The reliability and validity of the Norwegian version of the Victorian Institute of Sports Assessment for gluteal tendinopathy questionnaire (VISA-G-Norwegian) for patients with greater trochanteric pain syndrome.

BACKGROUND: Greater Trochanteric Pain Syndrome (GTPS) is a common chronic musculoskeletal condition that may affect physical function, quality of life and sleep. The Victorian Institute of Sport Assessment-Gluteal questionnaire (VISA-G) has been developed as a Patient-Reported Outcome Measurement (PROM) to address pain, everyday activities, physical activities, and difficulty with weight bearing activities. The aim of the study was to test the reliability, validity and floor and ceiling effects of the Norwegian version of the VISA-G (VISA-G-Norwegian) in a population with GTPS in a specialist health care setting. METHODS: This psychometric evaluation of the VISA-G-Norwegian questionnaire were conducted with a prospective observational design. The VISA-G was translated into Norwegian following recommended guidelines. A subgroup repeated the VISA-G-Norwegian a week after the initial submission. For the reliability, the Intraclass Correlation Coefficient (ICC2.1), Standard Error of the Measurement (SEM) and the Smallest Detectable Change (SDC95%) were calculated. Internal consistency was measured using a Cronbach´s alpha. Floor and ceiling effects were evaluated, and construct validity was assessed with three a priori hypotheses. RESULTS: 78 participants were included in the study of which 47 stable participants undertook the test-retest reliability arm of the study. The ICC2.1 for the total score was 0.85 (95% CI 0.68, 0.92), SEM was 6.6 points and SDC95% 18.4 points. Cronbach`s alpha was 0.77 (95% CI 0.69, 0.84). No floor or ceiling effects were found in the total score, but ceiling effect was found in three of the eight items. For construct validity, one of the three hypotheses were confirmed. VISA-G-Norwegian correlated to the modified Harris Hip Score (mHHS), Oswestry Disability Questionnaire (ODI) and Numeric Pain Rating Scale (NPRS), 0.64, -0.75 and - 0.63 respectively. CONCLUSION: The VISA-G-Norwegian has acceptable reliability and validity, despite ceiling effect of individual items. The large SDC95% should be considered when measuring change in similar cohorts with GTPS. For a potential future version, it would be recommended to consider response options for questions with ceiling effect and the comprehensibility of question eight. TRIAL REGISTRATION: Registered at ClinicalTrials.gov the 28/02/2020 (NCT04289922).

Effects of a focused training on first-year osteopathic medical students' ability to incorporate point-of-care ultrasound in assessment of the anterior knee.

CONTEXT: Patients frequently present to the outpatient clinic, urgent care, or emergency department with a painful, swollen knee. Differentiating the underlying etiology can be a challenge for both medical students and seasoned clinicians alike. Because this scenario can represent a time-sensitive emergency, developing skills to diagnose the underlying cause quickly and accurately is essential for proper management, whether the patient would benefit from osteopathic manipulation, prompt administration of antibiotics, or a more invasive procedure like joint aspiration or surgery. OBJECTIVES: The objectives are to determine the effects of a focused ultrasound training on first-year osteopathic medical students' ability to identify normal sonographic anatomy of the anterior knee and to differentiate between three common pathologies: joint effusion, prepatellar bursitis, and cellulitis. METHODS: First-year osteopathic medical students voluntarily participated in this cross-sectional study. The study protocol included a focused ultrasound training (online materials, brief didactic and single hands-on sessions) followed by a hands-on assessment. A written test and 5-point Likert scale questionnaire were administered before and after the focused training. Nine weeks later, students completed a follow-up written test. The proportion of students who correctly identified common pathologies on written tests before (pretest) and after (posttest) training and on the follow-up written test were compared utilizing the Fisher's exact test. A t test was utilized to compare data from the pretraining and posttraining questionnaires. RESULTS: Of 101 students completing the written pretest and pretraining questionnaire, 95 (94.1 %) completed the written posttest and posttraining questionnaire, and 84 (83.2 %) completed the follow-up written test. Students had limited previous experience with ultrasound; 90 (89.1 %) students had performed six or fewer ultrasound examinations before the focused ultrasound training. On written tests, students accurately identified joint effusion (22.8 % [23/101] pretest, 65.3 % [62/95] posttest, 33.3 % [28/84] follow-up test), prepatellar bursitis (14.9 % [15/101] pretest, 46.3 % [44/95] posttest, 36.9 % [31/84] follow-up test), and cellulitis (38.6 % [39/101] pretest, 90.5 % [86/95] posttest, 73.8 % [62/84] follow-up test). Differences were found between pretest and posttest for identification of all three pathologies (all p<0.001) and between the pretest and 9-week follow-up test for identification of prepatellar bursitis and cellulitis (both p≤0.001). For questionnaires, (where 1=strongly agree, 5=strongly disagree), the mean (standard deviation [SD]) confidence for correctly identifying normal sonographic anatomy of the anterior knee was 3.50 (1.01) at pretraining and 1.59 (0.72) at posttraining. Student confidence in the ability to differentiate joint effusion, prepatellar bursitis, and cellulitis utilizing ultrasound increased from 4.33 (0.78) at pretraining to 1.99 (0.78) at posttraining. For the hands-on assessment, 78.3 % (595 correct/760 aggregated responses) of the time students correctly identified specific sonographic landmarks of the anterior knee. When the evaluation combined real-time scanning with a prerecorded sonographic video clip of the anterior knee, 71.4 % (20/28) accurately identified joint effusion, 60.9 % (14/23) correctly diagnosed prepatellar bursitis, 93.3 % (28/30) recognized cellulitis, and 47.1 % (8/17) diagnosed the normal knee. CONCLUSIONS: Our focused training was effective at immediately increasing basic knowledge, as well as confidence of first-year osteopathic medical students when assessing the anterior knee with point-of-care ultrasound. However, spaced repetition and deliberate practice may be useful for learning retention.

Factors related to initial treatment for adhesive capsulitis in the medicare population.

BACKGROUND: Primary adhesive capsulitis (AC) is not well understood, and controversy remains about the most effective treatment approaches. Even less is known about the treatment of AC in the Medicare population. We aimed to fully characterize initial treatment for AC in terms of initial treatment utilization, timing of initial treatments and treatment combinations. METHODS: Using United States Medicare claims from 2010-2012, we explored treatment utilization and patient characteristics associated with initial treatment for primary AC among 7,181 Medicare beneficiaries. Patients with primary AC were identified as patients seeking care for a new shoulder complaint in 2011, with the first visit related to shoulder referred to as the index date, an x-ray or MRI of the shoulder region, and two separate diagnoses of AC (ICD-9-CM codes: 726.00). The treatment period was defined as the 90 days immediately following the index shoulder visit. A multivariable logistic model was used to assess baseline patient factors associated with receiving surgery within the treatment period. RESULTS: Ninety percent of beneficiaries with primary AC received treatment within 90 days of their index shoulder visit. Physical therapy (PT) alone (41%) and injection combined with PT (34%) were the most common treatment approaches. Similar patient profiles emerged across treatment groups, with higher proportions of racial minorities, socioeconomically disadvantaged and more frail patients favoring injections or watchful waiting. Black beneficiaries (OR = 0.37, [0.16, 0.86]) and those residing in the northeast (OR = 0.36, [0.18, 0.69]) had significantly lower odds of receiving surgery in the treatment period. Conversely, younger beneficiaries aged 66-69 years (OR = 6.75, [2.12, 21.52]) and 70-75 years (OR = 5.37, [1.67, 17.17]) and beneficiaries with type 2 diabetes had significantly higher odds of receiving surgery (OR = 1.41, [1.03, 1.92]). CONCLUSIONS: Factors such as patient baseline health and socioeconomic characteristics appear to be important for physicians and Medicare beneficiaries making treatment decisions for primary AC.

Effect of Physical Therapy and Rehabilitation Timing on Rotator Cuff Repair Revisions and Capsulitis.

INTRODUCTION: One variable that could potentially affect failure of a rotator cuff repair (RCR) is the timing of beginning physical therapy (PT) after the procedure. Although many studies have demonstrated decreased stiffness with beginning PT early, studies have also demonstrated that early PT increases repair failure. The goal of this study was to identify revision surgery and capsulitis rates after RCRs from an available database and determine whether an association was present with the timing of PT post-RCR. METHODS: Medicare patients within the PearlDiver database who underwent RCR were stratified based on the timing of their first PT session postoperatively, and revision surgery and capsulitis rates were determined among the groups for both open and arthroscopic RCR. Demographics and comorbidities of the cohort were also used to formulate a multivariate analysis for revision surgery rate. RESULTS: The cohort consisted of 64,842 patients who underwent RCR and started PT within 13 weeks of surgery. Starting PT within 1 week postoperatively resulted in a significantly higher revision surgery rate compared with starting PT in weeks 2 to 5, 6 to 9, or 10 to 13 (6.9% vs. 3.6% among all other groups, P = <0.001). The multivariate analysis for revision surgery further demonstrated that starting PT within 1 week postoperatively was associated with a significantly higher rate of revision surgery compared with beginning PT after 1 week (OR = 2.086, P < 0.001). No association was found between timing of beginning PT and capsulitis rates. CONCLUSION: In the Medicare patient cohort, beginning PT within 1 week postoperatively was associated with a significantly higher revision surgery rate; however, no associated benefit was noted in capsulitis rates for beginning PT early. This calls into question the use of an early passive range of motion protocol for older patient cohort; however, further studies should be completed to conclusively determine the most efficacious time to begin rehabilitation post-RCR. LEVEL OF EVIDENCE: Level III.

Assessment of isolated glenohumeral range of motion in patients with adhesive capsulitis can help predict failure of conservative treatment: a pilot study.

PURPOSE: To prospectively evaluate a cohort of patients with adhesive capsulitis and identify predictors of failure of conservative treatment in the first 2 months of therapy. METHODS: This was a single-cohort, prospective observational study that included 20 participants (13 females/7 males; median age of 51.8 years [interquartile range: 8.65]) with primary adhesive capsulitis managed conservatively and evaluated clinically every month for at least 2 years of follow-up (29 [5] months). The evaluation included stage of the disease, treatment applied, radiological findings, pain levels and range of motion (active and passive ROM in the four planes and isolated glenohumeral passive ROM in abduction [GH-ABD], external rotation [GH-ER] and internal rotation). The main outcome assessed was failure of conservative treatment defined as the need for surgery and persistent pain or CMS below 70 points at the 1-year follow-up. RESULTS: Seven patients (7/20, 35%) were considered to have failed conservative treatment because they required arthroscopic capsular release 5.2 (2.1) months after the initial diagnosis. Of all the clinical and epidemiological variables, absence of improvement during the first 2 months in isolated glenohumeral ROM abduction and external rotation predicted failure of conservative treatment: improvement in GH-ABD (10° or more) occurred in 10/13 patients in the conservative treatment group and in 1/7 patients in the surgery group (p = 0.017). Improvement in GH-ER (10° or more) occurred in 9/13 patients in the conservative treatment group and in 0/7 patients in the surgery group (p = 0.005). CONCLUSIONS: Precise assessment of isolated glenohumeral ROM in patients with adhesive capsulitis can help identify patients in which conservative treatment might fail. In this study, patients who did not experience early improvements in isolated glenohumeral ROM often required surgery. LEVEL OF EVIDENCE: III (Prospective cohort study).

The epidemiology and etiology of adhesive capsulitis in the U.S. Medicare population.

BACKGROUND: Adhesive capsulitis (AC) of the shoulder, also known as frozen shoulder, causes substantial pain and disability. In cases of secondary AC, the inflammation and fibrosis of the synovial joint can be triggered by trauma or surgery to the joint followed by extended immobility. However, for primary AC the inciting trigger is unknown. The burden of the disorder among the elderly is also unknown leading to this age group being left out of therapeutic research studies, potentially receiving delayed diagnoses, and unknown financial costs to the Medicare system. The purpose of this analysis was to describe the epidemiology of AC in individuals over the age of 65, an age group little studied for this disorder. The second purpose was to investigate whether specific medications, co-morbidities, infections, and traumas are risk factors or triggers for primary AC in this population. METHODS: We used Medicare claims data from 2010-2012 to investigate the prevalence of AC and assess comorbid risk factors and seasonality. Selected medications, distal trauma, and classes of infections as potential inflammatory triggers for primary AC were investigated using a case-control study design with patients with rotator cuff tears as the comparison group. Medications were identified from National Drug codes and translated to World Health Organization ATC codes for analysis. Health conditions were identified using ICD9-CM codes. RESULTS: We found a one-year prevalence rate of AC of approximately 0.35% among adults aged 65 years and older which translates to approximately 142,000 older adults in the United States having frozen shoulder syndrome. Diabetes and Parkinson's disease were significantly associated with the diagnosis of AC in the elderly. Cases were somewhat more common from August through December, although a clear seasonal trend was not observed. Medications, traumas, and infections were similar for cases and controls. CONCLUSIONS: This investigation identified the burden of AC in the US elderly population and applied case-control methodology to identify triggers for its onset in this population. Efforts to reduce chronic health conditions such as diabetes may reduce seemingly unrelated conditions such as AC. The inciting trigger for this idiopathic condition remains elusive.

Automatic Functional Shoulder Task Identification and Sub-task Segmentation Using Wearable Inertial Measurement Units for Frozen Shoulder Assessment.

Advanced sensor technologies have been applied to support frozen shoulder assessment. Sensor-based assessment tools provide objective, continuous and quantitative information for evaluation and diagnosis. However, the current tools for assessment of functional shoulder tasks mainly rely on manual operation. It may cause several technical issues to the reliability and usability of the assessment tool, including manual bias during the recording and additional efforts for data labeling. To tackle these issues, this pilot study aims to propose an automatic functional shoulder task identification and sub-task segmentation system using inertial measurement units to provide reliable shoulder task labeling and sub-task information for clinical professionals. The proposed method combines machine learning models and rule-based modification to identify shoulder tasks and segment sub-tasks accurately. A hierarchical design is applied to enhance the efficiency and performance of the proposed approach. Nine healthy subjects and nine frozen shoulder patients are invited to perform five common shoulder tasks in the lab-based and clinical environments, respectively. The experimental results show that the proposed method can achieve 87.11% F-score for shoulder task identification, and 83.23% F-score and 427 mean absolute time errors (milliseconds) for sub-task segmentation. The proposed approach demonstrates the feasibility of the proposed method to support reliable evaluation for clinical assessment.

Surgical treatments compared with early structured physiotherapy in secondary care for adults with primary frozen shoulder: the UK FROST three-arm RCT.

BACKGROUND: Frozen shoulder causes pain and stiffness. It affects around 10% of people in their fifties and is slightly more common in women. Costly and invasive surgical interventions are used, without high-quality evidence that these are effective. OBJECTIVES: To compare the clinical effectiveness and cost-effectiveness of three treatments in secondary care for adults with frozen shoulder; to qualitatively explore the acceptability of these treatments to patients and health-care professionals; and to update a systematic review to explore the trial findings in the context of existing evidence for the three treatments. DESIGN: This was a pragmatic, parallel-group, multicentre, open-label, three-arm, randomised superiority trial with unequal allocation (2 : 2 : 1). An economic evaluation and a nested qualitative study were also carried out. SETTING: The orthopaedic departments of 35 hospitals across the UK were recruited from April 2015, with final follow-up in December 2018. PARTICIPANTS: Participants were adults (aged ≥ 18 years) with unilateral frozen shoulder, characterised by restriction of passive external rotation in the affected shoulder to < 50% of the opposite shoulder, and with plain radiographs excluding other pathology. INTERVENTIONS: The inventions were early structured physiotherapy with a steroid injection, manipulation under anaesthesia with a steroid injection and arthroscopic capsular release followed by manipulation. Both of the surgical interventions were followed with post-procedural physiotherapy. MAIN OUTCOME MEASURES: The primary outcome and end point was the Oxford Shoulder Score at 12 months post randomisation. A difference of 5 points between early structured physiotherapy and manipulation under anaesthesia or arthroscopic capsular release or of 4 points between manipulation under anaesthesia and arthroscopic capsular release was judged clinically important. RESULTS: The mean age of the 503 participants was 54 years; 319 were female (63%) and 150 had diabetes (30%). The primary analyses comprised 473 participants (94%). At the primary end point of 12 months, participants randomised to arthroscopic capsular release had, on average, a statistically significantly higher (better) Oxford Shoulder Score than those randomised to manipulation under anaesthesia (2.01 points, 95% confidence interval 0.10 to 3.91 points; p = 0.04) or early structured physiotherapy (3.06 points, 95% confidence interval 0.71 to 5.41 points; p = 0.01). Manipulation under anaesthesia did not result in statistically significantly better Oxford Shoulder Score than early structured physiotherapy (1.05 points, 95% confidence interval -1.28 to 3.39 points; p = 0.38). No differences were deemed of clinical importance. Serious adverse events were rare but occurred in participants randomised to surgery (arthroscopic capsular release,n = 8; manipulation under anaesthesia,n = 2). There was, however, one serious adverse event in a participant who received non-trial physiotherapy. The base-case economic analysis showed that manipulation under anaesthesia was more expensive than early structured physiotherapy, with slightly better utilities. The incremental cost-effectiveness ratio for manipulation under anaesthesia was £6984 per additional quality-adjusted life-year, and this intervention was probably 86% cost-effective at the threshold of £20,000 per quality-adjusted life-year. Arthroscopic capsular release was more costly than early structured physiotherapy and manipulation under anaesthesia, with no statistically significant benefit in utilities. Participants in the qualitative study wanted early medical help and a quicker pathway to resolve their shoulder problem. Nine studies were identified from the updated systematic review, including UK FROST, of which only two could be pooled, and found that arthroscopic capsular release was more effective than physiotherapy in the long-term shoulder functioning of patients, but not to the clinically important magnitude used in UK FROST. LIMITATIONS: Implementing physiotherapy to the trial standard in clinical practice might prove challenging but could avoid theatre use and post-procedural physiotherapy. There are potential confounding effects of waiting times in the trial. CONCLUSIONS: None of the three interventions was clearly superior. Early structured physiotherapy with a steroid injection is an accessible and low-cost option. Manipulation under anaesthesia is the most cost-effective option. Arthroscopic capsular release carries higher risks and higher costs. FUTURE WORK: Evaluation in a randomised controlled trial is recommended to address the increasing popularity of hydrodilatation despite the paucity of high-quality evidence. TRIAL REGISTRATION: Current Controlled Trials ISRCTN48804508. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 71. See the NIHR Journals Library website for further project information.

Frozen shoulder occurs when the soft tissue envelope around the shoulder joint becomes inflamed, scarred and contracted, making movement painful and stiff. It affects around 1 in 10 people and is more common in women. Most patients are treated in the community. Those who do not improve are offered treatments in hospital. This includes costly and invasive surgical options. It is unclear which treatment provides the best patient outcomes and is cost-effective. UK FROST (UK FROzen Shoulder Trial) comprised 503 patients (from 35 UK hospitals) who randomly received one of three commonly offered treatments for frozen shoulder: early physiotherapy to restore movement, including a steroid injection for pain reliefmanipulation under anaesthesia, to stretch and tear the tight capsule to restore movement, and a steroid injection followed by physiotherapyarthroscopic capsular release, which uses keyhole surgery, including manipulation, to restore movement, followed by physiotherapy with pain medication. No important differences were found between the three treatments in shoulder function or pain at 12 months. Fewer patients who received arthroscopic capsular release required further treatment, and patients who received arthroscopic capsular release had slightly better shoulder function and pain outcomes than those who received the manipulation procedure or early physiotherapy. This improvement, however, was unlikely to be of clinical benefit to patients. Arthroscopic capsular release had slightly higher risks and substantially higher costs. Six serious complications were reported in patients who received arthroscopic capsular release (mostly owing to co-existing health problems) and two were reported in patients who received manipulation under anaesthesia. Physiotherapy was the least expensive treatment, but patients who received manipulation under anaesthesia had slightly better general health than those who received physiotherapy. Early physiotherapy with steroid injection could be accessed quicker than the surgical alternatives. Manipulation under anaesthesia cost more than physiotherapy but provided the best value for money. Patients in the study wanted early access to medical help to improve their shoulder problems.

Management of adults with primary frozen shoulder in secondary care (UK FROST): a multicentre, pragmatic, three-arm, superiority randomised clinical trial.

BACKGROUND: Manipulation under anaesthesia and arthroscopic capsular release are costly and invasive treatments for frozen shoulder, but their effectiveness remains uncertain. We compared these two surgical interventions with early structured physiotherapy plus steroid injection. METHODS: In this multicentre, pragmatic, three-arm, superiority randomised trial, patients referred to secondary care for treatment of primary frozen shoulder were recruited from 35 hospital sites in the UK. Participants were adults (≥18 years) with unilateral frozen shoulder, characterised by restriction of passive external rotation (≥50%) in the affected shoulder. Participants were randomly assigned (2:2:1) to receive manipulation under anaesthesia, arthroscopic capsular release, or early structured physiotherapy. In manipulation under anaesthesia, the surgeon manipulated the affected shoulder to stretch and tear the tight capsule while the participant was under general anaesthesia, supplemented by a steroid injection. Arthroscopic capsular release, also done under general anaesthesia, involved surgically dividing the contracted anterior capsule in the rotator interval, followed by manipulation, with optional steroid injection. Both forms of surgery were followed by postprocedural physiotherapy. Early structured physiotherapy involved mobilisation techniques and a graduated home exercise programme supplemented by a steroid injection. Both early structured physiotherapy and postprocedural physiotherapy involved 12 sessions during up to 12 weeks. The primary outcome was the Oxford Shoulder Score (OSS; 0-48) at 12 months after randomisation, analysed by initial randomisation group. We sought a target difference of 5 OSS points between physiotherapy and either form of surgery, or 4 points between manipulation and capsular release. The trial registration is ISRCTN48804508. FINDINGS: Between April 1, 2015, and Dec 31, 2017, we screened 914 patients, of whom 503 (55%) were randomly assigned. At 12 months, OSS data were available for 189 (94%) of 201 participants assigned to manipulation (mean estimate 38·3 points, 95% CI 36·9 to 39·7), 191 (94%) of 203 participants assigned to capsular release (40·3 points, 38·9 to 41·7), and 93 (94%) of 99 participants assigned to physiotherapy (37·2 points, 35·3 to 39·2). The mean group differences were 2·01 points (0·10 to 3·91) between the capsular release and manipulation groups, 3·06 points (0·71 to 5·41) between capsular release and physiotherapy, and 1·05 points (-1·28 to 3·39) between manipulation and physiotherapy. Eight serious adverse events were reported with capsular release and two with manipulation. At a willingness-to-pay threshold of £20 000 per quality-adjusted life-year, manipulation under anaesthesia had the highest probability of being cost-effective (0·8632, compared with 0·1366 for physiotherapy and 0·0002 for capsular release). INTERPRETATION: All mean differences on the assessment of shoulder pain and function (OSS) at the primary endpoint of 12 months were less than the target differences. Therefore, none of the three interventions were clinically superior. Arthoscopic capsular release carried higher risks, and manipulation under anaesthesia was the most cost-effective. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Assessment of Scapulothoracic, Glenohumeral, and Elbow Motion in Adhesive Capsulitis by Means of Inertial Sensor Technology: A Within-Session, Intra-Operator and Inter-Operator Reliability and Agreement Study.

Adhesive capsulitis (AC) is a glenohumeral (GH) joint condition, characterized by decreased GH joint range of motion (ROM) and compensatory ROM in the elbow and scapulothoracic (ST) joint. To evaluate AC progression in clinical settings, objective movement analysis by available systems would be valuable. This study aimed to assess within-session and intra- and inter-operator reliability/agreement of such a motion capture system. The MVN-Awinda® system from Xsens Technologies (Enschede, The Netherlands) was used to assess ST, GH, and elbow ROM during four tasks (GH external rotation, combing hair, grasping a seatbelt, placing a cup on a shelf) in 10 AC patients (mean age = 54 (± 6), 7 females), on two test occasions (accompanied by different operators on second occasion). Standard error of measurements (SEMs) were below 1.5° for ST pro-retraction and 4.6° for GH in-external rotation during GH external rotation; below 6.6° for ST tilt, 6.4° for GH flexion-extension, 7.1° for elbow flexion-extension during combing hair; below 4.4° for GH ab-adduction, 13° for GH in-external rotation, 6.8° for elbow flexion-extension during grasping the seatbelt; below 11° for all ST and GH joint rotations during placing a cup on a shelf. Therefore, to evaluate AC progression, inertial sensors systems can be applied during the execution of functional tasks.

A large-scale assessment of the healthcare burden of adhesive capsulitis of the shoulder joint.

BACKGROUND AND AIM: Frozen shoulder is a poorly understood pathological entity that is characterised by a painful and stiff shoulder. To analyse the socioeconomic impact of frozen shoulder in terms of cost generation and prolonged absence from work, we conducted a retrospective cohort study based on shoulder injuries through accidents in Switzerland. METHODS: Data were obtained from the comprehensive database of the Statistical Service for the Swiss National Accident Insurances (SSUV). Cases with shoulder injuries (ICD-10 codes S4* and M84.3*) and/or an additional code of adhesive capsulitis (M75.0) were extracted. Outcomes were work incapacity, with long-term work incapacity defined as absence from work for >90 days and very-long-term cases with >360 days lost. Healthcare and treatment costs as well as total insurance expenses were measured over a 5-year follow-up. Multivariate statistical analyses were used to quantify the effect of the frozen shoulder complication. RESULTS: Among all 456,926 patients with a shoulder injury, 5% or a total of 22,228 posttraumatic frozen shoulder cases were observed over the 8-year period. Patients suffering from a frozen shoulder after shoulder injury showed significantly longer sick leave periods with 30.8% long-term and 9.7% very-long-term cases compared with 9.4% and 1.3%, respectively, in the non-frozen shoulder cohort. Overall costs per case for an injured shoulder without developing a frozen shoulder was roughly CHF 8000, whereas expenses for cases with posttraumatic and postoperative frozen shoulder were CHF 34,000 per case. CONCLUSION: Developing a frozen shoulder after a shoulder injury is associated with significant longer work incapacities (3.3–7.5 times) and is responsible for costs of CHF 78 million every year. The presented numbers are for cases covered by the compulsory accident insurance only and do not include the even more frequent idiopathic frozen shoulder cases.

Radiomorphometric assessment of the pterygoid hamulus as a factor promoting the pterygoid hamulus bursitis.

BACKGROUND: The pterygoid hamulus (PH) is a small protrusion on the base of the pterygoid process of the sphenoid bone. PH is a site of insertion of many muscles and ligaments. Its topography can determine predilection for developing the pterygoid hamulus bursitis (PHB). MATERIALS AND METHODS: The study was conducted based on the morphometric analysis of 100 PHs on cone beam computed tomography scans. RESULTS: Based on statistical analysis, we found numerous significant correlations between the morphometric parameters. CONCLUSIONS: Considering our results, it can be concluded that the main pathogenic factor in PHB is an extensive medial deviation of the pterygoid hamulus in the frontal plane.

Late Shoulder-Arm Morbidity Using Ultrasound Scalpel in Axillary Dissection for Breast Cancer: A Retrospective Analysis.

BACKGROUND: We aimed to assess whether the use of the harmonic scalpel (HS) in axillary dissection would reduce long-term shoulder-arm morbidity compared to traditional instruments (TIs). MATERIALS AND METHODS: A retrospective analysis on 180 patients who underwent standard axillary dissection for breast cancer between 2007 and 2015 was carried out. All patients were evaluated for postoperative pain, impairment of shoulder-arm mobility, seroma formation in axilla, frozen shoulder, and lymphedema. RESULTS: HS procedure on average was 50% shorter compared to the TI technique. HS reduced by 4.5 times the risk of axillary seroma. TIs were associated with 4 times higher risk of developing a painful frozen shoulder. CONCLUSIONS: Use of the HS was associated with reduced costs and a positive long-term effect on shoulder-arm morbidity. Axillary seromas are not the only reason of later postoperative shoulder-arm morbidity: other mechanisms are hypothesized in the onset of this very disabling disorder.

3D volumetric MR arthrographic assessment of shoulder joint capacity in patients with primary adhesive capsulitis.

OBJECTIVE: To evaluate the three-dimensional (3D) volumetric MR arthrographic findings of shoulder joint capacity in patients with primary adhesive capsulitis. METHODS: Thin-section 3D volumetric MR arthrography sequences of the shoulder joint were obtained in 28 patients with clinically and radiologically proven primary adhesive capsulitis and in 25 controls. Volumetric measurements of the total glenohumeral joint capacity, extra-articular contrast material leakage, and the rotator interval, axillary recess, and biceps tendon sheath capacities were performed for the study and control groups. RESULTS: Mean volume of the rotator interval was 7.67 ± 2.6 cm3 in the study group, which was significantly lower than in the control group (12.31 ± 2.5 cm3) (p < 0.0001). Mean volume of the bicipital groove was significantly decreased in the patient group compared to the control group (1.67 ± 0.9 cm3 vs 2.88 ± 0.9 cm3) (p ≤ 0.0001). Mean volume of extra articular contrast material extravasation was 9.93 ± 1.7 cm3 in the patient group, which was significantly higher than in the control group (5.1 ± 1.4 cm3) (p = 0.002). Mean total glenohumeral joint volume was 22.52 ± 1.1 cm3 in the patient group and 26.01 ± 1.2 cm3 in the control group (p = 0.003). CONCLUSION: On 3D volumetric MR arthrographic examination, obliterations in the biceps tendon sheath and rotator interval as well as decreased joint capacity may be useful imaging criteria for diagnosing primary adhesive capsulitis. ADVANCES IN KNOWLEDGE: In the present study, MR arthrography showed contrast material extravasation in 71% of the patients and showed extra articular contrast material extravasation in 48% of the control subjects. On 3D volumetric MR arthrographic examination, obliterations in the biceps tendon sheath and rotator interval as well as decreased joint capacity may be useful imaging criteria for diagnosing primary adhesive capsulitis.In patients with primary adhesive capsulitis, thin-section 3D volumetric MR arthrography is a useful imaging modality to evaluate both joint capacity and capsular structure.

Contribution of a new radiologic calcaneal measurement to the treatment decision tree in Haglund syndrome.

INTRODUCTION: In Haglund syndrome, standard radiologic measurements lack specificity and reliability in assessing etiologic morphologic calcaneal abnormalities. We report a simple X/Y ratio to measure posterior calcaneal length, where X is calcaneal length on lateral weight-bearing view and Y is greater tuberosity length. OBJECTIVE: To compare this new parameter against the radiologic gold standard in a group of Haglund patients and a healthy control group. HYPOTHESIS: Measuring this ratio significantly distinguishes between Haglund patients and healthy subjects. MATERIAL AND METHODS: A retrospective study included 50 Haglund syndrome patients and 30 healthy controls. Standard measurements (Fowler-Philipangle, Chauveaux-Liet angle, Ruch pitch, Heneghan-Pavlov test) and X/Y ratio were calculated twice by 2 independent observers. Intra- and inter-observer correlations were calculated, as were the specificity and sensitivity of the various parameters, with a ROC curve to establish the X/Y threshold. RESULTS: All measurements were reproducible on intra- and inter-observer testing. There were no significant inter-group differences in standard measurement specificity or sensitivity. The Haglund group showed significantly lower X/Y ratio (2.07) than controls (2.70; p<0.0001), with a cut-off at 2.5. Threshold sensitivity in confirming Haglund syndrome was 100% (p<0.0001) and specificity 95% (p<0.0001). DISCUSSION: This new parameter measures the length of the calcaneus and its greater tuberosity. It is more reliable and reproducible in terms of sensitivity and specificity than standard measurements in Haglund syndrome. The 2.5 ratio threshold can guide surgical decision-making. LEVEL OF EVIDENCE: III.

Shoulder adhesive capsulitis: epidemiology and predictors of surgery.

BACKGROUND: Adhesive capsulitis is characterized by a gradual, painful loss of shoulder motion. This study evaluated patient variables significantly associated with developing adhesive capsulitis compared with a sex-matched control group without adhesive capsulitis. We also sought to determine those factors associated with adhesive capsulitis patients requiring surgical intervention. METHODS: All patients presenting to our hospital with adhesive capsulitis between 2004 and 2014 were identified. Demographic characteristics were collected, and a sex-matched control group was randomly generated from the electronic medical record and used for comparison. Patients who underwent surgical intervention for adhesive capsulitis were also identified, and factors associated with surgical intervention were identified with logistic regression analysis. RESULTS: Included were 2190 adhesive capsulitis patients with a normal age distribution of 56.4 ± 13.1 years. Most were classified as overweight (30.7%) or obese (27.0%). Compared with controls, adhesive capsulitis patients were more likely to be younger (<50 vs. ≥50 years; odds ratio [OR], 0.69; P < .001), obese (OR, 1.26; P < .001), black/African American (OR, 1.71; P < .001), Hispanic/Latino (OR, 4.85; P < .001), or diabetic (OR, 1.12; P < .001) and less likely to have hypertension (OR, 0.93; P = .006). Overall, 361 subsequently underwent surgical intervention. Older patients, racial minorities, and government-sponsored/uninsured patients were significantly less likely to have surgery for adhesive capsulitis (P < .01), whereas workers' compensation patients were 8 times more likely to receive surgery compared with privately insured patients (P < .001). CONCLUSIONS: Obesity and diabetes were significantly associated with adhesive capsulitis and should be considered modifiable patient factors. Additionally, younger patients and racial minorities were also significantly more likely to be diagnosed with adhesive capsulitis. Younger, white, and workers' compensation patients were more likely to receive surgery, whereas patients with government-sponsored or no insurance status were more likely to receive nonoperative treatment.

Comparison Between Image-Guided and Landmark-Based Glenohumeral Joint Injections for the Treatment of Adhesive Capsulitis: A Cost-Effectiveness Study.

OBJECTIVE: The purpose of this study was to determine the cost-effectiveness of landmark-based and image-guided intraarticular steroid injections for the initial treatment of a population with adhesive capsulitis. MATERIALS AND METHODS: A decision analytic model from the health care system perspective over a 6-month time frame for 50-year-old patients with clinical findings consistent with adhesive capsulitis was used to evaluate the incremental cost-effectiveness of three techniques for administering intraarticular steroid to the glenohumeral joint: landmark based (also called blind), ultrasound guided, and fluoroscopy guided. Input data on cost, probability, and utility estimates were obtained through a comprehensive literature search and from expert opinion. The primary effectiveness outcome was quality-adjusted life years (QALY). Costs were estimated in 2017 U.S. dollars. RESULTS: Ultrasound-guided injections were the dominant strategy for the base case, because it was the least expensive ($1280) and most effective (0.4096 QALY) strategy of the three options overall. The model was sensitive to the probabilities of getting the steroid into the joint by means of blind, ultrasound-guided, and fluoroscopy-guided techniques and to the costs of the ultrasound-guided and blind techniques. Two-way sensitivity analyses showed that ultrasound-guided injections were favored over blind and fluoroscopy-guided injections over a range of reasonable probabilities and costs. Probabilistic sensitivity analysis showed that ultrasound-guided injections were cost-effective in 44% of simulations, compared with 34% for blind injections and 22% for fluoroscopy-guided injections and over a wide range of willingness-to-pay thresholds. CONCLUSION: Ultrasound-guided injections are the most cost-effective option for the initial steroid-based treatment of patients with adhesive capsulitis. Blind and fluoroscopy-guided injections can also be cost-effective when performed by a clinician likely to accurately administer the medication into the correct location.

Radiotherapy for calcaneodynia, achillodynia, painful gonarthrosis, bursitis trochanterica, and painful shoulder syndrome - Early and late results of a prospective clinical quality assessment.

BACKGROUND: The aim of this prospective clinical quality assessment was to evaluate the short-term and long-term efficacy of low dose radiotherapy (RT) for calcaneodynia, achillodynia, painful gonarthrosis, painful bursitis trochanterica, and painful shoulder syndrome. METHODS: Between October 2011 and October 2013, patients with calcaneodynia, achillodynia, painful gonarthrosis, painful bursitis trochanterica, and painful shoulder syndrome were recruited for this prospective clinical quality assessment. Single doses of 0.5-1.0 Gy and a total dose of 6.0 Gy per series were used. Pain was measured before and directly after RT (early response) with a visual analogue scale (VAS). Additionally, pain relief was measured with the four-scale pain score according to "von Pannewitz" (VPS) immediately at the end of RT and during follow-up. Within this context we defined a good response as complete pain relief and markedly improved. The assessment of the long-term efficacy was carried out by a telephone survey. RESULTS: 703 evaluable patients (461 female, 242 male) with a mean age of 63.2 years (28-96) were recruited for this prospective clinical quality assessment. In 254 patients RT was performed with the linear accelerator, 449 patients received orthovoltage radiotherapy. After a median follow-up of 33 months (3-60) 437 patients could be reached for evaluation of follow up results. The mean VAS value before treatment was 6.63 (1.9-10) and immediately on completion of RT 4.51 (0-10) (p < 0,001). Concerning the VPS immediately on completion of RT, a good response could be achieved in 264/703 patients (37.6%), and with the follow up in 255/437 patients (58.4%) (p < 0.001). Only in patients with gonarthrosis we could not observe a significantly improved long-term success in comparison to the results immediately after RT (30.2% versus 29.9%). CONCLUSION: Low dose RT is a very effective treatment for the management of calcaneodynia, achillodynia, painful gonarthrosis, painful bursitis trochanterica, and painful shoulder syndrome. Due to the delayed onset of analgesic effects low dose RT results in a significantly improved long-term efficacy in comparison to the results immediately after RT particularly in patients with calcaneodynia, achillodynia, bursitis trochanterica, and shoulder syndrome.

Outcomes and cost-effectiveness of ultrasound-guided injection of the trochanteric bursa.

We hypothesized that ultrasound (US) guidance improves outcomes of corticosteroid injection of trochanteric bursitis. 40 patients with greater trochanteric pain syndrome defined by pain to palpation over the trochanteric bursa were randomized to injection with 5 ml of 1% lidocaine and 80 mg of methylprednisolone using (1) conventional anatomic landmark palpation guidance or (2) US guidance. Procedural pain (Visual Analogue Pain Scale), pain at outcome (2 weeks and 6 months), therapeutic duration, time-to-next intervention, and costs were determined. There were no complications in either group. Ultrasonography demonstrated that at least a 2-in (50.8 mm) needle was required to consistently reach the trochanteric bursa. Pain scores were similar at 2 weeks: US: 1.3 ± 1.9 cm; landmark: 2.2 ± 2.5 cm, 95% CI of difference: - 0.7 < 0.9 < 2.5, p = 0.14. At 6 months, US was superior: US: 3.9 ± 2.0 cm; landmark: 5.5 ± 2.6 cm, 95% CI of difference: 0.8 < 1.6 < 2.4, p = 0.036. However, therapeutic duration (US 4.7 ± 1.4 months; landmark 4.1 ± 2.9 months, 95% CI of difference - 2.2 < - 0.6 < 1.0, p = 0.48), and time-to-next intervention (US 8.7 ± 2.9 months; landmark 8.3 ± 3.8 months, 95% CI of difference - 2.8 < - 0.4 < 2.0, p = 0.62) were similar. Costs/patient/year was 43% greater with US (US $297 ± 99, landmark $207 ± 95; p = 0.017). US-guided and anatomic landmark injection of the trochanteric bursa have similar 2-week and 6-month outcomes; however, US guidance is considerably more expensive and less cost-effective. Anatomic landmark-guided injection remains the method of choice, but should be routinely performed using a sufficiently long needle [at least a 2 in (50.8 mm)]. US guidance should be reserved for extreme obesity or injection failure.