Pharmacological interventions for early-stage frozen shoulder: a systematic review and network meta-analysis.

OBJECTIVES: To evaluate the efficacy of pharmacological interventions for treating early-stage, pain predominant, adhesive capsulitis, also known as frozen shoulder. METHODS: We performed a systematic review in accordance with PRSIMA guidelines. Searches were conducted on PUBMED, EMBASE and Cochrane Central Register of Controlled Trials on the 24th of February 2022. Outcomes were shoulder pain, shoulder function and range of movement. Synthesis involved both qualitative analysis for all studies and pairwise meta-analyses followed by a network meta-analysis for randomised controlled trials (RCTs). RESULTS: A total of 3,252 articles were found, of which 31 met inclusion criteria, and 22 of these were RCTs. Intraarticular (IA) injection of corticosteroids (8 RCTS, 340 participants) and IA injection of platelet-rich plasma (PRP) (3 RCTs, 177 participants) showed benefit at 12 weeks compared with physical therapy in terms of shoulder pain and function, while oral non-steroidal anti-inflammatories (NSAIDs) (2 RCTs, 44 participants) and IA injection of hyaluronate (2 RCTs, 42 participants) did not show a benefit. Only IA PRP showed benefit over physical therapy for shoulder range of movement. CONCLUSION: These results shows that IA corticosteroids IA PRP injections are beneficial for early-stage frozen shoulder. These findings should be appraised with care considering the risk of bias, heterogeneity, and inconsistency of the included studies. We believe that research focused on early interventions for frozen shoulder could improve patient outcomes and lead to cost-savings derived from avoiding long-term disability. Further well-designed studies comparing with standardised physical therapy or placebo are required to improve evidence to guide management.

Are patients with newly diagnosed frozen shoulder more likely to be diagnosed with type 2 diabetes? A cohort study in UK electronic health records.

AIM: To estimate the association between newly diagnosed frozen shoulder and a subsequent diagnosis of type 2 diabetes in primary care. METHODS: We conducted an age-, gender- and practice-matched cohort study in UK primary care electronic medical records containing 31 226 adults diagnosed with frozen shoulder, matched to 31 226 without frozen shoulder. Patients with pre-existing diabetes were excluded. Variables were identified using established Read codes. A hazard ratio (HR) for the association between incident frozen shoulder and a subsequent type 2 diabetes diagnosis was estimated using shared frailty Cox regression, adjusted for age and gender. To determine whether the association could be explained by increased testing for type 2 diabetes based on other risk factors, a secondary analysis involved re-running the Cox model adjusting for the mean number of consultations per year, hyperlipidaemia, hypertension, obesity, thyroid dysfunction, ethnicity, deprivation, age, and gender. RESULTS: Participants with frozen shoulder were more likely to be diagnosed with type 2 diabetes (1559 out of 31 226 patients [5%]) than participants without frozen shoulder (88 out of 31 226 patients [0.28%]). The HR for a diagnosis of type 2 diabetes in participants with frozen shoulder versus people without frozen shoulder was 19.4 (95% confidence interval [CI] 15.6-24.0). The secondary analysis, adjusting for other factors, produced similar results: HR 20.0 (95% CI 16.0-25.0). CONCLUSIONS: People who have been newly diagnosed with frozen shoulder are more likely to be diagnosed with type 2 diabetes in the following 15.8 years. The value of screening patients presenting with frozen shoulder for type 2 diabetes at presentation, alongside more established risk factors, should be considered in future research.

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

OBJECTIVE: To compare the efficacy of rotator interval (RI) vs posterior approach (PA) ultrasound (US) guided corticosteroid injections into the glenohumeral (GH) joint in primary frozen shoulder (PFS). DATA SOURCES: A systematic literature search for all relevant studies on Medline, Scopus, Embase, Web of Science, and Cochrane Central, up to January 2023 was conducted. STUDY SELECTION: Randomized controlled trials that directly compared the US-guided corticosteroid injection into the RI and GH joint using PA in patients clinically and radiographically diagnosed with PFS. DATA EXTRACTION: The primary outcome was pain, and the secondary outcomes were function, and range of motion (ROM). Two authors independently assessed the risk of bias using the Cochrane risk-of-bias tool version 2. A random-effects model and generic inverse variance method were performed. Effect sizes were estimated using mean difference (MD) and standardized mean difference (SMD). DATA SYNTHESIS: A total of 5 clinical trials involving 323 subjects were included for the meta-analysis. US-guided corticosteroid injections into the RI revealed significant pain relief (MD 1.33 [95% confidence interval (CI) 0.20 to 2.46]; P=.02) and significant functional improvement (SMD 1.31 [95% CI 0.11 to 2.51]; P=.03) compared with the PA after 12 weeks. CONCLUSION: The results suggest the injection of corticosteroid into RI space is more effective than PA after 12 weeks in improving both pain and functional scores in patients with PFS.

Pharmacoacupuncture for the Treatment of Frozen Shoulder: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Pharmacoacupuncture (PA) is an alternative injection therapy for a broad range of conditions. This meta-analysis evaluates the effectiveness and safety of PA in treating frozen shoulder (FS) and aims to standardise PA characteristics in clinical practice. METHODS: Randomized controlled trials (RCTs) assessing PA for FS were systematically reviewed from seven electronic databases up to August 31, 2023. Outcomes measured included the visual analogue scale (VAS) or numerical rating scale (NRS), effective rate, Constant-Murley Score (CMS), Shoulder Pain and Disability Index (SPADI), ROM, quality of life (QoL), and adverse events. Data analysis was conducted using RevMan 5.3, with the risk of bias in each trial evaluated using Cochrane's risk of bias tool. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool assessed the quality of evidence. RESULTS: Thirteen RCTs involving 1034 patients met the inclusion criteria, with eleven RCTs and 872 patients included in the meta-analysis. PA showed low-quality evidence of improvement in VAS, effective rate, CMS Total, and CMS Pain. Moderate-quality evidence indicated improvement in CMS ADL and CMS Mobility. PA was effective in four SF-36 subscales: physical function, social role function, mental health, and emotional role function. No significant difference in CMS strength was observed. One trial reported mild anaphylaxis reaction to bee venom as an adverse event. CONCLUSION: PA may offer potential benefits as an alternative injection therapy for FS patients. Further well-designed RCTs with rigorous methodology are required to substantiate its therapeutic efficacy and clinical utility. REGISTRATION: PROSPERO (CRD42023445708).

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 combined ultrasound-guided hydrodilatation with hyaluronic acid and physical therapy in patients with adhesive capsulitis: A randomised controlled trial.

OBJECTIVE: To evaluate the therapeutic effect of combining ultrasound-guided hydrodilatation with hyaluronic acid and physical therapy compared with physical therapy alone in patients with adhesive capsulitis. DESIGN: A prospective, single-blinded, randomised controlled trial. SETTING: Single medical centre. PARTICIPANTS: Patients with adhesive capsulitis (N = 62) were divided into group A: ultrasound-guided hydrodilatation with hyaluronic acid + physical therapy (N = 31) and group B: physical therapy alone (N = 31). INTERVENTIONS: Group A received three doses of ultrasound-guided hydrodilatation with hyaluronic acid-based injectates (20 mL in total). Both groups underwent structured physical therapy. OUTCOME MEASURES: The primary outcome measure was Constant score, while secondary outcomes included Shoulder Pain and Disability Index score, numerical rating scale (at rest, night, and during motion), 36-item Short Form Health Survey, and range of motion of the shoulder. All measurements were collected at baseline, 6 weeks, and 12 weeks post-injection. RESULTS: At week 12, the Constant scores were 68.29 ± 14.55 and 62.77 ± 14.44 for groups A and B, respectively. There was a greater reduction in the Constant score, Shoulder Pain and Disability Index, and numerical rating scale between the baseline and 6 weeks and between the baseline and 12 weeks in group A (Constant score: p < 0.05, Shoulder Pain and Disability Index: p < 0.01, and numerical rating scale: p < 0.05). CONCLUSION: The combination of ultrasound-guided hydrodilatation with hyaluronic acid in conjunction with physical therapy provides additional benefits compared to physical therapy alone for the treatment of adhesive capsulitis at up to 12 weeks. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02708706.

Rehabilitation in subjects with frozen shoulder: a survey of current (2023) clinical practice of Italian physiotherapists.

OBJECTIVE: Frozen Shoulder (FS) is a musculoskeletal pathology that leads to disability, functional decline, and a worsening in quality of life. Physiotherapists are the primary professionals involved in the treatment of FS, and it is essential to determine if their practice aligns with evidence-based suggestions. AIM: The aim is to assess the knowledge, skills, and operational strategies of Italian physiotherapists regarding FS and compare them with the existing literature. METHODS: A web-based, anonymous, and voluntary cross-sectional survey was developed and administered to Italian physiotherapists to evaluate their clinical practices. RESULTS: A total of 501 physiotherapists (38.5% female), completed the survey. More than half were under 35 years old (67.8%), declared working in private practice settings or being self-employed (57.1%), and were primarily engaged with musculoskeletal patients (81.8%). For subjects with FS at their first access, 21.4% identified X-rays as the most useful imaging technique to recognize pathologies beyond rehabilitation competence. In terms of general management, the majority reported working with an orthopaedic or physiatrist (47.5%) or in a multidisciplinary team (33.5%). Regarding manual therapy techniques, 63.3% of physiotherapists preferred intense degree mobilization, posterior direction, and moderate pain at the end of the range of motion for low irritable/high stiffness FS; however, there is a lack of consensus for managing very irritable/low stiffness FS. The majority of physiotherapists (57.7%) concurred that stretching improves the balance between metalloproteinase and its inhibitors. Additionally, 48.3% of physiotherapists selected mobile phone videos and messages to improve patients' compliance with exercises at home and for motivational/educational purposes. DISCUSSION AND CONCLUSION: The clinical practices of Italian physiotherapists in FS subjects sometimes deviate from evidence-based recommendations. While some discrepancies may be attributed to the existing uncertainties in the literature regarding knowledge and management strategies for FS patients, the authors recommend a stronger adherence to evidence-based practice.

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).

Translational targeting of inflammation and fibrosis in frozen shoulder: Molecular dissection of the T cell/IL-17A axis.

Frozen shoulder is a common fibroproliferative disease characterized by the insidious onset of pain and restricted range of shoulder movement with a significant socioeconomic impact. The pathophysiological mechanisms responsible for chronic inflammation and matrix remodeling in this prevalent fibrotic disorder remain unclear; however, increasing evidence implicates dysregulated immunobiology. IL-17A is a key cytokine associated with inflammation and tissue remodeling in numerous musculoskeletal diseases, and thus, we sought to determine the role of IL-17A in the immunopathogenesis of frozen shoulder. We demonstrate an immune cell landscape that switches from a predominantly macrophage population in nondiseased tissue to a T cell-rich environment in disease. Furthermore, we observed a subpopulation of IL-17A-producing T cells capable of inducing profibrotic and inflammatory responses in diseased fibroblasts through enhanced expression of the signaling receptor IL-17RA, rendering diseased cells more sensitive to IL-17A. We further established that the effects of IL-17A on diseased fibroblasts was TRAF-6/NF-κB dependent and could be inhibited by treatment with an IKKß inhibitor or anti-IL-17A antibody. Accordingly, targeting of the IL-17A pathway may provide future therapeutic approaches to the management of this common, debilitating disease.

Psychometric properties of the Disability of Arm Shoulder and Hand (DASH) in subjects with frozen shoulder: a reliability and validity study.

BACKGROUND: Frozen Shoulder (FS) is a painful condition characterized by severe pain and progressive restriction of shoulder movement, leading to functional impairment and reduced quality of life. While different Patient Reported Outcome Measurements (PROMs) tools exist for assessing shoulder diseases, few specific PROMs are validated for FS patients. PURPOSE: This study aims to assess the psychometric properties of the Disability of Arm, Shoulder, and Hand (DASH) questionnaire in FS patients. METHODS: One hundred and twenty-four subjects (mean ± SD age = 55.4 ± 7.9 years; 55.6% female) diagnosed with FS were included and completed the DASH questionnaire, the Numerical Pain Rating Scale (NPRS), the Shoulder Pain and Disability Index (SPADI), and the Short-Form Health Survey 36 (SF-36). Floor or ceiling effects were investigated. Structural validity was analysed through a unidimensional Confirmatory Factor Analysis (CFA), internal consistency through Cronbach's alpha, test-retest reliability through the Intraclass Correlation coefficient (ICC), measurement error through the Standard Error of Measurement (SEM), and the Minimum Detectable Change (MDC), and construct validity through the hypothesis testing with the correlation with the other outcome measures used. RESULTS: No floor or ceiling effects were observed. CFA confirmed a one-factor structure after addressing local item dependency (Root Mean Square Error of Approximation = 0.055; Standardized Root Mean Square Residual = 0.077; Comparative Fit Index = 0.970; Tucker-Lewis Index = 0.968). Cronbach's alpha was high (= 0.951), and test-retest reliability was excellent (ICC = 0.999; 95% CI: 0.998-1.000). SEM was equal to 0.5 points, and MDC to 1.5 points. Construct validity was considered satisfactory as 80% of the a-priori hypotheses were met. CONCLUSION: The DASH questionnaire demonstrated good psychometric properties in FS patients, supporting its use as a valuable tool for assessing the impact of FS in clinical and research settings.

Frozen shoulder: subjects' needs and perspectives and clinicians' beliefs and management strategies: do they align? A cross-sectional study.

OBJECTIVE: Physiotherapists (PTs) play a crucial role in managing individuals with Frozen Shoulder (FS), frequently being the first healthcare professionals involved in the treatment of this condition. AIM: This study aimed to compare the beliefs, expectations, and perspectives of individuals with FS with the knowledge, skills, and strategies of PTs, highlighting similarities and differences. METHOD: This study adhered to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). From May 1st to August 1st, 2023, a two-part survey was conducted involving PTs and individuals diagnosed with FS. The survey focused on comparing key areas such as clinical assessment, patient education, treatment expectations, and the psychological aspects of the patient-clinician relationship. RESULTS: A total of 501 PTs and 110 subjects with FS participated in the survey. Most PTs showed proficiency in FS pathoanatomical conditions and were also attentive to psychological aspects (88.4%), describing the pathology evolution in three or two stages (68.2%). They also highlighted the importance of patient education (89.6%) and recognized the potential benefits of a multiprofessional collaboration in managing FS (82.2%). Reassurance was reported as a priority by 32.3% of PTs. Subjects with FS expressed a preference for PTs who are both expert and empathetic (73.6%). Regarding their understanding of FS, 29.09% of subjects reported receiving a three-phase explanation, while 26.36% felt inadequately informed. Nearly half of the subjects (49.09%) anticipated being managed independently by a PT, with 93.64% prioritizing the improvement of their range of motion. CONCLUSION: This study revealed a general agreement between subjects with FS and PTs regarding aspects of the therapeutic relationship, patient education, pathology management, compliance and motivation strategies, and pain management preferences. However, significant differences emerged concerning the perception of physiotherapy effectiveness, primary treatment goals, subjects' priorities, and the importance of psychological assessment.

The clinical efficacy and safety of platelet-rich plasma on frozen shoulder: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: To systematically review the clinical efficacy (pain, function, quality of life) and safety of platelet-rich plasma (PRP) in the treatment of frozen shoulder through meta-analysis, and provide evidence-based medical evidence for the effectiveness of PRP in the treatment of frozen shoulder. METHODS: A search was conducted on international databases (Pubmed, Web of science, Embase) and Chinese databases (CNKI, Wanfang, VIP) to search the clinical studies on the efficacy of platelet-rich plasma in treating frozen shoulder (adhesive capsulitis/periarthritis/50 shoulder) and their corresponding references published from inception until January 2024. Thoroughly excluded literature not meeting the predetermined inclusion criteria, extracted relevant data from the literature, and input it into RevMan5.4 for meta-analysis. RESULTS: This study ultimately included 14 RCTs, with a total of 1024 patients. The results showed that PRP has significant advantages compared with control groups in VAS (mean difference (MD) =-0.38, 95% confidence interval(CI)(-0.73, -0.03), P = 0.03), UCLA (MD = 3.31, 95% CI (1.02,5.60),P = 0.005), DASH (MD = -4.94,95% CI (-9.34, -0.53),P = 0.03), SPADI (SPADI Total: MD =-16.87, 95% CI (-22.84, -10.91), P < 0.00001; SPADI Pain: MD =-5.38, 95% CI (-7.80, -2.97), P < 0.0001; SPADI Disability: MD =-11.00, 95% CI (-13.61,-8.39), P < 0.00001), and the active and passive Range of Motion (active flexion: MD = 12.70, 95% CI (7.44, 17.95), P < 0.00001; passive flexion: MD = 9.47, 95% CI(3.80, 15.14), P = 0.001; active extension: MD = 3.45, 95% CI(2.39, 4.50), P < 0.00001; active abduction: MD = 13.54, 95% CI(8.42, 18.67), P < 0.00001; passive abduction: MD = 14.26, 95% CI (5.97, 22.56), P = 0.0008; active internal rotation: MD = 5.16, 95% CI (1.84, 8.48), P = 0.002; passive internal rotation: MD = 3.65, 95% CI(1.15, 6.15), P = 0.004; active external rotation: MD = 10.50, 95% CI(5.47, 15.53), P < 0.0001; passive external rotation: MD = 6.00, 95% CI (1.82, 10.19), P = 0.005) except passive extension (MD = 2.25, 95% CI (-0.77, 5.28), P = 0.14). In terms of safety, most studies reported no adverse effects, and only one study reported common complications of joint puncture such as swelling and pain after treatment in both PRP and control groups. Previous studies have shown a risk of osteonecrosis caused by corticosteroids. Therefore, the safety of PRP treatment is more reliable. CONCLUSION: The results showed that PRP was more durable and safer than corticosteroids and other control groups in the treatment of frozen shoulder. STUDY DESIGN: Systematic review. TRIAL REGISTRATION: PROSPERO CRD42022359444, date of registration: 22-09-2022.

Decreased rotator cuff muscle cross-sectional areas in subjects with adhesive capsulitis: a study comparing male and female subjects.

OBJECTIVE: To compare rotator cuff (RC) muscle cross-sectional areas (CSA) in subjects with adhesive capsulitis (AC) to age- and sex-matched controls. MATERIALS AND METHODS: We retrospectively analyzed 97 shoulder MRIs or MR arthrography studies, of which 42 were clinically diagnosed with AC (27 female, 15 male) and 55 were age- and sex-matched controls (38 female, 17 male). All AC subjects underwent imaging ≥ 6 months after symptom onset. All imaging was examined to exclude RC full-thickness tears and prior surgery. A standardized T1 sagittal MR image was segmented in each subject to obtain the CSA of subscapularis (SSC), supraspinatus (SSP), and infraspinatus (ISP) muscles. Differences in CSAs between AC and control subjects were analyzed by sex (females and males separately) and all subjects combined. RESULTS: AC females had significantly decreased SSC (P = 0.002) and total (P = 0.006) CSAs compared to controls. Male AC subjects showed decreased SSC (P = 0.044), SSP (P = 0.001), and total (P = 0.005) CSAs. Across all subjects, male and female, the AC cohort had significantly decreased SSC (P = 0.019) and total (P = 0.029) CSAs compared to controls. CONCLUSION: Decreased RC muscle CSAs were present in AC subjects with ≥ 6 months of symptom duration, with decreased SSC and total CSAs in male and female subjects, and decreased SSP CSA in males.

Diagnostic performance and interreader agreement of individual and combined non-enhanced and contrast-enhanced MR imaging parameters in adhesive capsulitis of the shoulder.

OBJECTIVE: The aims of our study were to analyze agreement among readers with different levels of expertise and diagnostic performance of individual and combined imaging signs for the diagnosis of adhesive capsulitis of the shoulder. METHODS: In a retrospective study, contrast-enhanced shoulder MRIs of 60 patients with and 120 without clinically diagnosed adhesive capsulitis were evaluated by three readers independently. As non-enhanced imaging signs, readers evaluated signal intensity and thickness of the axillary recess capsule, thickness of the rotator interval capsule and the coracohumeral ligament as well as obliteration of subcoracoid fat. Furthermore, contrast enhancement of axillary recess and rotator interval capsule were evaluated. Data analysis included interreader reliability, ROC analysis, and logistic regression (p < 0.05). RESULTS: Contrast-enhanced parameters showed substantially higher agreement among readers (ICC 0.79-0.80) than non-enhanced parameters (0.37-0.45). AUCs of contrast-enhanced signs (95.1-96.6%) were significantly higher (p < 0.01) than of non-enhanced imaging signs (61.5-85.9%) when considered individually. Combined evaluation of axillary recess signal intensity and thicknesses of axillary recess or rotator interval-when at least one of two signs was rated positive-increased accuracy compared to individual imaging signs, however not statistically significant. CONCLUSION: Contrast-enhanced imaging signs show both distinctly higher agreement among readers and distinctly higher diagnostic performance compared to non-enhanced imaging signs based on the imaging protocol used in this study. Combined evaluation of parameters showed a tendency to increase discrimination; however, the effect on diagnosis of ACS was not statistically significant.

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.

MR imaging signs of shoulder adhesive capsulitis: analysis of potential differentials and improved diagnostic criteria.

OBJECTIVE: To evaluate the prevalence of shoulder adhesive capsulitis (AC) signs on MR studies of patients with various common shoulder conditions. METHODS: MR images of 316 patients were retrospectively evaluated. Patients were divided into three groups: controls (66 patients), clinical AC (63 patients), and study group (187 patients). The final diagnosis of AC was reached clinically. The study group was composed of patients with focal and massive rotator cuff tears, active hydroxyapatite deposition disease, fractures around the shoulder, and post-surgery. The following AC signs were evaluated: inferior glenohumeral ligament (IGHL) thickening; coracohumeral ligament (CHL) thickening; and hyperintensity of the inferior glenohumeral ligament, which was graded in four classes. RESULTS: The IGHL signal intensity was statistically higher in patients with fractures than in controls (P = 0.008). There was no statistically significant difference in IGHL signal between the AC group and patients with massive rotator cuff tears and active hydroxyapatite deposition disease (P > 0.1). IGHL thickness in patients with fractures, massive rotator ruptures, and active hydroxyapatite deposition disease was significantly higher compared to controls (P < 0.02) and significantly lower compared to the AC group (P < 0.0001). Based on these findings, a grading system for fibro-inflammatory capsular changes is proposed. CONCLUSION: MR AC signs are frequent in patients with shoulder conditions other than AC; however, in these patients, capsular changes are less prominent than in patients with clinical AC.

A high level of scientific evidence is available to guide treatment of primary shoulder stiffness: The SIAGASCOT consensus.

PURPOSE: Shoulder stiffness (SS) is a condition characterised by active and passive restricted glenohumeral range of motion, which can occur spontaneously in an idiopathic manner or be associated with a known underlying aetiology. Several treatment options are available and currently no consensus has been obtained on which treatment algorithm represents the best choice for the patient. Herein we present the results of a national consensus on the treatment of primary SS. METHODS: The project followed the modified Delphi consensus process, involving a steering, a rating and a peer-review group. Sixteen questions were generated and subsequently answered by the steering group after a thorough literature search. A rating group composed by professionals specialised in the diagnosis and treatment of shoulder pathologies rated the question-answer sets according to the scientific evidence and their clinical experience. RESULTS: Recommendations were rated with an average of 8.4 points out of maximum 9 points. None of the 16 answers received a rating of less than 8 and all the answers were considered as appropriate. The majority of responses were assessed as Grade A, signifying a substantial availability of scientific evidence to guide treatment and support recommendations encompassing diagnostics, physiotherapy, electrophysical agents, oral and injective medical therapies, as well as surgical interventions for primary SS. CONCLUSIONS: A consensus regarding the conservative and surgical treatment of primary SS could be achieved at a national level. This consensus sets basis for evidence-based clinical practice in the management of primary SS and can serve as a model for similar initiatives and adaptable guidelines in other European countries and potentially on a global scale. LEVEL OF EVIDENCE: Level I.

Common characteristics of shoulder injury related to vaccine administration following COVID-19 vaccination: a comprehensive systematic review.

BACKGROUND: The pathogenesis of shoulder injury related to vaccine administration (SIRVA) is incompletely understood, but it is postulated to be an immune-mediated inflammatory response to a vaccine antigen, leading to shoulder pain and dysfunction. The purpose of this investigation is to systematically review the literature related to SIRVA specifically after the COVID-19 vaccination by describing the diagnostic and clinical characteristics, diagnoses associated with SIRVA, and incidence between vaccine types. METHODS: A systematic review was performed to identify level I to IV studies and case descriptions of shoulder pain occurring after COVID-19 vaccination. To confirm that no studies were missing from the systematic review, references of studies from the initial search were scanned for additional relevant studies. RESULTS: A total of 22 studies, comprised of 81 patients, were identified meeting the inclusion/exclusion criteria. Reports were most commonly published from countries in Asia (53.1%; n = 43/81). The most commonly described vaccines were Oxford-AstraZeneca at 37.0% (n = 30/81) and Pfizer-BioNTech at 33.3% (n = 27/81). Symptoms occurred most commonly after at least 72 hours of administration (30.9%, n = 25/81). One hundred percent of patients (n = 81/81) described pain as an associated symptom and 90.1% of patients (n = 73/81) described multiple symptoms. The diagnostic modalities utilized to identify a specific pathology consisted of magnetic resonance imaging (55.6%; n = 45/81), ultrasound (28.4; n = 23/81), radiograph (25.9%; n = 21/81), and computed tomography (4.9%; 4/81). Nearly a third of patients (32.1%; n = 26/81) were diagnosed with bursitis, while 22 (27.2%) were diagnosed with adhesive capsulitis, 17 (21.0%) with either rotator cuff tear or tendinopathy, and 14 (17.3%) with polymyalgia rheumatica or polymyalgia rheumatica-like syndrome. The 2 most common treatment options were physical therapy (34.6%; n = 28/81) and nonsteroidal anti-inflammatory medications (33.3%; 27/81). The majority of SIRVA cases (52.1%; n = 38/73) completely resolved within a few weeks to months. CONCLUSION: Despite the limited quality and lack of large-scale studies, it is important for providers to recognize SIRVA as a potential risk factor as the number of patients receiving COVID-19 vaccinations and boosters continues to rise.

Patient-reported allergies are associated with increased rate of postoperative stiffness after arthroscopic rotator cuff repair.

BACKGROUND: Several risk factors have been identified for the development of postoperative shoulder stiffness, and there has been increasing interest in orthopedic literature regarding patient-reported allergy (PRA) as an identifiable risk factor for adverse outcomes. The purpose of this study is to determine whether PRAs are associated with subsequent rates of diagnosis of adhesive capsulitis (AC) or return to the operating room for postoperative shoulder stiffness within 2 years after arthroscopic rotator cuff repair (ARCR). METHODS: Current Procedural Terminology surgical billing codes were used to retrospectively identify patients who underwent ARCR at a single urban academic institution from January 2012 to December 2020 with minimum 2-year follow-up. Lysis of adhesions (LOA), manipulation under anesthesia (MUA), and AC of the shoulder were further queried within 2 years postoperatively for the ipsilateral shoulder. Patients were excluded if they had undergone ipsilateral MUA/LOA or received a diagnosis of AC before the index procedure. Demographic characteristics and medical comorbidities (hypertension, diabetes, hyperlipidemia, and hypothyroidism) were extracted from electronic medical records. Baseline characteristics were compared between patients with and without PRAs. Multivariate logistic regression analyses were performed to determine the association of the presence of PRAs overall, as well as the presence of 1, 2, or 3 or more PRAs, with subsequent MUA/LOA or diagnosis of AC within 2 years postoperatively. RESULTS: Of 7057 patients identified in the study period, 6583 were eligible for the final analysis. The mean age was 56.6 ± 11.7 years, and the mean body mass index was 29.1 ± 5.6. Overall, 19.3% of patients (n = 1271) reported at least 1 allergy, and 7.1% (n = 469) had >1 PRA. A total of 44 patients (0.7%) underwent subsequent ipsilateral MUA/LOA within 2 years postoperatively, whereas 93 patients (1.4%) received a diagnosis of ipsilateral AC in the same time frame. PRAs were significantly associated with subsequent diagnosis of AC (odds ratio [OR]: 2.39; 95% confidence interval [CI]: 1.45-3.92; P < .001), but not MUA/LOA (OR: 1.97, 95% CI: 1.26-3.61; P = .133). Patients with 2 PRAs had greater odds of being diagnosed with AC than patients with 1 PRA (OR: 2.74; 95% CI: 1.14-5.99; P = .012). Although this association was nonsignificant for MUA/LOA, patients with 2 PRAs (OR: 2.67; 95% CI: 0.96-8.80; P = .059) demonstrated a similar statistical trend. CONCLUSION: PRAs are associated with increased odds of receiving a diagnosis of AC within 2 years after ARCR but were not found to be associated with return to the operating room for postoperative stiffness.

Does concomitant thyroid disorder lead to worse outcomes in frozen shoulder? - A systematic review.

BACKGROUND: Frozen shoulder is a common pathology characterized by significant shoulder pain, range of motion limitation and physical disability. There exists a clear association between the prevalence of frozen shoulder and thyroid disease. However, the effects of concomitant thyroid disease on clinical outcomes of frozen shoulder are less well established. This study aims to evaluate if the presence of thyroid disease predisposes to poorer clinical outcomes in patients with frozen shoulder. METHODOLOGY: The study was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and registered with PROSPERO. Two databases (PubMed and Embase) were searched from date of inception to 9 January 2024. Human studies reporting clinical outcomes of patients with concomitant thyroid disorder and frozen shoulder were included. Risk of bias was assessed based on the Quality In Prognosis Studies (QUIPS) tool and quality of evidence was judged based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework in the domains of range of motion, responsiveness to treatment or timeliness of recovery, and multidimensional scoring systems. RESULTS: Seven studies comprising 167,397 subjects (mean age 52.7 to 58 years, female proportion 67.1%), including 49,314 patients with concomitant thyroid disorder and frozen shoulder were included. Amongst the seven included studies: one study reported improved clinical outcomes in patients with concomitant frozen shoulder and hypothyroidism, one study reported that presence of thyroid disorder led to worse outcomes, while the remaining five studies did not demonstrate evidence of statistically worse outcomes in patients with concomitant thyroid disorder. Based on the GRADE framework, there was no consistent prognostic association between thyroid disorder and frozen shoulder in the domains of range of motion, responsiveness to treatment or timeliness of recovery, and multidimensional scoring systems, and the quality of evidence ranged from 'Very Low' to 'Low'. RISK OF BIAS ASSESSMENT: Based on the QUIPS tool, three studies were assessed to have low risk of bias, while four studies were assessed to have moderate risk of bias. CONCLUSION: Though there exists an association between the prevalence of frozen shoulder and thyroid disorder, there is no consistent evidence in available literature to suggest that concomitant thyroid disorder predisposes to worse clinical outcomes.