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Published 2/1/2010
Carolyn M. Hettrich, MD, MPH; Jo A. Hannafin, MD, PhD

How sex influences joint contractures

Why do men get Dupuytren’s contracture and women get adhesive capsulitis?

The myofibroblast is implicated in several superficial (fascial) fibrosing disorders that occur at different ages and are more likely to be found in specific areas of the body depending on the sex of the patient. These conditions have common histopathologic features and are characterized by inflammation, myofibroblast proliferation, and dense scar formation. Men are primarily affected with Dupuytren’s, Ledderhose, and Peyronie’s diseases. Men also have an increased incidence of posttraumatic elbow contracture. Women have a higher incidence of adhesive capsulitis.

Fibrosing disorders in men
Dupuytren’s contracture is reported to be up to nine times more likely to occur in men than in women. This condition consists of nodules and cords that cause contractures of the palmar fascia—most commonly affecting the ring and little fingers. The result is a progressive flexion deformity, preventing the patient from extending the affected digits.

It has been associated with trauma, diabetes, alcoholism, liver disease, and epilepsy therapy with phenytoin. The clinical description of Dupuytren’s uses stages based on the degree of flexion contracture; the histological description uses proliferative, involutional, and residual stages.

Ledderhose disease is the corresponding condition in the plantar fascia of the feet. It is also more common in men through the sixth decade of life.

Peyronie’s disease is contracture of the fascia in the tunica albicans of the penis. It is most commonly acquired at the age of 55. This causes a lump or plaque within the penis and a persistent curvature with erection. Although Peyronie’s disease does not cause impotence, it can cause a change in the erect penis through indentation, diameter, or length. As many as 20 percent of men with Peyronie’s disease have associated Dupuytren’s or Ledderhose disease.

Fibrosing disorders in women
In women, a predilection for the myofibroblast to cause adhesive capsulitis can be found; 70 percent of all cases of adhesive capsulitis occur in women. Adhesive capsulitis is characterized by a painful, gradual loss of both active and passive glenohumeral motion resulting from progressive fibrosis and ultimate contracture of the glenohumeral joint capsule. The development of adhesive capsulitis has been associated with diabetes mellitus, thyroid dysfunction, Dupuytren’s contractures, autoimmune diseases, and the treatment of breast cancer.

Adhesive capsulitis is characterized by four clinical stages, as well as a three-stage histopathologic progression. Stage 1 is the ‘pre-adhesive’ stage, which is characterized by gradual onset of pain and loss of range of motion. A biopsy will show hypervascular and hypertrophic synovitis with normal capsular tissue. Motion can be restored with an intra-articular injection of local anesthetic and corticosteroid.

Stage 2 is the “freezing” stage, with increasing pain and restriction of motion that cannot be restored under anesthesia. A biopsy taken during this stage of the disease will show hypervascular and hypertrophic synovitis as well as perivascular and capsular scarring, with dense myofibroblast proliferation.

Stage 3 is the “frozen” stage, with pain limited to the end range of motion, and a significant decrease in range of motion. Intra-articular injections of lidocaine are not effective. A biopsy taken during this state will show a thin synovial layer without hypertrophy or hypervascularity, dense scar tissue, and a proliferation of myofibroblasts within the capsular tissue.

Stage 4 is the “thawing” stage, with minimal pain and gradual improvement in range of motion. Without corticosteroid injections or surgery, it can take up to 2 years to completely regain strength and motion.

Does sex make a difference?
Why does the myofibroblast cause contractures in different joints in men than in women? This is unknown at this time, but is yet another example of how the same disease process affects your male and female patients differently.

Carolyn M. Hettrich, MD, MPH, and Jo A. Hannafin, MD, PhD, are members of the AAOS and the Ruth Jackson Orthopaedic Society.

Dr. Hettrich can be reached at hettrichc@hss.edu; Dr. Hannafin can be reached at hannafinj@hss.edu

Putting Sex in Your Orthopaedic Practice
This quarterly column from the AAOS Women’s Health Issues Advisory Board and the Ruth Jackson Orthopaedic Society provides important information for your practice about issues related to sex (determined by our chromosomes) and gender (how we present ourselves as male or female, which can be influenced by environment, families and peers, and social institutions). It is our mission to promote the philosophy that male and female patients experience and react to musculoskeletal conditions differently; when it comes to patient care, surgeons should not have a one-size-fits-all mentality.