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Arthroscopic capsular release is a most well-known technique with favorable outcomes for frozen shoulder. However, considering the surgical trauma and the improvement of multisite injection, we design a study to compare the pain relief and safety of multisite injection (MI) versus arthroscopic capsular release (ACR) for frozen shoulder. A total of 80 patients with unilater al frozen shoulder were enrolled in this study. Group RBT (n = 40) received multisite injection (0.5% lidocaine and triamcinolone acetonide, once a week, no more than 2 injections), while Group ACR received arthroscopic capsular release. The following parameters were employed to compare: visual analog scale (VAS), range of motion (ROM), the Disability of Arm, Hand, and Shoulder (DASH) score and Oxford shoulder score (OSS). Side effects were also recorded. The VAS, ROM, DASH and OSS all improved significantly (P < 0.001). Internal rotation and external rotation at 1 month after operation were better in ACR group (40.35 ± 4.79 Vs 36.58 ± 7.49, 40.55 ± 4.37 Vs 38.63 ± 4.01, P = 0.009,0.043). However, no significance in terms of functional results and ROM was found at 6 months after operation. The OSS, DASH and VAS in patients with diabetes were 44.25 ± 3.05, 2.29 ± 1.12 and 0.50 ± 0.72, compared with 43.89 ± 3.09, 2.34 ± 1.49 and 0.29 ± 0.56 in patients without diabetes (P = 0.636, 0.889, 0.157). Multisite injection and arthroscopic capsular release are both effective treatments in the treatment of frozen shoulder. However, multisite injection is a simple, cost effective and superior alternative. [ABSTRACT FROM AUTHOR]

Abstract Arthroscopic capsular release is a most well-known technique with favorable outcomes for frozen shoulder. However, considering the surgical trauma and the improvement of multisite injection, we design a study to compare the pain relief and safety of multisite injection (MI) versus arthroscopic capsular release (ACR) for frozen shoulder. A total of 80 patients with unilater al frozen shoulder were enrolled in this study. Group RBT (n = 40) received multisite injection (0.5% lidocaine and triamcinolone acetonide, once a week, no more than 2 injections), while Group ACR received arthroscopic capsular release. The following parameters were employed to compare: visual analog scale (VAS), range of motion (ROM), the Disability of Arm, Hand, and Shoulder (DASH) score and Oxford shoulder score (OSS). Side effects were also recorded. The VAS, ROM, DASH and OSS all improved significantly (P

Objective Frozen shoulder (FS) is a painful and debilitating condition affecting the shoulder joint. When patients fail to improve after conservative treatments, operative treatments including arthroscopic capsular release (ACR) and manipulation under anesthesia (MUA) are recommended. However, the comparison between these two interventions remains controversial. This study aimed to compare the efficacy and safety of ACR and MUA for refractory FS. Methods A systematic review and meta‐analysis was conducted following the Preferred Reporting Items for Systematic Review and Meta‐analyses (PRISMA) guidelines. PubMed, EMBASE, Cochrane Library, and Web of Science were searched for eligible studies until December 10, 2023. Meta‐analyses were conducted using Manager V.5.3.3. Pooled effect sizes were expressed as the weighted mean difference (WMD) or odds ratio (OR) with 95% confidence intervals (CIs). Results A total of eight comparative studies with 768 patients were included. Compared with MUA, ACR had statistically better Δ VAS (WMD, −0.44; 95% CI, −0.71 to −0.18; I2 = 6%; p = 0.001) at over 12‐month follow‐up, which did not reach the minimal clinically important difference (MCID). Other outcomes regarding pain relief, function, and range of motion (ROM) improvements were not statistically different between the two groups at different follow‐up timepoints. Compared with the MUA group, the ACR group had a significantly higher rate of severe complications (OR, 4.14; 95% CI, 1.01 to 16.94; I2 = 0%; p = 0.05), but comparable rates of mild complications and additional intervention. Conclusions In treating refractory FS, ACR demonstrated comparable pain relief, functional and ROM improvements, rates of mild complications and additional intervention but a higher risk of severe complications to MUA during short‐term follow‐up periods. Notably, ACR exhibited statistically superior improvement in the long‐term pain relief compared to the MUA group, although it did not reach the MCID.

Objective: Frozen shoulder (FS) is a painful and debilitating condition affecting the shoulder joint. When patients fail to improve after conservative treatments, operative treatments including arthroscopic capsular release (ACR) and manipulation under anesthesia (MUA) are recommended. However, the comparison between these two interventions remains controversial. This study aimed to compare the efficacy and safety of ACR and MUA for refractory FS. Methods: A systematic review and meta‐analysis was conducted following the Preferred Reporting Items for Systematic Review and Meta‐analyses (PRISMA) guidelines. PubMed, EMBASE, Cochrane Library, and Web of Science were searched for eligible studies until December 10, 2023. Meta‐analyses were conducted using Manager V.5.3.3. Pooled effect sizes were expressed as the weighted mean difference (WMD) or odds ratio (OR) with 95% confidence intervals (CIs). Results: A total of eight comparative studies with 768 patients were included. Compared with MUA, ACR had statistically better Δ VAS (WMD, −0.44; 95% CI, −0.71 to −0.18; I2 = 6%; p = 0.001) at over 12‐month follow‐up, which did not reach the minimal clinically important difference (MCID). Other outcomes regarding pain relief, function, and range of motion (ROM) improvements were not statistically different between the two groups at different follow‐up timepoints. Compared with the MUA group, the ACR group had a significantly higher rate of severe complications (OR, 4.14; 95% CI, 1.01 to 16.94; I2 = 0%; p = 0.05), but comparable rates of mild complications and additional intervention. Conclusions: In treating refractory FS, ACR demonstrated comparable pain relief, functional and ROM improvements, rates of mild complications and additional intervention but a higher risk of severe complications to MUA during short‐term follow‐up periods. Notably, ACR exhibited statistically superior improvement in the long‐term pain relief compared to the MUA group, although it did not reach the MCID. [ABSTRACT FROM AUTHOR]

Purpose of Review: Arthroscopy has become increasingly popular for a addressing a wide variety of shoulder pathology. However, despite increasing interest, there is still much uncertainty and variability amongst providers regarding optimal post-operative rehabilitation. This review provides an overview of the evidence underlying common rehab protocols used following arthroscopic interventions for rotator cuff disease, shoulder instability, superior labral anterior to posterior (SLAP) tears and adhesive capsulitis. Recent Findings: For small and medium sized rotator cuff tears, early motion protocols do not seem to affect healing or retear rates, however there is no difference with regards to long term functional outcomes when compared to standard motion protocols. For larger tears (> 3 cm), early active motion may be associated with impaired tendon integrity. Early range of motion following arthroscopic Bankart repair has not been shown to increase rate of recurrence, however the data on return to sport requires more granularity to effectively guide care. Further research needs to be done to compare rehab protocols following SLAP repair and arthroscopic capsular release. Summary: Rehabilitation protocols following rotator cuff surgery and anterior shoulder stabilization have garnered the most research interest. However, there is still a need for larger higher-level studies examining the long-term effects of different rehab protocols. Regarding the arthroscopic management of other types of shoulder instability, SLAP tears and adhesive capsulitis, there is paucity of high-quality evidence. This knowledge gap likely underpins the variability in different rehab protocols seen in clinical practice, highlighting the need for more research. [ABSTRACT FROM AUTHOR]

Background: This study aimed to investigate risk factors for recurrence of frozen shoulder after shoulder manipulation under ultrasound-guided cervical nerve root block (MUC). Methods: We retrospectively reviewed 135 frozen shoulders in 121 patients who underwent MUC. We defined frozen shoulder as a limited shoulder range of motion (ROM) (passive forward flexion

Background: Current treatment options for frozen shoulder are not established as the standard-of-care. The condition may resolve without intervention, but symptoms may persist despite treatment. Frozen shoulder is associated with inflammatory reactions that can reduce quality of life. Our aim was to determine whether triamcinolone acetonide, an immunosuppressive steroid, improved functional recovery when administered after arthroscopic capsular release (ACR) for frozen shoulder. Methods: We selected participants using inclusion and exclusion criteria designed to reduce the impact of potential confounding factors. Under general anesthesia, we performed ACR followed by manipulation to ensure adequate range of motion (ROM) and wound closure. In the steroid treatment group, we injected triamcinolone acetonide into the glenohumeral joint immediately prior to wound closure. The follow-up period was six months. To determine the efficacy of steroids in improving overall post procedure functional recovery we statistically analyzed data from various qualitative and quantitative variables. Results: Our study consisted of 22 patients with frozen shoulder, 11 in each of the surgery-only and surgery with steroid injection groups. There were no significant differences between groups in the demographic data of the study participants. We observed significantly greater improvements in abduction ROM in the steroid treatment group than in the surgery-only group, at three and six months post treatment. Improvements in other movement parameters were similar in both groups. The steroid-treated group had a significantly higher numerical rating scale score for night pain at three months post treatment than the surgery-only group. Conclusions: Postoperative steroid treatment led to early recovery of the abduction ROM in patients with frozen shoulder. Hence, the current standard-of-care protocol for frozen shoulder and other similar conditions requiring surgical intervention should include this type of treatment. Therapeutic reduction in the inflammatory response following ACR can significantly improve prognosis and quality of life.

Aims: Early large treatment effects can arise in small studies, which lessen as more data accumulate. This study aimed to retrospectively examine whether early treatment effects occurred for two multicentre orthopaedic randomized controlled trials (RCTs) and explore biases related to this. Methods: Included RCTs were ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation), a two-arm study of surgery versus non-surgical treatment for proximal humerus fractures, and UK FROST (United Kingdom Frozen Shoulder Trial), a three-arm study of two surgical and one non-surgical treatment for frozen shoulder. To determine whether early treatment effects were present, the primary outcome of Oxford Shoulder Score (OSS) was compared on forest plots for: the chief investigator’s (CI) site to the remaining sites, the first five sites opened to the other sites, and patients grouped in quintiles by randomization date. Potential for bias was assessed by comparing mean age and proportion of patients with indicators of poor outcome between included and excluded/non-consenting participants. Results: No bias in treatment effect was observed overall for the CI site, or the first five sites, compared with the remaining sites in either trial. An early treatment effect on the OSS was observed for the first quintile of participants recruited to ProFHER only (clinically relevant difference of seven points). Selection bias for age was observed in the ProFHER trial only, with slightly younger patients being recruited into the study. Both trials showed some selection bias for markers of poor prognosis, although these did not appear to change over time. Conclusion: No bias in treatment effects overall were found at the CI or early sites set-up. An early treatment effect was found in one of the two trials, which was likely a chance effect as this did not continue during the study. Selection bias was observed in both RCTs, however this was minimal and did not impact on outcome. Cite this article: Bone Jt Open 2023;4(2):96–103.

Purpose: One-stage arthroscopic rotator cuff repair with manipulation has been recently performed for rotator cuff tears with shoulder stiffness, whereas some patients require capsular release due to severe stiffness that is difficult to treat with manipulation. The purpose of this study was to analyze patient backgrounds and related factors of success or failure of manipulation alone for the treatment of shoulder stiffness associated with rotator cuff tears. Methods: This study included 64 patients with rotator cuff tears and shoulder stiffness who underwent arthroscopic rotator cuff repair with manipulation alone or with manipulation and capsular release of the glenohumeral joint at our institution between January 2015 and September 2019. The patients were divided into two groups: those whose shoulder stiffness could be improved by manipulation alone (Manipulation group) and those whose stiffness could not be improved by manipulation alone and required capsular release (Capsular release addition group). Analysis was performed between the two groups regarding patient backgrounds and related factors, including rotator cuff tear morphology and range of motions pre- and postoperatively. Results: Exactly 45 patients and 19 patients were included in Manipulation group and Capsular release addition group, respectively. A comparison between the two groups showed that patient age (p = 0.0040), sex (p = 0.0005), and injury due to trauma (p = 0.0018) were significantly related to the success or failure of manipulation alone. Multivariate logistic regression analysis on these three factors showed that sex (odds ratio, 5.5; p = 0.048) was significantly associated with the success or failure of manipulation alone. In both groups, the passive ROM of all patients improved at the last postoperative follow-up compared to their pre-operative values (p < 0.001), except for internal rotation in the Capsular release addition group (p = 0.49). Conclusion: Young male patients who have shoulder stiffness associated with rotator cuff tears should be considered for arthroscopic capsular release rather than manipulation. [ABSTRACT FROM AUTHOR]

Purpose: Arthroscopic capsular release (ACR) and Manipulation under anaesthesia(MUA) have been widely used in the treatment of frozen shoulder (FS). However, there is only limited Level-I evidence to prefer ACR over MUA. The purpose of our study was to conduct a randomised trial comparing ACR versus MUA to assess the difference in outcome, complications and cost-effectiveness of both procedures.Methods: From May 2020 to June 2021, patients presenting with FS were randomised into two groups ACR (n = 44) and MUA (n = 41). Patients with arthritis, full-thickness cuff tears, history of trauma/previous surgery around the shoulder were excluded from the study. Range of movement (ROM), pain grading using visual analogue scale (VAS), functional scores- UCLA, CONSTANT and EuroQol-5D scores were measured pre-operatively and post-operatively. MRI was done at three weeks post-operatively for screening complications of either procedure. Quality-adjusted life years (QALY) was used for cost-analysis.Results: Post-operatively, patients had significant improvement in pain, ROM and functional scores in both groups (P < 0.001) with no significant difference between groups at 24 weeks of follow-up. Diabetic patients undergoing ACR had lesser improvement in abduction and external rotation when compared to non-diabetic patients. Labral tears in MUA group and bone bruises in ACR group were the most common complications noted on the post-operative MRI. For ACR cost per QALY gained was 896 USD while that for MUA was 424 USD.Conclusion: Both ACR and MUA resulted in good improvement in pain and shoulder function. Good outcomes, simple technique and better cost-effectiveness would still make MUA an attractive option over ACR for treating FS. [ABSTRACT FROM AUTHOR]

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.

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.

Background: We aimed to retrospectively determine the effects of arthroscopic pan-capsular release with or without entire coracohumeral ligament (CHL) release and diabetes mellitus (DM) in patients with frozen shoulder (FS). Methods: The study included 34 patients (20 male and 14 female patients) who underwent arthroscopic pan-capsular release without entire CHL release (group 1) and 26 patients (6 male and 20 female patients) who underwent entire CHL release for FS (group 2). Patients with a minimum of 12 months of follow-up were included, and range of motion (ROM) and the shoulder rating scale of the University of California at Los Angeles (UCLA) scoring system were evaluated. Results: In group 2, external rotation and hand-behind-the-back (HBB) ROMs were significantly increased compared with group 1 at the final follow-up (external rotation, 53.1° ± 15.2° vs. 41.3° ± 20.5° [P = .044]; HBB level, T6 [interquartile range, T5-T9] vs. T11 [interquartile range, T8-L4] [P < .001]). Total UCLA scores and UCLA scores for pain (9.2 ± 1.5 vs. 10.0, P = .003), function (8.5 ± 1.4 vs. 10.0, P < .001), and active forward flexion (4.6 ± 0.6 vs. 4.9 ± 0.2, P < .011) were significantly greater in group 2 at the final follow-up. Patients without DM tended to have greater recovery of forward flexion and HBB ROMs and better total, pain, and function UCLA scores compared with those with DM. In group 2, there were no significant differences in ROMs and UCLA scores between the patients with DM and those without DM. Conclusion: Arthroscopic entire CHL release is an essential treatment option for FS patients to regain ROMs and function and to reduce pain.

Background: Proximal humeral fractures are one of the most common fractures in adults. Some patients treated operatively have restriction in range of motion (ROM) after surgery. This study aimed to evaluate arthroscopic pancapsular release in patients with severe stiffness after treatment with intramedullary nailing for proximal humeral fractures. Methods: This study included 12 patients (7 women and 5 men) who underwent arthroscopic pancapsular release in the beach-chair position between May 2015 and February 2018. Intraoperative findings were recorded, and ordinary (with scapulothoracic motion) and true (without scapulothoracic motion) glenohumeral ROMs were measured with a goniometer. The American Shoulder and Elbow Surgeons shoulder score, Shoulder Rating Scale score of the University of California, Los Angeles scoring system, and Constant score were compared before and after the release. The Wilcoxon signed rank and Mann-Whitney U tests were used to analyze data. Results: The average age of the patients was 65.1 years (standard deviation, 9.5 years), and the mean follow-up period after the release was 30.6 months (standard deviation, 11.7 months). All ROMs on the affected side after surgery were significantly greater than those before surgery in all directions. However, ROMs in forward flexion, lateral elevation, and external rotation with the arm at the side and at 90° of forward flexion on the affected side postoperatively were significantly lower than those on the unaffected side. All scores were significantly greater after surgery than before surgery. Conclusion: Arthroscopic pancapsular release is effective for patients with proximal humeral fractures treated with intramedullary nailing.

Background: When adhesive capsulitis develops, it causes shoulder pain and limits ranges of motion in the 2 passive and active ways. Following an arthroscopic release of the frozen shoulder, the pain intensity and frequency were found to be significantly reduced. Objective: This work was performed to assess the clinical findings after use of arthroscopic capsular release in management of shoulder adhesive capsulitis that had not responded to at least six months of conservative treatment prior and to study how much is the regaining of functions of shoulder after the operation. Patients and methods: A total of 18 Egyptian patients with frozen shoulder recruited and treated by arthroscopic capsular release. Preoperative evaluation was done and 1 week, 6 weeks, 12 weeks, and 24 weeks of follow-up after surgery. We used Constant score for assessment of shoulder functions and pain. Results: All of internal rotation, external rotation, abduction, forward flexion, and range of motion significantly increased from pre- to last follow up as follows 3.66 ± 1.2, 3.77 ± 1.25, 4.77 ± 1.21, 4.88 ± 1.40, and 17.11 ± 3.83 preoperative versus 8.44 ± 1.46, 8.33 ± 1.41, 8.55 ± 1.14, 9.0 ± 1.57, and 31.88 ± 7.52 respectively in last post-operative follow up. Strength of abduction significantly increased from 13.33 ± 1.71 preoperative to 20.50 ± 3.01 in last follow up postoperative. Pain Constant score significantly increased from 5.94 ± 1.43 to 13.44 ± 2.66. Total shoulder Constant score significantly increased from 48.16 ± 6.31to 84.50 ± 11.96. Conclusion: Shoulder adhesive capsulitis that has not well responded to conservative treatment can be successfully treated with arthroscopic surgery. [ABSTRACT FROM AUTHOR]

Background: Arthroscopic capsular release is an effective treatment for refractory shoulder stiffness, yet there are no basic studies that can explain the extent of the release. Purpose: This study aimed to compare the genetic expression of inflammation- and fibrosis-related factors between the anterior and posterior capsules in patients with shoulder stiffness and rotator cuff tear. Study Design: Descriptive laboratory study. Methods: Enrolled in this study were 35 patients who underwent arthroscopic capsular release for shoulder stiffness along with the rotator cuff repair. Anterior and posterior glenohumeral joint capsular tissues were obtained during the capsular release. For the control tissue, anterior capsule was obtained from 40 patients without stiffness who underwent arthroscopic rotator cuff repair. The gene expression of collagen types I and III, fibronectin, extracellular matrix, basic fibroblast growth factor, transforming growth factor–β, connective tissue growth factor, matrix metalloproteinase (MMP)-1, MMP-2, MMP-9, tissue inhibitor of metalloproteinase (TIMP)-1, TIMP-2, intercellular adhesion molecule 1, interleukin 1, and tumor necrotizing factor–α were analyzed using real-time reverse transcription polymerase chain reaction. Differences in gene expression between the anterior capsule, the posterior capsule, and the control tissue were compared with the Kruskal-Wallis test. Results: The expression levels of collagen types I and III were significantly higher in the anterior capsule with stiffness com (pared with both the posterior capsule with stiffness (P =.010 for both) and the control (P =.038 and.010, respectively). The levels of fibronectin, MMP-2, and MMP-9 in the anterior capsule were significantly higher than in both the posterior capsule (P =.013,.003, and.006, respectively) and the control (P =.014,.003, and.005, respectively). Conclusion: Genetic analysis of the shoulder capsule revealed that more fibrogenic processes occur in the anterior capsule compared with the posterior capsule in patients with shoulder stiffness. Clinical Relevance: Capsular release for shoulder stiffness should be more focused on the anterior capsule than on the posterior capsule. [ABSTRACT FROM AUTHOR]

Purpose: Intra-articular pathologies, such as labral and chondral lesions, are common in patients with frozen shoulder. This study evaluated the correlations between the range of motion and labral and chondral lesions in patients with frozen shoulder and investigated their pathophysiologies. Methods: In total, 125 individuals (53 men and 72 women) who underwent arthroscopic pan-capsular release between 2014 and 2020 were included in the study. The range of motion was measured using scapular fixation and true glenohumeral motion under general anaesthesia. The American Shoulder and Elbow Surgeons Shoulder score and the Shoulder Rating Scale score of the University of California, Los Angeles were used to compare intra-articular pathologies. Results: More than 80% of patients with frozen shoulder had labral pathologies, and nearly half of them had chondral pathologies. Labral lesions extending to the anterior rim of the glenoid had a greater range of motion and the greatest total American Shoulder and Elbow Surgeons Shoulder score. More severe chondral lesions had a lesser range of motion, but presented the greatest function scores and the lowest strength scores according to the Shoulder Rating Scale of the University of California, Los Angeles. The pain scores of the American Shoulder and Elbow Surgeons Shoulder score and the Shoulder Rating Scale of the University of California, Los Angeles were not correlated with the degree of these pathologies. The traction force affected the labrum during true range of motion, and the compression force occurred on the articular cartilage during internal rotation at 90° of forward flexion during diagnostic arthroscopy. Conclusion: Labral and chondral lesions are common in patients with frozen shoulder. Adherence to the capsulolabral complex induced a limited range of motion and labral and chondral pathologies. Diagnostic arthroscopy with motion is an important method of reproducing the pathogenesis of intra-articular structures for patients with frozen shoulder. Level of evidence: Level III. [ABSTRACT FROM AUTHOR]

Among all the prevalent painful conditions of the shoulder, frozen shoulder remains one of the most debated and ill-understood conditions. It is a condition often associated with diabetes and thyroid dysfunction, and which should always be investigated in patients with a primary stiff shoulder. Though the duration of 'traditional clinicopathological staging' of frozen shoulder is not constant and varies with the intervention(s), the classification certainly helps the clinician in planning the treatment of frozen shoulder at various stages. Most patients respond very well to combination of conservative treatment resulting in gradual resolution of symptoms in 12–18 months. However, the most effective treatment in isolation is uncertain. Currently, resistant cases that do not respond to conservative treatment for 6–9 months could be offered surgical treatment as either arthroscopic capsular release or manipulation under anaesthesia. Though both invasive options are not clinically superior to another, but manipulation could result in unwarranted complications like fractures of humerus or rotator cuff tear. [ABSTRACT FROM AUTHOR]

The optimal timing of arthroscopic capsular release in patients with frozen shoulder is controversial. Some surgeons delay surgery in the belief that early surgical intervention results in a poorer prognosis. However, whether early surgical intervention causes inferior clinical outcomes and a longer duration of symptoms in frozen shoulder remains unclear. The objective of this study was to compare the clinical outcomes and overall duration of symptoms in frozen shoulder between patients who underwent early surgical intervention and those subjected to late surgical intervention. Our hypotheses were that (1) early surgical intervention would provide significant improvement in symptoms but inferior clinical outcomes because of more severe synovitis compared with late surgical intervention and (2) early surgical intervention would shorten the overall duration of symptoms compared with late surgical intervention. We reviewed 60 consecutive patients with frozen shoulder who underwent arthroscopic capsular release. We compared clinical outcomes and the overall duration of symptoms between 2 groups: Group I comprised 27 patients who underwent surgery <6 months after onset (mean, 3.8 months), whereas group II comprised 33 patients who underwent surgery ≥6 months after onset (mean, 11.1 months). The severity of glenohumeral synovitis at the time of surgery was evaluated. Patient-reported pain, shoulder function, and range of motion, as well as the presence of sleep disturbance, were assessed preoperatively and at 3 and 6 months after surgery. Both groups showed significant improvements in the visual analog scale pain score, Japanese Orthopaedic Association score, American Shoulder and Elbow Surgeons score, and prevalence of sleep disturbance after surgery (P <.001), although the glenohumeral synovitis score was significantly higher in group I than in group II (P <.0001). Forward flexion at 6 months after surgery was significantly greater in group I than in group II (P =.007). The overall duration of symptoms was shorter in group I than in group II (P <.0001). Neither the pain score, functional score, prevalence of sleep disturbance, nor postoperative recovery time differed between groups. Arthroscopic capsular release provided significant pain relief and improvement in shoulder function in patients with frozen shoulder regardless of the timing of surgery. Early surgical intervention might shorten the overall duration of symptoms in frozen shoulder and is not associated with inferior clinical outcomes when compared with late surgical intervention. Surgeons do not need to delay surgical intervention for patients who have intolerable pain and/or nocturnal pain with sleep disturbance. [ABSTRACT FROM AUTHOR]

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

Abstract Background The purpose of this study was to investigate the long-term clinical outcome and its related factors regarding the severity of adhesion of CH ligament over long head of biceps (LHB) after shoulder arthroscopic capsular release for frozen shoulder with technical points in 255 patients. Methods We performed arthroscopic capsular release for frozen shoulder in 267 shoulders of 255 patients, 112 males and 143 females, with mean age of 56.39 years, mean disease duration periods of 0.934 years for conservative treatment, and mean follow-up periods of 5.6 years. The frozen shoulders were divided based on the severity of adhesion between CH ligament over LHB: those with slight degree of synovitis, no adhesion by obtuse rod, and slight thickness of the released capsule (type A), those with moderate degree of synovitis, moderate adhesion of the LHB by obtuse rod, and moderate thickness of the released capsule (type B), and those with severe degree of synovitis, severe adhesion of the LHB by obtuse rod, and severe thickness of the released capsule adhesion and a flatly shaped LHB (type C). We assessed the clinical factors related to the scoring of the shoulders by the criteria of the American Shoulder and Elbow Surgeons (ASES) and the relationship with severity of LHB adhesion. Results The ASES scores improved at 5 years postoperatively in all three groups significantly. The range of motion also significantly improved in all three groups significantly. The severity of the LHB adhesion over the CH ligament was confirmed to influence the ASES scores before and after the arthroscopic capsular release. There was a significant difference between type A and type B (p

A thickened joint capsule is believed to be one of the most specific manifestations of and the primary restraint against range of motion (ROM) in frozen shoulders. The purpose of this study was to evaluate the relationship among ROMs under general anesthesia before surgery and the effects of each joint capsular release on ROM. ROM was measured using a goniometer with scapular fixation. Arthroscopic pan-capsular release was performed with the patient in the beach-chair position in the following order: (1) rotator interval, (2) coracohumeral ligament, (3) superior capsule, (4) middle glenohumeral ligament, (5) anterior inferior glenohumeral ligament, and (6) posterior inferior glenohumeral ligament. ROMs in forward flexion (FF), lateral elevation (LE), external rotation with the arm at the side (ER1), external rotation at 90° of LE (ER2), internal rotation at 90° of LE (IR2), horizontal flexion, external rotation at 90° of FF (ER3), and internal rotation at 90° of FF (IR3) were evaluated before and after each release. A total of 32 consecutive shoulders were included. After each capsular release, the ROM recovered; the final ROM was significantly greater on the affected side than on the unaffected side. Significant correlations were found between FF and LE, FF and ER1, ER1 and ER2, ER1 and ER3, ER2 and ER3, and IR2 and IR3 on both sides, regardless of surgery. Each segment of the joint capsule affected ROM in all directions, supporting the need for whole-joint capsular release; ROM was significantly greater on the affected side than on the unaffected side after surgery. [ABSTRACT FROM AUTHOR]

To determine if arthroscopic capsular release (ACR) shortens duration of illness in frozen shoulder (FS) in comparison to the depicted natural course of 30.1 months and to identify risk factors for persisting complaints. A consecutive group of 71 shoulders in 70 patients with mean age of 54 (37–74) years with FS were treated by ACR and enrolled in our study with follow-up investigation at 1, 3, 6 and finally 32 (19–49) months postoperatively. Patients had complaints for 8 (3–60) months preoperatively. 8 shoulders (11%) were classified as primary and 63 (89%) shoulders as secondary type FS. 6 patients were lost to follow-up. Relative Constant score increased significantly from 31% before surgery to 103% at last follow-up. 55 patients (85%) achieved subjective remission after 7 (1.5–18) months, postoperatively. Overall duration of illness was 16 (5–72) months. All patients with primary FS achieved remission and all patients with persisting symptoms had secondary FS. Duration of illness was shortened by more than 12 months compared with the natural time course defined by Reeves. Secondary FS, especially ac-joint pathologies, previous surgery, diabetes and more than 12 months preoperative illness duration were identified as risk factors for persisting complaints. Hypothesis of worse outcome in secondary FS was confirmed. [ABSTRACT FROM AUTHOR]

Abstract Background Frozen shoulder (also known as adhesive capsulitis) occurs when the capsule, or the soft tissue envelope around the ball and socket shoulder joint, becomes scarred and contracted, making the shoulder tight, painful and stiff. It affects around 1 in 12 men and 1 in 10 women of working age. Although this condition can settle with time (typically taking 1 to 3 years), for some people it causes severe symptoms and needs referral to hospital. Our aim is to evaluate the clinical and cost-effectiveness of two invasive and costly surgical interventions that are commonly used in secondary care in the National Health Service (NHS) compared with a non-surgical comparator of Early Structured Physiotherapy. Methods We will conduct a randomised controlled trial (RCT) of 500 adult patients with a clinical diagnosis of frozen shoulder, and who have radiographs that exclude other pathology. Early Structured Physiotherapy with an intra-articular steroid injection will be compared with manipulation under anaesthesia with a steroid injection or arthroscopic (keyhole) capsular release followed by manipulation. Both surgical interventions will be followed with a programme of post-procedural physiotherapy. These treatments will be undertaken in NHS hospitals across the United Kingdom. The primary outcome and endpoint will be the Oxford Shoulder Score (a patient self-reported assessment of shoulder function) at 12 months. This will also be measured at baseline, 3 and 6 months after randomisation; and on the day that treatment starts and 6 months later. Secondary outcomes include the Disabilities of Arm Shoulder and Hand (QuickDASH) score, the EQ-5D-5 L score, pain, extent of recovery and complications. We will explore the acceptability of the different treatments to patients and health care professionals using qualitative methods. Discussion The three treatments being compared are the most frequently used in secondary care in the NHS, but there is uncertainty about which one works best and at what cost. UK FROST is a rigorously designed and adequately powered study to inform clinical decisions for the treatment of this common condition in adults. Trial registration International Standard Randomised Controlled Trial Register, ID: ISRCTN48804508 . Registered on 25 July 2014.

Introduction: While the exact mechanism of primary adhesive capsulitis is unknown, we know that it has strong associations with diabetes mellitus (DM). Although self-limiting, a significant percentage of patients still have persistent pain and stiffness beyond 3 years. Arthroscopic capsular release (ACR) has been described as a successful intervention for recalcitrant adhesive capsulitis that provides early and long-term recovery. The aim of this study is to investigate the relationship between DM and ACR. Methods: We reviewed prospectively collected data of 56 consecutive patients with idiopathic frozen shoulder who underwent ACR (360° arthroscopic capsulotomy) under a single surgeon. Range of motion, pain score and shoulder function (Constant Shoulder Score, Oxford Shoulder Score, University of California Los Angeles Shoulder Score) were documented preoperatively and one year postoperatively. Patients were dichotomized into diabetic (n=32) and non-diabetic patients (n=24) and compared using a mixed ANOVA design to investigate for differences in outcomes. Results: Both group of patients had significant improvement in range of motion, reduced pain scores and improved shoulder scores one year postoperatively (p=0.000). Diabetic patients had poorer internal rotation (p=0.000), forward flexion (p=0.035) and poorer postoperative Constant Shoulder score (p < 0.05). Otherwise both groups improved equally in all other aspects. Conclusion: ACR offered good outcomes in both diabetic and non-diabetic patients in terms of range of motion, pain relief and shoulder function. However diabetic patients had poorer improvement in internal rotation and forward flexion postoperatively. Preoperative counselling and postoperative rehabilitation can be better tailored to treat diabetic patients with idiopathic adhesive capsulitis. [ABSTRACT FROM AUTHOR]

Abstract Background Frozen shoulder is a painful joint disease. Patients with diabetes seem to have worse clinical symptoms and surgery in this patient population is believed to be more common. The objective postoperative evaluation indicates inferior results when surgically treating diabetics, but no previous studies have investigated exclusively the subjective patient satisfaction with arthroscopic capsular release. Materials and methods A total of 93 patients were included. All had persistent symptoms despite conservative treatment for at least six months. The patients were retrospectively divided into two groups based on diabetes status: Group 1 consisted of patients with type 1 or type 2 diabetes (18) and group 2 consisted of the remaining patients (75). Evaluation was performed prior to arthroscopic capsular release and at six months follow-up. The web-based questionnaire consisted of two different evaluation forms: The Oxford Shoulder Score (OSS) and a visual quality scale (VQS). Results Both groups reported a statistically significant improvement in both evaluations. OSS in group 1 improved by 11.5 [95% CI: 6.2 ; 16.4] and by 15.8 [95% CI: 13.6 ; 17.9] in group 2. The improvement was more pronounced in group 2, though not statistically significant (p = 0.09). The VQS improved 39.6 in group 1 and 44.5 in group 2, (p = 0.50). Conclusion Diabetic and non-diabetic patients reported equal symptom relief after arthroscopic capsular release of frozen shoulder when selected for operation without considering diabetic status. We will continue to select patients for arthroscopic release without differences in preoperative counseling between diabetics and non-diabetics. [ABSTRACT FROM AUTHOR]

Background: This study aimed to investigate risk factors for recurrence of frozen shoulder after shoulder manipulation under ultrasound-guided cervical nerve root block (MUC)., Methods: We retrospectively reviewed 135 frozen shoulders in 121 patients who underwent MUC. We defined frozen shoulder as a limited shoulder range of motion (ROM) (passive forward flexion <120°, external rotation <30°, or internal rotation lower than L3). Patients fulfilling any one criteria were considered to have frozen shoulder. If patients continued to have severe pain and limited ROM at 3 months after MUC, we defined as recurrence of frozen shoulder and they were offered a further MUC or arthroscopic capsular release (ACR). We compared the ROM, Constant Shoulder (CS) score, and University of California, Los Angeles score before and 3 months after MUC between patients with the successful of MUC group (Success group) with those recurrence of frozen shoulder who required a further MUC or ACR group (Recurrence group). Multiple logistic regression analysis was used to identify risk factors for recurrence of frozen shoulder after MUC., Results: Patients who underwent MUC were retrospectively enrolled and divided into: the successful of MUC group (Success group, n = 112) and required a further MUC or ACR group (Recurrence group, n = 9). The Recurrence group had significantly lower external rotation and CS score before MUC than those in the Success group ( P  < .05). The Recurrence group showed significantly inferior all ROM and functional scores 3 months after MUC ( P  < .05). The levels of blood glucose and hemoglobin A1c both before and 3 months after MUC in the Recurrence group showed inferior compared with those of Success group. The difference, although not statistically significant, trended towards significance (before MUC/3 months after MUC; the glucose levels P  = .06/.06, the hemoglobin A1c levels P  = .07/.09, respectively). The visual analog scale pain score (at rest, during activity, at night) both before and 3 months after MUC in the Recurrence group showed significantly higher scores compared with those of Success group ( P  < .05). Multiple logistic regression analysis revealed that lower CS score before MUC was independent risk factor for recurrence of frozen shoulder after MUC., Conclusion: The overall incidence of recurrence of frozen shoulder after MUC was 7.4%. The lower CS score before MUC was an independent risk factor for recurrence of frozen shoulder after MUC. Moreover, patients in the Recurrence group tended to have poorly controlled diabetes and higher visual analog scale pain score both before and 3 months after MUC., (© 2023 The Author(s).)

Background Arthroscopic capsular release (ACR) and hydrodilatation (HD) have been developed for the management of frozen shoulder refractory to conservative treatment. To date no randomized trial has directly compared the efficacy of both interventions. The aim of this trial was to determine whether the Oxford Shoulder Score (OSS) differs between patients with frozen shoulder randomized to treatment with ACR or HD. Methods Patients presenting with severe idiopathic frozen shoulder deemed suitable for surgical intervention by a consultant shoulder surgeon were randomized to ACR or HD. The primary outcome measure was OSS at 6 months, with secondary outcomes measures of the EuroQol-5D visual analog scale, external rotation, complications, and crossover rate also recorded. Results Between June 2013 and December 2016, 50 patients were randomized to HD or ACR. The average age of the HD and ACR cohorts was 55.2 and 52.6 years, respectively ( P  = .36). At 6 months after the intervention, 20 patients were available for follow-up in the HD cohort and 19 in the ACR cohort. Both groups demonstrated significant improvements in OSS from baseline, but the OSS was significantly higher in the ACR cohort than the HD cohort (43.8 vs. 38.5, P  = .023). The OSS was noted to improve rapidly after the intervention, with 75% of improvement in OSS noted at 6 weeks after surgery in both groups. Conclusions Patients randomized to ACR reported a significantly higher OSS at 6 months than those randomized to HD. Both groups, however, showed a significant improvement. [ABSTRACT FROM AUTHOR]

Background: Frozen shoulder (also known as adhesive capsulitis) occurs when the capsule, or the soft tissue envelope around the ball and socket shoulder joint, becomes scarred and contracted, making the shoulder tight, painful and stiff. It affects around 1 in 12 men and 1 in 10 women of working age. Although this condition can settle with time (typically taking 1 to 3 years), for some people it causes severe symptoms and needs referral to hospital. Our aim is to evaluate the clinical and cost-effectiveness of two invasive and costly surgical interventions that are commonly used in secondary care in the National Health Service (NHS) compared with a non-surgical comparator of Early Structured Physiotherapy.Methods: We will conduct a randomised controlled trial (RCT) of 500 adult patients with a clinical diagnosis of frozen shoulder, and who have radiographs that exclude other pathology. Early Structured Physiotherapy with an intra-articular steroid injection will be compared with manipulation under anaesthesia with a steroid injection or arthroscopic (keyhole) capsular release followed by manipulation. Both surgical interventions will be followed with a programme of post-procedural physiotherapy. These treatments will be undertaken in NHS hospitals across the United Kingdom. The primary outcome and endpoint will be the Oxford Shoulder Score (a patient self-reported assessment of shoulder function) at 12 months. This will also be measured at baseline, 3 and 6 months after randomisation; and on the day that treatment starts and 6 months later. Secondary outcomes include the Disabilities of Arm Shoulder and Hand (QuickDASH) score, the EQ-5D-5 L score, pain, extent of recovery and complications. We will explore the acceptability of the different treatments to patients and health care professionals using qualitative methods.Discussion: The three treatments being compared are the most frequently used in secondary care in the NHS, but there is uncertainty about which one works best and at what cost. UK FROST is a rigorously designed and adequately powered study to inform clinical decisions for the treatment of this common condition in adults.Trial Registration: International Standard Randomised Controlled Trial Register, ID: ISRCTN48804508 . Registered on 25 July 2014. [ABSTRACT FROM AUTHOR]

Background: To compare the clinical outcomes of arthroscopic capsular release in patients with and without inferior capsular release for shoulder stiffness. Methods: Between January 2010 and December 2015, 39 patients who underwent arthroscopic capsular release for shoulder stiffness were enrolled and randomized into two groups. In group I, 19 patients underwent arthroscopic capsular release of the rotator interval and anterior capsule. In group II, 20 patients underwent arthroscopic capsular release of the anterior to inferior capsule, including the rotator interval. The American Shoulder and Elbow Surgeons score, Constant scoring system, Simple Shoulder Test, visual analogue scale for pain, and range of motion (ROM) were used for evaluation before surgery, at 3, 6, and 12 months after surgery and on the last follow-up. Results: Preoperative demographic data revealed no significant differences (p>0.05). The average follow-up was 16.07 months. Both groups showed significantly increased ROM at the last follow-up compared with preoperative (p<0.05). At the last follow-up, no statistical differences were found (p>0.05) between groups I and II in functional scores and ROM (forward flexion, p=0.91; side external rotation, p=0.17; abduction external rotation, p=0.72; internal rotation, p=0.61). But we found that group II gained more flexion compared to group I at 3 months and 6 months (p<0.05) after the surgery. Conclusions: Both techniques of capsular release are effective for stiffness shoulder. However, the extended inferior capsular release shows superiority in forward flexion over anterior capsular release alone during 6 months of follows-up (level of evidence: Level I, therapeutic randomized controlled trial). [ABSTRACT FROM AUTHOR]

Background: Adhesive capsulitis of the shoulder is a painful and debilitating condition. While the majority of patients improve with conservative treatment, those who do not improve require surgery such as arthroscopic capsular release (ACR) for symptom relief. However, there is limited literature regarding the optimal timeframe to proceed with surgery., Methods: This retrospective cohort evaluated 134 Hispanic patients who underwent ACR for the treatment of adhesive capsulitis. Patients were divided into an early and a delayed treatment group that included all patients. Patients were then divided into diabetic and idiopathic subgroups. Early vs. delayed treatment outcomes (forward flexion, external rotation, Visual Analog Scale pain scores, and recurrence requiring reoperation) were assessed in all patients and in each subgroup., Results: No statistically significant differences were found between the early and delayed release groups in postoperative forward flexion, external rotation, pain intensity scores, and recurrence requiring reoperation at 1 month, 3 months, and 6 months of follow-up in the all-patient group. In the idiopathic frozen shoulder subgroup, no significant differences were observed in postoperative forward flexion, external rotation, pain intensity scores, and recurrence requiring reoperation at 1 month, 3 months, and 6 months of follow-up. In the diabetic frozen shoulder subgroup, no significant differences were observed in postoperative forward flexion, external rotation, pain intensity scores, and recurrence requiring reoperation at 1 month and 6 months of follow-up visits., Conclusions: There was no difference in outcomes following ACR for adhesive capsulitis between patients who underwent early release vs. delayed release. There were no significant differences in outcomes between early and delayed arthroscopic release in patients with a history of diabetes mellitus., (© 2023 The Author(s).)

Adhesive capsulitis, colloquially known as "frozen shoulder," is a relatively common disorder, affecting approximately 2% to 5% of the general population. The incidence may be higher as the condition can be relatively mild and self-limited and thus many patients who experience it may never present for treatment. It involves a pathologic process of gradual fibrosis of the glenohumeral joint that leads to limited active and passive range of motion, contracture of the joint capsule, and shoulder pain., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)