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Manipulation for frozen shoulder: Long-term results
Manipulation for frozen shoulder: Long-term results Christopher M. Farrell, MD,a John W. Sperling, MD,a and Robert H. Cofield, MD,a Rochester, MN
Although much has been published regarding shoulder manipulation under anesthesia for the treatment of frozen shoulder, there are no reported long-term results. In 25 patients (26 shoulders) in whom nonoperative treatment for idiopathic frozen shoulder had failed, we performed manipulation under anesthesia. All had had physical therapy for a mean of 6.2 months. Follow-up was by examination until the end of active treatment. Longer-term follow-up was obtained in 18 patients (19 shoulders) by questionnaire and averaged 15 years (range, 8.1 to 20.6 years). There were significant improvements in forward elevation from a mean of 104° before manipulation (range, 70° to 140°) to 168° (range, 90° to 180°) and in external rotation from 23° (range, –5° to 70°) to 67° (range, 0° to 90°). There were 16 shoulders with no pain or slight pain and 3 with occasional moderate or severe pain. There were no fractures, dislocations, or other complications. Of the 19 shoulders, 18 required no further surgery. At long-term follow-up, the mean Simple Shoulder Test score was 9.5 out of 12 and the mean American Shoulder and Elbow Surgeons score was 80 out of 100. Treatment of idiopathic frozen shoulder by manipulation under anesthesia leads to sustained improvement in shoulder motion and function at a mean of 15 years after the procedure. (J Shoulder Elbow Surg 2005;14:480-484.)
D uplay
2
described a painful stiffening of the shoulder, which he named humero-scapular periarthritis in 1872. He attributed the disease to inflammation of the subacromial bursa and proposed manipulation under anesthesia as a form of treatment for the disorder. Later, Codman1 utilized the term frozen shoulder to describe the condition of a painful restriction of shoulder motion. His comments describing the condition as “difficult to define, difficult to treat and difficult to explain from the point of view of pathology” remain true toady. Neviaser7 recorded his operative
From Mayo Clinic,a Rochester, MN, USA. Reprint requests: John W. Sperling, MD, Mayo Clinic, 200 First St, SW, Rochester MN 55905 (E-mail: [email protected]). Copyright © 2005 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2005/$30.00 doi:10.1016/j.jse.2005.02.012
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and histologic observations in 10 affected patients and in 63 cadaveric shoulders. He found the subacromial bursa to be unaffected and the capsule to be thickened and adherent to the humeral head. He proposed that the pathology primarily involved the shoulder capsule, suggesting the term adhesive capsulitis as a better name for the disease. Reeves11 believed the condition to involve 3 phases: the painful phase, the frozen phase, and the thawing phase, where motion and pain gradually improve but last a variable course, estimated to be 12 to 42 months. Thus, frozen shoulder has been defined as a condition of uncertain etiology, characterized by painful restriction of active and passive shoulder motion occurring in the absence of a known intrinsic shoulder disorder.5 The overall objective in the treatment of patients with frozen shoulder is to relieve pain and restore motion. The treatment modalities used today usually begin with nonoperative measures including anti-inflammatory medications, injections, and physical therapy. However, it has been reported that a substantial subset of patients, up to 30%, do not improve with these measures.12 Adjunctive treatment might include capsular distention or brisement, manipulation under anesthesia, or arthroscopic or open capsule releases. Although most clinicians concede that the conservative measures should be first-line measures to combat this frequently self-limiting disease, there is little consensus on the second line of treatment for a frozen shoulder resistant to conservative modalities. Much has been written on manipulation under anesthesia,3,4,9,10 and many authors have reported on this as a safe and effective treatment. However, critics cite reports of iatrogenic fracture, glenohumeral dislocation, rotator cuff tearing, and nerve injuries as reasons to avoid this treatment method. The purpose of this study was to evaluate manipulation under anesthesia in a carefully selected group of patients with idiopathic frozen shoulder to identify whether the procedure is safe and effective over the long term. We also wished to learn whether subsequent shoulder problems developed. MATERIALS AND METHODS With the use of the surgical indices as a database, patients who underwent manipulation under anesthesia for frozen shoulder between 1981 and 1993 were identified.
Farrell, Sperling, and Cofield
J Shoulder Elbow Surg Volume 14, Number 5
All manipulations were done by the senior author. The criteria for patient selection included the diagnosis of frozen shoulder characterized by pain and limited active and passive range of motion (ROM) of the shoulder for which no other cause could be identified, no prior surgery of the affected shoulder, no previous fracture or dislocation of the affected shoulder, no history of any other intrinsic or extrinsic cause of stiffness, and a normal radiograph of the affected shoulder. Magnetic resonance imaging or arthrography was performed in all patients except one who had smooth subacromial motion, no weakness, and no signs or symptoms focal to the supraspinatus area. Each of the arthrograms and magnetic resonance images was negative for a full-thickness rotator cuff tear. We identified 25 patients (26 shoulders) who satisfied these criteria. There were 16 women and 9 men. The mean age was 50 years (range, 33 to 69 years). Of the patients, 21 had known occupations; there were 5 who did light labor, 3 who did heavy labor, 3 managers, 6 professionals, 2 homemakers, and 2 retired persons. Eight patients had diabetes mellitus. Twenty-three patients had physical therapy before manipulation under anesthesia. One, who did not have physical therapy, had diabetes mellitus and a rapid onset of progression of pain and limited motion; the physical therapy program could not be tolerated. The second patient had a frozen shoulder on the opposite side 18 months earlier, had failed physical therapy, and had undergone successful manipulation under anesthesia and wished to proceed without further delay. The length of pre-manipulation physical therapy averaged 199 days (range, 10 to 731 days). Nineteen patients had an injection before manipulation. The overall time from the onset of symptoms to treatment averaged 11 months (range, 2 months to 3 years). All patients had shoulder manipulation under general anesthesia with adjunctive muscle paralysis. No patient had regional anesthesia for perioperative pain management. The method of manipulation was standard. The patient was placed in the supine position. The shoulder was moved into flexion until the point of resistance. Continuing gentle pressure was applied on the distal humerus until adhesions gave way. The shoulder was then externally rotated with the arm in 90° of abduction. Usually little resistance was encountered. If resistance was present, gentle pressure was applied, and the maximal amount of external rotation was attained. The arm was then moved into full abduction. Next, stretching was performed in internal rotation at 90° of abduction. Then cross-body adduction was performed. Finally, the arm was gently externally rotated at 45°, 30°, and 0° of abduction to attain the maximum movement in all positions. Patients’ arms were placed in an abduction humeral splint at 80° of abduction. Patients underwent gentle active-assisted motion by a physical therapist in the hospital on the afternoon of the manipulation. Motion was practiced in flexion, abduction, adduction, and internal and external rotation. On the next day, the abduction splint was removed, and a sling was supplied for brief intermittent use. The patient was discharged from the hospital on the afternoon of the second day. Physical therapy continued on an outpatient basis and included
481
supervised and home exercise programs focused on stretching. Physical therapy was then progressed to include isometric strengthening exercises followed by use of elastic bands. Follow-up was by office visit at 2 weeks and generally each subsequent 6 weeks until the end of treatment. Longterm follow-up was obtained by a standardized questionnaire for mailing or telephone interview. Five patients died before long-term follow-up could be completed; one patient declined participation in this study and was lost to followup. Longer-term follow-up was obtained in 19 shoulders and averaged 15 years (range, 8.1 to 20.6 years). For the 19 shoulders available for long-term follow-up, data were collected with regard to level of pain, ROM, function, and overall satisfaction. A pain scale was used to assess overall pain, night pain, rest pain, and pain with activity both before the procedure and at long-term follow-up. At longterm follow-up, patients were asked if they required overthe-counter or narcotic analgesics for pain. Subjective stability and strength were evaluated on a 10-point scale. In addition, each patient was asked about overall satisfaction and willingness to have the same procedure again should he or she experience the problem in the opposite shoulder. Each patient was assigned a Simple Shoulder Test and American Shoulder and Elbow Surgeons score for the involved side and the uninvolved side for comparison.
RESULTS Complications
There were no observed complications from treatment; specifically, there were no intraoperative fractures, dislocations, symptomatic rotator cuff tears, regional pain disorders, or neurovascular injuries as a result of the manipulation. One patient required surgery for a symptomatic rotator cuff tear 3 years later. She had had an excellent result after the manipulation with regard to pain relief and motion for over a year until the development of further symptoms. Of note, after undergoing rotator cuff repair and acromioplasty, she again developed a frozen shoulder. Motion
Range of motion was documented before manipulation, during manipulation, at the last visit, and at long-term follow-up by surveys (Table I). Pre-manipulation elevation averaged 104° (range, 70° to 140°), external rotation averaged 23° (range, –5° to 70°), and internal rotation was to the fifth lumbar vertebral (range, trochanter to T12). Average motion during manipulation measured 175° of forward elevation (range, 160° to 180°) and 83° of external rotation (range, 70° to 100°). Average ROM at the last office visit measured 149° of elevation (range, 105° to 180°), 49° of external rotation (range, 15° to 90°), and internal rotation to L4 (range, abdomen to T10). For the 19 patients available for longer follow-up, average forward elevation was 168° (range, 90° to
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J Shoulder Elbow Surg September/October 2005
Table I Preoperative, intraoperative, and follow-up data regarding forward elevation and external rotation
Patient No.
Age (y)
Sex
Occupation
Preoperative FE (°)
Intraoperative FE (°)
Long-term FE (°)
FE in uninvolved shoulder at long-term follow-up (°)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
52 48 63 49 51 52 48 51 51 51 59 40 52 52 36 46 70 48 53
F M F F F F M F M F M F F F M M F F F
Light labor Professional Professional Retired Retired Retired Manager Manager Professional Homemaker Light labor Professional Homemaker Retired Heavy labor Manager Retired Professional Light labor
135 120 105 100 95 90 80 135 120 120 90 70 70 100 110 110 100 140 90
180 175 175 180 180 170 175 175 180 170 180 175 170 180 165 180 170 180 170
150 180 150 180 180 180 160 160 180 180 180 180 180 180 150 180 180 180 90
180 180 180 180 180 180 180 170 180 180 180 180 180 180 140 180 180 180 180
Preoperative ER (°)
Intraoperative ER (°)
Long-term ER (°)
ER in uninvolved shoulder at long-term follow-up (°)
70 25 35 0 30 15 40 20 10 20 20 20 25 0 20 10 – 25 50
90 80 80 80 75 80 85 85 90 75 75 80 80 90 100 80 80 85 80
30 60 90 50 90 90 50 40 90 20 90 90 60 90 10 90 0 90 30
80 60 90 50 90 90 50 40 90 50 90 90 60 90 0 90 0 90 30
FE, forward elevation; ER, external rotation.
180°), external rotation was 61° (range, 0° to 90°), and internal rotation was to T12 (range, L5 to T5). The Wilcoxon signed rank test was used to compare motion in the 19 shoulders available for longerterm follow-up. In these patients, forward elevation and external rotation preoperatively were compared with measurements taken intraoperatively, immediately by postoperatively, at last clinical follow-up, and at longer-term follow-up. A P value less than .05 was considered significant. For this subset of patients, intraoperative forward elevation increased 70° (P ⬍ .01) compared with preoperatively. Immediate postoperative forward elevation increased 47.5° (P ⬍ .01) compared with preoperatively. At least clinical follow-up, forward elevation increased 50° (P ⬍ .01) compared with preoperatively. At longer-term follow-up, based on survey data, forward elevation increased 70° (P ⬍ .01). For this subset of patients, intraoperative external rotation increased 60° (P ⬍ .01) compared with external rotation preoperatively. Immediate postoperative external rotation had increased 25° (P ⬍ .01) compared with preoperatively. At last clinical followup, external rotation increased 30° (P ⬍ .01) compared with preoperatively. At longer-term follow-up, based on survey data, external rotation increased 38° (P ⬍ .01). Pain
For the 19 shoulders available for longer followup, 10-point pain scales were used to establish the level of overall pain, night pain, resting pain, and
activity pain. Overall, 13 shoulders had no pain, 3 had slight pain, 2 had occasional moderate pain, and 1 had moderate pain. Thirteen shoulders had no night pain, two had slight night pain, two had occasional moderate night pain, and two had moderate to severe night pain. Thirteen shoulders had no rest pain, five had slight rest pain, one had occasional moderate rest pain, and none had severe rest pain. Twelve shoulders had no activity-related pain, three had slight pain on activity, three had occasional minor to moderate activity-related pain, and one had moderate to severe activity-related pain. In all but 2 patients, pain in the affected and unaffected shoulder was nearly the same. Stability and strength
All patients felt that they had a stable shoulder. Sixteen had normal to good shoulder strength, one had fair strength, and two had poor strength in the shoulder. Satisfaction
Patients were asked to indicate their level of overall satisfaction with their shoulder before manipulation and at long-term follow-up. All patients rated their satisfaction as poor before manipulation (1/10 on digital scale). The mean score after manipulation was very good (8/10 on digital scale). As a corollary to this, the patients were asked if would they choose to undergo manipulation under anesthesia if they had the same problem in the opposite shoulder. Twelve patients indicated that they would chose to do so, and
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Table II ASES pain score, functional score, and overall score, as well as Simple Shoulder Test scores tabulated for each patient with regard to involved and uninvolved shoulders ASES pain score
ASES function score
ASES overall score
Simple Shoulder Test score
Patient No.
Age (y)
Sex
Occupation
Involved
Uninvolved
Involved
Uninvolved
Involved
Uninvolved
Involved
Uninvolved
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
52 48 63 49 51 52 48 51 51 51 59 40 52 52 36 46 70 48 53
F M F F F F M F M F M F F F M M F F F
Light labor Professional Professional Retired Retired Retired Manager Manager Professional Homemaker Light labor Professional Homemaker Retired Heavy labor Manager Retired Professional Light labor
35 40 20 50 50 50 50 35 50 25 50 50 50 50 35 50 50 50 5
40 40 40 50 50 50 50 50 50 30 50 35 50 50 30 50 50 50 50
30 48 30 40 47 47 42 28 50 22 50 18 50 50 33 50 33 50 12
42 47 47 40 47 47 48 45 50 28 50 40 50 50 32 50 33 50 27
65 88 50 90 97 97 92 63 100 47 100 68 100 100 68 100 83 100 17
82 87 87 90 97 97 98 95 100 58 100 75 100 100 62 100 83 100 77
7 12 6 10 12 12 11 4 12 6 12 12 12 10 9 12 9 12 1
10 12 12 9 12 12 11 8 12 6 12 30 12 10 7 12 9 12 7
ASES, American Shoulder and Elbow Surgeons.
four indicated that they would not. Two others did not answer the question.
mean difference in the overall American Shoulder and Elbow Surgeons score for the involved and uninvolved shoulders was 9 (P ⫽ .04) (Table II).
Result ratings
The 19 shoulders available for longer follow-up were evaluated by use of the Simple Shoulder Test and the American Shoulder and Elbow Surgeons score (Table II). Nine patients scored 12 of 12 on the Simple Shoulder Test. Twelve scored 10 or better on the Simple Shoulder Test, five patients scored between 6 and 9, and two scored less than 6. The mean Simple Shoulder Test score was 9.5 on the involved side and 11.3 on the uninvolved side. The mean difference in the Simple Shoulder Test score for the involved and uninvolved shoulders was 1.8 (P ⫽ .10). On the functional component of the American Shoulder and Elbow Surgeons scoring system, 11 patients scored 40 to 50, 6 scored between 20 and 39, and 2 scored below 20. The mean American Shoulder and Elbow Surgeons functional score was 38 on the involved side and 43 on the uninvolved side. The most common activities that patients either were unable to perform or had greater difficulty performing with the involved shoulder were washing the back/putting on a bra and lifting 10 lb above the shoulder (7 shoulders). The mean difference between involved and uninvolved shoulders for the functional American Shoulder and Elbow Surgeons score was 5 (P ⫽ .01). The mean American Shoulder and Elbow Surgeons overall score, including the pain rating, was 80 on the involved side and 89 on the uninvolved side. The
DISCUSSION
For the small number of patients in whom conservative treatment for frozen shoulder fails,6,12 manipulation under anesthesia has been advocated as a useful treatment option. Hill and Bogumill4 studied 17 patients who were followed up for a mean of 22 months, and they found that 70% had returned to work in less than 6 months and had improved motion and no complications. Placzek et al10 studied 31 patients who underwent translational manipulation and followed them up for a mean of 14 months. These patients demonstrated a mean improvement in ROM in flexion of 63°, in external rotation of 58°, and in internal rotation of 47°. They also had a reduction in pain, and there were no complications. Neviaser reported the 5-year follow-up of 46 cases of manipulation under anesthesia.8 In this study, all patients had obtained their 5-year follow-up range of motion within 6 months from the manipulation except those patients with diabetes. Our study is the first to review the results of longerterm outcomes in patients who have an idiopathic frozen shoulder and who have undergone treatment by manipulation under anesthesia. Inclusion criteria were selective in order to exclude related but dissimilar conditions. During this longer period of follow-up, ROM continued to be improved, with mean improvement in elevation of 70° and in external rotation of
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53°. This is similar to the shorter-term reviews. Pain improved to none in 13, slight in 3, and occasionally moderate in 2 with only 1 patient reporting severe pain at longer follow-up. This patient with severe overall pain interestingly developed spasmodic torticollis several years after manipulation; this is not considered to be a result of the manipulation. One patient with occasional moderate overall pain had sustained a fracture in a fall 8 years after manipulation, and at the time of longer-term assessment, it had only been 18 months since closed treatment of this injury was performed. In the other patient with occasional moderate overall pain, glenohumeral arthritis developed 16 years after manipulation. On the basis of result ratings for the involved shoulder, the mean Simple Shoulder Score at longer follow-up was 9.5 for the involved side and 11.3 for the uninvolved side. This difference was not significant (P ⫽ .01). With regard to the American Shoulder and Elbow Surgeons score at longer-term follow-up, the mean for the involved shoulder was 80, and the mean for the uninvolved shoulder was 89. Although this difference is statistically significant (P ⫽ .04), the difference is small. The patients continued to report their satisfaction with manipulation. Of 16, 12 answered that they would undergo the procedure again if the problem developed on the contralateral side. A possible reason for motion restriction and pain in some patients may be a loss of ligament flexibility and degenerative rotator cuff disease that may have developed in the time since the manipulation. It may be possible that the patients who felt that they would not have the manipulation again were convinced that their present symptoms were a result of the manipulation rather than from other processes.
J Shoulder Elbow Surg September/October 2005
In conclusion, manipulation under anesthesia for the treatment of idiopathic frozen shoulder is safe and is reasonably effective for treatment should this prove to be necessary. With longer follow-up, the results have remained stable and, importantly, it is unlikely that additional shoulder problems will develop. REFERENCES
1. Codman EA. The shoulder: rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa. Boston, 1934. 2. Duplay S. De la peri-arthrite scapulo-humerale et des raideurs de l’epaule qui ensont la consequence. Arch Gen Med 1872;20: 513. 3. Helbig B, Wagner P, Dohler R. Mobilization of frozen shoulder under general anesthesia. Acta Orthop Belg 1983;49:267-74. 4. Hill JJ Jr, Bogumill H. Manipulation in the treatment of frozen shoulder. Orthopedics 1988;11:1255-60. 5. Iannotti JP, Williams GR. Disorders of the shoulder: diagnosis and management. Philadelphia: Lippincott Williams and Wilkins; 1999. 6. Murnaghan JP. Frozen shoulder. In: Rockwood C, Matsen FA, editors. The shoulder. 1st ed. Philadelphia: Saunders, 1990. p. 837-62. 7. Neviaser JS. Adhesive capsulitis of the shoulder. J Bone Joint Surg 1945;27:211. 8. Neviaser TJ. Adhesive capsulitis. In: McGinty JB, Caspari RB, Jackson RW, Poehling GG, eds. Operative arthroscopy. 2nd ed. Philadelphia, Lippincott-Raven; 1996. p. 785–91. 9. Ogilvie-Harris DJ, Biggs DJ, Fitsialos DP, MacKay M. The resistance frozen shoulder: manipulation versus arthroscopic release. Clin Orthop 1995;391:238-48. 10. Placzek JD, Roubal PJ, Freeman DC, et al. Long-term effectiveness of translational manipulation for adhesive capsulitis. Clin Orthop 1988;356:181-91. 11. Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol 1975;14:193-6. 12. Shafer B, Tibone JE, Kerlan RK. Frozen shoulder long-term followup. J Bone Joint Surg Am 1992;74:738-46.
Although much has been published regarding shoulder manipulation under anesthesia for the treatment of frozen shoulder, there are no reported long-term results. In 25 patients (26 shoulders) in whom nonoperative treatment for idiopathic frozen shoulder had failed, we performed manipulation under anesthesia. All had had physical therapy for a mean of 6.2 months. Follow-up was by examination until the end of active treatment. Longer-term follow-up was obtained in 18 patients (19 shoulders) by questionnaire and averaged 15 years (range, 8.1 to 20.6 years). There were significant improvements in forward elevation from a mean of 104° before manipulation (range, 70° to 140°) to 168° (range, 90° to 180°) and in external rotation from 23° (range, –5° to 70°) to 67° (range, 0° to 90°). There were 16 shoulders with no pain or slight pain and 3 with occasional moderate or severe pain. There were no fractures, dislocations, or other complications. Of the 19 shoulders, 18 required no further surgery. At long-term follow-up, the mean Simple Shoulder Test score was 9.5 out of 12 and the mean American Shoulder and Elbow Surgeons score was 80 out of 100. Treatment of idiopathic frozen shoulder by manipulation under anesthesia leads to sustained improvement in shoulder motion and function at a mean of 15 years after the procedure. (J Shoulder Elbow Surg 2005;14:480-484.)
D uplay
2
described a painful stiffening of the shoulder, which he named humero-scapular periarthritis in 1872. He attributed the disease to inflammation of the subacromial bursa and proposed manipulation under anesthesia as a form of treatment for the disorder. Later, Codman1 utilized the term frozen shoulder to describe the condition of a painful restriction of shoulder motion. His comments describing the condition as “difficult to define, difficult to treat and difficult to explain from the point of view of pathology” remain true toady. Neviaser7 recorded his operative
From Mayo Clinic,a Rochester, MN, USA. Reprint requests: John W. Sperling, MD, Mayo Clinic, 200 First St, SW, Rochester MN 55905 (E-mail: [email protected]). Copyright © 2005 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2005/$30.00 doi:10.1016/j.jse.2005.02.012
480
and histologic observations in 10 affected patients and in 63 cadaveric shoulders. He found the subacromial bursa to be unaffected and the capsule to be thickened and adherent to the humeral head. He proposed that the pathology primarily involved the shoulder capsule, suggesting the term adhesive capsulitis as a better name for the disease. Reeves11 believed the condition to involve 3 phases: the painful phase, the frozen phase, and the thawing phase, where motion and pain gradually improve but last a variable course, estimated to be 12 to 42 months. Thus, frozen shoulder has been defined as a condition of uncertain etiology, characterized by painful restriction of active and passive shoulder motion occurring in the absence of a known intrinsic shoulder disorder.5 The overall objective in the treatment of patients with frozen shoulder is to relieve pain and restore motion. The treatment modalities used today usually begin with nonoperative measures including anti-inflammatory medications, injections, and physical therapy. However, it has been reported that a substantial subset of patients, up to 30%, do not improve with these measures.12 Adjunctive treatment might include capsular distention or brisement, manipulation under anesthesia, or arthroscopic or open capsule releases. Although most clinicians concede that the conservative measures should be first-line measures to combat this frequently self-limiting disease, there is little consensus on the second line of treatment for a frozen shoulder resistant to conservative modalities. Much has been written on manipulation under anesthesia,3,4,9,10 and many authors have reported on this as a safe and effective treatment. However, critics cite reports of iatrogenic fracture, glenohumeral dislocation, rotator cuff tearing, and nerve injuries as reasons to avoid this treatment method. The purpose of this study was to evaluate manipulation under anesthesia in a carefully selected group of patients with idiopathic frozen shoulder to identify whether the procedure is safe and effective over the long term. We also wished to learn whether subsequent shoulder problems developed. MATERIALS AND METHODS With the use of the surgical indices as a database, patients who underwent manipulation under anesthesia for frozen shoulder between 1981 and 1993 were identified.
Farrell, Sperling, and Cofield
J Shoulder Elbow Surg Volume 14, Number 5
All manipulations were done by the senior author. The criteria for patient selection included the diagnosis of frozen shoulder characterized by pain and limited active and passive range of motion (ROM) of the shoulder for which no other cause could be identified, no prior surgery of the affected shoulder, no previous fracture or dislocation of the affected shoulder, no history of any other intrinsic or extrinsic cause of stiffness, and a normal radiograph of the affected shoulder. Magnetic resonance imaging or arthrography was performed in all patients except one who had smooth subacromial motion, no weakness, and no signs or symptoms focal to the supraspinatus area. Each of the arthrograms and magnetic resonance images was negative for a full-thickness rotator cuff tear. We identified 25 patients (26 shoulders) who satisfied these criteria. There were 16 women and 9 men. The mean age was 50 years (range, 33 to 69 years). Of the patients, 21 had known occupations; there were 5 who did light labor, 3 who did heavy labor, 3 managers, 6 professionals, 2 homemakers, and 2 retired persons. Eight patients had diabetes mellitus. Twenty-three patients had physical therapy before manipulation under anesthesia. One, who did not have physical therapy, had diabetes mellitus and a rapid onset of progression of pain and limited motion; the physical therapy program could not be tolerated. The second patient had a frozen shoulder on the opposite side 18 months earlier, had failed physical therapy, and had undergone successful manipulation under anesthesia and wished to proceed without further delay. The length of pre-manipulation physical therapy averaged 199 days (range, 10 to 731 days). Nineteen patients had an injection before manipulation. The overall time from the onset of symptoms to treatment averaged 11 months (range, 2 months to 3 years). All patients had shoulder manipulation under general anesthesia with adjunctive muscle paralysis. No patient had regional anesthesia for perioperative pain management. The method of manipulation was standard. The patient was placed in the supine position. The shoulder was moved into flexion until the point of resistance. Continuing gentle pressure was applied on the distal humerus until adhesions gave way. The shoulder was then externally rotated with the arm in 90° of abduction. Usually little resistance was encountered. If resistance was present, gentle pressure was applied, and the maximal amount of external rotation was attained. The arm was then moved into full abduction. Next, stretching was performed in internal rotation at 90° of abduction. Then cross-body adduction was performed. Finally, the arm was gently externally rotated at 45°, 30°, and 0° of abduction to attain the maximum movement in all positions. Patients’ arms were placed in an abduction humeral splint at 80° of abduction. Patients underwent gentle active-assisted motion by a physical therapist in the hospital on the afternoon of the manipulation. Motion was practiced in flexion, abduction, adduction, and internal and external rotation. On the next day, the abduction splint was removed, and a sling was supplied for brief intermittent use. The patient was discharged from the hospital on the afternoon of the second day. Physical therapy continued on an outpatient basis and included
481
supervised and home exercise programs focused on stretching. Physical therapy was then progressed to include isometric strengthening exercises followed by use of elastic bands. Follow-up was by office visit at 2 weeks and generally each subsequent 6 weeks until the end of treatment. Longterm follow-up was obtained by a standardized questionnaire for mailing or telephone interview. Five patients died before long-term follow-up could be completed; one patient declined participation in this study and was lost to followup. Longer-term follow-up was obtained in 19 shoulders and averaged 15 years (range, 8.1 to 20.6 years). For the 19 shoulders available for long-term follow-up, data were collected with regard to level of pain, ROM, function, and overall satisfaction. A pain scale was used to assess overall pain, night pain, rest pain, and pain with activity both before the procedure and at long-term follow-up. At longterm follow-up, patients were asked if they required overthe-counter or narcotic analgesics for pain. Subjective stability and strength were evaluated on a 10-point scale. In addition, each patient was asked about overall satisfaction and willingness to have the same procedure again should he or she experience the problem in the opposite shoulder. Each patient was assigned a Simple Shoulder Test and American Shoulder and Elbow Surgeons score for the involved side and the uninvolved side for comparison.
RESULTS Complications
There were no observed complications from treatment; specifically, there were no intraoperative fractures, dislocations, symptomatic rotator cuff tears, regional pain disorders, or neurovascular injuries as a result of the manipulation. One patient required surgery for a symptomatic rotator cuff tear 3 years later. She had had an excellent result after the manipulation with regard to pain relief and motion for over a year until the development of further symptoms. Of note, after undergoing rotator cuff repair and acromioplasty, she again developed a frozen shoulder. Motion
Range of motion was documented before manipulation, during manipulation, at the last visit, and at long-term follow-up by surveys (Table I). Pre-manipulation elevation averaged 104° (range, 70° to 140°), external rotation averaged 23° (range, –5° to 70°), and internal rotation was to the fifth lumbar vertebral (range, trochanter to T12). Average motion during manipulation measured 175° of forward elevation (range, 160° to 180°) and 83° of external rotation (range, 70° to 100°). Average ROM at the last office visit measured 149° of elevation (range, 105° to 180°), 49° of external rotation (range, 15° to 90°), and internal rotation to L4 (range, abdomen to T10). For the 19 patients available for longer follow-up, average forward elevation was 168° (range, 90° to
482
Farrell, Sperling, and Cofield
J Shoulder Elbow Surg September/October 2005
Table I Preoperative, intraoperative, and follow-up data regarding forward elevation and external rotation
Patient No.
Age (y)
Sex
Occupation
Preoperative FE (°)
Intraoperative FE (°)
Long-term FE (°)
FE in uninvolved shoulder at long-term follow-up (°)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
52 48 63 49 51 52 48 51 51 51 59 40 52 52 36 46 70 48 53
F M F F F F M F M F M F F F M M F F F
Light labor Professional Professional Retired Retired Retired Manager Manager Professional Homemaker Light labor Professional Homemaker Retired Heavy labor Manager Retired Professional Light labor
135 120 105 100 95 90 80 135 120 120 90 70 70 100 110 110 100 140 90
180 175 175 180 180 170 175 175 180 170 180 175 170 180 165 180 170 180 170
150 180 150 180 180 180 160 160 180 180 180 180 180 180 150 180 180 180 90
180 180 180 180 180 180 180 170 180 180 180 180 180 180 140 180 180 180 180
Preoperative ER (°)
Intraoperative ER (°)
Long-term ER (°)
ER in uninvolved shoulder at long-term follow-up (°)
70 25 35 0 30 15 40 20 10 20 20 20 25 0 20 10 – 25 50
90 80 80 80 75 80 85 85 90 75 75 80 80 90 100 80 80 85 80
30 60 90 50 90 90 50 40 90 20 90 90 60 90 10 90 0 90 30
80 60 90 50 90 90 50 40 90 50 90 90 60 90 0 90 0 90 30
FE, forward elevation; ER, external rotation.
180°), external rotation was 61° (range, 0° to 90°), and internal rotation was to T12 (range, L5 to T5). The Wilcoxon signed rank test was used to compare motion in the 19 shoulders available for longerterm follow-up. In these patients, forward elevation and external rotation preoperatively were compared with measurements taken intraoperatively, immediately by postoperatively, at last clinical follow-up, and at longer-term follow-up. A P value less than .05 was considered significant. For this subset of patients, intraoperative forward elevation increased 70° (P ⬍ .01) compared with preoperatively. Immediate postoperative forward elevation increased 47.5° (P ⬍ .01) compared with preoperatively. At least clinical follow-up, forward elevation increased 50° (P ⬍ .01) compared with preoperatively. At longer-term follow-up, based on survey data, forward elevation increased 70° (P ⬍ .01). For this subset of patients, intraoperative external rotation increased 60° (P ⬍ .01) compared with external rotation preoperatively. Immediate postoperative external rotation had increased 25° (P ⬍ .01) compared with preoperatively. At last clinical followup, external rotation increased 30° (P ⬍ .01) compared with preoperatively. At longer-term follow-up, based on survey data, external rotation increased 38° (P ⬍ .01). Pain
For the 19 shoulders available for longer followup, 10-point pain scales were used to establish the level of overall pain, night pain, resting pain, and
activity pain. Overall, 13 shoulders had no pain, 3 had slight pain, 2 had occasional moderate pain, and 1 had moderate pain. Thirteen shoulders had no night pain, two had slight night pain, two had occasional moderate night pain, and two had moderate to severe night pain. Thirteen shoulders had no rest pain, five had slight rest pain, one had occasional moderate rest pain, and none had severe rest pain. Twelve shoulders had no activity-related pain, three had slight pain on activity, three had occasional minor to moderate activity-related pain, and one had moderate to severe activity-related pain. In all but 2 patients, pain in the affected and unaffected shoulder was nearly the same. Stability and strength
All patients felt that they had a stable shoulder. Sixteen had normal to good shoulder strength, one had fair strength, and two had poor strength in the shoulder. Satisfaction
Patients were asked to indicate their level of overall satisfaction with their shoulder before manipulation and at long-term follow-up. All patients rated their satisfaction as poor before manipulation (1/10 on digital scale). The mean score after manipulation was very good (8/10 on digital scale). As a corollary to this, the patients were asked if would they choose to undergo manipulation under anesthesia if they had the same problem in the opposite shoulder. Twelve patients indicated that they would chose to do so, and
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Table II ASES pain score, functional score, and overall score, as well as Simple Shoulder Test scores tabulated for each patient with regard to involved and uninvolved shoulders ASES pain score
ASES function score
ASES overall score
Simple Shoulder Test score
Patient No.
Age (y)
Sex
Occupation
Involved
Uninvolved
Involved
Uninvolved
Involved
Uninvolved
Involved
Uninvolved
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
52 48 63 49 51 52 48 51 51 51 59 40 52 52 36 46 70 48 53
F M F F F F M F M F M F F F M M F F F
Light labor Professional Professional Retired Retired Retired Manager Manager Professional Homemaker Light labor Professional Homemaker Retired Heavy labor Manager Retired Professional Light labor
35 40 20 50 50 50 50 35 50 25 50 50 50 50 35 50 50 50 5
40 40 40 50 50 50 50 50 50 30 50 35 50 50 30 50 50 50 50
30 48 30 40 47 47 42 28 50 22 50 18 50 50 33 50 33 50 12
42 47 47 40 47 47 48 45 50 28 50 40 50 50 32 50 33 50 27
65 88 50 90 97 97 92 63 100 47 100 68 100 100 68 100 83 100 17
82 87 87 90 97 97 98 95 100 58 100 75 100 100 62 100 83 100 77
7 12 6 10 12 12 11 4 12 6 12 12 12 10 9 12 9 12 1
10 12 12 9 12 12 11 8 12 6 12 30 12 10 7 12 9 12 7
ASES, American Shoulder and Elbow Surgeons.
four indicated that they would not. Two others did not answer the question.
mean difference in the overall American Shoulder and Elbow Surgeons score for the involved and uninvolved shoulders was 9 (P ⫽ .04) (Table II).
Result ratings
The 19 shoulders available for longer follow-up were evaluated by use of the Simple Shoulder Test and the American Shoulder and Elbow Surgeons score (Table II). Nine patients scored 12 of 12 on the Simple Shoulder Test. Twelve scored 10 or better on the Simple Shoulder Test, five patients scored between 6 and 9, and two scored less than 6. The mean Simple Shoulder Test score was 9.5 on the involved side and 11.3 on the uninvolved side. The mean difference in the Simple Shoulder Test score for the involved and uninvolved shoulders was 1.8 (P ⫽ .10). On the functional component of the American Shoulder and Elbow Surgeons scoring system, 11 patients scored 40 to 50, 6 scored between 20 and 39, and 2 scored below 20. The mean American Shoulder and Elbow Surgeons functional score was 38 on the involved side and 43 on the uninvolved side. The most common activities that patients either were unable to perform or had greater difficulty performing with the involved shoulder were washing the back/putting on a bra and lifting 10 lb above the shoulder (7 shoulders). The mean difference between involved and uninvolved shoulders for the functional American Shoulder and Elbow Surgeons score was 5 (P ⫽ .01). The mean American Shoulder and Elbow Surgeons overall score, including the pain rating, was 80 on the involved side and 89 on the uninvolved side. The
DISCUSSION
For the small number of patients in whom conservative treatment for frozen shoulder fails,6,12 manipulation under anesthesia has been advocated as a useful treatment option. Hill and Bogumill4 studied 17 patients who were followed up for a mean of 22 months, and they found that 70% had returned to work in less than 6 months and had improved motion and no complications. Placzek et al10 studied 31 patients who underwent translational manipulation and followed them up for a mean of 14 months. These patients demonstrated a mean improvement in ROM in flexion of 63°, in external rotation of 58°, and in internal rotation of 47°. They also had a reduction in pain, and there were no complications. Neviaser reported the 5-year follow-up of 46 cases of manipulation under anesthesia.8 In this study, all patients had obtained their 5-year follow-up range of motion within 6 months from the manipulation except those patients with diabetes. Our study is the first to review the results of longerterm outcomes in patients who have an idiopathic frozen shoulder and who have undergone treatment by manipulation under anesthesia. Inclusion criteria were selective in order to exclude related but dissimilar conditions. During this longer period of follow-up, ROM continued to be improved, with mean improvement in elevation of 70° and in external rotation of
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53°. This is similar to the shorter-term reviews. Pain improved to none in 13, slight in 3, and occasionally moderate in 2 with only 1 patient reporting severe pain at longer follow-up. This patient with severe overall pain interestingly developed spasmodic torticollis several years after manipulation; this is not considered to be a result of the manipulation. One patient with occasional moderate overall pain had sustained a fracture in a fall 8 years after manipulation, and at the time of longer-term assessment, it had only been 18 months since closed treatment of this injury was performed. In the other patient with occasional moderate overall pain, glenohumeral arthritis developed 16 years after manipulation. On the basis of result ratings for the involved shoulder, the mean Simple Shoulder Score at longer follow-up was 9.5 for the involved side and 11.3 for the uninvolved side. This difference was not significant (P ⫽ .01). With regard to the American Shoulder and Elbow Surgeons score at longer-term follow-up, the mean for the involved shoulder was 80, and the mean for the uninvolved shoulder was 89. Although this difference is statistically significant (P ⫽ .04), the difference is small. The patients continued to report their satisfaction with manipulation. Of 16, 12 answered that they would undergo the procedure again if the problem developed on the contralateral side. A possible reason for motion restriction and pain in some patients may be a loss of ligament flexibility and degenerative rotator cuff disease that may have developed in the time since the manipulation. It may be possible that the patients who felt that they would not have the manipulation again were convinced that their present symptoms were a result of the manipulation rather than from other processes.
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In conclusion, manipulation under anesthesia for the treatment of idiopathic frozen shoulder is safe and is reasonably effective for treatment should this prove to be necessary. With longer follow-up, the results have remained stable and, importantly, it is unlikely that additional shoulder problems will develop. REFERENCES
1. Codman EA. The shoulder: rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa. Boston, 1934. 2. Duplay S. De la peri-arthrite scapulo-humerale et des raideurs de l’epaule qui ensont la consequence. Arch Gen Med 1872;20: 513. 3. Helbig B, Wagner P, Dohler R. Mobilization of frozen shoulder under general anesthesia. Acta Orthop Belg 1983;49:267-74. 4. Hill JJ Jr, Bogumill H. Manipulation in the treatment of frozen shoulder. Orthopedics 1988;11:1255-60. 5. Iannotti JP, Williams GR. Disorders of the shoulder: diagnosis and management. Philadelphia: Lippincott Williams and Wilkins; 1999. 6. Murnaghan JP. Frozen shoulder. In: Rockwood C, Matsen FA, editors. The shoulder. 1st ed. Philadelphia: Saunders, 1990. p. 837-62. 7. Neviaser JS. Adhesive capsulitis of the shoulder. J Bone Joint Surg 1945;27:211. 8. Neviaser TJ. Adhesive capsulitis. In: McGinty JB, Caspari RB, Jackson RW, Poehling GG, eds. Operative arthroscopy. 2nd ed. Philadelphia, Lippincott-Raven; 1996. p. 785–91. 9. Ogilvie-Harris DJ, Biggs DJ, Fitsialos DP, MacKay M. The resistance frozen shoulder: manipulation versus arthroscopic release. Clin Orthop 1995;391:238-48. 10. Placzek JD, Roubal PJ, Freeman DC, et al. Long-term effectiveness of translational manipulation for adhesive capsulitis. Clin Orthop 1988;356:181-91. 11. Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol 1975;14:193-6. 12. Shafer B, Tibone JE, Kerlan RK. Frozen shoulder long-term followup. J Bone Joint Surg Am 1992;74:738-46.