Published online Dec 6, 2023. doi: 10.12998/wjcc.v11.i34.8147
Peer-review started: September 1, 2023
First decision: September 20, 2023
Revised: September 30, 2023
Accepted: November 21, 2023
Article in press: November 21, 2023
Published online: December 6, 2023
Processing time: 95 Days and 20.9 Hours
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.
To describe the arthroscopic findings in patients with idiopathic adhesive cap
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.
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 an
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.
Core Tip: Manipulation under anesthesia for a frozen shoulder can lead to damage to other intra-articular structures besides the rupture of the capsule, which is the main aim of this procedure. In most cases, it leads to rupture of the anterior capsule. This is the same area where arthroscopic releases are most often performed. Rupture of the posterior and inferior capsule can also occur depending on the rotational and adduction manipulation of the shoulder.
- Citation: Mlv SK, Mittal R, Chauhan N. Arthroscopic findings after manipulation under anesthesia in idiopathic capsulitis of the shoulder: A prospective study. World J Clin Cases 2023; 11(34): 8147-8152
- URL: https://www.wjgnet.com/2307-8960/full/v11/i34/8147.htm
- DOI: https://dx.doi.org/10.12998/wjcc.v11.i34.8147
Adhesive capsulitis, popularly known as ‘frozen shoulder’, is a common cause of shoulder pain and stiffness of the glenohumeral joint. It is thought to afflict between 2% and 5% of the population[1]. The condition has been described by some as self-limiting, lasting on average for a period of 2-3 years[2-4]. However, some studies have shown that between 20% and 50% of the patients still experience discomfort and stiffness beyond 3 years[5,6]. Although it is a self-limiting condition, patients find it impractical and challenging to wait for such a long period as it interferes with everyday life tasks. Most of the studies have reported manipulation under anesthesia (MUA) to be efficacious[7,8] and at least equi
Iatrogenic injuries to the upper limb including humeral fractures, glenohumeral dislocations, rotator cuff tears, glenoid fractures, brachial plexus injuries, labral tears, and hematomas pose the biggest risk and challenge during MUA[11]. Even though MUA is a very commonly practiced modality of treatment of adhesive capsulitis of the shoulder, there is not enough literature that documents the intra-articular changes after MUA. We could find only three published reports that described the arthroscopic findings post MUA[12-14], and only two publications have described the imaging of the shoulder after MUA[15,16]. Our study documented the arthroscopic findings after MUA of the shoulder in patients with idiopathic adhesive capsulitis of the shoulder.
The study was performed after obtaining institutional ethical committee clearance. Twenty-eight patients were included in this study for arthroscopic capsular release for idiopathic adhesive capsulitis of the shoulder. All patients included in the study had idiopathic stiffness of the shoulder with global restriction of shoulder movements for the prior 6 mo. Patients with a prior history of trauma or surgery to the shoulder were excluded. Any patient who received any form of treatment other than physiotherapy was also excluded. There were 20 females and 8 males. The ages ranged from 42 years to 62 years with an average age of 49.7 years. All patients had complaints of spontaneous onset of pain and stiffness of the shoulder. The opposite shoulder was normal.
All the patients had preoperative X-rays and magnetic resonance imaging (MRI) scans completed to rule out any secondary cause of adhesive capsulitis of the shoulder. The MRI was performed with the patient in a supine position and arms by the side. The images were obtained in axial, coronal oblique, and sagittal oblique planes. The protocols used were T1-weighted and T2-weighted with fat saturation and inversion recovery sequences.
The patients did not show improvement in their symptoms with physiotherapy and analgesics for at least 6 mo. After the administration of general anesthesia, manipulation of the shoulder was performed in a supine position. Manipulation was first done in flexion. Following this, the limb was manipulated in abduction. During the MUA, the proximal humerus was held with one hand close to the axilla and the other hand stabilized the scapula. Gentle pressure was used to mani
The patient was then placed in a semi-lateral position and the arm was abducted using a traction tower for arthroscopic global capsular release. Intra-articular findings were recorded before proceeding with capsular release. Entering the shoulder joint with sheath and trocar through the posterior portal was difficult compared to a non–stiff shoulder. The presence of blood and blood clots in the joint was the first arthroscopic finding. This required repeated joint lavage to clear all the blood and blood clots. When all the clots and blood were removed from the joint, the intra-articular struc
To make the anterior portal, the rotator interval was identified. The rotator interval had shrunken in size and had the presence of synovitis. A needle was passed from the outside to locate the site of the anterior portal within the rotator interval. The two portals were used alternately to pass the instruments and arthroscope to evaluate all the corners of the shoulder joint and perform a global capsular release. After surgery, patients were provided adequate analgesia and began active and passive range of motion exercises of the shoulder. The patients were followed at monthly intervals up to 5 mo, and all patients had significant relief in pain and improvement in range of motion.
Out of the twenty-eight patients, 27 had global synovitis, and 1 patient had synovitis localized to the rotator interval. Twenty-seven patients had thickening of the middle glenohumeral ligament, while one patient had normal ligaments. There were tears in the anterior capsule in 27 patients, whereas 1 patient had an anterior glenoid rim avulsion. The avulsed fragment was not repaired, and the patient had no complaints during follow-up. There were no instances of humeral head fracture or posterior capsular tear. Four patients experienced partial rotator cuff tears, which were not evident in the preoperative MRI. Since the tear involved less than 50% of cuff thickness, it was only debrided. There was also an instance of superior labrum anterior posterior tear that was not evident in preoperative MRI in 1 patient. It was not repaired, and the patient had an uneventful follow-up (Table 1).
Sample number | Arthroscopic finding | Patients, n |
1 | Global synovitis | 27 |
2 | Synovitis limited to rotator interval | 1 |
3 | Anterior capsular tears | 27 |
4 | Anterior glenoid rim avulsion | 1 |
5 | Thickened middle glenohumeral ligament | 27 |
6 | Normal middle glenohumeral ligament | 1 |
7 | Superior labrum anterior posterior tears | 1 |
8 | Rotator cuff tears | 4 |
Manipulation under general anesthesia is a widely practiced method of treatment of a frozen shoulder. In this technique, the shoulder joint capsule is gently stretched by moving the humerus after stabilizing the scapula into flexion and abdu
Atoun et al[16] evaluated the rotator cuff by ultrasound before and after MUA. They did not find any rotator cuff lesi
Sasanuma et al[15] performed MRI examination before and after MUA. They found tears in the inferior capsule either in the mid-substance or near the humeral insertion of the inferior capsule. They reported anterior and posterior tears of the inferior capsule but did not report any tears in the anterior capsule. This was quite different from the results of our study where we found only anterior tears. This could be due to the difference in the method of manipulation of the shoulder. Unlike these authors, we did not aim to achieve a range of motion equal to the opposite side. We applied gentle force and stopped short of forceful manipulations. In addition, we did not perform any rotational movements of the shoulder during MUA.
Gerber et al[17] described a correlation between the limb position and tension in the articular capsule. They reported tension in the posterior capsule in the position of internal rotation and adduction. These movements were not performed in the manipulation in our study, and this may explain the lack of posterior capsular tears in our patients. A combination of abduction/external rotation and forward flexion tightened the anterior inferior capsule. The presence of anterior injuries in our study can be explained by the flexion and abduction manipulation of the joint. Sasanuma et al[15] also reported four labrum tears occurring in patients with mid-substance tears of the inferior capsule and the absence of any new rotator cuff tears. However, Loew et al[14] described MUA quite similar to that performed by Sasanuma et al[15], and they found capsular ruptures all around the shoulder.
Wiley et al[12] in their landmark paper presented the arthroscopy findings of frozen shoulder. They described the arth
Uitvlugt et al[13] presented arthroscopy findings of frozen shoulder patients. They described 21 patients before mani
Loew et al[14] documented arthroscopic findings after manipulation in 30 patients. They found anterior capsule rup
We have noticed anterior capsular tears post-manipulation in our patients. As the MUA for a frozen shoulder has a risk of iatrogenic fractures, we have not attempted rotational manipulation. Hence, we performed arthroscopic global cap
Our strict inclusion and exclusion criteria during the patient recruitment is a strength of our study, and a low sample size is our limitation. Arthroscopic findings of the shoulder both before and after the MUA can provide better insight and should be considered as a potential area for future research.
MUA leads to rupture of the capsule, which is the desired outcome. The site of rupture of the capsule depends on the maneuver of manipulation. In most cases, it leads to rupture of the anterior capsule. This is the same area where arthroscopic releases are most often performed. Rupture of the posterior and inferior capsule can also occur depending on the rotational and adduction manipulation of the shoulder. In addition, partial tears of the rotator cuff and osteochondral frac
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 desc
Even though MUA is a very commonly practiced modality of treatment of adhesive capsulitis of the shoulder, there is not enough literature that documents the intraarticular changes after MUA.
The object of this study was to document the arthroscopic findings after MUA of the shoulder in patients with idiopathic adhesive capsulitis of the shoulder.
This was a prospective study to describe the arthroscopic findings in patients with idiopathic adhesive capsulitis of the shoulder after MUA.
All patients showed the presence of synovitis. Most patients had global synovitis, while 1 patient had synovitis limited to the rotator interval. A majority of patients post manipulation showed tears in anterior capsule, whereas only 1 patient had avulsion of the anterior labrum post manipulation.
MUA leads to the 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 glen
MUA for a frozen shoulder can lead to damage to other intra-articular structures besides the rupture of the capsule, which is the main aim of this procedure. In most cases, it leads to rupture of the anterior capsule.
Provenance and peer review: Invited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Medicine, research and experimental
Country/Territory of origin: India
Peer-review report’s scientific quality classification
Grade A (Excellent): 0
Grade B (Very good): 0
Grade C (Good): C
Grade D (Fair): 0
Grade E (Poor): 0
P-Reviewer: Luo ZW, China S-Editor: Wang JJ L-Editor: Filipodia P-Editor: Wang JJ
1. | Cleland J, Durall CJ. Physical Therapy for Adhesive Capsulitis: Systematic Review. Physiotherapy. 2002;88:450-457. [DOI] [Cited in This Article: ] [Cited by in Crossref: 27] [Cited by in F6Publishing: 26] [Article Influence: 1.2] [Reference Citation Analysis (0)] |
2. | Vermeulen HM, Obermann WR, Burger BJ, Kok GJ, Rozing PM, van Den Ende CH. End-range mobilization techniques in adhesive capsulitis of the shoulder joint: A multiple-subject case report. Phys Ther. 2000;80:1204-1213. [PubMed] [Cited in This Article: ] |
3. | Jayson MI. Frozen shoulder: adhesive capsulitis. Br Med J (Clin Res Ed). 1981;283:1005-1006. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 31] [Cited by in F6Publishing: 33] [Article Influence: 0.8] [Reference Citation Analysis (0)] |
4. | Baslund B, Thomsen BS, Jensen EM. Frozen shoulder: current concepts. Scand J Rheumatol. 1990;19:321-325. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 39] [Cited by in F6Publishing: 39] [Article Influence: 1.1] [Reference Citation Analysis (0)] |
5. | Binder AI, Bulgen DY, Hazleman BL, Roberts S. Frozen shoulder: a long-term prospective study. Ann Rheum Dis. 1984;43:361-364. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 219] [Cited by in F6Publishing: 188] [Article Influence: 4.7] [Reference Citation Analysis (0)] |
6. | Shaffer B, Tibone JE, Kerlan RK. Frozen Shoulder. A Long-Term Follow-Up. J Bone Joint Surg Am. 1992;74:738-746. [DOI] [Cited in This Article: ] [Cited by in Crossref: 369] [Cited by in F6Publishing: 308] [Article Influence: 9.6] [Reference Citation Analysis (0)] |
7. | Dodenhoff RM, Levy O, Wilson A, Copeland SA. Manipulation under anesthesia for primary frozen shoulder: effect on early recovery and return to activity. J Shoulder Elbow Surg. 2000;9:23-26. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 111] [Cited by in F6Publishing: 113] [Article Influence: 4.7] [Reference Citation Analysis (0)] |
8. | Ahmad D, Hashim JA, Asim HM. Outcome of manipulation under anaesthesia in adhesive capsulitis patients. J Coll Physicians Surg Pak. 2014;24:293-294. [PubMed] [Cited in This Article: ] |
9. | Quraishi NA, Johnston P, Bayer J, Crowe M, Chakrabarti AJ. Thawing the frozen shoulder. A randomised trial comparing manipulation under anaesthesia with hydrodilatation. J Bone Joint Surg Br. 2007;89:1197-1200. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 91] [Cited by in F6Publishing: 93] [Article Influence: 5.8] [Reference Citation Analysis (0)] |
10. | Kivimäki J, Pohjolainen T. Manipulation under anesthesia for frozen shoulder with and without steroid injection. Arch Phys Med Rehabil. 2001;82:1188-1190. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 57] [Cited by in F6Publishing: 43] [Article Influence: 1.9] [Reference Citation Analysis (0)] |
11. | Hsu JE, Anakwenze OA, Warrender WJ, Abboud JA. Current review of adhesive capsulitis. J Shoulder Elbow Surg. 2011;20:502-514. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 216] [Cited by in F6Publishing: 214] [Article Influence: 16.5] [Reference Citation Analysis (0)] |
12. | Wiley AM. Arthroscopic appearance of frozen shoulder. Arthroscopy. 1991;7:138-143. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 145] [Cited by in F6Publishing: 140] [Article Influence: 4.2] [Reference Citation Analysis (0)] |
13. | Uitvlugt G, Detrisac DA, Johnson LL, Austin MD, Johnson C. Arthroscopic observations before and after manipulation of frozen shoulder. Arthroscopy. 1993;9:181-185. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 89] [Cited by in F6Publishing: 85] [Article Influence: 2.7] [Reference Citation Analysis (0)] |
14. | Loew M, Heichel TO, Lehner B. Intraarticular lesions in primary frozen shoulder after manipulation under general anesthesia. J Shoulder Elbow Surg. 2005;14:16-21. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 148] [Cited by in F6Publishing: 116] [Article Influence: 6.1] [Reference Citation Analysis (0)] |
15. | Sasanuma H, Sugimoto H, Kanaya Y, Iijima Y, Saito T, Takeshita K. Magnetic resonance imaging and short-term clinical results of severe frozen shoulder treated with manipulation under ultrasound-guided cervical nerve root block. J Shoulder Elbow Surg. 2016;25:e13-e20. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 18] [Cited by in F6Publishing: 23] [Article Influence: 2.9] [Reference Citation Analysis (0)] |
16. | Atoun E, Funk L, Copland SA, Even T, Levy O, Rath E. The effect of shoulder manipulation on rotator cuff integrity. Acta Orthop Belg. 2013;79:255-259. [PubMed] [Cited in This Article: ] |
17. | Gerber C, Werner CM, Macy JC, Jacob HA, Nyffeler RW. Effect of selective capsulorrhaphy on the passive range of motion of the glenohumeral joint. J Bone Joint Surg Am. 2003;85:48-55. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 106] [Cited by in F6Publishing: 105] [Article Influence: 5.0] [Reference Citation Analysis (0)] |