Of 935 consecutive patients referred with shoulder pain, 50 fitted the criteria for primary frozen shoulder. Twelve patients who failed to improve after conservative treatment and manipulation had excision of the coracohumeral ligament and the rotator interval of the capsule. The specimens were examined histologically, using special stains for collagen. Immunocytochemistry was performed with monoclonal antibodies against leucocyte common antigen (LCA, CD45) and a macrophage/synovial antigen (PGMI, CD68) to assess the inflammatory component, and vimentin and smooth-muscle actin to evaluate fibroblasts and myofibroblasts. Our histological and immunocytochemical findings show that the pathological process is active fibroblastic proliferation, accompanied by some transformation to a smooth muscle phenotype (myofibroblasts). The fibroblasts lay down collagen which appears as a thick nodular band or fleshy mass. These appearances are very similar to those in Dupuytren's disease of the hand, with no inflammation and no synovial involvement. The contracture acts as a check-rein against external rotation, causing loss of both active and passive movement.

We describe an apparently unreported finding during hip operations: a tear at the insertion of gluteus medius and gluteus minimus. This defect may well be known to many surgeons with experience of hip replacement and hemiarthroplasty for fractures of the neck of the femur, but a Medline search has failed to find a previous description. We made a prospective study of 50 consecutive patients with fractures of the neck of the femur to quantify the incidence of this condition: 11 (22%) had such a tear.

F rozen shoulder is a chronic fibrosing condition of the capsule of the joint. The predominant cells involved are fibroblasts and myofibroblasts which lay down a dense matrix of type-I and type-III collagen within the capsule. This subsequently contracts leading to the typical features of pain and stiffness. Cytokines and growth factors regulate the growth and function of the fibroblasts of connective tissue and remodelling of the matrix is controlled by the matrix metalloproteinases (MMPs) and their inhibitors. Our aim was to determine whether there was an abnormal expression or secretion of cytokines, growth factors and MMPs in tissue samples from 14 patients with frozen shoulder using the reverse transcription/polymerase chain reaction (RT/PCR) technique and to compare the findings with those in tissue from four normal control shoulders and from five patients with Dupuytren's contracture. Tissue from frozen shoulders demonstrated the presence of mRNA for a large number of cytokines and growth factors although the frequency was only slightly higher than in the control tissue. The frequency for a positive signal for the proinflammatory cytokines Il-1 and TNF-and TNF-, was not as great as in the Dupuytren's tissue. The presence of mRNA for fibrogenic growth factors was, however, more similar to that obtained in the control and Dupuytren's tissue. This correlated with the histological findings which in most specimens showed a dense fibrous tissue response with few cells other than mature fibroblasts and with very little evidence of any active inflammatory cell process. Positive expressions of the mRNA for the MMPs were also increased, together with their natural inhibitor TIMP. The notable exception compared with control and Dupuytren's tissue was the absence of MMP-14, which is known to be a membrane-type MMP required for the activation of MMP-2 (gelatinase A). Understanding the control mechanisms which play a part in the pathogenesis of frozen shoulder may lead to the development of new regimes of treatment for this common, protracted and painful chronic fibrosing condition. The term 'frozen shoulder' was first used by Codman 1 who described the common features such as pain of gradual onset, which is felt near the insertion of the deltoid, inability to sleep on the affected side, painful restriction of elevation and external rotation and a normal radiological appearance. The disorder is characterised by dense fibrosis of the capsule of the shoulder, 2-4 in which the cellular element consists of fibroblasts and myofibroblasts, 5,6 leading to a contracture of the rotator interval and the coracohumeral ligament, which restricts movement. 7-9 Cytokines and other cellular growth factors are known to regulate the growth and function of fibroblasts in connective tissue. They are cell messengers derived from lymphoid cells, platelets, epithelial cells, endothelial cells, mesangial cells and fibroblasts and act in minute concentrations (nanomolar and femtomolar) by binding to cell receptors , causing a hormone-like acti...

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Received 4 February 1999; Accepted after revision 2 July 1999The term 'frozen shoulder' was first used by Codman 1 who described the common features such as pain of gradual onset, which is felt near the insertion of the deltoid, inability to sleep on the affected side, painful restriction of elevation and external rotation and a normal radiological appearance. The disorder is characterised by dense fibrosis of the capsule of the shoulder, 2-4 in which the cellular element consists of fibroblasts and myofibroblasts, 5,6 leading to a contracture of the rotator interval and the coracohumeral ligament, which restricts movement. 7-9Cytokines and other cellular growth factors are known to regulate the growth and function of fibroblasts in connective tissue. They are cell messengers derived from lymphoid cells, platelets, epithelial cells, endothelial cells, mesangial cells and fibroblasts and act in minute concentrations (nanomolar and femtomolar) by binding to cell receptors, causing a hormone-like action. One of their basic functions is the control of healing in damaged tissues. This process involves the accumulation of fibroblasts at the site of healing and is brought about by chemotaxis (attracting fibroblasts from elsewhere) and proliferation of fibroblasts. Cytokines and growth factors can also modulate the synthesis of collagen by fibroblasts.The histological feature of frozen shoulder is a matrix of type-I and type-III collagen populated by fibroblasts and myofibroblasts which suggests that the condition may be modulated by an abnormality in the production of cytokines and growth factors. Previous studies have shown a striking resemblence between the histology, immunocytochemistry,

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We describe an apparently unreported finding during hip operations: a tear at the insertion of gluteus medius and gluteus minimus. This defect may well be known to many surgeons with experience of hip replacement and hemiarthroplasty for fractures of the neck of the femur, but a Medline search has failed to find a previous description.We made a prospective study of 50 consecutive patients with fractures of the neck of the femur to quantify the incidence of this condition: 11 (22%) had such a tear.

No abstract