|Year : 2021 | Volume
| Issue : 2 | Page : 50-53
A comparative study on the association of hypothyroidism with adhesive capsulitis of shoulder
AD Greeshma, Ravi Sankaran, Narikunnel G Joseph, Kutickat Surendran
Department of Physical Medicine and Rehabilitation, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
|Date of Submission||14-May-2021|
|Date of Acceptance||22-May-2021|
|Date of Web Publication||09-Aug-2021|
Dr. Narikunnel G Joseph
Department of Physical Medicine and Rehabilitation, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala.
Source of Support: None, Conflict of Interest: None
Objective: Adhesive capsulitis (AC) is a pathologic condition characterized by pain and limitation of shoulder movements. Thyroid dysfunction often accompanies musculoskeletal disorders, and undiagnosed hypothyroidism can delay response to treatment outcomes. Early diagnosis and treatment of hypothyroidism in patients with AC of shoulder could help to improve pain and disability. This study was done to assess the association of hypothyroidism with AC of shoulder and to find the correlation of severity of pain and disability in AC with hypothyroidism. Materials and Methods: In this case–control study, patients who attended PMR OPD during a period of 2 years with pain and limitation of shoulder movements satisfying the inclusion and exclusion criteria were included as cases and patients without AC as controls. Fifty-seven patients were selected as cases and 114 patients as controls. Serum thyroid-stimulating hormone (TSH) level and free tetraiodothyronine level were estimated. Shoulder range of motion (ROM) measurement and radiographs were performed in cases, and the TSH values obtained were compared with the severity of ROM restriction, Visual Analog Scale score, and Shoulder Pain and Disability Index Scale (SPADI) score. Statistical analysis was done using IBM SPSS 20 (SPSS Inc., Chicago, IL, USA). Results: Among cases, 8 (14%) patients had hypothyroidism and 16 (28.1%) had subclinical hypothyroidism, and among controls, 4 (3.5%) had hypothyroidism and 9 (7.9%) had subclinical hypothyroidism. Among the 24 patients with elevated TSH, 16 (66.6%) had mild-to-moderate pain and 8 (33.3%) had severe pain. Mean TSH was elevated in patients with severe pain compared with those with mild-to-moderate pain (5.43 ± 2.31 vs. 3.35 ± 2.48 µIU/mL, P = 0.031). TSH levels showed a positive correlation with SPADI pain score (r =0.335, P = 0.011) and SPADI disability score (r = 0.375, P = 0.004), respectively. There was significant restriction in ROM in patients with higher TSH levels (P < 0.001). Conclusion: Patients with AC have higher prevalence of hypothyroidism and subclinical hypothyroidism compared with those who did not. Patients with higher TSH levels had more severe pain, restriction of movement, and overall disability when compared with euthyroid patients. Proper management of hypothyroidism along with the standard measures of management may result in more speedy relief from symptoms and recovery of function in these patients.
Keywords: Adhesive capsulitis, frozen shoulder, hypothyroidism, ROM, SPADI
|How to cite this article:|
Greeshma A, Sankaran R, Joseph NG, Surendran K. A comparative study on the association of hypothyroidism with adhesive capsulitis of shoulder. Amrita J Med 2021;17:50-3
|How to cite this URL:|
Greeshma A, Sankaran R, Joseph NG, Surendran K. A comparative study on the association of hypothyroidism with adhesive capsulitis of shoulder. Amrita J Med [serial online] 2021 [cited 2021 Dec 9];17:50-3. Available from: https://www.ajmonline.org.in/text.asp?2021/17/2/50/323549
| Introduction|| |
Adhesive capsulitis (AC), also known as “frozen shoulder,” is characterized by painful restriction of shoulder range of motion (ROM) in patients with normal radiographs. AC occurs in approximately 2–5% of the general population. It is two to four times more common in women than in men and most frequently seen in individuals between 40 and 70 years of age. AC is more common among diabetic patients. It is proposed that inflammation is an important event that leads to stiffness, pain, and capsular fibrosis. Joint capsule and coracohumeral ligament of patients with AC show active fibrotic proliferation accompanied by some transformation to myofibroblast and inflammation of synovial membrane.
The condition was first described as periarthritis by Duplay in 1872, later termed as frozen shoulder by Codman in 1934 and as AC by Neviesar in 1945.
Thyroid diseases are among the commonest endocrine disorders worldwide. It is estimated that about 42 million people in India suffer from thyroid diseases. Clinical hypothyroidism is present in around 4% of the general population, whereas another 9% have subclinical hypothyroidism. Many studies have pointed out the association between hypothyroidism and AC. It is found that the prevalence of hypothyroidism in patients with AC is much more than that in the general population. It is possible that hypothyroidism may play an important role in the causation as well as influencing the severity of symptoms in AC.
Understanding the association of AC and hypothyroidism is important in guiding physicians who manage these patients. It may guide research studies evaluating interventions in AC. Furthermore, understanding the relationship between AC of shoulder and hypothyroidism may provide further insights into the pathogenesis of AC. It may also be important to control hypothyroidism to reduce the severity of symptoms as well as speeding up the recovery in these patients. This study aims to understand the relationship between hypothyroidism and AC.
The primary objective was to estimate the prevalence of hypothyroidism in patients with and without AC attending the PMR OPD. The secondary objective was to look for any association between the thyroid-stimulating hormone (TSH) levels and severity of symptoms in patients with AC.
| Materials and Methods|| |
It was designed as a cross-sectional comparative study to compare the prevalence of hypothyroidism in AC patients with that in the local population without AC and to see whether elevated TSH levels in AC patients have a bearing on the severity of pain and shoulder restriction. Based on the results observed in an earlier publication on the prevalence of hypothyroidism in patients with AC of shoulder (27.2%) and in patients without AC of shoulder (10.7%) and with 95% confidence interval and 80% power and with the odds ratio of 1 (case): 2 (controls), the minimum sample size was calculated as 57 patients and 114 controls. The duration of the study was 2 years, and the study period was September 2017 to August 2019.
Patients with AC of the shoulder in the age group of 40–70 years were included in the study. AC is defined as painful restriction of shoulder movements with no other detectable local pathology and with normal shoulder radiographs.
Patients with history of previous fracture or surgery at or near the shoulder joint, clinical and radiographic evidence of arthritis of the shoulder, impingement syndrome, hemiplegic shoulder pain, supraspinatus calcific tendonitis, rotator cuff tear, chronic regional pain syndrome, various rheumatological conditions, cardiac disease, and other significant chronic diseases were excluded from the study.
The study was conducted in the Department of PMR, AIMS, Kochi, after obtaining institutional dissertation protocol review (scientific and ethical) committee approval [No. IRB-AIMS-2018–228] on September 18, 2018. Cases were selected from the patients attending the Department of PMR with AC and satisfying the inclusion criteria. Controls were selected from those without AC. Informed consent was obtained. Patient’s identity such as name, address, and MRD number were kept confidential.
All cases were evaluated with detailed case history and complete physical examination of the shoulders. The range of movement of shoulder in abduction, external rotation, and internal rotation was assessed. External rotation and abduction were measured using a goniometer, and internal rotation was determined by counting the vertebral levels reached with the dorsum of hand.
Restriction in ROM was graded as mild, moderate, and severe according to the criteria proposed by Checchia et al. Based on this criterion, restriction in the level of elevation when compared with the normal side was considered. Passive elevation <50% is considered as severe restriction, 50–75% as moderate restriction, and >75% as mild restriction. Disability was measured using Shoulder Pain and Disability Index scale (SPADI). Pain was assessed with Visual Analog Scale (VAS) and categorized as mild pain (0–3), moderate pain (4–6), and severe pain (7–10). Anteroposterior X-ray of shoulder was taken in all patients diagnosed to have AC. Blood samples were also collected from all patients to determine blood levels of TSH and free tetraiodothyronine (fT4). Reference values for TSH and fT4 were 0.27–4.2 mIU/L and 1.0–1.6 ng/dL, respectively. The results of TSH obtained were compared with the severity of ROM restriction, VAS score, and SPADI score.
Statistical analysis was done using IBM SPSS 20 (SPSS Inc., Chicago, IL, USA). For all the continuous variables, the results are given as mean ± SD and for categorical variables as percentage. To obtain the association of categorical variables between the groups, χ2 test was applied. To test the statistical significance of difference in mean TSH level with respect to age group and VAS score group in patients with AC of shoulder, Student’s t-test was applied. To test the significant correlation of TSH levels with SPADI pain score, SPADI disability score, and total SPADI score, Pearson’s correlation coefficient was applied. A P-value less than 0.05 was considered statistically significant.
| Results|| |
Our study was conducted on 57 cases and 114 controls. Among cases who were included in the study, 15 (26.3%) were males and 42 (73.7%) were females and in the control group, 46 (40.4%) were males and 68 (59.6%) were females. Among the 57 cases,16 (28.1%) had subclinical hypothyroidism, 8 (14%) had clinical hypothyroidism, 30 (52.6%) patients were euthyroid, 2 (3.5%) had subclinical hyperthyroidism, and 1 (1.8%) had hyperthyroidism. Among the 114 controls, 9 (7.9%) had subclinical hypothyroidism, 4 (3.5%) had clinical hypothyroidism, 97 (85.1%) were euthyroid, and 4 (3.5%) had subclinical hyperthyroidism [Table 1].
[Table 2] shows the relationship between TSH levels and the severity of pain as assessed by VAS score. Thirty-three patients with AC had normal or low TSH levels, of which 31 (93.93%) had mild-to-moderate pain, whereas 2 (6.07%) had severe pain. Among the 24 patients with elevated TSH, 16 (66.6%) had mild-to-moderate pain and 8 (33.3%) had severe pain.
|Table 2: Relation between TSH level and VAS score in patients with AC of shoulder|
Click here to view
[Table 3] represents the comparison of mean TSH level with VAS score in the patients. The mean TSH value in patients with mild-to-moderate pain (VAS score 0–6) was 3.35 ± 2.48 and in severe pain (VAS score 7–10) it was 5.43 ± 2.31. The comparison was statistically significant (P = 0.031). It was found that the patients with severe pain had a higher mean TSH value when compared with patients with mild-to-moderate pain.
|Table 3: Comparison of mean TSH levels with VAS score in patients with AC of shoulder|
Click here to view
[Table 4] as well as [Graph 1] shows the relation between severity of ROM restriction and TSH levels. Out of the 57 cases, 24 had elevated TSH levels and 30 had TSH in the normal range. Among the 30 patients with normal TSH, 25 (83.3%) had mild ROM restriction and 5 (16.7%) had moderate-to-severe restriction. Among the 24 patients with elevated TSH level levels, 7 (29.2%) had mild restriction in ROM, whereas 17 (70.8%) had moderate-to-severe restriction.
|Table 4: Association of severity of ROM restriction and TSH levels in AC patients|
Click here to view
|Graph 1: Association of severity of ROM restriction and TSH levels in patients with AC|
Click here to view
A statistically significant moderate positive correlation was noticed between TSH levels and SPADI pain score and SPADI disability score with correlation coefficient r =0.335 (P = 0.011) and r = 0.375 (P = 0.004), respectively. [Graph 2] represents the relation between TSH levels and total SPADI score, which shows a moderate positive correlation coefficient (r = 0.394).
| Discussion|| |
Our study compares the prevalence of hypothyroidism including subclinical hypothyroidism in patients with AC of shoulder (cases) with that in the local population without AC (controls) and also tries to find its association with disease severity.
Out of the 57 patients included in the study, 24 (42.1%) had either clinical or subclinical hypothyroidism, whereas it was only 13 among the 114 controls that make an incidence of just 11.4%. These results show a significant association between AC and hypothyroidism. According to a recent study conducted among adult population in India and published in Indian Journal of Endocrinology and Metabolism by Unnikrishnan and Menon, the prevalence of hypothyroidism has been estimated to be 3.9% and that of subclinical hypothyroidism was 9.4%, making a total of 13.3%. The present study also shows similar prevalence in the control group.
The association between TSH levels and intensity of pain was assessed by VAS score. Among the 33 patients with low or normal TSH, 31 (93.93%) had mild-to-moderate pain and only 2 (6.07%) had severe pain, whereas 16 (66.6%) of the 24 patients with elevated TSH had mild-to-moderate pain while 8 (33.3%) had severe pain (P = 0.02). This indicates that the TSH levels may have a direct relation with the intensity of pain in these patients.
The mean TSH level was also found to have a direct relation with VAS score. The mean TSH value in patients with mild-to-moderate pain was 3.35 ± 2.48 and that in patients with severe pain was 5.43 ± 2.31 (P = 0.031). This again indicates a strong association between elevated TSH level and severity of pain.
We also noticed an association between the severity of ROM restriction and TSH levels. Among the 24 patients with elevated TSH levels, 17 (70.8%) had moderate-to-severe restriction, whereas it was only 5 (16.7%) among the 30 patients with normal TSH. This association is statistically significant with P-value <0.001. In other words, patients with high TSH levels tend to have more severe restriction of ROM.
Another observation was a direct relation between TSH levels and SPADI pain and disability scores. The total SPADI score showed a moderate positive correlation coefficient (r = 0.394), which was found to be statistically significant with a P-value of 0.002.
These observations indicate the need for evaluation of thyroid function in all patients presenting with AC.
Our study has a few limitations. The number of patients studied is relatively small, and a study involving a larger population may establish a more relevant relation between the two conditions. Other comorbidities such as diabetes, hypertension, etc. were not taken into account while analyzing the data. These comorbidities may also have influence on the severity of symptoms in these patients.
In conclusion, the present study indicates a higher prevalence of hypothyroidism in patients with AC in comparison with people without and also detects a significant association between TSH levels and severity of symptoms. Patients with higher TSH levels tend to have more pain and limitation of shoulder movement.
TSH estimation should be made a routine investigation like blood sugar in those with AC. Appropriate management of hypothyroidism, if detected, may speed up recovery in these patients and also may lead to better control of symptoms.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tamai K, Akutsu M, Yano Y Primary frozen shoulder: Brief review of pathology and imaging abnormalities. J Orthop Sci 2014;19:1-5.
Armstrong A Diagnosis and clinical assessment of a stiff shoulder. Shoulder Elbow 2015;7:128-34.
D’Orsi GM, Via AG, Frizziero A, Oliva F Treatment of adhesive capsulitis: A review. Muscles Ligaments Tendons J 2012;2:70-8.
Unnikrishnan AG, Menon UV Thyroid disorders in India: An epidemiological perspective. Indian J Endocrinol Metab 2011;15:S78-81.
Michael W, O’Dell C, Lin D, Christolias GC. The psychiatric history and physical examination. In: Cifu D, editor. Braddom’s Physical Medicine and Rehabilitation. 5th ed., Philadelphia, PA: Elsevier; 2016. p. 1-39.
Checchia SL, Santos PD, Martinez E, Garcia S CM, Leal H. Tratamento da Capsulate Adesiva do ombro pelo bloqueio do nervo supraescapular associado ao uso de corticoide. Rev Bras Ortop1994;29:627-34.
Tveitå EK, Ekeberg OM, Juel NG, Bautz-Holter E Responsiveness of the shoulder pain and disability index in patients with adhesive capsulitis. BMC Musculoskelet Disord 2008;9:161.
Manske RC, Prohaska D Diagnosis and management of adhesive capsulitis. Curr Rev Musculoskelet Med 2018;1:180-9.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]