Shoulder:The Stiff Shoulder - Revision history

Alexandre.laedermann at 11:38, 8 July 2021

2021-07-08T11:38:22Z

Alexandre.laedermann at 11:35, 8 July 2021

2021-07-08T11:35:59Z

Alexandre.laedermann at 11:10, 8 July 2021

2021-07-08T11:10:13Z

Alexandre.laedermann at 10:05, 8 July 2021

2021-07-08T10:05:43Z

Alexandre.laedermann at 09:52, 8 July 2021

2021-07-08T09:52:26Z

Alexandre.laedermann at 09:24, 8 July 2021

2021-07-08T09:24:14Z

Alexandre.laedermann at 09:06, 8 July 2021

2021-07-08T09:06:36Z

Alexandre.laedermann at 09:05, 8 July 2021

2021-07-08T09:05:08Z

Alexandre.laedermann at 08:37, 8 July 2021

2021-07-08T08:37:00Z

Show changes

Alexandre.laedermann: /* Prognosis */

2020-08-06T20:57:40Z

Prognosis

@@ Line 92: / Line 92: @@
 ''General complications are'':
-* Residual pain
+*Residual pain
-* Residual stiffness
+*Residual stiffness
-* Fracture of the humerus
+*Fracture of the humerus
-* Rupture of the biceps tendon after shoulder manipulation
+*Rupture of the biceps tendon after shoulder manipulation
 Pearls and Other Issues
@@ Line 237: / Line 237: @@
 Primary idiopathic frozen shoulder is an extremely disabling condition, which does pass through a typical 3 stage progression.  However, full recovery at the conclusion of the 3 phases is not common.  Early surgical intervention has significant benefits for those patients that are unable to cope with non-operative treatment.
-References
+== References ==
 <references />

@@ Line 70: / Line 70: @@
 ==Staging==
-Gradual restriction of passive shoulder motion characterizes a natural course of frozen shoulder. The development is commonly described as progressing through 3 overlapping phases (4 stages classification can also be found in the literature). However, from a practical point of view, we recommended using 2-stage scheme: early and developed frozen shoulder.
+Gradual restriction of passive shoulder motion characterizes a natural course of frozen shoulder. The development is commonly described as progressing through 3 overlapping phases (4 stages classification can also be found in the literature).
 Freezing (2 to 9 months): Early
@@ Line 88: / Line 90: @@
 ==Complications==
-Residual pain
+''General complications are'':
 Residual stiffness
-Fracture of the humerus
+* Residual pain
-Rupture of the biceps tendon after shoulder manipulation
+* Residual stiffness
 Pearls and Other Issues
@@ Line 97: / Line 101: @@
 ==Enhancing Healthcare Team Outcomes==
-The management of frozen shoulder is usually done by a team of healthcare professionals that include the orthopedic surgeon, a rehabilitation specialist, nurse practitioner, pharmacist, and a pain consultant. In addition,  the pharmacist must educate the patient on the management of pain. In addition, patients managed with corticosteroids will need to be monitored for adverse side effects of the drug. For most patients, enrolling in a physical therapy program is the key to recovery. Some patients may benefit from supervised home physical therapy. Finally, patients have to be told that recovery will occur but it is gradual and may take several years.<ref>Lee SH, Yoon C, Chung SG, Kim HC, Kwak Y, Park HW, Kim K. Measurement of Shoulder Range of Motion in Patients with Adhesive Capsulitis Using a Kinect. PLoS ONE. 2015;10:e0129398</ref><ref>Yamada E, Thomas DC. Common musculoskeletal diagnoses of upper and lower extremities in older patients. Mt. Sinai J. Med. 2011;78:546-57</ref><ref>Robb G, Arroll B, Reid D, Goodyear-Smith F. Summary of an evidence-based guideline on soft tissue shoulder injuries and related disorders--Part 2: Management. J Prim Health Care. 2009;1:42-9</ref>
+The management of frozen shoulder is usually done by a team of healthcare professionals that include an orthopedic surgeon, a rehabilitation specialist, a nurse practitioner, a pharmacist, and a pain consultant. In addition, the pharmacist must educate the patient on the pain management. Patients managed with corticosteroids will need to be additionally monitored for drug adverse side effects. For most patients enrollment in a physical therapy program is the key to recovery. Some patients may benefit from supervised home physical therapy. Finally, patients have to be told that recovery will occur but it is gradual and may take several years.<ref>Lee SH, Yoon C, Chung SG, Kim HC, Kwak Y, Park HW, Kim K. Measurement of Shoulder Range of Motion in Patients with Adhesive Capsulitis Using a Kinect. PLoS ONE. 2015;10:e0129398</ref><ref>Yamada E, Thomas DC. Common musculoskeletal diagnoses of upper and lower extremities in older patients. Mt. Sinai J. Med. 2011;78:546-57</ref><ref>Robb G, Arroll B, Reid D, Goodyear-Smith F. Summary of an evidence-based guideline on soft tissue shoulder injuries and related disorders--Part 2: Management. J Prim Health Care. 2009;1:42-9</ref>
 ==Outcomes==
-Frozen shoulder does recover in most people but the recovery may take 1-3 years. In most cases, physical therapy and arm exercise will gradually result in diminishing symptoms. So far, data do not show that diabetics have worse outcomes compared to non-diabetics. About 10% of patients will have residual shoulder stiffness and disability. After arthroscopic surgery, there is a gradual improvement in symptoms with slow recovery. However, postoperative physical therapy is a must after surgery to ensure recovery.<ref name=":2" /><ref>Lamplot JD, Lillegraven O, Brophy RH. Outcomes From Conservative Treatment of Shoulder Idiopathic Adhesive Capsulitis and Factors Associated With Developing Contralateral Disease. Orthop J Sports Med. 2018;6:2325967118785169</ref>
+Frozen shoulder does recover in most people but the recovery may take 1-3 years. In most cases, physical therapy and arm exercise will gradually result in diminishing symptoms. So far, data do not show that diabetics have worse outcomes than non-diabetics. About 10% of patients will have residual shoulder stiffness and disability. After arthroscopic surgery, there is a gradual improvement in symptoms with slow recovery. However, postoperative physical therapy is a must after surgery to ensure recovery.<ref name=":2" /><ref>Lamplot JD, Lillegraven O, Brophy RH. Outcomes From Conservative Treatment of Shoulder Idiopathic Adhesive Capsulitis and Factors Associated With Developing Contralateral Disease. Orthop J Sports Med. 2018;6:2325967118785169</ref>
 =What would Codman have thought about this?=

@@ Line 44: / Line 44: @@
 Frozen shoulder is a clinical diagnosis made by medical history, physical examination, and imaging modalities (ruling out another condition, rather than confirming the diagnosis of AC). No specific test (laboratory or imaging) alone provides the definitive confirmation of the frozen shoulder diagnosis.<ref name=":0" /><ref name=":1" /><ref>Wu F, Kachooei AR, Ebrahimzadeh MH, Bagheri F, Hakimi E, Shojaie B, Nazarian A. Bilateral Arm-Abduction Shoulder Radiography to Determine the Involvement of the Scapulothoracic Motion in Frozen Shoulder. Arch Bone Jt Surg. 2018;6:225-32</ref>
-Diagnostic imaging of frozen shoulder can be challenging because as the findings based on currently available methods (such as radiographs, ultrasound, plain magnetic resonance imaging, and computed tomography) are usually unremarkable. Imaging is therefore limited to ruling out concurrent pathologies, like rotator cuff tendon tears and glenohumeral joint osteoarthritis. The imaging tool mostly applied to patients with AC is high-resolution musculoskeletal ultrasonography (MUS), which has emerged to be the first line to scrutinize shoulder pathology. Nevertheless, until now, there is lack of specific ultrasound findings for diagnosis of frozen shoulder. To be more comprehensive, several investigators reported thickening of the coracohumeral ligament to be a sonographic characteristic in patients with frozen shoulder. Another commonly referred ultrasound finding is the presence of fluid accumulation around the long head of the biceps tendon. Although biceps peri-tendinous effusion is prevalent in shoulders with frozen shoulder, it is specific to frozen shoulder because it might be a result of other shoulder pathology (e.g., rotator cuff disorders or biceps tenosynovitis). Furthermore, ultrasound is less useful in the pathology associated with instability or superior labrum anterior posterior (SLAP) lesion. A plain radiograph is of limited diagnostic values in patients with frozen shoulder. Nevertheless, it is reasonable to obtain routine shoulder radiographs to rule out other etiologies (e.g., tumors, acromioclavicular and glenohumeral osteoarthritis). Magnetic resonance imaging (MRI) may show thickening of the coracohumeral ligament and glenohumeral joint capsule. Magnetic resonance imaging (MRI) arthrography may show a volume reduction of the joint space.
+Diagnostic imaging of frozen shoulder can be challenging because the findings based on currently available methods (such as radiographs, ultrasound, plain magnetic resonance imaging, and computed tomography) are usually unremarkable. Imaging is therefore limited to ruling out concurrent pathologies, like rotator cuff tendon tears and glenohumeral joint osteoarthritis. The imaging tool mostly applied to patients with AC is high-resolution musculoskeletal ultrasonography (MUS), which has emerged to be the first line to scrutinize shoulder pathology. Nevertheless, until now, there is lack of specific ultrasound findings for diagnosis of frozen shoulder. To be more comprehensive, several investigators reported thickening of the coracohumeral ligament to be a sonographic characteristic in patients with frozen shoulder. Another commonly referred ultrasound finding is the presence of fluid accumulation around the long head of the biceps tendon. Although biceps peri-tendinous effusion is prevalent in shoulders with frozen shoulder, it is specific to frozen shoulder because it might be a result of other shoulder pathology (e.g., rotator cuff disorders or biceps tenosynovitis). Furthermore, ultrasound is less useful in the pathology associated with instability or superior labrum anterior posterior (SLAP) lesion. A plain radiograph is of limited diagnostic values in patients with frozen shoulder. Nevertheless, it is reasonable to obtain routine shoulder radiographs to rule out other etiologies (e.g., tumors, acromioclavicular and glenohumeral osteoarthritis). Magnetic resonance imaging (MRI) may show thickening of the coracohumeral ligament and glenohumeral joint capsule. MRI arthrography may show a volume reduction of the joint space.
-The “lidocaine test” is subacromial injection test that may be helpful in establishing the diagnosis in ambiguous clinical scenarios, to rule out subacromial conditions. In patients with AC, passive movement limitation persists after injection of local anesthetics into the subacromial space. On the other hand, patients suffering from subacromial impingement syndrome (e.g., pathology of the rotator cuff or bursa) usually experience improved passive range of motion after injection. The injection can easily be performed with ultrasound guidance.
+The “lidocaine test” is a subacromial injection test that may be helpful in establishing the diagnosis in ambiguous clinical scenarios, to rule out subacromial conditions. In patients with AC, passive movement limitation persists after injection of local anesthetics into the subacromial space. On the other hand, patients suffering from subacromial impingement syndrome (e.g., pathology of the rotator cuff or bursa) usually experience improved passive range of motion after injection. The injection can easily be performed with ultrasound guidance.
 ==Treatment / Management==
@@ Line 52: / Line 52: @@
 ===Early Frozen Shoulder===
-An early stage of AC is often managed as subacromial pathology. The early “freezing” AC mentioned above can be considered as inflammatory. On the other hand, the inflammation becomes less accentuated in the later stages, where ROM limitation is predominant, and inflammation-related pain is not as much pronounced. In the light of above differences, we must consider the disease stage when planning the treatment strategy. The correct recognition of the clinical stage may help tailor treatment plans more specifically. The aim of treatment in the “freezing” stage should focus on pain control, reduction of inflammation and patient education. Initial treatment options for adhesive capsulitis may include acetaminophen or NSAID. Although evidence regarding NSAID for the treatment of frozen shoulder is limited, they can be prescribed to provide short-term relief from the night pain if present. However, in severe cases, opioid analgesics may be required. Physical therapy is important for pain control and restoration of normal shoulder mobility. Those comprise manual therapies based on soft tissue mobilization and gentle stretching. Regarding physical modalities, no particular agent has shown to be superior. The patient can be prescribed, e.g., therapeutic ultrasound, cryotherapy or transcutaneous electrical nerve stimulation (TENS) unit. Physical therapy management should focus on therapeutic exercise. Although not all patients can tolerate mobilization exercise within the initial stage of the frozen shoulder due to severe pain, a supervised therapeutic exercise should be conducted to slow down ROM restriction. Furthermore, a home exercise program should be given to the patients on a daily basis. In patients suffering from moderate to severe pain who are not responsive to non-operative treatments, intra-articular injection of corticosteroid should be considered. The injection should be performed under ultrasonographic or fluoroscopic guidance to ensure the correct needle placement. Last but not least, rehabilitation exercise should be prescribed after injection.
+An early stage of AC is often managed as subacromial pathology. The early “freezing” AC mentioned above can be considered as inflammatory. On the other hand, the inflammation becomes less accentuated in the later stages, where ROM limitation is predominant, and inflammation-related pain is not as much pronounced. In the light of above differences, we must consider the disease stage when planning the treatment strategy. The correct recognition of the clinical stage may help to tailor treatment plans more specifically. The treatment aim in the “freezing” stage should focus on pain control, reduction of inflammation and patient education. Initial treatment options for adhesive capsulitis may include acetaminophen or NSAID. Although evidence regarding NSAID for the treatment of frozen shoulder is limited, they can be prescribed to provide short-term relief from the night pain if present. However, in severe cases, opioid analgesics may be required. Physical therapy is important for pain control and restoration of normal shoulder mobility. Those comprise manual therapies based on soft tissue mobilization and gentle stretching. Regarding physical modalities, no particular agent has shown to be superior. The patient can be prescribed, e.g., therapeutic ultrasound, cryotherapy or transcutaneous electrical nerve stimulation (TENS) unit. Physical therapy management should focus on therapeutic exercise. Although not all patients can tolerate mobilization exercise within the initial stage of frozen shoulder due to severe pain, a supervised therapeutic exercise should be conducted to slow down ROM restriction. Furthermore, a home exercise program should be given to the patients on a daily basis. In patients suffering from moderate to severe pain who are not responsive to non-operative treatments, intra-articular injection of corticosteroid should be considered. The injection should be performed under ultrasonographic or fluoroscopic guidance to ensure the correct needle placement. Last but not least, rehabilitation exercise should be prescribed after injection.
 ===Developed Frozen Shoulder===
-After the inflammation-related painful period subsides, the condition progresses to a “frozen” and subsequently into a “thawing” phases. Treatment objectives in the advanced stages should focus on regaining ROM limitation. The physical therapists should provide more intensive (compared, e.g., to subacromial pathologies) mobilization exercise to restore joint mobility. In patients who do not respond well to non-operative treatments, a more invasive therapy should be considered. The addition of suprascapular nerve or interscalene brachial plexus blockage may result in further improvement. In patients with refractory cases of frozen shoulder who do not improve after 6 months of non-operative treatment, more aggressive treatments such as capsular hydrodilatation (stretching the joint capsule by the saline injectate pressure), manipulation under anesthesia (tearing of the contracted capsule), and arthroscopic capsular release (particularly in the rotator interval) can be considered.
+After the inflammation-related painful period subsides, the condition progresses to a “frozen” and subsequently into a “thawing” phases. Treatment objectives in the advanced stages should focus on regaining ROM limitation. The physical therapists should provide more intensive (compared, e.g., to subacromial pathologies) mobilization exercise to restore joint mobility. In patients who do not respond well to non-operative treatments, a more invasive therapy should be considered. The addition of suprascapular nerve or interscalene brachial plexus blockage may result in further improvement. In patients with refractory cases of frozen shoulder, who do not improve after 6 months of non-operative treatment, more aggressive treatments such as capsular hydrodilatation (stretching the joint capsule by the saline injectate pressure), manipulation under anesthesia (tearing of the contracted capsule), and arthroscopic capsular release (particularly in the rotator interval) can be considered.
 ==Differential Diagnosis==
-Frozen  shoulder, particularly in early (freezing) stage might be a diagnostic challenge as it may mimic subacromial pathology and rotator cuff tendinopathy. Presentations mentioned above may result in the delay in diagnosis of AC in the early phases. Regarding shoulder impingement and rotator cuff pathology, patients report predominantly pain with less pronounced passive range of motion. However, several facets help to distinguish frozen shoulder from other shoulder disorders. Regarding the causes other than frozen  shoulder, patients often state lifting a heavy object or performing repetitive overhead movements. In contrast, frozen shoulder patients usually describe spontaneous onset without an apparent cause or a history of overuse activity. Extra precaution should be paid in case of the history of malignancy.
+Frozen  shoulder, particularly in early (freezing) stage might be a diagnostic challenge as it may mimic subacromial pathology and rotator cuff tendinopathy. Mentioned above presentations may result in the delay of AC diagnosis in the early phases. Regarding shoulder impingement and rotator cuff pathology, patients report predominantly pain with less pronounced passive range of motion. However, several facets help to distinguish frozen shoulder from other shoulder disorders. Regarding the causes other than frozen  shoulder, patients often state lifting a heavy object or performing repetitive overhead movements. In contrast, frozen shoulder patients usually describe spontaneous onset without an apparent cause or a history of overuse activity. Extra precaution should be paid in case of the history of malignancy.
 Common conditions that may mimic early adhesive capsulitis:
@@ Line 67: / Line 67: @@
 *Referred pain (cervical spine or malignancy, e.g., Pancoast tumor)
-Age of onset provides additional clues to diagnose AC. Frozen shoulder is unlikely in patients younger than 40 years of age, and patients older than 70 are more likely to develop rotator cuff tears or glenohumeral osteoarthritis instead of frozen shoulder.
+Age of onset provides additional clues to diagnose AC. Frozen shoulder is unlikely in patients younger than 40 years old, and patients older than 70 years old are more likely to develop rotator cuff tears or glenohumeral osteoarthritis than frozen shoulder.
 ==Staging==
@@ Line 73: / Line 73: @@
 Freezing (2 to 9 months): Early
 Frozen (4 to 12 months): Developed
 Thawing (12 to 42 months): Developed
-The second phase with stiffness and persisted glenohumeral joint motion limitation, but with less pain than that at the “Freezing” stage.
+Freezing is an initial, painful phase with predominant pain that is worse at night, with gradually increased glenohumeral joint ROM restriction.
-Thawing
+Frozen is the second phase with stiffness and persisted glenohumeral joint motion limitation, but with less pain than that at the “Freezing” stage.
-The third (recovery) phase with the gradual return of range of motion.
+Thawing is the third (recovery) phase with the gradual return of range of motion.
 ==Prognosis==

@@ Line 35: / Line 35: @@
 The physical findings are essential for a frozen shoulder diagnosis, although pain and stiffness make it difficult for patients to comply with a complete set of physical examination.
-Two physical examinations are commonly used for diagnosing frozen shoulder, including tests of combined motion, as touching the scapula from behind the neck and from behind the back.
+Two physical examinations are commonly used to diagnose frozen shoulder, including tests of combined motion, as touching the scapula from behind the neck and from behind the back.
-However, the most pathognomonic feature for frozen shoulder is a loss of passive range of motion. Practically, in cases of significant restriction of passive ROM, an examination of active motion can be skipped. Nevertheless, as an undetectable limitation of shoulder motion may be present in the early stage, frozen shoulder diagnosis should be reconsidered in patients who present with a gradual restriction of range of motion at follow-ups.
+However, the most pathognomonic feature for frozen shoulder is a loss of passive range of motion (''ROM''). Practically, in cases of significant restriction of passive ROM, an examination of active motion can be skipped. Nevertheless, as an undetectable limitation of shoulder motion may be present in the early stage, frozen shoulder diagnosis should be reconsidered in patients who present with a gradual restriction of range of motion at follow-ups.
 In general, patients with frozen shoulder usually demonstrate significant restriction in active and passive range of motion, particularly in external rotation and abduction movement. Restricted motion in every direction not only indicates the presence of a developed frozen shoulder, but it may be a “red flag” for possible underlying malignancy or fracture.

@@ Line 28: / Line 28: @@
 ==Histopathology==
-The studies of histopathology for the glenohumeral capsule have confirmed a significant increase in fibroblasts, myofibroblasts, and inflammatory cells, like B-lymphocytes, mast cells, and macrophages.
+The studies of the glenohumeral capsule histopathology have confirmed a significant increase in fibroblasts, myofibroblasts, and inflammatory cells, like B-lymphocytes, mast cells, and macrophages.
 ==History and Physical==

@@ Line 5: / Line 5: @@
 ==Introduction==
-Frozen shoulder, also known as adhesive capsulitis, is an insidious painful condition of the shoulder persisting more than 3 months. This inflammatory condition that causes fibrosis of the glenohumeral joint capsule is accompanied by gradually progressive stiffness and significant restriction of range of motion (typically external rotation). However, the patients may develop symptoms suddenly and have a slow recovery phase. The recovery is satisfying in most of the cases, even though this may take up to 2 to 3 years.<ref name=":0">Hubbard MJ, Hildebrand BA, Battafarano MM, Battafarano DF. Common Soft Tissue Musculoskeletal Pain Disorders. Prim. Care. 2018;45:289-303</ref><ref name=":1">Xiao RC, DeAngelis JP, Smith CC, Ramappa AJ. Evaluating Nonoperative Treatments for Adhesive Capsulitis. J Surg Orthop Adv. 2017,26:193-9</ref>
+Frozen shoulder, also known as adhesive capsulitis, is an insidious painful condition of the shoulder persisting more than 3 months. This inflammatory condition that causes fibrosis of the glenohumeral joint capsule is accompanied by gradually progressive stiffness and significant restriction of range of motion (''ROM''), typically external rotation. However, the patients may develop symptoms suddenly and have a slow recovery phase. The recovery is satisfying in most of the cases, even though this may take up to 2 to 3 years.<ref name=":0">Hubbard MJ, Hildebrand BA, Battafarano MM, Battafarano DF. Common Soft Tissue Musculoskeletal Pain Disorders. Prim. Care. 2018;45:289-303</ref><ref name=":1">Xiao RC, DeAngelis JP, Smith CC, Ramappa AJ. Evaluating Nonoperative Treatments for Adhesive Capsulitis. J Surg Orthop Adv. 2017,26:193-9</ref>
 ==Etiology==
@@ Line 20: / Line 20: @@
 ==Epidemiology==
-Frozen shoulder occurs in up to 5%. Females are 4 times more often affected than men, while the non-dominant shoulder is more prone to be affected.<ref name=":0" /><ref name=":1" />
+Frozen shoulder occurs in up to 5%. Women are 4 times more often affected than men, while the non-dominant shoulder is more prone to be affected.<ref name=":0" /><ref name=":1" />
 ==Pathophysiology==

@@ Line 1: / Line 1: @@
 =Primary Frozen Shoulder=
-From <ref>Mezian K, Chang KV. Frozen Shoulder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan</ref>, with permission.
+From <ref>Mezian K, Coffey R, Chang KV. Frozen Shoulder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.[Updated 2020 Sep 3]. </ref>, with permission.
 ==Bullet Points==
 ==Introduction==
-Frozen shoulder, also known as adhesive capsulitis, is an insidious painful condition of the shoulder persisting more than 3 months. This inflammatory condition that causes fibrosis of the glenohumeral joint capsule is accompanied by gradually progressive stiffness and significant restriction of range of motion (typically external rotation). However, the patients may develop symptoms suddenly and have a slow recovery phase. The recovery is satisfying in most of the cases, even though this may take up to 2 to 3 years.<ref name=":0">Hubbard MJ, Hildebrand BA, Battafarano MM, Battafarano DF. Common Soft Tissue Musculoskeletal Pain Disorders. Prim. Care. 2018;45:289-303</ref><ref name=":1">Xiao RC, DeAngelis JP, Smith CC, Ramappa AJ. Evaluating Nonoperative Treatments for Adhesive Capsulitis. J Surg Orthop Adv. 2017,26(4):193-199</ref>
+Frozen shoulder, also known as adhesive capsulitis, is an insidious painful condition of the shoulder persisting more than 3 months. This inflammatory condition that causes fibrosis of the glenohumeral joint capsule is accompanied by gradually progressive stiffness and significant restriction of range of motion (typically external rotation). However, the patients may develop symptoms suddenly and have a slow recovery phase. The recovery is satisfying in most of the cases, even though this may take up to 2 to 3 years.<ref name=":0">Hubbard MJ, Hildebrand BA, Battafarano MM, Battafarano DF. Common Soft Tissue Musculoskeletal Pain Disorders. Prim. Care. 2018;45:289-303</ref><ref name=":1">Xiao RC, DeAngelis JP, Smith CC, Ramappa AJ. Evaluating Nonoperative Treatments for Adhesive Capsulitis. J Surg Orthop Adv. 2017,26:193-9</ref>
 ==Etiology==
@@ Line 25: / Line 25: @@
 Frozen shoulder is usually described as fibrotic, inflammatory contracture of the rotator interval, capsule, and ligaments. However, the development of frozen shoulder remains not fully understood. Although disagreements exist, the most recognized pathology is cytokine-mediated synovial inflammation with fibroblastic proliferation based on arthroscopic observations. Additional findings include adhesions around the rotator interval caused by increased collagen and nodular band formation.
-The structure usually affected first is the coracohumeral ligament the roof of the rotator cuff interval. Contraction of the coracohumeral ligament limits external rotation of the arm, which is usually first affected in early frozen shoulder. In advanced stages, thickening and contraction of the glenohumeral joint capsule develop, further limiting the range of motion in all directions.[5]
+The structure usually affected first is the coracohumeral ligament the roof of the rotator cuff interval. Contraction of the coracohumeral ligament limits external rotation of the arm, which is usually first affected in early frozen shoulder. In advanced stages, thickening and contraction of the glenohumeral joint capsule develop, further limiting the range of motion in all directions.<ref name=":1" />
 ==Histopathology==
@@ Line 42: / Line 42: @@
 ==Evaluation==
-Frozen shoulder is a clinical diagnosis made by medical history, physical examination, and imaging modalities (ruling out another condition, rather than confirming the diagnosis of AC). No specific test (laboratory or imaging) alone provides the definitive confirmation of the frozen shoulder diagnosis.<ref name=":0" /><ref>Xiao RC, DeAngelis JP, Smith CC, Ramappa AJ. Evaluating Nonoperative Treatments for Adhesive Capsulitis. J Surg Orthop Adv. 2017,26(4):193-199</ref><ref>Wu F, Kachooei AR, Ebrahimzadeh MH, Bagheri F, Hakimi E, Shojaie B, Nazarian A. Bilateral Arm-Abduction Shoulder Radiography to Determine the Involvement of the Scapulothoracic Motion in Frozen Shoulder. Arch Bone Jt Surg. 2018;6(3):225-232</ref>
+Frozen shoulder is a clinical diagnosis made by medical history, physical examination, and imaging modalities (ruling out another condition, rather than confirming the diagnosis of AC). No specific test (laboratory or imaging) alone provides the definitive confirmation of the frozen shoulder diagnosis.<ref name=":0" /><ref name=":1" /><ref>Wu F, Kachooei AR, Ebrahimzadeh MH, Bagheri F, Hakimi E, Shojaie B, Nazarian A. Bilateral Arm-Abduction Shoulder Radiography to Determine the Involvement of the Scapulothoracic Motion in Frozen Shoulder. Arch Bone Jt Surg. 2018;6:225-32</ref>
 Diagnostic imaging of frozen shoulder can be challenging because as the findings based on currently available methods (such as radiographs, ultrasound, plain magnetic resonance imaging, and computed tomography) are usually unremarkable. Imaging is therefore limited to ruling out concurrent pathologies, like rotator cuff tendon tears and glenohumeral joint osteoarthritis. The imaging tool mostly applied to patients with AC is high-resolution musculoskeletal ultrasonography (MUS), which has emerged to be the first line to scrutinize shoulder pathology. Nevertheless, until now, there is lack of specific ultrasound findings for diagnosis of frozen shoulder. To be more comprehensive, several investigators reported thickening of the coracohumeral ligament to be a sonographic characteristic in patients with frozen shoulder. Another commonly referred ultrasound finding is the presence of fluid accumulation around the long head of the biceps tendon. Although biceps peri-tendinous effusion is prevalent in shoulders with frozen shoulder, it is specific to frozen shoulder because it might be a result of other shoulder pathology (e.g., rotator cuff disorders or biceps tenosynovitis). Furthermore, ultrasound is less useful in the pathology associated with instability or superior labrum anterior posterior (SLAP) lesion. A plain radiograph is of limited diagnostic values in patients with frozen shoulder. Nevertheless, it is reasonable to obtain routine shoulder radiographs to rule out other etiologies (e.g., tumors, acromioclavicular and glenohumeral osteoarthritis). Magnetic resonance imaging (MRI) may show thickening of the coracohumeral ligament and glenohumeral joint capsule. Magnetic resonance imaging (MRI) arthrography may show a volume reduction of the joint space.
@@ Line 49: / Line 49: @@
 ==Treatment / Management==
-Despite the number of published literature on the frozen shoulder, there is no consistent consensus about its management. The majority of treatment options are non-operative and include pharmacological management and physical therapy.<ref>Oderuth E, Ali M, Atchia I, Malviya A. A double blind randomised control trial investigating the efficacy of platelet rich plasma versus placebo for the treatment of greater trochanteric pain syndrome (the HIPPO trial): a protocol for a randomised clinical trial. Trials. 2018;19(1):517</ref><ref>Wong CK, Strang BL, Schram GA, Mercer EA, Kesting RS, Deo KS. A pragmatic regional interdependence approach to primary frozen shoulder: a retrospective case series. J Man Manip Ther. 2018;26(2):109-118</ref>
+Despite the number of published literature on the frozen shoulder, there is no consistent consensus about its management. The majority of treatment options are non-operative and include pharmacological management and physical therapy.<ref>Oderuth E, Ali M, Atchia I, Malviya A. A double blind randomised control trial investigating the efficacy of platelet rich plasma versus placebo for the treatment of greater trochanteric pain syndrome (the HIPPO trial): a protocol for a randomised clinical trial. Trials. 2018;19:517</ref><ref>Wong CK, Strang BL, Schram GA, Mercer EA, Kesting RS, Deo KS. A pragmatic regional interdependence approach to primary frozen shoulder: a retrospective case series. J Man Manip Ther. 2018;26:109-18</ref>
 ===Early Frozen Shoulder===
@@ Line 100: / Line 100: @@
 ==Enhancing Healthcare Team Outcomes==
-The management of frozen shoulder is usually done by a team of healthcare professionals that include the orthopedic surgeon, a rehabilitation specialist, nurse practitioner, pharmacist, and a pain consultant. In addition,  the pharmacist must educate the patient on the management of pain. In addition, patients managed with corticosteroids will need to be monitored for adverse side effects of the drug. For most patients, enrolling in a physical therapy program is the key to recovery. Some patients may benefit from supervised home physical therapy. Finally, patients have to be told that recovery will occur but it is gradual and may take several years.<ref>Lee SH, Yoon C, Chung SG, Kim HC, Kwak Y, Park HW, Kim K. Measurement of Shoulder Range of Motion in Patients with Adhesive Capsulitis Using a Kinect. PLoS ONE. 2015;10(6):e0129398</ref><ref>Yamada E, Thomas DC. Common musculoskeletal diagnoses of upper and lower extremities in older patients. Mt. Sinai J. Med. 2011;78(4):546-57</ref><ref>Robb G, Arroll B, Reid D, Goodyear-Smith F. Summary of an evidence-based guideline on soft tissue shoulder injuries and related disorders--Part 2: Management. J Prim Health Care. 2009;1(1):42-9</ref>
+The management of frozen shoulder is usually done by a team of healthcare professionals that include the orthopedic surgeon, a rehabilitation specialist, nurse practitioner, pharmacist, and a pain consultant. In addition,  the pharmacist must educate the patient on the management of pain. In addition, patients managed with corticosteroids will need to be monitored for adverse side effects of the drug. For most patients, enrolling in a physical therapy program is the key to recovery. Some patients may benefit from supervised home physical therapy. Finally, patients have to be told that recovery will occur but it is gradual and may take several years.<ref>Lee SH, Yoon C, Chung SG, Kim HC, Kwak Y, Park HW, Kim K. Measurement of Shoulder Range of Motion in Patients with Adhesive Capsulitis Using a Kinect. PLoS ONE. 2015;10:e0129398</ref><ref>Yamada E, Thomas DC. Common musculoskeletal diagnoses of upper and lower extremities in older patients. Mt. Sinai J. Med. 2011;78:546-57</ref><ref>Robb G, Arroll B, Reid D, Goodyear-Smith F. Summary of an evidence-based guideline on soft tissue shoulder injuries and related disorders--Part 2: Management. J Prim Health Care. 2009;1:42-9</ref>
 ==Outcomes==
-Frozen shoulder does recover in most people but the recovery may take 1-3 years. In most cases, physical therapy and arm exercise will gradually result in diminishing symptoms. So far, data do not show that diabetics have worse outcomes compared to non-diabetics. About 10% of patients will have residual shoulder stiffness and disability. After arthroscopic surgery, there is a gradual improvement in symptoms with slow recovery. However, postoperative physical therapy is a must after surgery to ensure recovery.<ref>Lamplot JD, Lillegraven O, Brophy RH. Outcomes From Conservative Treatment of Shoulder Idiopathic Adhesive Capsulitis and Factors Associated With Developing Contralateral Disease. Orthop J Sports Med. 2018;6(7):2325967118785169</ref><ref>Oderuth E, Ali M, Atchia I, Malviya A. A double blind randomised control trial investigating the efficacy of platelet rich plasma versus placebo for the treatment of greater trochanteric pain syndrome (the HIPPO trial): a protocol for a randomised clinical trial. Trials. 2018;19(1):517</ref>
+Frozen shoulder does recover in most people but the recovery may take 1-3 years. In most cases, physical therapy and arm exercise will gradually result in diminishing symptoms. So far, data do not show that diabetics have worse outcomes compared to non-diabetics. About 10% of patients will have residual shoulder stiffness and disability. After arthroscopic surgery, there is a gradual improvement in symptoms with slow recovery. However, postoperative physical therapy is a must after surgery to ensure recovery.<ref>Lamplot JD, Lillegraven O, Brophy RH. Outcomes From Conservative Treatment of Shoulder Idiopathic Adhesive Capsulitis and Factors Associated With Developing Contralateral Disease. Orthop J Sports Med. 2018;6:2325967118785169</ref><ref>Oderuth E, Ali M, Atchia I, Malviya A. A double blind randomised control trial investigating the efficacy of platelet rich plasma versus placebo for the treatment of greater trochanteric pain syndrome (the HIPPO trial): a protocol for a randomised clinical trial. Trials. 2018;19:517</ref>
 =What would Codman have thought about this?=

@@ Line 86: / Line 86: @@
 == Prognosis ==
-The duration of AC is from 1 to 3.5 years with a mean of 30 months. In about 15% of patients, the contra-lateral shoulder becomes affected within 5 years.
+The duration of frozen shoulder is from 1 to 3.5 years with a mean of 30 months. In about 15% of patients, the contra-lateral shoulder becomes affected within 5 years.
 == Complications ==