Adhesive capsulitis (a.k.a frozen shoulder) is associated with synovitis and a capsular contracture of the shoulder joint. (1) Patients with frozen shoulder often have limited active and passive range of motion, significant pain throughout their shoulder range of motion, and associated upper quarter muscle strength deficits. Since the joint capsule is suggested to be the structure limiting movement, range of motion deficits are often greatest in shoulder external rotation > abduction > internal rotation. While adhesive capsulitis is often thought to be a self-limiting condition, studies have reported "ranges of between 20 and 50% of patients with adhesive capsulitis which suffer long-term ROM deficits that may last up to 10 years." (2) As a healthcare practitioner it is important to know the expected prognosis and understand the potential for long-standing symptoms does exist. It is also important to understand what is the current best evidence for treatment of adhesive capsulitis and common management strategies if conservative management fails.

In this post, I will be discussing one of the surgical management options for adhesive capsulitis: Shoulder Manipulation under Anesthesia (MUA). 

1. Post-manipulation ​range of motion should be initiated within the first few days following the procedure. This will vary from surgeon to surgeon, but many protocols recommend physical therapy within 24 hours post-surgery.  Early range of motion and education is essential! 
2. While the manipulation is targeted at the joint capsule, other structures are likely to be torn or injured. A 2005 study by Loew et al assessed 30 subjects with shoulder synovitis following MUA. They found "the capsule was seen to be ruptured superiorly in 11 patients, the anterior capsule was ruptured up to the infraglenoid pole in 24 patients, and 16 patients each had a capsular lesion located posteriorly. In 18 patients no additional joint damage was found after manipulation. In 4 patients, iatrogenic superior labrum anterior-posterior lesions were observed. Further injuries detected were 3 fresh partial tears of the subscapularis tendon, 4 anterior labral detachments (1 with a small osteochondral defect), and 2 tears of the middle glenohumeral ligament." In other words, the manipulation is not a specific technique.
3. Due to the amount of stress across the shoulder, mitigating pain while maximizing range of motion should be your primary focus of treatment!   

Depending on the research article, the post-manipulation prognosis is scattered with results ranging from no effect to moderately effective. Per the clinical practice guidelines on Shoulder Pain and Mobility Deficits: Adhesive Capsulitis, there is Grade C for effectiveness of a MUA. This indicates relatively weak evidence for use of the intervention in individuals who are not responding to conservative care. 

References:
1. Adhesive Capsulitis - Physiopedia, universal access to physiotherapy knowledge. Physio - pediacom . 2017. Available at: http://www.physio - pedia.com/Adhesive_Capsulitis. Accessed March 28, 2017. 
2. Bulgen DY, Binder AI, Hazleman BL, Dutton J, Roberts S. Frozen shoulder: a prospective clinical study with an evaluation of three treatment regimens. Ann Rheum Dis. 1984;43:353–60. doi: 10.1136/ard.43.3.353. 
3. Manipulation under Anestesia. Shoulder Doc. 2017. Available at https://www.shoulderdoc.co.uk/article/1223. Accessed 12/25/17.

Several patients I've seen recently with scapular and/or posterior shoulder pain have presented with restricted rib 2-4 mobility (or some variation). They didn't have any pain with breathing, however, had significant reduction in pain and improved mobility following simply grade IV mobilizations to the restricted ribs. Even greater improvement was noted in the following day. Now the mechanism is not fully understood as manual therapy can have quite a few different effects. It's possible the patient would have had just as effective or more effective response to other treatments. Nonetheless, with the excellent response by my patient, I plan on regularly incorporating upper rib assessment to determine if there are some patterns for application.

​-Dr. Chris Fox, PT, DPT, OCS