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Shoulder, Frozen

  • National Taiwan University Hospital, Bei-Hu Branch
Shoulder, Frozen
Kamal Mezian; Ke-Vin Chang1.
1 National Taiwan University Hospital
Last Update: February 25, 2018.
Adhesive capsulitis (AC), is also known as frozen shoulder an insidious
painful condition of the shoulder persisting more than 3 months. This
inflammatory condition that causes fibrosis of the glenohumeral joint capsule
is accompanied by gradually progressive stiffness and significant restriction
of range of motion (typically external rotation). However, the patients may
develop symptoms suddenly and have a slow recovery phase. The recovery is
satisfying in most of the cases, even though this may take up to 2 to 3 years.
The etiology of frozen shoulder is not yet fully understood. However, some
plausible risk factors have been identified:
Diabetes mellitus (with a prevalence up to 20%)
Thyroid disorder
Shoulder injury
Dupuytren disease
Parkinson disease
Complex regional pain syndrome
Adhesive capsulitis occurs in up to 5%. Females are 4 times more often
affected than men, while the non-dominant shoulder is more prone to be
Frozen shoulder is usually described as fibrotic, inflammatory contracture of
the rotator interval, capsule, and ligaments. However, the development of AC
remains not fully understood. Although disagreements exist, the most
recognized pathology is cytokine-mediated synovial inflammation with
fibroblastic proliferation based on arthroscopic observations. Additional
findings include adhesions around the rotator interval caused by increased
collagen and nodular band formation.
The structure usually affected first is the coracohumeral ligament the roof of
the rotator cuff interval. Contraction of the coracohumeral ligament limits
external rotation of the arm, which is usually first affected in early AC. In
advanced stages, thickening and contraction of the glenohumeral joint
capsule develop, further limiting the range of motion in all directions.
The studies of histopathology for the glenohumeral capsule have confirmed a
significant increase in fibroblasts, myofibroblasts, and inflammatory cells,
like B-lymphocytes, mast cells, and macrophages.
History and Physical
Patients suffering from early AC usually present with a sudden onset of
unilateral anterior shoulder pain. The typical symptoms comprise passive and
active range of motion restriction, first affecting external rotation and later
abduction of the shoulder. In general, depending on the stage and severity,
the condition is self-limiting, interfering with activities of daily living, work,
and leisure activities. Functional impairments caused by frozen shoulder
consist of limited reaching, particularly during overhead (e.g., hanging
clothes) or to-the-side (e.g., fasten one's seat belt) activities. Patients also
suffer from restricted shoulder rotations, resulting in difficulties in personal
hygiene, clothing and brushing their hair. Another common concomitant
condition with frozen shoulder is neck pain, mostly derived from overuse of
cervical muscles to compensate the loss of shoulder motion.
The physical findings are essential for a frozen shoulder diagnosis, although
pain and stiffness make it difficult for patients to comply with a complete set
of physical examination.
Two physical examinations are commonly used for diagnosing AC, including
tests of combined motion, as touching the scapula from behind the neck and
from behind the back.
However, the most pathognomonic feature for AC is a loss of passive ROM.
Practically, in cases of significant restriction of passive ROM, an
examination of active motion can be skipped. Nevertheless, as an
undetectable limitation of shoulder motion may be present in the early stage,
AC diagnosis should be reconsidered in patients who present with a gradual
restriction of range of motion at follow-ups.
In general, patients with frozen shoulder usually demonstrate significant
restriction in active and passive range of motion, particularly in external
rotation and abduction movement. Restricted motion in every direction not
only indicates the presence of a developed frozen shoulder, but it may be a
“red flag” for possible underlying malignancy or fracture.
Frozen shoulder is a clinical diagnosis made by medical history, physical
examination, and imaging modalities (ruling out another condition, rather
than confirming the diagnosis of AC). No specific test (laboratory or
imaging) alone provides the definitive confirmation of the AC diagnosis.
Diagnostic imaging of AC can be challenging because as the findings based
on currently available methods (such as radiographs, ultrasound, plain
magnetic resonance imaging, and computed tomography) are usually
unremarkable. Imaging is therefore limited to ruling out concurrent
pathologies, like rotator cuff tendon tears and glenohumeral joint
osteoarthritis. The imaging tool mostly applied to patients with AC is high-
resolution musculoskeletal ultrasonography (MUS), which has emerged to be
the first line to scrutinize shoulder pathology. Nevertheless, until now, there
is lack of specific ultrasound findings for diagnosis of AC. To be more
comprehensive, several investigators reported thickening of the
coracohumeral ligament to be a sonographic characteristic in patients with
AC. Another commonly referred ultrasound finding is the presence of fluid
accumulation around the long head of the biceps tendon. Although biceps
peri-tendinous effusion is prevalent in shoulders with AC, it is specific to AC
because it might be a result of other shoulder pathology (e.g., rotator cuff
disorders or biceps tenosynovitis). Furthermore, ultrasound is less useful in
the pathology associated with instability or SLAP (superior labrum anterior
posterior) lesion. A plain radiograph is of limited diagnostic values in
patients with frozen shoulder. Nevertheless, it is reasonable to obtain routine
shoulder radiographs to rule out other etiologies (e.g., tumors,
acromioclavicular and glenohumeral osteoarthritis). MRI may show
thickening of the coracohumeral ligament and glenohumeral joint capsule.
MRI arthrography may show a volume reduction of the joint space.
The “lidocaine test” is subacromial injection test that may be helpful in
establishing the diagnosis in ambiguous clinical scenarios, to rule out
subacromial conditions. In patients with AC, passive movement limitation
persists after injection of local anesthetics into the subacromial space. On the
other hand, patients suffering from subacromial impingement syndrome (e.g.,
pathology of the rotator cuff or bursa) usually experience improved passive
range of motion after injection. The injection can easily be performed with
ultrasound guidance.
Treatment / Management
Despite the number of published literature on the AC, there is no consistent
consensus about management of AC. The majority of treatment options for
AC are non-operative and include pharmacological management and physical
Early Frozen Shoulder
An early stage of AC is often managed as subacromial pathology. The early
“freezing” AC mentioned above can be considered as inflammatory. On the
other hand, the inflammation becomes less accentuated in the later stages,
where ROM limitation is predominant, and inflammation-related pain is not
as much pronounced. In the light of above differences, we must consider the
disease stage when planning the treatment strategy. The correct recognition
of the clinical stage may help tailor treatment plans more specifically. The
aim of treatment in the “freezing” stage should focus on pain control,
reduction of inflammation and patient education. Initial treatment options for
adhesive capsulitis may include acetaminophen or NSAID. Although
evidence regarding NSAID for the treatment of frozen shoulder is limited,
they can be prescribed to provide short-term relief from the night pain if
present. However, in severe cases, opioid analgesics may be required.
Physical therapy is important for pain control and restoration of normal
shoulder mobility. Those comprise manual therapies based on soft tissue
mobilization and gentle stretching. Regarding physical modalities, no
particular agent has shown to be superior. The patient can be prescribed, e.g.,
therapeutic ultrasound, cryotherapy or transcutaneous electrical nerve
stimulation (TENS) unit. Physical therapy management should focus on
therapeutic exercise. Although not all patients can tolerate mobilization
exercise within the initial stage of the frozen shoulder due to severe pain, a
supervised therapeutic exercise should be conducted to slow down ROM
restriction. Furthermore, a home exercise program should be given to the
patients on a daily basis. In patients suffering from moderate to severe pain
who are not responsive to non-operative treatments, intra-articular injection
of corticosteroid should be considered. The injection should be performed
under ultrasonographic or fluoroscopic guidance to ensure the correct needle
placement. Last but not least, rehabilitation exercise should be prescribed
after injection.
Developed Frozen Shoulder
After the inflammation-related painful period subsides, the condition
progresses to a “frozen” and subsequently into a “thawing” phases. Treatment
objectives in the advanced stages should focus on regaining ROM limitation.
The physical therapists should provide more intensive (compared, e.g., to
subacromial pathologies) mobilization exercise to restore joint mobility. In
patients who do not respond well to non-operative treatments, a more
invasive therapy should be considered. The addition of suprascapular nerve
or interscalene brachial plexus blockage may result in further improvement.
In patients with refractory cases of frozen shoulder who do not improve after
6 months of non-operative treatment, more aggressive treatments such as
capsular hydrodilatation (stretching the joint capsule by the saline injectate
pressure), manipulation under anesthesia (tearing of the contracted capsule),
and arthroscopic capsular release (particularly in the rotator interval) can be
Differential Diagnosis
Adhesive capsulitis, particularly in early (freezing) stage might be a
diagnostic challenge as it may mimic subacromial pathology and rotator cuff
tendinopathy. Presentations mentioned above may result in the delay in
diagnosis of AC in the early phases. Regarding shoulder impingement and
rotator cuff pathology, patients report predominantly pain with less
pronounced passive range of motion. However, several facets help to
distinguish frozen shoulder from other shoulder disorders. Regarding the
causes other than AC, patients often state lifting a heavy object or performing
repetitive overhead movements. In contrast, frozen shoulder patients usually
describe spontaneous onset without an apparent cause or a history of overuse
activity. Extra precaution should be paid in case of the history of malignancy.
Common conditions that may mimic early adhesive capsulitis:
Subacromial pathology and rotator cuff tendinopathy
Post-stroke shoulder subluxation
Referred pain (cervical spine or malignancy, e.g., Pancoast tumor)
Later in the course of frozen shoulder, as severe restriction of motion comes
to predominate, the diagnosis becomes more apparent. However,
glenohumeral joint arthritis should also be considered, which can be ruled out
by free shoulder movement following lidocaine injection to the glenohumeral
Age of onset provides additional clues to diagnose AC. Frozen shoulder is
unlikely in patients younger than 40 years of age, and patients older than 70
are more likely to develop rotator cuff tears or glenohumeral osteoarthritis
instead of AC.
Gradual restriction of passive shoulder motion characterizes a natural course
of AC. The development is commonly described as progressing through 3
overlapping phases (4 stages classification can also be found in the
literature). However, from a practical point of view, we recommended
using 2-stage scheme: early and developed frozen shoulder.
1. Freezing (2 to 9 months): Early
2. Frozen (4 to 12 months): Developed
3. Thawn (12 to 42 months): Developed
An initial, painful phase with predominant pain that is worse at night, with
gradually increased glenohumeral joint ROM restriction.
The second phase with stiffness and persisted glenohumeral joint motion
limitation, but with less pain than that at the “Freezing” stage.
The third (recovery) phase with the gradual return of range of motion.
The duration of AC is from 1 to 3.5 years with a mean of 30 months. In about
15% of patients, the contra-lateral shoulder becomes affected within 5 years.
Pearls and Other Issues
Considering the diagnostic accuracy of frozen shoulder, researchers should
keep investigating the pathomechanism of AC. Some studies have recently
reported the application of contrast-enhanced ultrasonography in the
diagnosis of frozen shoulder. Application of the microbubble-based
ultrasound contrast agents (increasing a liquid substance echogenicity) in
musculoskeletal medicine has already been adopted for selected indications.
Looking ahead, the utility of contrast agents in a frozen shoulder diagnosis
seems to be promising particularly in ambiguous cases.
To access free multiple choice questions on this topic, click here.
1. Kanbe K, Inoue K, Inoue Y, Chen Q. Inducement of mitogen-activated
protein kinases in frozen shoulders. J Orthop Sci. 2009 Jan;14(1):56-
61. [PMC free article] [PubMed]
2. Chang KV, Lew HL, Wang TG, Chen WS. Use of contrast-enhanced
ultrasonography in musculoskeletal medicine. Am J Phys Med
Rehabil. 2012 May;91(5):449-57. [PubMed]
Reeves B. The natural history of the frozen shoulder syndrome. Scand.
J. Rheumatol. 1975;4(4):193-6. [PubMed]
Zuckerman JD, Rokito A. Frozen shoulder: a consensus definition. J
Shoulder Elbow Surg. 2011 Mar;20(2):322-5. [PubMed]
Song A, Higgins LD, Newman J, Jain NB. Glenohumeral corticosteroid
injections in adhesive capsulitis: a systematic search and review. PM
R. 2014 Dec;6(12):1143-56.[PMC free article] [PubMed]
Jain TK, Sharma NK. The effectiveness of physiotherapeutic
interventions in treatment of frozen shoulder/adhesive capsulitis: a
systematic review. J Back Musculoskelet Rehabil. 2014;27(3):247-
73. [PubMed]
Özçakar L, Kara M, Chang KV, Tekin L, Hung CY, Ulaülı AM, Wu
CH, Tok F, Hsiao MY, Akkaya N, Wang TG, Çarli AB, Chen WS, De
Muynck M. EURO-MUSCULUS/USPRM Basic Scanning Protocols
for shoulder. Eur J Phys Rehabil Med. 2015 Aug;51(4):491-
6. [PubMed]
Harris G, Bou-Haidar P, Harris C. Adhesive capsulitis: review of
imaging and treatment. J Med Imaging Radiat Oncol. 2013
Dec;57(6):633-43. [PubMed]
Ozaki J, Nakagawa Y, Sakurai G, Tamai S. Recalcitrant chronic
adhesive capsulitis of the shoulder. Role of contracture of the
coracohumeral ligament and rotator interval in pathogenesis and
treatment. J Bone Joint Surg Am. 1989 Dec;71(10):1511-5. [PubMed]
Maund E, Craig D, Suekarran S, Neilson A, Wright K, Brealey S,
Dennis L, Goodchild L, Hanchard N, Rangan A, Richardson G,
Robertson J, McDaid C. Management of frozen shoulder: a systematic
review and cost-effectiveness analysis. Health Technol
Assess. 2012;16(11):1-264. [PMC free article] [PubMed]
Copyright © 2018, StatPearls Publishing LLC.
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.
Full-text available
In this protocol, the patient/probe positionings, anatomical drawings and ultrasound images of commonly scanned shoulder structures are described. This practical guide is prepared (with an international consensus of several expert physiatrists) to serve as a uniform/standard approach especially for beginner sonographers.
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Frozen shoulder is a common condition, yet its treatment remains challenging. In this review, the current best evidence for the use of physical therapy interventions (PTI) is evaluated.METHOD: MEDLINE, CINAHL, Cochrane, PEDro, ProQuest, Science Direct, and Sport Discus were searched for studies published in English since 2000. 39 articles describing the PTI were analyzed using Sackett's levels of evidence and were examined for scientific rigor. The PTI were given grades of recommendation that ranged from A to C. Therapeutic exercises and mobilization are strongly recommended for reducing pain, improving range of motion (ROM) and function in patients with stages 2 and 3 of frozen shoulder. Low-level laser therapy is strongly suggested for pain relief and moderately suggested for improving function but not recommended for improving ROM. Corticosteroid injections can be used for stage 1 frozen shoulder. Acupuncture with therapeutic exercises is moderately recommended for pain relief, improving ROM and function. Electro- therapy can help in providing short-term pain relief. Continuous passive motion is recommended for short-term pain relief but not for improving ROM or function. Deep heat can be used for pain relief and improving ROM. Ultrasound for pain relief, improving ROM or function is not recommended.
Full-text available
Frozen shoulder is condition in which movement of the shoulder becomes restricted. It can be described as either primary (idiopathic) whereby the aetiology is unknown, or secondary, when it can be attributed to another cause. It is commonly a self-limiting condition, of approximately 1 to 3 years' duration, though incomplete resolution can occur. To evaluate the clinical effectiveness and cost-effectiveness of treatments for primary frozen shoulder, identify the most appropriate intervention by stage of condition and highlight any gaps in the evidence. A systematic review was conducted. Nineteen databases and other sources including the Cumulative Index to Nursing and Allied Health (CINAHL), Science Citation Index, BIOSIS Previews and Database of Abstracts of Reviews of Effects (DARE) were searched up to March 2010 and EMBASE and MEDLINE up to January 2011, without language restrictions. MEDLINE, CINAHL and PsycINFO were searched in June 2010 for studies of patients' views about treatment. Randomised controlled trials (RCTs) evaluating physical therapies, arthrographic distension, steroid injection, sodium hyaluronate injection, manipulation under anaesthesia, capsular release or watchful waiting, alone or in combination were eligible for inclusion. Patients with primary frozen shoulder (with or without diabetes) were included. Quasi-experimental studies were included in the absence of RCTs and case series for manipulation under anaesthesia (MUA) and capsular release only. Full economic evaluations meeting the intervention and population inclusion criteria of the clinical review were included. Two researchers independently screened studies for relevance based on the inclusion criteria. One reviewer extracted data and assessed study quality; this was checked by a second reviewer. The main outcomes of interest were pain, range of movement, function and disability, quality of life and adverse events. The analysis comprised a narrative synthesis and pair-wise meta-analysis. A mixed-treatment comparison (MTC) was also undertaken. An economic decision model was intended, but was found to be implausible because of a lack of available evidence. Resource use was estimated from clinical advisors and combined with quality-adjusted life-years obtained through mapping to present tentative cost-effectiveness results. Thirty-one clinical effectiveness studies and one economic evaluation were included. The clinical effectiveness studies evaluated steroid injection, sodium hyaluronate, supervised neglect, physical therapy (mainly physiotherapy), acupuncture, MUA, distension and capsular release. Many of the studies identified were at high risk of bias. Because of variation in the interventions and comparators few studies could be pooled in a meta-analysis. Based on single RCTs, and for some outcomes only, short-wave diathermy may be more effective than home exercise. High-grade mobilisation may be more effective than low-grade mobilisation in a population in which most patients have already had treatment. Data from two RCTs showed that there may be benefit from adding a single intra-articular steroid injection to home exercise in patients with frozen shoulder of < 6 months' duration. The same two trials showed that there may be benefit from adding physiotherapy (including mobilisation) to a single steroid injection. Based on a network of nine studies the MTC found that steroid combined with physiotherapy was the only treatment showing a statistically and clinically significant beneficial treatment effect compared with placebo for short-term pain (standardised mean difference -1.58, 95% credible interval -2.96 to -0.42). This analysis was based on only a subset of the evidence, which may explain why the findings are only partly supportive of the main analysis. No studies of patients' views about the treatments were identified. Average costs ranged from £36.16 for unguided steroid injections to £2204 for capsular release. The findings of the mapping suggest a positive relationship between outcome and European Quality of Life-5 Dimensions (EQ-5D) score: a decreasing visual analogue scale score (less pain) was accompanied by an increasing (better) EQ-5D score. The one published economic evaluation suggested that low-grade mobilisation may be more cost-effective than high-grade mobilisation. Our tentative cost-effectiveness analysis suggested that steroid alone may be more cost-effective than steroid plus physiotherapy or physiotherapy alone. These results are very uncertain. The key limitation was the lack of data available. It was not possible to undertake the planned synthesis exploring the influence of stage of frozen shoulder or the presence of diabetes on treatment effect. As a result of study diversity and poor reporting of outcome data there were few instances where the planned quantitative synthesis was possible or appropriate. Most of the included studies had a small number of participants and may have been underpowered. The lack of available data made the development of a decision-analytic model implausible. We found little evidence on treatment related to stage of condition, treatment pathways, the impact on quality of life, associated resource use and no information on utilities. Without making a number of questionable assumptions modelling was not possible. There was limited clinical evidence on the effectiveness of treatments for primary frozen shoulder. The economic evidence was so limited that no conclusions can be made about the cost-effectiveness of the different treatments. High-quality primary research is required.
Full-text available
Mitogen-activated protein (MAP) kinases are well-known molecules that play key roles in mechanical stress signals during skeletal development. To test our hypothesis that the synovium in frozen shoulders is induced by MAP kinases, immunohistochemical analyses for detecting expression and signal transduction of MAP kinases were performed in synovial tissue obtained from the rotator interval (RI) in frozen shoulders. Synovial tissues were examined from 10 frozen shoulder patients with a mean age of 55.4 years (46-62 years). Synovial tissues between the long head of the biceps tendon (LHB) and the RI in frozen shoulders were stained with hematoxylin and eosin (H&E) and then examined with immunohistochemical staining. Extracellular signal-regulated (ERK), the Jun N-terminal (JNK), and p38 mitogen-activated protein (MAP) kinases, nuclear factor kappaB (NF-kappaB), p50, CD29 (beta(1)-integrin), matrix metalloproteinase (MMP)-3, interleukin-6 (IL-6), CD56, CD68, S-100, and vascular endothelial growth factor (VEGF) were analyzed to detect expression patterns. H&E showed vascular proliferation with fibrin and fibrous tissue in the synovium of frozen shoulders. ERK was expressed in the epithelial cells of vascular tissue, and JNK was expressed strongly in the interstitial cells around vascular tissue; p38 MAPK was not expressed. NF-kappaB was expressed in vascular tissue, and IL-6 was expressed around vascular tissue. CD29 (beta1-integrin) was expressed in vascular tissue and in superficial cells of synovial tissue. MMP-3 and VEGF were expressed on the surface layer of synovial tissue and vascular tissue, and CD68 was expressed on the surface layer. Nerve-related proteins, CD56 and S-100, were expressed weakly. Mechanical stress on the LHB and RI in the shoulder may induce ERK and JNK to express NF-kappaB by CD29 to develop capsule contracture, producing MMP-3, IL-6, and VEGF.
Objective: To assess the literature on outcomes of corticosteroid injections for adhesive capsulitis, and, in particular, image-guided corticosteroid injections. TYPE: Systematic search and review. Literature survey: The databases used were PubMed (1966-present), EMBASE (1947-present), Web of Science (1900-present), and the Cochrane Central Register of Controlled Trials. Upon reviewing full-text articles of these studies, a total of 25 studies were identified for inclusion. The final yield included 7 prospective studies, 16 randomized trials, and 2 retrospective studies. Methodology: This systematic review was formatted by using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study criteria were limited to clinical trials, prospective studies, and retrospective studies that specifically evaluated intra-articular corticosteroid injections, both alone and in combination with other treatment modalities, for shoulder adhesive capsulitis. We included studies that were not randomized control trials because our review was not a meta-analysis. Data items extracted from each study included the following: study design, study population, mean patient age, duration of study, duration of symptoms, intervention, single or multiple injections, location of injections, control population, follow-up duration, and outcome measurements. A percentage change in outcome measurements was calculated when corresponding data were available. Risk of bias in individual studies was assessed when appropriate. Synthesis: All the studies involved at least 1 corticosteroid injection intended for placement in the glenohumeral joint, but only 8 studies used image guidance for all injections. Seven of these studies reported statistically significant improvements in range of motion at or before 12 weeks of follow-up. Ninety-two percent of all the studies documented a greater improvement in either visual analog pain scores or range of motion after corticosteroid injections in the first 1-6 weeks compared with the control or comparison group. Conclusions: Corticosteroid injections offer rapid pain relief in the short-term (particularly in the first 6 weeks) for adhesive capsulitis. Long-term outcomes seem to be similar to other treatments, including placebo. The added benefit of image-guided corticosteroid injections in improving shoulder outcomes needs further assessment.
Adhesive capsulitis is one of the most common conditions affecting the shoulder; however, early clinical diagnosis can be challenging. Treatment is most effective when commenced prior to the onset of capsular thickening and contracture; consequently, the role of imaging is increasing. The aim of this review is to demonstrate the typical imaging appearances of adhesive capsulitis and to examine some of the evidence regarding each of these imaging modalities. An evaluation of the various management options available to the clinician is also presented.
Ultrasound contrast agents enhance blood flow signals and allow assessment of microcirculation. The objective of this review is to systematically identify and summarize the literature on the use of contrast-enhanced ultrasonography in the musculoskeletal field. A literature search was conducted using the following keywords: ultrasound, contrast agent, and relevant musculoskeletal terms (muscle, tendon, joint, or bone). Only articles devoted to human research were reviewed. Information about each study, including category, subject, site, type of contrast agent, imaging technique, and contribution, was summarized. We reviewed 44 of the 260 retrieved articles. The associated categories were muscle (21 articles), tendon (4 articles), joint (17 articles), and bone (2 articles). Contrast-enhanced ultrasonography has been widely applied to the clinical evaluation of rheumatoid arthritis (n = 12) and research of muscle perfusion (n = 20). SonoVue (n = 20) was the most commonly used contrast agent, followed by Levovist (n = 17), Definity (n = 6), and Sonazoid (n = 1). Gray scale sonography (n = 3), color Doppler sonography (n = 4), power Doppler sonography (n = 15), and nonlinear imaging techniques specific for the existence of microbubbles (n = 22) were used according to different protocols. Contrast-enhanced ultrasonography has emerged as a promising diagnostic and research tool in musculoskeletal systems. Its application in bony structures is limited, owing to poor ultrasound penetration; however, development of nonlinear imaging techniques may promote advanced research on microcirculation in tendons.
Frozen shoulder (FS) is a common diagnosis treated by orthopaedic surgeons and other physicians caring for musculoskeletal problems. However, there is no standard definition and classification for this common condition. We asked 211 clinician members of the American Shoulder and Elbow Surgeons to review our proposed definition of FS and its classification into primary and secondary types. Secondary FS was further divided into intrinsic, extrinsic, and systemic types. The survey required responses to 5 specific questions via an analog scale (1, strongly disagree; 5, strongly agree). Agreement was defined as a 4 or 5 on the analog scale. We received 190 responses (90%). Eighty-two percent agreed with the proposed definition of FS. Eighty-five percent agreed that FS should be divided into primary and secondary types. Sixty-six percent agreed with subdivision of secondary FS into intrinsic, extrinsic, and systemic types. Eighty-four percent agreed that there was a clinical entity of primary or idiopathic FS. Eighty-five percent agreed that obtaining a consensus definition and classification of FS was a worthwhile endeavor. Significant benefits can be gained from the development of a standard definition and classification of FS, achieved through a consensus of shoulder specialists, that provides a strong foundation for potential acceptance by all musculoskeletal specialists who treat this condition.
A prospective study has been made of 49 patients with the frozen shoulder syndrome (as distinct from tendinitis, calcific deposits and frozen shoulders occurring after coronary infarction or with pulmonary tuberculosis) of whom forty-one have been followed up for 5-10 years, always to their greatest recovery. There were three consecutive stages: pain, stiffness, and recovery. The stiffness stage was usually related to the duration of the recovery stage. The total duration was longer than is generally supposed (an average total of 30.1 months in contrast to about 18 months as often postulated). Generally speaking, the longer the stiffness stage is, the longer is the recovery stage. In 4 patients the second shoulder became similarly affected, 6 months to 7 years after the first, and followed a similar chronological sequence to the first. After greatest recovery, slight restriction of movement was found in more than half the cases, but in only 3, all of long duration, was the restriction a handicap. Arthrography, carried out on both shoulders in all patients during the recovery stage, showed in the affected shoulder fewer rotator cuff defects than expected at this age and fewer (four) than in the contralateral one (twenty-three); seemingly, the condition leads to the obliteration of some defects.
Seventeen patients who had recalcitrant chronic adhesive capsulitis were operated on between 1979 and 1986 and were followed for an average of 6.8 years. At operation, the major cause of the restricted glenohumeral movement was found to be contracture of the coracohumeral ligament and rotator interval. Release of the contracted structures relieved pain and restored motion of the shoulder in all patients. Histological study showed fibrosis, hyalinization, and fibrinoid degeneration in the contracted connective tissues, as well as fibrosis of the subsynovial tissue and an absence of the synovial cell layer on the joint side of the rotator interval. The contracture of the coracohumeral ligament and rotator interval appears to be the main lesion in chronic adhesive capsulitis. Resection of these structures, combined with appropriate exercise, will relieve pain and restore motion to the shoulder.