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

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

Factors associated with better treatment outcome of physical therapy interventions after shoulder arthroplasty: A systematic review.

OBJECTIVE: To summarize factors that are associated with a better treatment outcome after post-operative physical therapy in patients with shoulder arthroplasty. DATA SOURCES: PubMed, Cochrane, and Web of Science. REVIEW METHODS: Studies examining factors that are associated with a better outcome after post-operative physical therapy interventions in patients with shoulder arthroplasty were included. Two independent reviewers performed screening, extracted data, and assessed the risk of bias and level of evidence, using the Quality In Prognosis Studies tool and Evidence-Based Guideline Development checklist. PRISMA guidelines were followed. RESULTS: In total, 460 articles were found and 14 studies were included. Two of the included articles had a moderate risk of bias, 12 high. The overall number of patients in the included studies varied from 20 to 2053. Patients had either a reverse (N = 1863), an anatomic total shoulder arthroplasty (N = 1029) or, a hemiarthroplasty (N = 133). Anatomic total shoulder arthroplasty patients with a neutral rotation sling position showed less night pain and greater range of motion, which was awarded moderate evidence. Other modifiable and non-modifiable factors such as telemedicine, immediate range of motion exercises, and pre-operative function were only awarded preliminary or conflicting evidence. CONCLUSION: Mainly preliminary and conflicting evidence was found. The possible causes of the conflicting evidence were the different measurement methods, implant types, and follow-up times used. The methodological quality was low and physical therapy protocols differed greatly. More high-quality research with standardized protocols is needed to determine the association of various factors with treatment outcomes after post-operative physical therapy in patients with shoulder arthroplasty.

Tendon progenitor cells as biological augmentation improve functional gait and reduce scar formation after rotator cuff repair.

BACKGROUND: High rates of structural failure are reported after rotator cuff repairs due to inability to recreate the native enthesis during healing. The development of biological augmentation methods that mitigate scar formation and regenerate the enthesis is still an unmet need. Since neonatal enthesis is capable of regeneration after injury, this study tested whether delivery of neonatal tendon progenitor cells (TPCs) into the adult injured environment can enhance functional and structural supraspinatus enthesis and tendon healing. METHODS: TPCs were isolated from Ai14 Rosa26-TdTomato mouse Achilles tendons and labeled using adenovirus-Cre. Fifty-two CB57BL/6J mice underwent detachment and acute repair of the supraspinatus tendon and received either a fibrin-only or TPC-fibrin gel. Immunofluorescence analysis was carried out to determine cellularity (DAPI), fibrocartilage (SOX9), macrophages (F4/80), myofibroblasts (α-smooth muscle actin), and scar (laminin). Assays for function (gait and biomechanical testing) and structure (micro-computed tomography imaging, picrosirius red/Alcian Blue staining, type I and III collagen staining) were carried out. RESULTS: Analysis of TdTomato cells after injury showed minimal retention of TPCs by day 7 and day 14, with detected cells localized near the bursa and deltoid rather than the enthesis/tendon. However, TPC delivery led to significantly increased %Sox9+ cells in the enthesis at day 7 after injury and decreased laminin intensity across almost all time points compared to fibrin-only treatment. Similarly, TPC-treated mice showed gait recovery by day 14 (paw area and stride length) and day 28 (stance time), while fibrin-treated mice failed to recover gait parameters. Despite improved gait, biomechanical testing showed no differences between groups. Structural analysis by micro-computed tomography suggests that TPC application improves cortical thickness after surgery compared to fibrin. Superior collagen alignment at the neo-enthesis was also observed in the TPC-augmented group at day 28, but no difference was detected in type I and III collagen intensity. CONCLUSION: We found that neonatal TPCs improved and restored functional gait by reducing overall scar formation, improving enthesis collagen alignment, and altering bony composition response after supraspinatus tendon repair. TPCs did not appear to integrate into the healing tissue, suggesting improved healing may be due to paracrine effects at early stages. Future work will determine the factors secreted by TPCs to develop translational targets.

Editorial Commentary: Taming Hard Problems With Soft Tissues? Anterior Shoulder Instability After Prior Bone Block Stabilization.

Recurrent anterior shoulder instability after prior bone block stabilization is a therapeutically challenging condition. Historically, repeated glenoid bone grafting has been advocated in such cases to achieve lasting shoulder stability. However, recent insights into the pathomechanics of shoulder instability, especially regarding bipolar bony lesions, have renewed our interest in the arthroscopic treatment of Hill-Sachs lesions and the role of soft-tissue interventions after bone block procedures.

Analysis of failures after the Bristow-Latarjet procedure for recurrent shoulder instability.

PURPOSE: Despite good clinical results and low recurrence rates, post-operative complications of coracoid process transfer procedures are not well understood. This study aims to evaluate the underlying failure mechanism in cases requiring major open revision surgery after prior Bristow or Latarjet stabilization. METHODS: Between January 2006 and January 2017, 26 patients underwent major open revision after primary Bristow or Latarjet procedure. Clinical notes and radiographic images were retrospectively reviewed for all cases to determine underlying pathology. Choice of treatment and clinical and radiographic outcome were similarly reported for all cases. RESULTS: The underlying failure mechanism was associated with non-union in 42.3%, resorption in 23.1%, graft malpositioning in 15.4%, and trauma or graft fracture in 19.2% of cases. Although none of the patients reported any dislocations, mean subjective shoulder score was 60.2% and WOSI scores averaged 709.3 points at final follow-up. Radiographic signs of deteriorating degenerative arthritis were seen in 34.6%. CONCLUSION: Graft non-union resulting in recurrent instability was the main indication for open revision surgery after Bristow or Latarjet procedure, followed by resorption, malpositioning, and graft fracture in this retrospective case series. Revision surgery consisted of a structural iliac crest bone graft in the majority of cases. Clinical and radiographic outcomes are predictably variable in this population of multioperated patients.

Can the contralateral scapula be used as a reliable template to reconstruct the eroded scapula during shoulder arthroplasty?

HYPOTHESIS: The contralateral scapula can be used as a reliable template to determine scapular offset, glenoid inclination, and version of the native scapula in view of reconstructing pathologic scapulae. METHODS: Three-dimensional measurements of scapular offset, inclination, and version were performed using data from a set of 50 bilateral computed tomography scans of full scapulae to determine direct side-to-side differences. RESULTS: The scapula pairs had a mean bilateral difference of 2 mm in offset, 2° in inclination, and 2° in version. Ninety percent of the scapula pairs showed an offset difference smaller than 3 mm. In 96% and 94% of the scapula pairs, the inclination difference and version difference, respectively, were smaller than 5°. The maximum bilateral difference for offset, inclination, and version was 6 mm, 6°, and 8°, respectively. DISCUSSION AND CONCLUSION: The anatomic parameters of scapular offset, glenoid inclination, and version are quite symmetrical and fall into the currently technically feasible accuracy of shoulder arthroplasty implantation. The healthy scapula can be used as a template to guide the reconstruction of the glenoid during shoulder arthroplasty planning in the case of unilateral advanced arthropathy.

Restoration of Articular Geometry Using Current Graft Options for Large Glenoid Bone Defects in Anterior Shoulder Instability.

PURPOSE: The purpose of this cadaveric study was to compare standard and modified coracoid transfer procedures, bicortical and tricortical iliac crest autografts, and tibial plafond and glenoid allografts with respect to glenoid surface curvature restoration. METHODS: Computed tomography scans of 8 cadaveric shoulders were acquired in 9 conditions: (1) intact, (2) 25% width defect, (3) classic Latarjet, (4) modified congruent-arc Latarjet, (5) tricortical iliac crest inner table, (6) outer table, (7) bicortical iliac crest, (8) distal tibia, and (9) glenoid allograft. Outcome measures included articular surface area, width, depth, axial and coronal radius of curvature, and subchondral articular step-off, analyzed in bone and soft-tissue window. RESULTS: Reconstruction of the articular surface area was optimal with the glenoid allograft (99.4%), classic Latarjet (97.4%), and iliac crest bicortical graft (93.2%). Depth was best restored by the congruent-arc Latarjet (101.0%), tibial (98.9%), and glenoid (95.3%) allografts. Axial curvature was closely matched by the glenoid allograft (97.5%), classic Latarjet (108.7%), and iliac bicortical graft (91.2%). Coronal curvature was most accurately restored by the glenoid allograft (102.6%), the tibial allograft (115.0%), and the classic Latarjet (55.9%). The articular step-off was smallest using the glenoid allograft. CONCLUSIONS: Overall, glenoid allografts most accurately restored articular geometry. Alternative grafts provided restoration of some parameters but not others. Classic Latarjet performed well in axial and coronal curvature on average but exhibited large variability. Tibial allograft produced the poorest results in axial curvature, despite excellent coronal curvature reconstruction. The congruent-arc Latarjet did not restore the axial curvature accurately and overcorrected coronal curvature. Graft geometry must be weighed against availability, morbidity, and the role of additional stabilizers. CLINICAL RELEVANCE: Accurate graft morphology may help prevent postoperative osteoarthritis. Grafts differ significantly regarding geometric parameters. The findings of this study will help surgeons select the most appropriate graft for glenoid reconstruction.

Efficacy of Different Types of Mobilization Techniques in Patients With Primary Adhesive Capsulitis of the Shoulder: A Systematic Review.

OBJECTIVE: To systematically review the literature for efficacy of isolated articular mobilization techniques in patients with primary adhesive capsulitis (AC) of the shoulder. DATA SOURCES: PubMed and Web of Science were searched for relevant studies published before November 2014. Additional references were identified by manual screening of the reference lists. STUDY SELECTION: All English language randomized controlled trials evaluating the efficacy of mobilization techniques on range of motion (ROM) and pain in adult patients with primary AC of the shoulder were included in this systematic review. Twelve randomized controlled trials involving 810 patients were included. DATA EXTRACTION: Two reviewers independently screened the articles, scored methodologic quality, and extracted data for analysis. The review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. All studies were assessed in duplicate for risk of bias using the Physiotherapy Evidence Database Scale for randomized controlled trials. DATA SYNTHESIS: The efficacy of 7 different types of mobilization techniques was evaluated. Angular mobilization (n=2), Cyriax approach (n=1), and Maitland technique (n=6) showed improvement in pain score and ROM. With respect to translational mobilizations (n=1), posterior glides are preferred to restore external rotation. Spine mobilizations combined with glenohumeral stretching and both angular and translational mobilization (n=1) had a superior effect on active ROM compared with sham ultrasound. High-intensity mobilization (n=1) showed less improvement in the Constant Murley Score than a neglect group. Finally, positive long-term effects of the Mulligan technique (n=1) were found on both pain and ROM. CONCLUSIONS: Overall, mobilization techniques have beneficial effects in patients with primary AC of the shoulder. Because of preliminary evidence for many mobilization techniques, the Maitland technique and combined mobilizations seem recommended at the moment.

Reliability analysis of glenoid component inclination measurements on postoperative radiographs and computed tomography-based 3D models in total and reversed shoulder arthroplasty patients.

BACKGROUND: Only a few articles describe the reproducibility and clinical feasibility of glenoid inclination measurements on conventional radiographs, and none of them validated their method in shoulder arthroplasty cases. From a clinical point of view, the angle measured between the supraspinatus fossa and the glenoid fossa line (angle ß) appears to be the most interesting angle to assess glenoid inclination. This study aimed to validate the angle ß in shoulder arthroplasty patients to facilitate the assessment of glenoid component inclination. MATERIALS AND METHODS: Seventeen patients who underwent total or reverse shoulder arthroplasty were evaluated. The angle ß was measured by 2 independent observers on postoperative radiographs and 3-dimensional (3D) models. The interobserver variability and accuracy of angle ß were analyzed by calculating the intraclass correlation coefficient (ICC) and by generating Bland-Altman plots. RESULTS: The angle ß showed a good interobserver variability (ICC = 0.971 for radiographs, ICC = 0.980 for 3D models) and a good agreement between the radiographic and 3D measurements (ICC = 0.904 for observer 1 and ICC = 0.908 for observer 2). Bland-Altman plots demonstrated that in 95% of the measurements on radiographs, the error will be <10. In the investigated population, 85% showed an error <6. CONCLUSION: This study demonstrates that angle ß can be measured on radiographs to assess glenoid component inclination in total and reverse shoulder arthroplasty, but clinicians and researchers should keep in mind that measurement errors of 10° may occur in a minority of cases.

Patient-specific instrument guidance of glenoid component implantation reduces inclination variability in total and reverse shoulder arthroplasty.

BACKGROUND: The aim of this study was to assess the influence of 3-dimensional (3D) preoperative planning and patient-specific instrument (PSI) guidance of glenoid component positioning on its inclination in total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA). MATERIALS AND METHODS: Thirty-six shoulder arthroplasties (12 TSAs, 24 RSAs) were analyzed, of which 18 procedures (6 TSAs, 12 RSAs) were executed using preoperative 3D planning and patient-specific guides to position the central guide pin for glenoid component implantation. In 9 cases, the glenoid anatomy was severely distorted through wear or previous surgery. The inclination of the glenoid component was measured by 2 observers, using the angle between the glenoid baseplate and the floor of the supraspinatus fossa (angle ß) on postoperative radiographs. RESULTS: For TSA, the average angle ß was 74 ± 9 in the PSI group and 86 ± 12 in the non-PSI group; for RSA, the average angle ß was 83 ± 7 in the PSI group and 90 ± 17 in the non-PSI group. Extreme angles ß, which represent extreme values of glenoid component inclination, are more likely to occur in the non-PSI group than in the PSI group (P < .001 for TSA; P = .02 for RSA). CONCLUSIONS: The3D preoperative surgical planning and PSI guidance reduce variability in glenoid component inclination and avoid extreme inclination errors for TSA and RSA.

Iliac bone grafting of the intact glenoid improves shoulder stability with optimal graft positioning.

BACKGROUND: Bone grafting procedures are increasingly popular for the treatment of anterior shoulder instability. In patients with a high risk of recurrence, open coracoid transplantation is preferred but can be technically demanding. Free bone graft glenoid augmentation may be an alternative strategy for high-risk patients without significant glenoid bone loss. This biomechanical cadaveric study assessed the stabilizing effect of free iliac crest bone grafting of the intact glenoid and the importance of sagittal graft position. METHODS: Eight fresh frozen cadaveric shoulders were tested. The bone graft was fixed on the glenoid neck at 3 sagittal positions (50%, 75%, and 100% below the glenoid equator). Displacement and reaction force were monitored with a custom device while translating the humeral head over the glenoid surface in both anterior and anteroinferior direction. RESULTS: Peak force (PF) increased significantly from the standard labral repair to the grafted conditions in both anterior (14.7 ± 5.5 N vs 27.3 ± 6.9 N) and anteroinferior translation (22.0 ± 5.3 N vs 29.3 ± 6.9 N). PF was significantly higher for the grafts at the 50% and 75% positions compared with the grafts 100% below the equator with anterior translation. Anteroinferior translation resulted in significantly higher values for the 100% and 75% positions compared with the 50% position. CONCLUSIONS: This biomechanical study confirms improved anterior glenohumeral stability after iliac crest bone graft augmentation of the anterior glenoid. The results also demonstrate the importance of bone graft position in the sagittal plane, with the ideal position determined by the direction of dislocation.

Long-term survival of the glenoid components in total shoulder replacement for arthritis.

PURPOSE: Aseptic glenoid component loosening remains a common problem in total shoulder arthroplasty (TSA). This study presents long-term prospective follow-up after implantation of a glenoid component using the "cancellous compaction technique" and its effect on clinical outcome and presence and progression of radiolucent lines (RLLs). METHOD: Thirty-nine TSAs were performed for primary osteoarthritis by one surgeon using the same technique. For the glenoid side, a keeled, polyethylene, convex-backed component was implanted using the "cancellous compaction technique" consisting of minimal reaming, compaction bone grafting of the glenoid and minimal addition of cement. Postoperative clinical outcome was analysed using Constant scores and patient's subjective evaluation. Independent observers evaluated postoperative X-rays for radiolucent lines (RLL) around the base plate and keel. RESULTS: At an average follow-up of 8.5 years (range 4.7-12.5), the Constant score improved from 33.5 to 73.0 points (P < 0.0001). Active anterior elevation improved from an average 95 ° to 140° (P < 0.0001), and active external rotation improved from 20° to 45° (P < 0.0001). Pain score improved from 3.1 to 13.6 (P < 0.0001). Radiologically, the RLL score increased from 1.09 (range, 0-3) postoperative to 5.7 (range, 0-18) (P < 0.0001) at final follow-up. The occurrence of definite radiological glenoid loosening was 15.5 %. Constant scores deteriorated with the progression of RLLs (P = 0.006). The rate of revision surgery for glenoid loosening was 2.5 %. CONCLUSIONS: This study showed highly satisfactory clinical outcomes and low rates of revision for glenoid loosening using a bone-saving compaction technique for implantation of an all-polyethylene glenoid component.

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

BACKGROUND: the pathogenesis of frozen shoulder (FS) is thought to be one of inflammation and fibrosis possibly influenced by hyperglycemia. Biomechanical changes of the shoulder joint in terms of muscle strength, scapular kinematics and proprioception might occur in FS. OBJECTIVES: to compare muscle strength, scapular kinematics, proprioception, and blood glucose levels within patients with FS and to asymptomatic individuals. DESIGN: cross-sectional study. METHOD: Thirty-five patients with FS and 35 asymptomatic age and gender-matched individuals underwent physical assessment to determine muscle strength (abduction, external and internal rotation), scapular kinematics (both visually and with a plurimeter), proprioception (joint position sense), and blood glucose level. RESULTS: Patients with FS showed a decrease in muscle strength in their affected shoulder compared to both the unaffected shoulder and asymptomatic individuals. Significant differences were found between the affected and unaffected shoulder in the FS group and between groups (FS versus controls) in scapular upward rotation (plurimeter) at 30° and 60° abduction. No difference in scapular kinematics (visual observation), proprioception, and blood glucose levels was found neither between shoulders in the FS group nor between groups. CONCLUSION: A clinically relevant difference in muscle strength and increase in scapular upward rotation were found in the affected shoulder of patients with FS compared to their unaffected side and controls. However, no evidence of different levels of scapular kinematics (visual observation), proprioception, and blood glucose levels in the affected shoulder compared to the unaffected shoulder or controls is lacking.

Arthroscopic bone block augmentation of the anterior glenoid through the rotator interval: a cadaveric feasibility study.

HYPOTHESIS: Arthroscopic augmentation of the anterior glenoid using a free bone graft through the rotator interval is possible without compromising the fixation and position of the graft MATERIAL AND METHODS: In 7 cadavers arthroscopic augmentation of the anterior glenoid was performed. A preshaped, free graft was introduced and fixated with 1 central screw without desinsertion or split of the subscapularis tendon. Postoperatively, the orientation and position of the screw and position of the graft in the vertical and horizontal plane were analyzed on computer tomography (CT) scan. Macroscopic dissection was performed to assess damage to the conjoined and subscapularis tendon and surrounding neurovascular structures and to verify the position of the graft. RESULTS: Postoperative CT scans showed no intra-articular perforation of the screw. The mean inclination angle in the axial plane was 21,2° (range, 9-48°). Postoperative dissection showed no damage to surrounding neurovascular structures. Fraying occurred at the lateral border of the conjoined tendon in 3 specimens, at the upper border of the subscapularis in 5 cases, but no tears were noted. In the vertical plane, the augmentation block was correctly (subequatorial) positioned in 5 cases; 2 blocks were at the level of the equator. In the horizontal plane, the augmentation block was flush with the articular surface in 5 cases and too medial in 2 cases (<5 mm). CONCLUSION: This study showed that it is technically possible to perform a bone block procedure arthroscopically through the rotator interval without compromising the position and fixation of the graft and fixation screw.

Clinical and radiological outcome of all-suture anchors in shoulder and elbow surgery.

Background: All-suture anchors (ASAs) are noted to cause various bone reactions when used in upper limb surgery but clinical implications are unknown. Methods: 88 shoulders and 151 elbows with a mean follow-up of 47.1 ± 17.7 months were invited for follow-up including clinical examination, questionnaires and radiographs. The anchor drill holes were radiographically assessed. Results: At final follow up, mean DASH was 12.9 ± 13.8 and mean VAS 2.2 ± 2.4 in the shoulder population. In the elbow group mean MEPS was 91.8 ± 12.7 and mean VAS 1.5 ± 1.9. Implant-specific complications were seen in 10 elbow cases but none in the shoulder group. The mean diameter of the 1.4 mm all-suture anchor drill hole was enlarged to 2.5 ± 1.4 mm in the shoulder group and to 2.9 ± 1.0 mm in the elbow group. 50% of the 1.4 mm anchor drill holes showed abnormal morphology but these morphologic changes did not correlate with clinical outcome, complications or reoperation rate. Discussion: Satisfying clinical outcomes are found in upper limb surgery using ASAs. Various bone changes are seen after implantation of an ASA, but these are not clinically relevant. Long-term consecutive follow-up data is required.

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

BACKGROUND: Contradictory evidence exists regarding the clinical course of frozen shoulder (FS). OBJECTIVES: To explore the clinical course of FS regarding disabilities, pain, range of motion (ROM), muscle strength, scapular upward rotation, and proprioception and to establish longitudinal correlations between these variables. METHODS: Patients with FS were prospectively followed for 9 months at 3-month intervals. Assessment included the Disabilities of the Arm, Shoulder and Hand questionnaire; visual analogue scale for pain; an inclinometer for shoulder external rotation (ER), internal rotation (IR), flexion, and abduction ROM, and scapular upward rotation and proprioception, as well as handheld dynamometry for muscle strength in shoulder abduction, ER, and IR. RESULTS: Initially, 149 patients (98 females; mean (SD) age 53 (9) years) were included, with 88 completing all follow-up assessments. Most variables showed early improvement in the clinical course of FS, particularly ER and IR at 90° abduction, which continued to improve from 6 to 9 months of follow-up. Associations were observed between disabilities and pain (r = 0.61), disabilities/pain and ROM (r=-0.62 to -0.59 and r=-0.47 to -0.39, respectively), disabilities/pain and muscle strength (r=-0.24 to -0.35 and r=-0.36 to -0.17, respectively), and between disabilities/pain and scapular upward rotation below shoulder level (r = 0.23 to 0.38 and r = 0.24 to 0.30, respectively). ROM correlated with muscle strength (r = 0.14 to 0.44), while both ROM and ER muscle strength correlated with scapular upward rotation below shoulder level (r=-0.37 to -0.23 and r=-0.17 to -0.12, respectively). Muscle strength correlated with scapular upward rotation above shoulder level (r = 0.28 to 0.38) and lift-off muscle strength correlated with joint repositioning (r=-0.17 to -0.15). CONCLUSION: Almost all factors improved in the early phase (3-6 months) after baseline assessment, while ER and IR ROM at shoulder level continued to improve long term.

Exploration of the clinical course and longitudinal correlations in frozen shoulder: The role of autonomic function, central pain processing, and psychological variables. A longitudinal multicenter prospective observational study.

BACKGROUND: Altered central pain processing (CPP) and dysautonomia might play a role in the clinical course of frozen shoulder and psychological factors, like pain catastrophizing and hypervigilance, might influence clinical variables in frozen shoulder. OBJECTIVES: To explore the clinical course of frozen shoulder regarding CPP, dysautonomia, pain catastrophizing, and hypervigilance and to explore whether longitudinal correlations between these outcomes and pain intensity were present. DESIGN: prospective longitudinal observational study. METHOD: Participants with frozen shoulder were recruited at hospitals and general practitioner practices and followed for 9 months. They completed six questionnaires (about demographics, shoulder pain and disability, pain intensity, pain catastrophizing, pain hypervigilance, and autonomic symptoms) and underwent tactile sensitivity (allodynia), pressure pain thresholds (hyperalgesia), temporal summation, and conditioned pain modulation during four timeframes (3-month intervals). RESULTS: Initially, 149 participants with frozen shoulder were recruited and 88 completed all the measurements. An improvement from baseline to at least one follow-up measurement was found for shoulder pain and disability, pain intensity, pain catastrophizing, hypervigilance, and dysautonomia. A fair longitudinal correlation was found between pain intensity and catastrophizing and hypervigilance (r = 0.301-0.397). Poor longitudinal correlations were found between pain intensity and allodynia and hyperalgesia (r = -0.180-0.193), between pain catastrophizing and dysautonomia (r = 0.209) and between hypervigilance and hyperalgesia (r = -0.159). CONCLUSION: Patients with frozen shoulder showed an early improvement that flattened with time in several pain and psychological variables over the course of 9 months. However, autonomic symptoms rather showed a late improvement over 9 months.

Thermal capsulorrhaphy in internal shoulder impingement: a 7-year follow-up study.

UNLABELLED: This study aimed to evaluate the long-term results of arthroscopic thermal shrinkage of the anterior capsule in athletes with internal shoulder impingement. In recent years, opinion with regards to the aetiology of internal shoulder impingement has changed significantly. The traditional treatment of internal impingement consisted of debridement of labral and/or undersurface cuff lesions. The use of concomitant thermal capsulorrhaphy, based on the concept of anteroinferior laxity, has also been advocated with excellent short-term results. In this study we investigated the long-term effects of this technique. Twelve overhead athletes with internal impingement underwent traditional arthroscopic treatment plus thermal capsulorrhaphy for internal impingement. All patients were evaluated 1, 2 and 7 years postoperatively using a questionnaire regarding their sports activity, and the modified Rowe score. At 1, 2 and 7 years postoperatively there was a significant improvement in the modified Rowe score when compared to the preoperative scores. However, follow-up at 7 years showed a significant deterioration of the initial 1 and 2 year results (p < 0.001), with only 25% of the athletes able to perform sports at their preoperative level. CONCLUSION: Excellent short-term results with thermal capsulorrhaphy, in addition to traditional arthroscopic treatment, in patients with internal shoulder impingement were not sustained over time. After 7 years, only 25% of the athletes were able to perform sports at their preoperative level.

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

OBJECTIVES: The pathophysiology of a frozen shoulder (FS) is thought to be related to chronic inflammation. Chronic inflammation may disturb the immune system and consequently the nervous system as part of an overarching system. The aim of this study was to determine the presence of disturbed autonomic nervous system function and altered central pain processing (CPP) in patients with FS. Secondarily, the presence of psychological variables (catastrophizing and hypervigilance) and self-reported associated symptoms of altered CPP in patients with FS were investigated. METHODS: Patients with FS and healthy controls completed the Composite Autonomic Symptom Score (autonomic function) and underwent quantitative sensory testing to assess tactile sensitivity (ie, allodynia), pressure pain thresholds (PPTs, ie, hyperalgesia), temporal summation of pain, and Conditioned Pain Modulation (CPM). Psychological issues were explored with the Pain Catastrophizing Scale and the Pain Vigilance and Awareness Questionnaire, and self-reported symptoms associated with altered CPP were determined with the Central Sensitization Inventory. RESULTS: Thirty-two patients with FS and 35 healthy controls were analyzed in the study. Patients with FS showed more self-reported autonomic symptoms and symptoms of altered CPP, higher levels of pain catastrophizing and hypervigilance, and are more sensitive to tactile touches and mechanical pressure compared with controls. DISCUSSION: On the basis of the effect sizes, between-group differences in allodynia, hyperalgesia, catastrophizing, and hypervigilance were clinically relevant, but only local allodynia, hyperalgesia, catastrophizing, and hypervigilance were statistically different. Therefore, obvious altered CPP was not present at the group level in patients with FS compared with controls.

An Instrument-Assisted Coracoid Pain Test: An Exploratory Diagnostic Accuracy Study.

The coracoid pain test (CPT) could contribute to the diagnosis of frozen shoulder (FS) with palpation. However, due to assessor performance these values might be unreliable. Therefore, the aim was to explore the diagnostic accuracy of an instrument-assisted CPT and two alternative approaches (pain severity and side comparison) for assistance in the diagnosis of FS. Patients with FS and healthy age-matched controls were recruited. All participants underwent the instrument-assisted CPT on both shoulders with a pressure algometer. Sensitivity, specificity, and likelihood ratios were determined for the three approaches. In total, 35 patients with FS and 35 healthy participants were included. The original approach was positive in eight participants (11.4%), with only sufficient specificity to draw a conclusion. The pain severity approach was positive in 31 participants (44.3%) with sufficient sensitivity, specificity and likelihood ratios. The side comparison approach was positive in 10 participants (14.3%) with excellent specificity and positive likelihood ratio. The specificity of the instrument-assisted CPT can be used to increase the probability of FS with both the original and alternative approaches. Only the pain severity approach can draw a conclusion with a negative test result. This study should be repeated with a cross-sectional design to strengthen and confirm the conclusions.