Dr. Ammerman is an intern and on her general surgery rotation, so I am presenting in her place. We have no disclosures that are relevant to this talk. So there have been multiple published studies on the treatment options for adhesive capsulitis, and we know that it's both an inflammatory and fibrosing condition that is dependent on the stage of disease. The pathophysiology supports the rationale for an interarticular corticosteroid injection to treat the synovial inflammation that's seen in the early stages of disease, the stage one and stage two patients. What we know also is that most studies that have been published have failed to stratify the cohorts based on the stage of their disease in their outcomes analysis, which may affect the understanding of the results of the intervention. Stage one disease of adhesive capsulitis is characterized by synovial inflammation and a lack of significant scar formation, and you can see in these pictures on the right the lymphocytic infiltration, but also normal capsular tissue, whereas stage two disease also has synovial inflammation, but it does have a thickened capsule and synovial scar formation, and we know that this scar formation is generally related to the duration of symptoms, so as the patients have longer course of their disease, they develop a thicker scar capsule. The corticosteroid injection is what chemically ablates the synovitis, which then allows for PT or home exercise program to help resolve the thickened capsule. So the hypothesis of this study was that an interarticular ultrasound-guided glenohumeral injection of corticosteroid in patients with stage one or stage two idiopathic adhesive capsulitis would result in timely functional recovery and resolution of pain and stiffness. We also hypothesized that the stage one patients would have a faster recovery of their range of motion, and that the duration of symptoms prior to the injection would correlate with the time to recovery of their range of motion. So our methods, all patients were seen by a single physician, our senior author, and diagnosed using history and physical exam. Stage one disease was diagnosed as patients with night pain or rest pain, and pain with passive range of motion, mostly seen in external rotation, and then stage two patients exhibited the same characteristics as the stage one patients, except they had additional stiffness at the end of their range of motion. The interarticular injection was five cc's of one percent lidocaine, three cc's of quarter percent marcaine, and 80 milligrams of depomedrol. And the range of motion measurements which were performed pre- and post-op injection were documented. That included forward flexion, abduction, internal rotation, and external rotation with neutral abduction. The exact time to recovery of their motion was difficult to determine as their follow-up visits varied in time, and improvements in motion may have been seen in different planes of motion more quickly than others. So to account for this variability, the recovery criteria were defined a priori as forward flexion, abduction, or external rotation within 15 degrees of their contralateral side, as well as internal rotation within three spinal levels of their contralateral side. There were 61 patients included in the study. Their average age was 55 years. Eighty percent of the patients were female, 18 percent of them had concomitant thyroid disease, and three percent had concomitant diabetes. There were 11 patients in the stage one cohort, and the average length of their days of symptoms was 68 days, and there were 50 patients in the stage one cohort with an average duration of symptoms of 141 days. The recovery percentages for patients in the stage one was 100 percent of patients recovered their forward flexion and internal rotation, 91 percent of patients recovered their abduction, and 73 recovered their external rotation. This was done in a quick time period we see here, ranging from 11 days to 26 days. For the stage two patients, there was a much lower rate of recovery of the range of motion, and the range of days to recovery was much broader, and we think that this reflects the heterogeneity of the patients in the stage two with respect to their time of symptoms. If we compare the time to recovery for stage one versus stage two patients, they were all statistically significantly different, and the time to recovery for stage one was between two to six weeks, and the time to recovery for stage two was between seven to ten weeks. In conclusion, what this study shows is that the stage one patients demonstrate rapid recovery of their range of motion if the ultrasound guided glenohumeral injection was performed early following the onset of pain and stiffness, and that the recovery in stage two was more variable and based on the duration of symptoms prior to their injection. We know that in stage two, injection can still be helpful to eliminate pain because it chemically ablates the synovitis, and therefore permits the physical therapy or the home exercise program to treat the levels of capsular fibrosis. And what's most important and what we try to identify in this study is that it's very important to distinguish the stage of disease when you're reporting the efficacy of intervention for adhesive capsulitis, and we think that this will help in the future in larger studies to show that the efficacy of ultrasound guided glenohumeral injection, and we think future studies should report stages of disease. The limitations are that we had a retrospective analysis of data, and it was a single investigator. There was no control group, as the senior author offered an injection to all patients who presented with stage one or two adhesive capsulitis. We did have some loss to follow-up. There were 10 patients in stage one and two in stage two that did not return, and we hypothesized that this is because they had complete resolution of their symptoms in a very early time period, and that there was no definitive recovery as defined by specific arcs of motion. And lastly, the varying intervals of follow-up, which impacted our data, but we did find that this was done at a consistent level throughout the cohort. Thank you very much. Thank you.

adhesive capsulitis

frozen shoulder

treatment options

corticosteroid injections

ultrasound-guided injections