Lazarus, Mark D

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What\u27s Good for the Heart Is Good for the Shoulder? Commentary on an article by Chang-Meen Sung, MD, et al.: \u22Are Serum Lipids Involved in Primary Frozen Shoulder? A Case-Control Study\u22.

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Thomas Jefferson UniversityJefferson Digital CommonsRothman Institute Rothman Institute11-5-2014What's Good for the Heart Is Good for theShoulder? Commentary on an article by Chang-Meen Sung, MD, et al.: "Are Serum Lipids Involvedin Primary Frozen Shoulder? A Case-ControlStudy".Mark D LazarusDepartment of Orthopaedic Surgery, Rothman Institute, Sidney Kimmel Medical College,Mark.Lazarus@rothmaninstitute.comLet us know how access to this document benefits youFollow this and additional works at: http://jdc.jefferson.edu/rothman_institutePart of the Orthopedics Commons, and the Surgery CommonsThis Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of ThomasJefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarlypublications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers andinterested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion inRothman Institute by an authorized administrator of the Jefferson Digital Commons. For more information, please contact:JeffersonDigitalCommons@jefferson.edu.Recommended CitationLazarus, Mark D, "What's Good for the Heart Is Good for the Shoulder? Commentary on an articleby Chang-Meen Sung, MD, et al.: "Are Serum Lipids Involved in Primary Frozen Shoulder? A Case-Control Study"." (2014). Rothman Institute. Paper 57.http://jdc.jefferson.edu/rothman_institute/57Commentary & PerspectiveWhat’s Good for the Heart Is Good for the Shoulder?Commentary on an article by Chang-Meen Sung, MD, et al.: “Are Serum Lipids Involved in Primary Frozen Shoulder? A Case-Control Study”Mark D. Lazarus, MDThere are countless jokes told about the supposed lack of general medical knowledge held by the typical orthopaedic surgeon.Perhaps studies such as this may slowly erode that source of humor.One would have to be isolated from all lay press to be ignorant of the association between hyperlipidemia and heart disease.Less known is the correlation with orthopaedic conditions, speciﬁcally problems of the shoulder. For instance, the data on therelationship between hypercholesterolemia and rotator cuff tear have been mixed, with some studies1 recognizing a connection andothers2 failing to demonstrate a link. In an animal model, hypercholesterolemia has been shown to negatively affect the mechanicalproperties of the rotator cuff tendon3.Similarly, there has been some controversy with regard to the relationship between hypercholesterolemia and hyperlipidemiawith frozen shoulder; some studies have suggested a strong association4 but others have not found any signiﬁcant relationship5.Some of these differences may lie in which lipoproteins were measured and by what testing technique. Alternatively, the differentconclusions may simply reﬂect differences in the patient populations. In their study, Dr. Sung and colleagues observed patients froma single practice, with an age and sex-matched control group, to attempt to rectify these differences. Also, in contrast with priorstudies, the authors excluded patients with diabetes and thyroid abnormalities. Finally, the cholesterol and lipoprotein testingprotocol was thorough. These authors demonstrated that total cholesterol, low-density lipoprotein, and high-density lipoproteinlevels are signiﬁcantly associated with idiopathic frozen shoulder. Similar associations were found between certain inﬂammatorylipoproteinemias. No connection was found with hypertriglyceridemia.Case-control studies such as this clearly have inherent methodological limits that restrict drawing any conclusions other thanassociations. For instance, there may be dramatic differences between the case and control populations other than their serum lipidproﬁle. Did the two patient populations have similar dietary and exercise habits? What percentage of the patients in each group wastaking statin medications? We know that the use of certain medications is associated with frozen shoulder. Was there an associationwith the use of statin medications and the development of frozen shoulder? More importantly, was normalizing the serumcholesterol level by use of statin medications associated with a lower risk of developing frozen shoulder?The authors tell us that serum high-density lipoprotein may be an acute-phase reactant, naturally elevated in response toinﬂammatory conditions. Because the initial phase of frozen shoulder is an intense inﬂammation (synovitis and capsulitis), are theﬁndings of elevated serum high-density lipoprotein presented in this study merely an inﬂammatory marker responding to an inﬂam-matory process? In the study patient population, there was awide range in the duration of symptoms at the time of presentation (less thanone to sixty months) and in the time from initial presentation to blood sampling (zero to 118 days), potentially further confusing the roleof inﬂammatory response as a cause of higher serum high-density lipoprotein levels in the study population.The authors include a large number of controls (three times the number of patients), so the differences in cholesterol andlipoprotein levels between patients and controls easily reach signiﬁcance. However, the larger question is whether the differences areclinically important. Some of the absolute differences between cases and controls are small, and there is a large overlap in the rangeof ﬁndings between the groups. For instance, is an 8-point difference in the low-density lipoprotein level or a 3-point difference inthe high-density lipoprotein level clinically important? Would a physician apply a treatment to reduce a low-density lipoproteinlevel from 126 mg/dL to 118 mg/dL? The authors do comment on this and suggest that, in the cardiology literature, these smallnumerical differences are still clinically important.Finally, the conclusions in this article hold only for idiopathic frozen shoulder and only in patients with this speciﬁcnationality. Shoulder stiffness secondary to trauma, surgery, diabetes, or any of the other known underlying etiologies of frozenshoulder may not have the same correlation with hypercholesterolemia and hyperlipidemia. Similarly, patients of different na-tionalities may not demonstrate the same associations.Despite these weaknesses, the demonstration of an association among cholesterol, lipoproteins, and frozen shoulder leads tosome intriguing hypotheses. Early idiopathic frozen shoulder, prior to the freezing phase, can be a difﬁcult diagnosis tomake. Coulde187(1)COPYRIGHT  2014 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATEDJ Bone Joint Surg Am. 2014;96:e187(1-2) d http://dx.doi.org/10.2106/JBJS.N.00913demonstrating a speciﬁc pattern of serum lipid protein elevation differentiate frozen shoulder from other inﬂammatory diagnoses?Can the incidence or disease course of frozen shoulder be modulated by employing strategies to reduce hypercholesterolemia andhyperlipoproteinemia, such as exercise, diet change, and medical management?The authors should be congratulated for a rigorously performed study that provides important conclusions. They have alsogiven us a hospital cafeteria conversation starter with our medical colleagues. Maybe if we all alert our internal medicine andcardiology friends to the association between hypercholesterolemia or hyperlipidemia and shoulder pathology, we can slowlyeliminate the use of the medically ignorant orthopaedic surgeon as the butt of so many jokes.Mark D. Lazarus, MD*Department of Orthopaedic Surgery,The Rothman Institute,Sidney Kimmel Medical College at Thomas Jefferson University,Philadelphia, Pennsylvania*The author did not receive payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect ofthis work. He, or his institution, has had a ﬁnancial relationship, in the thirty-six months prior to submission of this work, with an entity in thebiomedical arena that could be perceived to inﬂuence or have the potential to inﬂuence what is written in this work. The author has not had anyother relationships, or engaged in any other activities, that could be perceived to inﬂuence or have the potential to inﬂuence what is written in thiswork. The completeDisclosures of Potential Conﬂicts of Interest submitted by authors are always provided with the online version of the article.References1. Abboud JA, Kim JS. The effect of hypercholesterolemia on rotator cuff disease. Clin Orthop Relat Res. 2010 Jun;468(6):1493-7.2. Longo UG, Franceschi F, Spiezia F, Forriol F, Maffulli N, Denaro V. Triglycerides and total serum cholesterol in rotator cuff tears: do they matter? Br J Sports Med. 2010Oct;44(13):948-51. Epub 2009 Apr 8.3. Beason DP, Hsu JE, Marshall SM, McDaniel AL, Temel RE, Abboud JA, Soslowsky LJ. Hypercholesterolemia increases supraspinatus tendon stiffness and elastic modulusacross multiple species. J Shoulder Elbow Surg. 2013 May;22(5):681-6. Epub 2012 Sep 13.4. Bunker TD, Esler CN. Frozen shoulder and lipids. J Bone Joint Surg Br. 1995 Sep;77(5):684-6.5. Milgrom C, Novack V, Weil Y, Jaber S, Radeva-Petrova DR, Finestone A. Risk factors for idiopathic frozen shoulder. Isr Med Assoc J. 2008 May;10(5):361-4.e187(2)THE JOURNAL OF BONE & JOINT SURGERY d J B J S .ORGVOLUME 96-A d NUMBER 21 d NOVEMBER 5, 2014COMMENTARY & PERSPECTIVE

What\u27s Good for the Heart Is Good for the Shoulder? Commentary on an article by Chang-Meen Sung, MD, et al.:  Are Serum Lipids Involved in Primary Frozen Shoulder? A Case-Control Study .

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What\u27s Good for the Heart Is Good for the Shoulder? Commentary on an article by Chang-Meen Sung, MD, et al.: Are Serum Lipids Involved in Primary Frozen Shoulder? A Case-Control Study .

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