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Manipulation or intra-articular steroids in the management of adhesive capsulitis of the shoulder? A prospective randomized trial

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Background

The management of adhesive capsulitis (frozen shoulder) is controversial. The authors present a prospective randomized study comparing the outcome, at a two-year follow-up period, of two groups of patients treated either by manipulation of the shoulder under anaesthetic or by intra-articular shoulder injections using steroid with distension.

Methods

Fifty-three patients suffering from Idiopathic “Primary” Frozen Shoulder were prospectively randomized into two treatment groups and followed up for two years from the start of treatment. Patients were assessed using the Constant score, a Visual Analogue Score, and the SF36 questionnaire.

Results

No statistical differences were found between the two groups of patients with regards to the outcome measures.

Conclusion

Treatment using steroid injections with distension as an out-patient is therefore recommended for the treatment of Idiopathic “Primary” Frozen Shoulder. This has the same clinical outcome as a manipulation under anaesthetic with less attendant risks.

Level of evidence

Level 1; Randomized controlled trial, therapeutic study.

Section snippets

Patients and methods

The study cohort comprised 53 consecutive patients, aged 40 to 75 years, who presented to the upper limb service at the Royal Oldham Hospital with primary frozen shoulder. A closed envelope method was use to randomize patients to MUA or injection. The MUA group received treatment with a manipulation under general anesthesia, followed by physiotherapy as an outpatient. The injection group was treated by distension with local anaesthetic and a steroid, followed by physiotherapy. Ideally, the

Results

The MUA group contained 28 patients, of which 15 (54%) were women, with a median age of 56.5 years. The injection group contained 25 patients, of which 20 (80%) were women, with a median age of 57.0 years. The median duration of symptoms before presentation in the MUA group was 19 weeks compared with 16 weeks in the injection group, suggesting that most patients were in the “freezing” stage of the disease. The dominant limb was affected in 46% of the MUA group and in 24% of the injection group.

Discussion

In 1980 Thomas et al38 reported a study comparing treatment by MUA and steroid injection with steroid injection alone and showed that those who received MUA had a more rapid improvement in pain and function than those who did not. Gam et al12 had previously reported in their study comparing patients treated with either 6-week injections providing distension and steroid, or steroid alone, that those receiving distension gained a faster improvement in range of motion and reduction in pain. Thus

Conclusions

In view of the potential risks of an MUA and the relative ease and safety of steroid with distension injections, we recommend the use of these injections, rather than MUA and physiotherapy, as a first-line treatment for patients in the “freezing” phase of idiopathic (primary) frozen shoulder. Because the availability of hospital beds is universally becoming increasingly difficult, this outpatient mode of treatment also has obvious advantages in terms of health economics.

Acknowledgment

We would like to thank sincerely all the Specialist Registrars from the North-West Specialist Registrar rotation (United Kingdom) who helped the main author with conducting this study. Without their help this work would never had been completed. The study had Full Local Research and Ethical Committee approval from The Royal Oldham Hospital (ref: 3/96/1(a)). The authors are not aware of any conflicts of interest.

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