Non-Surgical Management of Frozen Shoulder Using Manipulation Under Local Anesthesia: A Retrospective Study

Introduction

Frozen shoulder (FS), also known as adhesive capsulitis, is a common shoulder pathology characterized by progressive limitation of glenohumeral movements with pain in the shoulder joint, resulting in significant functional loss [1]. FS is one of the most common but challenging shoulder pathologies encountered in orthopedic clinics. The prevalence of FS is 2% to 5% and it is more common in women than men [2,3]. Since the natural history and pathogenesis of FS have not been extensively investigated, cause-and-effect relationships are not yet fully understood. FS is clinically manifested by limited shoulder joint motion, both actively and passively, despite normal radiological imaging of the glenohumeral joint [3]. As a result of the research conducted so far, FS can be clinically divided into 3 stages. Stage 1 is freezing (onset of shoulder pain with progressive limitation of movement), stage 2 is frozen (relative reduction of pain, reduction of joint stiffness with active and passive range of motion (ROM), and stage 3 is thawing (gradual improvement of shoulder joint motion and progressive reduction of pain) [4]. Histopathology findings include thickening of the capsule with an inflammatory appearance of the coracohumeral and middle glenohumeral ligaments. The affected capsule contains many fibroblasts, mast cells, macrophages, and T cells. The synovitis present is associated with an increase in fibrotic growth factors, inflammatory cytokines, and interleukins [5,6]. Treatment of FS is a difficult and grueling process for both patients and physicians. A number of conservative treatment modalities have been used to treat FS, including joint mobilization, which improves tissue stretching, increases range of motion, reduces pain, decreases soft-tissue edema, increases synovial fluid levels, and stimulates peripheral mechanoreceptors [7,8]. In addition to all these treatment methods, a growing number of publications show the effect of joint mobilization techniques in the treatment of FS. Most mobilization techniques can be combined with each other or with different physical therapy methods [7,9]. A true evidence-based model for the medical management of surgical and conservative treatments has yet to be defined. From the international level to the clinical level, patient pain management varies widely [10]. The British Elbow and Shoulder Association/British Society of Orthopedics (BESS/BOA) has published an advisory patient care guide for people with FS. Studies are being conducted to compare the clinical and cost-effectiveness of patients with FS, early physiotherapy, joint manipulation under anesthesia, and arthroscopic capsular release [11]. Here, we assessed shoulder manipulation under local anesthesia in outpatient clinic conditions without hospitalization of patients with FS, without general or sedoanalgesia.

Material and Methods

PROTOCOL:

By using the goniometer before the treatment we measured and recorded flexion, extension, abduction, adduction, and external and internal rotation values. VAS, SPADI, and ROM values were recorded by the same surgeon before and after manipulation and at the 3-month follow-up. Before manipulation, the procedure was explained to the patients in detail and their consent was obtained. In aseptic conditions, a mixture of approximately 20 cc of 2% prilocaine (19 cc) and 40 mg methylprednisolone acetate (1 cc) was injected into the shoulder with FS from 6 different points (glenohumeral joint, tuberculum majus, tuberculum minus, coracoid, supraglenoid tubercle, and subacromial bursa), with 3 to 3.5 cc injected at each point (Figure 1). All patients received a single set of injections. After the injection, we waited 15 minutes for the effect of local anesthesia to start. Patients were placed in supine position and passive manipulation was performed sequentially in 4 directions (abduction, flexion, extension, and external rotation). Passive manipulation was performed as slowly as possible and by giving commands to the patient so that the patients had less pain during the procedure and performed their movements in a coordinated manner. These movements were performed sequentially until the patient reached maximum shoulder abduction, flexion, extension, and external rotation.

In the method described in this study, patients remain awake throughout the procedure and gradually increase shoulder ROM by passive manipulation movement under local anesthesia. Patients were given home exercise programs to maintain the ROM obtained after the procedure and were called for follow-up. The home exercise program included active-assisted and passive shoulder ROM exercises (flexion, abduction, external and internal rotation), performed 3 to 4 times daily, with each session lasting approximately 15 to 20 minutes.

STATISTICAL ANALYSIS:

Statistical analyzes were performed usinf SPSS version 25.0. The conformity of the variables to normal distribution was examined by histogram graphics and the Kolmogorov–Smirnov test. Mean, standard deviation, median, and min-max values were to presenting results of descriptive analyses. The Mann-Whitney U test was used when evaluating non-normally distributed (nonparametric) variables between 2 groups. The Friedman test and Wilcoxon test were used when comparing the changes in before and after manipulation and LC (last check) measurements within the group, and repeated measures analysis was used when comparing between groups. Spearman correlation analysis was used for between-group comparisons. P values below 0.05 were considered as statistically significant results.

Results

A total of 32 patients, 10 male and 22 female, were included in the study. The mean age of the patients was 54.81±8.23 years, with an age range of 36 to 71 years. There were 17 patients with right shoulder direction and 15 patients with left shoulder direction. There were 2 patients with asthma, 2 patients with diabetes mellitus (DM), 1 patient with DM and hypertension (HT), and 1 patient with hyperthyroidism. Demographic data of the patients are shown in Table 1.

The clinical diagnosis of frozen shoulder was made by physical examination according to ISAKOS criteria. All patients had painful and limited ROM. Direct radiographs and magnetic resonance imaging (MRI) were performed to assess for additional pathologies in patients diagnosed by physical examination. Patients with additional pathology on MRI and direct radiography that could limit shoulder ROM were excluded from the study to prevent a different pathology in the shoulder from affecting the results of our treatment modality.

After passive manipulation, shoulder abduction and flexion improved rapidly and extension improved over time.

Extension (Ext), flexion (Flex), abduction (Abd), adduction (Add), internal rotation (IR), external rotation (ER), and VAS were assessed 3 times before and after manipulation and LC. The change in these measurements was examined and a significant relationship was found (P<0.05) Accordingly, Ex, Flex, Abd, Add, IR, and ER values increased significantly after manipulation compared to before manipulation (P<0.05). Ex, Flex, Abd, Add, IR, and ER values increased significantly at the LC compared to before and after manipulation, while VAS value decreased significantly (P<0.05) (Table 2, Figure 2).

Shoulder Pain Score (SPS), Shoulder Pain Score%, Shoulder Disability Score (SDS), S.Disabilİty Score%, Shoulder Total Score (STS), and Shoulder Total Score% values were measured twice as pre-manipulation and as LC. The change in these measurements was examined and a significant relationship was found (P<0.05). Accordingly, SPS, SPS%, SDS, SDS%, STS, and STS% values were decreased at the LC compared to before manipulation (Table 3).

Discussion

LIMITATIONS:

The first limitation of this study is that it was a retrospective study. Therefore, there was no control group and patients were not randomized. Secondly, the wide age range of the patients and age-related physiologic changes in muscle strength and joint ROM may have affected the results. Third, long-term patient outcomes were not included because follow-up data from the retrospective study were missing. Although multiple treatment modalities are described in the literature, there is a lack of evidence regarding manipulation under local anesthesia, which is a gap this study addresses.

Conclusions

This study describes a general management approach that focuses on the clinical manifestation of FS, which can be painful and disabling. The results show that passive manipulation performed in communication with the patient under local anesthesia and subsequent home exercise programs significantly improve FS. The fact that patients are awake minimizes the risk of complications. The materials we used in this treatment are cheap and easily available, and it can be a useful method for patients unwilling to undergo surgery. Although our study had a small sample size, we think that this method for treatment of FS can be applied to a larger population.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.