Adhesive capsulitis of the shoulder: arthrographic diagnosis and treatment

Voxel-based Three-dimensional Segmentation of the Capsulo-synovium from Contrast-enhanced MRI Can Represent Clinical Impairments in Adhesive Capsulitis

The purposes were to calculate total voxel volume of the entire capsulo-synovial enhanced portion on contrast-enhanced (CE) MRI in adhesive capsulitis, and to investigate its association with glenohumeral joint volume and passive range of motions (ROMs), which are a well-known diagnostic reference standard and clinical hallmark of this condition. Medical records of 169 consecutive patients who underwent ultrasound-guided intraarticular injection with adhesive capsulitis and CE-MRI to exclude other mimicking shoulder diseases were retrospectively reviewed. To calculate total voxel volume of entire capsulo-synovial enhanced portion on CE-MRI, voxel-based 3-dimensional (3D) segmentation was obtained semi-automatically using Fiji, an open-source image processing software. Pearson’s correlation coefficients were analyzed. Sixty patients who met eligibility criteria were included. Total voxel volume showed a significant inverse correlation with the glenohumeral joint volume (r = −0.528, P < 0.001), forward elevation, external rotation, and abduction (r = −0.407, P = 0.001; r = −0.342, P = 0.007; r = −0.275, P = 0.034, respectively). Intra-observer and inter-observer reliabilities, measured by intraclass correlation coefficients (ICC), were excellent (ICC = 0.87 and 0.77, respectively). This study’s results indicate that voxel-based 3D segmentation of entire capsulo-synovial enhanced portion from CE-MRI can represent the severity of clinical impairments, such as obliterated joint volume and limited passive ROMs in adhesive capsulitis.

Determination of magnetic resonance imaging criteria for diagnosis of adhesive capsulitis

The objective of this study was to identify optimal magnetic resonance imaging (MRI) parameters and their cutoff values for diagnosing adhesive capsulitis (AC). One hundred shoulder MRI images with stage 2 AC (AC group) and 100 MRI images without AC (control group) were randomly reviewed by two experienced shoulder specialists. They were asked whether MRI findings were compatible with AC and measurement of MRI parameters. Sensitivity, specificity, and accuracy were calculated. Correlation between MRI parameters and the range of motions was also analyzed. The mean capsular thickness in the axillary recess (AR) (5.9 mm in the AC group vs. 3.6 mm in the control group) on coronal oblique T2-weighted images and the rotator interval (RI) (7.2 mm vs. 4.8 mm, respectively) on oblique sagittal proton-density images were significantly greater in the AC group than in the control group, whereas the width of RI showed no significant difference between two groups. The highest diagnostic cutoff values were 4.5 mm for the AR and 6 mm for the RI, with sensitivity (91% and 88%, respectively), specificity (90% and 90%), and accuracy (90% and 89%). Capsular thickness in the AR and RI was significantly correlated with external rotation (P = 0.047) and internal rotation (P = 0.023). On conventional MRI, capsular thickness greater than 4.5 mm in the AR or 6 mm in the RI can be an optimal criterion for diagnosing AC. Capsular thickness in the AR and RI was correlated with the range of rotational motion.

Analysis of hydrodilatation as part of a combined service for stiff shoulder

BACKGROUND

Adhesive capsulitis is a common cause of stiff shoulder and may result in pain and restriction of movement. The study aimed to investigate the role of hydrodilatation of the glenohumeral joint in the management of adhesive capsulitis.

METHODS

Patients referred from the shoulder clinic underwent hydrodilatation under ultrasound guidance. Of 209 referred for hydrodilatation, 163 underwent the procedure and attended follow-up physiotherapy. Outcome measures were available for 118 patients (58 men and 60 women). Mean age of the study group was 52.6 years.

RESULTS

There was a statistically significant improvement in both Oxford Shoulder Score (OSS) and Disability Arm Shoulder Hand Scores (Quick DASH) in the first 4 weeks after the procedure, which was maintained but not improved to the end of the study period. Patients presenting with pain, those who had a history of steroid injections and older patients all had worse functional scores at presentation. Diabetes (both Type I and II), previous physiotherapy, length of history and whether pain or stiffness, or both, were the predominant symptom did not have any statistical significance at presentation. These factors were not predictors of any statistically significant improvement in functional scores.

CONCLUSIONS

Hydrodilatation results in a significant improvement of symptoms in patients with adhesive capsulitis.

CT arthrography of adhesive capsulitis of the shoulder: Are MR signs applicable?

OBJECTIVE

To determine if diagnostic signs of adhesive capsulitis (AC) of the shoulder at Magnetic Resonance Imaging (MRI) and arthrography (MRA) are applicable to CT arthrography (CTA).

METHODS

22 shoulder CTAs with AC were retrospectively reviewed for features described in MR literature. The control group was composed of 83 shoulder CTA divided into four subgroups 1) normal (N = 20), 2) omarthrosis (N = 19), 3) labral injury (N = 23), and 4) rotator cuff tear (N = 21). Two musculoskeletal radiologists assessed the rotator interval (RI) for obliteration, increased width and thickening of coracohumeral ligament (CHL). The width and capsule thickness of the axillary recess were measured.

RESULTS

The width of the axillary recess was significantly decreased in the AC group (4.6 ± 2.6 mm versus 9.9 ± 4.6 mm, p ≤ 0.0001; sensitivity and specificity of 84% and 80%). Thickness of the medial and lateral walls of the axillary capsule was significantly increased in the AC group (5.9 ± 1.3 mm versus 3.7 ± 1.1 mm, p ≤ 0.0001 and 5.7 ± 1 mm versus 3.5 ± 1.3 mm, p ≤ 0.0001, respectively). CHL thickness was significantly increased in the AC group (4.1 ± 1 mm (p ≤ 0.001)) in comparison to others groups. Obliteration of the RI was statistically significantly more frequent in patients with AC (72.7% (16/22) vs. 12% (10/83), p < 0.0001). Width of the RI did not differ significantly between patients and controls (p ≥ 0.428).

CONCLUSION

Decreased axillary width, and thickened axillary capsule are MR signs of AC applicable to CTA. Evaluation of rotator interval seems useful and reproducible only for obliteration.

Thawing frozen shoulder by steroid injection

BACKGROUND

Frozen shoulder is not an uncommon disorder, and steroid injection into the glenohumeral (GH) joint is one of the most well-known approaches for the frozen shoulder. However, their results have been varied with beneficial effects or no additional advantage. With the understanding about the pathological changes taking place in frozen shoulder and the biomechanics involved, we wanted to evaluate the short- and long-term efficacy of steroid injection by a novel three-site (NTS) injection technique and compare it with the single-site injection (SSI).

MATERIAL AND METHODS

This was a prospective study with 85 patients including all stages and randomized into two groups. SSI group received steroid injection through posterior approach. NTS group received the same dose of steroid in diluted doses at three sites (posterior capsule, subacromial and subcoracoid). Second sitting was repeated after 3 weeks. Both groups had received the same physiotherapy. The patients were evaluated by CONSTANT score at initial, 3 week, 6 week and 6 month.

RESULTS

NTS group patients had significant pain relief and early improvement in activities of daily living ( p < 0.005). Both groups had improvement in shoulder movements but with NTS group, early near-normal scores were attained and sustained after 6 months. About 43% in SSI group could not attain near-normal levels and had relapses.

CONCLUSION

The three-site approach to steroid instillation in frozen shoulder is a safe method and provides early recovery and better improvement in shoulder function with less relapses.

Metabolic patterns of the shoulder joint on (18)F-fluorodeoxyglucose positron emission tomography/computed tomography in adhesive capsulitis

OBJECTIVE

The purpose of our study was to demonstrate metabolic patterns on (18)F-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) in patients with adhesive capsulitis (AC).

METHODS

We retrospectively reviewed (18)F-FDG PET/CT performed on 22 shoulders of 21 patients diagnosed with AC: 2 shoulders with stage I, 14 with stage II, and 6 with stage III. A clinical diagnosis of AC was retrospectively made based on clinical examination, clinical course, and imaging. The pattern of radiotracer uptake was analyzed. Standardized uptake values in rotator interval (RI), anterior joint capsule (AJC), axillary recess (AR), and greater tuberosity were measured and compared to those of the contralateral side and the control group consisting of 40 shoulders in 20 subjects without shoulder pain.

RESULTS

Four patterns of uptake were noted: (1) glenoid type I (n = 16), with uptake in RI, AJC, and AR; (2) glenoid type II (n = 2),with uptake in AJC and AR; (3) glenoid type III (n = 2), with uptake in RI and AJC; (4) focal type (n = 2), with uptake in RI or AR. Affected side SUVmax for RI, AJC, and AR was significantly higher compared with the unaffected side and the control group. Two shoulders with stage I AC had patterns similar to the ones with stage II or III.

CONCLUSION

Specific patterns of (18)F-FDG uptake with dominant uptake in RI, AJC, or AR may be related to AC.

Correlation between magnetic resonance imaging and clinical impairment in patients with adhesive capsulitis

OBJECTIVE

To determine the relationship between clinical impairment and MRI findings in patients with adhesive capsulitis.

MATERIALS AND METHODS

Contrast-enhanced MRI of 97 patients with a clinical diagnosis of adhesive capsulitis (AC) were retrospectively reviewed. Specific MRI criteria, including thickness and gadolinium enhancement of the joint capsule in the axillary recess and subcoracoid fat obliteration in the rotator interval, were correlated with limited range of motion (ROM) and pain. Other variables considered in this study were rotator cuff pathology, arm dominance, diabetes mellitus, age, and gender. Statistical analysis was performed using logistic and linear regression analysis.

RESULTS

Thickening of the joint capsule in the axillary recess correlated with limited external rotation (p < 0.01), gender (p < 0.01) and arm dominance (p < 0.05). Gadolinium enhancement of the joint capsule in the axillary recess correlated with pain intensity (p < 0.05). Subcoracoid fat obliteration in the rotator interval was not correlated with limited ROM or pain.

CONCLUSIONS

MRI can be a useful technique to assess several clinical impairment measures in patients with adhesive capsulitis. Thickening and gadolinium enhancement of the joint capsule in the axillary recess on MRI are associated with limited ROM and pain.

QUANTITATIVE EVALUATION OF THE MOTION OF FROZEN SHOULDERS TREATED WITH ACUPUNCTURE BY PUNCTURING FROM TIAOKOU (ST. 38) TOWARDS CHENGSHAN (U.B. 57)

Frozen shoulder is one of the most commonly reported shoulder disorders in adults between 40 and 60 years of age with significant pain and loss of joint range of motion (ROM), resulting in huge impact on the activities of daily living. Treatment of frozen shoulders with drugs, physical therapy and surgery that dealt with adhesive tissues may come with complications. Therefore, acupuncture therapy has become an important alternative. Puncturing needles from Tiaokou (St. 38) towards Chengshan (U.B. 57) has been used as a treatment specifically for frozen shoulders. To this day, no study on the quantitative evaluation of the efficacy of the treatment has been found in the literature. A quantitative and objective method using video-based stereophotogrammery system was developed to evaluate the treatment efficacy of acupuncture by inserting needle from St. 38 to U.B. 57. It was found that the treatment increased significantly the humeral elevation ROM from 102.91 ° ± 24.82 ° before treatment to 111.25 ° ± 22 ° after, with a mean increase of 8.34 °. This finding confirms the teachings described in the classical Chinese medical literature and will be helpful for the planning and implementation of long-term studies on the treatment mechanism and efficacy of acupuncture in frozen shoulder.

Arthroscopic capsular release for refractory shoulder stiffness: a critical analysis of effectiveness in specific etiologies

HYPOTHESIS

The purpose of this study is to report and compare the outcome of arthroscopic capsular release in patients with shoulder stiffness with post-traumatic, postsurgical, and idiopathic etiologies. We hypothesize that patients with idiopathic or post-traumatic stiffness have better outcomes after arthroscopic capsular release than those with shoulder stiffness with a postsurgical etiology.

MATERIALS AND METHODS

A retrospective review of 115 patients who underwent arthroscopic capsular release for refractory shoulder stiffness was performed. There were 60 men and 55 women with a mean age of 49 years (range, 27 to 81 years). The patients were divided into 3 groups according to the etiology of stiffness: post-traumatic (26 patients), postsurgical (48 patients), and idiopathic (41 patients). Arthroscopic capsular release was performed in all patients after a mean of 9 months of physical therapy (range, 6 to 13 months).

RESULTS

At a mean follow-up of 46 months (range, 25 to 89 months), the overall subjective shoulder value in all groups improved from 29% to 73% and the age- and gender-adjusted Constant score improved from 35% to 86%. The mean pain score decreased from 7.5 to 1, and mean active forward flexion, external rotation, and internal rotation increased from 97 degrees , 14 degrees , and the L5 vertebral level, respectively, to 135 degrees , 38 degrees , and the T11 vertebral level, respectively (P < .0001). There was no significant difference between the outcomes of idiopathic and post-traumatic stiffness (P = .7). However, the Constant score and subjective shoulder value were significantly lower in the postsurgical group compared with the idiopathic and post-traumatic groups (P = .0001 and P = .006, respectively).

CONCLUSIONS

Arthroscopic capsular release is an effective treatment for refractory shoulder stiffness. Patients with idiopathic and post-traumatic shoulder stiffness have better outcomes than patients with postsurgical stiffness.

Shoulder kinematic features using arm elevation and rotation tests for classifying patients with frozen shoulder syndrome who respond to physical therapy

Physical therapy is an intervention commonly used in the treatment of subjects with frozen shoulder symptoms, with limited proven effect. The purpose of this study was to identify the kinematic features of patients with frozen shoulder who are more likely to respond to physical therapy. Thirty-four subjects presenting frozen shoulder syndrome were studied to determine altered shoulder kinematics and functional disability. Subjects received the same standardized treatment with passive mobilization/stretching techniques, physical modalities (i.e. ultrasound, shortwave diathermy and/or electrotherapy) and active exercises twice a week for 3 months. Initially, subjects were asked to perform full active motion in 3 tests: abduction in the scapular plane, hand-to-neck and hand-to-scapula. During the test, shoulder kinematics were measured using a 3-D electromagnetic motion-capturing system. In the initial and follow-up sessions, the self-reported Flexilevel Scale of Shoulder Function (FLEX-SF) was used to determine functional disability from symptoms. Improvement with treatment was determined using percent change in FLEX-SF scores over three months of treatment [(final score-initial score)/initial score x 100, >20% improvement and < = 20% nonimprovement]. Shoulder kinematics were first analysed for univariate accuracy in predicting improvement and then combined into a multivariate prediction method. A prediction method with two variables (scapular tipping >8.4 degrees during arm elevation, and external rotation >38.9 degrees during hand to neck) were identified. The presence of these two variables (positive likelihood ratio=15.71) increased the probability of improvement with treatment from 41% to 92%. It appears that shoulder kinematics may predict improvement in subjects with frozen shoulder syndrome. Prospective validation of the proposed prediction method is warranted.

Diagnosis and management of adhesive capsulitis

Adhesive capsulitis is a musculoskeletal condition that has a disabling capability. This review discusses the diagnosis and both operative and nonoperative management of this shoulder condition that causes significant morbidity. Issues related to medications, rehabilitation, and post surgical considerations are discussed.

Magnetic resonance imaging of adhesive capsulitis: correlation with clinical staging

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

Alterations in scapular kinematics in subjects with idiopathic loss of shoulder range of motion

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To determine the effect of idiopathic loss of shoulder range of motion on scapular kinematics.

BACKGROUND

Subjects with idiopathic loss of shoulder range of motion have difficulty performing activities of daily living. Previous investigations have focused on the glenohumeral component of shoulder complex motion.

MATERIALS AND METHODS

Seventeen unilaterally impaired and 17 nonimpaired subjects. The 3-dimensional motion of the humerus, scapula, and trunk were measured withthe Fastrak electromagnetic motion-tracking system during humerus-to-trunk scapular plane elevation. An analysis of variance compared the impaired subjects noninvolved to the nonimpaired subjects' scapulae at 4 scapularplane elevation positions. A repeated-measures analysis of variance compared the impaired subjects' involved and noninvolved scapulae at 3 scapular plane elevation positions, and matched-pairs t test compared peak elevation values.

RESULTS

The between-group ANOVAs demonstrated no difference in anterior tipping, internal rotation, or upward rotation. The repeated-measures ANOVAs demonstrated no difference in anterior tipping or internal rotation and a position-by-side interaction in upward rotation. The involved-side scapulae were more upwardly rotated (7.7 degrees) at peak humerus-to-trunk scapular plane elevation.

DISCUSSION AND CONCLUSION

The impaired subjects' noninvolved scapular kinematics were not significantly different than the nonimpaired subjects, but were significantly different than their involved scapulae. The upward rotation differences may be a substitution pattern used to accomplish functional elevation.

Arthrographic joint distension with saline and steroid improves function and reduces pain in patients with painful stiff shoulder: results of a randomised, double blind, placebo controlled trial

OBJECTIVE

To determine whether arthrographic distension with a mixture of saline and steroid, in patients with painful stiff shoulder for at least 3 months, is better than placebo in improving function, pain, and range of motion at 3, 6, and 12 weeks.

METHODS

A randomised, placebo controlled trial with participant and outcome assessor blinding in which shoulder joint distension with normal saline and corticosteroid was compared with placebo (arthrogram). Outcome measures, assessed at 3, 6, and 12 weeks, included a shoulder-specific disability measure (SPADI), a patient preference measure (Problem Elicitation Technique (PET)), pain, and range of active motion.

RESULTS

From 96 potential participants, 48 were recruited. Four withdrew from the placebo group after the 3 week assessment and three subsequently received arthrographic distension with saline and steroid. At 3 weeks, significantly greater improvement in SPADI (p = 0.005), PET, overall pain, active total shoulder abduction, and hand behind back was found in participants in the joint distension and steroid group than in the placebo group. At 6 weeks the results of the intention to treat analysis favoured joint distension, although the between-group differences were only significant for improvement in PET (difference in mean change in PET between groups = 45.9 (95% CI 3.2 to 88.7). Excluding the four withdrawals, the between-group differences for the disability and pain measures significantly favoured distension over placebo. At 12 weeks, both the intention to treat analysis and an analysis excluding the four withdrawals demonstrated a significantly greater improvement in PET score for the distension group.

CONCLUSIONS

Short term efficacy of arthrographic distension with normal saline and corticosteroid over placebo was demonstrated in patients with painful stiff shoulder.

Adhesive Capsulitis of the Shoulder

OBJECTIVE

The purpose of this study was to assess the usefulness of magnetic resonance (MR) arthrography of the glenohumeral joint in the diagnosis of adhesive capsulitis.

METHODS

MR arthrography of the glenohumeral joint was performed in 16 patients with arthroscopically proven adhesive capsulitis and 11 controls. Thickness of the joint capsule and synovium, filling ratio of the fluid-distended axillary recess to the posterior joint cavity, and a width of the rotator cuff interval were measured by 2 musculoskeletal radiologists. The measurements of those parameters for the patients with adhesive capsulitis and the controls were compared. Interobserver variability for the measurements of each parameter was calculated.

RESULTS

The mean thickness of the joint capsule and synovium was 2.97 mm in patients with adhesive capsulitis and 1.86 mm in controls (P < 0.001). The mean filling ratio of the fluid-distended axillary to the posterior joint cavity was 0.51 in patients with adhesive capsulitis and 0.82 in controls (P = 0.004). The mean width of the rotator cuff interval was 7.45 mm in patients with adhesive capsulitis and 8.48 mm in controls (P > 0.05). Intraclass correlation coefficient for interobserver variability showed good agreement (95% CI; 0.72-0.95).

CONCLUSIONS

On MR arthrography, thickening of the joint capsule and synovium and diminished filling ratio of the axillary recess to posterior joint cavity appeared to be useful diagnostic criteria for the diagnosis of adhesive capsulitis of the shoulder.

Shoulder kinematics in subjects with frozen shoulder11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVES

To describe 3-dimensional humeral motion in subjects with frozen shoulder and to determine whether a consistent capsular pattern of restriction was present.

DESIGN

Descriptive study including repeated measurements of shoulder kinematics.

SETTING

Motion-analysis laboratory.

PARTICIPANTS

Ten (9 women, 1 man) volunteers with a diagnosis of idiopathic adhesive capsulitis and 10 (9 women, 1 man) subjects with asymptomatic shoulders as comparison subjects.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Electromagnetic tracking sensors monitored the 3-dimensional position of the trunk, scapula, and humerus throughout active shoulder motions. Peak humeral positions relative to the trunk and scapula were determined for shoulder flexion, abduction, scapular plane abduction, external rotation (ER), and internal rotation (IR). Descriptive statistics (means, standard deviations, percentage of normal) were calculated and capsular patterns described.

RESULTS

For humeral position relative to the trunk, subjects' mean peak motion was as follows: abduction, 98.4 degrees; ER at the side, 4.5 degrees; ER with the arm abducted, 33.5 degrees; flexion, 116.9 degrees; IR at the side, 54.3 degrees; IR with the arm abducted, 17.8 degrees; and scapular plane abduction, 113.4 degrees. For humeral position relative to the scapula, subjects' mean peak motion was as follows: abduction, 46.4 degrees; ER at the side, 34.7 degrees; ER with the arm abducted, 45.3 degrees; flexion, 70.5 degrees; IR at the side, 10.3 degrees; IR with the arm abducted, -6.4 degrees; and scapular plane abduction, 61.7 degrees.

CONCLUSIONS

Symptomatic subjects demonstrated substantial kinematic deficits during humeral range of motion. No single capsular pattern emerged.

Arthroscopic treatment of shoulder stiffness

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

Addressing glenohumeral stiffness while treating the painful and stiff shoulder arthroscopically

The shoulder can be primarily or secondarily stiff. Cadaveric cutting studies have shown increases in passive range of glenohumeral motion when certain portions of the capsule are released. This study has recorded the intraoperative gains made in passive range of motion for external rotation, flexion, abduction, and internal rotation with sequential release of the rotator interval, inferior capsule, and posterosuperior capsule, regardless of initial etiology, and followed-up over time. Thirty one of 60 shoulders, found clinically to have a loss of passive range of motion and having failed a nonoperative approach, underwent a capsular release. Eighteen patients underwent a partial capsular release (group 1) and 13 patients (group 2) underwent a complete capsular release. Thirty of 31 shoulders had statistically significant gains in passive range of motion with sequential release. In general, resection of the rotator interval contributed to gains in external rotation; resection of the inferior capsule (anteroinferior and posteroinferior) contributed gains to external rotation, forward flexion, and internal rotation; and resection of the posterosuperior capsule contributed to gains only in internal rotation. At a minimum of 18 months follow-up, 30 of 31 shoulders retained their intraoperative gains. There was no difference in the results between primarily and secondarily stiff shoulders for motion gains (P >.05). Arthroscopically addressing capsular tightness is beneficial in returning shoulders with a loss of passive glenohumeral motion to normal regardless of the etiology.

Frozen shoulder: a 12-month clinical outcome trial

A prospective study was undertaken of 73 patients with frozen shoulder syndrome who were treated with an arthroscopic capsulotomy. All of the patients were assessed for pain, function, and range of motion before surgery and were monitored through to 1-year follow up. Improvement in all parameters was achieved, with pain taking an average of 2.24 weeks to diminish and range of motion improving to within 10% of the other side at an average of 5.5 weeks after surgery. Patients were discharged with a full range of motion and without pain at an average of 8.9 weeks. There was, however, some mild reaggravation of most patients' pain within the postoperative period (mean 4.5 weeks). This pain usually settled with appropriate massage within a 2-week period. In 37% of cases, however, an injection of corticosteroid was required as part of the postoperative management. These cases were usually in that subgroup of patients who still had significant night pain and were in stage 2 or 3 of the disease process at the time of surgery. The postoperative results continued to the 12-month follow-up, with 11% of patients having a recurrence of pain or stiffness. This study has demonstrated that arthroscopic capsulotomy is an effective technique in the management of the frozen shoulder. It also has enabled the authors to document postoperative recovery times, which has given prospective patients realistic time frames of functional expectation in their postoperative recovery.

Long-term effectiveness of translational manipulation for adhesive capsulitis

Long term effects of glenohumeral joint translational (gliding) manipulation on range of motion, pain, and function in patients with adhesive capsulitis were studied. Thirty-one patients underwent brachial plexus block followed by translational manipulation of the glenohumeral joint. Changes in range of motion and pain were assessed before manipulation with the patient under anesthesia, immediately after manipulation with the patient still under anesthesia, at early followup (5.3 +/- 3.2 weeks), and at long term followup (14.4 +/- 7.3 months). Passive range of motion increased significantly for flexion, abduction, external rotation, and internal rotation. Significant decreases in visual analog pain scores between initial evaluation and the followup assessments also occurred. Furthermore, Wolfgang's criteria score increased significantly between initial evaluation and followup assessments. Translational manipulation provides a safe, effective treatment option for adhesive capsulitis.

A profile of patients with adhesive capsulitis

The purpose of this descriptive study is to develop a profile of patients with adhesive capsulitis and to describe the patients' perceived clinical progression. A total of 32 patients diagnosed with adhesive capsulitis and 31 control subject completed anonymous questionnaires designed to elicit demographic data as well as medical information. The adhesive capsulitis and control samples were selected from the same facilities in an effort to reduce bias. Data comparing the adhesive capsulitis group with the control group was analyzed using the Odds Ratio and Taylor Series Confidence Interval for Odds Ratio. Twenty-seven patients (84.4%) diagnosed with adhesive capsulitis fell within the age range of 40-59 years. Diabetes and heart disease appeared to be more prevalent in patients diagnosed with adhesive capsulitis as compared with the control group and general population. The majority of patients with adhesive capsulitis (90.6%) reported a perceived clinical progression that started with a pattern of pain followed by loss of motion. Age and concomitant medical conditions appeared to be most correlated with the occurrence of adhesive capsulitis. Possible reasons for the prevalence of diabetes and heart disease in adhesive capsulitis patients are discussed.

Arthroscopic capsular release for the stiff shoulder. Description of technique and anatomic considerations

The anatomic proximity of several neurovascular structures remains a major concern to the surgeon interested in performing arthroscopic capsular release. We evaluated the anatomic relationships between the released capsule and the axillary nerve, posterior circumflex humeral artery, and brachial artery in a frozen cadaveric model. With the aid of electrocautery, seven cadaveric shoulders underwent complete arthroscopic capsular release. The release was performed circumferentially, approximately 1 cm lateral to the glenoid rim. All shoulders were subsequently frozen and sectioned through the plane of the capsular release while the shoulder was maintained in the lateral arthroscopic position (45 degrees of abduction and 20 degrees of flexion). Anatomic dissection revealed an average distance from the capsular release to the axillary nerve of 7.04 mm (95% confidence interval, 5.62, 8.47), to the posterior circumflex humeral artery of 8.2 mm (95% confidence interval, 6.41, 9.99), and to the brachial artery of 15.97 mm (95% confidence interval, 9.85, 22.09). As the axillary nerve was followed medially from the released capsule, the inferior border of the subscapularis muscle became interposed between the capsule and the axillary nerve. This limited anatomic study shows that a relatively safe margin between the capsule and the neighboring neurovascular structures can be obtained by releasing the capsule within 1 cm of the glenoid rim.

Thawing the frozen shoulder: the "patient" patient

Many different modalities have been advocated for the treatment of frozen shoulder (adhesive capsulitis), some of which can be associated with complications and morbidity. We retrospectively reviewed 50 patients with adhesive capsulitis treated by the senior author over a 10-year period. Treatment consisted of closely monitored home therapy using moist heat and antiinflammatory medication, and a physician-directed rehabilitation program. Without exception, every patient regained a significant amount of motion and returned to activities of daily living without pain.

Glenohumeral gliding manipulation following interscalene brachial plexus block in patients with adhesive capsulitis

Previous studies describing nonconservative treatment of shoulder adhesive capsulitis include distention arthrography, brisement techniques, arthrotomy of the anterior/inferior axillary fold and subscapularis tendon, and manipulation under general anesthesia. The purpose of this study was to develop and describe an alternative treatment method that utilizes glide manipulation under interscalene brachial plexus block. Eight patients (four females and four males), age 31-55 years, with a mean age of 44 years, were treated conservatively for adhesive capsulitis of the shoulder and failed to produce increased measurable objective active or passive ranges of motion. Symptoms of adhesive capsulitis in these patients range from 3 to 16 months, 7 months average. Premanipulation treatment ranged from 1 to 21 weeks, with an average of 9 weeks. Two additional patients were considered for manipulation after a trial of conservative treatment, but the interscalene brachial plexus block and manipulation were not performed. One patient was eliminated from the study due to excessive osteoarthritis in the shoulder girdle, and the other patient was eliminated from the study due to a high cardiac risk. The eight patients chosen for manipulation underwent interscalene brachial plexus blocks. They were immediately sent to the physical therapist for manipulation under anesthesia following the interscalene brachial plexus blocks. Immediately following manipulation, the average increases in passive range of motion for flexion, abduction, external rotation, and internal rotation were 68 degrees, 77 degrees, 49 degrees, and 45 degrees, respectively. At the time of discharge, average increases in passive range of motion/active range of motion for flexion, abduction, external rotation, and internal rotation were 76/67 degrees, 82/73 degrees, 50/44 degrees, and 49/40 degrees, respectively. All patients manipulated showed increases in function, such as overhead activities, dressing activities, and hair care. These preliminary findings show that effective gliding manipulation can be carried out under regional blockade and performed in an office setting by practitioners knowledgeable in manipulation techniques.

Arthroscopic treatment of adhesive capsulitis

Although conservative management with or without manipulation performed with the patient under anesthesia is the generally accepted treatment strategy for adhesive capsulitis, considerable interest is being shown in arthroscopic surgical procedures for this disorder. This study reviews the outcome of patients who underwent an arthroscopic release of the inferior capsule, reproducing in a controlled fashion the traumatic disruption of the inferior capsule commonly caused by manipulation with the patient under anesthesia. The outcome of 24 patients (26 shoulders) was assessed with an average follow-up of 13.5 months. A total of 88% of patients were very satisfied with the procedure, and no operative complications occurred. A return to normal or near normal shoulder function in 76% or more of the study group for forward flexion, abduction, and external rotation was demonstrated. A total of 50% of patients still had some restriction in internal rotation. The Constant Scoring system, also used to assess clinical shoulder function, revealed 87% of patients had achieved an excellent or good result when compared with the contralateral normal shoulder score. Our results suggest that arthroscopic capsular release is a safe and effective treatment for adhesive capsulitis, with patterns of recovery that compare favorably to other treatment modalities.

Distention arthrography in the treatment of adhesive capsulitis of the shoulder

PURPOSE

Adhesive capsulitis involving the glenohumeral joint (frozen shoulder) is an insidious and painful condition that results in gradual loss of joint motion. Recovery is frequently prolonged despite multiple therapeutic maneuvers. The authors investigate the mechanism of action and the long-term clinical result of distention arthrography for the treatment of patients with frozen shoulder.

PATIENTS AND METHODS

Sixteen patients with adhesive capsulitis of the shoulder were treated with therapeutic capsular distention by using intra-articular injection of a 30-mL mixture of lidocaine, corticosteroid, and contrast media immediately following diagnostic arthrography.

RESULTS

Capsular disruption was demonstrated in all cases. Thirteen patients (80%) experienced immediate pain relief and increased shoulder mobility. This improvement was maintained over a follow-up interval of 6 months or more. Disruption occurred at the subscapular bursa in eight patients, the subacromial bursa in six, and the distal bicipital tendon sheath in two. These latter two patients had no pain relief.

CONCLUSION

Arthrographic distention of the constricted capsule appears to be an excellent therapeutic intervention for achieving rapid symptomatic relief from adhesive capsulitis.

The value of shoulder distension arthrography with intraarticular injection of steroid and local anaesthetic: a follow-up study

A series of 51 patients, seen in Leicester, with "frozen shoulder", and referred for arthrographic examination, were assessed both before and after distension arthrography, using air and a low-osmolar contrast media combined with a steroid and local anaesthetic injection. 38 attended for further assessment at up to 6 months later. 16 patients were found to have a rotator cuff tear. There was no significant change in the mean range of active movement in the patients with rotator cuff tears, but symptomatic improvement ensued in 44% of cases. In those found to have no rotator cuff tear, and external rotation of less than 35 degrees, a significant improvement in range of movement was seen. While those with less limitation of external rotation showed no change in their range of movement, they did experience symptomatic improvement in 73% of cases. We conclude that shoulder distension arthrography, with steroid and local anaesthetic injection, may be of symptomatic benefit in patients with frozen shoulder and without a rotator cuff tear, while only those with external rotation of less than 35 degrees are likely to improve their range of motion.

Frozen shoulder syndrome: a review of literature

Physical therapists in a variety of settings treat individuals with frozen shoulder syndrome. Frozen shoulder syndrome is a condition in which a soft tissue glenohumeral capsular lesion is accompanied by painful and restricted active and passive shoulder motion. Despite its common occurrence, there is a significant knowledge void concerning frozen shoulder syndrome and its treatment. The purpose of this paper was to review the literature and to advance clear, current information regarding the clinical manifestations of frozen shoulder syndrome; its natural history; and views regarding pathogenesis, pathophysiology, and treatment. Further research is necessary to elucidate a clear, factual basis for therapeutic interventions.

Painful shoulder syndromes: diagnosis and management

Painful shoulder conditions are common primary care problems. Providers should learn the topographical landmarks about the shoulder and understand shoulder mechanics. A careful clinical evaluation will usually provide a likely diagnosis. In unclear cases with marked pain, weakness, and reduced mobility, or with a suspected rotator cuff tear or rupture, arthrography or MRI will usually establish a diagnosis. Therapy of bursitis/tendinitis consists of a steroid injection into the inflamed subacromial area or a 14-day trial of an NSAID. Therapy of bicipital tendinitis, largely empiric because definitive studies are unavailable for any specific treatment, includes judicious peritendinous steroid injections and avoiding aggravating activities. In the management of patients with suspected tendon tears or rupture, primary care practitioners can confirm the diagnosis by ordering MRI or arthrography before referring these patients to an orthopedist for definitive surgical therapy. Optimal management of adhesive capsulitis remains unclear, but an intraarticular steroid injection appears beneficial at least in temporarily diminishing pain. Pendular motion exercising is also an integral part of therapy. Deleterious effects of peribursal or intraarticular steroid infiltration appear minimal; but injections into the tendon or frequent, repetitive injections are contraindicated. Each shoulder condition has a variable course, depending on the structure(s) and extent of involvement.

Range of motion and arthrography in the frozen shoulder

The relationship between the range of motion and the arthrographic measurements were assessed in 91 patients with frozen shoulders. Range of motion was recorded in flexion, abduction, external rotation, and internal rotation. On the arthrogram the following parameters were measured: depth of the axillary pouch, width of the anterior ballooning, extent of the subscapularis bursa, filling of the biceps tendon sheath, and the irregularity of the capsular outline in the anteroposterior view. Both the subscapularis bursa and the biceps tendon sheath were also assessed in the scapular Y view. There were mild correlations between external rotation and the anterior ballooning and between internal rotation and the axillary pouch, but the coefficient of determination (r-square) in each correlation was small. No significant correlation was observed between flexion or abduction and any of the arthrographic measurements. Although these arthrographic findings are characteristic to frozen shoulders, none of them is a good predictor of the severity of restricted motion.

Frozen shoulder: current concepts

The literature on frozen shoulder (FS) is reviewed. The etiology of FS is still not known and our understanding of the pathogenesis is limited. Studies on treatment programs under controlled conditions are few and incomplete. Further research is urgently needed.

Manipulation in the treatment of frozen shoulder

The treatment of frozen shoulder has been an area of controversy in orthopedics for many years. The natural history of this condition would indicate that most patients recover painless range of motion of the shoulder by 2 years after the onset of symptoms. However, work and economic pressures often make it important to establish a treatment program that can enable these patients to return to a functional, painless range of motion as soon as possible. In this retrospective study, 17 frozen shoulders in 15 patients who did not respond to physical therapy were manipulated. Of those patients not able to work prior to their shoulder problems, 70% had returned to work within an average of 2.6 months of manipulation. All of the patients in this study had a significant improvement in shoulder flexion and abduction, returning to a functional range of shoulder motion. Manipulation allowed the patients studied to return to a normal lifestyle and to work much sooner than the reported natural history of this condition would indicate.

Adhesive capsulitis of the shoulder: current concepts and treatment

Primary adhesive capsulitis of the shoulder is a common cause of a painful shoulder in clinical practice. The pathogenesis remains unclear. Many patients continue to have significant long-term restrictions in their range of motion although few are functionally restricted. Prevention is the ideal treatment. Patients respond to treatment plans directed at pain relief and improving the range of motion, however, ongoing controlled therapeutic trials are necessary to better refine the selection of treatment for individual patients.