Associations with frozen shoulder (FS)
Associated condition
Author/year
Results/conclusions
Gender
Female
Austin et al. (2014) [11]
In a series of patients with FS, 59 % were women and 41 % were men
Female
White et al. (2011) [4]
Women had an observed rate of FS of 3.38 per 1000 person-years in comparison with 2.36 in men
Age
Increasing age
White et al. (2011) [4]
In women, every 10-year incremental increase in age resulted in an 8 % greater FS rate
Increasing age
Balci et al. (1999) [13]
Average patient age of 59.2 with FS vs. 53.6 without disease in type II diabetes mellitus (DM)
Increasing age
Arkkila et al. (1996) [12]
Average patient age of 46.7 with FS vs. 31.7 without disease in type I diabetes and 65.3 with FS vs. 59.9 without disease in type II DM
Trauma
Minor trauma
Austin et al. (2014) [11]
In 38 % of patients with FS a history of minor trauma was reported
Minor trauma
Hand et al. (2008) [19]
In 22 % of patients a history of minor trauma was reported
Minor trauma
Bulgen et al. (1984) [18]
In 34 % of patients a history of minor trauma was reported
Postsurgical
Post-shoulder or upper limb surgery
Austin et al. (2014) [11]
In 21 % of patients a history of previous upper limb surgery was reported
Post-cardiac surgery
Tuten et al. (2000) [61]
Noted a 3.3 % incidence of postoperative development of FS in male cardiac surgery patients
Post-acute cerebral aneurysm surgery
Tanishima and Yoshimasu (1997) [62]
Up to 41 % of patients develop FS following acute aneurysm surgery possibly due to immobilization
Post-catheterization of brachial artery
Pineda et al. (1994) [63]
Case series of seven patients who developed FS post-cardiac catheterization of the brachial artery
Post-radical neck dissection
Patten and Hillel (1993) [64]
Reported that 70 % of patients undergoing a radical neck dissection developed shoulder disability consistent with FS
Post-neurosurgical
Bruckner and Nye (1981) [65]
23 % of patients developed FS after neurosurgical procedures. Within this group, there was an association with hemiparesis
Cardiovascular disease
Hypertension
Austin et al. (2014) [11]
A 50 % increase in the prevalence of anti-hypertension medications observed within FS patients
Myocardial infarction/coronary heart disease
Arkkila et al. (1996) [12]
Reported an odds ratio for myocardial infarction of 13.7 (95 % CI 1.3–139.5) in type I DM patients with FS. Higher prevalence of FS in type I DM with coronary artery disease
Ischemic heart disease
Bridgeman (1972) [17]
It was observed that 8 of 14 nondiabetic patients with FS also had ischemic heart disease
Peripheral vascular disease (PVD)
Arkkila et al. (1996) [12]
Prevalence of FS of 28.9 % in type I diabetics with PVD while only 7.4 % in those without PVD
Hypertension
Arkkila et al. (1996) [12]
Prevalence of FS of 21.7 % in type I DM with HTN while only 6.3 % in those without HTN
Diabetes mellitus (DM)
Diabetes
Lo et al. (2014) [5]
Incidence of FS was three times greater in patients with DM in comparison with controls
Diabetes
Huang et al. (2013) [23]
After onset of DM, patients had a hazard ratio of 1.32 (95 % CI 1.22–1.42) for developing FS in comparison with controls
Diabetes
Austin et al. (2014) [11]
Prevalence of diabetic medications in FS patients was over two times that observed in the general population
Diabetes
Severity of diabetes
Ramchurn et al. (2009) [22]
In diabetics, 25 % had FS or shoulder tendonitis compared to 2 % of control group. Poor glycemic control associated with increased risk of upper limb disability
Diabetes or prediabetes
Tighe and Oakley (2008) [16]
When testing patients diagnosed with FS, 38.6 % had diabetes and 33.0 % had prediabetes. In this series, 2 % were newly diagnosed with diabetes and 28.4 % with prediabetes
Diabetes
Duration of diabetes
Thomas et al. (2007) [21]
In diabetics, 4.3 % had FS in comparison with 0.5 % of control group. Observed a positive association with duration of diabetes
Diabetes
Duration of diabetes
Diabetes complications
Balci et al. (1999) [13]
It was reported that 29 % of diabetics have FS. Patients with FS had diabetes for 7.5 years on average vs. 6.0 years without FS. Significant association observed between FS and retinopathy in diabetics
Diabetes
Duration of diabetes
Diabetes complications
Arkkila et al. (1996) [12]
FS observed in 10.3 % of type I and 22.4 % of type II DM. Associated with duration of type I DM. Significantly increased odds ratio for autonomic neuropathy in diabetics with FS
Diabetes
Severity of diabetes
Bridgeman (1972) [17]
In diabetics, 10.8 % have FS compared to 2.3 % of nondiabetics. Insulin-dependent diabetics have higher rates of FS than non-insulin-dependent
Metabolic disorders
Hyperlipidemia
Lo et al. (2014) [5]
Hyperlipidemia independently increased risk of FS with a hazard ratio of 1.29 (95 % CI 1.11–1.49)
Hypercholesterolemia
Hypertriglyceridemia
Bunker and Esler (1995) [66]
Patients with FS had significantly higher serum cholesterol and serum triglyceride concentrations
Hormonal disorders
Hyperthyroidism
Huang et al. (2014) [20]
Patients with hyperthyroidism had an adjusted hazard ratio of 1.22 for developing FS
Hypothyroidism
Hyperthyroidism
Cakir et al. (2003) [15]
Overall, 10.3 % of patients with thyroid dysfunction have FS. Observed in 17.4 % of those with subclinical thyrotoxicosis and 13 % in hypothyroidism
ACTH deficiency
Choy et al. (1991) [67]
Case report of bilateral FS in an ACTH-deficient patient
Hypothyroidism
Bowman et al. (1988) [14]
Case report of bilateral FS, oligoarthropathy, and myopathy in hypothyroidism
Hyperthyroidism
Wohlgethan (1987) [68]
Case report of bilateral FS in a patient with hyperthyroidism
Musculoskeletal
Limited joint mobility
Balci et al. (1999) [13]
Reported an odds ratio of 2.1 (95 % CI 1.2–3.7) of limited joint mobility in diabetic patients with FS
Limited joint mobility
Arkkila et al. (1996) [12]
Prevalence of FS of 28.4 % in type II DM with limited joint mobility but only 13.2 % in those without
Dupuytren’s disease
Smith et al. (2001) [50]
In patients with FS, 52 % have evidence of Dupuytren’s disease, which is 8.27 (95 % CI 6.25–11.2) greater than the general population
Dupuytren’s disease
Balci et al. (1999) [13]
Anodds ratio of 2.4 (95 % CI 1.3–4.4) of Dupuytren’s disease in diabetic patients with FS was reported
Dupuytren’s disease
Arkkila et al. (1996) [12]
Prevalence of FS of 25.0 % in type I DM with Dupuytren’s disease while only 7.6 % in those without
Tennis elbow (lateral epicondylitis)
Hakim et al. (2003) [69]
FS and tennis elbow are observed together in individuals 2–3 times more often than expected. Although investigated in a twin study, the association was not thought to be genetic
Neurologic conditions
Stroke
Kang et al. (2010) [70]
After developing FS, patients had an adjusted hazard ratio of stroke of 1.22 (95 % CI 1.06–1.40)
Stroke
Lo et al. (2003) [43]
FS is responsible for 50 % of cases of shoulder pain following stroke, making it a common post-stroke morbidity
Parkinson’s disease
Riley et al. (1989) [71]
In patients with Parkinson’s disease, 12.7 % had FS in comparison with 1.7 % of control group. FS may be a presenting symptom of the disease
Hemiparesis
Impaired consciousness
Bruckner and Nye (1981) [65]
Hemiparesis and impairment of consciousness were associated with FS in post-neurosurgical patients
Psychological
Depressed personality
Bruckner and Nye (1981) [65]
Depressive personality was associated with the development of FS in post-neurosurgical patients. More recent studies have suggested personality traits may not be associated with adhesive capsulitis [72]
Drug induced
Vaccinations (influenza and pneumococcal)
Bodor and Montalvo (2007) [73]
A case series of two patients who developed FS and additional shoulder pathology following injection. Likely injected into the sub-acromial bursa
Highly active antiretroviral therapy (HIV medications)
De Ponti et al. (2006) [74]
A case series of six patients who developed FS while on HIV therapy
Fluoroquinones (antibiotic)
Freiss et al. (2000) [75]
A case series of two patients who developed FS following antibiotic therapy
Protease inhibitors: indinavir (HIV medications)
Grasland et al. (2000) [76]
A series of eight patients is presented who developed FS (four bilaterally) while taking the medication
Matrix metalloproteinase inhibitor (chemotherapy)
Hutchinson et al. (1998) [77]
In a case series of patients treated with this drug, 6 out of 12 developed FS
Triple antiretroviral therapy (HIV)
Zabraniecki et al. (1998) [78]
A series of three patients who developed arthrography confirmed FS without other causes
Flunarizine (calcium channel blockers)
Franck and Beurrier (1996) [79]
A case report of a patient who developed severe bilateral FS that resolved after discontinuation of the medication
Others
Malignancy
Gheita et al. (2010) [80]
In patients with known malignancies, 15 % of them have FS
Osteopenia
Okamura and Ozaki (1999) [81]
In women with FS, there was a significant decrease in bone mineral density in the proximal humerus
These and other studies merely confirm that the pathophysiology of FS is complex and there are seemingly multiple pathways contributing to disease initiation and progression. It is the senior author’s (JDK) contention that the term “idiopathic” FS will be ultimately abandoned as a causal link with some proinflammatory state will eventually be demonstrated in most cases.
Although the outcomes and treatment modalities in patients with different risk factors for FS may differ, we still know little about how each specific risk factor precisely contributes to pathologic changes.
Treatment and Outcomes
Historically, conservative management has been the treatment of choice for FS. Surgical measures have been reserved for patients failing nonoperative treatment for more than 6 months [25]. However, the time course for improvement and recovery in patients varies. With such uncertainty, some patients may prefer options with potential to expedite recovery. Additionally some data supports the use of earlier arthroscopic intervention. Baums and colleagues showed that after only 6 months of failed conservative management, arthroscopic release was an effective treatment. Further, their group noted significant difficulty experienced by patients waiting for resolution of a painful frozen shoulder [82]. In a small case series, Sabat and colleagues demonstrated that arthroscopic release was an effective treatment as early as 3 months and after only 6 weeks of failed conservative management. In that series, all patients returned to work in 3–5 months [83]. Despite results such as these, conservative management continues to be the gold standard for the initial treatment of FS [1, 6, 25, 34]. There are many forms of noninvasive treatment including physical therapy, anti-inflammatory medications, corticosteroid injections (CSI), sodium hyaluronate injections, acupuncture, and extracorporeal shockwave therapy. There remains a frustrating lack of consensus regarding which therapies, individual or combined, lead to the best outcomes (see Table 14.2).
Table 14.2
Conservative treatment options
Conservative treatments for FS | ||||
|---|---|---|---|---|
Study/year | Study group | Interventions | Follow-up | Results/conclusions |
Corticosteroids | ||||
Yoon et al. (2013) [84] | Randomized controlled trial of 53 patients with primary FS in the freezing stage with symptoms for at least 1 month. Cases of secondary FS including diabetics were excluded | 1. High-dose intra-articular corticosteroid injection (40 mg triamcinolone) 2. Low dose intra-articular corticosteroid injection (20 mg triamcinolone) 3. Placebo injection | 12 weeks | Both cortisone injection treatment groups showed significant improvements in shoulder disability, pain, and range of motion in comparison with placebo. There was not a significant difference between the two doses administered. All treatment groups showed significant improvement with time |
Roh et al. (2012) [85] | Randomized controlled trial of 45 diabetic patients with FS who had failed conservative therapy (stretching and NSAIDs) for at least 3 months. Patients were excluded if they had other shoulder pathology or systemic causes of disease | 1. Intra-articular corticosteroid injection (40 mg triamcinolone) and home exercise with NSAIDs 2. Home exercise with NSAIDs | 24 weeks | At the 4-week follow-up, the steroid injection group had significantly less pain than the home exercise group. At the 12-week follow-up, the steroid injection group has significantly greater range of motion. There were no significant differences in range of motion or pain scores between groups at the 24-week follow-up |
Bal et al. (2008) [86] | Randomized controlled trial of 80 patients with FS who had been symptomatic for 6 weeks to 6 months. Patients with previous surgery or diabetes were excluded | 1. Intra-articular corticosteroid injection (40 mg methylprednisolone with 12 weeks of home exercise) 2. Intra-articular injection of saline with 12 weeks of home exercise | 12 weeks | At week 2, shoulder pain and disability scores were significantly reduced in the corticosteroid group in comparison with the placebo. At the week 12 visit, there were no significant differences in pain or disability scores between the groups |
Buchbinder et al. (2006) [87] | Cochrane review of oral steroids for FS | 1. Oral corticosteroids 2. Other interventions including placebo | Various | Concluded that oral steroids provide significant short-term benefits in pain and disability but that these benefits may not last beyond 6 weeks. However, there were not enough studies to complete a meta-analysis |
Buchbinder et al. (2004) [88] | Randomized controlled trial of 46 patients with FS for more than 3 weeks. Patients were excluded if they had other shoulder pathology or systemic causes of disease | 1. Oral corticosteroid (30 mg prednisolone) 2. Placebo | 12 weeks | The oral corticosteroid group showed significant improvement in pain, disability, and range of motion at 3 weeks. At 6 weeks and 12 weeks, there were no significant differences in any measures between the groups |
Widiastuti-Samekto and Sianturi (2004) [89] | Randomized prospective trial of 26 patients in the frozen or thawing stage of FS. Patients were excluded if they had other shoulder pathology or systemic causes of disease | 1. Triamcinolone intra-articular injection (40 mg) 2. Oral triamcinolone | 3 weeks | Significantly more patients were considered cured at week 1 in the intra-articular injection group. There were no significant differences in cure rates at week 2 or week 3 |
Buchbinder et al. (2003) [90] | Cochrane review of intra-articular corticosteroid injections for shoulder pain | 1. Intra-articular corticosteroids 2. Other interventions including placebo | Various | Concluded that intra-articular corticosteroid injections may be of limited short-term benefit in FS; however, there were not enough high-quality studies to complete a meta-analysis |
Corticosteroids vs. physiotherapy | ||||
Ryans et al. (2005) [91] | Randomized controlled trial of 80 patients with FS symptoms from 1 to 6 months’ duration. Patients were excluded if they had other shoulder pathology or systemic causes of disease | 1. Corticosteroid injection (20 mg triamcinolone) and eight sessions of physical therapy 2. Corticosteroid injection 3. Placebo injection and physical therapy 4. Placebo injection | 16 weeks | At 6 weeks, corticosteroid injections were associated with significantly less patient-reported shoulder disability, while physical therapy was associated with an increased range of motion. At 16 weeks, there were no significant differences between any of the groups |
Carette et al. 2003 [92] | Randomized controlled trial of 93 individuals. Only patients with idiopathic FS were included although the study did not exclude diabetic patients | 1. Corticosteroid injection (40 mg triamcinolone) 2. Corticosteroid injection with physical therapy 3. Saline injection with physical therapy 4. Saline injection | 12 months | Cortisone injection alone provided significantly more improvement than other groups. At 12 months, all interventions were equal for all outcome measures. Concluded that a single steroid injection with simple home exercises is best and that physical therapy alone has limited utility |
Arslan and Celiker (2001) [93] | Randomized trial of 20 individuals with FS in the setting of no other shoulder abnormalities | 1. Intra-articular corticosteroid injection (40 mg methylprednisolone) 2. Physiotherapy consisting of hot pack application, ultrasound, passive stretching, pendulum exercises, and NSAIDs | 12 weeks | Both groups demonstrated significant improvements in range of motion with no significant differences between the groups. Both interventions resulted in significantly improved pain scores |
Physiotherapy | ||||
Russell et al. (2014) [94] | Randomized controlled trial of 75 patients with primary idiopathic FS and at least 3 months of symptoms. Patients were excluded if they had other shoulder pathology or systemic causes of disease | 1. Group exercise classes twice per week with a physical therapist 2. Individual sessions twice per week with a physical therapist 3. Home exercises and an informational booklet | 12 months | Patients in the group exercise class had significantly less symptoms at 1 year than those in the individual or home-based therapy groups. Both individual and group therapy had significantly greater range of motion than home-based patients. Significant improvements were seen in all three interventions |
Dundar et al. (2009) [95] | Randomized prospective trial of 57 patients with primary FS in the painful or stiff phases. Patients with additional shoulder pathology were excluded | 1. Continuous passive motion for 1 h/day for 20 days 2. Daily physical therapy with active stretching and pendulum exercises for 20 days | 12 weeks | Patients in the CPM group showed significantly greater reductions in pain than those in the physical therapy group. All patients showed significant decreases in pain and increases in range of motion regardless of treatment protocol |
Diercks and Stevens (2004) [96]
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