consensus were determined: strong (>75%), broad (60%-74.9%), inconclusive (40%-59.9%), or disagreement (<40%).

Result:

Overall, 142 of the 230 participants in the specialist group and all 15 participants in the faculty group responded to the survey. Both groups strongly agreed that plain radiographs are required to rule out a secondary cause of FS, routine magnetic resonance imaging is not indicated to confirm FS, nonsteroidal anti-inflammatory drugs should be administered at bedtime, steroid injection (triamcinolone or methylprednisolone) is the next best option if analgesics fail to provide pain relief, passive physical therapy should be avoided in the freezing phase, <10% of patients would require any surgical intervention, and patients with diabetes and thyroid dysfunction tend to fare poorly. There was broad agreement that routine thyroid dysfunction screening is unnecessary for women, a single 40-mg steroid injection via intra-articular route is preferred, and arthroscopic capsular release (ACR) results in a better outcome than manipulation under anesthesia (MUA). Agreement was inconclusive regarding the use of combined random blood sugar (RBS) and glycosylated hemoglobin versus lone RBS to screen for diabetes in patients with FS, preference of ACR versus MUA to treat resistant FS, and the timing of surgical intervention. There was disagreement over the most appropriate term for FS, the preferred physical therapy modality for pain relief, the most important movement restriction for early diagnosis of FS, and complications seen after MUA.

Conclusion:

This survey summarized the trend in prevalent practices regarding FS among the shoulder specialists and senior shoulder surgeons of SESI.

The Effect of Manipulation Under Anesthesia for Secondary Frozen Shoulder: A Randomized Controlled Trial

INTRODUCTION

Manipulation under anesthesia (MUA) is often used for frozen shoulder treatment, but controversy still exists regarding MUA compared with conservative treatment. This research was conducted to compare the outcome between MUA and celecoxib (CLX) in secondary frozen shoulder.

METHODS

Patients with secondary frozen shoulder were randomized into two groups, an MUA plus exercise (EX) group and a CLX plus EX group. Clinical outcomes were documented at baseline and at 1 day, 2, 4, and 12 weeks after intervention, including Constant-Murley Score (CMS) for function, Pain Rating Index (PRI) and Present Pain Intensity (PPI) for pain, passive range of motion (ROM) measurements including external rotation, internal rotation, forward flexion, and abduction. Primary outcome was CMS. Secondary outcomes were PRI, PPI, and passive ROM.

RESULTS

Sixty-seven patients out of 68 in the MUA group and 66 out of 68 in the CLX group finished the entire study period. There were no significant differences in basic properties of the two groups before intervention. As the primary outcome, CMS changes in the MUA group improved faster than the CLX group. Secondary outcomes, passive ROM, and pain PPI were faster and significant in the MUA group from 1 day after intervention compared with CLX (P < 0.05). At 12 weeks, a statistically significant difference was not observed in the PPI (P > 0.05). A statistically significant difference was not observed in the PRI between groups in 1 day (P > 0.05). For the primary outcome, from 0 to 12 weeks the mean changes in CMS were 44.00 for MUA plus EX (95% CI 43.07-44.93, P < 0.001) and 27.09 for CLX plus EX (26.20-27.98, P < 0.001). The significant difference in improvement appeared from 2 weeks.

CONCLUSION

To treat secondary frozen shoulder with MUA, this treatment could achieve better therapeutic effects on improvement of function, pain, and passive ROM than CLX did.

CLINICAL TRIAL REGISTRATION

The trial was registered at www.chictr.org.cn , identifier ChiCTR2200060269.

Comparison of the Efficacy of Platelet-Rich Plasma (PRP) and Local Corticosteroid Injection in Periarthritis Shoulder: A Prospective, Randomized, Open, Blinded End-Point (PROBE) Study

Background

Periarthritis or frozen shoulder, also called adhesive capsulitis, is characterized by stiffness and pain along with gradual loss of active and passive movement in the glenohumeral joint. More than 2-5% of the population suffers from periarthritis with a higher incidence in the age group of 40-60 years. The various treatment modalities used for its management include simple physiotherapy, short-wave therapy, ultrasonic therapy, transcutaneous electrical nerve stimulation, hydrotherapy, analgesics, intra-articular injections, manipulation under general anesthesia (MUA), and surgical management. The application of intra-articular steroid injection has been a common and efficacious option in rapidly diminishing shoulder pain and disability. Some recent studies reported a better outcome using platelet-rich plasma (PRP) injections in frozen shoulder cases. Hence, this randomized controlled trial was conducted to compare the efficacy of intra-articular injections of PRP and triamcinolone in patients of shoulder periarthritis in a population from the eastern region of India

Methodology

A total of 60 patients with periarthritis shoulder were allocated into two groups after randomization. Group A received 2 mL autologous PRP, and Group B received 2 mL of triamcinolone (40 mg/mL) intra-articular injection. Patients were followed up on the 4th week, 12th week, and 24th week. The assessment of pain and function using the visual analog scale (VAS) score and the Disabilities of Arm, Shoulder, and Hand (DASH) score, respectively, was done at each follow-up. The primary analyses of both primary and secondary outcomes were conducted in the intention-to-treat (ITT) population. SPSS version 24 (IBM Corp., Armonk, NY, USA) was used for data analysis.

Results

The mean VAS score in the PRP and triamcinolone groups was 14.33 ± 3.79 and 31.63 ± 7.62, respectively (p = 0.0001) after 24 weeks. The mean DASH score in the PRP and triamcinolone groups was 18.08 ± 8.08 and 31.76 ± 3.63, respectively (p = 0.0001), which shows significant improvement in both pain and disability scores in the PRP group after 24 weeks.

Conclusions

The triamcinolone group showed better short-term outcomes whereas PRP showed better long-term outcomes in reducing pain and disability scores in terms of VAS and DASH scores.

Effect of manipulation technique using ultrasound-guided cervical nerve root block on range of motion at the shoulder joint in frozen shoulder: a retrospective study

Purpose

The aim of this study was to evaluate the range of motion (ROM) at the shoulder joint before and after silent manipulation.

Methods

This retrospective study included all patients who underwent silent manipulation at our institution between January 2013 and December 2017. In total, 1,665 shoulders in 1,610 patients (519 men, 1,146 women; mean age 55.4 ± 8.8 years) were treated during the study period. The mean symptom duration was 6.6 ± 7.1 months. ROM at the shoulder joint was measured in flexion, abduction, and external rotation before silent manipulation and at 1 week and 1, 2, and 3 months after the procedure.

Results

Mean ROM at the shoulder was 98.8° (95% confidence interval [CI] 97.9–99.8) before silent manipulation and 155.5° (154.1–156.8) after 3 months in flexion (p = 0.0000), 75.6° (74.5–76.8) and 152.9° (151.0–154.9), respectively, in abduction (p = 0.0000), and 12.7° (12.0–13.4) and 45.9° (44.4–47.4) in external rotation (p = 0.0000). All ROM values were significantly increased at all time points after the procedure. There were no unanticipated adverse events or serious adverse reactions.

Conclusions

This study reports on the efficacy and safety of manipulation using conduction anesthesia for shoulder contractures in a large group of patients. Silent manipulation can increase ROM at the shoulder safely and effectively.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40634-022-00500-z.

Risk Factors for the Onset of Frozen Shoulder in Middle-Aged and Elderly Subjects Within 1 Year of Discharge From a Hospitalization That Involved Intravenous Infusion: A Prospective Cohort Study

AIM

To investigate the incidence of frozen shoulder and risk factors for the onset of frozen shoulder in middle-aged and elderly subjects within 1 year of discharge from a hospitalization that involved intravenous infusion in Zhangjiagang Second People's Hospital.

METHODS

A total of 1,900 subjects who were discharged from a hospitalization that involved intravenous infusion in the hospital between May 2020 and September 2020 met the inclusion criteria for this study: 950 subjects had a mean daily duration of intravenous infusion ≤ 2 h (low exposure) and 950 subjects had a mean daily duration of intravenous infusion ≥3 h (high exposure). Subjects were followed up by telephone at 6 months ± 1 week and 12 months ± 1 week after discharge the incidence of frozen shoulder.

RESULTS

The cumulative incidence rate of frozen shoulder within 1 year of discharge was 5.2%. Multivariate logistic regression analysis revealed the risk of frozen shoulder was higher in subjects with a mean daily duration of intravenous infusion ≥3 h compared to ≤ 2 h (OR = 3.082, 95% CI 1.919-4.949, P < 0.001); subjects hospitalized for 11-30 days had a higher risk of frozen shoulder compared to those hospitalized for 10 days or less (OR = 6.836, 95%CI 4.363-10.709, P < 0.001); subjects who were overweight/ obese (BMI ≥ 25 kg/m²) had a higher risk of frozen shoulder compared to those of normal weight (BMI 18.5-24.9 kg/m²) (OR = 2.166, 95%CI 1.376-3.410, P = 0.001); subjects in the 56-70-year-old age group had a higher risk of developing frozen shoulder compared to those in the 40-55-year-old age group (OR = 1.977, 95%CI 1.154-3.387, P = 0.013); diabetes increased the risk of frozen shoulder (OR = 3.009, 95%CI 1.826-4.959, P < 0.001). The 71-85 years old age group and hypertension were statistically significant in univariate analysis but not in multivariate analysis (P > 0.05).

CONCLUSION

Compared with middle-aged and elderly in the general population, middle-aged and elderly subjects who received intravenous infusion during a hospitalization had a higher cumulative incidence rate of frozen shoulder within 1 year after discharge. Independent risk factors for the onset of frozen shoulder included mean daily duration of intravenous infusion ≥3 h, length of hospital stay 11-30 days, BMI ≥ 25 kg/m², age 56-70 years, and diabetes.

Surgical versus Nonsurgical Multimodality Treatment in an Idiopathic Frozen Shoulder: A Retrospective Study of Clinical and Functional Outcomes

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.

MR Imaging Biomarkers for Clinical Impairment and Disease Progression in Patients with Shoulder Adhesive Capsulitis: A Prospective Study

BACKGROUND

MRI diagnostic criteria of shoulder adhesive capsulitis (AC) are nowadays widely used, but there is little information available on the association between MRI findings and clinical impairment.

PURPOSE

To determine the correlation of MRI findings with the Constant-Murley Score (CMS), pain duration and symptoms at the one-year follow-up in AC patients.

MATERIALS AND METHODS

This monocentric prospective study included 132 patients with a clinical diagnosis of shoulder AC who underwent shoulder MRI. Mean patient age was 54.1 ± 9.3 years, and there were 55 men and 77 women. A radiologist examined all patients and completed the CMS just prior to MRI. Pain duration was assessed along with the signal intensity and measured the maximal thickness of the inferior glenohumeral ligament (IGHL) by two radiologists. Medical record analysis was performed in a sub-group of 49 patients to assess prognosis approximately one year after the MRI examination. Linear regression analysis with the Pearson test and the Fisher exact test were used to determine the association between MRI findings and clinical impairment.

RESULTS

There was a significant difference in mean pain duration score (3.8 ± 1.2 versus 3.2 ± 0.9 and 3.8 ± 1.2 versus 3.2 ± 0.9, respectively, for readers 1 and 2) and in mean mobility scores (15.7 ± 8 points versus 19.6 ± 10.1 points and 15.8 ± 8.2 points versus 19.4 ± 10 points, respectively, for readers 1 and 2) in patients with a high IGHL signal compared to those with a low IGHL signal (p < 0.05). IGHL was thicker in patients with clinical improvement at one-year follow-up compared to those presenting clinical stability or worsening (p < 0.05).

CONCLUSIONS

In patients with shoulder AC, the degree of signal intensity at the IGHL was inversely related to shoulder pain duration and range of motion, and a thickened IGHL indicated a favorable outcome at one-year follow-up.