Aims

Is it feasible to conduct a definitive multicentre trial in community settings of corticosteroid injections (CSI) and hydrodilation (HD) compared to CSI for patients with frozen shoulder? An adequately powered definitive randomized controlled trial (RCT) delivered in primary care will inform clinicians and the public whether hydrodilation is a clinically and cost-effective intervention. In this study, prior to a full RCT, we propose a feasibility trial to evaluate recruitment and retention by patient and clinician willingness of randomization; rates of withdrawal, crossover and attrition; and feasibility of outcome data collection from routine primary and secondary care data.

Estimated to affect 2–5% of the population, adhesive capsulitis is a common cause of shoulder pain and dysfunction. The objective of this study is to determine if arthrographic injection of the shoulder joint with steroid, local anesthetic and contrast is an effective treatment modality for adhesive capsulitis and whether it is superior to arthrographic injection with local anesthetic and contrast alone.

This is a double-blinded RCT of patients with a diagnosis of adhesive capsulitis who were randomly assigned to receive an image guided arthrographic glenohumeral injection with either triamcinalone (steroid), lidocaine (local anesthetic) and contrast or lidocaine and contrast alone. Outcome measures included active and passive shoulder range of motion (ROM) and functional outcomes assessed using the Shoulder Pain and Disability Index (SPADI), the Constant Score and a Visual Analog Scale for pain. Post-operative evaluation occurred at 3 weeks, 6 weeks and 12 weeks. Descriptive statistics were utilised to summarise patient demographics and other study parameters. One-way ANOVAs compared the VAS, Constant and SPADI scores across the different time points for both study groups. The post hoc Bonferroni correction was used to adjust for multiple comparisons.

There were 37 shoulders injected with follow-up visits at 12 weeks. Twenty shoulders were randomised to receive local plus steroid and 17 shoulders received local anesthetic only. There were 21 females and 14 males with an average age of 54 years (range, 42–70). VAS scores for both patient groups were significantly improved (p<0.05) at all follow-up times. Goniometric testing demonstrated significant improvements in forward flexion and internal rotation at 90 degrees in the local group and only abduction in the local plus steroid group. There were no significant changes in the Constant scores for the local group (p=0.08), however, the Constant scores showed significant improvement for the local plus steroid group (p=0.003) at all follow-up time points. The local group showed significant improvement in their SPADI pain scores at the 12 week follow-up only (p=0.01). There were no significant differences in their SPADI disability scores (p=0.09). The local plus steroid group had significant improvement in SPADI pain and disability scores at all follow-up time points (p=0.001).

The optimal treatment for adhesive capsulitis remains unclear. Our study demonstrated that patients receiving an arthrographic injection of either steroid and local anesthetic or local anesthetic alone had significantly improved post-injection pain scores. However, only the steroid and local anesthetic group demonstrated improved SPADI disability and Constant scores. Thus, we believe that either treatment may be a good option for patients with adhesive capsulitis and can reliably relieve pain, but we would recommend the steroid with local anesthetic over the local anesthetic alone as it may provide improved function.

Introduction. Superior Labral Anterior Posterior Tears are being treated surgically in increasing numbers. Stiffness is the most common complication. We reviewed 115 cases of SLAP repairs to try and identify preoperative risk factors if any for stiffness. Methods. Retrospective cohort study of 115 patients who underwent SLAP repair. All patients failed attempts at conservative therapy including NSAIDS, Physical Therapy and cortisone injections. Results. Age ranged from 16–71 years, with an average age of 46. Male 84, Female 31. patient charts and operative notes were examined from 2004–2009. We used an average of 1.64 anchors per case; we performed arthroscopic Mumford on 15 patients, subscap repair (4), 19 cases with concomitant SLAP repair and Arthroscopic rotator cuff repair Other procedures included Biceps tenotomy and tenodesis, chondroplasty, Microfracture, removal of loose bodies, synovectomy and lysis of adhesions. Twelve patients underwent revision surgery(10%) We had 5 cases of stiffness which required lysis of adhesions and synovectomy, 4 cases had previous SLAP and concomitant rotator cuff repair done at the index surgery, 4 cases had arthrosis noted at index surgery and underwent chondroplasty and 2 of them underwent micro fracture. During the revision surgery 4 had also a concomitant cuff tear (new) which required repair Average time from index surgery to revision was 11 months, the patients who developed adhesive Capsulitis and stiffness the average age was 56 years. We had 2 titanium metal anchors pull out and present as loose bodies with one of the anchor causing chondral damage, we stopped using metal anchors and we have not had this problem recur since.5 cases had Mumford procedure done during the revision surgery.5 cases needed repeat SLAP repairs and by increasing use of biceps tenotomy this incidence should decrease. Conclusions. Our large retrospective case series shows an acceptable complication rate. Stiffness (5%) is still the most common complication especially in patients older than 50, withpreexisting Glenohumeral arthritis and concomitant rotator cuff tears. Hopefully our early aggressive mobilization will decrease this incidence

Adhesive capsulitis of the shoulder is a common debilitating condition with prevalence in the order of 2 to 5%. Whilst it is usually a self-limiting condition, patients are typically not willing, nor are they able, to wait to the end of the recovery phase. A number of treatment strategies have been described. Manipulation under anaesthesia can significantly increase motion in all planes, but carries a significant risk of fracture. Capsular release also significantly improves motion with fewer potential side effects.

We hypothesise that performing an arthroscopic excision of the abnormal capsulitis tissue will give better results with least risk of recurrence. Data was collected both retrospectively and prospectively for patients undergoing this procedure. Range of motion and Oxford shoulder scores was documented pre-operatively and post-operatively, at 6 weeks, 3 months and 6 months. 41 patients were included. At 3 months mean flexion had increased from 101 to 152 degrees, abduction from 91 to 151 degrees, and external rotation from 18 to 44 degrees. Mean Oxford shoulder score had increased from 20.6 to 35.8 at 3 months.

The results support the use of this technique for treating adhesive capsulitis. Larger patient numbers and longer term follow up will help compare it against the other well established techniques.

Our aim was to determine the prevalence of shoulder symptoms in patients with type I compared to type 2 diabetes mellitus and evaluate the clinical presentation of patients diagnosed with adhesive capsulitis. This was a retrospective case-note review of 164 diabetic patients treated for shoulder symptoms from 1996 to 2007. Diabeta 3 for relevant Diabetic data. We used ANOVA, Tukey HSD, Chi-Square and Fisher’s Exact tests. The incidence of treated shoulder patients in diabetic population: 1.04%. 86 males; 78 females. Average age 58 years (22 – 83). DM Type I 34% (46/136); Type II 66% (90/136). Mean duration of DM at presentation: 10 years (1–33). Mean HbA1c at presentation 8.3%. Retinopathy 16% (19/90); Neuropathy 12% (12/88). The diagnoses were: Impingement 101 (62%); Adhesive Capsulitis 35 (21%); Cuff tear 17 (10%); Arthritis 11 (7%). Mean recorded pre-treatment ROM: Impingement (flexion 117°, abduction 103°, ER 36°); Adhesive Capsulitis (flexion 90°, abduction 75°, ER 12°); Cuff tear (flexion 109°, abduction 95°, ER 45°); Arthritis (flexion 67°, abduction 93°, ER 18°). Adhesive Capsulitis was significantly related to: HbA1c (9.9%); p< 0.001, Type I DM; p< 0.003, Duration of DM (average 17.5 yrs); p< 0.03. An interesting statistically significant (p< 0.003) correlation was found between Type 2 DM and Impingement Syndrome. Treatments included: Injection (53), MUA (49), Arthroscopy (99), Open Surgery (56). 82% patients satisfactorily discharged (mild/no pain and improved ROM: flexion > 150°, abduction > 150° and ER > 50°) after an average 3.4 months. Three referred to pain clinic, sixteen patients didn’t attend their follow-up appointment and seven died. Eleven relapsed (eight adhesive capsulitis). Persistent symptoms were more common in Diabetic patients with adhesive capsulitis, which was found to be significantly related to Type I DM, its duration and control (HbA1c levels). Type II Diabetics are more likely to be affected with impingement syndrome. Close liaison with the Diabetology Department is essential for effective treatment of Diabetic Shoulder pathology

Background: Comparison of intra-articular corticoid injections and oral corticosteroids in the treatment of adhesive capsulitis of the shoulder

Methods: In a prospective randomized evaluation two different treatment regimen were compared. 40 patients with idiopathic adhesive capsulitis of the shoulder were treated either with an oral (20) corticoid treatment regimen for 4 weeks or intra-articular (20) injection series of corticosteroids (3 injections- 4, 8, 12 weeks).Patient groups were comparable in sex, age and affected side. Follow-up periods were after 4,8,12 weeks, 6 and 12 months. For the clinical evaluation the Constant and Murley Score, the Simple Shoulder Test and visual analog scales for pain, function and satisfaction were used.

Results: In the patients group treated with oral glucocorticoids significant improvements were found for the Constant and Murley Score (p< .0001), the Simple Shoulder Test (p=.035) and range of motion for flexion (p< .0001), abduction (p< .0001), external (p=.001) and internal rotation (p=.028) already at 4 weeks follow-up. The visual analog scales for pain, function and patient satisfaction also improved significantly after 4 weeks of treatment (p< .0001).)

The patient group treated with an intra-articular glucocorticoid injection series also showed significant improvements for the Constant and Murley Score (p< .0001), the Simple Shoulder Test (p< .0001) and the visual analog scales for pain, function and patient satisfaction (p< .0001) after 4 weeks and also at any other follow up. Significant improvements were also seen in abduction (p< .0001), flexion (p< .0001) and external rotation (p=.001) and internal rotation (p=.035) after 4 weeks of treatment. These results were confirmed at any other follow up.

Comparison of the two treatment regimen showed superior short term results for the intra-articular treatment regimen in range of motion, Constant Score and Simple Shoulder Test and patient satisfaction (p< .05). No significant differences were found in the visual analog scales for pain and function (p> .05).

Conclusion: The use of cortisone in the treatment of idiopathic adhesive capsulitis of the shoulder leads to fast pain relief and improves range of motion. Intra-articular injections of glucocorticoids showed superior short term results in objective shoulder scores, range of motion and patient satisfaction compared with a short course of oral corticosteroids.

Introduction More than 2% of the general population is reported to be affected by adhesive capsulitis. The incidence is greater in patients with diabetes than in the general population for both IDDM and NIDDM. This study sought to test the hypotheses that diabetes does not have an effect on outcome and does not contribute to morbidity.

Materials and methods Data were collected retrospectively by reviewing medical records from 1996 to 2005. A total of 148 case notes were evaluated to identify patients with a diagnosis of frozen shoulder who underwent MUA ± arthroscopy ± release. Twenty-two patients (22 shoulders), 12 of whom had diabetes, agreed to participate and were included. The diabetic and non-diabetic groups were broadly comparable with respect to demographic characteristics. Invited patients were asked to assess current physical function and symptoms by completing a shortened version of the DASH outcome measure questionnaire prior to attending the clinic and a further questionnaire detailing pre-op symptoms. Physical function was assessed and calculated using the Constant score system.

Results The median pre-operative DASH score was 72.73 in the diabetic group and 71.00 in the non-diabetic group (difference 2.3%). The median post-operative DASH score was 27.27 in the diabetic group and 28.86 in the non-diabetic group (difference 5.51%). The median postoperative Constant score was 60.00 in the diabetic group and 59.50 in the non-diabetic group (difference 0.83%).

Conclusion The pre- and post-operative DASH results and post-operative Constant score showed little difference between diabetic and non-diabetic patients. While giving due cognisance to the small number of patients included and the retrospective design of the study, the results support the hypothesis that diabetes does not have an effect on outcome following MUA or arthroscopy for adhesive capsulitis and does not contribute to morbidity.

Background Adhesive capsulitis of the shoulder is a painful condition that results in gradual loss of joint movement. Numerous treatment modalities have been utilised with variable benefits. Because of the risk of brachial plexus injury and fracture, manipulation under anaesthesia is considered with caution.

Aim To determine the rate of manipulation under anaesthesia (MUA) following primary distension arthrogram for adhesive capsulitis of the shoulder.

Patients and Methods The case notes of 40 patients (42 shoulders) between 1998 to 2004 at Glenfield Hospital, Leicester under the care of one consultant with adhesive capsulitis of the shoulder treated with distension arthrogram by using intra-articular injection of local anaesthetic, corticosteroid, contrast media and air were reviewed.

Results Capsular disruption into the subscapular bursa was demonstrated in all cases. 15 of 42 (36%) shoulders underwent MUA following distension arthrogram. The average period of pain prior to distension arthrogram for these patients was 42 weeks (range: 7–156). 35 of 40 (88%) patients were pain free following primary distension arthrogram.

One patient experienced a vasovagal episode during the distension arthrogram.

Conclusion Distension arthrogram can be used as a therapeutic procedure for achieving symptomatic pain relief in the early phase of adhesive capsulitis and decreasing the risk of MUA of the shoulder.

Introduction This prospective study was carried out to assess the outcome of manipulation of the shoulder with interscalene block as a treatment for adhesive capsulitis of the shoulder.

Materials and Methods 31 patients underwent manipulation under general anaesthesia and interscalene block followed by intra-articular glenohumeral injection of steroid and local anaesthetic. Physiotherapy was started on the day of surgery. Shoulder function was assessed with range of movement, Constant score and DASH score (Disability of the Arm, Shoulder and Hand) by specialist upper limb physiotherapists, pre-operatively, and post-operatively at 6 weeks, 3, 6 and 12 months.

Results The DASH score improved from a mean of 60.1 pre-operatively to a mean of 24.1 at final follow up. Constant scores improved from a mean of 34.4 pre-operatively to 65.8. The mean improvement in Constant scores was 31.5 points. Pre-operative range of movement (expressed as a percentage of the total ROM of the unaffected side) was 51.5%. The mean post-operative ROM was 85.4%. External rotation improved from 41.7% of the unaffected side preoperatively to 77.7% at final review. Abduction improved from 47.4% to 85.4% and forward flexion improved from 59.1% to 90%. No patients required further manipulation.

Discussion All outcome measures improved following treatment. These improvements were sustained at 12 months follow-up. In particular external rotation, which was the most restricted movement preoperatively, was seen to improve and this improvement was maintained throughout follow-up.

Conclusion We conclude that manipulation of the shoulder under interscalene block and general anaesthetic for adhesive capsulitis results in a sustained improvement in function and movement.

Aim: This prospective study was carried out to assess the outcome of manipulation of the shoulder as a treatment for adhesive capsulitis of the shoulder.

Method: 31 patients were followed prospectively for twelve months after shoulder manipulation for adhesive capsulitis. All patients underwent manipulation under general anaesthetic and scalene block followed by intra-artificial gleno-humeral injection of steroid and local anaesthetic. Postoperative physiotherapy was started on the day of surgery. Shoulder function was assessed with range of movement, Constant and Murley score and DASH score (Disability of the Arm, Shoulder and Hand by specialist upper limb physiotherapists, pre-operatively, and post – operatively at 6 weeks, 3, 6, and 12 months.

Results: The DASH score improved from a mean of 60.1 (range 27–98) pre-operatively to a mean of 24.1 (range 5–83) at final follow up. Constant scores improved from a mean of 34.4 (range 16–51) pre-operatively to 65.8 (range 35–88). The mean improvement in Constant scores was 31.5 points.

Pre-operative range of movement (expressed as a percentage of the total ROM of the unaffected side) was 51.5 % (range 23.8–67.2). The mean postoperative ROM was 85.4% (range 56.2 – 99.3). External rotation improved from 41.7% (range 23.5 – 81.5) of the unaffected side preoperatively to 77.7% (range 44.1 – 105.3) at final review. Abduction improved from 47.4 % (range 23.3 – 70.6) to 85.4% (range 49.7 – 100) and forward flexion improved from 59.1% (range 33.5 – 73.9) to 90o (range 64.3 – 100.6). No patients required further manipulation.

Conclusion: All outcome measure improved following treatment. These improvements were sustained at 12-month follow up. In particular, external rotation which was the most restricted movement pre-operatively was seen to improve and this improvement was maintained throughout follow-up. We conclude that manipulation of the shoulder under inter-scalene block and general anaesthetic for adhesive capsulitis results in a sustained improvement in function and movement.

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.

Two hundred patients with Adhesive Capsulitis according to Codman’s criteria were treated with manipulation under anaesthetic and hydraulic distension by the senior author. The procedure and subsequent rehabilitation was uniform for all patients. The average age at time of procedure was sixty years (range 36–91 years). Follow-up was performed using a self-assessment booklet which we devised to examine outcome in the following areas: Pain Visual Analogue Score, Ten Activities of Daily Living, Ability to Sleep & Lie on Affected Shoulder, Range of Motion and overall satisfaction. The average length of follow-up was sixty-two months (range 12–125 months). One hundred and forty-five patients were available for follow-up and completed the assessment correctly. Results: There were no operative complications in this group. Pain was significantly decreased from a mean pre-operative pain visual analogue score of 7.9 to 1.4 post-operatively. Shoulder pain causing difficulty sleeping was reduced from 85% of patients pre-operatively to 15% post-operatively. Range of motion was assessed in comparison to pre-operative values of the affected side and current values of the unaffected side. Regarding patient satisfaction 90% of patients were improved post-operatively, 7.5% unchanged and 1.5% felt that their symptoms were worse following the procedure. The procedure was well tolerated and 97% of patients would have the procedure again. Patients who had the procedure within nine months following onset of symptoms had better long-term range of motion and functional outcome than those who had a greater delay in treatment. Our results indicate manipulation and hydraulic distension is a safe effective treatment for adhesive capsulitis and that a more favourable outcome is achieved if it is performed at an early stage