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1.  Treatment of Frozen Shoulder Using Distension Arthrography (Hydrodilatation) 
Frozen shoulder (adhesive capsulitis) is a common, painful and disabling condition which is typically slow to resolve. Patients with this condition will be seen in every musculoskeletal practitioner’s clinic on a regular basis. There is a wide variety of treatment modalities available, some more effective than others. This article reviews the literature on the aetiology and natural history of the condition, and the common treatments provided. The literature on hydraulic arthrographic capsular distension (hydrodilatation) is reviewed and six cases referred for this treatment from a chiropractic clinic are presented.
PMCID: PMC2051310  PMID: 17987207
Frozen shoulder; hydrodilatation; case series
2.  Hydrodilatation, corticosteroids and adhesive capsulitis: A randomized controlled trial 
Background
Hydrodilatation of the glenohumeral joint is by several authors reported to improve shoulder pain and range of motion for patients with adhesive capsulitis. Procedures described often involve the injection of corticosteroids, to which the reported treatment effects may be attributed. Any important contribution arising from the hydrodilatation procedure itself remains to be demonstrated.
Methods
In this randomized trial, a hydrodilatation procedure including corticosteroids was compared with the injection of corticosteroids without dilatation. Patients were given three injections with two-week intervals, and all injections were given under fluoroscopic guidance. Outcome measures were the Shoulder Pain and Disability Index (SPADI) and measures of active and passive range of motion. Seventy-six patients were included and groups were compared six weeks after treatment. The study was designed as an open trial.
Results
The groups showed a rather similar degree of improvement from baseline. According to a multiple regression analysis, the effect of dilatation was a mean improvement of 3 points (confidence interval: -5 to 11) on the SPADI 0–100 scale. T-tests did not demonstrate any significant between-group differences in range of motion.
Conclusion
This study did not identify any important treatment effects resulting from three hydrodilatations that included steroid compared with three steroid injections alone.
Trial registration
The study is registered in Current Controlled Trials with the registration number ISRCTN90567697.
doi:10.1186/1471-2474-9-53
PMCID: PMC2374785  PMID: 18423042
3.  Hydrodilatation (distension arthrography): a long‐term clinical outcome series 
Objectives
To describe and compare the medium to long‐term effectiveness of hydrodilatation and post‐hydrodilatation physiotherapy in patients with primary and secondary glenohumeral joint contracture associated with rotator cuff pathology.
Methods
Patients with primary and secondary glenohumeral contractures associated with rotator cuff pathology were recruited into a 2‐year study. They all underwent hydrodilatation, followed by a structured physiotherapy programme. Patients were assessed at baseline, 3 days, 1 week, 3 months, 1 year and 2 years after hydrodilatation with primary outcome measures (Shoulder Pain and Disability Index, Shoulder Disability Index and percentage rating of “normal” function; SD%) and secondary outcome measures (range of shoulder abduction, external rotation and hand behind back). Comparisons in recovery were made between the primary and secondary glenohumeral contracture groups at all timeframes and for all outcome measures.
Results
A total of 53 patients (23 with primary and 30 with secondary glenohumeral contractures) were recruited into the study. At the 2‐year follow‐up, 12 patients dropped out from the study. At baseline, the two contracture groups were similar with respect to their demographic and physical characteristics. The two groups of patients recovered in a similar fashion over the 2‐year follow‐up period. A significant improvement was observed in all outcomes measures over this period (p<0.01), so that both function and range of movement increased. The rate of improvement was dependent on the outcome measure that was used.
Conclusions
Hydrodilatation and physiotherapy increase shoulder motion in individuals with primary and secondary glenohumeral joint contracture associated with rotator cuff pathology. This benefit continues to improve or is maintained in the long term, up to 2 years after hydrodilatation.
doi:10.1136/bjsm.2006.028431
PMCID: PMC2465214  PMID: 17178772
4.  Assessment of anterior shoulder instability by CT arthrography. 
Computed tomography (CT) immediately after double-contrast shoulder arthrography was taken in twenty-two young male patients with anterior shoulder instability including recurrent dislocation and subluxation. This recently developed technique called CT arthrography can provide significant information about patients with glenohumeral instability which is difficult to obtain by conventional arthrography. Information about glenoid labrum pathology is useful for proper management of the shoulder with instability. Lesions identified in this study include anterior labral defects (attenuation, tear, displacement), anterior capsular distension and/or detachment, Hill-Sachs lesion, anterior glenoid rim compression fracture, and fracture of scapula. This article describes the method used in CT arthrography of the glenohumeral joint, reviews the normal cross-sectional anatomy, and emphasizes the importance of the application of CT arthrography in the shoulder disorder with instability. CT arthrography of the glenohumeral joint is easy to perform, is accurate, and has lower radiation dose than arthrotomography.
PMCID: PMC3053628  PMID: 3268172
5.  Frozen shoulder: an arthrographic and radionuclear scan assessment. 
Annals of the Rheumatic Diseases  1984;43(3):365-369.
The diagnostic criteria and nomenclature used to describe the painful stiff shoulder remain confused. Arthrographic features of capsulitis have come to be accepted as characteristic of the frozen shoulder. Increased technetium uptake has also been noted. Both features have been considered to have possible prognostic and therapeutic importance. During a therapeutic study of strictly defined clinical frozen shoulder 35 of 38 patients showed increased technetium diphosphonate uptake in the affected shoulder in comparison with the opposite side. Of 36 patients who had arthrography 15 showed evidence of capsulitis, 11 rupture of the rotator cuff, and five no abnormality. Five tests failed owing to technical difficulty. There was no association between the technetium uptake and the arthrographic features, and neither was useful in predicting the rate or extent of recovery. Frozen shoulder of traumatic onset behaved no differently from that which arose spontaneously. We do not therefore consider that arthrography or technetium diphosphonate scanning performed at presentation contributes to the assessment of the painful stiff shoulder.
Images
PMCID: PMC1001346  PMID: 6742897
6.  Systematic review of randomised controlled trials of interventions for painful shoulder: selection criteria, outcome assessment, and efficacy. 
BMJ : British Medical Journal  1998;316(7128):354-360.
OBJECTIVE: To review the efficacy of common interventions for shoulder pain. DESIGN: All randomised controlled trials of non-steroidal anti-inflammatory drugs, intra-articular and subacromial glucocorticosteroid injection, oral glucocorticosteroid treatment, physiotherapy, manipulation under anaesthesia, hydrodilatation, and surgery for shoulder pain that were identified by computerised and hand searches of the literature and had a blinded assessment of outcome were included. MAIN OUTCOME MEASURES: Methodological quality (score out of 40), selection criteria, and outcome measures. Effect sizes were calculated and combined in a pooled analysis if study population, end point, and intervention were comparable. RESULTS: Thirty one trials met inclusion criteria. Mean methodological quality score was 16.8 (9.5-22). Selection criteria varied widely, even for the same diagnostic label. There was no uniformity in the outcome measures used, and their measurement properties were rarely reported. Effect sizes for individual trials were small (range -1.4 to 3.0). The results of only three studies investigating "rotator cuff tendinitis" could be pooled. The only positive finding was that subacromial steroid injection is better than placebo in improving the range of abduction (weighted difference between means 35 degrees (95% confidence interval 14 to 55)). CONCLUSIONS: There is little evidence to support or refute the efficacy of common interventions for shoulder pain. As well as the need for further well designed clinical trials, more research is needed to establish a uniform method of defining shoulder disorders and developing outcome measures which are valid, reliable, and responsive in affected people.
PMCID: PMC2665551  PMID: 9487172
7.  The Frozen Shoulder: Myths and Realities 
Frozen shoulder is a common, disabling but self-limiting condition, which typically presents in three stages and ends in resolution. Frozen shoulder is classified as primary (idiopathic) or secondary cases. The aetiology for primary frozen shoulder remains unknown. It is frequently associated with other systemic conditions, most commonly diabetes mellitus, or following periods of immobilisation e.g. stroke disease. Frozen shoulder is usually diagnosed clinically requiring little investigation. Management is controversial and depends on the phase of the condition. Non-operative treatment options for frozen shoulder include analgesia, physiotherapy, oral or intra-articular corticosteroids, and intra-articular distension injections. Operative options include manipulation under anaesthesia and arthroscopic release and are generally reserved for refractory cases.
doi:10.2174/1874325001307010352
PMCID: PMC3785028  PMID: 24082974
Frozen shoulder; adhesive capsulitis; arthroscopic release
8.  Diagnostic performance of magnetic resonance arthrography of the shoulder in the evaluation of anteroinferior labrum abnormalities: a prospective study 
Insights into Imaging  2013;4(2):157-162.
Objective
To evaluate the diagnostic performance of magnetic resonance (MR) arthrography of the shoulder in the diagnosis of anteroinferior labrum lesions, using arthroscopy as the reference standard and to classify these lesions.
Methods
Institutional review board approval was obtained. The study population included 59 consecutive patients with history and clinical diagnosis of acute or chronic anterior shoulder instability. A total of 62 MR arthrograms were performed, since three patients had undergone a bilateral procedure. Arthroscopy, which was performed within a mean of 3 months (range 2–5 months) after MR arthrography, was used as the reference standard. Sensitivity, specificity, accuracy, positive and negative predictive values were then calculated.
Results
MR arthrography showed a sensitivity of 96 % and a specificity of 80 % for the overall detection of anteroinferior labrum abnormalities. The diagnostic accuracy was 95 % and the positive and negative predictive values were 98 % and 66 % respectively. Ten lesions were non-classifiable on surgery, of which eight were non classifiable on MR arthrography also.
Conclusions
MR arthrography is highly accurate for the detection and classification of shoulder anteroinferior labrum lesions. Shoulder surgeons can confidently rely on this method to determine which patients will benefit from arthroscopy.
Main Messages
• MR arthrography is accurate for the detection and classification of shoulder labrum lesions.
• MR arthrography is a valuable tool for the preoperative planning in acute or chronic instability.
• Shoulder surgeons can rely on this method to determine which patients will benefit from arthroscopy.
doi:10.1007/s13244-013-0225-0
PMCID: PMC3609957  PMID: 23397520
Shoulder; Anteroinferior labrum; MR arthrography; Arthroscopy; Shoulder instability
9.  Lessons learnt from the painful shoulder; a case series of malignant shoulder girdle tumours misdiagnosed as frozen shoulder 
Adhesive capsulitis or frozen shoulder is a common condition characterized by shoulder pain and stiffness. In patients in whom conservative measures have failed, more invasive interventions such as arthrographic or arthroscopic distension can be very effective in relieving symptoms and improving range of movement. However, absolute contraindications to these procedures include the presence of neoplasia around the shoulder girdle. We present five cases referred to our institution where the diagnosis of shoulder joint malignancy was delayed, following prolonged, ineffective treatment for frozen shoulder. These cases highlight the importance of careful review of the radiology and the need for reconsideration of the diagnosis in refractory "frozen shoulder".
doi:10.1186/1477-7800-2-2
PMCID: PMC546198  PMID: 15647117
Frozen shoulder; adhesive capsulitis; hydrodilatation; distension; tumour
10.  Deltoid muscle shape analysis with magnetic resonance imaging in patients with chronic rotator cuff tears 
Background
It seems appropriate to assume, that for a full and strong global shoulder function a normally innervated and active deltoid muscle is indispensable. We set out to analyse the size and shape of the deltoid muscle on MR-arthrographies, and analyse its influence on shoulder function and its adaption (i.e. atrophy) for reduced shoulder function.
Methods
The fatty infiltration (Goutallier stages), atrophy (tangent sign) and selective myotendinous retraction of the rotator cuff, as well as the thickness and the area of seven anatomically defined segments of the deltoid muscle were measured on MR-arthrographies and correlated with shoulder function (i.e. active abduction). Included were 116 patients, suffering of a rotator cuff tear with shoulder mobility ranging from pseudoparalysis to free mobility. Kolmogorov-Smirnov test was used to determine the distribution of the data before either Spearman or Pearson correlation and a multiple regression was applied to reveal the correlations.
Results
Our developed method for measuring deltoid area and thickness showed to be reproducible with excellent interobserver correlations (r = 0.814–0.982).
The analysis of influencing factors on active abduction revealed a weak influence of the amount of SSP tendon (r = −0.25; p < 0.01) and muscle retraction (r = −0.27; p < 0.01) as well as the stage of fatty muscle infiltration (GFDI: r = −0.36; p < 0.01). Unexpectedly however, we were unable to detect a relation of the deltoid muscle shape with the degree of active glenohumeral abduction. Furthermore, long-standing rotator cuff tears did not appear to influence the deltoid shape, i.e. did not lead to muscle atrophy.
Conclusions
Our data support that in chronic rotator cuff tears, there seems to be no disadvantage to exhausting conservative treatment and to delay implantation of reverse total shoulder arthroplasty, as the shape of deltoid muscle seems only to be influenced by natural aging, but to be independent of reduced shoulder motion.
doi:10.1186/1471-2474-14-247
PMCID: PMC3751864  PMID: 23957805
Rotator cuff tear; Pseudoparalysis; Deltoid muscle; Myotendinous retraction
11.  Comparison of Sono-guided Capsular Distension with Fluoroscopically Capsular Distension in Adhesive Capsulitis of Shoulder 
Objective
To investigate the short-term effects and advantages of sono-guided capsular distension, compared with fluoroscopically guided capsular distension in adhesive capsulitis of shoulder.
Method
In this prospective, randomized, and controlled trial, 23 patients (group A) were given an intra-articular injection of a mixture of 0.5% lidocaine (9 ml), contrast dye (10 ml), and triamcinolone (20 mg); they received the injection once every 2 weeks, for a total of 6 weeks, under sono-guidance. Twenty-five patients (group B) were treated similarly, under fluoroscopic guidance. Instructions for the self-exercise program were given to all subjects, without physiotherapy and medication. Effects were then assessed using a visual numeric scale (VNS), and the shoulder pain and disability index (SPADI), as well as a range of shoulder motion examinations which took place at the beginning of the study and 2 and 6 weeks after the last injection. Incremental cost-effective ratio (ICER), effectiveness, preference, and procedure duration were evaluated 6 weeks post-injection.
Results
The VNS, SPADI, and shoulder motion range improved 2 weeks after the last injection and continued to improve until 6 weeks, in both groups. However, no statistical differences in changes of VNS, SPADI, ROM, and effectiveness were found between these groups. Patients preferred sono-guided capsular distension to fluoroscopically guided capsular distension due to differences in radiation hazards and positional convenience. Procedure time was shorter for sono-guided capsular distension than for fluoroscopically guided capsular distension.
Conclusion
Sono-guided capsular distension has comparable effects with fluoroscopically guided capsular distension for treatment of adhesive capsulitis of the shoulder. Sono-guided capsular distension can be substituted for fluoroscopic capsular distension and can be advantageous from the viewpoint of radiation hazard mitigation, time, cost-effectiveness and convenience.
doi:10.5535/arm.2012.36.1.88
PMCID: PMC3309313  PMID: 22506240
Sono-guided; Fluoroscopically; Capsular distension; Adhesive capsulitis
12.  The CT-arthrography in the antero-inferior glenoid labral lesion: Pictorial presentation and diagnostic value 
Objective:
To present the Computed Tomography (CT)-Arthrography appearance of the most common types of anterior labral lesion and to assess the diagnostic value of this technique in the detection and classification of the antero-inferior labral tears in glenohumeral joint instability.
Materials and Methods:
The pre-operative CT-Arthrography records of 43 patients, who underwent surgery for anterior shoulder instability, were retrospectively evaluated independently by two radiologists. The data were compared with arthroscopic results and the diagnostic accuracy of CT-Arthrography was calculated to detect the labral lesion and the agreement between the CT-Arthrography lesions classification and the arthroscopy classification.
Results:
The CT-Arthrography sensitivity, specificity and accuracy were: 92% / 89% (reader 1/reader 2), 86% / 86% and 91% / 88% respectively. The CT-Arthrography classification was correct in 86% of cases.
Conclusions:
CT-Arthrography appears to be an accurate means for identification and classification of the anterior labral tears and, identifying the labral degeneration, this technique can be very helpful in the selection of patient for arthroscopic stabilization of the shoulder.
doi:10.4103/0973-6042.39581
PMCID: PMC3022144  PMID: 21264149
Arthrography; CT; instability; labral lesion; shoulder
13.  Correlation of Magnetic Resonance Arthrography with Revision Hip Arthroscopy 
Background
Arthroscopic approaches for the diagnosis and treatment of hip disorders are well established; however, there are limited data regarding revision hip arthroscopy. There have been several studies evaluating the findings of MR arthrography with primary hip arthroscopy, but to our knowledge, no study has evaluated the diagnostic value of MR arthrography before revision hip arthroscopy.
Questions/purposes
We obtained sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of MR arthrography to detect labral lesions, chondral lesions and loose bodies before revision hip arthroscopy.
Methods
We performed a single-surgeon, retrospective review of 70 revision hip arthroscopies (62 patients) and assessed the association between MR arthrography findings and intraoperative findings. There were 43 females and 19 males with a mean age of 36 years (range, 17–59 years). Radiographic interpretation was performed by one of four fellowship-trained musculoskeletal radiologists at three institutions, who had at least 5 years of experience. Radiographic findings were compared with surgical findings by one of the authors for calculation of sensitivity, specificity, PPV, and NPV.
Results
The sensitivity, specificity, PPV, and NPV of MR arthrography for detecting labral tears were 82%, 70%, 94%, and 39%, respectively. The sensitivity, specificity, PPV, and NPV of MR arthrography for detecting chondral damage were 65%, 90%, 94%, and 50%, respectively. The sensitivity, specificity, PPV, and NPV of MR arthrography for detecting loose bodies were 33%, 100%, 100%, and 88%, respectively.
Conclusions
Our study showed the utility of MR arthrography to assist in the diagnosis and treatment of patients with ongoing or recurrent symptoms who have had prior hip arthroscopy. Our data show that MR arthrography is superior at ruling in, rather than ruling out, labral lesions, chondral lesions, and loose bodies, as there were studies interpreted as normal which in fact showed disorders.
Level of Evidence
Level III, diagnostic study. See the Instructions for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-013-3202-5
PMCID: PMC3825902  PMID: 23904247
14.  Shoulder pain 
Clinical Evidence  2010;2010:1107.
Introduction
Shoulder pain is a common problem with an estimated prevalence of 4% to 26%. About 1% of adults aged over 45 years consult their GP with a new presentation of shoulder pain every year in the UK. The aetiology of shoulder pain is diverse and includes pathology originating from the neck, glenohumeral joint, acromioclavicular joint, rotator cuff, and other soft tissues around the shoulder girdle. The most common source of shoulder pain is the rotator cuff, accounting for over two-thirds of cases.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of oral drug treatment, topical drug treatment, local injections, non-drug treatment, and surgical treatment? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 71 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, arthroscopic subacromial decompression, autologous whole blood injection, corticosteroids (oral, subacromial injection, or intra-articular injection), electrical stimulation, excision of distal clavicle, extracorporeal shock wave therapy, ice, laser treatment, manipulation under anaesthesia, suprascapular nerve block, non-steroidal anti-inflammatory drugs (oral, topical or intra-articular injection), opioid analgesics, paracetamol, physiotherapy (manual treatment, exercises), platelet-rich plasma injection, rotator cuff repair, shoulder arthroplasty, and ultrasound.
Key Points
Shoulder pain encompasses a diverse array of pathologies and can affect as many as one quarter of the population depending on age and risk factors. Shoulder pain may be due to problems with the neck, glenohumeral joint, acromioclavicular joint, rotator cuff, or other soft tissues around the shoulder.
Rotator cuff problems are the most common source of shoulder pain, accounting for more than two-thirds of cases. Rotator cuff disorders are associated with musculoskeletal problems that affect the joints and muscles of the shoulder, cuff degeneration due to ageing and ischaemia, and overloading of the shoulder.
Frozen shoulder (adhesive capsulitis) accounts for 2% of cases of shoulder pain. Risk factors for frozen shoulder include female sex, older age, shoulder trauma and surgery, diabetes, and cardiovascular, cerebrovascular, and thyroid disease.
In many people, the cornerstone of treatment is achieving pain control to permit a return to normal functional use of the shoulder and encourage this with manual exercises. In people with acute post-traumatic tear, an early surgical option is warranted.
We don't know whether topical NSAIDs, oral corticosteroids, oral paracetamol, or opioid analgesics improve shoulder pain, although oral NSAIDs may be effective in the short term in people with acute tendonitis/subacromial bursitis. If pain control fails, the diagnosis should be reviewed and other interventions considered.
Physiotherapy may improve pain and function in people with mixed shoulder disorders compared with placebo.
Intra-articular corticosteroid injections may reduce pain in the short term compared with physiotherapy and placebo for people with frozen shoulder, but their benefit in the long term and when compared with local anaesthetic is unclear.
Platelet-rich plasma injections may improve the speed of recovery in terms of pain and function in people having open subacromial decompression for rotator cuff impingement, but further evidence is needed.
Acupuncture may not improve pain or function in people with rotator cuff impingement compared with placebo or ultrasound.
Extracorporeal shock wave therapy may improve pain in calcific tendonitis.
We found some evidence that suprascapular nerve block, laser treatment, and arthroscopic subacromial decompression may be effective in some people with shoulder pain.
We don't know whether autologous blood injections, intra-articular NSAID injections, subacromial corticosteroid injections, electrical stimulation, ice, ultrasound, rotator cuff repair, manipulation under anaesthesia, or shoulder arthroplasty are effective as we found insufficient evidence on their effects.
PMCID: PMC3217726  PMID: 21418673
15.  Comparison between Conventional MR Arthrograhphy and Abduction and External Rotation MR Arthrography in Revealing Tears of the Antero-Inferior Glenoid Labrum 
Korean Journal of Radiology  2001;2(4):216-221.
Objective
To compare, in terms of their demonstration of tears of the anterior glenoid labrum, oblique axial MR arthrography obtained with the patient's shoulder in the abduction and external rotation (ABER) position, with conventional axial MR arthrography obtained with the patient's arm in the neutral position.
Materials and Methods
MR arthrography of the shoulder, including additional oblique axial sequences with the patient in the ABER position, was performed in 30 patients with a clinical history of recurrent anterior shoulder dislocation. The degree of anterior glenoid labral tear or defect was evaluated in both the conventional axial and the ABER position by two radiologists. Decisions were reached by consensus, and a three-point scale was used: grade 1=normal; grade 2=probable tear, diagnosed when subtle increased signal intensity in the labrum was apparent; grade 3=definite tear/defect, when a contrast material-filled gap between the labrum and the glenoid rim or deficient labrum was present. The scores for each imaging sequence were averaged and to compare conventional axial and ABER position scans, Student's t test was performed.
Results
In 21 (70%) of 30 patients, the same degree of anterior instability was revealed by both imaging sequences. Eight (27%) had a lower grade in the axial position than in the ABER position, while one (3%) had a higher grade in the axial position. Three whose axial scan was grade 1 showed only equivocal evidence of tearing, but their ABER-position scan, in which a contrast material-filled gap between the labrum and the glenoid rim was present, was grade 3. The average grade was 2.5 (SD=0.73) for axial scans and 2.8 (SD=0.46) for the ABER position. The difference between axial and ABER-position scans was statistically significant (p<0.05).
Conclusion
MR arthrography with the patient's shoulder in the ABER position is more efficient than conventional axial scanning in revealing the degree of tear or defect of the anterior glenoid labrum. When equivocal features are seen at conventional axial MR arthrography, oblique axial imaging in the ABER position is helpful.
doi:10.3348/kjr.2001.2.4.216
PMCID: PMC2718124  PMID: 11754329
Shoulder, arthrography; Shoulder, injuries; Shoulder, MR
16.  Shoulder pain 
Clinical Evidence  2006;2006:1107.
Introduction
Shoulder pain covers a wide range of problems and affects up to 20% of the population. It is not a specific diagnosis. Shoulder pain can be caused by problems with the acromioclavicular joint, shoulder muscles, or referred pain from the neck. Rotator cuff problems account for 65-70% of cases of shoulder pain.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of oral drug treatment; topical drug treatment; local injections; non-drug treatment; and surgical treatment? We searched: Medline, Embase, The Cochrane Library and other important databases up to February 2006 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 53 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: arthroscopic laser subacromial decompression, corticosteroid injections (intra-articular), corticosteroids (oral, subacromial injection), electrical stimulation, extracorporeal shock wave therapy, guanethidine (intra-articular), ice, laser treatment, manipulation under anaesthesia (plus intra-articular injection in people with frozen shoulder), multidisciplinary biopsychosocial rehabilitation, nerve block, non-steroidal anti-inflammatory drugs (oral, topical or intra-articular injection), opioid analgesics, paracetamol, phonophoresis, physiotherapy (manual treatment, exercises), surgical arthroscopic decompression, transdermal glyceryl trinitrate, ultrasound.
Key Points
Shoulder pain covers a wide range of problems and affects up to 20% of the population. It is not a specific diagnosis. Shoulder pain can be caused by problems with the acromioclavicular joint, shoulder muscles, or referred pain from the neck.
Rotator cuff problems account for 65-70% of cases of shoulder pain. Rotator cuff disorders are associated with musculoskeletal problems that affect the joints and muscles of the shoulder, cuff degeneration due to ageing and ischaemia, and overloading of the shoulder.
Adhesive capsulitis (frozen shoulder) accounts for 2% of cases of shoulder pain. Risk factors for frozen shoulder include female sex, older age, shoulder trauma and surgery, diabetes, and cardiovascular, cerebrovascular and thyroid disease.
In many people, the cornerstone of treatment is achieving pain control to allow appropriate physiotherapy to proceed. In people with acute post traumatic tear, an early surgical option is warranted.
We don't know whether oral or topical NSAIDs, oral paracetamol, opioid analgesics or transdermal glyceryl trinitrate improve shoulder pain. If pain control fails, the diagnosis should be reviewed and other interventions considered.
Physiotherapy improves pain and function in people with mixed shoulder disorders compared with placebo or sham laser treatment. Physiotherapy seems to be of similar efficacy to intra-articular or sub-acromial corticosteroid injections or surgical arthroscopic decompression over 6-12 months.
Intra-articular injections may be beneficial but only if accurately sited. Intra-articular corticosteroid injections may reduce pain in the short term compared with physiotherapy, but their benefit compared with placebo or local anaesthetic is unclear.Clinical outcome correlates with accuracy of injection, but even experienced clinicians may fail to locate the correct site in the majority of cases.
Suprascapular nerve blocks improve pain at 1 month in people with adhesive capsulitis and degenerative disease but we don't know whether it improves shoulder pain from other causes.
Extracorporeal shock wave therapy may improve pain in calcific tendonitis, and manipulation under anaesthesia may reduce symptoms of adhesive capsulitis, but neither intervention is beneficial in rotator cuff lesions.
PMCID: PMC2907630
17.  Anatomy, Variants, and Pathologies of the Superior Glenohumeral Ligament: Magnetic Resonance Imaging with Three-Dimensional Volumetric Interpolated Breath-Hold Examination Sequence and Conventional Magnetic Resonance Arthrography 
Korean Journal of Radiology  2014;15(4):508-522.
The purpose of this review was to demonstrate magnetic resonance (MR) arthrography findings of anatomy, variants, and pathologic conditions of the superior glenohumeral ligament (SGHL). This review also demonstrates the applicability of a new MR arthrography sequence in the anterosuperior portion of the glenohumeral joint. The SGHL is a very important anatomical structure in the rotator interval that is responsible for stabilizing the long head of the biceps tendon. Therefore, a torn SGHL can result in pain and instability. Observation of the SGHL is difficult when using conventional MR imaging, because the ligament may be poorly visualized. Shoulder MR arthrography is the most accurately established imaging technique for identifying pathologies of the SGHL and associated structures. The use of three dimensional (3D) volumetric interpolated breath-hold examination (VIBE) sequences produces thinner image slices and enables a higher in-plane resolution than conventional MR arthrography sequences. Therefore, shoulder MR arthrography using 3D VIBE sequences may contribute to evaluating of the smaller intraarticular structures such as the SGHL.
doi:10.3348/kjr.2014.15.4.508
PMCID: PMC4105815  PMID: 25053912
Superior glenohumeral ligament; Anterosuperior impingement; Shoulder; MR arthrography; VIBE sequence
18.  Comparison of Three-Dimensional Isotropic and Two-Dimensional Conventional Indirect MR Arthrography for the Diagnosis of Rotator Cuff Tears 
Korean Journal of Radiology  2014;15(6):771-780.
Objective
To compare the accuracy between a three-dimensional (3D) indirect isotropic T1-weighted fast spin-echo (FSE) magnetic resonance (MR) arthrography and a conventional two-dimensional (2D) T1-weighted sequences of indirect MR arthrography for diagnosing rotator cuff tears.
Materials and Methods
The study was approved by our Institutional Review Board. In total, 205 patients who had undergone indirect shoulder MR arthrography followed by arthroscopic surgery for 206 shoulders were included in this study. Both conventional 2D T1-weighted FSE sequences and 3D isotropic T1-weighted FSE sequence were performed in all patients. Two radiologists evaluated the images for the presence of full- or partial-thickness tears in the supraspinatus-infraspinatus (SSP-ISP) tendons and tears in the subscapularis (SSC) tendons. Using the arthroscopic findings as the reference standard, the diagnostic performances of both methods were analyzed by the area under the receiver operating characteristic curve (AUC).
Results
Arthroscopy confirmed 165 SSP-ISP tendon tears and 103 SSC tendon tears. For diagnosing SSP-ISP tendon tears, the AUC values were 0.964 and 0.989 for the 2D sequences and 3D T1-weighted FSE sequence, respectively, in reader I and 0.947 and 0.963, respectively, in reader II. The AUC values for diagnosing SSC tendon tears were 0.921 and 0.925, respectively, for reader I and 0.856 and 0.860, respectively, for reader II. There was no significant difference between the AUC values of the 2D and 3D sequences in either reader for either type of tear.
Conclusion
3D indirect isotropic MR arthrography with FSE sequence and the conventional 2D arthrography are not significantly different in terms of accuracy for diagnosing rotator cuff tears.
doi:10.3348/kjr.2014.15.6.771
PMCID: PMC4248633  PMID: 25469089
Magnetic resonance imaging; Indirect MR arthrography; Isotropic; Shoulder; Rotator cuff
19.  Responsiveness of the Shoulder Pain and Disability Index in patients with adhesive capsulitis 
Background
Instruments designed to measure the subjective impact of painful shoulder conditions have become essential in shoulder research. The Shoulder Pain and Disability Index (SPADI) is one of the most extensively used scales of this type. The objective of this study was to investigate reproducibility and responsiveness of the SPADI in patients with adhesive capsulitis.
Methods
SPADI test-retest reproducibility was estimated by the "intraclass correlation coefficient" (ICC) and the "smallest detectable difference" (SDD). Responsiveness was assessed by exploring baseline and follow-up data recorded in a recently reported clinical trial regarding hydrodilatation and corticosteroid injections in 76 patients with adhesive capsulitis. "Standardized response mean" (SRM) and "reliable change proportion" (RCP) for SPADI were compared with corresponding figures for shoulder range-of-motion (ROM). The relationship between SPADI and ROM change scores was investigated through correlation and linear regression analyses.
Results
Results for test-retest reproducibility indicated a smallest detectable difference of 17 points on the 0–100 scale, and an intraclass correlation coefficient of 0.89. The SPADI was generally more responsive than ROM. Weak to moderately strong associations were identified between SPADI and ROM change scores. According to the regression model, the three variables baseline SPADI, baseline active ROM and change in active ROM together explained 60% of the variance in SPADI improvement.
Conclusion
This study supports the use of SPADI as an outcome measure in similar settings.
doi:10.1186/1471-2474-9-161
PMCID: PMC2633286  PMID: 19055757
20.  DOUBLE CONTRAST VISUALIZATION OF JOINTS 
California Medicine  1953;78(5):424-427.
Double contrast arthrography, a method in which a dye and then oxygen is injected, can be used to visualize pathologic changes in the knee joint, that otherwise cannot be recognized preoperatively. In 28 cases in which the procedure was carried out there was no evidence of damage owing to it.
This method is worthy of consideration for visualization of conditions in the shoulder joint, hip, or any joint having a distensible cavity.
Images
PMCID: PMC1521727  PMID: 13042673
21.  Intra-articular distension and steroids in the management of capsulitis of the shoulder. 
BMJ : British Medical Journal  1991;302(6791):1498-1501.
OBJECTIVE--To determine whether there is any synergistic effect in the administration of intraarticular steroids with distension in the management of early capsulitis of the shoulder. DESIGN--Prospective randomised trial of three treatments--namely distension only, steroid only, and steroid with distension. SETTING--Academic department of orthopaedic and accident surgery at Queen's Medical Centre, Nottingham. SUBJECTS--47 patients (30 women) with capsulitis affecting 50 shoulders. INTERVENTIONS--Three intra-articular injections into the shoulder given at six week intervals by the same technique. MAIN OUTCOME MEASURES--Passive range of abduction, forward flexion, and external rotation; results of shoulder dynamometry measuring work done and torque produced; pain levels at rest and with resisted movement. RESULTS--All patients reported improvement during the study. Analysis of the mean improvements in abduction and forward flexion showed these to be significantly greater in the steroid with distension and steroid only groups than in the distension only group (mean improvements in abduction (degrees/week (95% confidence interval)) 4.3 (3.4 to 5.2), 3.4 (2.4 to 4.5), and 1.0 (-0.8 to 2.8) in the three groups respectively; mean improvements in flexion (degrees/week (95% confidence interval)) 3.6 (3.2 to 4.0), 3.3 (2.3 to 4.3), and 1.5 (0.5 to 2.5) respectively). Shoulder dynamometry failed to show a significant difference among the treatment groups. No severe complications occurred as a result of the injections, but two patients reported facial flushing related to the use of steroids. CONCLUSION--Intra-articular steroid injections have a useful role in the outpatient management of early capsulitis.
Images
PMCID: PMC1670184  PMID: 1855018
22.  The Natural History of Idiopathic Frozen Shoulder: A 2- to 27-year Followup Study 
Background
The natural history of spontaneous idiopathic frozen shoulder is controversial. Many studies claim that complete resolution is not inevitable. Based on the 40-year clinical experience of the senior author, we believed most patients with idiopathic frozen shoulder might have a higher rate of resolution than earlier thought.
Questions/purposes
We determined the length of symptoms, whether spontaneous frozen shoulder recovered without any treatment, and whether restored ROM, pain relief, and function persisted over the long term.
Methods
We retrospectively reviewed 83 patients treated for frozen shoulder (84 shoulders; 56 women) 2 to 27 years (mean, 9 years) after initial consultation. The mean age at onset of symptoms was 53 years. Fifty-one of the 83 patients (52 shoulders) were treated with observation or benign neglect only (untreated group), and 32 had received some kind of nonoperative treatment before the first consultation with the senior author (nonoperative group). We also evaluated all 20 patients (22 shoulders; 13 women) with spontaneous frozen shoulder who underwent manipulation under anesthesia during the same time (manipulation group). The mean age of these patients was 49 years. The minimum followup was 2 years (mean, 14 years; range, 2–24 years). We determined duration of the disease, pain levels, ROM, and Constant-Murley scores.
Results
The duration of the disease averaged 15 months (range, 4–36 months) in the untreated group, and 20 months (range, 6–60 months) in the nonoperative group. At last followup the ROM had improved to the contralateral level in 94% in the untreated group, in 91% in the nonoperative group, and in 91% in the manipulation group. Fifty-one percent of patients in the untreated group, 44% in the nonoperative group, and 30% in the manipulation group were totally pain free at rest, during the night, and with exertion. Pain at rest was less than 3 on the VAS in 94% of patients in the untreated group, 91% in the nonoperative group, and 90% of the manipulation group. The Constant-Murley scores averaged 83 (86%) in the untreated group, 81 (77%) in the nonoperative group, and 82 (71%) in the manipulation group, reaching the normal age- and gender-related Constant-Murley score.
Conclusions
We found 94% of patients with spontaneous frozen shoulder recovered to normal levels of function and motion without treatment.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-011-2176-4
PMCID: PMC3293960  PMID: 22090356
23.  Magnetic Resonance Arthrography of the Glenohumeral Joint: Ultrasonography-Guided Technique Using a Posterior Approach 
Objective:
The purpose of this study was to assess the efficacy and feasibility of ultrasound (US)-guided magnetic resonance (MR) arthrography of the glenohumeral joint via a posterior approach.
Materials and Methods:
Thirty-four patients (18 males and 16 females) who were suspected to have glenohumeral joint pathology were examined using MR arthrography. The patients ranged in age from 21 to 85 years, and the average age was 45±15.9 years. A Toshiba Xario US unit was utilized. Ultrasonography examinations were conducted using a broad-band 5–12 MHz linear array transducer. Gadolinium was injected into the shoulder joint using an 18–20 gauge needle. MR imaging was performed within the first 30 min after the injection.
Results:
The injection of gadolinium into the shoulder joint was successfully accomplished in all 34 patients. Major contrast media extravasation outside the joint was depicted in only two patients (5.9%). No major complications were encountered.
Conclusion:
Ultrasonography is an effective alternate guidance technique for the injection of gadolinium into the glenohumeral joint for MR arthrography. US-guided arthrography via a posterior approach to the glenohumeral joint is safe, accurate, well tolerated by patients and easy to perform with minimal training.
doi:10.5152/eajm.2012.18
PMCID: PMC4261291  PMID: 25610213
Arthrography technique; MR arthrography; Shoulder; Ultrasound guided
24.  Comparison of idiopathic, post-trauma and post-surgery frozen shoulder after manipulation under anesthesia 
International Orthopaedics  2006;31(3):333-337.
Manipulation under anesthesia (MUA) has been used to speed up the recovery of frozen shoulder, which is said to be a self-limiting process. We would like to elucidate the short- and long-term results of the treatment of frozen shoulders by manipulation under anesthesia and compare the results of idiopathic, post-trauma and post-surgery frozen shoulders. We applied an adjusted Constant score (Constant score after excluding the 25 points allocated for the assessment of muscle strength) to assess all patients. In our series, 47 cases with 51 frozen shoulders were collected and evaluated retrospectively. The adjusted Constant score at pre-manipulation was on average 22.8±4.9 (10–31) points. The score from the 3-week follow-up was 52.6±9.2 (31–67) points on average. The score from the averaged 82-month follow-up was on average 70.1±6.2 (54–75) points, with 23 shoulders scored for a maximum point number of 75. The score at the early and late follow-ups was significantly lower for the post-surgery group (63.2±6.7) when compared to the other two groups (P<0.001). Our results revealed that manipulation under anestheia is a very simple and noninvasive procedure for shortening the course of an apparently self-limiting disease and can improve shoulder function and symptoms within a short period of time. However, we found less improvement in post-surgery frozen shoulders, especially in residual pain and limited range of motion (ROM), which may be influenced by the initial injury or initial surgery. Although less improvement in pain and ROM was noted, manipulation is still a good and simple way to treat post-surgery frozen shoulders.
doi:10.1007/s00264-006-0195-7
PMCID: PMC2267597  PMID: 16927088
25.  Efficacy of labral repair, biceps tenodesis, and diagnostic arthroscopy for SLAP Lesions of the shoulder: a randomised controlled trial 
Background
Surgery for type II SLAP (superior labral anterior posterior) lesions of the shoulder is a promising but unproven treatment. The procedures include labral repair or biceps tenodesis. Retrospective cohort studies have suggested that the benefits of tenodesis include pain relief and improved function, and higher patient satisfaction, which was reported in a prospective non-randomised study. There have been no completed randomised controlled trials of surgery for type II SLAP lesions. The aims of this participant and observer blinded randomised placebo-controlled trial are to compare the short-term (6 months) and long-term (2 years) efficacy of labral repair, biceps tenodesis, and placebo (diagnostic arthroscopy) for alleviating pain and improving function for type II SLAP lesions.
Methods/Design
A double-blind randomised controlled trial are performed using 120 patients, aged 18 to 60 years, with a history for type II SLAP lesions and clinical signs suggesting type II SLAP lesion, which were documented by MR arthrography and arthroscopy. Exclusion criteria include patients who have previously undergone operations for SLAP lesions or recurrent shoulder dislocations, and ruptures of the rotator cuff or biceps tendon. Outcomes will be assessed at baseline, three, six, 12, and 24 months. Primary outcome measures will be the clinical Rowe Score (1988-version) and the Western Ontario Instability Index (WOSI) at six and 24 months. Secondary outcome measures will include the Shoulder Instability Questionnaire (SIQ), the generic EuroQol (EQ-5 D and EQ-VAS), return to work and previous sports activity, complications, and the number of reoperations.
Discussion
The results of this trial will be of international importance and the results will be translatable into clinical practice.
Trial Registration
[ClinicalTrials.gov NCT00586742]
doi:10.1186/1471-2474-11-228
PMCID: PMC2958985  PMID: 20929552

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