Aims. To achieve expert clinical consensus in the delivery of hydrodilatation for the treatment of primary frozen shoulder to inform clinical practice and the design of an intervention for evaluation. Methods. We conducted a two-stage, electronic questionnaire-based, modified Delphi survey of shoulder experts in the UK NHS. Round one required positive, negative, or neutral ratings about hydrodilatation. In round two, each participant was reminded of their round one responses and the modal (or ‘group’) response from all participants. This allowed participants to modify their responses in round two. We proposed respectively mandating or encouraging elements of hydrodilatation with 100% and 90% positive consensus, and respectively disallowing or discouraging with 90% and 80% negative consensus. Other elements would be optional. Results. Between 4 August 2020 and 4 August 2021, shoulder experts from 47 hospitals in the UK completed the study. There were 106 participants (consultant upper limb orthopaedic surgeons, n = 50; consultant radiologists, n = 52; consultant physiotherapist, n = 1; extended scope physiotherapists, n = 3) who completed round one, of whom 97 (92%) completed round two. No elements of hydrodilatation were “mandated” (100% positive rating). Elements that were “encouraged” (≥ 80% positive rating) were the use of image guidance, local anaesthetic, normal saline, and steroids to deliver the injection. Injecting according to patient tolerance, physiotherapy, and home exercises were also “encouraged”. No elements were “discouraged” (≥ 80% negative rating) although using hypertonic saline was rated as being “disallowed” (≥ 90% negative rating). Conclusion. In the absence of rigorous evidence, our Delphi study allowed us to achieve expert consensus about positive, negative, and neutral ratings of hydrodilatation in the management of frozen shoulder in a hospital setting. This should inform clinical practice and the design of an intervention for evaluation. Cite this article: Bone Jt Open 2022;3(9):701–709

Aims. A pragmatic multicentre randomized controlled trial, UK FROzen Shoulder Trial (UK FROST), was conducted in the UK NHS comparing the cost-effectiveness of commonly used treatments for adults with primary frozen shoulder in secondary care. Methods. A cost utility analysis from the NHS perspective was performed. Differences between manipulation under anaesthesia (MUA), arthroscopic capsular release (ACR), and early structured physiotherapy plus steroid injection (ESP) in costs (2018 GBP price base) and quality adjusted life years (QALYs) at one year were used to estimate the cost-effectiveness of the treatments using regression methods. Results. ACR was £1,734 more costly than ESP ((95% confidence intervals (CIs) £1,529 to £1,938)) and £1,457 more costly than MUA (95% CI £1,283 to £1,632). MUA was £276 (95% CI £66 to £487) more expensive than ESP. Overall, ACR had worse QALYs compared with MUA (-0.0293; 95% CI -0.0616 to 0.0030) and MUA had better QALYs compared with ESP (0.0396; 95% CI -0.0008 to 0.0800). At a £20,000 per QALY willingness-to-pay threshold, MUA had the highest probability of being cost-effective (0.8632) then ESP (0.1366) and ACR (0.0002). The results were robust to sensitivity analyses. Conclusion. While ESP was less costly, MUA was the most cost-effective option. ACR was not cost-effective. Cite this article: Bone Jt Open 2021;2(8):685–695

Aims. This systematic review places a recently completed multicentre randomized controlled trial (RCT), UK FROST, in the context of existing randomized evidence for the management of primary frozen shoulder. UK FROST compared the effectiveness of pre-specified physiotherapy techniques with a steroid injection (PTSI), manipulation under anaesthesia (MUA) with a steroid injection, and arthroscopic capsular release (ACR). This review updates a 2012 review focusing on the effectiveness of MUA, ACR, hydrodilatation, and PTSI. Methods. MEDLINE, Embase, PEDro, Science Citation Index, Clinicaltrials.gov, CENTRAL, and the World Health Organization (WHO) International Clinical Trials Registry were searched up to December 2018. Reference lists of included studies were screened. No language restrictions applied. Eligible studies were RCTs comparing the effectiveness of MUA, ACR, PTSI, and hydrodilatation against each other, or supportive care or no treatment, for the management of primary frozen shoulder. Results. Nine RCTs were included. The primary outcome of patient-reported shoulder function at long-term follow-up (> 6 months and ≤ 12 months) was reported for five treatment comparisons across four studies. Standardized mean differences (SMD) were: ACR versus MUA: 0.21 (95% confidence interval (CI) 0.00 to 0.42), ACR versus supportive care: -0.13 (95% CI -1.10 to 0.83), and ACR versus PTSI: 0.33 (95% CI 0.07 to 0.59) and 0.25 (95% CI -0.34 to 0.85), all favouring ACR; MUA versus supportive care: 0 (95% CI -0.44 to 0.44) not favouring either; and MUA versus PTSI: 0.12 (95% CI -0.14 to 0.37) favouring MUA. None of these differences met the threshold of clinical significance agreed for the UK FROST and most confidence intervals included zero. Conclusion. The findings from a recent multicentre RCT provided the strongest evidence that, when compared with each other, neither PTSI, MUA, nor ACR are clinically superior. Evidence from smaller RCTs did not change this conclusion. The effectiveness of hydrodilatation based on four RCTs was inconclusive and there remains an evidence gap. Cite this article: Bone Jt Open 2021;2(9):773–784

The purpose of the study was to test the hypothesis that cellular mechanisms of fibroblasts derived from primary frozen shoulder (PFS) exhibit similar activity in terms of contraction, response to cytokine transforming growth factor-beta1 (TGF beta1) and mechanical stimulation similar to that generated by fibroblasts derived from Dupuytren’s disease. Frozen shoulder has been postulated to be Dupuytren’s disease of the shoulder with an association inferred since 1936. Primary explant cultures of fibroblasts from seven patients with PFS and five control patients were obtained using standard tissue culture techniques. Fibroblasts were seeded in 3-D collagen constructs and contraction force generated over 24 hours measured using a culture force monitor (CFM) in real time. Increasing concentrations of TGF-beta1 were added to cell seeded gels and force generated measured using the CFM over 24 hours. These mechanical output data were statistically compared to data available from Dupuytren’s disease. Compared to Dupuytren’s fibroblasts, PFS fibroblasts showed a statistically reduced ability to contract a 3-D collagen gel over 24 hours (p< 0.01). In Dupuytren’s disease, fibroblasts derived from nodules and cords generate peak forces of 140 dynes and 110 dynes respectively, while PFS fibroblasts generated peak force of 8 dynes The response to TGF-beta1 stimulation, which has been shown to enhance peak force contraction in Dupuytren’s fibroblasts had no effect on PFS fibroblasts and this was statistically significant (p< 0.01). These data suggest intrinsic differences in cellular activity and mechanisms between Dupuytren’s and Primary Frozen Shoulder even though clinically they both manifest with a contracted extracellular matrix affecting function and requiring surgical intervention. This may explain increased post surgical recurrence in Dupuytren’s as compared to Primary Frozen Shoulder release

The purpose of the study was to test the hypothesis that cellular mechanisms of fibroblasts derived from primary frozen shoulder(PFS) exhibit similar activity in terms of contraction, response to cytokine (transforming growth factor-beta1) and mechanical stimulation similar to that generated by fibroblasts derived from dupuytren’s disease. PFS is a debilitating disease of unknown aetiology, characterised by fibrosis with contracture of the cora-cohumeral ligament, tissues of the rotator interval and glenohumeral ligaments, leading to restrictive shoulder movements. Frozen shoulder has been postulated to be Dupuytren’s disease of the shoulder with an association inferred since 1936. Materials and Methods: Primary explant cultures of fibroblasts from seven patients with PFS and five control patients were obtained using standard tissue culture techniques. Fibroblasts were seeded in 3-D collagen constructs and contraction force generated over 24hours measured using a culture force monitor(CFM) in real time. Increasing concentrations of TGF-beta1 were added to cell seeded gels and force generated measured using the CFM over 24hours. These mechanical output data were statistically compared to data available from Dupuytren’s disease. Results and Discussion: Compared to Dupuytren’s fibroblasts, PFS fibroblasts showed a statistically reduced ability to contract a 3-D collagen gel over 24hours (p< 0.01). In Dupuytren’s disease, fibroblasts derived from nodules and cords generate peak forces of 140dynes and 110dynes respectively, while PFS fibro-blasts generated peak force of 8dynes The response to TGF-beta1 stimulation, which has been shown to enhance peak force contraction in Dupuytren’s fibro-blasts had no effect on PFS fibroblasts and this was statistically significant (p< 0.01). Conclusion: These data suggest intrinsic differences in cellular activity and mechanisms between Dupuytren’s and Primary Frozen Shoulder even though clinically they both manifest with a contracted extracellular matrix affecting function and requiring surgical intervention. This may explain increasing post surgically recurrence in Dupuytren’s as compared to Primary Frozen Shoulder release

In patients with DM (Diabetes Mellitus types I & II), primary frozen shoulders tend to be refractory to all forms of treatment. We collected tissue from the joint capsule of shoulder joints from a variety of patients undergoing surgery as follows:. Diabetic Group (DFS): patients with DM who have primary frozen shoulders. Other patients suffering from primary frozen shoulders (FS). Control group (NS). Patients undergoing shoulder surgery that does not involve stiffness of the gleno-humeral joint. Tissue was collected from near to the rotator interval under arthroscopic control. Fibroblast lines were established by serial passage. Thereafter they were exposed to graded concentrations of insulin in vitro for 24 hours and the supernatant retained for assay. Fibroblast lines were analysed from 3 subjects in each group (n=9). Luminex multiplex analysis was performed for MMPs (Matrix Metalloproteinases). TIMP-1 (Tissue Inhibitor of MetalloProteinases) expression. Informed consent was obtained from all subjects. Results: Production of MMP 1,2,3 and 8 by fibroblast lines were distinct between patient groups. MMP-1 production in DFS (mean 716pg/mL) was significantly reduced compared to FS derived patient cells (mean 972pg/mL) (p=0.0138, Mann-Whitney Test). Moreover, striking differences were observed when fibroblasts from DFS patients were compared with those from NS controls (mean 5898pg/mL) (p< 0.000). Calculating MMP-1/TIMP-1 ratios revealed significantly lower ratios in DFS (2597), or FS (2860) compared with NS (24,326) (p < 0.001). There was no significant difference between ratios of MMP1/TIMP1 in DFS and FS (p=0.977). MMPs 7,9,12 and 13 were not detected in any of the samples. This is the first time these enzymes have been measured and quantified in cells derived from shoulder tissues. Primary Frozen Shoulders produce less MMPs and have a smaller MMP/TIMP ratio than controls. Similarly the diabetic patient derived cells produce less MMP-1, at an even lower level. These deficiencies in MMP1 production may reflect an altered capacity for local tissue re-modelling. MMP modulation may allow therapeutic intervention in the diabetic and frozen shoulder group of patients

Background. Frozen Shoulder is a common condition which causes significant morbidity in people of working age. The 2 most popular forms of surgical treatment for this condition are Manipulation under Anaesthesia (MUA) or MUA plus Arthroscopic Capsular Release (ACR). Both treatment modalities are known to give good results, but no-one has compared the two to see which is better. Aim. To compare the outcome in patients with primary frozen shoulder, who are treated by either MUA or MUA plus ACR. Methods. 56 patients with primary frozen shoulder were treated by either MUA or MUA plus ACR. Each patient had their American Shoulder and Elbow Score (ASES), and their Oxford Shoulder Score (OSS) measured pre- and post-operatively. Results. The patients who had MUA plus ACR had a mean ASES of 19.6 pre-operatively, 78.3 at 6 months, and a mean of 80.1 at 12 months. The mean OSS was 32.5 pre-operatively, 53.6 at 6 months and 53.8 at 12 months. The patients who had a MUA had a mean ASES of 28.7 pre-operatively, 57.9 at 6 months and 58 at 12 months. The mean OSS was 33 pre-operatively, 42.5 at 6 months and 48 at 12 months. Conclusions. Both treatments give good results; MUA plus ACR give significantly superior results at 6 to 12 months post-operatively. However, there is no significant difference beyond 12 months

Aim: The purpose of this study was to evaluate the results of arthroscopic capsular release in patients with primary adhesive capsulitis of the glenohumeral joint. Methods: Twenty-eight shoulders in 27 patients with adhesive capsulitis of the glenohumeral joint were treated with manipulation and arthroscopic capsular release. Their average age was 54.5 years (range, 39–67). During surgery, synovectomy and a combined anterior, posterior and inferior arthroscopic release using electrocautery or laser was performed. Range of motion and evaluation with the Constant score before and after surgery was performed in all patients. Results: The mean follow-up was 32 months (24–63). The mean Constant score significantly improved from 44.6 (28–52) preoperatively to 86.3 (73–52) postoperatively (p< 0.001, paired t-test). Range of motion for all planes significantly improved. Abduction improved from 72° preoperatively to 165° postoperatively; Internal rotation improved from 13° to 60° and external rotation from 10° to 75°. Subjectively all patients had remarkably less pain, and there were no complications. Conclusions: Our study suggest that arthroscopic treatment of primary adhesive capsulitis with capsular release is an effective and reliable method for restoring a painless motion of the glenohumeral joint

Background – Frozen Shoulder is a common condition which causes significant morbidity in people of working age. The 2 most popular forms of surgical treatment for this condition are Manipulation under Anaesthesia (MUA) or MUA plus Arthroscopic Capsular Release (ACR). Both treatment modalities are known to give good results, but no-one has compared the 2 to see which is better. Aim – To compare the outcome in patients with primary frozen shoulder, who are treated by either MUA or MUA plus ACR. Method – 61 patients with primary frozen shoulder were treated by either MUA or MUA plus ACR. Each patient had their American Shoulder and Elbow Score (ASES), and their Oxford Shoulder Score (OSS) measured pre and post-operatively. Results – The patients who had MUA plus ACR had a mean ASES of 24.8 preoperatively, 64 at 4 months, and a mean of 75.4 at 12 months. The mean OSS was 32.5 pre-operatively, 48.5 at 4 months and 53.4 at 12months. The patients who had a MUA had a mean ASES of 28.7 pre-operatively, 60.9 at 4months and 69.6 at 12months. The mean OSS was 33 preoperatively, 46.5 at 4 months and 50.9 at 12 months. Conclusions – Both treatments give good results. MUA plus ACR give superior numerical results at 6 to 12 months post-operatively, however, these figures did not reach statistical significance

Manipulation under anaesthetic (MUA) for the treatment of frozen shoulder is well established and effective however timing of surgery remains controversial. Intervention before 9 months has previously been shown to be associated with improved outcome. We test this theory by measuring Oxford Shoulder Score (OSS), re-MUA and subsequent surgery rate. A retrospective review of a prospectively collected, single surgeon, consecutive patient series revealed 244 primary frozen shoulders treated by MUA within 4 weeks of presentation. The mean duration of antecedent symptoms was 28 weeks (95% CI 4-44 weeks) and time to follow up was 26 days (95% CI 11-41 days). The mean OSS improved by 16 points (2-tailed t test p< 0.001) with a mean follow up OSS of 43 (95% CI 38-48). 195 shoulders were manipulated before 38 weeks (9 months) and had the same mean change in OSS (16) as the 49 shoulders manipulated after 38 weeks. 48 shoulders, including 15 diabetic shoulders required further MUA. 8 shoulders had subsequent surgery. These events were also independent of antecedent symptom duration. Early MUA does not appear to produce improved outcomes when compared to later intervention but we note does result in an earlier return to function

This is the largest reported natural history study of frozen shoulder. 500 patients were identified from a specialist shoulder clinic register with a diagnosis of frozen shoulder based on Codman’s criteria. 273 patients with primary frozen shoulder replied to a detailed postal questionnaire regarding their condition. Mean follow up from symptom onset was 52 months (range 12–240months), with 89% of shoulders followed up for a minimum of 3 years. A positive family history was identified in 20% (n=45) of 1st degree relatives. The relative risk to siblings compared with a control population was 4:1. Patients with mild to moderate symptoms recovered more quickly than those with severe or unbearable symptoms. The mean age of onset was 53 years (range27–85yrs). The female to male ratio was 1.6:1. The condition was bilateral in 20%, with no incidence of ipsilateral recurrence. 22% of patients reported a history of minor trauma to the upper limb prior to the onset of symptoms. 16% were diabetic and 4% reported a history of Dupuytren’s contracture. Right and left arms were affected equally with no relationship to hand dominance. 61% reported slow, and 39% reported sudden onset of symptoms. Generally pain and stiffness improved with time but at 3 and 4 years after onset 13% and 9% respectively still had symptoms. Frozen shoulder affects people mainly in their 6th decade. Genetic factors play an important role in the aetiology. The natural history is for improvement with time, with the less severe symptoms at onset improving most quickly. 9% of patients were still symptomatic at 4 year follow up

Aim: To compare 2 rehabilitation regimes after arthroscopic interval release: immediate mobilization versus immediate mobilization and external rotation night splint for ten days. Methods: 30 patients aged 40–67 years with primary frozen shoulder were included in the study. The surgical procedure consisted of release of the coracohumeral ligament, rotator interval and the posterior capsule with electrocautery, followed by gentle manipulation. Patients were randomised into 2 rehabilitation groups: immediate mobilization (IM) or immediate mobilization with external rotation night splint (ERS) used for 10 days post-operatively. Patients were assessed pre & post operatively and using the visual analogue score for pain, Constant and Oxford scoring systems. Results: There were 15 patients in the IM group and 15 in ERS group. In the IM group the Constant score improved from 35±10 (mean±SD) pre-operatively to 63±14 at 1 month and 75±11 at 6 months, and in the ERS group the Constant score improved from 33±9 pre-operatively to 59±14 at 1 month and 75±7 at 6 months. The Oxford score in the IM group improved from 35±9 pre-operatively to 25±8 at 1 month and 18±9 at 6 months, and in the ERS group from 38±9 pre-operatively to 27±8 at 1 month and 18±8 at 6 months (all changes P< 0.001 cf pre-operative, but NS from 1 to 6 months). Improvements in VAS were significant in both groups (P< 0.02) at 6 months but not at 1 month. There was no significant difference between the two groups in terms of Oxford or Constant scores or VAS at 1 and 6 months. Conclusion: Arthroscopic interval release is successful in restoring range of motion in patients with idiopathic frozen shoulder. Both groups showed significant improvement during the study period with most improvement in terms of range of movement occurring in the first month. There was no significant difference in outcome between the two groups studied

Aims: To prospectively compare the progress and outcomes during a follow-up period of two years in patients who were in the ‘freezing phase’ of Primary (Idiopathic) Frozen Shoulder following either manipulation of the shoulder under general anaesthetic (MUA) or intra-articular shoulder joint distension injections using steroid and local anaesthetic. Methods: 53 consecutive patients aged between 40 and 75 years with Frozen Shoulder were randomised to receive either MUA followed by out-patient physiotherapy or up to 3 distension injections at six weekly intervals in the first 12 weeks. Outcomes were measured using Constant-Murley Shoulder Function Assessment Score (CS), Visual Analogue Score (VAS) for pain level, and the SF-36 Health Evaluation Questionnaire. All patients were reviewed at 2, 6 and12 weeks, then at 6, 9, 12, 18 and 24 months. At each visit the CS and the VAS were repeated. The SF-36 was undertaken at initial and final visits. Results: Group 1 (MUA) contained 28 patients of which 15 (54%) were female. Group 2 (Distension Injection) contained 25 patients of which 20 (80%) were female. No statistical difference was identified between the 2 groups in terms of outcome for the affected shoulders, for the SF36 scores, CS and the VAS. Maximum benefit was seen by 12 weeks in both groups. In group 2 this equated to 2 distension injections. No complications were noted in either group. Conclusion: Frozen Shoulder is accepted to be a self-limiting condition with resolution by 2 years from onset. Any treatment aims to reduce this period of pain and disability. The potential risks of MUA include fracture and rotator cuff ruptures are well documented in the literature. Distension injections are easily performed in clinic without the need for admission, a general anaesthetic, or the risk of the complications associated with MUA. In view of there being no difference between the treatment modalities we recommend the use of 2 distension injections as the first line treatment for Frozen Shoulder

The June 2014 Shoulder & Elbow Roundup³⁶⁰ looks at: suprascapular nerve and rotator cuff pathology; anchors in Bankart repair: it’s not what you’ve got, but how you use it; not all shoulder PROMs are equal; reverse shoulder arthroplasty OK in trauma; not all in the mind: frozen shoulder personality debunked; open and arthroscopic repair equivalent in shoulder instability; natural history of olecranon fractures not so bleak?; and resurfacing of the shoulder: a Danish perspective.

The October 2015 Shoulder & Elbow Roundup³⁶⁰ looks at: Culture time important in propionibacterium acnes; Microvascularisation of the cuff footprint; Degenerative cuff tears: evidence for repair; Middle ground in distal humeral fractures?; Haste needed in elbow heterotopic ossification; Iatrogenic frozen shoulder; Salvage of failed humeral fixation