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Operative Treatment for Adhesive Capsulitis

Manipulation Under Anesthesia

Manipulation under anesthesia (MUA) has been used to treat adhesive capsulitis for many years. This treatment has commonly been described to prospective patients as “stretching the tight capsule” or “breaking up adhesions” within the shoulder joint. Arthroscopic visualization of the glenohumeral joint after this procedure, however, reveals that a MUA does not stretch a tight capsule; instead, it uniformly results in a traumatic rupture of the inferior glenohumeral capsule which extends superiorly into both the anterior and posterior capsule to varying degrees, depending on the severity of the contracture present. Although incidental findings of labral tearing and rotator cuff tearing have been observed, they are not routinely encountered after this procedure. Post manipulation dislocation, fractures of the humerus or glenoid, and neurologic injury to the brachial plexus have also been described. Although these types of complications are serious, and they may result in a more complicated course of treatment, their occurrence is uncommon and is reported by Harryman and Lazarus to be less than 1%.

The results of manipulation under anesthesia for patients with adhesive capsulitis have been reported upon by many authors with an average success rate of approximately 70% at 3 to 6 months of follow-up , but with variation in satisfactory outcomes ranging from as little as 30%  to as high as 97%. An average recurrence rate of stiffness seems to be approximately 8%. The treatment of patients with adhesive capsulitis and diabetes mellitus traditionally has seemed to be more difficult to most clinicians than the treatment of patients who have only adhesive capsulitis. This impression was confirmed by Janda and Hawkins who reported in 1993 that MUA in a group of six of these patients resulted in 100% recurrence of stiffness at 8 months. Goldberg et al also found poorer outcomes with MUA in diabetic patients. Although they observed a 70% response rate to MUA in patients without diabetes, their results decreased to what they termed a “partial response” in approximately 25% of patients with shoulder stiffness who also had endured insulin-dependant diabetes mellitus for more than 10 years. Other authors, however, have offered more encouraging observations on their treatment of diabetic patients using MUA. Massoud et al. found 80% acceptable results in those diabetic patients whose contracture yielded to a “gentle manipulation.” (In their study protocol, those patients with more severe contractures, which would require a “forceful” MUA, received a different treatment.) Andersen et al. , who treated adhesive capsulitis with manipulation under anesthesia and diagnostic arthroscopic evaluation, found no difference in results for diabetic versus nondiabetic patients. Seventy-five percent of their patients returned to work after 9 weeks, and 79% had slight or no pain at both 6 and 12 months follow up. A report by Pollock et al.  reviewed their experience with a treatment regimen consisting of a gentle manipulation under anesthesia followed by arthroscopic glenohumeral and subacromial debridement. These investigators “aggressively debrided” rotator interval synovitis, coracohumeral ligament and anterosuperior capsular tissues torn by the MUA, and bursal adhesions when present. They also occasionally used electrocautery to detach the coracohumeral ligament in those patients in whom full external rotation was not accomplished by the MUA, and in some cases performed acromioplasty and acromioclavicular joint debridement. They had excellent results in patients with idiopathic adhesive capsulitis, for whom they reported 100% success, but this approach provided only 64% success in their diabetic patients. In light of these studies, there seems to be grounds for greater optimism than Janda’s initial paper suggested; however, most practitioners continue to find the management of adhesive capsulitis in patients with diabetes mellitus to be more challenging than in those without diabetes, and many remain cautious to utilize MUA to treat this group of patients.

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