Indian Journal of Orthopaedics (2021) 55:299–309

https://doi.org/10.1007/s43465-021-00351-3

REVIEW ARTICLE

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

Vivek Pandey1   · Sandesh Madi1

Received: 7 November 2020 / Accepted: 2 January 2021 / Published online: 1 February 2021
© The Author(s) 2021

Abstract
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.

Keywords  Frozen shoulder · Adhesive capsulitis · Shoulder · Treatment · Conservative · Manipulation · Arthroscopic
capsular release · Review

Introduction disorder. The prevalence of frozen shoulder is estimated to

affect 2–5% of the population [2, 3], and affects men more
Among almost all conditions of the shoulder, frozen shoul- than women [4]. The peak incidence is observed between
der (FS) has been most debated right from its terminology 40 and 60 years [5]. 20% of patients develop similar symp-
to the most optimal treatment and prognosis. Although toms in the opposite shoulder [4, 6]. Bilateral simultaneous
the term FS and adhesive capsulitis have been used quite involvement could be observed in 14% of the patients [7].
extensively, current ISAKOS guidelines favour use of the Associated conditions: Primary frozen shoulder is idio-
term frozen shoulder and discourage adhesive capsulitis as pathic, but two conditions are classically associated with FS;
there are no adhesions in the shoulder joint [1]. The ISA- diabetes mellitus (DM) and thyroid dysfunction. The inci-
KOS Upper Limb Committee has classified a stiff shoulder dence of frozen shoulder in diabetic patients could vary from
into the primary idiopathic stiff shoulder (frozen shoulder) 10.8 to 30% [8, 9] with a tendency of more severe symptoms
and secondary stiff shoulder [1]. FS or primary idiopathic and resistance to treatment [10]. The prevalence of DM is
stiff shoulder terms are used to describe a stiff shoulder that ten times higher in patients with frozen shoulder, and higher
develops without any specific trauma or any underlying dis- HbA1C in a poorly controlled diabetes is associated with
ease process. The patient can have a condition that is known the development of FS [11]. Several studies have confirmed
to have a link to stiffness (diabetes, thyroid disorders) but higher prevalence (27.2%) and incidence (10.9%) of hypo-
not necessarily known to cause stiffness. Secondary stiff- thyroidism in patients with FS [12, 13]. Another recent study
ness is reserved to describe shoulder stiffness with a known suggested 2.69 times higher risk of developing FS in patient
underlying cause such as trauma, infection, or inflammatory with thyropathy [14]. Other associated conditions with FS
are smoking, cardiac disease, Parkinson’s disease, stroke,
neck and cardiac surgery, hyperlipidaemia and Dupuytren’s
* Vivek Pandey contracture [1, 15].
[email protected] Pathology: FS is characterized by intense inflamma-
1
Department of Orthopaedics, Kasturba Medical College,
tory changes in capsule indicating a role of inflammatory
Manipal, Manipal Academy of Higher Education, mediators (interleukins, cytokines, B- and T-lymphocytes,
Udupi 576104, India

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growth factors, matrix metalloproteinases, tumor necrosis by Hanchard et al. as ‘pain predominant’ and ‘stiffness pre-
factors and fibroblast activation markers) and disturbance dominant’ is also useful in clinical practice [32].
in local collagen translation, which result in global fibropla- The principal clinical characteristics of three stages are
sia [16–19]. Macroscopically, the capsule of the FS appears pain, pain and stiffness, and stiffness, respectively.
thick, congested and inflamed, particularly around the rota-
tor interval and anteroinferior capsule along with thickened a. Freezing stage (stage 1): It may last for 2–6 months.
coracohumeral ligament (CHL) and superior–middle–infe- Clinically, stage 1 is predominantly characterized by
rior glenohumeral ligaments resulting in loss of flexion, moderate-severe pain and partial restriction of ROM.
abduction and rotations [20, 21]. The tissue samples from Pathologically, it is characterized by a slow onset of
FS reveal dense collagen matrix and high population of widespread inflammation involving capsule and syn-
fibroblasts and contractile myofibroblasts, a process similar ovium of the shoulder joint resulting in gradual onset of
to Dupuytren’s contracture, with the fibrotic process pre- ’pain’ as a principal symptom. Mere pain and only ter-
dominantly limited to anterior capsule [22, 23]. An early minal loss of ROM in the early period of freezing stage
immune response with elevated levels of alarmins, bind- of FS could be confused with rotator cuff tendinopa-
ing to the receptor of advance glycation end products and thy as latter also presents with painful loss of terminal
accrued irreversible crosslinks between various collagen ROM. However, ROM does not progressively worsen in
protein molecules through glycosylation is observed at the RC tendinopathy whereas it continues to worsen at every
beginning of the cascade [24, 25]. Increased expression of follow up in FS.
vascular endothelial growth factors (especially in diabetics b. Frozen stage (stage 2): It may last for 4–12 months.
with high glycosylated haemoglobin), nerve growth factor Clinically, this stage is characterized by both ‘pain and
receptor and neoangiogenesis are also noted, and that may stiffness’ in varying proportions. Patients in the early
help explain severe pain and stiffness in patients with FS [26, phase of stage 2 have more pain while later phase of
27]. In summary, the frozen shoulder appears to start as an stage 2 comprises of more stiffness than pain. Patho-
inflammatory reaction in capsule with associated synovitis logically, it is characterized by a gradual diminution in
that progresses to the fibrotic contracture of the capsule. inflammation and onset of widespread fibrosis of capsule
and ligaments which results in gross restriction of ROM.
c. Thawing stage (stage 3): It may last for 6–26 months.
Clinically, this stage is characterized by minimal pain
Clinical Features and Clinicopathological and gradual resolution of stiffness. Pathologically, it is
Stages characterized by gradual resolution of inflammation and
fibrosis, resulting in minimal pain and the progressive
Patients with FS complain of insidious onset of pain and return of movements.
stiffness without any preceding traumatic, infective, or
inflammatory event. Pain is usually poorly localized, around
the shoulder and is almost always troublesome in the night Investigations
while the patient lies on the affected side. The index shoul-
der examination reveals global restriction of both active and The relationship between an established DM and thyroid
passive range of movements (ROM) at least in two planes, dysfunction with FS is a known fact but the evidence to
and that is one of the critical findings. The loss of external investigate an apparently ‘normoglycemic FS patient’ with
rotation with arm by the side of the chest is one of the earli- fasting blood glucose level and haemoglobin A1C is mount-
est signs. According to ISAKOS guidelines; if the range of ing as several studies have confirmed that latter two investi-
movement is less than 100° in forward flexion, less than 10° gations are often deranged in patients with FS [11, 33–35].
in external rotation, and less than L5 vertebral level in inter- Further, thyroid dysfunction should also be investigated if
nal rotation, it is defined as a global restriction of ROM [1]. there is a clinical suspicion [12]. Primary frozen shoulder
In a recently published FROST trial, investigators defined is essentially a clinical diagnosis, and, therefore, the radio-
FS as a condition characterised by the restriction of passive graphic studies are performed to exclude other secondary
external rotation in the affected shoulder to less than 50% causes of shoulder pain such as calcific tendinitis, rotator
of the opposite shoulder with normal radiographs [28]. The cuff tear, arthritis of glenohumeral and acromioclavicu-
strength of the rotator cuff is relatively unaffected. lar joint or a neoplastic process. The plain radiograph of
Traditionally, FS is described in ‘three clinico-patholog- the shoulder is essentially normal in patients with 1° FS.
ical stages’ (freezing, frozen, and thawing), which we find However, osteopenia of the humeral head is not uncommon
practical to understand and explain to the patients and decide and should alert the surgeon if manipulation is planned
the treatment plan [29–31]. Another classification suggested [36]. MRI is not routinely performed in patients with FS to

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diagnose the condition. However, it could be done to rule by deploying a structured and well-sustained mobilisa-
out any secondary cause of FS if there is a clinical suspicion. tion PT program. Hydrodilatation (HD) could also be
In an early freezing stage, MRI may show edema of joint used as an adjunct in early frozen stage to break capsu-
capsule and obliteration of the sub-coracoid fat triangle. In lar fibrosis and accelerate the gain in ROM. Occasional
the frozen stage; MRI shows capsular and CHL thicken- analgesics keep the pain at bay. If sincere attempts of
ing, poor capsular distension, volume reduction of the axil- PT for several weeks–months and or HD fail to improve
lary pouch, and scar formation in the rotator interval [37]. functional ROM and pain, MUA or ACR could be con-
Recently, ultrasonography (USG) has emerged as a primary sidered to accelerate the functional recovery in terms of
diagnostic tool in establishing the diagnosis of the frozen regaining ROM and minimizing pain.
shoulder which reveals thickened CHL (mean thickness c. Thawing stage: This stage is characterised by minimal or
1.2 mm, observed in 96.7% cases), increased vascularity in no pain and gradually improving ROM for past several
the rotator interval, and presence of hypoechoic soft tissue weeks. Hence, sustained PT remains the mainstay of the
thickness in the rotator interval [38]. treatment in this stage, which aims to gradually regain
the ‘functional’ followed by total recovery of shoulder
ROM. Any surgical interventions are hardly required in
Treatment this stage.

By and large, conservative treatment of frozen shoulder is Non‑operative Treatment of Frozen Shoulder
successful in up to 90% patients [39–41]. Only a few require
operative intervention in the form of manipulation under 1. NSAIDs and other analgesics: NSAIDs remain one of
anaesthesia (MUA) or arthroscopic capsular release (ACR). the most common medical intervention in treating frozen
In clinical practice, the strategy opted to treat frozen shoul- shoulder [45]. A short course of NSAIDs for 2–3 weeks
der often depends upon the clinicopathological stage of fro- is very frequently used to minimise intense pain of
zen shoulder. Further, the patients with FS should also be the freezing stage. However, course of NSAIDs does
treated for underlying medical disorder (DM and thyroid not alter course of the frozen shoulder but enables the
dysfunction) as poor control of these disorders may result in patient to carry out their ADLs in a more relaxed fashion
prolonged severity of disease. Although diabetics often tend and perform PT (retaining ROM) with ease. However,
to have severe disease and require prolonged conservative there is a paucity of high-quality studies discussing the
treatment and require surgical treatment more often than utility of NSAIDs in comparison to other drugs, espe-
non-diabetics [42–44], one must not give up conservative cially corticosteroids. In patients with NSAID allergy or
treatment trial and expedite surgical treatment in diabetics. contraindication, Opioid analgesics can be used.
2. Corticosteroid: Apart from NSAIDs, steroids are the sec-
a. Freezing stage: Since this stage is characterized by the ond most commonly used drugs in the treatment of the
presence of intense pain due to underlying capsule– frozen shoulder. Both oral steroid and local steroid injec-
ligament–synovium inflammation, the treatment strat- tions are widely used. A paramount point to note that
egy deployed in this stage should aim at minimizing steroids in any form are beneficial only in early stages
pain. Many options are used to alleviate pain, such as (freezing and early frozen) of frozen shoulder to con-
NSAIDs, steroids (local or oral), and pain-relieving trol inflammation and ensuing pain, and there may not
physiotherapy (PT). A point needs to be stressed that be any rationale to prescribe it in late stages of frozen
none of these measures would relieve the pain entirely, shoulder with established fibrosis without much inflam-
and the entire exercise of pain minimization is aimed at mation.
enabling the patient to perform activities of daily living a Oral steroids: In several high-quality studies, moderate
(ADL) with more ease, sleep better and gradually initi- evidence was found in favour of oral steroid for improv-
ate the joint mobilisation PT. The mobilisation PT is ing pain, ROM and function when prescribed for ‘short
principally aimed at ‘retaining’, and ‘slowly regaining’ term’ (6 weeks) in stage 1 [46, 47]. However, the effects
the ROM. Of note-during the stage of intense pain, vig- were not maintained beyond 6 weeks after stopping it.
orous mobilization PT must be avoided as it can exac- Nevertheless, disastrous complication of avascular
erbate the inflammation resulting in increased intensity necrosis of femoral head has to be feared of, even with
of pain. a short course of oral steroid [48].
b. Frozen stage: In this stage; pain is less, but the loss of b. Local injectable steroids: Local injectable steroid is most
ROM is profound due to fibrosis of capsulo-ligament frequently deployed medical method to provide relief
complex. Hence the treatment strategy should be princi- from severe pain in freezing stage of FS. Systematic
pally aimed to gradually ‘increase and regain’ the ROM reviews and metanalysis have confirmed strong evi-

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dence in favour of steroid injections in improving pain injections must be avoided in patients with retroviral
and ROM as compared to placebo in the short term, therapy due to the risk of drug interaction causing iat-
and moderate evidence in the midterm [46, 49]. Two rogenic Cushing syndrome [62].
RCTs concluded that injectable steroid provide superior 3. Physiotherapy (PT): Along with NSAIDs and steroids,
clinical results compared to oral steroid [50, 51]. Steroid PT remains one of the cornerstones in the treatment of
injection is certainly superior to PT in reducing pain but the frozen shoulder. The arms of PT consist of ‘pain-
evidence is conflicting regarding restoration of ROM relieving PT’, ‘mobilization PT’ and ‘strengthening PT’.
while comparing steroid injection with PT or MUA [46]. In the freezing stage, it is better to use pain-relieving PT
  Furthermore, many issues regarding use of local and avoid aggressive mobilization techniques as latter
injectable steroids such as optimal dose [52, 53], single can exacerbate the pain. There are various modalities
or multiple injection, site of injection (intraarticular/sub- of ‘pain relieving PT’ such as Laser, short wave dia-
acromial/rotator interval) [54, 55], molecule (Triamci- thermy, ultrasound and hot packs [46, 63]. PT, along
nolone/Methylprednisolone) [56–58], injection with or with NSAIDs or steroid injection, is better in providing
without imaging [59] remain contentious and are briefly symptomatic relief than PT alone [64–66].
mentioned in Table 1.   Once pain decreases, ‘mobilization PT’ can be started
  Of-note, steroid injections carry a risk of a transient to retain and gradually regain ROM. The patients receiv-
increase in blood glucose levels (BGLs) occurring ing PT must start with 3–4 sessions per day, with each
within 1–5 days in diabetic patients [60]. However, the session of 10–15 min, comprising of active-assisted
rise in BGLs returns to baseline within 24 h to 10 days, ROM exercises, including forward elevation, abduc-
and the benefit of steroid injection in improving pain tion, rotations, and cross-body adduction. This must be
scores and function outweighs any transient increase in combined with scapular and cuff rehabilitation along
BGLs. Nevertheless, steroid injections must be avoided with core strengthening. Grigg’s et al. confirmed that
in patients with uncontrolled Diabetes, especially if patients in phase II of frozen shoulder report high sat-
BGL is more than 250 mg% [60]. isfaction with four-direction stretching exercise [67]. In
  Adverse events with injectable steroids: Minor com- the late frozen stage, low-and high-grade mobilization
plications such as facial flushing, chest or shoulder pain, techniques could be implemented to regain the ROM
dizziness and nausea are reported due to vasovagal reac- along with ‘muscle strengthening PT’ [46].
tions during injection [61]. Furthermore, Triamcinolone

Table 1  Summary of various debatable parameters regarding injectable steroids

Parameters Reference Conclusions

1 High dose (40 mg), low dose (20 mg) or Kim et al., RCT, 2018 [52] 1. No difference between 40 mg vs 20 mg
very low dose (10 mg) steroid Yoon et al., RCT, 2013 [53] 2. 10 mg is less effective than 40 mg
2 Single vs. Multiple injections Erickson et al., 2019 [44]; retrospective Multiple are no better than single injection in
study of 1377 patient improving clinical outcome
3 Site: IA vs SA vs RI Shang et al., 1. No overall significant difference
Meta-analysis, systematic review, 2019 [54] 2. Pain scores better in IA groups
3. IR better in SA groups
4. SA injection result in lesser BGL fluctua-
tion
Sun et al., RCT, 2018 [55] Single injection into SA, IA and RI resulted
in better pain, ROM and functional scores
in RI group
4 Triamcinolone (TA) vs. Methylprednisolone Sakeni et al., Level II, 2007 [57] One injec- TA gave superior result in resistant cases and
(MTP) tion a week for 3 weeks Diabetics compared to MTP
Choudhary et al., 2015 [56]; TA group had better pain scores and ROM
Three injection every three weeks in either
group
Lopez et al., 2008 [58] More relief of pain in MTP than TA
5 With or without image (USG or fluoro- Song et al., Systematic review, 2014 [59] Added benefit of Image guided injections over
scopic) guidance blind injection in improving pain and ROM.
However, needs further evaluation

IA Intraarticular, SA Subacromial, RI Rotator interval IR, Internal rotation, ROM range of movement, USG Ultrasonography, BGL blood glucose
level. Number in [] denotes reference in the text

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Indian Journal of Orthopaedics (2021) 55:299–309 303

  In comparison to PT vs. MUA in the frozen stage, there is little evidence in literature for its routine use in
a high-quality RCT confirmed the superiority of MUA the treatment of primary FS [78].
compared to home exercise alone [68]. 8. Nerve block: Several authors report that single or multi-
4. Hydrodilatation (HD): In late freezing or early frozen ple injections to block Suprascapular nerve in the treat-
stage, HD of the glenohumeral joint using saline, ster- ment of frozen shoulder result in improved pain score
oid, local anaesthetic agent is supposed to distend the and ROM [79, 80]. However, there is lack of high-qual-
capsule by breaking the ‘early intracapsular fibrosis’ ity evidence in favour of the nerve block and is not rou-
which helps in improving ROM [2]. A single HD pro- tinely performed.
cedure is superior to placebo in improving ROM, pain,
and function in the short term [69]. However, more than
one repeated HD after 2 weeks has no added effect over
a single HD procedure [70]. Nevertheless, HD may not Operative Management of Frozen Shoulder
offer any advantage in comparison to IA steroid injec-
tion [71, 72]. Invasive operative methods (manipulation or surgical release
5. Calcitonin: Calcitonin decreases systemic inflammatory of capsule) to improve function in patients with primary
response and stimulate the release of endorphins [73]. FS are recommended only when an extended conservative
Yang et al. confirmed that addition of salmon calci- treatment for a period of 6–9 months fails to provide sig-
tonin in biopsied tissues from frozen shoulder improves nificant relief to the patient [35, 41, 81]. The surgical tech-
mRNA expression of fibrosis-related molecules and niques consist of manipulation under anaesthesia (MUA)
decreased the enhanced cell-substrate adhesion ability of and arthroscopic capsular release (ACR).
frozen shoulder [74]. A level II RCT concluded that the
addition of Calcitonin along with PT and NSAIDs alle- 1. Manipulation under anaesthesia: MUA is a method
viates pain and functional outcome better than mere PT wherein fibrosed capsulo-ligament complex of shoul-
and NSAIDs [73]. However, further research is required der, which is a hindrance in regaining ROM, is forcibly
in this area to validate the role of Calcitonin in frozen broken by manoeuvring the shoulder across the ROM
shoulder. under anaesthesia. Krall et  al. suggested that MUA
6. Extracorporeal shock wave therapy (ECSWT): An RCT is an effective method to improve function in patient
involving 40 patients treated with ECSWT versus oral with refractory FS in stage II, external rotation < 50%
steroid confirmed that ECSWT significantly improves compared to opposite side and failure to respond to IA
the functional outcome and ROM without any adverse steroid infiltration [82]. Of note: MUA should not be
events [75]. In a systematic review of 19 trials (1249 performed for secondary stiffness of the shoulder, and
patients), the use of ECSWT did not beget any major such patients must undergo arthroscopic capsular release
adverse event [63]. Further, ECSWT is a suitable alter- if need be.
native in patients with uncontrolled diabetics or where   Technique: Under anaesthesia, the arm of the patient
oral steroids cannot be prescribed. is held with a short lever and shoulder is gently moved
7. Acupuncture: Though few centres have tried using acu- in flexion, abduction followed by external and internal
puncture in the treatment of FS and reported reasonable rotation in 90° abduction (Figs.1 and 2). Next, the shoul-
relief in pain and improved forward flexion [76, 77], der joint is taken into external rotation with arm by the
chest followed by cross-chest adduction. These manoeu-

Fig. 1  a–c Shows the MUA of left shoulder with a ‘short-lever arm’ rior subluxation of head while tearing of inferior capsule. During
while arm being taken in flexion, abduction and external rotation in external rotation movement in 9­ 0° abduction, the scapula is stabilised
­90° abduction. Of-note: during abduction beyond ­90°, head of the by the assistant’s hand over the scapula
humerus is supported with a fist of assistant in axilla to prevent infe-

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304 Indian Journal of Orthopaedics (2021) 55:299–309

Fig. 2   a–c Shows MUA of left shoulder with a ‘short-lever arm’ internal rotation movement in ­90° abduction, the scapula is stabilised
while arm is taken in internal rotation in ­90° abduction, cross-chest by the assistant’s hand over the scapula
adduction and external rotation with arm by the side of chest. During

vres result in tearing of fibrosed capsule and ligament,   Complications of MUA: Literature reports an overall
which can often be felt or heard during MUA. Of note- complication rate of 0.4%, and a re-intervention rate of
no movement should be forced if ‘excess’ resistance is 14% [82]. Although MUA improves flexion and abduc-
felt during the range of that movement, and it is better tion, limitation in rotation in early phase after MUA
to perform the next manoeuvre rather than applying too remains a concern as surgeons often avoid forcible
much force to regain that movement to avoid complica- rotations during MUA due to the fear of complications.
tions. At the end, all movements are repeated to confirm Albeit rare, various complications can occur during
that end range has been achieved. The authors prefer to MUA, especially while achieving a terminal range of
inject 40 mg of triamcinolone and 10 ml of 0.25% Bupi- movement such as Humerus shaft fracture, rotator cuff
vacaine to minimise postoperative pain and inflamma- tear, shoulder dislocation, labral tear, nerve injury, and
tion. Many other authors too prefer post MUA injection complex regional pain syndrome [90, 93–96].
of steroid and local anaesthetic agent [83, 84]. However, 2. Arthroscopic capsular release: Although all high-quality
concrete evidence for the benefit of the same is lacking. clinical studies have failed to reveal any major advantage
  Many studies have reported good to excellent long- of ACR over MUA [28, 97]; of late, ACR has emerged
term clinical outcome after MUA [85–87]. Said that, as ‘preferred’ surgical option for the treatment of refrac-
several debatable pertinent questions regarding MUA; tory FS as ACR allows controlled and precise release of
such as timing [88], with or without steroid injection fibrosed capsule–ligament complex under vision avoid-
[84], its efficacy in comparison to other conservative ing the said complications of MUA under the same
options [68, 89], and role in diabetics [42, 90–92] are anaesthetic burden [41, 95]. Further, ACR enables the
mentioned in Table 2. surgeon to thoroughly inspect and treat a “clinically or

Table 2  Summary of various contentious parameters regarding comparing two commonly used steroid molecules and outcome in
manipulation under anaesthesia (MUA) such as timing, with or with- diabetic vs. noon-diabetic frozen shoulders
out steroid injection, comparison with other conservative method,

Parameters Reference Conclusions

1 Timing of MUA (early or delayed) Vastamaki et al., 2015 [88] Delayed between 6 and 8 months while shoulder
is in late frozen phase. Early MUA in freezing
or early frozen phase could result in aggravation
of symptoms
2 With or without intraarticular steroid injection Kivimaki et al., RCT, 2001 [84] No difference. Hence, authors recommended that
(after MUA, in operating room itself) addition of steroid is of no use
3 Comparison with other conservative methods such Kivimaki et al., RCT, 2007 [68] No difference
as therapeutic exercise; steroids and distention Jacobs LG et al., RCT, 2009 [89]
4 Outcome of MUA in diabetics vs controls Hamdan et al., 2003 [90] Diabetics have poor outcome
Wang JP et al., 2010 [42] No difference
Jenkins et al., 2012 [91] 36% of diabetics may require repeat MUA com-
pared to 15% controls
Woods et al., 2017 [92] 38% risk of repeat MUA in diabetics compared to
18% as a group

RCT​randomised controlled trial. Number in [] denotes reference in the text

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radiologically missed” concomitant lesion of the carti-

lage, rotator cuff, labrum and subacromial space, if any,
which may be contributing to the pathology. Like MUA,
ACR should be performed between 6 and 8 months of
onset of frozen shoulder.

Many studies have shown excellent short-, mid- and

long-term results both in terms of lasting pain relief and
ROM gains with ACR [98–101]. Comparing diabetics with
non-diabetics, a recent systemic review concluded that clini-
cal outcomes after ACR were inferior (more residual pain,
reduced motion) in a diabetic patient compared to non-dia-
betic, and that must be explained to the patient during pre-
ACR counselling [102].
Technique: Under anaesthesia, diagnostic arthroscopy Fig. 4  Arthroscopic view (from anterior portal) of inflamed syn-
is performed from the posterior portal. The entry into the ovium-capsule over the infraspinatus
joint is often tricky, and care must be taken while insert-
ing the trocar to avoid damage to the articular cartilage of
humerus or glenoid. In case entry in the joint is not possible, is shifted to the anterior portal, and the posterior capsule is
force must be avoided, and gentle, controlled manipulation released till the posteroinferior corner. Due to the proximity
of joint should be done to break the extremely tight capsule, of the inferior capsule to the axillary nerve, the inferior-most
and that would enable the surgeon to insert the arthroscope. capsule is not released surgically but is broken with gentle
Lafosse et al. recommended lateral entry via rotator interval MUA at the end of the procedure [103]. Literature remains
in tight shoulders to avoid damage to intraarticular struc- contentious regarding clinical outcome after limited anterior
tures during forcible entry [100]. In almost all cases; the capsule release and MUA vs. circumferential release [41].
rotator interval is contracted and inflamed (Fig. 3), intra- Next, arthroscope is shifted to the subacromial space, and
articular part of the biceps tendon may reveal inflamma- subacromial adhesion or inflamed bursa, if any, is debrided.
tion, and synovitis is often present in the joint, especially With arthroscope in lateral portal, CHL is again inspected,
over the capsule covering the under-surface of the supra-and and should be released if found to be incompletely released.
infraspinatus (Fig. 4). Through the standard anterior portal, Further, adhesions over the bursal and articular side of sub-
the RI and CHL are released using a radiofrequency device scapularis muscle is released up to the base of the coracoid
(RFD), and synovitis is gently debrided. The tight MGHL to improve the mobility of the subscapularis, and thereby
is released followed by release of anterior capsule till the improving external rotation. At the end of the procedure,
anteroinferior corner of the capsule using RFD. The scope surgeon must gently move the shoulder in all directions to
ensure that the entire fibrotic capsule–ligamentous complex
is released [41]. Post MUA or ACR, authors prefer to inject
40 mg of Triamcinolone along with 10 ml of 0.25% Bupiv-
acaine to minimise post-procedure inflammation and pain.
Although many authors prefer injecting steroid post-ACR
[83, 104–106], only a few report superior outcome after the
injection [106]. However, larger consensus regarding utility
of steroid injection post-ACR is lacking.
Pain control and rehabilitation after MUA and ACR:
Adequate pain control for 2–3 weeks using NSAIDs and
local ice pack is quintessential for pain relief. Structured PT
must follow immediately after the procedure, and continue
for 4–6 months aiming to retain ’regained intra-operative’
ROM. The PT program should consist of early passive
and active-assisted ROM along with scapula stabilisa-
tion followed by active ROM combined with strengthen-
ing exercises for rotator cuff, scapular muscles, and core
Fig. 3  Arthroscopic view (from posterior portal) of inflammed and
contracted rotator interval (blue star) of right-side frozen shoulder. rehabilitation.
SSc subscapularis, BT biceps tendon

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otherwise in a credit line to the material. If material is not included in
gan et al. concluded that ACR is more costly and associated the article’s Creative Commons licence and your intended use is not
with serious adverse events (4%) while MUA is most cost- permitted by statutory regulation or exceeds the permitted use, you will
effective procedure [28]. However, in a systematic review of need to obtain permission directly from the copyright holder. To view a
22 studies (21 were level IV), Grant et al. concluded that rate copy of this licence, visit http://creat​iveco​mmons​.org/licen​ses/by/4.0/.
of complications with either procedure (MUA and ACR) is
less than 0.5% [97].
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