s d ito, t Di ated shoulder that is treated by a variety of medical specialists physiatrists. However, it is also one of the most poorly shows 3,586 references when the search terms ‘‘frozen of a specific definition of this condition makes it difficult to compare the results of modalities for this condition. that have been used by different authors. On the basis of d e w Surgeons (ASES). At that time, there were 128 members of the organization and 112 responded to our survey. Many members provided additional comments to the questions that were asked. At that time, we elected to consider this feedback and to repeat the survey at a later time, after the *Reprint requests: Joseph D. Zuckerman, MD, Department of Ortho- paedic Surgery, NYU Hospital for Joint Diseases, 301 E 17th St, 14th Floor, New York, NY 10003. E-mail addre J Shoulder Elbow Surg (2011) 20, 322-325 1058-2746/$ - s doi:10.1016/j.jse ss:
[email protected] (J.D. Zuckerman). shoulder’’ were used. Further review of the literature indicates that there is an absence of a specific definition of frozen shoulder, and as such, it has not been classified into this review, we developed a preliminary classification an definition of frozen shoulder. We previously surveyed th membership of the American Shoulder and Elbo understood shoulder conditions. A Medline search of the National Library of Medicine Citations from 1966-2008 We performed an extensive literature review of frozen shoulder in an effort to determine the specific definitions including orthopaedic surgeons, rheumatologists, and different studies that describe either diagnostic or treatment for this common condition. Materials and methods: We asked 211 clinician members of the American Shoulder and Elbow Surgeons to review our proposed definition of FS and its classification into primary and secondary types. Secondary FS was further divided into intrinsic, extrinsic, and systemic types. The survey required responses to 5 specific questions via an analog scale (1, strongly disagree; 5, strongly agree). Agreement was defined as a 4 or 5 on the analog scale. Results: We received 190 responses (90%). Eighty-two percent agreed with the proposed definition of FS. Eighty-five percent agreed that FS should be divided into primary and secondary types. Sixty-six percent agreed with subdivision of secondary FS into intrinsic, extrinsic, and systemic types. Eighty-four percent agreed that there was a clinical entity of primary or idiopathic FS. Eighty-five percent agreed that obtaining a consensus definition and classification of FS was a worthwhile endeavor. Discussion: Significant benefits can be gained from the development of a standard definition and classi- fication of FS, achieved through a consensus of shoulder specialists, that provides a strong foundation for potential acceptance by all musculoskeletal specialists who treat this condition. Level of evidence: Basic Science Survey Study. � 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Frozen shoulder; intrinsic, extrinsic and systematic types; primary or idiopathic FS Frozen shoulder is a common condition affecting the different subtypes. The absence physicians caring for musculoskeletal problems. However, there is no standard definition and classification Frozen shoulder: a consensu Joseph D. Zuckerman, MD*, Andrew Rok Department of Orthopaedic Surgery, NYU Hospital for Join Introduction: Frozen shoulder (FS) is a common diagnosis tre ee front matter � 2011 Journal of Shoulder and Elbow Surgery .2010.07.008 efinition MD seases, New York, NY, USA by orthopaedic surgeons and other www.elsevier.com/locate/ymse Board of Trustees. unremarkable except for the possible presence of osteopenia or calcific tendonitis (Figure 1). Frozen shoulder 323 Classification: We used the following classification: A. Primary: Primary frozen shoulder is considered a diagnosis for all cases for which an underlying etiology or associated condition cannot be identified (as specified for the secondary types). B. Secondary: The secondary types of frozen shoulder include all cases of frozen shoulder in which an underlying etiology Society had grown and become more international in its membership. As a result, the survey was redone to increase the number of participating shoulder specialists. We now report the results of the follow-up survey and, based on these results, propose a definition and classification for frozen shoulder that reflects the consensus of our survey of the membership of ASES. Materials and methods Surveys were sent by standard mail to 211 clinician members of ASES. Three weeks after the initial mailing, a second survey was sent to those members who had not responded in an effort to maximize the response. A third mailing was sent a further 3 weeks later to all nonresponders for the same reason. Proposed definition and classification Definition: Frozen shoulder is a condition characterized by functional restriction of both active and passive shoulder motion for which radiographs of the glenohumeral joint are essentially Classification: Frozen Shoulder Primary Secondary )cihtapoidi( Systemic Extrinsic Intrinsic rotator cuff tendinitis impingement biceps tendinitis calcific tendinitis Figure 1 Proposed classification of frozen shoulder. or associated condition can be identified. This is further subdivided into 3 categories. 1. Intrinsic: This category includes limitation of active and passive range of motion that occurs in association with rotator cuff disorders (tendonitis and partial- or full- thickness tears), biceps tendonitis, or calcific tendonitis (in the case of calcific tendonitis, an acceptable radio- graphic finding would include calcific deposits within the subacromial space/rotator cuff tendons). 2. Extrinsic: Cases in this category are those in which there is an association with an identifiable abnormality remote to the shoulder itself. Examples would include limitation of active and passive motion found in association with previous ipsilateral breast surgery, cervical radiculopathy, chest wall tumor, previous cerebrovascular accident, or more local extrinsic problems, including previous humeral shaft fracture, scapulothoracic abnormalities, acromio- clavicular arthritis, or clavicle fracture. 3. Systemic: These cases occur in association with systemic disorders, including but not limited to diabetes mellitus, hyperthyroidism, hypothyroidism, hypoadrenalism, or any other condition that has been documented to have an association with development of frozen shoulder. After reading this proposed definition and classification system, each ASES member was asked to respond to 5 specific questions as follows: Question 1: Do you agree with the proposed definition of frozen shoulder? Question 2: Do you agree that frozen shoulder should be divided into primary and secondary types? Question 3: Is the division of secondary types into intrinsic, extrinsic, and systemic appropriate? Question 4: Do you feel there is truly a primary or idiopathic frozen shoulder? Question 5: Do you feel that obtaining a consensus definition and classification of frozen shoulder is a worthwhile endeavor? For each question, respondents were asked to indicate their level of agreement or disagreement using a Likert scale as follows: 1, strongly disagree; 2, disagree; 3, no opinion; 4, agree; and 5, strongly agree. Responses to each question were tabulated, and a mean score was calculated. Results We sent 211 questionnaires to the clinician members of ASES. Those members who were primarily involved in basic science research and were not clinicians were not included in this survey. Of the 211 members who received the survey, 138 responded to the first mailing, 36 responded to the second mailing, and 16 responded to the third mailing, for a total of 190 responses and a response rate of 90%. Not all of the questions had been answered on some of the returned questionnaires. This represented a small number of questionnaires as follows: for question 1, 6 questionnaires did not include answers; for questions 2 and 3, 3 questionnaires did not include answers; and for ques- tions 4 and 5, 2 questionnaires did not include answers. The results for each of the 5 questions that were included in the questionnaire are summarized in Table I. Question 1 asked, ‘‘Do you agree with the proposed definition of frozen shoulder?’’ Of the 184 members who answered this question, 82% either agreed or strongly agreed with the definition of frozen shoulder; 13% either disagreed or strongly disagreed with the definition of frozen shoulder. The mean score for question 1 was 4.08. Question 2 asked, ‘‘Do you agree that frozen shoulder should be divided into primary and secondary types?’’ Of the 187 members who responded to this question, 85% agreed with this approach; 11%either disagreed or strongly disagreed with this approach. The mean score for question 2 was 4.38. ee 61 3 15% 66% 3.80 129 2 6% 84% 4.44 324 J.D. Zuckerman, A. Rokito Question 3 asked, ‘‘Is the division of secondary types into intrinsic, extrinsic, and systemic appropriate?’’ Of those members who responded, 66% either agreed or strongly agreed with this approach; 15% of those responding disagreed or strongly disagreed. This question had the highest number of ‘‘neutral’’ responses, represent- ing 19% of respondents. The mean score for question 3 was Table I Summary of responses to questionnaire Question Response 1: Strongly disagree 2: Disagree 3: No opinion 4: Agr 1 (n ¼ 184) 3 21 9 77 2 (n ¼ 187) 5 16 7 29 3 (n ¼ 187) 7 22 34 63 4 (n ¼ 188) 5 7 18 29 5 (n ¼ 188) 7 4 18 72 Table II Number and nature of written comments Question Total written comments No. of positive comments No. of negative comments 1 18 15 3 2 21 19 2 3 29 22 7 4 19 14 7 5 7 7 0 3.80. Question 4 asked, ‘‘Do you feel there is truly a primary or idiopathic frozen shoulder?’’ Of those responding, 84% agreed or strongly agreed with this statement; 6% disagreed or strongly disagreed. The mean score for question 4 was 4.44. Question 5 asked, ‘‘Do you feel that obtaining a consensus definition and classification of frozen shoulder was a worthwhile endeavor?’’ Of those responding, 85% agreed or strongly agreed with this statement; 6% disagreed or strongly disagreed. The mean score for question 5 was 4.21. Included in the questionnaire was the opportunity for respondents to ‘‘provide any additional comments.’’ Of the 190 returned questionnaires, 48 questionnaires included written comments. The total number of comments on these 48 questionnaires totaled 94. These comments were divided into different categories based on the specific questions asked and whether the comments were supportive/positive or nonsupportive/negative. The results are summarized on Table II. The vast majority (82%) of the comments were supportive/positive. The comments covered the complete wide spectrum, and there were no specific areas that received significant emphasis. Discussion Since Duplay7 described painful stiffening of the shoulder, which he termed ‘‘humeroscapular periarthritis,’’ many articles and chapters have been published that address the definition, etiology, clinical presentation, and treatment of frozen shoulder.1-25 The review of a selected number of these articles,1-13,15-22,24,25 as well as textbooks,14,23 indi- cates a lack of a consistent definition of frozen shoulder/ adhesive capsulitis. Faced with this problem, we believed it would be helpful to develop a definition and classification of frozen shoulder/adhesive capsulitis (Figure 1) and then attempt to develop a consensus among a large number of shoulder specialists. The justification for this is clear: a consensus definition and classification would allow investigators to more consistently define the clinical problem being treated and to determine effective treatment approaches and also allow investigators to compare treat- ment results knowing with greater certainty that a specific patient group is being treated. The level of agreement for the questions asked was quite good for question 1 (4.04), question 2 (4.38), question 4 (4.44), and question 5 (4.21). Question 3 (‘‘Is the division of secondary types into intrinsic, extrinsic, and systemic appropriate?’’) showed the lowest level of agreement, at 3.80, but still indicated a consensus, with 66% of respondents agreeing or strongly agreeing and only 15% disagreeing or strongly disagreeing. A classification system has to be relatively simple and easy to use, as well as reproducible with satisfactory intraobserver and intraobserver reliability. Our initial 87 2 6% 85% 4.21 a d fi 130 3 11% 85% 4.38 Percent 1 or 2 Percent 4 or 5 Mean score 5: Strongly agree No response 74 6 13% 82% 4.08 nalysis of reliability has shown good results, yet sufficient ata are not available to confirm this aspect of the classi- cation. There is clearly a limitation of this exercise. Conclusion The true value of the classification system can only be determined when it is used, and time will tell whether this classification system will be used. However, our goal in using this consensus approach was to obtain the valuable input of shoulder specialists so that the classification proposed would be more readily accepted and used. Time will determine whether we have been successful. Acknowledgments We acknowledge the contributions of Arash Araghi, DO, and Frances Cuomo, MD, and the editorial assistance of Jim Madden. Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not received anyfinancial payments or other benefits from any 8. Farrell CM, Sperling JW, Cofield RH. Manipulation for frozen shoulder: long term results. J Shoulder Elbow Surg 2005;14:480-4. doi:10.1016/j.jse.2005.02.012 9. Grey RG. The natural history of ‘‘idiopathic’’ frozen shoulder. J Bone Joint Surg Am 1978;60:564. 10. Griggs SM, Ahn A, Green A. Idiopathic adhesive capsulitis. A prospective functional outcome study of nonoperative treatment. J Bone Joint Surg Am 2000;82:1398-407. 11. Hand C, Clipsham K, Rees JL, Carr AJ. Long-term outcome of frozen shoulder. J Shoulder Elbow Surg 2008;17:231-6. doi:10.1016/j.jse. 2007.05.009 12. Hand CG, Athanasui NA, Matthews T, Carr AJ. The pathology of frozen shoulder. J Bone Joint Surg Br 2007;89:928-32. doi:10.1302/ 0301-620X.89B7.19097 13. Hazleman BD. The painful stiff shoulder. Rheumatol Phys Med 1972; 11:413-21. doi:10.1093/rheumatology/11.8.413 14. Iannotti JP, Williams GR. Disorders of the shoulder: diagnosis and management. Philadelphia: Lippincott Williams & Wilkins; 2007. 15. Levine W, Kashyap CP, Bak SF, Ahmad C, Blaine T, Bigliani L. Nonoperative management of idiopathic adhesive capsulitis. J Shoulder Elbow Surg 2007;16:569-73. doi:10.1016/j.jse.2006.12.007 16. Lippman RK. Frozen shoulder: periarthritis: bicipital tenosynovitis. Frozen shoulder 325 commercial entity related to the subject of this article. References 1. Baslund B, Thomsen BS, Jensen EM. Frozen shoulder: current concepts. Scand J Rheumatol 1990;19:321-5. doi:10.3109/03009749009096786 2. Binder A, Bulgen DY, Hazleman BL. Frozen shoulder: a long-term prospective study. Ann Rheum Dis 1984;43:361-4. doi:10.1136/ard. 43.3.361 3. Bridgman JF. Periarthritis of the shoulder and diabetes mellitus. Ann Rheum Dis 1972;31:69-71. doi:10.1136/ard.31.1.69 4. Codman EA. The shoulder: rupture of the supraspinatus tendon and other lessons in and about the subacromial bursae. Boston: privately printed; 1934. 5. DePalma AF. Loss of scapulohumeral motion (frozen shoulder). Ann Surg 1952;135:193-204. doi:10.1097/00000658-195202000-00005 6. Dickson JA, Crosby EH. Periarthritis of the shoulder: analysis of 200 cases. JAMA 1932;99:2252-7. 7. Duplay S. De la pe´ri-arthrite scapulo-hume´rale et des raideurs de l’e´paule qui en sont la consequence. Arch Gen Med 1872;20:513-4. Arch Surg 1943;47:283-96. 17. Lorbach O, Anagnostakos K, Scherf C, Seil R, Kohn D, Pape D. Nonoperative management of adhesive capsulitis of the shoulder: oral cortisone application versus intra-articular cortisone injections. J Shoulder Elbow Surg 2010;19:172-9. 18. McLaughlin HL. On the ‘‘frozen shoulder.’’ Bull Hosp Jt Dis Orthop Inst 1951;12:383-93. 19. Nevaiser JS. Adhesive capsulitis of the shoulder: study of pathological findings in periarthritis of the shoulder. J Bone Joint Surg 1945;27: 211-22. 20. Neviaser RJ, Nevaiser TJ. The frozen shoulder: diagnosis and management. Clin Orthop Relat Res 1987;223:59-64. doi:10.1097/ 00003086-198710000-00008 21. Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol 1975;4:193-6. doi:10.3109/03009747509165255 22. Rizk TE, Pinals RS. Frozen shoulder. Semin Arthritis Rheum 1982;11: 440-52. doi:10.1016/0049-0172(82)90030-0 23. Rockwood C, Matsen F, Wirth M, Lippitt S. The shoulder. 4th Ed. Philadelphia: Saunders; 2009. 24. Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder long term follow- up. J Bone Joint Surg Am 1992;74:738-46. 25. Wohlgethan JR. Frozen shoulder in hyperthyroidism. Arthritis Rheum 1987;30:936-9. doi:10.1002/art.1780300815 Frozen shoulder: a consensus definition Materials and methods Proposed definition and classification Results Discussion Conclusion Acknowledgments Disclaimer References