Efficacy and safety of topical NSAIDs combined with physiotherapy for frozen shoulder: a randomized controlled trial.

OBJECTIVE: Frozen shoulder is a prevalent condition among individuals in their middle and later years. Invasive therapy has shown promising results in the treatment of frozen shoulders, but its widespread adoption has been hampered by high costs and the need for advanced medical technology. As a result, patients with frozen shoulders often turn to non-steroidal anti-inflammatory drugs (NSAIDs) for symptomatic relief. However, the oral administration of NSAIDs can lead to troublesome adverse effects on the gastrointestinal, cardiovascular, and urinary systems. In contrast, topical NSAIDs have gained attention for their excellent efficacy and lower adverse effects in various chronic pain conditions. Therefore, our study aimed to investigate the efficacy and safety of topical NSAIDs in improving pain and mobility among patients with frozen shoulders. PATIENTS AND METHODS: A total of 108 patients experiencing moderate to severe pain and mobility impairment due to frozen shoulder were enrolled in this study. The participants were randomly assigned to either the experimental group (n=72) or the control group (n=36). The experimental group received daily treatment with the loxoprofen hydrogel patch (LOX-P) in addition to basic rehabilitation physiotherapy. The control group was treated with flurbiprofen cataplasm (FLU-C) twice a day, along with rehabilitation physiotherapy. The primary endpoint for evaluating the efficacy of the two patches was the Constant-Murley score (CMS). Clinical symptom data, adverse events, and patient satisfaction were also recorded. RESULTS: After 14 days of treatment, the effective rate was 66.67% (n=48) in the experimental group and 41.67% (n=15) in the control group. The overall difference in the effective rates was 25.00% (95% CI=5.20-42.52; p=0.013). The safety profiles of the two topical agents were similar, with only a few adverse events reported. CONCLUSIONS: The loxoprofen hydrogel patch demonstrates a significant ability to alleviate shoulder pain and restore shoulder function in the treatment of frozen shoulder, with minimal adverse reactions. Chictr.org.cn ID: ChiCTR2100052375.

Patient experiences of hydrodistension as a treatment for frozen shoulder: A longitudinal qualitative study.

BACKGROUND: Frozen shoulder is a condition associated with severe shoulder pain and loss of function impacting on a persons' physical and mental health. Hydrodistension treatment that has been widely adopted within the UK National Health Service for the condition. However, evidence of clinical effectiveness and understanding of the patient experiences of this treatment are lacking. This study explored the experiences of people with a frozen shoulder who received hydrodistension treatment. METHODS: A qualitative design with repeat semi-structured interviews was used to explore participants' experiences of hydrodistension treatment. Participants were interviewed 2-4 weeks and again at 8-10 weeks after treatment. Interviews were audio-recorded and transcribed verbatim. Findings were analysed using an inductive thematic analysis framework. The study is reported in accordance with the consolidated criteria for reporting qualitative (COREQ) research. RESULTS: 15 participants were interviewed online or over the phone. Three themes were identified: 'Preparing for and having a hydrodistension', 'Physiotherapy after hydrodistension', and 'Outcome of hydrodistension '. Participants believed hydrodistension would benefit them, was well tolerated by many, and the effects were apparent to most within the first week. Physiotherapy still seemed to be valued to support recovery beyond this timepoint, despite these early effects. Some participant's experienced harms including severe procedural pain and blood sugar dysregulation. CONCLUSION: This is the first study to investigate the experiences of people who undergo hydrodistension for frozen shoulder. Hydrodistension appears an acceptable treatment to participants with a frozen shoulder, acceptability is enhanced through adequate shared decision making. Further high-quality research is required to understand the comparative effectiveness of hydrodistension as a treatment for frozen shoulder, including adverse events, and the benefit of treatment by a physiotherapist after hydrodistension.

[OLECRANON BURSITIS].

INTRODUCTION: The olecranon bursa is a pocket-like structure located at the posterior aspect of the elbow that is responsible for the smooth movement of the surrounding tissues. Frequently, it is the source of elbow pain due to an inflammation which may be caused by local injury or penetration of bacteria through the skin. This can lead to an initial acute and possibly a late chronic inflammation. Chronic inflammation may originate from systemic diseases such as gout and rheumatoid arthritis as well. The treatment of olecranon bursitis may be conservative (non-surgical) or surgical. Recently, there is more supporting evidence for the use of conservative management over surgical intervention in treating olecranon bursitis.

[Frozen Shoulder - a short review for the practice].

INTRODUCTION: The Frozen Shoulder is a frequently encountered pathology in clinical practice. This condition often coexists with various comorbidities and is characterized by severe pain and a significantly restricted motion of the affected shoulder. A limited passive external rotation with the arm in adduction, with no signs of any other pathology that could explain the finding, such as shoulder osteoarthritis or an undetected posterior dislocation, is pathognomonic. The course of the disease typically spans over one to two years and is usually self-limiting. In the vast majority of cases, this condition can be managed conservatively. Keywords: shoulder, shoulder stiffness, shoulder pain, conservative therapy.

Efficacy of a high-intensity home stretching device and traditional physical therapy in non-operative management of adhesive capsulitis - a prospective, randomized control trial.

BACKGROUND: Historically, in-person physical therapy serves as a foundational component of nonoperative treatment of adhesive capsulitis (AC). This study compares the effectiveness of an at-home high-intensity stretch (HIS) device to traditional physical therapy (PT) and to PT in combination with the HIS device. We hypothesize that the HIS device will be as effective as PT alone or as combination therapy in the first-line treatment of AC and use of the HIS device will exhibit improvement at higher rate. METHODS: Thirty-four patients with idiopathic adhesive capsulitis and a minimum of 12 months follow-up were included in this study. Patients were randomized into one of the three groups: HIS device, PT alone, or HIS device + PT. Passive range of motion (ROM), American Shoulder and Elbow Surgeons (ASES), and Simple Shoulder Test (SST) scores were measured. Additionally, patient satisfaction, compliance and complications were recorded. Paired t-test, ANOVA and Chi-squared tests were used in analysis. RESULTS: Final ROM in all planes improved for all groups compared to baseline (p < 0.001), with only HIS device group able to restore > 95% of contralateral ROM in all planes at final follow-up. Patients with PT alone were on average slowest to improve ROM from baseline, at 3 months, 6 months, and 1 year in all planes except internal rotation. ASES and SST scores improved for all groups when compared to baseline (p < 0.001). Use of HIS-device resulted in greater improvement in SST and ASES Total scores compared to PT alone (p = 0.045, and p = 0.048, respectively). CONCLUSIONS: Use of an at-home high-intensity stretching device for conservative treatment of idiopathic adhesive capsulitis improves outcomes in ROM and in ASES and SST scores both when used as an adjunct to physical therapy and when used alone. TRIAL REGISTRATION: The study protocol was registered at www. CLINICALTRIALS: gov (20/05/2022, NCT05384093).

Adhesive capsulitis: Utility of magnetic resonance imaging as a primary diagnostic tool and clinical management support.

OBJECTIVE: Adhesive capsulitis (AC) has traditionally been a clinical diagnosis characterized by progressive shoulder pain and decreased range of motion. Our aim is to examine the role of shoulder MRI in making the diagnosis of AC, and to identify the frequency of cases where MRI was the primary method in diagnosing AC amongst medical providers. METHODS: This was an anonymized retrospective analysis. Patients with positive MRI features suggestive for AC from 2015 to 2018 were included. Pre and post MRI clinical notes were assessed in order to ascertain the clinical suspicion of AC. A total of 117 cases were included for this study. RESULTS: Our results demonstrated the number of patients whose management were influenced by shoulder MRI. When all of the imaging parameters by MRI are taken into account by aggregate, there is a statistically significant difference (p-value < 0.01) with regards to orthopedists having their working diagnosis of AC confirmed by the MRI results as compared to the primary care physicians. CONCLUSION: This study supports the role of shoulder MRI in the evaluation of AC. Not only does shoulder MRI assist ordering clinicians with providing additional evidence to support a suspected diagnosis of AC, but also plays a primary role in making the diagnosis of AC in cases in which it was not initially suspected, ultimately impacting management.

Impact of open bursectomy and biceps tendon release with closed manipulation in frozen shoulder.

This retrospective observational study evaluated the efficacy of 2 different surgical approaches for the treatment of frozen shoulder (adhesive capsulitis). This study aimed to compare the efficacy, safety, and recovery times of the 2 treatment modalities. Fifty patients diagnosed with frozen shoulder and treated at Seyhan State Hospital were included in the study. The patients were retrospectively divided into 2 groups based on the treatment received. Group 1 consisted of 25 patients who underwent standard closed manipulation under anesthesia, a technique involving passive movements of the shoulder joint to tear the tight capsule and expand the range of motion (ROM). Group 2, which included 25 patients, underwent closed manipulation in addition to open bursectomy and biceps tendon capsule release. Open bursectomy involves surgical removal of the bursa to alleviate inflammation, while biceps tendon capsule release addresses chronic biceps tendonitis by partially removing the capsule of the tendon. Data on demographic information, operative details, preoperative and postoperative conditions, and patient-reported outcomes were collected and analyzed. Data analysis revealed that the combination of closed manipulation with open bursectomy and biceps tendon capsule release was more effective in reducing pain, increasing ROM, and improving quality of life than closed manipulation alone. The discussion would typically elaborate on how the results compare with existing literature, the clinical implications, and any potential limitations of the study. The results showed that the method that combined closed manipulation with open bursectomy and biceps tendon capsule release was better than closed manipulation alone in terms of reducing pain, increasing ROM, and improving quality of life.

Dynamics of disability and pain indicators under the influence of physical therapy for adhesives capsulitis and myofascial pain syndrome.

OBJECTIVE: Aim: To compare the effectiveness of end-range mobilization and therapeutic exercises, used in combination with ischemic compression, on disability and pain indicators among patients with adhesive capsulitis of the shoulder joint and thoracic myofascial pain syndrome. PATIENTS AND METHODS: Materials and Methods: The study involved 68 patients. Goniometry of the shoulder joint, assessment of pain in myofascial trigger points, and the Shoulder Pain and Disability Index questionnaire were used before and after physical therapy. The duration of physical therapy comprised 3 weeks. Physical therapy of the first group of patients consisted of end-range mobilization and ischemic compression. Patients of the second group performed therapeutic exercises and ischemic compression. RESULTS: Results: Both groups demonstrated positive dynamics of shoulder joint mobility, Shoulder Pain and Disability Index and pain in trigger points. However, the final results of the studied indicators were better in the first group of patients. CONCLUSION: Conclusions: Physical therapy based on the combination of end-range mobilization and ischemic compression had a more positive impact on disability and pain indicators for adhesive capsulitis of the shoulder joint and myofascial pain syndrome as compared to the combination of therapeutic exercises and ischemic compression.

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.

What factors influence pain scores following Corticosteroid injection in patients with Greater Trochanteric Pain Syndrome? A systematic review.

BACKGROUND: Cortico-Steroid Injections (CSI) are commonly used to treat patients with Greater Trochanteric Pain Syndrome (GTPS) but it is unclear which patients will experience improvements in pain. OBJECTIVES: To identify factors that influence improvements in pain for patients with GTPS treated with CSI. DESIGN: Systematic review. METHODS: A search was undertaken of AMED, CINAHL, Cochrane Library, EMBASE, Medline and PEDro databases. Studies were eligible for inclusion if they investigated factors that influenced changes in pain experienced by patients with GTPS who received a CSI. Studies needed to include relevant summary statistics and tests of clinical significance. Risk Of Bias in Non-randomised Trials Of Interventions (ROBINS-I) and Risk Of Bias 2 (ROB2) tools were used to assess bias. RESULTS: The search identified 466 studies, 8 were included in the final review with a total of 643 participants. There was no association between demographic variables such as age, sex, symptom duration or obesity and pain outcomes post-CSI. Having a co-existing musculoskeletal (MSK) condition such as knee osteoarthritis or sacroiliac/lumbar spine pain was associated with less pain reduction post-CSI. Injections into the Trochanteric Bursa were associated with longer lasting pain reduction than Gluteus Medius Bursa or extra-bursal injections. Image guidance of CSI maintained lower pain scores at six months but did not increase the duration of the therapeutic effect past six months. The presence of specific ultrasound scan features was not associated with differences in pain scores. CONCLUSIONS: Patients with co-existing MSK conditions may not respond to CSI as well as those without. Injections into the Greater Trochanteric Bursa may have longer lasting benefit. Further research is needed on the use of USS imaging findings and image guidance.

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.

Transarterial Embolization for Adhesive Capsulitis of the Shoulder: Midterm Outcomes on Function and Pain Relief.

PURPOSE: To determine the safety and potential effectiveness of transarterial embolization for adhesive capsulitis of the shoulder. MATERIALS AND METHODS: This prospective study analyzed consecutive adult patients with adhesive capsulitis referred for embolization between January 2018 and May 2023 after a poor response to treatment (symptoms and limitation of motion in ≥2 axes; ≤120° flexion, ≤50° external rotation and/or internal rotation with the shoulder abducted 90°) persisting for >3 months after having completed ≥6 weeks of analgesics and physical therapy. Different types of pain and mobility were measured before embolization and 1, 3, and 6 months after embolization. Overall upper limb function (Quick Disabilities of Arm, Shoulder, and Hand) and patient satisfaction were measured before and 6 months after embolization. Long-term follow-up comprised telephone interviews and clinical history reviews. RESULTS: A total of 20 patients (12 [60%] women; median age, 50.7; interquartile ranges [IQR], 45‒55 years) were included; 6 (30%) had diabetes and 15 (75%) were off work. Median duration of symptoms before embolization was 39.4 weeks (IQR, 28‒49 weeks), and median duration of rehabilitation therapy was 12.8 weeks (IQR, 8‒16 weeks). Six months after embolization, significant improvements were observed in nocturnal pain (P = .003), pain on moving (P = .001), external rotation (P < .001), internal rotation (P < .001), active flexion (P < .001), passive flexion (P = .03), active abduction (P < .001), passive abduction (P < .001), and overall function (P < .001). Despite objective improvements, patient satisfaction was nearly unchanged. Only 1 patient experienced a mild adverse event. CONCLUSION: Transarterial embolization is safe and potentially effective in treating adhesive capsulitis of the shoulder refractory to conventional treatment. Clinical improvements were maintained in the mid to long term.

Injections of the Hip and Knee.

Hip and knee injections are useful diagnostic and therapeutic tools for family physicians. This article reviews anatomic landmark-guided and ultrasound-guided injections and aspiration techniques for greater trochanteric pain syndrome, the hip joint, the knee joint, the pes anserine bursa, and the iliotibial band. Indications for injections include acute and chronic inflammatory conditions, such as rheumatoid arthritis; osteoarthritis; overuse; and traumas. Joint aspirations may be performed to aid in the diagnosis of unexplained effusions and to relieve pain. Technique, injectant, and follow-up timing depend on the physician's comfort, experience, and preference. Infections of the skin or soft tissue are the primary contraindications to injections. The most common complications are local inflammatory reactions to the injectant. These reactions usually cause soreness for 24 to 48 hours, then spontaneously resolve. Follow-up after injections is usually scheduled within two to six weeks.

Proteomics and phosphoproteomics to study Tuina reverses capsule fibrosis in frozen shoulder: a research report based on rats.

Frozen shoulder (FS) is a common disorder often treated with Tuina, but the mechanisms involved remain unclear. We employed proteomics and phosphoproteomics to investigate the mechanisms associated with the treatment of capsule fibrosis in FS rats. We used a method composed of three weeks of cast immobilization to establish a model of FS. We then administered Tuina once daily for 14 days, evaluated glenohumeral range of motion (ROM), assessed histological changes, and identified differentially expressed proteins (DEPs) using proteomics and phosphoproteomics. This study demonstrated that Tuina could improve glenohumeral ROM and reserve capsule fibrosis in FS rats. Proteomics revealed proteins regulated by Tuina belonging to the PI3K-AKT and ECM receptor interaction signaling pathways. Phosphoproteomics detected differentially phosphorylated proteins regulated by Tuina to be enriched in the MAPK signaling pathway. The combination of proteomics and phosphoproteomics for Protein-Protein Interaction (PPI) network analysis revealed that the phosphorylation of Myh3 and Srsf1 with a node degree larger than the average degree were considered the central regulatory protein modulated by Tuina to reverse capsule fibrosis. Thbs1, Vtn, and Tenascin-W were significantly enriched in PI3K-AKT and ECM receptor interaction signaling pathways and highly expressed in model rats. Tuina resulted in reduced expression of these proteins. Our findings demonstrated some of mechanisms behind the reversal of FS capsule fibrosis following Tuina, a scientific medical therapy for FS patients.

Low-dose radiotherapy for greater trochanteric pain syndrome-a single-centre analysis.

PURPOSE: To determine predictive factors associated with a good response (GR) to and efficacy of low-dose radiotherapy (LDRT) in patients with greater trochanteric pain syndrome (GTPS). METHODS: Patients with GTPS were irradiated on a linear accelerator with 0.5-1.0 Gy per fraction to a total dose of 3.0-4.0 Gy per series. The endpoint was subjective good response (GR) to treatment 2 months after completion of the last LDRT series, defined as complete pain relief or marked improvement assessed using the von Pannewitz score. A positive response to steroid injection (SI) was defined as pain relief of at least 7 days. Patient and treatment-related characteristics were evaluated with respect to LDRT outcomes. RESULTS: Outcomes were assessed for 71 peritrochanteric spaces (PTSs; 65 patients, 48 females, with mean age of 63 [44-91] years). Prior SI had been given to 55 (77%) PTSs and 40 PTSs received two series of LDRT. Two months after completion of LDRT, GR was reported in 42 PTSs (59%). Two series of LDRT provided a significantly higher rate of GR than one series (72.5 vs. 42% PTSs, p = 0.015). Temporary pain relief after prior SI predicted GR to LDRT compared with PTSs which had not responded to SI (73 vs. 28% PTSs, p = 0.001). A regional structural abnormality, present in 34 PTSs (48%), was associated with a reduction of GR to LDRT (44 vs. 73% PTSs, p = 0.017). CONCLUSION: LDRT is an effective treatment for GTPS. Administration of two LDRT series, prior response to SI, and absence of structural abnormalities may predict significantly better treatment outcomes.

Ultrasound-guided hydrodilatation for adhesive capsulitis: capsule-preserving versus capsule-rupturing technique.

OBJECTIVE: To compare the clinical efficacy of capsule-rupturing versus capsule-preserving ultrasound-guided hydrodilatation in patients with shoulder adhesive capsulitis (AC). To determine potential factors affecting the outcome over a 6-month follow-up. MATERIALS AND METHODS: Within a 2-year period, 149 consecutive patients with AC were prospectively enrolled and allocated into (i) group-CR, including 39 patients receiving hydrodilatation of the glenohumeral joint (GHJ) with capsular rupture and (ii) group-CP, including 110 patients treated with GHJ hydrodilatation with capsular preservation. Demographics, affected shoulder, and AC grade were recorded. Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and visual analog scale (VAS) were used for clinical assessment at baseline/1/3/6 months. Comparisons were performed with Mann-Whitney U test and Kolmogorov-Smirnov test. Linear regression was used to identify predictors of outcome. P value < 0.05 defined significance. RESULTS: DASH and VAS scores in both groups improved significantly compared to baseline (P < 0.001) and were significantly lower in the CP compared to CR group at all time-points following intervention (P < 0.001). Capsule rupture was a significant predictor of DASH score at all time-points (P < 0.001). DASH scores correlated to initial DASH score at all time-points (P < 0.001). DASH/VAS scores at 1 month were correlated to the AC grade (P = 0.025/0.02). CONCLUSION: GHJ hydrodilatation results in pain elimination and functional improvement till the mid-term in patients with AC, with improved outcome when adopting the capsule-preserving compared to the capsule-rupturing technique. Higher initial DASH score is predictive of impaired functionality in the mid-term.