Decoding the Optimal Intervention for Adhesive Capsulitis
As orthopaedic and sports physiotherapists, we frequently encounter patients suffering from adhesive capsulitis, commonly known as frozen shoulder. While conservative management, including targeted manual therapy and progressive range-of-motion exercises, remains our first line of defense, a subset of patients inevitably plateau. When conservative treatment fails, orthopaedic surgeons typically turn to two primary interventions: Arthroscopic Capsular Release (ACR) and Manipulation Under Anaesthesia (MUA). Despite their widespread use, high-quality Level-I evidence comparing the two has been surprisingly scarce. A recent prospective randomized study sought to fill this gap, evaluating the functional outcomes, complication rates, and cost-effectiveness of both procedures.
Analyzing the Prospective Randomized Trial Data
The study followed patients presenting with frozen shoulder from May 2020 to June 2021. The cohort was randomized into two distinct groups: those undergoing ACR (44 patients) and those undergoing MUA (41 patients). To ensure the integrity of the results, the researchers excluded individuals with preexisting shoulder arthritis, full-thickness rotator cuff tears, and any history of shoulder trauma or prior surgeries. The clinical assessment was rigorous. Researchers tracked Range of Movement (ROM), pain levels using the Visual Analogue Scale (VAS), and multiple functional scores including UCLA, CONSTANT, and EuroQol-5D both pre-operatively and post-operatively. Additionally, post-operative MRIs were conducted at the three-week mark to carefully screen for any procedure-related complications.
Clinical Outcomes and Post-Operative Nuances
The results at the 24-week follow-up revealed highly encouraging news for both interventions. Patients in both the ACR and MUA groups demonstrated significant improvements in pain reduction, ROM restoration, and overall functional shoulder scores. Statistically, there was no significant difference in the primary outcomes between the two groups. However, there were fascinating clinical nuances, particularly concerning comorbidities. Diabetic patients who underwent ACR demonstrated slightly less improvement in shoulder abduction and external rotation compared to their non-diabetic counterparts, a critical consideration for post-operative physiotherapy planning.
When reviewing the post-operative MRI data at three weeks, distinct complication profiles emerged for each procedure. The MUA group was more prone to sustaining labral tears, whereas the ACR group exhibited a higher incidence of bone bruising. As rehabilitation professionals, being aware of these specific micro-traumas can help us tailor our early post-operative loading strategies.
Cost-Effectiveness and Physiotherapy Implications
Beyond clinical efficacy, healthcare economics plays a vital role in surgical decision-making. The researchers utilized Quality-Adjusted Life Years (QALY) to conduct a robust cost-analysis. The data clearly favored the simpler procedure: the cost per QALY gained for ACR was $896 USD, compared to just $424 USD for MUA. Given the comparable improvements in pain and functional shoulder mobility, alongside its simpler technique and superior cost-effectiveness, MUA presents itself as a highly attractive option over ACR. For physiotherapists, this research reinforces that patients returning from MUA have the potential for excellent outcomes that match those of more invasive arthroscopic procedures, provided they receive structured, immediate post-operative rehabilitation to maintain the newly gained capsular mobility.
References
Sundararajan, S. R., Dsouza, T., Rajagopalakrishnan, R., Bt, P., Arumugam, P., & Rajasekaran, S. (2022). Arthroscopic capsular release versus manipulation under anaesthesia for treating frozen shoulder – a prospective randomised study. International orthopaedics. https://pubmed.ncbi.nlm.nih.gov/36048234/
