Biological Aspect of Pathophysiology for Frozen Shoulder

Differences in biomechanical and metabolic factors between patients with frozen shoulder and asymptomatic individuals. A cross-sectional study

BACKGROUND

the pathogenesis of frozen shoulder (FS) is thought to be one of inflammation and fibrosis possibly influenced by hyperglycemia. Biomechanical changes of the shoulder joint in terms of muscle strength, scapular kinematics and proprioception might occur in FS.

OBJECTIVES

to compare muscle strength, scapular kinematics, proprioception, and blood glucose levels within patients with FS and to asymptomatic individuals.

DESIGN

cross-sectional study.

METHOD

Thirty-five patients with FS and 35 asymptomatic age and gender-matched individuals underwent physical assessment to determine muscle strength (abduction, external and internal rotation), scapular kinematics (both visually and with a plurimeter), proprioception (joint position sense), and blood glucose level.

RESULTS

Patients with FS showed a decrease in muscle strength in their affected shoulder compared to both the unaffected shoulder and asymptomatic individuals. Significant differences were found between the affected and unaffected shoulder in the FS group and between groups (FS versus controls) in scapular upward rotation (plurimeter) at 30° and 60° abduction. No difference in scapular kinematics (visual observation), proprioception, and blood glucose levels was found neither between shoulders in the FS group nor between groups.

CONCLUSION

A clinically relevant difference in muscle strength and increase in scapular upward rotation were found in the affected shoulder of patients with FS compared to their unaffected side and controls. However, no evidence of different levels of scapular kinematics (visual observation), proprioception, and blood glucose levels in the affected shoulder compared to the unaffected shoulder or controls is lacking.

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.

Comparative effectiveness of low-level laser therapy versus muscle energy technique among diabetic patients with frozen shoulder: a study protocol for a parallel group randomised controlled trial

BACKGROUND

Diabetes mellitus is one of the fastest-growing health challenges of the twenty-first century with multifactorial impact including high rates of morbidity and mortality as well as increased healthcare costs. It is associated with musculoskeletal complications, with frozen shoulder being commonly reported. While low-level laser therapy (LLLT) and muscle energy technique (MET) are commonly used to manage  this condition, there remains a lack of agreement on the most effective approach, with limited research available on their comparative efficacy.

OBJECTIVES

To evaluate the comparative effectiveness of LLLT versus MET among diabetic patients with frozen shoulder.

METHODS

This is a single-centre, prospective, single-blind, randomised controlled trial with three parallel groups to be conducted at Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria. Sixty diabetic patients with frozen shoulder will be randomly assigned into LLLT group, MET group, or control group in a 1:1:1 ratio. All the groups will receive treatment three times weekly for 8 weeks. The primary outcome will be shoulder function and the secondary outcomes will include pain intensity, shoulder ROM, interleukin-6 (IL-6), depression, anxiety, and quality of life (QoL). All outcomes will be assessed at baseline, at post 8-week intervention, and at 3 months follow-up.

DISCUSSION

This will be the first randomised controlled trial to evaluate the comparative effectiveness of LLLT versus MET on both clinical and psychological parameters among diabetic patients with frozen shoulder. The findings of the study may provide evidence on the efficacy of these interventions and most likely, the optimal treatment approach for frozen shoulder related to diabetes, which may guide clinical practice.

TRIAL REGISTRATION

Pan African Clinical Trials Registry (PACTR202208562111554). Registered on August 10, 2022.

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.

A new perspective of frozen shoulder pathology; the interplay between the brain and the immune system

Frozen shoulder (FS), also known as adhesive capsulitis of the shoulder (FS), is a fibrotic inflammatory process of unknown etiology whose main symptoms are pain, stiffness and the loss of joint mobility. These symptoms may be associated with pathologies such as diabetes, Dupuytren's syndrome and the prevalence of today's sedentary lifestyle. This literature review provides an overview of the epidemiology and pathogenesis of this pathology, as well as the mechanisms of lowgrade chronic inflammation and infection, insulin resistance, and omics-science associated with it. We also propose a new hypothesis related to the possibility that the GABAergic system could play a decisive role in the development of frozen shoulder and that therefore diabetes type 1, endocrinological autoimmune disorders and frozen shoulder are connected by the same pathophysiological mechanisms. If that is true, the combined presence of psycho-emotional stress factors and pathogenic immune challenges could be the main causes of frozen shoulder syndrome. Finally, we propose a series of possible intervention strategies based on a multifactorial etiological and mechanistic concept.

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.

Allogenic Platelet-Rich Plasma for the Treatment of Adhesive Capsulitis

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

Exploration of the clinical course of frozen shoulder: A longitudinal multicenter prospective study of functional impairments

BACKGROUND

Contradictory evidence exists regarding the clinical course of frozen shoulder (FS).

OBJECTIVES

To explore the clinical course of FS regarding disabilities, pain, range of motion (ROM), muscle strength, scapular upward rotation, and proprioception and to establish longitudinal correlations between these variables.

METHODS

Patients with FS were prospectively followed for 9 months at 3-month intervals. Assessment included the Disabilities of the Arm, Shoulder and Hand questionnaire; visual analogue scale for pain; an inclinometer for shoulder external rotation (ER), internal rotation (IR), flexion, and abduction ROM, and scapular upward rotation and proprioception, as well as handheld dynamometry for muscle strength in shoulder abduction, ER, and IR.

RESULTS

Initially, 149 patients (98 females; mean (SD) age 53 (9) years) were included, with 88 completing all follow-up assessments. Most variables showed early improvement in the clinical course of FS, particularly ER and IR at 90° abduction, which continued to improve from 6 to 9 months of follow-up. Associations were observed between disabilities and pain (r = 0.61), disabilities/pain and ROM (r=-0.62 to -0.59 and r=-0.47 to -0.39, respectively), disabilities/pain and muscle strength (r=-0.24 to -0.35 and r=-0.36 to -0.17, respectively), and between disabilities/pain and scapular upward rotation below shoulder level (r = 0.23 to 0.38 and r = 0.24 to 0.30, respectively). ROM correlated with muscle strength (r = 0.14 to 0.44), while both ROM and ER muscle strength correlated with scapular upward rotation below shoulder level (r=-0.37 to -0.23 and r=-0.17 to -0.12, respectively). Muscle strength correlated with scapular upward rotation above shoulder level (r = 0.28 to 0.38) and lift-off muscle strength correlated with joint repositioning (r=-0.17 to -0.15).

CONCLUSION

Almost all factors improved in the early phase (3-6 months) after baseline assessment, while ER and IR ROM at shoulder level continued to improve long term.

Acute myopericarditis and left shoulder capsulitis following second dose of mRNA SARS-CoV-2 Moderna vaccination

Vaccination against mRNA SARS-CoV-2 has been administered on a very large scale and various side effects have been described. The increased risk of myopericarditis is known, and only a few cases of shoulder capsulitis have been reported after vaccination. These two pathologies have never been reported in the same patient after vaccination. Our article presents the history of a man in his 40s who presented with myopericarditis a few days after vaccination against SARS-CoV-2 with mRNA(Messenger RNA) Moderna® vaccine and who at the same time developed shoulder capsulitis. His cardiovascular symptoms resolved rapidly, and his shoulder symptoms improved/resolved within 1 year. This case should make physicians aware of the possibility of several concomitant side effects following vaccination against SARS-CoV-2.

Effects of Exercise Intervention (with and without Joint Mobilization) in Patients with Adhesive Capsulitis: A Systematic Review and Meta-Analysis

This review aimed to investigate the effects of exercise and exercise with joint mobilization on shoulder range of motion (ROM) and subjective symptom recovery in patients with adhesive capsulitis (AC). Related Studies published from 2000 to 2021 that were peer-reviewed and for which pre-and post-values could be calculated were extracted from PubMed, CINAHL, SPORTDiscus, and Web of Science. Nine studies met our inclusion criteria. As a result of calculating the standard mean difference (SMD) and 95% confidence intervals (CI), both exercise and exercise with joint mobilization showed a large effect on shoulder ROM and subjective outcomes. The combination showed a more significant effect than exercise alone on shoulder flexion (SMD = -1.59 [-2.34, -0.65]), extension (SMD = -1.47 [-2.05, -0.89]), internal rotation (SMD = -1.77 [-2.17, -1.36], external rotation (SMD = -2.18 [-2.92, -1.44]), and abduction ROM (SMD = -1.99 [CI -3.86, -0.12]). Patients who performed exercise alone showed a higher effect of improvement in subjective function (SMD = 3.15 [2.06, 4.24]) and pain (SMD = 4.13 [1.86, 6.41]). Based on these results, an AC rehabilitation exercise program should be developed by adjusting the amount of exercise and joint mobilization by identifying the patient's needs, subjective symptoms, and ROM.

Effectiveness of Pharmacopuncture Therapy in Adhesive Capsulitis: a Study Protocol for a Pragmatic Randomized Controlled Trial

Background

Adhesive capsulitis is a progressive, idiopathic disorder that significantly impacts individuals̓ daily lives and increases their medical burden. Pharmacopuncture therapy, which combines acupuncture techniques with herbal medicine, involves injecting herbal extracts into specific acupoints. This study aims to determine the effectiveness and safety of pharmacopuncture therapy in comparison to physiotherapy (PT) for treating adhesive capsulitis.

Methods

This research protocol outlines a two-arm, parallel, multi-center, pragmatic randomized controlled trial. Fifty participants will be randomly allocated to either the pharmacopuncture therapy or PT group, and they will receive 12 sessions of their respective therapies over a 6-week period. The primary outcome measure is the numeric rating scale for shoulder pain. Secondary outcomes include the visual analog scale score for shoulder pain, Shoulder Pain and Disability Index, Patients̓ Global Impression of Change score, Short Form-12 Health Survey Version 2 score, and EuroQol-5 Dimension. Statistical analysis will be conducted based on the intention-to-treat principle.

Discussion

This trial may offer high-quality and reliable clinical evidence for evaluating the effectiveness and safety of pharmacopuncture therapy compared to PT in the treatment of adhesive capsulitis. Furthermore, this study will serve as a valuable guideline for practitioners when making clinical decisions and managing adhesive capsulitis.

Cytokines' Role in the Pathogenesis and Their Targeting for the Prevention of Frozen Shoulder: A Narrative Review

Frozen shoulder (FS) is a common name for shoulder movement limitation with different degrees of shoulder rigidity and pain. It is characterized by varying developmental courses, different levels of shoulder movement limitation, and background ambiguity due to the multiplicity of its causative factors. Systemic inflammatory cytokines monitoring and restraining is easy to apply, fast to conduct, and needs lower costs compared to invasive methods for frozen shoulder stage evaluation and early controlling of its progress to the stage that necessitates surgical intervention. The aim of this review was to assess the recent findings concerning the role of cytokines in FS pathogenesis and the possibility of preventing or controlling their progress through targeting these cytokines by the new drugs candidates, such as hyaluronan (HA), botulinum toxin type A (BoNT A), Tetrandrine, tumor necrosis factor-stimulated gene-6 (TSG-6), and cannabidiol. Searching the PubMed site, we encountered out of 1608 records, from which 16 original studies were included for the quantitative construction of this systematic review screening of the recent studies to investigate the different FS pathogenic pathways. Most of the scenarios are centered around the inflammatory and fibrotic process triggered by synovial and capsular fibroblast stimulation. This mechanism depends mainly on alarmins cytokines, including thymic stromal lymphopoietin (TSLP), interleukin-33 (IL-33), and interleukin-25 (IL-25), with the stimulation of interleukin-1 α (IL-1α), interleukin-1 β (IL-1β), tumor necrosis alpha (TNF-α), cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) in a joint capsule. Different pathways of transforming growth factor- β (TGF-β) stimulation, resulting in overexpression of the fibrotic factors as tenascin C (TNC), fibronectin 1, collagen I (COL 1) and collagen III (COL III), and matrix metalloproteinases (MMPs) in the capsular or synovial/capsular fibroblasts. The overall investigation of these studies led us to conclude that the new drug candidates proved their efficiency in controlling the common pathogenesis of the inflammatory and fibrotic pathways of frozen shoulder and therefore represent a prospect for easy and early controlling and efficiently treating this serious disease.

Role of immune cell infiltration and small molecule drugs in adhesive capsulitis: Novel exploration based on bioinformatics analyses

Background

Adhesive capsulitis (AC) is a type of arthritis that causes shoulder joint pain, stiffness, and limited mobility. The pathogenesis of AC is still controversial. This study aims to explore the role of immune related factors in the occurrence and development of AC.

Methods

The AC dataset was downloaded from Gene Expression Omnibus (GEO) data repository. Differentially expressed immune-related genes (DEIRGs) were obtained based on R package "DESeq2" and Immport database. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) were performed to explore the functional correlation of DEIRGs. MCC method and Least Absolute Shrinkage and Selection Operator (LASSO) regression were conducted to identify the hub genes. The immune cell infiltration in shoulder joint capsule between AC and control was evaluated by CIBERSORTx, and the relationship between hub genes and infiltrating immune cells was analyzed by Spearman's rank correlation. Finally, potential small molecule drugs for AC were screened by the Connectivity Map database (CMap) and further verified by molecular docking.

Results

A total of 137 DEIRGs and eight significantly different types of infiltrating immune cells (M0 macrophages, M1 macrophages, regulatory T cells, Tfh cells, monocytes, activated NK cells, memory resting CD4+T cells and resting dendritic cells) were screened between AC and control tissues. MMP9, FOS, SOCS3, and EGF were identified as potential targets for AC. MMP9 was negatively correlated with memory resting CD4+T cells and activated NK cells, but positively correlated with M0 macrophages. SOCS3 was positively correlated with M1 macrophages. FOS was positively correlated with M1 macrophages. EGF was positively correlated with monocytes. Additionally, dactolisib (ranked first) was identified as a potential small-molecule drug for the targeted therapy of AC.

Conclusions

This is the first study on immune cell infiltration analysis in AC, and these findings may provide a new idea for the diagnosis and treatment of AC.

Autonomic Nervous System Function and Central Pain Processing in People With Frozen Shoulder: A Case-control Study

OBJECTIVES

The pathophysiology of a frozen shoulder (FS) is thought to be related to chronic inflammation. Chronic inflammation may disturb the immune system and consequently the nervous system as part of an overarching system. The aim of this study was to determine the presence of disturbed autonomic nervous system function and altered central pain processing (CPP) in patients with FS. Secondarily, the presence of psychological variables (catastrophizing and hypervigilance) and self-reported associated symptoms of altered CPP in patients with FS were investigated.

METHODS

Patients with FS and healthy controls completed the Composite Autonomic Symptom Score (autonomic function) and underwent quantitative sensory testing to assess tactile sensitivity (ie, allodynia), pressure pain thresholds (PPTs, ie, hyperalgesia), temporal summation of pain, and Conditioned Pain Modulation (CPM). Psychological issues were explored with the Pain Catastrophizing Scale and the Pain Vigilance and Awareness Questionnaire, and self-reported symptoms associated with altered CPP were determined with the Central Sensitization Inventory.

RESULTS

Thirty-two patients with FS and 35 healthy controls were analyzed in the study. Patients with FS showed more self-reported autonomic symptoms and symptoms of altered CPP, higher levels of pain catastrophizing and hypervigilance, and are more sensitive to tactile touches and mechanical pressure compared with controls.

DISCUSSION

On the basis of the effect sizes, between-group differences in allodynia, hyperalgesia, catastrophizing, and hypervigilance were clinically relevant, but only local allodynia, hyperalgesia, catastrophizing, and hypervigilance were statistically different. Therefore, obvious altered CPP was not present at the group level in patients with FS compared with controls.

Decreased Expression of Leptin among Patients with Shoulder Stiffness

Shoulder stiffness (SS) is a disease that is fibroblastic and inflammatory in nature. Leptin is an adipokine-mediating the fibroblastic and inflammatory processes of various diseases. Our study tried to investigate the role of leptin in SS pathogenesis. Subacromial bursa from stiff and non-stiff shoulders were obtained for reverse transcription-polymerase chain reaction (RT-PCR) analysis and immunoblotting. Subacromial fluid was obtained for enzyme-linked immunosorbent assay. We showed that the expression level of leptin was lower in the subacromial bursae from the stiff shoulders in RT-PCR analysis (p < 0.001) and immunoblotting (p < 0.001). The concentration of leptin was also lower in the subacromial fluid derived from stiff shoulders. The leptin level in the subacromial fluid was positively associated with the constant score, total range of motion, flexion, abduction, and external rotation. The synovial fibroblasts derived from stiff shoulder-retrieved subacromial bursa were treated by 0, 1, and 3 μM leptin. Under RT-qPCR analysis, leptin was shown to dose-dependently decrease the transcription of IL-6, IL-10, and IL-13, but without impact on IL-1β and IL-4 (p < 0.001, p = 0.001, p = 0.001, p = 0.137, and p = 0.883 by ANOVA test, respectively). These results shed light on the role of leptin in orchestrating the disease processes of SS.

Adhesive Capsulitis of the Hip: A Case Presentation and Review

There remains a paucity of literature addressing adhesive capsulitis of the hip (ACH), making the diagnosis and treatment a continued challenge for healthcare providers. ACH encompasses restricted hip range-of-motion and pain that progresses through analogous Stages (1-4) to adhesive capsulitis of the shoulder. We report a case presentation of a middle-aged man that illustrates the significance of certain patient factors and provide a review of current literature to aid in the diagnostic evaluation and treatment for addressing ACH. Initial conservative treatment of ACH includes the appropriate management of associated comorbidities, oral and/or injectable pharmacologics, and physical therapy. While frequently resolving with time, refractory cases of ACH may require more aggressive approaches including pressure dilation, manipulation under anesthesia, synovectomy, capsular release and, for select patients, total hip arthroplasty. Given the limited available literature addressing ACH, healthcare providers may be forced to rely on a small number of published case reports and outdated review articles to guide their diagnostic evaluation and treatment approaches. Thus, this case presentation and review provides an updated approach to better diagnose and manage patients with ACH.

Ultrasound-guided hydrodilatation of glenohumeral joint combined with acupotomy for treatment of frozen shoulder

BACKGROUND

Frozen shoulder (FS), also known as shoulder adhesive capsulitis, is a musculoskeletal disorder associated with pain and functional disability. There is a lack of evidence on the optimal treatment strategy for FS.

OBJECTIVE

The present study aimed to evaluate the effectiveness and safety of ultrasound-guided hydrodilatation of glenohumeral joint combined with acupotomy for treatment of FS.

METHODS

In this prospective randomized, double-blind, controlled study, 63 FS patients were recruited, and equally allocated to treatment group and control group. The treatment group was treated with ultrasound-guided hydrodilatation of glenohumeral joint combined with acupotomy, while the control group was only treated with ultrasound-guided hydrodilatation of glenohumeral joint. The pain and mobility of shoulder, overall efficacy and adverse reactions were evaluated 3 months after treatment.

RESULTS

At baseline, no significant difference in all characteristic value was found between the treatment group (n= 33) and control group (n= 30). Three months after operation, the joint's Active Range of Motion (AROM) and Constant-Murley Scale (CMS) scores in the experimental group were higher than those in the control group, and the coracohumeral ligament (CHL) thickness and the rate of hypoechoic thickening in rotator cuff space in the experimental group were lower than those in the control group (all P< 0.05). The amount of injection volume at the third hydrodilatation was significantly higher in the experimental group than that in the control group (15.8 ± 4.7 vs 12.2 ± 5.2, P= 0.03). After 2 times of treatment, the volume increment of glenohumeral joint Δ2 in the experimental group was greater than that in the control group (3.5 ± 1.8 vs 1.2 ± 1.6, P< 0.001). There were significant differences in the effective rate between the two groups (93.94% vs. 76.67%, P= 0.04).

CONCLUSION

The ultrasound-guided hydrodilatation of glenohumeral joint combined with acupotomy may benefit FS patients.

Frozen shoulder

Frozen shoulder is a common debilitating disorder characterized by shoulder pain and progressive loss of shoulder movement. Frozen shoulder is frequently associated with other systemic conditions or occurs following periods of immobilization, and has a protracted clinical course, which can be frustrating for patients as well as health-care professionals. Frozen shoulder is characterized by fibroproliferative tissue fibrosis, whereby fibroblasts, producing predominantly type I and type III collagen, transform into myofibroblasts (a smooth muscle phenotype), which is accompanied by inflammation, neoangiogenesis and neoinnervation, resulting in shoulder capsular fibrotic contractures and the associated clinical stiffness. Diagnosis is heavily based on physical examination and can be difficult depending on the stage of disease or if concomitant shoulder pathology is present. Management consists of physiotherapy, therapeutic modalities such as steroid injections, anti-inflammatory medications, hydrodilation and surgical interventions; however, their effectiveness remains unclear. Facilitating translational science should aid in development of novel therapies to improve outcomes among individuals with this debilitating condition.

Characteristics of gene expression in frozen shoulder

Background

Severe frozen shoulder (FS) is often resistant to treatment and can thus result in long-term functional impairment. However, its etiology remains unknown. We hypothesized that gene expression of FS would vary by synovial location.

Methods

The synovial tissues of patients with FS were collected prospectively and analyzed for the expression of 19 genes. Synovial tissues from patients with rotator cuff tear (RCT) or shoulder instability (SI) were also analyzed as controls. A total of 10 samples were analyzed from each group. The specimens were arthroscopically taken from three different locations: rotator interval (RI), axillary recess (AX), and subacromial bursa (SAB). Total RNA was extracted from the collected tissues and was analyzed by real-time polymerase chain reaction for the following genes: matrix metalloproteinases (MMPs); tissue inhibitors of metalloproteinases (TIMPs); inflammatory cytokines (IL1B, TNF, and IL6); type I and II procollagen (COL1A1 and COL2A1); growth factors (IGF1 and TGFB1); neural factors (NGF and NGFR); SOX9; and ACTA2.

Results

Site-specific analysis showed that MMP13, IL-6, SOX9, and COL1A1 were increased in all three sites. Four genes (MMP3, MMP9, COL2A1, and NGFR) were increased in the AX, MMP3 in the RI, and NGFR in the SAB were increased in the FS group than in the RCT and SI groups. In the FS group, there was a correlation between the expression of genes related to chondrogenesis (MMP2, IGF1, SOX9, COL2A1, NGF, and NGFR) or fibrosis (MMP9, TGFB1, and COL1A1).

Conclusion

The expression levels of numerous MMPs, pro-inflammatory cytokines, and collagen-related genes were increased in the FS group, suggesting that catabolic and anabolic changes have simultaneously occurred. In addition, genes related to chondrogenesis or fibrosis were highly expressed in the FS group, which might have affected the range of motion limitation of the shoulder. Compared to RI and SAB, the AX was the most common site of increased expression in FS. Analyzing the lower region of the shoulder joint may lead to the elucidation of the pathogenesis of FS.

Randomized controlled trial of suprascapular nerve blocks for subacute adhesive capsulitis

BACKGROUND

Shoulder pain and loss of function remain a therapeutic challenge in adhesive capsulitis. Suprascapular nerve blocks, a common treatment in adhesive capsulitis, are considered a safe and effective method for the resolution of pain and restoration of shoulder range of motion (ROM). To our knowledge, no data are available on the use of suprascapular nerve blocks in adhesive capsulitis in the subacute phase.

AIM

The aim of this study was to compare the efficacy of ultrasound-guided suprascapular nerve blocks versus saline injections for treating adhesive capsulitis in the subacute phase.

DESIGN

Randomized double-blinded controlled trial; level of evidence 2.

SETTING

Out-patient consultation of Physical and Rehabilitation Medicine in a general hospital.

POPULATION

Thirty-five patients with subacute adhesive capsulitis.

METHODS

Patients were randomly allocated to receive either 3 successive (1-week interval) ultrasound-guided suprascapular nerve blocks with ropivacaine 5 mL 2 mg/mL (intervention group) or ultrasound-guided injections of 5 mL sterile saline solution (NaCl 0.9%) (control group), at the floor of the suprascapular fossa. Primary outcome was shoulder function assessed by the Constant-Murley Score. Secondary outcomes were shoulder ROM and shoulder pain intensity. Assessments were performed before each injection and 4 weeks after the last injection.

RESULTS

A significant increase of Constant-Murley Score (P<0.001), increase of shoulder ROM (all directions: P<0.011) and decrease of pain (P<0.001), were observed over time in both study groups. However, no significant differences were observed between the intervention and the control group.

CONCLUSIONS

Three successive suprascapular nerve blocks did not provide a better outcome than saline injections on shoulder function, ROM, and pain in subacute adhesive capsulitis. These negative findings warrant some considerations on the natural history of adhesive capsulitis, as well as timing, type, and placebo effects of injections.

CLINICAL REHABILITATION IMPACT

The current place of suprascapular nerve blocks in the treatment strategy of adhesive capsulitis needs to be rediscussed.

Post-surgical physiotherapy in frozen shoulder: A review

Despite its prevalence, the optimal management of frozen shoulder is unclear. A range of conservative measures are often undertaken with varying degrees of success. In cases of severe and persistent symptoms, release procedures which could include any combination of manipulation under anaesthetic, arthroscopic capsular release or hydrodilatation are frequently offered, none of which has been shown to offer superior outcome over the others. When surgical release is performed a period of rehabilitation is normally recommended but no best practice guidelines exist resulting in considerable variations in practice which may or may not directly affect patient outcome. During this narrative review, we hypothesise that these differing responses to treatment (both conservative and surgical options) are potentially the result of different causal mechanisms for frozen shoulder and may also suggest that post-release rehabilitation may need to take this into account.

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

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

Evaluating whole-genome expression differences in idiopathic and diabetic adhesive capsulitis

BACKGROUND

Diabetic patients have a greater incidence of adhesive capsulitis (AC) and a more protracted disease course than patients with idiopathic AC. The purpose of this study was to compare gene expression differences between AC with diabetes mellitus and AC without diabetes mellitus.

METHODS

Shoulder capsule samples were prospectively obtained from diabetic or nondiabetic patients who presented with shoulder dysfunction and underwent arthroscopy (N = 16). Shoulder samples of AC with and without diabetes (n = 8) were compared with normal shoulder samples with and without diabetes as the control group (n = 8). Shoulder capsule samples were subjected to whole-transcriptome RNA sequencing, and differential expression was analyzed with EdgeR. Only genes with a false discovery rate < 5% were included for further functional enrichment analysis.

RESULTS

The sample population had a mean age of 47 years (range, 24-62 years), and the mean hemoglobin A_1c level for nondiabetic and diabetic patients was 5.18% and 8.71%, respectively. RNA-sequencing analysis revealed that 66 genes were differentially expressed between diabetic patients and nondiabetic patients with AC whereas only 3 genes were differentially expressed when control patients with and without diabetes were compared. Furthermore, 286 genes were differentially expressed in idiopathic AC patients, and 61 genes were differentially expressed in diabetic AC patients. On gene clustering analysis, idiopathic AC was enriched with multiple structural and muscle-related pathways, such as muscle filament sliding, whereas diabetic AC included a greater number of hormonal and inflammatory signaling pathways, such as cellular response to corticotropin-releasing factor.

CONCLUSIONS

Whole-transcriptome expression profiles demonstrate a fundamentally different underlying pathophysiology when comparing diabetic AC with idiopathic AC, suggesting that these conditions are distinct clinical entities. The new genes expressed explain the differences in the disease course and suggest new therapeutic targets that may lead to different treatment paradigms in these 2 subsets.

Treatment of partial rotator cuff lesions is associated with a higher frequency of post-operative shoulder stiffness. A prospective investigation on the role of surgery-related risk factors for this complication

PURPOSE

Post-operative shoulder stiffness (SS) is a common complication after arthroscopic rotator cuff (RC) repair. The aim of this prospective study is to evaluate the role of surgical risk factors in the development of this complication, with special focus on the characteristics of the RC tears.

METHODS

Two-hundred and twenty patients who underwent arthroscopic RC repair for degenerative posterosuperior RC tears were included. Surgery-related risk factors for development of post-operative SS belonging to the following five categories were documented and analyzed: previous surgery, RC tear characteristics, hardware and repair type, concomitant procedures, time and duration of surgery. The incidence of post-operative SS was evaluated according to the criteria described by Brislin and colleagues.

RESULTS

The incidence of post-operative SS was 8.64%. The treatment of partial lesions by tear completion and repair technique was significantly associated with development of post-operative SS (p = 0.0083, pc = 0.04). A multivariate analysis revealed that treatment of partial lesions in patients younger than 60 years was associated to a higher risk of developing post-operative SS (p = 0.007). Previously known pre-operative risk factors such as female sex and younger age were confirmed. No other significant associations were documented.

CONCLUSION

The treatment of partial lesions of the RC may lead to a higher risk of post-operative SS than the treatment of complete lesions, in particular in patients younger than 60 years. Possible explanations of this finding are the increased release of pro-inflammatory cytokines caused by the additional surgical trauma needed to complete the lesion and the different pain perception of the subgroup of patients who require surgical treatment already for partial tears.

EVIDENCE

A higher risk of post-operative SS should be expected after tear completion and repair of partial lesions, especially in young patients. Appropriate pre-operative counseling and post-operative rehabilitation should be considered when approaching this subgroup of RC tears.

LEVEL OF EVIDENCE

Prognostic study, level II.

Superior humeral head migration might be a radiological aid in diagnosing patients with adhesive capsulitis of the shoulder

Background

The diagnosis of adhesive capsulitis (AC) of the shoulder might be challenging, as it is a diagnosis of exclusion and mainly based on the clinical examination. The purpose of the present study was to investigate the validity and reliability of 4 commonly reported radiological parameters suggesting a superior humeral head migration on anteroposterior (a/p) shoulder radiograph in identifying patients with AC.

Methods

The a/p shoulder radiographs of 100 patients with AC and 100 control subjects were retrospectively reviewed. A disruption of the normal scapulohumeral arch (≥2 mm), the acromiohumeral interval (AHI), the inferior glenohumeral distance (IGHD), and the upward migration index (UMI) were measured.

Results

A disruption of the scapulohumeral arch was observed in 80% in the AC and 20% in the control group. The mean AHI was 9.3 ± 1.3 mm and 11.0 ± 1.7 mm (P < .001), the mean IGHD was 3.9 ± 3.0 mm and 0.9 ± 1.9 mm (P < .001), and the mean UMI was 1.37 ± 0.1 and 1.44 ± 0.1 (P < .001) in patients with AC and control subjects, respectively. The scapulohumeral arch's disruption demonstrated the best test characteristics with a sensitivity and specificity of 80% in detecting patients with an AC. Patients with a disruption of the scapulohumeral arch had 16 times increased odds of having an AC.

Conclusion

Measuring the superior humeral head migration might be a simple and clinically relevant tool in diagnosing an AC of the shoulder and could be reliably used by clinicians adjacent to the clinical examination without any additional cost. Especially a disruption of the scapulohumeral arch on the a/p shoulder radiograph should raise concerns of AC in the absence of a massive rotator cuff tear.

Recombinant TSG-6 protein inhibits the growth of capsule fibroblasts in frozen shoulder via suppressing the TGF-β/Smad2 signal pathway

Background

The tumor necrosis factor-stimulated gene-6 (TSG-6) has been confirmed to inhibit inflammation. It is now generally accepted that local inflammatory stimulation around shoulder capsule causes proliferative fibrosis. This study aims to investigate the mechanism of recombinant TSG-6 protein inhibiting the growth of capsule fibroblasts in frozen shoulder via the TGF-β/Smad2 signal pathway.

Methods

Human frozen shoulder capsule tissue was taken for primary and passage culture, and the 3rd generation fibroblasts from pathological frozen shoulder capsule were treated with different concentrations of recombinant TSG-6 protein, or with TGF-β1 agonist SRI-011381. Immunoconfocal analysis was used to identify the isolated fibroblasts, and MTT assay, colony formation assay, and flow cytometry were used to detect the viability, proliferation, and apoptosis rate of fibroblast. The contents of fibrosis and inflammation indexes COL1A1, TNF-α, IL-6, and IL-1β in the cell supernatant were detected using ELISA and then further examined by qRT-PCR. The expression of Bax, Bcl-2, and proteins related to TGF-β/Smad2 pathway were detected by Western Blot.

Results

Compared with the blank control group, fibroblasts intervened with TSG-6 (2 μg and 5 μg) showed significantly decreased viability and proliferation ability and enhanced cell apoptosis, concurrent with the reductions in Bcl-2 expression; COL1A1, TNF-α, IL-6, and IL-1β levels; and the expression of TGF-β1 and phosphorylated Smad22, and an increase in Bax expression, while SRI-011381 treatment would reverse the effect of recombinant TSG-6 protein.

Conclusion

Recombinant TSG-6 protein inhibited the growth of primary fibroblasts from human frozen shoulder capsule by suppressing the TGF-β/Smad2 signaling pathway.

An overview of effective and potential new conservative interventions in patients with frozen shoulder

Frozen shoulder (FS) is a pathology that is difficult to understand and difficult to manage. Over the last ten years, contradictory and new evidence is provided regarding the recovery and its natural course. This narrative review provides new information about the diagnosis and conservative treatment of patients with FS and ongoing research hypotheses that might provide new insights in the pathology and treatment options. FS has a characteristic course. People with Diabetes Mellitus and thyroid disorders have a higher risk of developing a FS. The diagnosis FS is based on pattern recognition and physical examination. Additionally, 'rule-in' and 'rule-out' criteria can be used to increase the likelihood of the frozen shoulder diagnosis. Recommended and most common physical therapy interventions are mobilization techniques and exercises, in which tissue irritability can guide its intensity. In addition, physical therapy is often complementary with patient education and pharmacotherapy. The latest evidence-based practice related to FS is proprioceptive neuromuscular facilitation and mirror therapy. In addition, interventions like pain neuroscience education, high-intensity interval training and lifestyle changes are still hypothetical. Finally, better insight in the involvement of biochemical processes, function of myofibroblasts and matrix metalloproteinases can provide better understanding in the pathophysiology and will be addressed in current review.

Effects of corticosteroids and platelet-rich plasma on synoviocytes in IL-1ß-induced inflammatory condition

AIMS

Corticosteroid injections are used to treat shoulder pain. Platelet-rich plasma (PRP) is known to have anti-inflammatory and anabolic effects, as well as cytoprotective effects against corticosteroids. Thus, this study was to investigate the effects of co-treatment of corticosteroid and PRP on anti-inflammatory and matrix homeostasis of synoviocytes in IL-1ß-induced inflammatory conditions.

MATERIALS AND METHODS

Synoviocytes were cultured with 1 ng/mL IL-1β, 1 μM dexamethasone, and 10% (vol/vol) Platelet-poor plasma (PPP), PRP200, PRP1000, and PRP4000 X 10³/μL. Gene expressions of pro-inflammatory and anti-inflammatory cytokines, degradative enzymes, and their inhibitors were evaluated and protein synthesis of degradative enzymes and their inhibitors were also examined.

RESULTS

Corticosteroid modulated anti-inflammatory and pro-inflammatory cytokines, and subsequent PRP treatment did not interfere with the effect of a corticosteroid and modulated the gene expressions of cytokines such as TNF-α and IL-4, which were not regulated by the corticosteroid alone. Gene expressions and protein expressions of degradative enzymes and their inhibitors were suppressed by corticosteroid. Additional PRPs did not alter the gene expression and protein regulated by the corticosteroid and inhibited the gene expression of ADAMTS-5 and protein synthesis of MMP-9 and ADAMTS-5, which were not modulated by the corticosteroid alone.

CONCLUSION

Corticosteroid regulated the inflammation and synovial homeostasis. When PRP and the corticosteroid were used together, it exhibited synergistic effects on synoviocytes by regulating the parts that were not controlled by corticosteroid alone while not interfering with the effects of the corticosteroid in an inflammatory condition.

Tetrandrine inhibits the occurrence and development of frozen shoulder by inhibiting inflammation, angiogenesis, and fibrosis

BACKGROUND

Frozen shoulders (FS) is a major clinical concern, where chronic synovial inflammation, abnormal angiogenesis, and fibrosis represent the critical pathologies in the glenohumeral capsule. However, no pharmacotherapy has been introduced to treat this pathology. Tetrandrine (TET) has been proposed as a treatment for many diseases due to its strong anti-inflammatory, anti-angiogenic, and anti-fibrotic effects.

PURPOSE

To study the anti-inflammatory, anti-angiogenic, and anti-fibrotic effects of TET on FS, and identify whether TET can prevent the development of FS in rats.

STUDY DESIGN

A controlled laboratory study.

METHODS

Forty-eight male Sprague-Dawley (SD) rats were randomly divided into control, TET, and FS groups. The TET group was intraperitoneally injected with TET every 2 days. TET and saline treatment were started on the day of FS surgery. After 8 weeks, the animals were sacrificed, and samples were collected for X-ray examination, glenohumeral range of motion (ROM) evaluation, histology and immunohistochemistry analysis, transmission electron microscopy (TEM) observation, and profibrogenic factors as well as proinflammatory cytokines measurements.

RESULTS

No significant difference in shoulder ROM was observed between the TET and control groups, but a significant difference was noted between these groups and the FS group (P < 0.01). Immunohistochemical staining showed no abnormal angiogenesis or fibrosis in the TET group or the control group. However, significant angiogenesis, collagen remodeling, and fibrosis were observed in the FS group, and the expression and proportion of type I and type III collagen in the FS group were significantly higher than those in the TET group or the control group (P < 0.01). TEM observation showed that TET protected the ultrastructure of collagen fibrous reticular arrangement of the articular capsule and prevented the formation of scar-like fibrotic structures, which are unique to FS. The significantly increased expression of Smad7 and the suppressed expression of Smad 2 in the TET group compared with that of the FS group indicated that TET also significantly inhibited the TGF-β1 intracellular signal pathway. The expression of profibrogenic factors and proinflammatory cytokines in the TET group and the control group was significantly lower than that in the TET group (P < 0.01).

CONCLUSION

The results demonstrated that TET protected the normal reticular structure of the capsule during the freezing period and prevented the development of FS by inhibiting inflammation, angiogenesis, and fibrosis in a rat FS model.

CLINICAL RELEVANCE

TET may be a safe and effective clinical medication for preventing and treating FS.

Allogenic Pure Platelet-Rich Plasma Therapy for Adhesive Capsulitis: A Bed-to-Bench Study With Propensity Score Matching Using a Corticosteroid Control Group

BACKGROUND

While platelet-rich plasma (PRP) has been widely studied for musculoskeletal disorders, few studies to date have reported its use for adhesive capsulitis (AC). Fully characterized and standardized allogenic PRP may provide clues to solve the underlying mechanism of PRP with respect to synovial inflammation and thus may clarify its clinical indications.

PURPOSE

To clinically evaluate the safety and efficacy of a fully characterized pure PRP injection in patients with AC and to assess the effects of pure PRP on synoviocytes with or without inflammation in vitro.

STUDY DESIGN

Controlled laboratory study and cohort study; Level of evidence, 3.

METHODS

For the clinical analysis, a total of 15 patients with AC received an ultrasonography-guided intra-articular PRP injection and were observed for 6 months. Pain, range of motion (ROM), muscle strength, shoulder function, and overall satisfaction in the patients were evaluated using questionnaires at 1 week as well as at 1, 3, and 6 months after the PRP injection and results were compared with the results of a propensity score-matched control group that received a corticosteroid injection (40 mg triamcinolone acetonide). For the in vitro analysis, synoviocytes were cultured with or without interleukin-1β (IL-1β) and PRP. The gene expression of proinflammatory and anti-inflammatory cytokines as well as matrix enzymes and their inhibitors was evaluated.

RESULTS

At 6-month follow-up, pure PRP significantly decreased pain and improved ROM, muscle strength, and shoulder function to levels comparable with those after a corticosteroid injection. All pain values, strength measurements, and functional scores significantly improved up to 6 months in the PRP group, but these measures improved up to 3 months and then were decreased at 6 months in the corticosteroid group. ROM was significantly improved in the 2 groups at 6 months compared with baseline. Allogenic PRP did not cause adverse events. For the in vitro findings, PRP induced inflammation but significantly improved the IL 1β-induced synovial inflammatory condition by decreasing proinflammatory cytokines such as IL-1β, tumor necrosis factor-α, IL-6, cyclooxygenase-2, and microsomal prostaglandin E synthase-1 and decreased matrix enzymes (matrix metalloproteinase-1, -3, and -13 as well as a disintegrin and metalloproteinase with thrombospondin motifs-4 and -5) and further increasing anti-inflammatory cytokines such as vasoactive intestinal peptide.

CONCLUSION

This study showed that PRP decreased pain and improved shoulder ROM and function to an extent comparable with that of a corticosteroid in patients with AC. Allogenic pure PRP acted in a pleiotropic manner and decreased proinflammatory cytokines only in the inflammatory condition.

CLINICAL RELEVANCE

Allogenic PRP could be a treatment option for the inflammatory stage of AC.

Comparison of ultrasound-guided platelet-rich plasma injection and conventional physical therapy for management of adhesive capsulitis: a randomized trial

OBJECTIVE

We evaluated the effect of ultrasound (US)-guided injection of platelet-rich plasma (PRP) into the shoulder joint in patients with adhesive capsulitis (AC) and compared its effect with that of conventional physiotherapy (CPT).

METHODS

Sixty-four subjects with AC were included and randomly allocated into two groups, as follows: PRP (n=32; intra-articular [IA] PRP [4 mL] was injected); and CPT (n=32; short wave diathermy and exercise therapy were performed at three sessions/week for 6 weeks). Treatment outcomes evaluated therapeutic effectiveness before and at 1, 3, and 6 weeks after PRP injection and CPT initiation.

RESULTS

Subjects in both groups showed a significant decrease in the visual analogue scale score for pain and shoulder and hand scores, and they a significant increase in shoulder passive range of motion at all evaluation time points. There was no significant difference in the measured outcomes between the two groups. However, there was less acetaminophen consumption after IA PRP injection compared with that after CPT.

CONCLUSIONS

IA PRP injection is a useful option for treating patients with AC, particularly those who have low therapeutic compliance for exercise therapy or have contraindications for corticosteroid injection or oral pain reduction medication.

A Comprehensive View of Frozen Shoulder: A Mystery Syndrome

Frozen shoulder is a common epidemiological affliction. Data acquired from people who suffer from this type of damage in other joints such as the hip, wrist and ankle also exist; although these syndromes are less common. Treatment for frozen shoulder is primarily physical (physiotherapy, manual therapy), secondary medical (corticosteroid injections) and finally surgical but with limited success. The difficulty in treating this type of condition successfully lies in the lack of knowledge about the risk factors involved and the pathophysiology underlying this mysterious syndrome. This review gives an overview of the current scientific position of frozen shoulder in terms of evolutionary factors, etiology, the different mechanisms of action involved, current treatment options and other possible interventions based on recent discoveries of pathophysiological mechanisms. The overall objective is to clarify several unknown aspects of a syndrome that affects up to 5% of the world's population.

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

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

Therapeutic efficacy of low-dose steroid combined with hyaluronidase in ultrasonography-guided intra-articular injections into the shoulder for adhesive capsulitis

PURPOSE

The purpose of this study was to compare the efficacy of low-dose steroid, high-dose steroid, and low-dose steroid combined with hyaluronidase with respect to intra-articular injection therapy for adhesive capsulitis (AC) of the shoulder.

METHODS

Thirty patients with primary AC in the initial stage were randomly assigned into three groups to receive ultrasound-guided intra-articular injections with 20 mg of triamcinolone acetonide (group A, n=10), 40 mg of triamcinolone acetonide (group B, n=10) and 20 mg of triamcinolone acetonide combined with hyaluronidase (group C, n=10). The outcome measures included a visual analogue scale (VAS), the Shoulder Disability Questionnaire (SDQ), abduction and external rotation range of motion, and intra-sheath fluid (ISF) before treatment and at 2, 4, 8, and 16 weeks after treatment.

RESULTS

Among the 30 patients, one participant in group B dropped out; therefore, a total of 29 patients completed this study and were successfully injected. After the injection, the VAS, SDQ, range of flexion and external rotation, and ISF improved in all groups compared with the preinjection status, regardless of treatment or time point. In the comparison between groups, the SDQ and ISF showed significantly greater improvements in groups B and C than in group A.

CONCLUSION

The therapeutic efficacy of combined low-dose corticosteroid and hyaluronidase is superior to that of low-dose corticosteroid and equivalent to that of high-dose corticosteroid in early AC.

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

Among all the prevalent painful conditions of the shoulder, frozen shoulder remains one of the most debated and ill-understood conditions. It is a condition often associated with diabetes and thyroid dysfunction, and which should always be investigated in patients with a primary stiff shoulder. Though the duration of 'traditional clinicopathological staging' of frozen shoulder is not constant and varies with the intervention(s), the classification certainly helps the clinician in planning the treatment of frozen shoulder at various stages. Most patients respond very well to combination of conservative treatment resulting in gradual resolution of symptoms in 12-18 months. However, the most effective treatment in isolation is uncertain. Currently, resistant cases that do not respond to conservative treatment for 6-9 months could be offered surgical treatment as either arthroscopic capsular release or manipulation under anaesthesia. Though both invasive options are not clinically superior to another, but manipulation could result in unwarranted complications like fractures of humerus or rotator cuff tear.

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

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

Capsular distention for adhesive capsulitis in a pediatric patient with acute flaccid myelitis: A case report

INTRODUCTION

Acute Flaccid Myelitis (AFM) is a recently recognized pediatric condition characterized by flaccid paralysis that can cause lifelong deficits. Adhesive Capsulitis (AC) is a chronic condition that causes loss of passive range of motion in the shoulder due to joint contracture.

CASE REPORT

This is a case report of a 15-year-old male who suffered from shoulder pain with progressive loss of passive range of motion after AFM, diagnosed with AC based on exam and radiology. After failing conservative management, the patient was successfully treated with ultrasound guided corticosteroid injection.

DISCUSSION/CONCLUSION

AC is uncommonly reported in pediatric patients. However, secondary adhesive capsulitis is frequently associated with disorders of shoulder immobility in adults. This case contributes to the body of literature regarding pediatric frozen shoulder, highlights the successful use of ultrasound guided injections for management, and suggests a relationship between AFM and AC which may be beneficial for pediatric physiatrists in treating patients with shoulder pain or immobility related to this condition.

The puzzling pathophysiology of frozen shoulders - a scoping review

Purpose

The pathophysiology of frozen shoulders is a complex and multifactorial process. The purpose of this review is to scope the currently available knowledge of the pathophysiology of frozen shoulders.

Methods

A systematic search was conducted in Medline, Embase and the Cochrane library. Original articles published between 1994 and October 2020 with a substantial focus on the pathophysiology of frozen shoulders were included.

Results

Out of 827 records, 48 original articles were included for the qualitative synthesis of this review. Glenohumeral capsular biopsies were reported in 30 studies. Fifteen studies investigated were classified as association studies. Three studies investigated the pathophysiology in an animal studies. A state of low grade inflammation, as is associated with diabetes, cardiovascular disease and thyroid disorders, predisposes for the development of frozen shoulder. An early immune response with elevated levels of alarmins and binding to the receptor of advance glycation end products is present at the start of the cascade. Inflammatory cytokines, of which transforming growth factor-β1 has a prominent role, together with mechanical stress stimulates Fibroblast proliferation and differentiation into myofibroblasts. This leads to an imbalance of extracellular matrix turnover resulting in a stiff and thickened glenohumeral capsule with abundance of type III collagen.

Conclusion

This scoping review outlines the complexity of the pathophysiology of frozen shoulder. A comprehensive overview with background information on pathophysiologic mechanisms is given. Leads are provided to progress with research for clinically important prognostic markers and in search for future interventions.

Level of evidence

Level V.

The Prevalence of Shoulder Pain and Its Functional Limitations Among Patients With Uncontrolled Diabetes

Objectives

To investigate the prevalence of shoulder pain and its functional limitations among patients with uncontrolled diabetes mellitus (DM).

Methods

This is a cross-sectional study that was conducted over a period of four months from October 2019 to January 2020 and included all patients with uncontrolled DM (HbA1c > 9) who are visiting the diabetes clinic at Security Forces Hospital during the study period. Telephone interviews were held by a physician from the Family Medicine Department using a previously validated questionnaire, that is, the American Shoulder and Elbow Surgeons Evaluation Form.

Results

A total of 285 patients were included in the study; 156 (54.7%) were females and 129 (45.3%) were males. Most (51.1%) of the patients aged 45-64 years. The majority of the patients 58.9% had type II DM and 41.1% of them had type I DM. The mean HbA1c level was 10.56. Of the patients are having shoulder pain (109; 38.2%), 42.5% were between 45 and 64 years of age and 44.1% were between 65 and 96 of years. While 176 (61.8%) of the participants had no pain at all, 70.5% males and 54.5% females did not have shoulder pain (p<0.001). The mean shoulder pain intensity for all patients was 5.81(SD=3.21), ranging from 4.71 (SD=3.15) to 6.13 (SD=3.29), according to different age groups, and showed a significant correlation (p<0.05).

Conclusions

Increasing prevalence of shoulder dysfunction is making physicians alert regarding early diagnosis and management of the disease. Thus, it should be mandatory to include screening, prevention, and rehabilitation strategies for shoulder dysfunction in diabetic care programs to improve the daily lifestyle of the patients.

Alleviation Effects and Mechanisms of Low-intensity Focused Ultrasound on Pain Triggered by Soft Tissue Injury

OBJECTIVES

Pain caused by soft tissue injury (STI) is always intractable and will eventually result in physical and psychological problems. This experiment aimed to assess the efficacy and mechanisms of low-intensity focused ultrasound (LIFU) for pain-related STI.

METHODS

Rabbits (n = 30) with STI were given fixed treatment for 20 seconds and then mobile treatment for 60 seconds daily for 10 consecutive days by an LIFU device with a power output of 5 to 6 W and a frequency of 0.8 MHz. To evaluate the degree of pain, the levels of β-endorphin in serum were measured by an enzyme-linked immunosorbent assay before and 5 to 10 minutes after the 1st, 3rd, 7th, and 10th treatments. The pain threshold was measured by an electronic analgesy meter on the 1st, 3rd, 7th, 10th, 17th, and 24th days after the start of the treatment. To investigate inflammation, prostaglandin E₂ , interleukin-1β, and 5-hydroxytryptamine levels were detected by an enzyme-linked immunosorbent assay, and nuclear factor κB messenger RNA levels were determined by a real-time quantitative polymerase chain reaction at the same time as the pain threshold was tested.

RESULTS

Compared with non-LIFU groups, β-endorphin levels and pain thresholds were significantly increased (P < .05), whereas nuclear factor- κB messenger RNA, prostaglandin E₂ , interleukin- 1β, and 5-hydroxytryptamine levels were significantly reduced (P < .05) after LIFU treatment in rabbits with STI.

CONCLUSIONS

Low-intensity focused ultrasound can alleviate pain induced by STI and could have further clinical applications.

Acupotomy Therapy for Shoulder Adhesive Capsulitis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective

Acupotomy therapy is widely used for pain management. However, the efficacy of acupotomy on shoulder adhesive capsulitis (SAC) is still uncertain. The aim of this study was to determine the effectiveness and safety of acupotomy therapy for SAC.

Methods

We searched seven electronic databases to collect randomized controlled trials (RCTs) of acupotomy for SAC published before April 2019. A meta-analysis was performed according to the Cochrane systematic review method by using RevMan 5.3 software.

Results

A total of eight RCTs involving 501 patients were enrolled. Meta-analysis showed that acupotomy was significantly better than the control group in debasing the Visual Analogue Scale (VAS) score (MD = −0.97, 95% CI = [−1.49, −0.45], P=0.0003) and improving the Constant–Murley Score (CMS) (MD = 8.46, 95% CI = [1.04, 15.87], P=0.03), and there was no significant difference in adverse events (OR = 1.24, 95% CI = [0.34, 4.52], P=0.74) between the two groups.

Conclusion

Acupotomy therapy is an effective and safe treatment for SAC, and this treatment can be recommended for the management of SAC. Due to the low quality and small sample size of the included studies, more rigorously designed RCTs with high quality and large-scale are recommended in future.

Intra-Articular versus Subacromial Corticosteroid Injection for the Treatment of Adhesive Capsulitis: A Meta-Analysis and Systematic Review

Background

Adhesive capsulitis is one of the most well-known causes of pain and stiffness of the shoulder. Corticosteroid injections have been used for many years. However, it is still controversial where corticosteroid should be injected, whether subacromial or intra-articular.

Objective

The objective of this meta-analysis was to compare the effects of intra-articular (IA) and subacromial (SA) corticosteroid injections for the treatment of adhesive capsulitis.

Materials and Methods

Four foreign databases and two Chinese databases were searched for RCTs and quasi-RCTs involving the comparison of IA and SA corticosteroid injection for the treatment of adhesive capsulitis. The Cochrane risk of bias tool and PEDro score were used to evaluate the quality of the studies. The primary clinical outcomes including VAS, Constant score, ASES score, and ROM were collected. The secondary outcome of corticosteroid-related adverse reactions was also compared between the two groups. The results were evaluated and compared at five time points. Subgroup analyses were performed to further explore the differences between groups.

Results

Eight RCTs and one quasi-RCT, involving 512 participants, were identified and included in this meta-analysis. All studies were of low risk of bias and medium-high quality with the PEDro score ≥5 points. The pooled effect showed that there was no significant difference in the primary outcomes between IA injection and SA injection, with an exception of VAS at 2-3 weeks (P=0.02) and ROM of internal rotation at 8–12 weeks (P=0.02). According to the results of subgroup analyses, the differences of VAS and ROM of internal rotation did not last beyond the 2-3-week time period. Additionally, SA injection had the advantage of avoiding adverse reactions from the corticosteroid, especially in avoiding a large fluctuation of serum blood glucose levels.

Conclusions

When corticosteroid injection is used to treat adhesive capsulitis, both injection sites can be selected. However, due to the scarcity of related studies, more rigorous trials are needed to confirm the current findings.

Effectiveness of extracorporeal shock-wave therapy for frozen shoulder: A protocol for a systematic review of randomized controlled trial

BACKGROUND

This systematic review aims to explore the effectiveness and safety of extracorporeal shock-wave therapy (ESWT) for patients with frozen shoulder.

METHODS

The sources of Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Allied and Complementary Medicine Database, Chinese Biomedical Literature Database, and Websites of Clinical Trials Registry will be searched. All databases and other sources will be searched from inception to the date of the search will be run. Only randomized controlled trials of ESWT for frozen shoulder will be considered for inclusion in this systematic review. Two authors independently screen the studies, extract the data, and evaluate the methodology quality for included trials. If sufficient trials will be included with fair heterogeneity, the data will be pooled, and the meta-analysis will be performed by using RevMan 5.3 software.

RESULTS

This systematic review will assess the effectiveness and safety of ESWT for frozen shoulder. The primary outcome includes pain intensity. The secondary outcomes consist of shoulder function, quality of life, and also the adverse events.

CONCLUSION

Its findings may provide latest evidence of ESWT for the treatment of frozen shoulder.

ETHICS AND DISSEMINATION

No research ethics approval is required in this study, because it is a systematic review and will not use individual data. The results of this study are expected to publish at peer-reviewed journals.