Intraarticular lesions in primary frozen shoulder after manipulation under general anesthesia

Improved range of motion after manipulation under anesthesia versus physiotherapy for stage two frozen shoulder: a randomized controlled trial

Background

Frozen shoulder (FS) is a common cause of shoulder pain and stiffness. Conservative treatment is sufficient for the majority of patients with long-term recovery of shoulder function. Manipulation under anesthesia (MUA) is known as a well-established treatment option if conservative treatment fails. It is unknown whether MUA does indeed shorten the duration of symptoms or leads to a superior outcome compared to conservative treatment. The objective of the current trial is to evaluate the effectiveness of MUA followed by a physiotherapy (PT) program compared to a PT program alone in patients with stage 2 FS.

Methods

A prospective, single-center randomized controlled trial was performed. Patients between 18 and 70 years old with stage 2 FS were deemed eligible if an initial course of conservative treatment consisting of PT and intra-articular corticosteroid infiltration was considered unsatisfactory. Patients were randomized, and data was collected with an online data management platform (CASTOR). MUA was performed by a single surgeon under interscalene block, and intensive PT treatment protocol was started within 4 hours after MUA. In the PT group, patients were referred to instructed physiotherapist, and treatment was guided by tissue irritability. The primary outcome was the Shoulder Pain and Disability Index (SPADI) score. Secondary outcomes were pain, range of motion (ROM), Oxford Shoulder Score, quality of life, and ability to work.

Results

In total, 82 patients were included, 42 in the PT group and 40 in the MUA group. There was a significant improvement in SPADI, Oxford Shoulder Score, pain, ROM, and quality of life in both groups at 1-year follow-up. SPADI scores at three months were significantly improved in favor of MUA. MUA showed a significantly bigger increase in anteflexion and abduction compared to PT at all points of follow-up. No significant differences between both groups were found for all other parameters. No fractures, dislocations, or brachial plexus injuries occurred in this trial.

Conclusion

MUA in stage 2 FS can be considered safe and results in a faster recovery of ROM and improved functional outcome, measured with SPADI scores, compared to PT alone in the short term. After 1 year, except for slightly better ROM scores for MUA, the result of MUA is equal to PT.

High satisfaction rate and range of motion can be expected in frozen shoulder after awake manipulation with brachial plexus block

BACKGROUND

Adhesive capsulitis (AC) is a disease of the glenohumeral joint that is characterized by pain and both passive and active global stiffness with a slow and insidious onset. The disease can occur spontaneously (primary AC) or it can be secondary to other comorbidities, surgery, or trauma, such as fracture or dislocation. Multiple treatment approaches have been suggested: intra-articular steroid injection, physical therapy, manipulation under total anesthesia, and arthroscopic or open surgery. Shoulder manipulation under anesthesia is usually proposed to patients that suffer from severe AC and have already undergone several nonoperative treatments without benefit. Different techniques have been proposed. This study presents our manipulation technique and the clinical results we achieved after shoulder mobilization under brachial plexus block in patients with phase III primary AC.

MATERIALS AND METHODS

A retrospective cohort study was performed on a sample of 110 patients with phase III AC who were treated with this manipulation and followed up for 1 year. Patients underwent two assessments-before the procedure (T0) and 4 months after it (T1)-based on the Numerical Rating Scale, Simple Shoulder Test, and joint range of motion to assess shoulder pain, function, and joint articulation, respectively. Furthermore, the patients had to express their degree of satisfaction with the procedure and the results achieved.

RESULTS

Positive and statistically significant results were recorded in terms of pain reduction (ΔNPRS = - 5.4; p < 0.01) and improved functionality (Simple Shoulder Test Δ = 5; p < 0.01). Passive range of motion was statistically significantly increased for each movement at T1. Large increases were observed in extrarotation range of motion (ROM): R1 (Δ = 77.5°) and R2 (Δ = 70°), whereas little improvements were observed in intrarotation ROM. Patients achieved satisfying functional and articular recovery in all cases. Complications that needed further treatment occurred in three cases: a brachial plexus injury, a glenoid flake fracture, and persistent pain and stiffness.

CONCLUSIONS

In this study, we proposed a standardized method of manipulation under brachial plexus block for patients affected by phase III adhesive capsulitis. The technique was applied among a large cohort of patients, who reported a high satisfaction rate and range-of-motion recovery after 4 months. This could represent an alternative treatment to surgery that has a shorter timeline and does not require patient hospitalization.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Risk factors for recurrence of frozen shoulder after shoulder manipulation under ultrasound-guided cervical nerve root block

Background

This study aimed to investigate risk factors for recurrence of frozen shoulder after shoulder manipulation under ultrasound-guided cervical nerve root block (MUC).

Methods

We retrospectively reviewed 135 frozen shoulders in 121 patients who underwent MUC. We defined frozen shoulder as a limited shoulder range of motion (ROM) (passive forward flexion <120°, external rotation <30°, or internal rotation lower than L3). Patients fulfilling any one criteria were considered to have frozen shoulder. If patients continued to have severe pain and limited ROM at 3 months after MUC, we defined as recurrence of frozen shoulder and they were offered a further MUC or arthroscopic capsular release (ACR). We compared the ROM, Constant Shoulder (CS) score, and University of California, Los Angeles score before and 3 months after MUC between patients with the successful of MUC group (Success group) with those recurrence of frozen shoulder who required a further MUC or ACR group (Recurrence group). Multiple logistic regression analysis was used to identify risk factors for recurrence of frozen shoulder after MUC.

Results

Patients who underwent MUC were retrospectively enrolled and divided into: the successful of MUC group (Success group, n = 112) and required a further MUC or ACR group (Recurrence group, n = 9). The Recurrence group had significantly lower external rotation and CS score before MUC than those in the Success group (P < .05). The Recurrence group showed significantly inferior all ROM and functional scores 3 months after MUC (P < .05). The levels of blood glucose and hemoglobin A1c both before and 3 months after MUC in the Recurrence group showed inferior compared with those of Success group. The difference, although not statistically significant, trended towards significance (before MUC/3 months after MUC; the glucose levels P = .06/.06, the hemoglobin A1c levels P = .07/.09, respectively). The visual analog scale pain score (at rest, during activity, at night) both before and 3 months after MUC in the Recurrence group showed significantly higher scores compared with those of Success group (P < .05). Multiple logistic regression analysis revealed that lower CS score before MUC was independent risk factor for recurrence of frozen shoulder after MUC.

Conclusion

The overall incidence of recurrence of frozen shoulder after MUC was 7.4%. The lower CS score before MUC was an independent risk factor for recurrence of frozen shoulder after MUC. Moreover, patients in the Recurrence group tended to have poorly controlled diabetes and higher visual analog scale pain score both before and 3 months after MUC.

A high level of scientific evidence is available to guide treatment of primary shoulder stiffness: The SIAGASCOT consensus

PURPOSE

Shoulder stiffness (SS) is a condition characterised by active and passive restricted glenohumeral range of motion, which can occur spontaneously in an idiopathic manner or be associated with a known underlying aetiology. Several treatment options are available and currently no consensus has been obtained on which treatment algorithm represents the best choice for the patient. Herein we present the results of a national consensus on the treatment of primary SS.

METHODS

The project followed the modified Delphi consensus process, involving a steering, a rating and a peer-review group. Sixteen questions were generated and subsequently answered by the steering group after a thorough literature search. A rating group composed by professionals specialised in the diagnosis and treatment of shoulder pathologies rated the question-answer sets according to the scientific evidence and their clinical experience.

RESULTS

Recommendations were rated with an average of 8.4 points out of maximum 9 points. None of the 16 answers received a rating of less than 8 and all the answers were considered as appropriate. The majority of responses were assessed as Grade A, signifying a substantial availability of scientific evidence to guide treatment and support recommendations encompassing diagnostics, physiotherapy, electrophysical agents, oral and injective medical therapies, as well as surgical interventions for primary SS.

CONCLUSIONS

A consensus regarding the conservative and surgical treatment of primary SS could be achieved at a national level. This consensus sets basis for evidence-based clinical practice in the management of primary SS and can serve as a model for similar initiatives and adaptable guidelines in other European countries and potentially on a global scale.

LEVEL OF EVIDENCE

Level I.

Arthroscopic findings after manipulation under anesthesia in idiopathic capsulitis of the shoulder: A prospective study

BACKGROUND

Manipulation under anesthesia (MUA) of the shoulder joint is a commonly used method for the treatment of adhesive capsulitis. Though it has been known to be associated with a variety of complications, there is a paucity of studies describing the arthroscopic findings after MUA.

AIM

To describe the arthroscopic findings in patients with idiopathic adhesive capsulitis of the shoulder after MUA.

METHODS

We recruited 28 patients with idiopathic adhesive capsulitis who underwent arthroscopic capsular release. Manipulation of the shoulder was performed under anesthesia in all of these patients before capsular release. Intra-articular findings were recorded during arthroscopic capsular release in these patients.

RESULTS

All patients showed the presence of synovitis. Twenty-seven patients showed tears in the capsule on the anterior aspect. One patient had an avulsion of the anterior rim of the glenoid and labrum following the manipulation. Four patients had partial rotator cuff tears, and one patient showed a superior labrum anterior posterior lesion, which was not diagnosed preoperatively on magnetic resonance imaging.

CONCLUSION

MUA leads to rupture of the capsule, which is the desired outcome. However, the site of rupture of the capsule is dependent on the maneuvers of MUA. In addition, partial tears of the rotator cuff and osteochondral fractures of the glenoid can also occur.

Clinical outcomes and cost-effectiveness of manipulation under brachial plexus block versus physiotherapy for refractory frozen shoulder: a prospective observational study

Background

Frozen shoulder (FS) is a pathological condition that involves a painful and stiff shoulder joint, most commonly in people aged 40-60 years. Most literature supports treatment with physical therapy (PT), although some studies have demonstrated years of continuing pain and functional deficits. Manipulation under anesthesia is effective at eliminating the contracture of intra-articular lesions for refractory FS. This study aimed to compare whether manipulation under anesthesia or PT is a more effective treatment in refractory FS.

Methods

This study was a prospective observational study. A total of 102 patients with refractory FS were enrolled in this study in the medical records, all of whom had severe and multidirectional loss of motion and thickening of the joint capsule and coracohumeral ligament on magnetic resonance imaging. Fifty-one patients were in the manipulation under brachial plexus block (MUB) group (34 females, median age: 57 years), and 51 patients were in the PT group (34 females, median age: 59 years). The MUB procedure consisted of the conventional method with additional adduction manipulation, in which one examiner initially abducted the shoulder joint as much as possible. We recorded the visual analog scale, shoulder range of motion, and American Shoulder and Elbow Surgeons and Constant Scores at the initial baseline visit and at the 1-, 3-, 6-, and 12-month follow-ups. The total cost was calculated from the medical records, and cost-effectiveness was evaluated using quality-adjusted life year and incremental cost-effectiveness ratio.

Results

Visual analog scale (P < .001), range of motion (P < .001), and American Shoulder and Elbow Surgeons and Constant Scores (P < .001) in the MUB group were significantly superior to those in the PT group at 1, 3, 6, and 12 months after treatment. The median cost and total quality-adjusted life year in the MUB and PT groups were $1375 versus $2751 and 2.95 versus 2.68, respectively, and the cost-effectiveness ratio between the MUB and PT groups was calculated as -$560.

Conclusions

The new MUB procedure provides a shorter treatment period, better clinical outcomes, and higher cost-effectiveness in patients with refractory FS compared to PT.

The S2e Guideline on Shoulder Stiffness

The clinical picture of "frozen shoulder" is still poorly understood. In order to present the current state of knowledge on aetiology, diagnosis, and treatment, and to provide recommendations for the professional groups involved, a working group was formed by the DGOU and the DVSE to create a German language, evidence-based guideline, which was published in 2022 by the AWMF. The following summarises the development and the most important results.

The Effect of Arthroscopic Extra-Articular Entire Coracohumeral Ligament Release for Patients with Recalcitrant Frozen Shoulder

OBJECTIVE

The thickened coracohumeral ligament (CHL) is an important part of the typical manifestations and magnetic resonance imaging of frozen shoulder. However, only a few clinical studies with limited cases on arthroscopic extra-articular entire CHL release exist in the literature. This study was to evaluate the effect of arthroscopic extra-articular entire CHL release for patients with recalcitrant frozen shoulder.

METHODS

From February 2014 to February 2020, 81 cases of recalcitrant frozen shoulder patients treated with surgery in a single-center shoulder department and followed for more than 2 years were analyzed. Arthroscopic 360° capsular release was performed with intra-articular partial release (IPR group) or additional extra-articular entire release (IPR + EER group) of CHL. The same rehabilitation program was performed after surgery in both groups. Visual analogue scale (VAS) for pain, range of motion (ROM), and the Constant-Murley scoring system was evaluated before operation, at 3 months after operation, 6 months after operation, and the final follow-up. T-test, Mann-Whitney U-test and chi-squared test were used to compared data.

RESULTS

There were 39 patients in the IPR group, with an average follow-up of 29.2 months. A total of Forty-two patients in the IPR + EER group completed a mean follow-up of 25.7 months. All incisions healed in stages. There were significant differences in Constant-Murley shoulder score, VAS score, and ROM before operation and at the final follow-up in both groups (both P < 0.001). The VAS score of the IPR + EER group was lower than that of the IPR group at 3 months after surgery (P < 0.05), and 6 months after operation (P < 0.05). External rotation, internal rotation, and abduction of ROMs and Constant-Murley shoulder score were significantly greater in the IPR + EER group at 3 months (P < 0.001, P < 0.05, P < 0.001, P < 0.05, respectively) and 6 months after operation (P < 0.001, P < 0.05, P < 0.001, P < 0.05, respectively). At the last follow-up, there was no significant difference in forward flexion, internal rotation, and abduction of ROMs, VAS, and the Constant-Murley shoulder score between the IPR and IPR + EER groups. The external rotation of the IPR + EER group was still greater than that of the IPR group at the last follow-up (P < 0.001).

CONCLUSION

Arthroscopic extra-articular entire coracohumeral ligament release could solve early pain of shoulder joint, recover shoulder joint functions effectively, and achieve a satisfactory efficacy in the treatment of recalcitrant frozen shoulder.

Sex Is Associated with the Success or Failure of Manipulation Alone for Joint Stiffness Associated with Rotator Cuff Repair

Purpose: One-stage arthroscopic rotator cuff repair with manipulation has been recently performed for rotator cuff tears with shoulder stiffness, whereas some patients require capsular release due to severe stiffness that is difficult to treat with manipulation. The purpose of this study was to analyze patient backgrounds and related factors of success or failure of manipulation alone for the treatment of shoulder stiffness associated with rotator cuff tears. Methods: This study included 64 patients with rotator cuff tears and shoulder stiffness who underwent arthroscopic rotator cuff repair with manipulation alone or with manipulation and capsular release of the glenohumeral joint at our institution between January 2015 and September 2019. The patients were divided into two groups: those whose shoulder stiffness could be improved by manipulation alone (Manipulation group) and those whose stiffness could not be improved by manipulation alone and required capsular release (Capsular release addition group). Analysis was performed between the two groups regarding patient backgrounds and related factors, including rotator cuff tear morphology and range of motions pre- and postoperatively. Results: Exactly 45 patients and 19 patients were included in Manipulation group and Capsular release addition group, respectively. A comparison between the two groups showed that patient age (p = 0.0040), sex (p = 0.0005), and injury due to trauma (p = 0.0018) were significantly related to the success or failure of manipulation alone. Multivariate logistic regression analysis on these three factors showed that sex (odds ratio, 5.5; p = 0.048) was significantly associated with the success or failure of manipulation alone. In both groups, the passive ROM of all patients improved at the last postoperative follow-up compared to their pre-operative values (p < 0.001), except for internal rotation in the Capsular release addition group (p = 0.49). Conclusion: Young male patients who have shoulder stiffness associated with rotator cuff tears should be considered for arthroscopic capsular release rather than manipulation.

Arthroscopic capsular release versus manipulation under anaesthesia for treating frozen shoulder - a prospective randomised study

PURPOSE

Arthroscopic capsular release (ACR) and Manipulation under anaesthesia(MUA) have been widely used in the treatment of frozen shoulder (FS). However, there is only limited Level-I evidence to prefer ACR over MUA. The purpose of our study was to conduct a randomised trial comparing ACR versus MUA to assess the difference in outcome, complications and cost-effectiveness of both procedures.

METHODS

From May 2020 to June 2021, patients presenting with FS were randomised into two groups ACR (n = 44) and MUA (n = 41). Patients with arthritis, full-thickness cuff tears, history of trauma/previous surgery around the shoulder were excluded from the study. Range of movement (ROM), pain grading using visual analogue scale (VAS), functional scores- UCLA, CONSTANT and EuroQol-5D scores were measured pre-operatively and post-operatively. MRI was done at three weeks post-operatively for screening complications of either procedure. Quality-adjusted life years (QALY) was used for cost-analysis.

RESULTS

Post-operatively, patients had significant improvement in pain, ROM and functional scores in both groups (P < 0.001) with no significant difference between groups at 24 weeks of follow-up. Diabetic patients undergoing ACR had lesser improvement in abduction and external rotation when compared to non-diabetic patients. Labral tears in MUA group and bone bruises in ACR group were the most common complications noted on the post-operative MRI. For ACR cost per QALY gained was 896 USD while that for MUA was 424 USD.

CONCLUSION

Both ACR and MUA resulted in good improvement in pain and shoulder function. Good outcomes, simple technique and better cost-effectiveness would still make MUA an attractive option over ACR for treating FS.

The Effect of Manipulation Under Anesthesia for Secondary Frozen Shoulder: A Randomized Controlled Trial

INTRODUCTION

Manipulation under anesthesia (MUA) is often used for frozen shoulder treatment, but controversy still exists regarding MUA compared with conservative treatment. This research was conducted to compare the outcome between MUA and celecoxib (CLX) in secondary frozen shoulder.

METHODS

Patients with secondary frozen shoulder were randomized into two groups, an MUA plus exercise (EX) group and a CLX plus EX group. Clinical outcomes were documented at baseline and at 1 day, 2, 4, and 12 weeks after intervention, including Constant-Murley Score (CMS) for function, Pain Rating Index (PRI) and Present Pain Intensity (PPI) for pain, passive range of motion (ROM) measurements including external rotation, internal rotation, forward flexion, and abduction. Primary outcome was CMS. Secondary outcomes were PRI, PPI, and passive ROM.

RESULTS

Sixty-seven patients out of 68 in the MUA group and 66 out of 68 in the CLX group finished the entire study period. There were no significant differences in basic properties of the two groups before intervention. As the primary outcome, CMS changes in the MUA group improved faster than the CLX group. Secondary outcomes, passive ROM, and pain PPI were faster and significant in the MUA group from 1 day after intervention compared with CLX (P < 0.05). At 12 weeks, a statistically significant difference was not observed in the PPI (P > 0.05). A statistically significant difference was not observed in the PRI between groups in 1 day (P > 0.05). For the primary outcome, from 0 to 12 weeks the mean changes in CMS were 44.00 for MUA plus EX (95% CI 43.07-44.93, P < 0.001) and 27.09 for CLX plus EX (26.20-27.98, P < 0.001). The significant difference in improvement appeared from 2 weeks.

CONCLUSION

To treat secondary frozen shoulder with MUA, this treatment could achieve better therapeutic effects on improvement of function, pain, and passive ROM than CLX did.

CLINICAL TRIAL REGISTRATION

The trial was registered at www.chictr.org.cn , identifier ChiCTR2200060269.

Assessment of isolated glenohumeral range of motion in patients with adhesive capsulitis can help predict failure of conservative treatment: a pilot study

PURPOSE

To prospectively evaluate a cohort of patients with adhesive capsulitis and identify predictors of failure of conservative treatment in the first 2 months of therapy.

METHODS

This was a single-cohort, prospective observational study that included 20 participants (13 females/7 males; median age of 51.8 years [interquartile range: 8.65]) with primary adhesive capsulitis managed conservatively and evaluated clinically every month for at least 2 years of follow-up (29 [5] months). The evaluation included stage of the disease, treatment applied, radiological findings, pain levels and range of motion (active and passive ROM in the four planes and isolated glenohumeral passive ROM in abduction [GH-ABD], external rotation [GH-ER] and internal rotation). The main outcome assessed was failure of conservative treatment defined as the need for surgery and persistent pain or CMS below 70 points at the 1-year follow-up.

RESULTS

Seven patients (7/20, 35%) were considered to have failed conservative treatment because they required arthroscopic capsular release 5.2 (2.1) months after the initial diagnosis. Of all the clinical and epidemiological variables, absence of improvement during the first 2 months in isolated glenohumeral ROM abduction and external rotation predicted failure of conservative treatment: improvement in GH-ABD (10° or more) occurred in 10/13 patients in the conservative treatment group and in 1/7 patients in the surgery group (p = 0.017). Improvement in GH-ER (10° or more) occurred in 9/13 patients in the conservative treatment group and in 0/7 patients in the surgery group (p = 0.005).

CONCLUSIONS

Precise assessment of isolated glenohumeral ROM in patients with adhesive capsulitis can help identify patients in which conservative treatment might fail. In this study, patients who did not experience early improvements in isolated glenohumeral ROM often required surgery.

LEVEL OF EVIDENCE

III (Prospective cohort study).

Effects of Different Types of Contraction Exercises on Shoulder Function and Muscle Strength in Patients with Adhesive Capsulitis

Although several studies have reported the effect of exercise therapy for adhesive capsulitis (AC), studies on the comparison of different exercise types on shoulder muscle strength and function in patients with AC are lacking. This study aimed to investigate the effect of different exercise types on shoulder muscle strength and function in patients with AC. Thirty female patients with AC were categorized into an eccentric contraction exercise group (ECG, n = 15; age, 51.53 ± 4.73 years) and a concentric contraction exercise group (CCG, n = 15; age, 52.40 ± 4.03 years). The participants in each group performed a different exercise program three times per week for 60 min per session for 12 weeks. The range of motion (ROM) of the shoulder joint, visual analog scale, shoulder muscle strength, and Constant-Murley score (CMS) were measured before the intervention and after 12 weeks of the exercise intervention. Shoulder ROM in flexion (increase of 31%) and external rotation (ER) (increase of 54%) showed a significant improvement in the ECG (p < 0.05). Muscle strength in ER was significantly different between the two groups (p < 0.05). Pain severity showed improvement in the ECG (decrease of 61%) after the intervention (p < 0.01). The CMS in the ECG (increase of 48%) showed a greater improvement than that in the CCG after the intervention (p < 0.01). This study showed that eccentric contraction exercise had a more beneficial effect than concentric contraction exercise for improving shoulder muscle strength and function in females with AC.

Surgical versus Nonsurgical Multimodality Treatment in an Idiopathic Frozen Shoulder: A Retrospective Study of Clinical and Functional Outcomes

This retrospective study compared the clinical and functional outcomes of patients diagnosed with an idiopathic frozen shoulder with symptom onset of a maximum of six months, treated by arthroscopic capsular release followed by corticosteroid injection and physiotherapy to patients who received only corticosteroid injection followed by physiotherapy. The patients who underwent arthroscopic capsular release, intraoperative corticosteroid injection, and physiotherapy (Group I, n = 30) or received only corticosteroids injection and physiotherapy (Group II, n = 29) were examined in terms of shoulder range of motion (ROM), pain intensity, and function before a given treatment and three, six, and twelve months later. The groups were comparable pre-treatment in terms of ROM, pain, and functional outcome. Group I had statistically and clinically significantly better ROM and function at three and six months post-treatment than Group II. Despite being statistically significant, the between-group differences at twelve-month follow-up in ROM and function were too small to be considered clinically notable. The between-group comparison of pain revealed no significant differences at any post-treatment point of time. The early arthroscopic capsular release preceding corticosteroid injection and physiotherapy seemed more effective at three- and six-month follow-up; however, it brought a comparable result to corticosteroid injection and subsequent physiotherapy at twelve months follow-up.

Nerve injury following ultrasound-guided nerve root block with 2% lidocaine for shoulder manipulation: a case report

Shoulder manipulation under ultrasound (US)-guided C5 and C6 nerve root block is effective for treating refractory adhesive capsulitis (AC). We herein report the development of cervical nerve root injury following manipulation under anesthesia (MUA) in a patient with AC. A 47-year-old woman underwent shoulder manipulation under US-guided C5 and C6 root block with 2% lidocaine for the management of AC-induced shoulder pain. For the procedure, 3 mL of 2% lidocaine (total of 6 mL) was injected around each C5 and C6 nerve root under US guidance. Seven days after the procedure, the patient visited a university hospital because of severe neuropathic pain (numeric rating scale score of 9) in the right anterior arm, lateral arm, and forearm areas. Sensory deficits in the corresponding C5 and C6 dermatomes and motor weakness of the right shoulder abductor, elbow flexor, and wrist extensor were observed. Electrophysiologic studies demonstrated C5 and C6 nerve root injury. The patient was diagnosed with right C5 and C6 nerve root injury following MUA, and lidocaine toxicity or ischemia was the suspected cause. Clinicians should be mindful of the possibility of this complication.

Arthroscopic release in adhesive capsulitis of the shoulder: a retrospective study with 2 to 6 years of follow-up

Background

This study aimed to evaluate the response rate to arthroscopic release treatment in adhesive capsulitis of the shoulder (ACS) for patients with refractory to conservative treatment.

Methods

In this retrospective study, 51 patients (age mean, 49.1±5.6 years) with unilateral adherent capsule underwent arthroscopic releasing surgery for the shoulder capsule. Etiologies of the ACS in 30 patients were idiopathic: 10 patients were affected after surgery and 11 patients following trauma. The patients were evaluated in terms of shoulder function, satisfaction rate, pain intensity, and joint range of motion (ROM) based on a Constant score, a Simple Shoulder Test, the visual analog scale, and four movements, respectively.

Results

The mean Constant score before surgery was 48.2±3.5 and reached 74.4±6 and 77.0±6.3 at 6 months and the final follow-up, respectively (p<0.001). The mean scores of pain intensity, a Simple Shoulder Test, and ROM showed significant improvement at all follow-ups (p<0.001). Sex, age, and diabetes did not have any significant effect on patient recovery. However, patients who experienced ACS after surgery had poorer results than others at all follow-up points.

Conclusions

Arthroscopic releasing surgery of the shoulder in patients with ACS refractory to conservative treatment produces rare complications and an effective injury response. It seems that patients suffering ACS following surgery have a weaker response to the treatment.

The efficacy of physiotherapy interventions in the treatment of adhesive capsulitis: A systematic review

BACKGROUND

Adhesive capsulitis is a debilitating condition which causes the capsule of the gleno-humeral joint to thicken and contract progressively. The effectiveness of various non-operative methods has been demonstrated to improve the pain, range of motion (ROM) and functional status of patients with adhesive capsulitis.

OBJECTIVE

This study aims to review recent evidence on the efficacy of physiotherapy interventions in the treatment of adhesive capsulitis.

METHODS

PubMed, Physiotherapy Evidence Database (PEDro), Science Direct and Cochrane databases were searched for studies published since 2013. The search terms included: Frozen shoulder, adhesive capsulitis, physical therapy, rehabilitation, manual therapy, mobilization, exercise, education, and electrotherapy. The search was limited to studies published in English and studies that used human subjects.

RESULTS

Quality scores of 33 articles were reviewed according to the Sackett's critical appraisal criteria and the grades of recommendation were determined for physiotherapy interventions used in the studies.

CONCLUSION

The empirical evidence suggests that certain physical therapy techniques and modalities are strongly recommended for pain relief, improvement of ROM, and functional status in patients with adhesive capsulitis, while others are either moderately or mildly recommended. However, the efficacy of one treatment modality over another is uncertain. The poor methodological rigors demonstrated in most of the reviewed studies emphasize the urgent need of properly conducted, adequately sampled randomized controlled trials with adequate follow up to determine the superior combination of treatment.

Does the timing of surgical intervention impact the clinical outcomes and overall duration of symptoms in frozen shoulder?

BACKGROUND

The optimal timing of arthroscopic capsular release in patients with frozen shoulder is controversial. Some surgeons delay surgery in the belief that early surgical intervention results in a poorer prognosis. However, whether early surgical intervention causes inferior clinical outcomes and a longer duration of symptoms in frozen shoulder remains unclear. The objective of this study was to compare the clinical outcomes and overall duration of symptoms in frozen shoulder between patients who underwent early surgical intervention and those subjected to late surgical intervention. Our hypotheses were that (1) early surgical intervention would provide significant improvement in symptoms but inferior clinical outcomes because of more severe synovitis compared with late surgical intervention and (2) early surgical intervention would shorten the overall duration of symptoms compared with late surgical intervention.

METHODS

We reviewed 60 consecutive patients with frozen shoulder who underwent arthroscopic capsular release. We compared clinical outcomes and the overall duration of symptoms between 2 groups: Group I comprised 27 patients who underwent surgery <6 months after onset (mean, 3.8 months), whereas group II comprised 33 patients who underwent surgery ≥6 months after onset (mean, 11.1 months). The severity of glenohumeral synovitis at the time of surgery was evaluated. Patient-reported pain, shoulder function, and range of motion, as well as the presence of sleep disturbance, were assessed preoperatively and at 3 and 6 months after surgery.

RESULTS

Both groups showed significant improvements in the visual analog scale pain score, Japanese Orthopaedic Association score, American Shoulder and Elbow Surgeons score, and prevalence of sleep disturbance after surgery (P < .001), although the glenohumeral synovitis score was significantly higher in group I than in group II (P < .0001). Forward flexion at 6 months after surgery was significantly greater in group I than in group II (P = .007). The overall duration of symptoms was shorter in group I than in group II (P < .0001). Neither the pain score, functional score, prevalence of sleep disturbance, nor postoperative recovery time differed between groups.

CONCLUSIONS

Arthroscopic capsular release provided significant pain relief and improvement in shoulder function in patients with frozen shoulder regardless of the timing of surgery. Early surgical intervention might shorten the overall duration of symptoms in frozen shoulder and is not associated with inferior clinical outcomes when compared with late surgical intervention. Surgeons do not need to delay surgical intervention for patients who have intolerable pain and/or nocturnal pain with sleep disturbance.

Clinical Guidelines in the Management of Frozen Shoulder: An Update!

Among all the prevalent painful conditions of the shoulder, frozen shoulder remains one of the most debated and ill-understood conditions. It is a condition often associated with diabetes and thyroid dysfunction, and which should always be investigated in patients with a primary stiff shoulder. Though the duration of 'traditional clinicopathological staging' of frozen shoulder is not constant and varies with the intervention(s), the classification certainly helps the clinician in planning the treatment of frozen shoulder at various stages. Most patients respond very well to combination of conservative treatment resulting in gradual resolution of symptoms in 12-18 months. However, the most effective treatment in isolation is uncertain. Currently, resistant cases that do not respond to conservative treatment for 6-9 months could be offered surgical treatment as either arthroscopic capsular release or manipulation under anaesthesia. Though both invasive options are not clinically superior to another, but manipulation could result in unwarranted complications like fractures of humerus or rotator cuff tear.

Results of repeat manipulation under ultrasound-guided cervical nerve root block with corticosteroid and local anaesthetic injection for recurrence of frozen shoulder

BACKGROUND

This study aimed to evaluate the clinical results of a repeat manipulation under ultrasound-guided cervical nerve root block (MUC) with corticosteroid and local anaesthetic injection for recurrence of idiopathic frozen shoulder after MUC.

METHODS

A consecutive series of 42 shoulders in 39 patients with idiopathic frozen shoulder underwent MUC. All patients were assessed according to the American Shoulder Elbow Surgeon (ASES) score and shoulder range of motion (ROM) both before MUC and at 1 year thereafter. If patients continued to have pain and limited ROM at 3 months after the procedure, they were offered a repeat MUC. Such patients were also assessed before the procedure and at 3 months and 1 year thereafter.

RESULTS

The initial MUC was successful in 31 shoulders (single group). Repeat MUC was required in 11 shoulders (repeat group). Patients in the single group showed significant improvement in ROM and ASES score at 1 year after the procedure (p < 0.001); similarly, patients in the repeat group had significant improvement in ROM and ASES score at 3 months and 1 year after the procedure (p < 0.001). Patients in the repeat group had had significantly more severely limited ROM (p < 0.01) and decreased ASES score (p < 0.001) before the procedure compared with those in the single group.

CONCLUSIONS

A repeat MUC with corticosteroid and local anaesthetic injection is a valuable option before proceeding to surgery for recurrence of idiopathic frozen shoulder. When there is severely limited ROM and decreased ASES score before the MUC, a repeat MUC may be necessary, which would require the patient's informed consent.

TRIAL REGISTRATION

Retrospectively registered.

Can manipulation under anesthesia alone provide clinical outcomes similar to arthroscopic circumferential capsular release in primary frozen shoulder (FS)?: the necessity of arthroscopic capsular release in primary FS

Background

We evaluated the need for arthroscopic capsular release (ACR) in refractory primary frozen shoulder (FS) by comparing clinical outcomes of patients treated with ACR and manipulation under anesthesia (MUA).

Methods

We assessed patients with refractory primary FS, 57 patients (group A) who were treated with MUA and 22 patients (group B) who were treated with ACR. In group A, manipulation including a backside arm-curl maneuver was performed under interscalene brachial block. In group B, manipulation was performed only to release the inferior capsule before arthroscopic circumferential capsular release, which was carried out for the unreleased capsule after manipulation. Pain, range of shoulder motion, and American Shoulder and Elbow Surgeons score were recorded at 1 week, 3 months, 6 months, and 1 year after surgery. We compared outcome variables between treatment groups and between diabetics and non-diabetics and also evaluated the numbers of patients receiving additional intra-articular steroid injection.

Results

Outcome variables at 3 months after surgery and improvements in outcome variables did not differ between groups. Group A showed significantly better results than group B in the evaluation of pain and range of motion at 1 week. Diabetics showed comparable outcomes to non-diabetics for most variables. Eleven patients required additional steroid injections between 8 to 16 weeks after surgery: 12.2% in group A, 18.2% in group B. Additional injections were given three times more often in diabetics compared to non-diabetics.

Conclusions

MUA alone can yield similar clinical outcomes to ACR in refractory FS.

Treatment of a rotator cuff tear combined with iatrogenic glenoid fracture and shoulder instability: A rare case report

BACKGROUND

The brisement manipulation is an effective treatment for refractory shoulder stiffness. Rotator cuff tears can sometimes exist in combination with adhesive capsulitis. Arthroscopic capsular release combined with rotator cuff repair has achieved good outcomes in published reports.

CASE SUMMARY

We report the case of a patient with right shoulder pain for more than 1 year that was suspected to have adhesive capsulitis and a rotator cuff tear that was treated with brisement manipulation and arthroscopic management. An iatrogenic glenoid fracture with shoulder instability occurred during the manipulation. Arthroscopic treatment for fracture fixation, capsular release, and rotator cuff repair was performed, and the functional results are reported.

CONCLUSION

Arthroscopic fixation for iatrogenic glenoid fracture and repairing coexisting rotator cuff tear can provide the stability needed for early rehabilitation.

Is single stage capsular release and rotator cuff repair suitable for rotator tears with concomitant stiffness?

Introduction

It is common for patients with a rotator cuff tear to present with shoulder stiffness. There is no consensus on the acceptable level of stiffness at time of rotator cuff repair.We aim to determine if patients with stiffness undergoing rotator cuff repair and concomitant capsular release have different outcome than those with no stiffness undergoing rotator cuff repair alone. We hypothesize that patients with stiffness will not have poorer outcome than patients with no stiffness.

Method

We conducted a retrospective study of prospectively collected data for 47 patients who underwent arthroscopic rotator cuff repair under a single surgeon from 2010 to 2015. 25 patients were considered stiff (Stiff group) and 22 patients were considered to have no pre-operative stiffness (Non-stiff group).Range of motion and functional outcomes were collected preoperatively and post-operatively at two-years.

Results

There were no significant differences in gender distribution, age and cuff tear size between both groups. Pre-operatively, patients in the Stiff group had significantly poorer active range of motion (Forward flexion - Stiff 74.8° vs Non-stiff 100.2°, P = 0.001) and poorer function (Constant score - Stiff 23.5 vs Non-stiff 43.2, P < 0.001). Post-operatively, both groups of patients had increased range of motion, strength and reported lesser pain compared to pre-operation. There were no significant differences in post-operative outcomes between both groups.

Conclusion

Single-stage surgery combining capsular release and rotator cuff repair is effective for patients with stiffness as they are able to achieve similar results to those without shoulder stiffness.

Effects of joint capsular release on range of motion in patients with frozen shoulder

BACKGROUND

A thickened joint capsule is believed to be one of the most specific manifestations of and the primary restraint against range of motion (ROM) in frozen shoulders. The purpose of this study was to evaluate the relationship among ROMs under general anesthesia before surgery and the effects of each joint capsular release on ROM.

METHODS

ROM was measured using a goniometer with scapular fixation. Arthroscopic pan-capsular release was performed with the patient in the beach-chair position in the following order: (1) rotator interval, (2) coracohumeral ligament, (3) superior capsule, (4) middle glenohumeral ligament, (5) anterior inferior glenohumeral ligament, and (6) posterior inferior glenohumeral ligament. ROMs in forward flexion (FF), lateral elevation (LE), external rotation with the arm at the side (ER1), external rotation at 90° of LE (ER2), internal rotation at 90° of LE (IR2), horizontal flexion, external rotation at 90° of FF (ER3), and internal rotation at 90° of FF (IR3) were evaluated before and after each release.

RESULTS

A total of 32 consecutive shoulders were included. After each capsular release, the ROM recovered; the final ROM was significantly greater on the affected side than on the unaffected side. Significant correlations were found between FF and LE, FF and ER1, ER1 and ER2, ER1 and ER3, ER2 and ER3, and IR2 and IR3 on both sides, regardless of surgery.

CONCLUSION

Each segment of the joint capsule affected ROM in all directions, supporting the need for whole-joint capsular release; ROM was significantly greater on the affected side than on the unaffected side after surgery.

Convalescence after arthroscopic capsular release in frozen shoulder

Introduction

To determine if arthroscopic capsular release (ACR) shortens duration of illness in frozen shoulder (FS) in comparison to the depicted natural course of 30.1 months and to identify risk factors for persisting complaints.

Materials and methods

A consecutive group of 71 shoulders in 70 patients with mean age of 54 (37-74) years with FS were treated by ACR and enrolled in our study with follow-up investigation at 1, 3, 6 and finally 32 (19-49) months postoperatively.

Results

Patients had complaints for 8 (3-60) months preoperatively. 8 shoulders (11%) were classified as primary and 63 (89%) shoulders as secondary type FS. 6 patients were lost to follow-up. Relative Constant score increased significantly from 31% before surgery to 103% at last follow-up. 55 patients (85%) achieved subjective remission after 7 (1.5-18) months, postoperatively. Overall duration of illness was 16 (5-72) months. All patients with primary FS achieved remission and all patients with persisting symptoms had secondary FS.

Conclusion

Duration of illness was shortened by more than 12 months compared with the natural time course defined by Reeves. Secondary FS, especially ac-joint pathologies, previous surgery, diabetes and more than 12 months preoperative illness duration were identified as risk factors for persisting complaints. Hypothesis of worse outcome in secondary FS was confirmed.

Surgical Treatment of Adhesive Capsulitis: A Retrospective Comparative Study of Manipulation Under Anesthesia and/or Capsular Release

Background

No consensus exists among orthopedic surgeons regarding the optimal intervention for adhesive capsulitis. The purpose of this study was to determine which treatment provides the best objective outcome following manipulation under anesthesia (MUA), MUA + arthroscopic capsular release (CR), or CR alone.

Methods

Between 2011 and 2015, 97 shoulders were treated for adhesive capsulitis (MUA, MUA+CR, CR) and followed for three months or until achieving full range of motion (ROM). Patients' charts were reviewed for demographic information, diabetes, pre/post-operative ROM, and complications.

Results

The average age at surgery was 57 years (range: 31-80 years) with a mean follow-up of 6.2 months (range: 2-43 months). ROM improved significantly regardless of treatment modality (p < 0.001). MUA had significantly more external rotation at follow-up than MUA+CR and CR alone (62 vs 49 vs 48, p = 0.02). Groups were similar in regards to post-operative elevation and internal rotation. Loss of external rotation following surgery was significantly more common in the MUA+CR group (p = 0.03). In diabetics, no treatment option was superior to another in regards to final ROM.

Conclusion

Operative treatment of idiopathic adhesive capsulitis is efficacious and safe for improving shoulder ROM across treatment modalities. Surgeon preference may effectively guide treatment independent of diabetic status.

Secondary frozen shoulder after traumatic anterior shoulder instability

Background

Secondary frozen shoulder after traumatic anterior shoulder instability is rare. The therapeutic management and clinical outcome of this condition are not well known. This study aimed to investigate the characteristics of such rare cases and verify treatment outcomes.

Methods

We reviewed the cases of 12 patients with secondary frozen shoulder after anterior shoulder dislocation or subluxation between April 2007 and March 2018. All patients underwent physical therapy along with an intra-articular injection. Patients with refractory stiffness received arthroscopic mobilization. The range of motion, Rowe score, and University of California, Los Angeles score were evaluated at the first and final visits. A telephone survey was performed to determine the long-term outcomes including recurrent instability, the Oxford Shoulder Score, and the Oxford Instability Score.

Results

The mean age of patients at the first visit was 42.5 years. Two patients underwent surgical treatment, which revealed scar-like tissue of the anteroinferior capsule. The range of motion, Rowe score, and University of California, Los Angeles score significantly improved at a mean follow-up of 15 months. At a mean follow-up of 82 months, the telephone survey revealed recurrent instability in 1 patient who was conservatively treated; the average Oxford Shoulder Score and Oxford Instability Score were 46.4 and 43.2, respectively.

Conclusions

The average patient age observed in this study was higher than the known peak age of traumatic anterior shoulder instability occurrence. Less activity, loss of capsule elasticity, or scarring after a capsular tear may lead to stiffness after traumatic anterior shoulder instability. Conservative treatment can be used as the first-line therapy, followed by effective arthroscopic mobilization when conservative treatment fails.

[Mid-term effectiveness of manipulation under anesthesia combined with arthroscopic capsular release and subacromial debridement for primary frozen shoulder]

OBJECTIVE

To evaluate mid-term effectiveness of manipulation under anesthesia combined with arthroscopic capsular release and subacromial debridement for primary frozen shoulder.

METHODS

Between January 2013 and December 2017, 33 patients of primary frozen shoulder were treated with manipulation under anesthesia combined with 360° arthroscopic capsular release and subacromial debridement. There were 10 males and 23 females, aged from 37 to 65 years, with a mean age of 50.9 years. The affected shoulder on left side in 17 cases and on right side in 16 cases. The disease duration was 6-13 months (mean, 8.4 months). Before and after operation, the visual analogue scale (VAS) score was used to evaluate the shoulder joint pain, Constant score was used to evaluate the shoulder joint function, and the flexion, abduction, and external rotation of shoulder joint were recorded. The internal rotation function was assessed based on the vertebral plane that the thumb could reach after internal rotation of the affected shoulder joint (the rank of internal rotation vertebra). X-ray film was taken to measure the distance of the subacromial space.

RESULTS

There was no fracture or labrum tear in all patients, and all the incisions healed by first intention. All the 33 patients were followed up 20-31 months, with an average of 24.1 months. During the follow-up, there was no complication such as wound infection and nerve injury. At last follow-up, the range of motion of shoulder flexion, abduction, and external rotation, the rank of internal rotation vertebra, the VAS score, Constant score, and subacromial space were significantly improved when compared with preoperative ones ( P<0.05).

CONCLUSION

Manipulation under anesthesia combined with arthroscopic capsular release and subacromial debridement can achieve a good mid-term effectiveness without complication for primary frozen shoulder.

Rotator cuff tear with joint stiffness: a review of current treatment and rehabilitation

Repair of the rotator cuff tear is a joint-tightening procedure that can worsen joint stiffness. This paradoxical phenomenon complicates treatment of rotator cuff tear with joint stiffness. As a result, there is controversy about how and when to treat joint stiffness. As many treatments have been published, this review discusses the latest findings on treatment of rotator cuff tear with joint stiffness.

Effects of resistance exercise using the elastic band on the pain and function of patients with degenerative knee arthritis

[Purpose] This study examined the effects of resistance exercise using the elastic band on the pain and function of patients with degenerative knee arthritis. [Participants and Methods] Thirty patients with degenerative knee arthritis were classified into an experimental group of 15 patients on whom resistance exercise using the elastic band was applied and a control group of 15 patients on whom conservative physical therapy was applied. Both groups received treatments three times a week for four weeks. Pain was measured by the visual analogue scale and function was evaluated by the Korean Western Ontario and McMaster Universities Osteoarthritis Index (K-WOMAC). [Results] The intragroup comparison showed significant decreases in the visual analogue scale and the K-WOMAC in both the experimental and control groups. In the intergroup comparison after treatment, the experimental group showed significantly lower visual analogue scale and K-WOMAC values than the control group. [Conclusion] The results suggest that resistance exercise using the elastic band is an effective intervention for the pain and function of patients with degenerative knee arthritis.

Outcomes of Arthroscopic Capsular Release in the Beach-Chair Versus Lateral Decubitus Position: A Systematic Review

Background:

Arthroscopic capsular release (ACR) for the treatment of adhesive capsulitis of the shoulder can be performed in either the beach-chair (BC) or lateral decubitus (LD) position.

Purpose:

To determine the clinical outcomes and recurrence rates after ACR in the BC versus LD position.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed by searching PubMed, Embase, and the Cochrane Library databases for studies reporting clinical outcomes of patients undergoing ACR in either the BC or LD position. All English-language literature from 1990 through 2017 reporting on clinical outcomes after ACR with a minimum 3-month follow-up were reviewed by 2 independent reviewers. Recurrence rates, range of motion (ROM) results, and patient-reported outcome (PRO) scores were collected. Study methodological quality was evaluated using the modified Coleman Methodology Score (MCMS).

Results:

A total of 30 studies (3 level 1 evidence, 2 level 2 evidence, 4 level 3 evidence, 21 level 4 evidence) including 665 shoulders undergoing ACR in the BC position (38.1% male; mean age, 52.0 ± 3.9 years; mean follow-up, 35.4 ± 18.4 months) and 603 shoulders in the LD position (41.8% male; mean age, 53.0 ± 2.3 years; mean follow-up, 37.2 ± 16.8 months) were included. There were no significant differences in overall mean recurrence rates between groups (BC, 2.5%; LD, 2.4%; P = .81) or in any PRO scores between groups (P > .05). There were no significant differences in improvement in ROM between groups, including external rotation at the side (BC, 36.4°; LD, 42.8°; P = .91), forward flexion (BC, 64.4°; LD, 79.3°; P = .73), abduction (BC, 77.8°; LD, 81.5°; P = .82), or internal rotation in 90° of abduction (BC, 40.8°; LD, 45.5°; P = .70). Significantly more patients in the BC group (91.6%) underwent concomitant manipulation than in the LD group (63%) (P < .0001). There were significantly more patients with diabetes in the LD group (22.4%) versus the BC group (9.6%) (P < .0001).

Conclusion:

Low rates of recurrent shoulder stiffness and excellent improvements in ROM can be achieved after ACR in either the LD or BC position. Concomitant manipulation under anesthesia is performed more frequently in the BC position compared with the LD position.

Outcomes of arthroscopic capsular release for the diabetic frozen shoulder in Asian patients

INTRODUCTION

Diabetic patients have been known to have a higher incidence of frozen shoulder. Arthroscopic capsular release has been described for diabetic frozen shoulder refractory to non-surgical treatment. We describe our single-surgeon experience of this procedure done in Asian patients presenting with diabetic frozen shoulder.

RESULTS

Data were prospectively collected from 25 patients from 2007 to 2008, who underwent arthroscopic capsular release for frozen shoulder with diabetes mellitus. This included the University of California-Los Angeles (UCLA) Shoulder Score by an independent observer. Mean follow-up duration was 44.3 ± 22 months with the age of 57.3 ± 10.9 years at the time of surgery. Mean duration of symptoms prior to surgery was 8.9 ± 7.5 months. Ten right shoulders and 15 left shoulders were operated on. Arthroscopic capsular release was performed in the beach chair position with the aid of a 90° electrocautery hook, from the rotator interval to posterior capsule. Significant improvement was observed in the UCLA scores post-operatively (preoperative total score 15.8 ± 3.6 vs. post-operative 33.3 ± 2.5, p < 0.00), including all domains of pain (3.9 ± 1.8 vs. 9.4 ± 0.9, p < 0.00), function (4.8 ± 1.7 vs. 9.4 ± 1.4, p < 0.00), active forward flexion (2.6 ± 0.7 vs. 4.6 ± 0.6, p < 0.00) and satisfaction (0.0 ± 0.0 vs. 5.0 ± 0.0, p < 0.00). No significant correlation between duration of symptoms and UCLA scores. Significant improvement was observed in forward flexion (preoperative 100.4 ± 18.8° vs. post-operative 157.6 ± 15.9°, p < 0.00) and external rotation (preoperative 14.4 ± 6.34° vs. post-operative 63.8 ± 8.3°, p < 0.00). Although the duration of symptoms correlated significantly with preoperative forward flexion ( r = 0.443 and p < 0.027), there was no significant correlation with post-operative forward flexion ( r = 0.023 and p < 0.91). No axillary nerve palsy observed.

CONCLUSION

The diabetic frozen shoulder can be treated favourably with arthroscopic capsular release and the duration of symptoms prior to surgery does not affect the outcomes.

Shoulder Impairment Following Critical Illness: A Prospective Cohort Study

Supplemental Digital Content is available in the text.

Objectives:

Identify the prevalence of shoulder impairment in ICU survivors within 6 months of discharge from ICU. Evaluate the impact of shoulder impairment on upper limb functional status in patients treated on an ICU. Identify risk factors for the development of shoulder impairment.

Design:

Prospective cohort study.

Setting:

A tertiary care medical-surgical-trauma ICU at a U.K. hospital over 18 months, with a further 6-month follow-up after hospital discharge.

Subjects:

Adult patients with an ICU length of stay of greater than 72 hours with no preexisting or new neurologic or traumatic upper limb injury.

Interventions:

None.

Measurements and Main Results:

Patients underwent targeted shoulder assessments (pain, range of movement, Constant-Murley Score, shortened version of the disabilities of the arm, shoulder, and hand [DASH] score [QuickDASH] score) at hospital discharge, 3 and 6 months after hospital discharge. Assessments were undertaken on 96 patients, with 62 patients attending follow-up at 3 months and 61 patients at 6 months. Multivariate regression analysis was used to investigate risk factors for shoulder impairment. ICU-related shoulder impairment was present in 67% of patients at 6 months following discharge from hospital. Upper limb dysfunction occurred in 46%, with 16% having severe dysfunction (equivalent to shoulder dislocation). We were unable to identify specific risk factors for shoulder impairment.

Conclusions:

Shoulder impairment is a highly prevalent potential source of disability in ICU survivors. This persists at 6 months after discharge with a significant impact on upper limb function. More research is needed into potential mechanisms underlying shoulder impairment and potential targeted interventions to reduce the prevalence.

Treatment Strategy for Frozen Shoulder

Frozen shoulder (FS) is a common shoulder disorder characterized by a gradual increase of pain of spontaneous onset and limitation in range of motion of the glenohumeral joint. The pathophysiology of FS is relatively well understood as a pathological process of synovial inflammation followed by capsular fibrosis, but the cause of FS is still unknown. Treatment modalities for FS include medication, local steroid injection, physiotherapy, hydrodistension, manipulation under anesthesia, arthroscopic capsular release, and open capsular release. Conservative management leads to improvement in most cases. Failure to obtain symptomatic improvement and continued functional disability after 3 to 6 months of conservative treatment are general indications for surgical management. However, there is no consensus as to the most efficacious treatments for this condition. In this review article, we provide an overview of current treatment methods for FS.

Shoulder manipulation under targeted ultrasound-guided rotator interval block for adhesive capsulitis

OBJECTIVE

To describe and evaluate the outcome following shoulder manipulation under rotator interval block for the treatment of adhesive capsulitis.

MATERIALS AND METHODS

Patients with adhesive capsulitis referred by our local orthopaedic shoulder surgeons consented to targeted ultrasound-guided injection of the glenohumeral joint via the rotator interval. Inclusion criteria included a failure to respond to conservative treatment and the absence of a full-thickness rotator cuff tear. Twelve millilitres of a mixture of local anaesthetic and steroid was injected into the rotator interval using a 21-gauge needle, with a small volume of the same solution instilled into the subacromial bursa. Following injection, under local anaesthetic block, patients were gently manipulated into abduction, external rotation and internal rotation as far as they could comfortably tolerate. Patients were assessed pre-injection with documented pain scores from 0 to 10 on a visual analogue scale (VAS) and the Oxford Shoulder Score (OSS) questionnaire. Initial follow-up comprised a VAS pain score at 1 h, 24 h and 2 weeks. Clinical review by the referring orthopaedic surgeon was performed at 2 months post-injection. Long-term follow-up involved a VAS pain score and the OSS questionnaire at 5 months.

RESULTS

Forty patients were suitable for inclusion in the study. Twenty-three were female (57.5%) and 17 were male. The mean age was 52 years (range, 31-73 years). Twelve patients were post-operative. The duration of symptoms ranged from 3 months to 18 months. Mean pre-procedure OSS was recorded as 23.3 (range, 4-36). The mean VAS pain score was 7.7 before the procedure (range, 4 - 10), 3.4 at 1 h (range, 0-8), 2.9 at 24 h (range, 0-8), and 1.8 at 2 weeks (range 1-4). Orthopaedic follow-up at an average of 66 days post-injection was recorded in 18 patients. All patients reported initial improvement of their shoulder pain and return to near full range of movement; however, recurrence of adhesive capsulitis symptoms was recorded in 5 patients. One case of rupture of the long head of the biceps tendon was reported, but the patient remained asymptomatic. Long-term follow-up at 5 months was obtained in 31 patients, with a mean OSS of 42 (range, 21-60) and VAS of 2.3 (range, 0-7).

CONCLUSION

Manipulation under general anaesthesia is a well-recognised treatment for adhesive capsulitis. We report that targeted ultrasound-guided injection of the rotator interval and manipulation of the shoulder under local anaesthetic blockade result in good outcomes in reducing shoulder pain and symptoms of adhesive capsulitis with low recurrence and complication rates.

Treatment of Adhesive Capsulitis of the Shoulder

Adhesive capsulitis presents clinically as limited, active and passive range of motion caused by the formation of adhesions of the glenohumeral joint capsule. Radiographically, it is thickening of the capsule and rotator interval. The pathology of the disease, and its classification, relates to inflammation and formation of extensive scar tissue. Risk factors include diabetes, hyperthyroidism, and previous cervical spine surgery. Nonsurgical management includes physical therapy, corticosteroid injections, extracorporeal shock wave therapy, calcitonin, ultrasonography-guided hydrodissection, and hyaluronic acid injections. Most patients will see complete resolution of symptoms with nonsurgical management, and there appears to be a role of early corticosteroid injection in shortening the overall duration of symptoms. Surgical intervention, including manipulation under anesthesia, arthroscopic capsular release both limited and circumferential, and the authors' technique are described in this article. Complications include fracture, glenoid and labral injuries, neurapraxia, and rotator cuff pathology. Postoperative care should always include early physical therapy.

The course and clinical impact of articular magnetic resonance imaging findings 6 months after shoulder manipulation under ultrasound-guided cervical nerve root block for frozen shoulder

Background

In our previous study, iatrogenic capsular tears, bone bruises of the humeral head, and labral tears were detected on magnetic resonance imaging (MRI) performed 1 week after manipulation following ultrasound-guided cervical nerve root block in patients with frozen shoulder 6 months after manipulation.

Methods

We studied 25 patients with frozen shoulder. MRI was performed before, 1 week after, and 6 months after manipulation. On the basis of the course of MRI findings over a period of 6 months, the patients were divided into 2 groups: those with MRI findings of bone bruises, capsular tears, and/or labral tears (19 patients) and those with no MRI findings (6 patients). The clinical outcomes of the 2 groups at 6 months after manipulation were compared using the Wilcoxon matched-pairs test, the Mann-Whitney test, and the Fisher exact probability test for statistical analysis.

Results

At 1 week after manipulation, 96% of patients had capsular tears, 40% had bone bruises, and 20% had labral tears; these percentages had decreased at 6 months after manipulation to 4%, 20%, and 8%, respectively. No significant differences in clinical outcomes were noted between patients with residual MRI findings 6 months after manipulation and those without any MRI findings.

Conclusion

Most of the iatrogenic capsular tears, bone bruises, and labral tears detected 1 week after manipulation had disappeared 6 months later. Residual MRI findings 6 months after manipulation had no significant correlation with clinical symptoms.

Manipulation under anaesthesia for frozen shoulders: outdated technique or well-established quick fix?

Manipulation under anaesthesia (MUA) for frozen shoulder (FS) leads to a considerable increase in range of motion and Oxford shoulder score, a significant reduction in pain and around 85% satisfaction.

A clearly defined indication for MUA in FS patients cannot be extracted from this review or the available literature. The associating criteria before proceeding to MUA vary widely.

All but one study in this review lacked a control group without intervention. Therefore, firm conclusions about the role of MUA in the treatment of FS cannot be drawn from the current literature.

An overall complication rate of 0.4% was found and a re-intervention rate of 14%, although most of the included papers were not designed to monitor complications.

The following criteria before proceeding to MUA are proposed: a patient unable to cope with a stiff and painful shoulder; clinical signs of a stage 2 idiopathic FS; lessening pain in relation to stage 1; external rotation < 50% compared to contralateral shoulder joint; a minimal duration of symptoms of three months; and failure to respond to an intra-articular corticosteroid infiltration.

Cite this article: EFORT Open Rev 2019;4:98-109. DOI: 10.1302/2058-5241.4.180044

Management of Concomitant Preoperative Rotator Cuff Pathology and Adhesive Capsulitis: A Systematic Review of Indications, Treatment Approaches, and Outcomes

PURPOSE

Concomitant preoperative adhesive capsulitis (AC) and rotator cuff (RC) pathology pose therapeutic challenges in light of contrasting interventional and rehabilitative goals. The purposes of this systematic review were to assess the literature regarding the management and rehabilitation of patients with concomitant RC tears and preoperative AC and to compare overall clinical outcomes between strategies for this common scenario.

METHODS

In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 3 databases (MEDLINE, Embase, and PubMed) were searched and screened in duplicate using predetermined criteria for studies on the aforementioned patient population. Descriptive statistics are presented.

RESULTS

Of 952 studies, 17 involving 662 shoulders, with a mean age of 59.6 ± 3.5 years, 57.9% female patients, and a mean follow-up period of 18.6 months, were included. Capsular release (CR) (86.1%) and manipulation under anesthesia (MUA) (33.1%) were the most common co-interventions with RC repair. Across studies, mean preoperative American Shoulder and Elbow Surgeons scores ranged from 29.0 to 61.3, visual analog scale scores (pain) ranged from 5.3 to 8.0, and Constant scores ranged from 18.0 to 48.0. Mean postoperative American Shoulder and Elbow Surgeons scores ranged from 76.9 to 92.0, visual analog scale scores (pain) ranged from 0.3 to 2.5, and Constant scores ranged from 72.6 to 93.2. Postoperative rehabilitation comprised abduction braces and passive range of motion immediately postoperatively for mean durations of 5.0 weeks and 5.3 weeks, respectively, followed by active range of motion at a mean of 5.3 weeks and strengthening at 10.9 weeks. Postoperative complications included stiffness, RC retear, instability, glenoid fracture, and superficial infection.

CONCLUSIONS

The results of this systematic review support treatment of patients with degenerative RC tears and concomitant AC with a combination of RC repair and MUA, CR, or both MUA and CR. Regardless of the treatment modality, accelerated postoperative rehabilitative protocols are beneficial in preventing postoperative persistence of AC and can be safely used in this scenario without a substantial increase in complication rates compared with patients undergoing RC repair alone with conservative rehabilitation.

LEVEL OF EVIDENCE

Level V, systematic review of Level II, III, IV, and V studies.

Clinical Results and Complications of Shoulder Manipulation under Ultrasound-Guided Cervical Nerve Root Block for Frozen Shoulder: A Retrospective Observational Study

Introduction

Manipulation under ultrasound-guided fifth and sixth cervical nerve root block (MUC) is a recognized form of treatment for patients with persistent frozen shoulder (FS). This study aimed to investigate the confirmatory hypothesis testing that the MUC has a significant clinical effect on FS refractory to conservative treatments and to assess its adverse events.

Methods

This is a retrospective observational study on patients with FS treated in the past 8 years. Although 77 patients were eligible for this study, only 68 were enrolled. The patients were evaluated immediately before the MUC and at 1, 3, and 6 months after with the use of the Japanese Orthopaedic Association shoulder score. Simultaneously, ranges of motion of the affected shoulder were measured in two directions: forward flexion and external rotation. A paired t test or a Wilcoxon signed-rank test was used to compare differences in outcomes between before and 6 months after MUC. We also assessed any adverse events during and after the MUC.

Results

Regarding the primary outcome, confirmatory testing showed statistically significant improvements in every outcome value at 6 months after MUC (p < 0.001). In terms of adverse events, two patients (2.9%) had vasovagal reflex, one (1.5%) had a panic attack during the block procedure, and a 72-year-old female patient (1.2%) had an avulsion fracture of the inferior glenoid during the manipulation procedure, although all of them recovered spontaneously without any residual functional impairment.

Conclusion

The results showed that significant clinical effects of the MUC on FS were observed through a confirmatory analysis with a sufficient sample size. However, several complications that could occur during the block and manipulation procedures should be considered.

Comparison of one-stage versus two-stage procedure for the management of patients with rotator cuff tear and concomitant shoulder stiffness

Background

To compare the clinical outcomes of one-stage and two-stage procedures for the management of patients with rotator cuff tear and concomitant shoulder stiffness.

Methods

From December 2013 to June 2016, we recruited 42 consecutive patients with rotator cuff tear and concomitant shoulder stiffness. Twenty-two patients underwent a one-stage procedure, including arthroscopic capsule release and concomitant rotator cuff repair, within 2 weeks of the diagnosis. For the remaining twenty patients, conservative treatment for the recovery of range of motion (ROM) was initially performed before arthroscopic rotator cuff repair. The ROM, visual analogue scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score, and satisfaction rate were assessed preoperatively; 3, 6, 12, and 24 months after surgery; and at final follow-up.

Results

The mean follow-up period was 26.3 months (range, 24–33 months). No significant difference was noted in preoperative demographic data (age, sex, dominant/non-dominant, diabetes mellitus, thyroid disease, and duration of symptoms) between the two groups (P = 0.165, P = 0.580, P = 0.662, P = 0.716, P = 0.231, and P = 0.152, respectively). After treatment, all patients exhibited significant improvement in ROM and functional scores (P = 0.001 and P = 0.001, respectively). At 3 months postoperatively, the two-stage group exhibited significantly improved forward flexion and internal rotation compared with the one-stage group (P = 0.001 and P = 0.038, respectively). No significant difference in ROM was noted between the two groups at 6, 12, 24 months postoperatively and the final follow-up. In addition, no significant differences in VAS, ASES, Constant-Murley score and satisfaction rate were noted between the two groups at final follow-up (P = 0.319, P = 0.529, P = 0.711, and P = 0.085, respectively).

Conclusion

In the treatment of rotator cuff tear with concomitant stiffness, although the recovery of ROM took longer in patients who underwent the one-stage procedure, satisfactory results at final follow-up can be achieved using either the one-stage procedure or two-stage procedure.

Study design

Case-control study.

Arthrofibrosis and large joint scarring

Large joint arthrofibrosis and scarring, involving the shoulder, elbow, hip, and knee, can result in the loss of function and immobility. The pathway of joint contracture formation is still being elucidated and is due to aberrations in collagen synthesis and misorientation of collagen fibrils. Novel antibodies are being developed to prevent arthrofibrosis, and current treatment methods for arthrofibrosis include medical, physical, and surgical treatments. This article describes the biology of joint contracture formation, along with current and future pharmacologic, biologic, and medical interventions.

Effects of Arthroscopic Coracohumeral Ligament Release on Range of Motion for Patients with Frozen Shoulder

Background:

A thickened coracohumeral ligament is a highly specific manifestation of, and primary restraint against external rotation in frozen shoulders.

Objective:

The purpose of this study was to evaluate the effects of complete arthroscopic coracohumeral ligament release on range of motion in frozen shoulder.

Methods:

Fifty-two consecutive shoulders in 52 patients were treated between April 2015 and June 2016. To evaluate solely glenohumeral range of motion, the scapula was fixed by an examiner with one hand (without palpating scapular motion), and range of motion was measured using a goniometer. For the first step, arthroscopic pancapsular release was performed in a beach-chair position with (Group 1) or without (Group 2) complete coracohumeral ligament release. For the final step, the remaining coracohumeral ligaments in Group 2 were released and the ranges of motion were compared to those in Group 1.

Results:

The average age of the patients was significantly higher in Group 1, but there were no significant differences between the two groups with respect to sex, affected side, preoperative range of motion, or American Shoulder and Elbow Society Score. Abduction, external rotation at adduction, and external and internal rotations at 90° of flexion in Group 1 were significantly greater than those in Group 2. After the additional release of the remaining coracohumeral ligaments in Group 2, all ranges of motion were significantly recovered and there was no significant difference between the groups.

Conclusion:

Complete coracohumeral ligament release is a recommended intraoperative procedure for regaining full range of motion in frozen shoulders.

The effectiveness of conservative and surgical treatment for shoulder stiffness: a systematic review of current literature

INTRODUCTION

Currently, no therapeutic intervention is universally accepted, and the most effective management for restoring motion and diminishing pain in patients with shoulder stiffness has yet to be defined. This systematic review analyses outcomes of conservative and surgical interventions to treat shoulder stiffness.

SOURCE OF DATA

A systematic review of literature according to the PRISMA guidelines was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, Ovid and Google Scholar databases using various combinations of the keywords 'shoulder', 'shoulder stiffness', 'stiff shoulder', 'conservative', since inception of databases to June 2018 was performed.

AREAS OF AGREEMENT

Shoulder stiffness could be treated with conservative means including nonsteroidal anti-inflammatory medications, corticosteroid injections, or transcutaneous electrical nerve stimulation, manipulation under anaesthesia, and arthroscopic capsular release.

AREAS OF CONTROVERSY

No therapeutic intervention is universally accepted, and the most effective management to restore motion and diminish pain in patients with shoulder stiffness has yet to be defined.

GROWING POINTS

The rate of failure after treatment for stiff shoulder is higher in the surgical group than in the conservative group.

AREAS TIMELY FOR DEVELOPING RESEARCH

There is insufficient evidence to establish whether surgical or conservative management is the best choice to manage shoulder stiffness. Prospective, randomized studies are needed to establish whether surgical or conservative management produce a clinically relevant difference in functional outcome.

A Rotator Cuff Tear Concomitant With Shoulder Stiffness Is Associated With a Lower Retear Rate After 1-Stage Arthroscopic Surgery

BACKGROUND

Few studies have reported on the radiological characteristics and repair integrity of coexistent rotator cuff tears (RCTs) and shoulder stiffness after simultaneous arthroscopic rotator cuff repair and capsular release.

PURPOSE

To evaluate the radiological characteristics and repair integrity of 1-stage arthroscopic surgery of RCTs concomitant with shoulder stiffness.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Among patients who underwent arthroscopic repair of full-thickness RCTs, the stiff group underwent simultaneous capsular release for shoulder stiffness, and the nonstiff group had no stiffness. Symptom duration, prevalence of diabetes, tear size, tendon involvement (type 1, supraspinatus; type 2, supraspinatus and subscapularis; and type 3, supraspinatus and infraspinatus; type 4, supraspinatus, subscapularis, and infraspinatus), and fatty infiltration (Goutallier stages 0-4) were evaluated. A retear was appraised using magnetic resonance imaging, and clinical outcomes were assessed using range of motion, the Korean Shoulder Scoring System (KSS), and the University of California, Los Angeles (UCLA) shoulder score.

RESULTS

The stiff group showed a significantly lower retear rate (1/39, 2.6%) than the nonstiff group (47/320, 14.7%) ( P = .043). There were significant differences in symptom duration (7.4 ± 6.6 vs 15.0 ± 23.7 months, respectively; P < .001), mediolateral tear size (18.9 ± 8.9 vs 24.1 ± 12.0 mm, respectively; P = .002), tendon involvement (94.9%, 5.1%, 0.0%, and 0.0% vs 85.3%, 6.9%, 7.8%, and 0.0%, respectively; P = .048), and fatty infiltration of the subscapularis (66.7%, 33.3%, 0.0%, 0.0%, and 0.0% vs 31.9%, 61.3%, 5.6%, 1.3%, and 0.0%, respectively; P < .001) and teres minor (74.4%, 20.5%, 5.1%, 0.0%, and 0.0% vs 47.2%, 48.8%, 3.8%, 0.0%, and 0.3%, respectively; P = .007) between the stiff and nonstiff groups. Preoperatively, the stiff group showed significantly worse forward flexion (95.9° ± 23.6° vs 147.7° ± 4.2°, respectively; P < .001), external rotation (17.4° ± 10.1° vs 51.6° ± 12.1°, respectively; P < .001), and internal rotation (L5 vs L2, respectively; P < .001) and lower KSS (52.1 ± 13.8 vs 66.3 ± 13.5, respectively; P < .001) and UCLA scores (18.7 ± 4.8 vs 22.5 ± 4.5, respectively; P < .001) than the nonstiff group. However, these differences became insignificant from 3 months postoperatively for forward flexion ( P > .05) and KSS ( P > .05) and UCLA scores ( P > .05), from 1 year postoperatively for external rotation ( P > .05), and at the last follow-up for internal rotation ( P > .05). A multiple logistic regression analysis revealed that only mediolateral tear size (odds ratio, 1.043; P = .014) and type 2 tendon involvement (odds ratio, 4.493; P = .003) were independent predictors of a retear.

CONCLUSION

RCTs concomitant with shoulder stiffness showed a smaller mediolateral tear size, anterosuperior tendon involvement, and less severe fatty infiltration preoperatively and better repair integrity postoperatively than RCTs without stiffness. Furthermore, the clinical outcomes and range of motion at final follow-up were similar between the 2 groups.

Comparison of Therapeutic Effectiveness Between Shoulder Distention Arthrography With Translation Mobilization and Distention Arthrography Alone in Patients With Frozen Shoulder

Objective

To evaluate the efficacy of distention arthrography (DA) alone and in combination with translational mobilization (TM) for treatment of patients with frozen shoulder (FS).

Methods

Eighty-five patients diagnosed with unilateral FS (freezing or frozen stage) were included. Forty-one patients were treated with DA and TM (group 1) and 44 patients with DA alone (group 2). Clinical assessments including visual analogue scale (VAS), Cyriax stage, and shoulder passive range of motion (PROM) including forward flexion, abduction, external rotation, and internal rotation were measured at baseline, 1 month, and 3 months following treatment.

Results

There were no significant differences in gender, side affected, symptom duration, presence of diabetes mellitus, VAS score, Cyriax stage, or shoulder PROM between the two patient groups at baseline. Compared with baseline metrics, patients in both groups demonstrated significantly improved outcome parameters at two post-treatment time points. However, mean all shoulder PROMs were significantly greater, and mean VAS score and Cyriax stage were lower in patients treated with DA and TM than in those treated with DA alone group at two post-treatment time points. At these times, mean interval change of all outcome parameters was significantly greater with DA and TM than DA alone. No serious complications were observed following treatment in either patient group.

Conclusion

Compared with DA alone, DA combined with TM more effectively alleviates shoulder pain and increases PROM in patients with freezing or frozen stage FS.

Short-term Clinical Results of Manipulation Under Ultrasound-Guided Brachial Plexus Block in Patients with Idiopathic Frozen Shoulder and Diabetic Secondary Frozen Shoulder

Purpose:

This study examined the effectiveness of manipulation under ultrasound-guided brachial plexus block in patients with recalcitrant idiopathic frozen shoulder and diabetic secondary frozen shoulder (diabetic frozen shoulder).

Methods:

Forty-four idiopathic frozen shoulders and 10 diabetic frozen shoulders with failed conservative treatment for at least 3 months were included in this study. The manipulation was performed under ultrasound-guided brachial plexus block and visual analogue scale, range of motion, and Constant scores were measured before manipulation and at the last follow-up examination.

Results:

No major complications were observed during the procedure. Sufficient improvement was not obtained in two patients during the procedure and to avoid complications, the procedure was discontinued and subsequently arthroscopic capsular release was performed. Visual analogue scale, range of motion towards all directions, and Constant scores were significantly improved after the manipulation in both the idiopathic frozen shoulder and diabetic frozen shoulder groups, however the diabetic group showed inferior results compared with those of the idiopathic group.

Conclusion:

This manipulation was effective and shortened the duration of symptoms in most of the idiopathic and diabetic frozen shoulders without major complications during the procedure. Diabetic frozen shoulder showed inferior clinical results and difficulty in recovery in range of motion, which indicated that diabetic frozen shoulder should be discussed as a different entity.

Translational manipulation under anesthesia for patients with frozen shoulder: a case series study with five-year health care utilization and post-manipulative arthroscopic findings

Study Design

Case series study.

Objectives

Although there have been no reported complications from translational manipulation under anesthesia (tMUA) for individuals with adhesive capsulitis (AC) there are no cases reporting surgical findings post tMUA. Also, there are no studies evaluating health care utilization following tMUA. The purpose of this study was to: (1) report clinical outcomes following tMUA, (2) describe relevant health care costs and utilization following tMUA, and (3) summarize findings from two cases receiving joint arthroscopy following tMUA.

Methods

Fourteen Individuals with AC underwent tMUA. Range of motion (ROM) and Shoulder Pain and Disability Index (SPADI) values were collected at baseline and six weeks follow-up. Shoulder-related health care cost and utilization were analyzed for a five-year period following tMUA. Two additional patients with AC underwent tMUA followed by arthroscopic assessment for evidence of iatrogenic injury.

Results

Thirteen patients completed the six-week follow-up. Mean change scores for ROM and SPADI values were flexion; +38.5°, abduction; +71.1°, external rotation (shoulder abducted); +49.8°, internal rotation (shoulder abducted); +26.6°, SPADI scores; +44.4. 13 patient records were analyzed for health care utilization. Ten of the 13 patients utilized no additional shoulder-related health care. Surgical evaluation revealed no evidence of iatrogenic injury.

Discussion

Clinical outcomes were similar to previous studies. Utilization data indicated that for the majority of patients, little shoulder-related health care was utilized. Surgical evaluation provided further evidence that tMUA performed by a physical therapist is safe. Future research will be required to establish a causal relationship between tMUA and the results observed in this study.

Level of Evidence

Therapy, Level 4.