Hydrodilatation, corticosteroids and adhesive capsulitis: a randomized controlled trial

British Elbow and Shoulder Society patient care pathway: Frozen shoulder

Background

Current guidelines from the British Elbow and Shoulder Society (BESS) were published in 2015 for managing frozen shoulders in the primary and secondary care setting. Updated guidelines have been developed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology.

Methods

A multi-disciplinary BESS Working Group defined key management questions based on agreed outcome measures and time points. A literature search, conducted up to March 2023 following PRISMA guidelines, identified randomised controlled trials, systematic reviews, and meta-analyses. Quality assessments were performed using the GRADE Decision Framework, considering bias, imprecision, indirectness, and inconsistency. Data were extracted for meta-analysis. In the absence of high-quality trials, narrative reviews were created.

Results

Consensus opinions produced statements based on the quality and volume of evidence and the magnitude of desirable and undesirable effects. These statements form a comprehensive framework for managing frozen shoulder.

Discussion

This updated guideline provides evidence-based guidance for managing frozen shoulder and identifies key areas for future research.

The statistical fragility of treatments for adhesive capsulitis: a systematic review of randomized controlled trials

BACKGROUND

Randomized controlled trials (RCTs) have assessed a range of treatments for shoulder adhesive capsulitis (AC), with conflicting results over the most clinically beneficial options. This study used the fragility index (FI), reverse fragility index (rFI), and fragility quotient (FQ) to evaluate statistical fragility of the outcomes reported in RCTs assessing the efficacy of shoulder AC treatments.

METHODS

PubMed and Embase were systematically searched for RCTs from January 1, 2004, to May 1, 2024 that assessed shoulder AC treatments. We quantified FI and rFI, which represent the amount of outcome event reversals necessary to change statistical significance for significant and nonsignificant findings, respectively. Subanalyses were performed for outcomes relating to clinical efficacy, patient satisfaction, pain, and adverse events. The FQ was determined by dividing the FI by the study sample size.

RESULTS

Of 468 articles screened, there were a total of 38 RCTs analyzed that yielded 67 outcomes of interest. Across the 67 outcomes, the median FI was 3 (interquartile range [IQR] 2-6) and the median FQ was 0.075 (IQR 0.034-0.100). The 17 statistically significant outcomes had a median FI of 2 (IQR 1-4) and a median FQ of 0.050 (IQR 0.018-0.091). The remaining 50 outcomes were statistically nonsignificant, with a median FI of 4 (IQR 2-6) and a median FQ of 0.079 (IQR 0.037-0.102). Notably, in 40.3% of all outcomes, loss-to-follow-up was greater or equal to the outcome's respective FI or rFI. The most fragile outcomes were related to patient satisfaction (FI 2) and adverse events (FI 2.5).

CONCLUSION

The outcomes of interest regarding treatments for AC from RCTs are statistically fragile, most notably significant outcomes and those pertaining to patient satisfaction. RCT results surrounding AC treatments remain inconclusive; thus, combining P values with both FI and FQ metrics may improve the interpretation of clinical findings regarding treatment modalities for AC. Future clinical RCTs may reduce outcome fragility by improving follow-up rates and increasing patient sample sizes.

Additive effect of glenohumeral joint hydrodilatation applied in addition to suprascapular nerve blockage in patients with adhesive capsulitis

BACKGROUND

We aimed to investigate the efficacy of shoulder hydrodilatation (HD) applied in addition to suprascapular nerve blockage (SSNB) on severity of pain, shoulder joint range of motion (ROM), functional status, handgrip (HG) strength in patients with adhesive capsulitis (AC).

METHODS

Forty-eight patients who were diagnosed with AC based on physical examination findings included in the study. The patients were randomized into two groups as combination of SSNB + HD and SSNB alone. Injections were performed under ultrasonography guidance. Shoulder ROM angles were measured with a goniometer. Pain intensity was evaluated with visual analog scale. Functional status was evaluated with Quick Disability of Arm, Shoulder, and Hand (QDASH). HG strength was measured by a Jamar dynometer. After the injection, a home-based exercise program was given to all patients. Patients were evaluated at baseline, 1st and 3rd month.

RESULTS

Abduction and external rotation ROM angles were statistically significantly limited in SSNB group, at baseline (p = 0.020, p = 0.018, respectively). In terms of other parameters, both groups were similar at baseline (p > 0.05). At comparison of baseline-1st month, a significant improvement was observed in VAS score, abduction and flexion ROM and QDASH score, in both groups (p < 0.05), however, there was no statistically significant difference between the groups. There is a statistically significant decrease in VAS score in both groups, at all times, but, no significant difference between the groups. At the comparison of baseline-3rd month measurements, it was observed that all of the parameters significantly improved in both groups, and there was no statistically significant difference between the groups except for abduction and external rotation ROM (p > 0.05). Abduction ROM and external rotation ROM were significantly higher in the SSNB group than SSNB + HD group at 3rd month.

CONCLUSIONS

Both SSNB + HD and SSNB alone provide significant improvement clinically especially in shoulder pain. HD added to SSNB does not seem to provide any additional benefit. SSNB is an effective treatment option for up to 3 months in patients with AC, mainly in abduction and external rotation limitation.

Sonographically-navigated frozen shoulder release (S-FSR): A modified technique for sonographically-navigated, in-office hydrodilatation of adhesive capsulitis

We describe a new technique for hydrodilatation of the frozen shoulder, which we coined 'Sonographically-Navigated Frozen Shoulder Release (S-FSR)' or 'Dr Gonzalez's technique.' Traditional treatments include a combination of conservative and surgical modalities, such as non-steroidal anti-inflammatories, physical therapy, and open capsular release. We describe a modification to hydrodilatation of the frozen shoulder. Our technique describes the gradual dilation of the glenohumeral (GH) capsule with the goal of seeing a gentle release of the frozen shoulder. Furthermore, we outline our protocol for patient preparation with preprocedural diazepam 5 mg and Hydrocodone 5 mg-Acetaminophen 325 mg, one tablet each. During the procedure, we inject a solution of 10 mL lidocaine mixed with 2 mL of 40 mg/mL triamcinolone acetonide injection (80 mg total) through an anterior approach at the level of the rotator interval for pain control. Following this injection, we proceed to fenestrate the superior glenohumeral ligament (SGHL) in the process. We conclude the procedure with hydrodilatation of the GH joint (GHJ) through the posterior approach with approximately 50 mL of 0.9% normal saline, or until an expansion and release of the GH joint is visualized under ultrasound visualization. A full instruction video can be found at: https://www.youtube.com/watch?v = ZNB0R0hkeok&ab_channel = DrJorgeA.Gonzalez.

Arthro-distension with early and intensive mobilization for shoulder adhesive capsulitis: A randomized controlled trial

BACKGROUND

There are several therapeutic options for the management of shoulder adhesive capsulitis (AC). The superiority of arthro-distension over intra-articular steroid injection (ISI) for AC remains controversial.

OBJECTIVES

To evaluate the efficacy of a single arthro-distension procedure combined with early and intensive mobilization (ADM) and physiotherapy, versus ISI and physiotherapy, in people with AC lasting ≥3 months.

METHODS

This was a prospective, 2 parallel-group, 2-center, observer-blind randomized controlled trial conducted in tertiary care settings. Adults with AC were randomly assigned to the treatment or control group. Efficacy was assessed using the self-administered Shoulder Pain and Disability Index (SPADI). Total, pain and disability SPADI scores 15 days, 6 weeks, and 3, 6 and 12 months after the procedure (total SPADI at 15 days: primary outcome; other outcomes were secondary) were compared between groups using analysis of covariance (ANCOVA). A post hoc analysis stratified on the initial range of passive glenohumeral abduction, which had not been pre-specified, was conducted.

RESULTS

There were 33 participants in each group. Both groups improved over time. Mean (SD) total SPADI score at 15 days was 33.8 (19.6) in the treatment group and 32.8 (17.5) in the control group, p = 0.393. There were no significant differences for any variables in the overall sample. The post hoc analysis found ADM to be associated with a significant decrease in total SPADI score at 15 days compared with ISI (p = 0.049) in individuals with initial passive glenohumeral abduction >45°.

CONCLUSIONS

The effects of ADM on pain and function were not statistically different from those of ISI. However, ADM may be useful in individuals with initial passive glenohumeral abduction >45°.

DATABASE REGISTRATION

NCT00724113.

Comparative outcome of ultrasound guided vs. fluoroscopy guided hydrodilatation in adhesive capsulitis: a prospective study

BACKGROUND

The incidence of adhesive capsulitis varies from 2-5% in the general population to 20% in people with diabetes. One of the most effective treatment methods is hydrodilatation, which can be done under US-guidance or Fluoroscopic guidance. However, the clinical effectiveness of US-guided injections in comparison to fluoroscopy-guided injections is still debatable. The possibility of severe side effects, the expense, and the time required to carry out this minimally invasive procedure highlight how crucial it is for patients to have a precise intra-articular injection. This study aims to compare the effectiveness of Ultrasound-guided vs. Fluoroscopic guided hydrodilatation for patients with adhesive capsulitis.

METHODS

Sixty-four patients were randomly selected for hydrodilatation using any one of the techniques. The patients were evaluated for clinical improvements using the visual analog scale (VAS), oxford shoulder score (OSS), and range of motion (ROM).

RESULTS

The US-guided group experienced more pain reduction than the fluoroscopy group within the first four weeks (P < 0.001). The increase in ROM was much more significant in the US-guided group for the first 8 weeks. Improvement in Abduction and External rotation was much more significant (P < 0.001) in the first 4 weeks after hydrodilatation in the US-guided group. The improvement in ROM was maintained on long-term follow-up (mean 24 months), with 45 out of 64 (70.3%) reporting a normal or near normal ROM. On assessing the Oxford shoulder score improvements, the US-guided group's score significantly increased after the first week (P = 0.003), but the fluoroscopy-guided group's score increased after the second week. On comparison between the two groups, the amount of score improvement was more significant in the US-guided group than in the fluoroscopy-guided group in the first 4 weeks (P < 0.001).

CONCLUSION

US-guided technique for intra-articular injection for patients with adhesive capsulitis provided a quicker pain reduction and a larger improvement in range of motion and overall shoulder functions.

A preliminary study of contrast-enhanced ultrasound guided capsule-preserving hydrodilatation in shoulder adhesive capsulitis

BACKGROUND

Capsule-preserving hydrodilatation is a common treatment for adhesive capsulitis (AC), and ultrasound (US) has recently become the most popular adjuvant tool for image-guided glenohumeral joint injection. However, traditional US is hardly adequate to assess extracapsular fluid leakage, which may decide the treatment outcomes. In this study, we explored the value of contrast-enhanced ultrasound (CEUS) guided capsule-preserving hydrodilatation with steroids and ultrasonic contrast agents for treatment of AC.

METHODS

A total of 40 consecutive patients with AC were prospectively enrolled and received CEUS-guided capsule-preserving hydrodilatation. The number of injection attempts, injection volume, and fluid leakage were recorded, and the correlations with clinical features were analyzed by Pearson or Spearman correlation coefficients. Outcome measures including visual analog scale (VAS) score, passive range of motion (ROM), and shoulder pain and disability index (SPADI) score were evaluated at baseline and 4 weeks after treatment. Comparisons between patients with good and poor clinical outcomes were performed with independent t-test, Mann-Whitney U test, and chi-square test. Logistic regression was used to identify predictors of good clinical outcomes. A P value <0.05 defined significance.

RESULTS

Access to the glenohumeral joint was successful in 87.5% patients on the first attempt. The infused fluid volume was 21.0±3.40 mL. Longer symptom duration (r=-0.676, P<0.001), greater SPADI (r=-0.148, P=0.007), and decreased ROM in abduction (r=0.38, P=0.016) were associated with a decreased volume of infused fluid. CEUS detected massive fluid leakage in 5 (12.5%) patients, with 4 capsule ruptures confirmed by magnetic resonance imaging (MRI). Longer symptom duration (r=0.485, P=0.001), decreased ROM in the direction of abduction (r=-0.33, P=0.037), and external rotation (r=-0.34, P=0.032) were correlated with an increased incidence of massive fluid leakage. Moreover, patients with good outcomes had significantly shorter symptom duration (5.7±2.09 vs. 11.2±3.89 months, P=0.002) and greater initial VAS score (6.9±1.04 vs. 6.3±0.50, P=0.022) than those with poor outcomes. Absence of massive fluid leakage was an independent predictor of clinical good outcomes at 4 weeks after treatment [odd ratio (OR) =0.05, 95% confidential interval (CI): 0.003-0.882, P=0.041].

CONCLUSIONS

CEUS-guided capsule-preserving hydrodilatation allows real-time visualization of capsule dilatation, accurate detection of extracapsular fluid leakage, and identification of risks for capsule rupture. It provides an effective treatment for AC, and is useful to predict patients' clinical outcomes.

The comparative effectiveness of combined hydrodilatation/corticosteroid procedure with two different quantities for adhesive capsulitis

OBJECTIVE

To assess the efficacy of injecting various amounts of fluid into the shoulder joints for capsule distension in patients with adhesive capsulitis.

DESIGN

A randomized controlled trial.

SETTING

Outpatient clinic of a tertiary care centre.

PARTICIPANTS

Eighty-four patients with adhesive capsulitis underwent a baseline (time0), 6 weeks (time1), and 12 weeks (time2) follow-up after hydrodilitation.

INTERVENTION

Group 1 (n  =  42) received 20 ml of lidocaine, steroid, and saline hydrodilatation via posterior glenohumeral recess, while Group 2 (n  =  42) received 10 ml of lidocaine, steroid, and saline hydrodilitation.

MAIN MEASURES

The primary outcome was the visual analogue scale for pain. The secondary outcomes were shoulder pain and disability index (SPADI) and ROM of the shoulder.

RESULTS

There was a significant reduce in VAS scores for pain, SPADI scores, and increased shoulder ROM in both groups over time; however, the group-by-time interactions for any of the outcomes between groups were not significant except VAS pain in motion. Post-hoc pairwise analysis of the marginal effect of time and group showed that the significant difference of VAS in motion is due to time effect: time1 vs time0 (95% CI -4.09 to -2.68), time2 vs time0 (-4.21 to -2.77), and time2 vs time1 (-0.83 to 0.63), without between-group difference: group 1 vs group 2 (-0.38 to 0.59).

CONCLUSION

Our study suggests hydrodilatation achieved an optimal effect at time1 for patients with adhesive capsulitis in both groups, and adding more saline offers additional benefits in flexion and external roatation until time2.

Efficacy of Combination Therapy (Hydrodilatation and Subdeltoid Bursa Injection With Corticosteroid, Mobilization, and Physical Therapy) vs Physical Therapy Alone for Treating Frozen Shoulder: A Randomized Single-Blind Controlled Trial, Phase I

OBJECTIVE

To compare the efficacy of combination therapy (hydrodilatation and subdeltoid bursa injection with corticosteroid, mobilization, and physical therapy [PT]) with that of PT alone for treating frozen shoulder.

DESIGN

A prospective, 2-arm parallel, single-blinded, randomized controlled trial.

SETTING

Rehabilitation clinic of a private academic hospital.

PARTICIPANTS

Patients (n=70) with frozen shoulder (freezing stage).

INTERVENTIONS

Participants (n=35) in the combination group underwent hydrodilatation and subdeltoid bursa injection with corticosteroid twice, mobilization, and usual-care PT for 8 weeks; participants (n=35) in the PT group received only the usual-care PT for 8 weeks.

MAIN OUTCOME MEASURES

The Shoulder Pain and Disability Index (SPADI) was the primary outcome measure. The secondary outcome measures were pain scores on a visual analog scale, range of motion (ROM), the Shoulder Disability Questionnaire (SDQ), quality of life (evaluated using the 36-item Short-Form Health Survey [SF-36]), and self-assessment of the treatment effect.

RESULTS

Compared with the PT group, the combination group had significantly better pain (during activity), SPADI, SDQ, active and passive ROM, and self-assessment scores (all P<.001) as well as scores on some parts of the SF-36 (physical function and bodily pain, P<.05). Between-group differences were significant at the 1-, 2-, 4-, and 6-month follow-ups.

CONCLUSIONS

A combination of hydrodilatation (with corticosteroid), bursal corticosteroid injection, and joint mobilization with PT was superior to PT alone for treating frozen shoulder, and the effects persisted for at least 6 months.

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

CONCLUSIONS

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

Efficacy of hydrodilatation in frozen shoulder: a systematic review and meta-analysis

INTRODUCTION

It is unclear whether hydrodilatation is beneficial in the management of frozen shoulder compared with other common conservative management modalities. This systematic review evaluates the efficacy of hydrodilatation for the management of frozen shoulder.

SOURCES OF DATA

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An extensive search of PubMed, Embase, Scopus, Cochrane Central, Web of Science and CINAHL databases using multiple keyword combinations of 'shoulder', 'rotator', 'adhesive capsulitis', 'hydrodilatat*', 'distension' since inception of the databases to June 2023 was implemented.

AREAS OF AGREEMENT

Hydrodilatation leads to at least transient more marked improvements in shoulder disability and passive external rotation compared with intra-articular corticosteroid injections.

AREAS OF CONTROVERSY

Hydrodilatation improves passive external rotation in the longer term. Moreover, hydrodilatation may be a preferable option over manipulation under anaesthesia, given its lower cost and better patient convenience.

GROWING POINTS

Intensive mobilization after hydrodilatation is a promising adjuvant treatment option for patients suffering from a frozen shoulder.

AREAS TIMELY FOR DEVELOPING RESEARCH

Although current evidence suggests that hydrodilatation provides a transient improvement in disability in patients with frozen shoulder, its clinical relevance remains unclear. Further research is necessary to establish its role in the management of the condition.

Glenohumeral Hydrodistension for Postoperative Stiffness After Arthroscopic Primary Rotator Cuff Repair

Background:

Postoperative stiffness is a known complication after rotator cuff repair (RCR). Glenohumeral hydrodistension (GH) has been a treatment modality for shoulder pathology but has not been used to treat postoperative stiffness after RCR.

Purpose/Hypothesis:

The purpose of this study was to identify the risk factors for postoperative stiffness after RCR and review outcomes after treatment with GH. Our hypotheses were that stiffness would be associated with diabetes and hyperlipidemia and correlated with the tendons involved and that patients with stiffness who underwent GH would have significant improvement in range of motion (ROM).

Study Design:

Case series; Level of evidence, 4.

Methods:

Included were 388 shoulders of patients who underwent primary RCR by a single surgeon between 2015 and 2019. Shoulders with revision RCRs were excluded. Patient characteristics, medical comorbidities, and perioperative details were collected. A total of 40 shoulders with postoperative stiffness (10.3%) received GH injectate of a 21-mL mixture (15 mL of sterile water, 5 mL of 0.5% ropivacaine, and 1 mL of triamcinolone [10 mg/mL]). The primary outcome measure was ROM in forward flexion, internal rotation, external rotation, and abduction. Statistical tests were performed using analysis of variance.

Results:

Patients with diabetes had significantly decreased internal rotation at final follow-up after RCR as compared with patients without diabetes. GH to treat stiffness was performed most commonly between 1 and 4 months after RCR (60%), and patients who received GH saw statistically significant improvements in forward flexion, external rotation, and abduction after the procedure. Patients with hyperlipidemia had the most benefit after GH. Among those undergoing concomitant procedures, significantly more patients who had open subpectoral biceps tenodesis underwent GH. Patients who underwent subscapularis repair or concomitant subacromial decompression had significant improvement in ROM after GH. Only 1 patient who received GH underwent secondary surgery for resistant postoperative stiffness.

Conclusion:

Patients with diabetes had increased stiffness. Patients with a history of hyperlipidemia or concomitant open subpectoral biceps tenodesis were more likely to undergo GH for postoperative stiffness. Patients who underwent subscapularis repair demonstrated the most improvement in ROM after GH. After primary RCR, GH can increase ROM and is a useful adjunct for patients with stiffness to limit secondary surgery.

The Efficacy of Manipulation with Distension Arthrography to Treat Adhesive Capsulitis: A Multicenter, Randomized, Single-Blind, Controlled Trial

Objective

To determine whether arthrographic distention combined with manipulation for frozen shoulder provides additional benefits.

Methods

A total of 180 participants from five clinical centers with pain and stiffness in predominantly 1 shoulder for >3 months entered the study, and 165 completed the study. The control group was treated with arthrographic distention alone, and the treatment group underwent manipulation after resting for 5 minutes following arthrographic distention. Patients were followed up at the one and two weeks and at three and six months. For the clinical evaluation, shoulder-specific disability measure (SPADI) score, the visual analog scales (VASs) for pain, and range of active motion were used.

Results

83 patients out of 90 in the treatment group and 82 out of 90 in the control finished the entire study period. SPADI, VAS, Constant-Murley (CM), and range of motion (ROM) were improved after treatments in both groups. The statistical differences were not observed in the CM, adduction, internal rotation, and posterior extension function between groups (P > .05) after the first treatment. And the statistical differences were not observed in the internal rotation, the extorsion, and posterior extension function (P > .05) after the second treatment.

Conclusion

Distention arthrography plus manual therapy provided faster pain relief, a higher level of patient satisfaction, and an earlier improvement in AROM of the shoulder than distention arthrography alone in patients with frozen shoulder.

Evaluating Utilization Trends in Adhesive Capsulitis of the Shoulder: A Retrospective Cohort Analysis of a Large Database

Background:

Nonoperative and operative treatment modalities have been used for symptom management of adhesive capsulitis, but neither has been shown to significantly alter the long-term natural history.

Purpose/Hypothesis:

The purpose was to evaluate the current trends in resource and treatment strategy utilization for patients with adhesive capsulitis. It was hypothesized that (1) patients with idiopathic adhesive capsulitis will primarily undergo nonoperative treatment and (2) patients with systemic medical comorbidities will demonstrate relatively higher utilization of nonoperative therapies.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

We searched the Mariner/PearlDiver database for Current Procedural Terminology and International Classification of Diseases codes to identify patients with adhesive capsulitis from 2010 to 2020 and to track their usage of diagnostic and therapeutic modalities, including radiography, magnetic resonance imaging (MRI), physical therapy, surgery, opioids, and injection. Patients with active records 1 year before and 2 years after initial diagnosis of adhesive capsulitis were eligible. Excluded were patients with secondary causes of adhesive capsulitis, such as fracture, infection, prior surgery, or other intra-articular pathology.

Results:

The median age of this 165,937-patient cohort was 58 years, with 67% being women. There was a high prevalence of comorbid diabetes (44.2%), thyroid disorder (29.6%), and Dupuytren contracture (1.3%). Within 2 years of diagnosis of adhesive capsulitis, diagnostic and therapeutic modality utilization included radiography (47.2%), opioids (46.7%), physical therapy (43.1%), injection (39.0%), MRI (15.8%), arthroscopic surgery (2.7%), and manipulation under anesthesia (2.5%). Over 68% of the diagnostic and therapeutic modalities were rendered from 3 months before to 3 months after diagnosis. Patients with diabetes, thyroid disorders, tobacco use, and obesity had greater odds for treatment with physical therapy, opioids, radiography, and injection when compared with patients without these comorbidities (odds ratio [OR] range, 1.05-2.21; P < .0001). Patients with diabetes and thyroid disorders had decreased odds for surgery (OR range, 0.88-0.91; P ≤ .003). Patients with Dupuytren contracture had increased odds for all therapeutic modalities (OR range, 1.20-1.68; P < .0001).

Conclusion:

Patients with adhesive capsulitis underwent primarily nonoperative treatment, with a high percentage utilizing opioids. The most active periods for treatment were from 3 months before diagnosis to 3 months after, and patients with medical comorbidities were more likely to undergo nonoperative treatment.

Comparative analysis of intra-articular injection of steroid and/or sodium hyaluronate in adhesive capsulitis: prospective, double-blind, randomized, placebo-controlled study

Background

Few studies have reported the effects of simultaneous injections of corticosteroid (CS) and hyaluronic acid (HA) on adhesive capsulitis (AC) of the shoulder. This study investigated the synergistic effects of simultaneous intra-articular injections of CS and compared them to those of CS or HA alone.

Method

Sixty patients with AC were enrolled in this randomized, placebo-controlled trial. The participants were divided into 4 groups: saline, CS, HA, and CS with HA groups. The primary outcome measure was changes in the Shoulder Pain and Disability Index (SPADI) scores at one month. The secondary outcome measures included changes in pain, range of motion, muscle strength, and additional shoulder functional scores at 1 day, 1 week, and 1, 3, and 6 months after injection.

Results

After 1 month, changes of the SPADI scores were significantly higher in the CS with HA group (−58.4%) than those in the saline (−7.7%) and HA (−14.4%) groups. The score changed more in the CS with HA group than that in the CS group (−43.7%), but there was no significant difference. In the changes in pain, the CS with HA group showed significantly better and faster effects than the saline and HA groups. In the changes of range of motion, functional scores, the CS with HA group showed better results than the saline and HA groups.

Conclusion

In the treatment of AC, the simultaneous injection of CS and HA was more effective in improving SPADI scores at one month after injection than a single injection of CS or HA.

Shoulder hydrodilatation for primary, post-traumatic and post-operative adhesive capsulitis

BACKGROUND

Adhesive capsulitis (frozen shoulder) is characterised by pain and loss of range of motion of the glenohumeral joint. It can be present as primary (idiopathic) or secondary to surgery, trauma or other conditions that restrict the use of the shoulder joint. Various treatment options have been adopted including physiotherapy, manipulation under anaesthetic, hydrodilatation and arthroscopic or open capsular release but the optimal form of management remains uncertain.

OBJECTIVES

The purpose of the study was to assess the clinical outcome of glenohumeral hydrodilatation in three cohorts of patients with different aetiologies with adhesive capsulitis.

STUDY DESIGN & METHODS

We carried out a retrospective study of patient who underwent hydrodilatation for adhesive capsulitis between 2013 and 2015. The procedure was performed by a specialist musculoskeletal radiologist under radiological guidance. The injection consisted of steroids, local anaesthetics and NaCl solution with a target volume around 35 mL. Our outcome measures were range of motion, and pre- and post-operative pain. Patients were divided into three groups based on the presumed cause of their stiffness: idiopathic, post-traumatic and post-surgical.

RESULTS

Two hundred fifty patients were included, with a mean age of 59 years (range: 20-79). Of these, 180 had idiopathic primary adhesive capsulitis (27 were diabetic), 23 were post-traumatic, and 20 following surgical procedures. Thirty-four required further intervention following initial hydrodilatation with 8 undergoing repeat hydrodilatation, and 26 requiring arthroscopic capsular release. The diabetic group accounted for 16 capsular releases and 4 repeat procedures, while the idiopathic group accounted for 9 and 4, respectively. One patient required capsular release in the surgical group. An improvement was recorded in ROM in all groups with mean abduction improving from 59° to 110°, flexion from 50° to 120° and external rotation from 20° to 50°. With regards to pain, the majority showed an improvement from severe or moderate pain to no or mild pain.

CONCLUSIONS

Results show that hydrodilatation resulted in an improvement in all outcome measures, with only a small number of patients, especially those with diabetes, needing further procedures or showing no improvement in range of motion and pain. There was no difference between the post-traumatic and post-surgical groups.

The outcome of hydrodilation in frozen shoulder patients and the relationship with kinesiophobia, depression, and anxiety

Purpose

The aims of this study were to (1) investigate the effect of hydrodilatation in frozen shoulder patients on objective indices of shoulder functionality and subjective outcomes of pain, mobility, kinesiophobia, depression, and anxiety, and (2) progress knowledge about the reciprocal temporal relationship between psychological parameters at baseline and objective and subjective outcomes at 3-month follow-up.

Methods

We evaluated the clinical and psychological status of 72 patients with a frozen shoulder before and after hydrodilatation, using the Constant Murley score, the Visual Analogue score, the Tampa Scale for Kinesiophobia, the Hospital Anxiety and Depression Scale, and the Shoulder Pain And Disability Index.

Results

We noted a significant improvement in functionality, pain and disability (p < .001). Depression and anxiety improved significantly (p < .001) between baseline and 3-month follow-up. Prospective analyses demonstrated that psychological factors are more likely to predict outcomes of hydrodilatation than vice versa.

Conclusion

Hydrodilatation followed by physiotherapy is an excellent way to treat patients with recalcitrant frozen shoulder, resulting in a continuous improvement of ROM and pain. Physiotherapists and physicians should be aware that psychological factors might have an impact on the treatment outcome.

Image-guided glucocorticoid injection versus injection without image guidance for shoulder pain

BACKGROUND

Despite widespread use, our 2012 Cochrane review did not confirm that use of imaging to guide glucocorticoid injection for people with shoulder pain improves its efficacy.

OBJECTIVES

To update our review and assess the benefits and harms of image-guided glucocorticoid injection compared to non-image-guided injection for patients with shoulder pain.

SEARCH METHODS

We updated the search of the Cochrane Central Register of Controlled Trials (CENTRAL, via Ovid), MEDLINE (Ovid), Embase (Ovid) and clinicaltrials.gov to 15 Feb 2021, and the World Health Organisation International Clinical Trials Registry Platform (http://www.who.int/trialsearch/Default.aspx) to 06 July 2020. We also screened reference lists of retrieved review articles and trials to identify potentially relevant studies.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials that compared image-guided glucocorticoid injection to injection without image guidance (either landmark-guided or intramuscular) injection in patients with shoulder pain (rotator cuff disease, adhesive capsulitis or mixed or undefined shoulder pain). Major outcomes were pain, function, proportion of participants with treatment success, quality of life, adverse events, serious adverse events and withdrawals due to adverse events. Minor outcomes were shoulder range of motion and proportion of participants requiring surgery or additional injections. There were no restrictions on language or date of publication.

DATA COLLECTION AND ANALYSIS

We used standard methodologic procedures expected by Cochrane.

MAIN RESULTS

Nineteen trials were included (1035 participants). Fourteen trials included participants with rotator cuff disease, four with adhesive capsulitis, and one with mixed or undefined shoulder pain. Trial size varied from 28 to 256 participants, most participants were female, mean age ranged between 31 and 60 years, and mean symptom duration varied from 2 to 23 months. Two trials were at low risk of bias for all criteria. The most notable sources of bias in the remaining trials included performance bias and detection bias. Moderate-certainty evidence (downgraded for bias) indicates that ultrasound-guided injection probably provides little or no clinically important benefits compared with injection without guidance with respect to pain (15 trials) or function (14 trials) at three to six weeks follow-up. It may not improve quality of life (2 trials, low-certainty evidence, downgraded due to potential for bias and imprecision) and we are uncertain about the effect of ultrasound-guided injection on participant-rated treatment success due to very low-certainty evidence (downgraded for bias, inconsistency and imprecision). Mean pain (scale range 0 to 10, higher scores indicate more pain) was 3.1 points with injection without image guidance and 0.5 points better (0.2 points better to 0.8 points better; 1003 participants, 15 trials) with an ultrasound-guided injection. This represents a slight difference for pain (0.5 to 1.0 points on a 0 to 10 scale). Mean function (scale range 0 to 100, higher scores indicate better function) was 68 points with injection without image guidance and 2.4 points better (0.2 points worse to 5.1 points better; 895 participants, 14 trials) with an ultrasound-guided injection. Mean quality of life (scale range 0 to 100, higher scores indicate better quality of life) was 65 with injection without image guidance and 2.8 points better (0.7 worse to 6.4 better; 220 participants, 2 trials) with an ultrasound-guided injection. In five trials (350 participants), 101/175 (or 606 per 1000) people in the ultrasound-guided group reported treatment success compared with 68/175 (or 389 per 1000) people in the group injected without image guidance (RR 1.56 (95% CI 0.89 to 2.75)), an absolute difference of 22% more reported success (4% fewer to 62% more). Low-certainty evidence (downgraded for bias and imprecision) indicates that ultrasound-guided injections may not reduce the risk of adverse events compared to injections without image guidance. In five trials (402 participants), 38/200 (or 181 per 1000) people in the ultrasound-guided group reported adverse events compared with 51/202 (or 252 per 1000) in the non-image-guided injection group (RR 0.72 (95% CI 0.4 to 1.28)), an absolute difference of 7% fewer adverse events (15% fewer to 7% more). Five trials reported that there were no serious adverse events. The remaining trials did not report serious adverse events. One trial reported that 1/53 (or 19 per 1000) in the injection without image guidance group and 0/53 in the ultrasound-guided group withdrew due to adverse events. Sensitivity analyses indicate that the effects for pain and function may have been influenced by selection bias, and the effects for function may have been influenced by detection bias. The test for subgroup differences indicated there were unlikely to be differences in pain and function across different shoulder conditions.

AUTHORS' CONCLUSIONS

Our updated review does not support use of image guidance for injections in the shoulder. Moderate-certainty evidence indicates that ultrasound-guided injection in the treatment of shoulder pain probably provides little or no benefit over injection without imaging in terms of pain or function and low-certainty evidence indicates there may be no difference in quality of life. We are uncertain if ultrasound-guided injection improves participant-rated treatment success, due to very low-certainty evidence. Low-certainty evidence also suggests ultrasound-guided injection may not reduce the risk of adverse events compared with non-image-guided injection. No serious adverse events were reported in any trial. The lack of significant benefit of image guidance over injection without image guidance to improve patient-relevant outcomes or reduce harms, suggests that any added cost of image guidance appears unjustified.

Efficacy of Arthroscopic Surgery in the Management of Adhesive Capsulitis: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials

PURPOSE

To determine which interventions optimize clinical outcomes in adhesive capsulitis by performing a network meta-analysis of randomized controlled trials.

METHODS

A systematic review was conducted of all clinical trials on adhesive capsulitis published since 2008. Patient cohorts were grouped into treatment categories; data collected included range of motion (ROM) and patient-reported outcome measures (PROMs). Interventions were compared across groups by means of arm-based Bayesian network meta-analysis in a random-effects model.

RESULTS

Sixty-six studies comprising 4042 shoulders (57.6% female patients, age 54.8 ± 3.2 years [mean ± standard deviation]) were included. The most commonly studied interventions were physical therapy (PT) or shoulder injections. Network meta-analysis demonstrated that arthroscopic surgical capsular release was the most effective treatment in increasing ROM. This effect was apparent in forward flexion (effect difference [ED] versus placebo, 44°, 95% confidence interval [CI] 31° to 58°), abduction (ED 58°, 45° to 71°), internal rotation (ED 34°, 24° to 44°), and external rotation (ED 59°, 37° to 80°). Interventions most effective for pain relief included PT supplemented with either medical therapy (ED -4.50, -9.80 to 2.80) or ultrasound therapy (ED -5.10, -5.10 to -1.40). Interventions most effective for improvement of functional status included PT, manipulation under anesthesia (MUA), intra-articular or subacromial steroid injection, surgical capsular release, and supplementation of PT with alternative therapy.

CONCLUSIONS

No one treatment emerged superior in regard to ROM, pain symptoms, and functional status. Surgery (after failure of conservative treatment) ranked highest across all ROM domains. Treatments that ranked highest for treatment of pain included PT supplemented with either medical therapy or ultrasound. Finally, treatments that ranked highest for improvements in functional status included MUA, PT with medical therapy, surgical intervention, PT with ultrasound, PT with injection, and injection alone.

LEVEL OF EVIDENCE

II, systematic review and network meta-analysis of level I and II studies.

Treatment of Primary Shoulder Stiffness: Results of a Survey on Surgeon Practice Patterns in Italy

Objectives  Shoulder stiffness is a condition of restricted glenohumeral range of motion (ROM), which can arise spontaneously or as consequence of a known cause. Several treatment options are available and currently no consensus has been obtained on which treatment algorithm represents the best choice for the patient. The aim of this study was to investigate surgeon practice patterns in Italy regarding treatment of primary shoulder stiffness.

Methods  A literature review was performed to identify randomized controlled trials reporting results of shoulder stiffness treatment. The following controversial or critical points in the treatment of primary shoulder stiffness were identified: modalities of physical therapy; indication for oral corticosteroid; indication and frequency for injective corticosteroid; technique and site of injection; and indication, timing, and technique for surgery. A survey composed by 14 questions was created and administrated to the members of a national association specialized in orthopaedics and sports traumatology (SIGASCOT at the time of survey completion, recently renamed SIAGASCOT after the fusion of the societies SIGASCOT and SIA).

Results  A total of 204 completed questionnaires were collected. Physical therapy was recommended by 98% of the interviewed. The use of oral corticosteroids was considered by 51%, and injections of corticosteroids by 72%. The posterior injection approach was the one preferred and a number of three was considered the upper limit for repeated injections. Injective therapy with local anesthetics and hyaluronic acid was considered by more than 20% of the interviewed. Thirty percent of the interviewed did not treat shoulder stiffness surgically.

Conclusion  Several approaches to shoulder stiffness have been proposed and high-level evidence is available to analyze and discuss their results. Several controversial points emerged both from a literature review and from this national survey. Treatment of shoulder stiffness should be tailored to the patient's clinical situation and the stage of its pathology and should aim at pain reduction, ROM restoration, functional regain, and shortening of symptoms duration, with conservative therapy remaining the mainstay of treatment.

Updates on the treatment of adhesive capsulitis with hydraulic distension

Adhesive capsulitis of the shoulder joint is a common disease characterized by pain at the insertional area of the deltoid muscle and decreased range of motion. The pathophysiological process involves fibrous inflammation of the capsule and intraarticular adhesion of synovial folds leading to capsular thickening and contracture. Regarding the multidirectional limitation of motion, a limitation in external rotation is especially prominent, which is related to not only global fibrosis but also to a localized tightness of the anterior capsule. Ultrasound and magnetic resonance imaging studies can be applied to rule out other structural lesions in the diagnosis of adhesive capsulitis. Hydraulic distension of the shoulder joint capsule provides pain relief and an immediate improvement in range of motion by directly expanding the capsule along with the infusion of steroids. However, the optimal technique for hydraulic distension is still a matter of controversy, with regards to the infusion volume and rupture of the capsule. By monitoring the real-time pressure-volume profile during hydraulic distension, the largest possible fluid volume can be infused without rupturing the capsule. The improvement in clinical outcomes is shown to be greater in capsule-preserved hydraulic distension than in capsule-ruptured distension. Moreover, repeated distension is possible, which provides additional clinical improvement. Capsule-preserved hydraulic distension with maximal volume is suggested to be an efficacious treatment option for persistent adhesive capsulitis.

Comparison of Treatments for Frozen Shoulder: A Systematic Review and Meta-analysis

IMPORTANCE

There are a myriad of available treatment options for patients with frozen shoulder, which can be overwhelming to the treating health care professional.

OBJECTIVE

To assess and compare the effectiveness of available treatment options for frozen shoulder to guide musculoskeletal practitioners and inform guidelines.

DATA SOURCES

Medline, EMBASE, Scopus, and CINHAL were searched in February 2020.

STUDY SELECTION

Studies with a randomized design of any type that compared treatment modalities for frozen shoulder with other modalities, placebo, or no treatment were included.

DATA EXTRACTION AND SYNTHESIS

Data were independently extracted by 2 individuals. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Random-effects models were used.

MAIN OUTCOMES AND MEASURES

Pain and function were the primary outcomes, and external rotation range of movement (ER ROM) was the secondary outcome. Results of pairwise meta-analyses were presented as mean differences (MDs) for pain and ER ROM and standardized mean differences (SMDs) for function. Length of follow-up was divided into short-term (≤12 weeks), mid-term (>12 weeks to ≤12 months), and long-term (>12 months) follow-up.

RESULTS

From a total of 65 eligible studies with 4097 participants that were included in the systematic review, 34 studies with 2402 participants were included in pairwise meta-analyses and 39 studies with 2736 participants in network meta-analyses. Despite several statistically significant results in pairwise meta-analyses, only the administration of intra-articular (IA) corticosteroid was associated with statistical and clinical superiority compared with other interventions in the short-term for pain (vs no treatment or placebo: MD, -1.0 visual analog scale [VAS] point; 95% CI, -1.5 to -0.5 VAS points; P < .001; vs physiotherapy: MD, -1.1 VAS points; 95% CI, -1.7 to -0.5 VAS points; P < .001) and function (vs no treatment or placebo: SMD, 0.6; 95% CI, 0.3 to 0.9; P < .001; vs physiotherapy: SMD 0.5; 95% CI, 0.2 to 0.7; P < .001). Subgroup analyses and the network meta-analysis demonstrated that the addition of a home exercise program with simple exercises and stretches and physiotherapy (electrotherapy and/or mobilizations) to IA corticosteroid may be associated with added benefits in the mid-term (eg, pain for IA coritocosteriod with home exercise vs no treatment or placebo: MD, -1.4 VAS points; 95% CI, -1.8 to -1.1 VAS points; P < .001).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that the early use of IA corticosteroid in patients with frozen shoulder of less than 1-year duration is associated with better outcomes. This treatment should be accompanied by a home exercise program to maximize the chance of recovery.

Frozen shoulder: overview of clinical presentation and review of the current evidence base for management strategies

Adhesive capsulitis of the shoulder (ACS) is a condition with significant clinical and economic implications. The etiology of adhesive capsulitis is not clearly understood and there remains lack of consensus in clinical management for this condition. It can occur as a primary idiopathic condition or secondary to medical conditions or trauma. The hallmarks of ACS are pain and stiffness, caused by formation of adhesive or scar tissue in the glenohumeral joint. Management strategies vary depending on stage of presentation, patient factors and clinician preferences, and can range from conservative options to surgical intervention. The aim of this review is to summarize the pathophysiology and clinical presentation of ACS and to discuss the evidence base for various management strategies employed today.

Frozen shoulder (FS) is a relatively common condition characterized by pain and stiffness of the shoulder joint. The exact cause of primary FS is unknown and in some patients the condition can persist for several years. Treatment strategies vary depending on stage of presentation, patient factors and clinician preferences. This review gives a summary of the clinical presentation of FS and an overview of the current evidence for both surgical and conservative treatment options for the condition.

Intra-articular distension preceded by physical therapy versus intra-articular distension followed by physical therapy for treating adhesive capsulitis of the shoulder

BACKGROUND

Intra-articular distension is a validated treatment in adhesive capsulitis of the shoulder and is commonly followed by intensive in-patient physical therapy. A recent meta-analysis found that physical therapy is as effective as intra-articular distension (IAD) and that an early distension could be the primary choice for treating frozen shoulder. The question of the additional contribution of physical therapy prior to IAD compared with IAD followed by physical therapy has not been raised.

OBJECTIVES

We compared IAD preceded by physical therapy to that followed by physical therapy in terms of pain relief and functional outcome.

METHODS

We enrolled patients with primitive adhesive capsulitis of the shoulder. The eligible patients were randomized into three groups: A, B and C. Group A received intra-articular distension followed by physical therapy, group B received intra-articular distension in the middle of physical therapy and group C received physical therapy alone. Patients were assessed at the beginning of the protocol (T0), after 6 weeks (T1) and after 12 weeks (T2). The main outcome measures were pain using a Visual Analog Scale and the Disabilities of Arm, Shoulder and Hand Questionnaire.

RESULTS

Out of the 179 enrolled patients, only 122 completed the follow up: group A (n= 34), group B (n= 46) and group C (n= 42). Compared to intra-articular distension preceded by physical therapy, IAD followed by physical therapy did not improve significantly the outcome in terms of pain relief (p= 0.123) but it enhanced the upper extremity function (p= 0.002). Upper extremity pain and function were found to improve with time regardless of the protocol (p< 0.001).

CONCLUSIONS

IAD followed by physical therapy is more beneficial than IAD preceded by physical therapy in terms of upper extremity function. IAD, whether or not preceded by physical therapy, does not significantly improve pain compared to physical therapy alone. Time is a crucial factor to take into consideration while treating adhesive capsulitis of the shoulder.

Intra-articular steroid for adhesive capsulitis: does hydrodilatation give any additional benefit? A randomized control trial

OBJECTIVES

To assess the benefit offered by capsular hydrodilatation in addition to intra-articular steroid injections in cases of adhesive capsulitis, assess outcomes in diabetic patients with capsular hydrodilatation as compared to non-diabetics and correlate duration of symptoms with outcome based on the type of intervention given.

MATERIALS AND METHODS

This prospective double-blinded randomized control trial included patients presenting with clinical features of adhesive capsulitis with no evidence of rotator cuff pathology and randomized them into two groups-intra-articular steroid with hydrodilatation (distension group) and only intra-articular steroid (non-distension group) with intervention being performed as per the group allotted. Primary outcome measure was Shoulder Pain and Disability Index (SPADI) scores which were taken pre-intervention, at 1.5, 3 and 6 months post-intervention, which were assessed by generalized linear model statistics and Pearson correlation.

RESULTS

Although there was statistically significant drop in SPADI in both groups over time [F(1.9, 137.6) = 112.2; p < 0.001], mean difference in SPADI between the 2 groups was not statistically significant (1.53; CI:-3.7 to 6.8; p = 0.56). There was no significant difference between both groups among diabetics [F(1,38) = 0.04; p = 0.95] and no significant difference between diabetic and non-diabetic patients who received hydrodilatation [F(1.8, 60) = 2.26; p = 0.12]. There was no significant correlation between the reduction in SPADI scores and duration of symptoms in any subset of the study population.

CONCLUSION

Shoulder joint hydrodilatation offered no additional benefit compared to intra-articular steroid injections for shoulder adhesive capsulitis. Outcome for diabetics and non-diabetics were similar and there was no correlation between duration of symptoms and outcome.

Evaluating the Outcome of Two Different Regimes in Adhesive Capsulitis: A Prospective Clinical Study

OBJECTIVE

Adhesive capsulitis or frozen shoulder is a painful condition affecting up to 5% of the general population. We conducted this study with the aim of evaluating the results of physiotherapy plus intra-articular methylprednisolone injection versus physiotherapy alone in idiopathic frozen shoulder.

METHODS

This prospective clinical study was conducted in a tertiary care center between August 2016 and August 2018. Patients who were diagnosed with idiopathic frozen shoulder were included in the study, and each patient was randomly allocated to one of two groups: physiotherapy alone (group A) and physiotherapy plus intra-articular steroid injection (group B).

RESULTS

A total of 52 cases diagnosed with idiopathic frozen shoulder were included and treated with the two modalities. There was a significant improvement in group B compared to group A at 6 weeks and 3 months in the range of flexion, abduction, and external rotation. The Shoulder Pain and Disability Index showed improvement in both pain and disability score in group B -compared to group A, and improvement was significant at 6 weeks and 3 months.

CONCLUSION

The results demonstrate the advantages of physiotherapy plus intra-articular steroid injection in idiopathic frozen shoulder. The predictability of results with physiotherapy plus intra-articular steroid injection in selected patients is excellent, and it is a better modality of treatment compared to physiotherapy alone.

Efficacy of Pharmacological Therapies for Adhesive Capsulitis of the Shoulder: A Systematic Review and Network Meta-analysis

BACKGROUND

Several pharmacological interventions are used for the management of adhesive capsulitis of the shoulder, although the optimal treatment has yet to be defined.

PURPOSE

To conduct a network meta-analysis to compare the effects of different pharmacological interventions for adhesive capsulitis, administered either alone or after distension of the shoulder capsule.

STUDY DESIGN

Network meta-analysis.

METHODS

The authors searched Scopus, PubMed, and the Cochrane Central Register of Controlled Trials up to April 22, 2018, for completed studies. They enrolled trials that assessed the results of different pharmacological treatments for the primary management of adhesive capsulitis. The primary outcome was pain relief as measured by self-administered questionnaires. The secondary outcome included the assessment of composite instruments that evaluated, at a minimum, pain and function. The authors clinically interpreted the results after back-transforming the standardized mean differences into mean differences in simple instruments and assessed the quality of the source studies using the Cochrane "risk of bias" tool.

RESULTS

The authors considered 30 trials with a total of 2010 participants in this systematic review. For pain relief, there was a significant difference in favor of intra-articular corticosteroids and distension of the shoulder capsule with steroids as compared with control in the short term (mean difference in visual analog scale (VAS): -1.4 [95% CI, -2.5 to -0.4] and -1.7 [95% CI, -3.2 to -0.1], respectively). Furthermore, rotator-interval injections were found to be superior to placebo (mean difference in VAS: -7.2; 95% CI, -10.1 to -4.4), although the intervention was considered in only 1 trial. Finally, there was a statistically significant difference in favor of multiple-site corticosteroid injections compared to placebo in both the short- (mean difference in Shoulder Pain and Disability Index [SPADI]: -86.7; 95% CI, -133.6 to -40) and intermediate-term assessment (mean difference in SPADI: -102.9; 95% CI, -163.9 to -41.8).

CONCLUSION

Intra-articular corticosteroid intervention, administered either alone or after distension of the shoulder capsule, provided clinically meaningful improvements in the short term. Likewise, rotator-interval corticosteroid injections yielded promising results in terms of pain relief. However, these short-term benefits of steroids dissipated over time. Multiple-site corticosteroid injections showed clinical advantage over placebo for short- and intermediate-term composite outcome assessments.

[Conservative treatment of frozen shoulder]

Idiopathic shoulder stiffness (i.e. frozen shoulder, FS) is a common pathology of the glenohumeral joint characterized by a sudden onset of pain syndrome and progressive restriction of the range of motion. While the histological changes of FS are accompanied by synovial inflammation and increasing capsular fibrosis, the underlying cause of FS is still unknown. The treatment options for FS are multifarious and include medication, local steroid injection, physiotherapy, hydrodistension, manipulation under anesthesia, arthroscopic and open capsular release. As the disease is usually self-limiting and the symptoms resolve after 2-3 years, especially conservative treatment measures are often clinically applied; however, in this context there is still no scientifically based consensus on which treatment measures are most likely to contribute to symptom relief in which phase of the disease. For this reason, this article focuses on the description of the scientifically investigated conservative treatment methods in FS and their temporal classification into the classical three-phase course of the disease.

Does muscle guarding play a role in range of motion loss in patients with frozen shoulder?

STUDY DESIGN

Observational: cross-sectional study.

BACKGROUND

Idiopathic frozen shoulder is a common cause of severe and prolonged disability characterised by spontaneous onset of pain with progressive shoulder movement restriction. Although spontaneous recovery can be expected the average length of symptoms is 30 months. Chronic inflammation and various patterns of fibrosis and contracture of capsuloligamentous structures around the glenohumeral joint are considered to be responsible for the signs and symptoms associated with frozen shoulder, however, the pathoanatomy of this debilitating condition is not fully understood.

OBJECTIVES

To investigate the feasibility of a muscle guarding component to movement restriction in patients with idiopathic frozen shoulder.

METHODS

Passive shoulder abduction and external rotation range of motion (ROM) were measured in patients scheduled for capsular release surgery for frozen shoulder before and after the administration of general anaesthesia.

RESULTS

Five patients with painful, global restriction of passive shoulder movement volunteered for this study. Passive abduction ROM increased following anaesthesia in all participants, with increases ranging from approximately 55°-110° of pre-anaesthetic ROM. Three of these participants also demonstrated substantial increases in passive external rotation ROM following anaesthesia ranging from approximately 15°-40° of pre-anaesthetic ROM.

CONCLUSION

This case series of five patients with frozen shoulder demonstrates that active muscle guarding, and not capsular contracture, may be a major contributing factor to movement restriction in some patients who exhibit the classical clinical features of idiopathic frozen shoulder. These findings highlight the need to reconsider our understanding of the pathoanatomy of frozen shoulder.

LEVEL OF EVIDENCE

Level 4.

A randomized controlled trial of arthroscopic capsular release versus hydrodilatation in the treatment of primary frozen shoulder

BACKGROUND

Arthroscopic capsular release (ACR) and hydrodilatation (HD) have been developed for the management of frozen shoulder refractory to conservative treatment. To date no randomized trial has directly compared the efficacy of both interventions. The aim of this trial was to determine whether the Oxford Shoulder Score (OSS) differs between patients with frozen shoulder randomized to treatment with ACR or HD.

METHODS

Patients presenting with severe idiopathic frozen shoulder deemed suitable for surgical intervention by a consultant shoulder surgeon were randomized to ACR or HD. The primary outcome measure was OSS at 6 months, with secondary outcomes measures of the EuroQol-5D visual analog scale, external rotation, complications, and crossover rate also recorded.

RESULTS

Between June 2013 and December 2016, 50 patients were randomized to HD or ACR. The average age of the HD and ACR cohorts was 55.2 and 52.6 years, respectively (P = .36). At 6 months after the intervention, 20 patients were available for follow-up in the HD cohort and 19 in the ACR cohort. Both groups demonstrated significant improvements in OSS from baseline, but the OSS was significantly higher in the ACR cohort than the HD cohort (43.8 vs. 38.5, P = .023). The OSS was noted to improve rapidly after the intervention, with 75% of improvement in OSS noted at 6 weeks after surgery in both groups.

CONCLUSIONS

Patients randomized to ACR reported a significantly higher OSS at 6 months than those randomized to HD. Both groups, however, showed a significant improvement.

Effectiveness of Hydrodilatation in Adhesive Capsulitis of Shoulder: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS:

Even though hydrodilatation has been used for 50 years, the evidence on its effectiveness is not clear. Only one earlier review has strictly focused on this treatment method. The aims of this study are to evaluate the evidence on the effectiveness of hydrodilatation in treatment of adhesive capsulitis and, if appropriate, to assess the correlation between the effects of this procedure and the amount of fluid injected.

MATERIALS AND METHODS:

A literature search on MEDLINE, Embase, Scopus, Cochrane Central, Web of Science, and CINAHL databases was done; random-effects meta-analysis and meta-regression were employed; and cost-effectiveness and safeness analyses were left outside the scope of the review.

RESULTS:

Of the 270 records identified through search, 12 studies were included in qualitative and quantitative analysis and seven were included in a meta-analysis. The lower 95% confidence interval for the effect of hydrodilatation on pain severity was 0.12 indicating small effect size and mean number needed to treat 12. The pooled effect of hydrodilatation on disability level was insignificant 0.2 (95% confidence interval: -0.04 to 0.44). The lower 95% confidence interval for the effect of hydrodilatation on the range of shoulder motion was close to zero (0.07) indicating small effect size with mean number needed to treat 12. The amount of injected solution did not have a substantial effect on pain severity or range of shoulder motion. The heterogeneity level I² was acceptable from 0% to 60%.

CONCLUSION:

According to current evidence, hydrodilatation has only a small, clinically insignificant effect when treating adhesive capsulitis.

Effectiveness of translational manipulation under interscalene block for the treatment of adhesive capsulitis of the shoulder: A nonrandomized clinical trial

Study Design: Nonrandomized controlled trial. Objective: To determine whether translational manipulation under anesthesia/local block (TMUA) adds to the benefit of mobilization and range of motion exercise for improving pain and functional status among patients with adhesive capsulitis of the shoulder (AC). Background: TMUA has been shown to improve pain and dysfunction in patients with AC. This intervention has not been directly compared to physical therapy treatment without TMUA in a prospective trial. Methods: Sixteen consecutive patients with a primary diagnosis of AC were divided into two groups. Patients in the first (TMUA) group received a session of translational manipulation under interscalene block, followed by six sessions of manipulation and exercise. Patients in the comparison group received seven sessions of manipulation and exercise. Outcome measures taken at baseline and 3, 6, 12 months and 4 years included Shoulder Pain and Disability Index (SPADI) scores. Four-year outcomes included percent of normal ratings, medication use, and activity limitations. Results: Both groups showed improved SPADI scores across all follow-up times compared to baseline. The TMUA group showed a greater improvement in SPADI scores than the comparison group at 3 weeks, with no significant differences in SPADI scores at other time points. However, at 4 years, significantly more subjects in the comparison group (5 of 8) had activity limitations versus subjects in the TMUA group (1 of 8). No subject experienced a complication from either intervention protocol. Conclusion: Physical therapy consisting of manual therapy and exercise provides benefit for patients with AC. Translational manipulation under local block may be a useful adjunct to manual therapy and exercise for patients with AC.

Can we improve the outcome of hydrodilatation for adhesive capsulitis?

BACKGROUND

Hydrodilatation (HD) has been shown to improve pain and function in patients with adhesive capsulitis (AC). There is no consensus concerning how HD should be performed or what volume should be injected. It has distinct advantages compared to surgery; however, it is a painful procedure and is often poorly tolerated.

METHODS

We retrospectively reviewed all patients referred for HD over a 2.5-year period aiming to assess whether volume injected influences outcome.

RESULTS

There were 107 patients treated with HD; of these, 76 (43 female, 32 male) had full data for analysis. The majority were classified as primary AC (n = 57) with an average age of 55.5 years. The mean improvement in Oxford Shoulder Score (OSS) was 12.1, with females (13.9) and post-traumatic cases of AC (14.1) demonstrating the best outcome. No complications were observed during the HD process. There was a negative correlation observed between volume injected and OSS improvement. Only two patients experienced a poor outcome and required further treatment with manipulation +/- arthroscopic arthrolysis.

CONCLUSIONS

The present study supports the use of HD as a first line treatment for AC regardless of the underlying cause, and also demonstrates that the volume injected does appear to influence the outcome.

Comparison of Therapeutic Effectiveness Between Shoulder Distention Arthrography With Translation Mobilization and Distention Arthrography Alone in Patients With Frozen Shoulder

Objective

To evaluate the efficacy of distention arthrography (DA) alone and in combination with translational mobilization (TM) for treatment of patients with frozen shoulder (FS).

Methods

Eighty-five patients diagnosed with unilateral FS (freezing or frozen stage) were included. Forty-one patients were treated with DA and TM (group 1) and 44 patients with DA alone (group 2). Clinical assessments including visual analogue scale (VAS), Cyriax stage, and shoulder passive range of motion (PROM) including forward flexion, abduction, external rotation, and internal rotation were measured at baseline, 1 month, and 3 months following treatment.

Results

There were no significant differences in gender, side affected, symptom duration, presence of diabetes mellitus, VAS score, Cyriax stage, or shoulder PROM between the two patient groups at baseline. Compared with baseline metrics, patients in both groups demonstrated significantly improved outcome parameters at two post-treatment time points. However, mean all shoulder PROMs were significantly greater, and mean VAS score and Cyriax stage were lower in patients treated with DA and TM than in those treated with DA alone group at two post-treatment time points. At these times, mean interval change of all outcome parameters was significantly greater with DA and TM than DA alone. No serious complications were observed following treatment in either patient group.

Conclusion

Compared with DA alone, DA combined with TM more effectively alleviates shoulder pain and increases PROM in patients with freezing or frozen stage FS.

Indications for hydrodilatation for frozen shoulder

Frozen shoulder causes significant functional disability and pain in a population group constituted by patients who are often middle-aged and working.

Frozen shoulder remains poorly understood. The available literature is limited and often prone to bias.

A rapid, non-surgical and cost-effective treatment that reduces pain and restores function is an attractive option.

Hydrodilatation is a potential first-line treatment of frozen shoulder in secondary care.

Cite this article: EFORT Open Rev 2017;2:462–468. DOI: 10.1302/2058-5241.2.160061

Hydrodilatation With Corticosteroid for the Treatment of Adhesive Capsulitis: A Systematic Review

BACKGROUND

Current evidence suggests that corticosteroid injection alone expedites the recovery of pain-free range of motion (ROM) in patients with adhesive capsulitis compared to physiotherapy or placebo. However, it remains unclear whether the addition of hydrodilatation with corticosteroid provides improvement in pain-free ROM as well as pain relief.

OBJECTIVE

A review of the literature was conducted to determine whether the combined intervention of hydrodilatation and corticosteroid injection expedites restoration of pain-free ROM compared to a control treatment of corticosteroid injection in patients with adhesive capsulitis.

METHODS

EMBASE, MEDLINE, and CINAHL were searched from database inception to January 2017. Relevant studies were determined as randomized controlled trials written in English, comparing the outcomes of hydrodilatation and corticosteroid injection to a control group treated with corticosteroid injection alone in patients with adhesive capsulitis. Two independent reviewers assessed manuscripts for study inclusion and extracted data.

RESULTS

A total of 2276 studies were identified through the search, of which 6 randomized controlled studies (involving 410 shoulders) met criteria for inclusion in this review. Mean age ranged from 51-61 years, with mean symptom duration of 4-9 months. Studies varied significantly regarding the volume of injectate, anatomical injection approach, symptom duration, and the method of glenohumeral capsule distension (capsular rupture versus preservation). Two studies demonstrated clinically and statistically significant improvement in the combination group at 3-month follow-up, and one study demonstrated clinically significant improvement only in ROM and/or pain/functional scales, compared to 3 studies demonstrating no benefit when compared to corticosteroid injection alone.

CONCLUSION

Combining hydrodilatation with corticosteroid injection potentially expedites recovery of pain-free ROM. The greatest benefit is experienced within the first 3 months of intervention. Differences in hydrodilatation techniques, inclusion of capsular preservation, anatomical approach, and length of symptoms may explain the variability in efficacy demonstrated. Further trials using larger sample sizes, better anatomical approaches, image guidance, and hydrodilatation techniques are required to determine the true nature of benefits of hydrodilatation with corticosteroid injection.

LEVEL OF EVIDENCE

II.

Comparative Efficacy of Intra-Articular Steroid Injection and Distension in Patients With Frozen Shoulder: A Systematic Review and Network Meta-Analysis

OBJECTIVE

To compare the efficacy of intra-articular (IA) steroid injection and distension in patients with frozen shoulder.

DATA SOURCES

Databases, including MEDLINE (via PubMed), Embase, Scopus, and Cochrane Library, were searched for studies published up to November 2016.

STUDY SELECTION

We included all published randomized controlled trials (RCTs), quasi-experimental studies, and observational studies investigating the effectiveness of IA steroid injection, distension, and physiotherapy in patients with frozen shoulder. Sixteen RCTs and 1 observational study were enrolled in meta-analysis.

DATA EXTRACTION

Full texts were independently reviewed, and quality of RCTs was assessed with The Cochrane Collaboration's tool. The primary outcome was functional improvement; the secondary outcomes included pain reduction and external rotation (ER) improvement.

DATA SYNTHESIS

In pairwise meta-analysis, pooled standardized mean difference (SMD) of functional improvement and pain reduction revealed equal efficacy at 3 follow-up time points. With respect to ER improvement, distension has a superior effect compared with IA steroid injection in the short term [(2-4wk; SMD, -.36; 95% confidence interval [CI], -.68 to -.04) and medium term (6-16wk; SMD, -0.80; 95% CI, -1.32 to -0.29). The network meta-analysis indicated a better efficacy for distension than for IA steroid injection in ER improvement only in the medium term (6-16wk; SMD, -0.70; 95% CI, -1.19 to -0.21).

CONCLUSIONS

IA steroid injection was as effective as distension in shoulder function improvement, pain reduction, and increasing ER of the shoulder. Distension yielded better ER improvement in the medium term but to a minor extent in the long term. For patients with predominant ER limitation, early distension could be considered the primary choice of treatment.

Effectiveness of Glenohumeral Joint Dilatation for Treatment of Frozen Shoulder: A Systematic Review and Meta-analysis of Randomized Controlled Trials

The objective was to explore the effectiveness of glenohumeral joint distension for the treatment of frozen shoulder. We searched electronic data sources including PubMed, Scopus, and Embase from the earliest records available to February 2017. Eleven randomized controlled trials including at least one pair of comparisons between capsular distension and a reference treatment were included, comprising 747 participants. Patients’ characteristics, details of reference treatments, aspects of capsular distension therapy, and outcome measurement were evaluated at three points in time: baseline, early following intervention, and at the trial’s end. The primary and secondary outcomes were the between-group standardized mean differences of changes in shoulder function and range of motion, respectively. Regarding the long-term primary outcome, the superiority of capsular distension to reference treatments was not identified. One secondary outcome (external rotation limitation) showed a probable early positive response to capsular distension when compared to intra-articular corticosteroid injection. Aspects of approaches, imaging guiding techniques and doses of distension were not found to modify treatment effectiveness. In conclusion, distension of the glenohumeral joint provides a similar long-term efficacy to all reference treatments. A single dose of a corticosteroid-contained regimen introduced through the ultrasound-guided posterior approach is a preferable practice of capsular distension for the management of frozen shoulder.

Recurrence of frozen shoulder after manipulation under anaesthetic (MUA)

Aims

Manipulation under anaesthetic (MUA) is a recognised form of treatment for patients with a frozen shoulder. However, not all patients benefit. Some have persistent or recurrent symptoms. There are no clear recommendations in the literature on the optimal management of recurrent frozen shoulder after a MUA. We aimed to address this issue in this study.

Patients and Methods

We analysed a prospectively collected, single-surgeon, consecutive series of patients who underwent MUA for frozen shoulder between January 1999 and December 2015. The Oxford Shoulder Scores (OSS) and range of movement were the outcome measures.

Results

A total of 730 patients (792 shoulders) underwent MUA during the study period. A further MUA was undertaken in 141 shoulders (17.8%), for which we had complete data for 126. The mean improvement in OSS for all patients undergoing MUA was 16 (26 to 42), and the mean post-operative OSS in those requiring a further MUA was 14 (28 to 42; t-test, no difference between mean improvements, p = 0.57). Improvement was seen after a further MUA, regardless both of the outcome of the initial MUA, and of the time of recurrence. Patients with type-1 diabetes mellitus were at a 38% increased risk of requiring a further MUA, compared with the 18% increased risk of the group as a whole (p < 0.0001).

Conclusion

Patients with a poor outcome or recurrent symptoms of a frozen shoulder after a MUA should be offered a further MUA with the expectation of a good outcome and a low complication rate. Cite this article: Bone Joint J 2017;99-B:812–17.

Sham surgery versus labral repair or biceps tenodesis for type II SLAP lesions of the shoulder: a three-armed randomised clinical trial

Background

Labral repair and biceps tenodesis are routine operations for superior labrum anterior posterior (SLAP) lesion of the shoulder, but evidence of their efficacy is lacking. We evaluated the effect of labral repair, biceps tenodesis and sham surgery on SLAP lesions.

Methods

A double-blind, sham-controlled trial was conducted with 118 surgical candidates (mean age 40 years), with patient history, clinical symptoms and MRI arthrography indicating an isolated type II SLAP lesion. Patients were randomly assigned to either labral repair (n=40), biceps tenodesis (n=39) or sham surgery (n=39) if arthroscopy revealed an isolated SLAP II lesion. Primary outcomes at 6 and 24 months were clinical Rowe score ranging from 0 to 100 (best possible) and Western Ontario Shoulder Instability Index (WOSI) ranging from 0 (best possible) to 2100. Secondary outcomes were Oxford Instability Shoulder Score, change in main symptoms, EuroQol (EQ-5D and EQ-VAS), patient satisfaction and complications.

Results

There were no significant between-group differences at any follow-up in any outcome. Between-group differences in Rowe scores at 2 years were: biceps tenodesis versus labral repair: 1.0 (95% CI −5.4 to 7.4), p=0.76; biceps tenodesis versus sham surgery: 1.6 (95% CI −5.0 to 8.1), p=0.64; and labral repair versus sham surgery: 0.6 (95% CI −5.9 to 7.0), p=0.86. Similar results—no differences between groups—were found for WOSI scores. Postoperative stiffness occurred in five patients after labral repair and in four patients after tenodesis.

Conclusion

Neither labral repair nor biceps tenodesis had any significant clinical benefit over sham surgery for patients with SLAP II lesions in the population studied.

Trial registration number

ClinicalTrials.gov identifier: NCT00586742

Adhesive Capsulitis of the Shoulder. Is there Consensus Regarding the Treatment? A Comprehensive Review

Background:

Adhesive capsulitis of the shoulder (ACS) is a common self-limiting condition characterized by disabling pain and restricted movements. Its pathophysiology is poorly understood, clinically it is characterized by stages of pain and stiffness, and finally often patients never recover fully. However, there is no consensus about available methods of treatment for ACS. The aims of this paper are to discuss and develop issues regarding approaches to management in ACS in the stages of it.

Methods:

A review of the literature was performed and guidelines for the treatment of that clinical entity for doctors and health care professionals are provided.

Results:

Anti-inflammatory medications, steroid and/or hyaluronate injections and physiotherapy is the mainstay of conservative management either alone in the first stages or in combination with other treatment modalities in the later stages. Next line of treatment, involving minor to moderate intervention, includes suprascapular nerve block, distension arthrography and manipulation under anaesthesia. In order to avoid complications of “blind intervention”, arthroscopic capsular release is gradually more commonly applied, and in recalcitrant severe cases open release is a useful option.

Conclusion:

Various modalities of conservative management and gradually more surgical release are applied. However, often clinicians choose on personal experience and training rather than on published evidence.

Clinical efficacy of hydrodistention with joint manipulation under interscalene block compared with intra-articular corticosteroid injection for frozen shoulder: a prospective randomized controlled study

BACKGROUND

Hydrodistention is known to be an effective method of treatment for frozen shoulder. However, hydrodistention is accompanied by severe pain during the procedure. An interscalene block may relieve the severe pain associated with the procedure of hydrodistention. This study compared the clinical efficacy of hydrodistention with joint manipulation under an interscalene block with that of intra-articular corticosteroid injection.

METHODS

This prospective randomized controlled study included 121 patients presenting with frozen shoulder. Patients were randomized into 2 groups; those in group A (60 patients) were treated by hydrodistention with joint manipulation under an interscalene block, and those in group B (61 patients) were managed with intra-articular corticosteroid injection. Pain intensity and patient satisfaction were assessed by the visual analog scale. Functional outcomes were assessed by the Constant score and the range of shoulder motion.

RESULTS

Group A demonstrated better patient satisfaction and earlier restoration of range of motion than group B at 6 weeks (P ≤ .001). At 12 weeks, the pain score was lower and the Constant score was better in group A than in group B. However, at 12 months after treatment, pain score (P = .717), patient satisfaction (P = .832), range of motion (P > .05), and Constant score (P = .480) were similar in the 2 groups.

CONCLUSION

Hydrodistention combined with joint manipulation under an interscalene block provided earlier pain relief and restoration of shoulder range of motion and function compared with single intra-articular corticosteroid injection in patients with primary frozen shoulder.

Correlations between MRI findings and outcome of capsular distension in adhesive capsulitis of the shoulder

[Purpose] The aim of this study was to investigate the association between magnetic resonance imaging (MRI) findings in patients with adhesive shoulder capsulitis and the therapeutic effect of capsular distension. [Subjects and Methods] We retrospectively reviewed the medical records of 57 patients who underwent capsular distension therapy after a diagnosis of adhesive capsulitis with clinical and MRI scans. Axillary joint capsular thickness by MRI was graded as I (≤3.6 mm), II (3.7–4.2 mm), and III (≥4.3 mm). Subcoracoid fat obliteration of the rotator interval was graded subjectively as absent, partial, and complete. [Results] Capsular thickness and fat replacement were correlated with passive range of motion (PROM) and pain score on a visual analog scale (VAS) by analysis of variance with a Bonferroni correction before treatment and by analysis of covariance with a Bonferroni correction after treatment. Visual analog scale (VAS) for patients with all grades decreased significantly after treatment and passive range of motion (PROM) for patients with all grades improved. No difference was detected between grades. [Conclusion] Although MRI is useful to evaluate adhesive capsulitis, MRI findings of shoulder did not predict the prognosis after capsular distension treatment.

EVALUATION AND TREATMENT OF A PATIENT DIAGNOSED WITH ADHESIVE CAPSULITIS CLASSIFIED AS A DERANGEMENT USING THE MCKENZIE METHOD: A CASE REPORT

BACKGROUND/PURPOSE

The McKenzie Method of mechanical diagnosis and therapy (MDT) is supported in the literature as a valid and reliable approach to the management of spine injuries. It can also be applied to the peripheral joints, but has not been explored through research to the same extent. This method sub-classifies an injury based on tissue response to mechanical loading and repeated motion testing, with directional preferences identified in the exam used to guide treatment. The purpose of this case report is to demonstrate the assessment, intervention, and clinical outcomes of a subject classified as having a shoulder derangement syndrome using MDT methodology.

CASE DESCRIPTION

The subject was a 52-year-old female with a four-week history of insidious onset left shoulder pain, referred to physical therapy with a medical diagnosis of adhesive capsulitis. She presented with pain (4-7/10 on the visual analog scale [VAS]) and decreased shoulder range of motion that limited her activities of daily living and work capabilities (Upper Extremity Functional Index (UEFI) score: 55/80). Active and passive ranges of motion (A/PROM) were limited in all planes. Repeated motion testing was performed, with an immediate reduction in pain and increased shoulder motion in all planes following repeated shoulder extension. As a result, her MDT classification was determined to be derangement syndrome. Treatment involved specific exercises, primarily repeated motions, identified as symptom alleviating during the evaluation process.

OUTCOMES

The subject demonstrated significant improvements in the UEFI (66/80), VAS (0-2/10), and ROM within six visits over eight weeks. At the conclusion of treatment, A/PROM was observed to be equal to the R shoulder without pain.

DISCUSSION

This subject demonstrated improved symptoms and functional abilities following evaluation and treatment using MDT methodology. While a cause-effect relationship cannot be determined with a single case, MDT methodology may be a useful approach to the examination, and potentially management, of patients with shoulder pain. This method offers a patient specific approach to treating the shoulder, particularly when the pathoanatomic structure affected is unclear.

LEVEL OF EVIDENCE

4.

Adhesive Capsulitis in Eight Dogs: Diagnosis and Management

OBJECTIVE

To describe clinical and diagnostic findings as well as management of adhesive capsulitis in dogs.

BACKGROUND

Adhesive capsulitis, also known as frozen shoulder, is a syndrome defined by loss of range of motion of the shoulder and may be the end-stage manifestation of several primary conditions.

EVIDENTIARY VALUE

This is a case series report of eight dogs with chronic forelimb lameness diagnosed with adhesive capsulitis.

METHODS

Medical records (June 1, 2010-September 1, 2015) including, physical examination findings, radiographic findings, magnetic resonance imaging (MRI) findings, arthroscopy findings, and treatment plans were reviewed.

RESULTS

All dogs presented with a chronic, grade III-VI/VI forelimb lameness. On orthopedic examination, all dogs had moderate to significant discomfort on shoulder extension and flexion and severe restriction of range of motion. Six of the eight dogs had evidence of bone remodeling and sclerosis in the affected shoulder on radiographs. Six of the dogs had an initial diagnostic ultrasound performed, which revealed evidence of fibrous scar tissue. Five dogs had MRI performed that revealed moderate shoulder effusion and enhancement of the synovial lining of the shoulder. Arthroscopy was performed in five of the eight patients. Three were noted to have significant contracture, adhesions, and fibrous scar tissue of the joint capsule. Severe inflammation was noted throughout the synovium of two patients. All eight patients tried conservative management consisting of oral medications and rehabilitation therapy. Five of the eight patients received extracorporeal shockwave therapy. Three patients received regenerative medicine treatment in the affected supraspinatus and shoulder. Regardless of the treatment elected, none of the dogs were reported to have significant improvement.

CONCLUSION

Adhesive capsulitis is an uncommon cause of chronic forelimb lameness. Further investigation is needed to describe the etiology and pathogenesis of adhesive capsulitis in dogs to evaluate the effectiveness of both non-surgical and surgical treatment modalities, establish treatment protocols, and evaluate short- and long-term clinical outcome of patients.

APPLICATION

Adhesive capsulitis should be considered in patients with chronic forelimb lameness and moderate to significant discomfort and restriction on shoulder range of motion.

Usefulness of a Hanging Position With Internal Rotation of Shoulder in Ultrasonography-Guided Intra-articular Steroid Injection for Adhesive Capsulitis

Objective

To evaluate the feasibility of a new position (internal rotation in hanging) in ultrasonography, we compared the length of the glenohumeral joint space and the effectiveness of steroid injection with the hanging position and with the commonly used abdomen or cross position.

Methods

A prospective, randomized controlled trial was performed in 42 patients with adhesive capsulitis of shoulder. We used three arm positions for the posterior approach as follows: the patient's palm on thigh, other hand on abdomen (abdomen position); hand on patient's opposite shoulder (cross position); arm in hanging position with internal rotation of shoulder (hanging position). The order of shoulder position was randomized and blinded. Real-time ultrasonography-guided intra-articular steroid injection was performed by posterior approach at the first position in each patient. The Brief Pain Inventory (BPI), the Shoulder Pain and Disability Index (SPADI), and range of motion (ROM) were measured before steroid injection and 2 weeks after injection.

Results

The lengths of the joint space were 2.88±0.75, 2.93±0.89, and 2.82±0.79 mm in abdomen, cross, and hanging position respectively, with no significant difference among the three positions (p=0.429). Treatment efficacy was significantly improved in ROM, total BPI, and SPADI in all three positions (p<0.001). The changes in ROM for shoulder abduction were 23.6°±19.7°, 22.2°±20.9°, and 10.0°±7.8° in abdomen, cross, and hanging position, respectively. Changes in total BPI scores were 25.1±15.7, 23.6.±18.0, 11.6±6.1, and changes in total SPADI score were 35.0±14.2, 30.9±28.9, and 16.5±10.3 in abdomen, cross, and hanging position, respectively. There were no significant difference among the three positions for all parameters (p=0.194, p=0.121, and p=0.108, respectively.

Conclusion

For patients with adhesive capsulitis who cannot achieve or maintain abdomen or cross position, scanning and injection with the shoulder in internal rotation with hanging position may be a useful alternative.