Female sex, age over 40, HLA-B27 positive, prior trauma, and extended immobilization of the glenohumeral joint are all risk factors for adhesive capsulitis. 70% of individuals with sticky shoulder capsulitis are women, according to estimates. Men also do not respond to therapies as effectively as women do. According to demographic research, the majority of individuals with adhesive capsulitis (84.4%) are between the ages of 40 and 59. A recent meta-analysis by Prodromidis and Charalambous revealed a genetic tendency to adhesive capsulitis, with white patients, patients with a positive family history, and patients with HLA-B27 positivity showing a higher predilection for this ailment.
Diabetes, thyroid illness, cerebrovascular disease, coronary artery disease, autoimmune disease, and Dupuytren's disease are all linked to adhesive capsulitis. Adhesive capsulitis is more common in diabetic people with type I and type II diabetes, with prevalence rates of 10.3 percent and 22.4 percent, respectively [6]. In comparison to nondiabetic individuals with adhesive capsulitis, diabetic patients with adhesive capsulitis had inferior functional results. Patients with hyperthyroidism have 1.22 times the chance of getting adhesive capsulitis than the general population, according to a countrywide population-based study done by Wei et al. Patients with cerebrovascular disease, particularly those surgically treated for subarachnoid hemorrhage, are more likely to develop adhesive shoulder capsulitis; in one prospective study of this high-risk group, 23 of 91 patients (25.3 percent) developed adhesive shoulder capsulitis within six months [7].
Dupuytren's disease was observed in 52 percent of patients (30 of 58) with adhesive capsulitis, according to a study. Although the prevalence of adhesive capsulitis is higher in patients with the above-mentioned disorders, more research is needed to understand why these associations arise [8].
The association of frozen shoulder with hyperlipidemia can be due to high lipids in diseases such as diabetes, epilepsy, alcoholism, heart disease and the prevalence of frozen shoulder in these pathologies. Some studies have cautiously hypothesized the association of frozen shoulder with autoimmune diseases.
In a study by Gumina et al., who looked at the relationship between blood tests and CSs in the first phase of the disease, about 56 patients who were treated conservatively at the first visit in the first phase of the disease were evaluated for their requested tests and CS, then after 4 months the tests and examinations were repeated. There was no statistically significant relationship between blood parameters of FBS, cholesterol, LDL, triglyceride, fibrinogen, white blood cells, ESR, CRP, rheumatoid factor and constant score. However, in the present study, there was a significant relationship between CRP and constant score (P = 0.02). In the above study, no treatment other than physiotherapy was performed for patients for 4 months to prevent any reduction of inflammatory factors in blood. But after 4 months, a significant inverse relationship was recorded between Constant score and glycemia (P = 007), triglyceride (P = 0.05), ESR (0.017), CRP (0.013) [4]. In the present study, the required treatment was prescribed and recommended according to the condition of each patient and after at least 9 months, only one patient underwent surgery. Due to the low mean score of CS (53.37), a number of patients were expected to undergo surgery, but due to the recovery and relative satisfaction of the patients, only one patient underwent surgery. There was no statistically significant relationship between ESR (P = 0973), CRP (P = 0.977), TG (P = 0.317) and surgery.
The Frozen shoulder inflammatory process hypothesis was confirmed by Bulgen et al. In 1982, who reported high CRP levels in 25% of patients and ESR in 20% of patients with normal lymphocyte counts [9]. In the present study, ESR was reported to be high in 7 patients (24.1%) and CRP in 2 patients (6.9%).
The association between frozen shoulder and blood lipids has been investigated by Bunker and Esler [10]. Because some pathological diseases such as diabetes [11], epilepsy [12], alcoholism [13] and heart disease [14] are more common among people with hyperlipidemia. The authors conclude that hyperlipidemia may be a common strand that binds adhesive capsules to these pathologies. They reported that fasting triglyceride and cholesterol levels were significantly increased in the frozen shoulder group compared with the control group. Unfortunately, they did not mention the percentage of patients with adhesive capsules and hyperlipidemia. Our data also confirms this association, showing that two-thirds and almost half of patients with adhesive capsules have high levels of cholesterol and triglycerides, respectively. Although we have confirmed this relationship, other studies are needed to gain a more accurate understanding of the factors that link the two conditions.
In the study of the effect of hypercholesterolemia on rotator cuff diseases, Abboud et al. Conducted a prospective study that collected serum cholesterol and lipid profiles in two populations of the same age. 74 patients (mean age, 66.3 years) had their rotator cuff tendon ruptured, while a control group of 73 patients (mean age, 67.4 years) was included in the study for shoulder complaints related to non-rotator cuff rupture. Total cholesterol, triglyceride and LDL concentrations were higher in patients with rotator cuff tendon rupture and HDL showed a lower trend than the control group. Forty-seven of 74 patients (63%) with rotator cuff rupture had serum cholesterol (total cholesterol greater than 240 mg/dL) compared with an overall rate of 28% in the control group [15]. In the present study, the mean age of patients was 55.59 years. LDL was observed in 8 patients (27.6%), VLDL in 11 patients (37.9%), triglyceride in 13 patients (44.8%), and cholesterol in 17 patients (58.6%).
Richardt et al. Conducted a cross-sectional study on the association of lifestyle and metabolic factors with shoulder pain and rotator cuff tendinitis in a population of 30 or older who participated in a Finnish national health survey from 2001–2002. Of the 7,977 eligible individuals, 6,237 (78.2%) participated in a structural interview and clinical examination. Chronic rotator cuff tendinitis was diagnosed clinically. Factors related to weight, reactive protein C (CRP) and internal carotid thickness were measured. The prevalence of shoulder joint pain over the past 30 days was 16% and chronic rotator cuff tendonitis was 2.8%. Smoking, waist circumference and waist to pelvic ratio were associated with an increased incidence of shoulder pain in both sexes. Metabolic syndrome, type 2 diabetes, and intimal media carotid thickness were associated with shoulder pain in men, while high CRP levels were associated with shoulder pain in women. Elevated waistline and type 1 diabetes were associated with chronic rotator cuff inflammation in men [16]. In the present study, only 4 patients had type 2 diabetes, of which 3 were female and 1 was male. Because most patients who knew they had diabetes were reluctant to retest, a test was performed on patients who had not been tested in recent years, so a number of diabetics were subconsciously excluded from the study. Also, the mean CRP was not different between the two sexes and had no statistically significant relationship with the sex (P = 0.502).
A case study by Wang et al. in 2022 on two patients with acute brucellosis knee arthritis reported increased levels of CRP and ESR in these patients, without leukocytosis [17]. Park et al. in 2020 investigated the levels of CRP in a group of 202 patients with idiopathic adhesive capsulitis (IAC), along with 606 healthy individuals, finding increased levels of CRP (> 1 mg/L) in these patients, while also suggesting that the level of CRP in IAC was associated with diabetes, FBS, hypertriglyceridemia and hypolipoproteinemia [18]. Aktar et al. in 2016 reported an ESR level of 40.9 ± 20.4 mm/h and a CRP level of 28.1 ± 22.4 mg/L in patients with Brucella arthritis [19]. Similarly, we also detected a statistically significant association among adhesive capsulitis, ESR and CRP, since our patients demonstrated increased levels of these pro-inflammatory markers as well (Table 2).
Table 2
Relationship between Constant shoulder score and paraclinical results.
Blood Values | Minimum | Maximum | Mean | Std. Deviation | Adopted range of normality | P value |
FBS | 83 | 150 | 100.61 | 17.29 | 70–110 mg/dl | 0.78 |
Platelets | 214*103 | 450*103 | 240*103 | 59*103 | 150–450 103/ µl | 0.75 |
WBC | 4.200 | 16.200 | 6.445 | 2.399 | 4–11 103/µl | 0.86 |
Neut. | 1.50 | 7.30 | 3.235 | 1.484 | 2–8 103/µl | 0.75 |
Lymph | 1400 | 3000 | 2119.8 | 418.17 | 0.9–5.2 103/µl | 0.69 |
ESR | 1 | 48 | 16.89 | 13.14 | 0–22 mm/h | 0.07 |
CRP | 0 | 36 | 2.85 | 6.88 | 0–10 mg/L | 0.02 |
LDL | 22 | 195 | 125.96 | 38.11 | 0-150 mg/dl | 0.66 |
VLDL | 11.5 | 120 | 41.60 | 28.65 | 2–30 mg/dl | 0.34 |
TG | 50 | 479 | 160.72 | 100.67 | 30–150 mg/dl | 0.3 |
Cholesterol | 75 | 350 | 216.13 | 62.04 | 0-200 mg/dl | 0.6 |
Fibrinogen | 200 | 472 | 300.26 | 66.09 | 200–400 mg/dl | 0.73 |
RF | 0 | 36 | 4.65 | 8.14 | 0–15 IU/ml | 0.34 |
CSs | 16 | 75 | 53.37 | 15.41 | | |