AB1100 A case of frozen hip – a diagnosis we should consider more often?

Background Adhesive Capsulitis of the hip or “frozen hip” is not a diagnosis well documented in rheumatological textbooks or literature. There are only a few isolated case reports of adhesive capsulitis affecting joints other than the shoulder, predominantly published in orthopaedic literature.1-3 Objectives To increase awareness of what is probably an under diagnosed condition within the rheumatology discipline and the population with diabetes. Methods A 42-year-old woman with an 18 year history of poorly controlled type 1 diabetes mellitus was seen in the rheumatology clinic with a 9 month history of bilateral hip pain and restriction of movement. Her HbA1c had been consistently greater than 119 mmol/mol(13%) for more than 6 years prior to presentation. She had already received 3 steroid injections for presumed trochanteric bursitis. Initial X-rays and MRI scan of her hips showed no abnormality. On presentation she was unable to weight bear on the left hip. On examination her left hip was extremely irritable, with severe capsular restriction of movement. Spinal movement was normal with no nerve root signs. Results Blood tests showed an HbA1c of 143 mmol/mol(15.2%), ESR 36mm/hr, CRP 5mg/L, normal thyroid function, creatine kinase, biochemical and haematological parameters. She was negative for HLA-B27, rheumatoid factor and antinuclear antibodies. Repeat MRI scan of the left hip, lumbar spine and sacroiliac joints looking for underlying psoas muscle pathology or referred spinal pain showed only mild degenerative changes at the L4/5 disc, considered irrelevant. Initial diagnostic fluroscopic guided injection into the left hip with 10mls of 0.5% bupivacaine followed by a further fluoroscopic guided injection 1 month later with 120mg of depomedrone mixed with 10mls of 0.5% bupivacaine resulted in a transient improvement in pain, but not mobility, for 3 weeks. Her symptoms recurred within a few weeks. She continued her treatment with physiotherapy, anti-inflammatory and analgesic medication. After 18 months she developed a similar pattern of symptoms affecting the right hip. Repeat MRI of the both hips showed only some non-specific oedema in the right tensor fascia lata. She was subsequently diagnosed with bilateral frozen hips. Due to failure of treatment she was referred to the orthopaedic department for manipulation and arthroscopic pressure dilatation under GA. Conclusions Adhesive capsulitis is a relatively common condition affecting the shoulder.4 It is