The outcome of manipulation under general anesthesia for the management of frozen shoulder in patients with diabetes mellitus

doi:10.1016/j.jse.2011.11.006

Journal of Shoulder and Elbow Surgery

Volume 21, Issue 11, November 2012, Pages 1492-1498

https://doi.org/10.1016/j.jse.2011.11.006 Get rights and content

Hypothesis

Frozen shoulder has a greater incidence, more severe course, and resistance to treatment in patients with diabetes mellitus compared with the general population. We hypothesized that diabetic patients with frozen shoulder undergoing treatment with manipulation under general anaesthesia (MUA) would have the same outcome as patients without diabetes.

Materials and methods

We retrospectively analyzed data collected during a 10-year period of referrals for frozen shoulder. In all cases, a standardized MUA protocol was followed once the diagnosis of frozen shoulder in the frozen phase was made; this included an early repeat MUA in individuals with recurrence. We compared outcomes for patients documented as having diabetes with a nondiabetic control group and assessed the effect of insulin dependence and frozen shoulder etiology within the diabetic group.

Results

Of a consecutive series of 315 frozen shoulders, 36 patients (39 shoulders) were included in the diabetic group, with 256 patients (274 shoulders) as controls. There was a significant improvement in range of movement and Oxford Shoulder Score (P all <.001), with no difference between diabetic and control groups at early or late follow-up (mean, 41 months). A repeat procedure was required in 36% of diabetic patients compared with 15% of control patients. Recurrence in the diabetic group was influenced by etiology (47% of primary vs 0% of secondary frozen shoulders) and insulin requirement (39% insulin-dependent vs. 31% non–insulin-dependent).

Conclusion

We provide a strategy for the management of diabetic frozen shoulders using MUA and estimates of success and recurrence rates that may be useful when informing consent.

Section snippets

Materials and methods

We retrospectively identified a consecutive series of patients who had presented with a diagnosis of frozen shoulder during a 10-year period from January 1999. All patients in the series had been assessed and managed by the lead surgeon (D.A.W.), who followed an identical protocol, in a single institution.

We identified from the clinical notes all patients who were known to be diabetic at the time their treatment commenced; the diagnosis of diabetes mellitus was sought as standard at the initial

Results

Between January 1999 and January 2009, 315 consecutive frozen shoulders were referred to the lead surgeon and 313 met the inclusion criteria. Of these, 39 shoulders (12%) were diabetic and entered into the study group, and 274 shoulders (88%) were not diabetic and formed the control group.

The study group comprised 36 patients (28 men, 8 women; 39 shoulders). The mean age was 49 years at the time of MUA (range, 35-72 years). IDDM was present in 22 patients (18 men, 4 women; 23 shoulders), and 17

Discussion

Frozen shoulder is perhaps the most disabling common musculoskeletal condition associated with diabetes mellitus.2, 3, 16, 18, 21, 22, 23 The occurrence of frozen shoulder is associated with increasing age in type 1 and type 2 diabetic patients and duration of diabetes in type 1 patients.¹ Some have suggested that patients presenting with a frozen shoulder should be screened for diabetes or impaired glucose tolerance because frozen shoulder may represent an index presentation of these

Conclusion

We concur with the body of evidence that suggests diabetic frozen shoulders are harder to manage than those in the general population. Our study adds to the existing literature by quantifying the success rate after a single MUA, determined by patient satisfaction with pain levels and ROM, at 64% with a failure rate of 36% during the 10 years of the study. Subsequent repeat MUA after failure of the initial procedure was successful in 85% of the shoulders treated. MUA remains a procedure with

Disclaimer

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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Cited by (44)

Risk factors for recurrence of frozen shoulder after shoulder manipulation under ultrasound-guided cervical nerve root block
2024, JSES International
This study aimed to investigate risk factors for recurrence of frozen shoulder after shoulder manipulation under ultrasound-guided cervical nerve root block (MUC).
We retrospectively reviewed 135 frozen shoulders in 121 patients who underwent MUC. We defined frozen shoulder as a limited shoulder range of motion (ROM) (passive forward flexion <120°, external rotation <30°, or internal rotation lower than L3). Patients fulfilling any one criteria were considered to have frozen shoulder. If patients continued to have severe pain and limited ROM at 3 months after MUC, we defined as recurrence of frozen shoulder and they were offered a further MUC or arthroscopic capsular release (ACR). We compared the ROM, Constant Shoulder (CS) score, and University of California, Los Angeles score before and 3 months after MUC between patients with the successful of MUC group (Success group) with those recurrence of frozen shoulder who required a further MUC or ACR group (Recurrence group). Multiple logistic regression analysis was used to identify risk factors for recurrence of frozen shoulder after MUC.
Patients who underwent MUC were retrospectively enrolled and divided into: the successful of MUC group (Success group, n = 112) and required a further MUC or ACR group (Recurrence group, n = 9). The Recurrence group had significantly lower external rotation and CS score before MUC than those in the Success group (P < .05). The Recurrence group showed significantly inferior all ROM and functional scores 3 months after MUC (P < .05). The levels of blood glucose and hemoglobin A1c both before and 3 months after MUC in the Recurrence group showed inferior compared with those of Success group. The difference, although not statistically significant, trended towards significance (before MUC/3 months after MUC; the glucose levels P = .06/.06, the hemoglobin A1c levels P = .07/.09, respectively). The visual analog scale pain score (at rest, during activity, at night) both before and 3 months after MUC in the Recurrence group showed significantly higher scores compared with those of Success group (P < .05). Multiple logistic regression analysis revealed that lower CS score before MUC was independent risk factor for recurrence of frozen shoulder after MUC.
The overall incidence of recurrence of frozen shoulder after MUC was 7.4%. The lower CS score before MUC was an independent risk factor for recurrence of frozen shoulder after MUC. Moreover, patients in the Recurrence group tended to have poorly controlled diabetes and higher visual analog scale pain score both before and 3 months after MUC.
Does capsular distension and a short period of countertraction improve outcome following manipulation under anesthesia for the treatment of primary adhesive capsulitis of the glenohumeral joint?
2022, Journal of Shoulder and Elbow Surgery
Despite the fact that primary adhesive capsulitis of the glenohumeral joint is often considered a self-limiting condition, not all patients make a full recovery. Manipulation under anesthesia (MUA) is performed to forcibly rupture the contracted capsule in a controlled manner. However, the technique, timing, and use of additional injections are often debated. In this study, we report the outcomes following the addition of capsular distension and countertraction to MUA as a treatment for adhesive capsulitis.
We performed a retrospective case-cohort study comparing 3 groups: Group 1 underwent MUA alone (n = 54); group 2, MUA with capsular distension (n = 114); and group 3, MUA with capsular distension and countertraction (n = 167). The re-MUA rate, Constant-Murley shoulder (CMS) score, and visual analog scale (VAS) score (for pain) were measured after 6 weeks and 6 months.
The re-MUA rate fell with the addition of both capsular distension and countertraction: 63% in group 1, 39% in group 2, and 18% in group 3. Patients in group 3 recorded the greatest improvement in the CMS score after 6 weeks (+90% vs. +68% in group 2 and +58% in group 1), with all groups showing improvements compared with before treatment. The only independent risk factor identified for re-MUA was smoking. If a second MUA was performed, the CMS (+67%) and VAS (+61%) scores improved, but at 6 months, the CMS score (74.57 ± 7.6 vs. 83.30 ± 5.5) and VAS score (10.57 ± 1.8 vs. 12.96 ± 1.5) remained inferior to those of patients who only needed a single MUA.
MUA combined with capsular distension and countertraction reduces the need for a second MUA and results in a faster improvement in functional outcome (CMS score) and reduction of pain (VAS score) compared with MUA alone or MUA with capsular distension. The results of this case-cohort study are of clinical relevance because they show that the efficacy of an MUA can be improved through relatively simple adaptations of the treatment protocol.
Prognostic factors of shoulder manipulation under ultrasound-guided cervical nerve root block for frozen shoulder for patient with diabetes mellitus: A retrospective cohort study
2021, International Journal of Surgery Case Reports
Shoulder manipulation under ultrasound-guided cervical nerve root block (MUC) gives good clinical results in patients with frozen shoulder 1 week after the procedure. However, some patients are refractory to MUC. The present study was performed to investigate the prognostic factors of MUC for frozen shoulder.
We evaluated 73 frozen shoulders (70 patients) to investigate the prognostic factors of MUC. The patients' mean age was 56.6 years, and 60% were female. The mean duration of symptoms before MUC was 8.6 months. We assessed pain using a numeric rating scale (NRS), range of motion (ROM), and the American Shoulder and Elbow Surgeons (ASES) score before and 1 year after MUC. We compared patients with an ASES score of <80 (defined as a poor clinical result) with those with an ASES score of ≥80 (good clinical result). To identify the risk factors for a poor clinical result, multiple logistic regression analysis was performed using the following variables: age, sex, duration of symptoms before MUC, diabetes mellitus (DM), initial NRS score, and initial ROM.
The initial NRS score and the prevalence of DM were significantly greater in the poor clinical results group. Multiple logistic regression analysis revealed that DM was the only independent risk factor for a poor clinical result after MUC (odds ratio, 51; 95% confidence interval, 10.9–237; p = .01).
DM is a negative prognostic factor of MUC for frozen shoulder, and patients with DM should be informed of this before they undergo treatment for frozen shoulder.
What is the optimum rehabilitation for patients who have undergone release procedures for frozen shoulder? A UK survey
2021, Musculoskeletal Science and Practice
Despite usually being considered necessary, the rehabilitation regime that optimises outcomes for patients following release procedures for frozen shoulder has not been established and no accepted best practice guidelines currently exist. The purpose of this study was to gain insight into what physiotherapists considered best practice and factors they considered likely to affect patient outcome.
A cross-sectional, self-administered online questionnaire was developed and distributed to UK based Physiotherapists, undergraduate students and support workers via email, social media and professional networks.
260 eligible and fully completed surveys were received. Clear preference for early (within 72 h), frequent (2–3 times per week or weekly) and prolonged (greater than 6 weeks) treatment delivered in a 1:1 setting was expressed. 99% were highly likely/likely to advocate education and advice, range of movement exercises (99.6%), stretching (73.5%) and strengthening (61.9%). More passive modalities (manual therapy, massage, electrotherapy, acupuncture) were highly unlikely/unlikely to be used and lack of manual therapy and insufficient contact with a physiotherapist were the reasons deemed least likely to affect outcome. Most clinicians (89.2%) were likely to prescribe exercises that patients reported as painful but persistent pain and poor adherence by patients to exercises were the top reasons given for poor outcome along with psychological and psychosocial patient characteristics.
Physiotherapists consistently advocate early, frequent, prolonged, 1:1 treatment following release procedures for frozen shoulder. Most patients are discharged whilst still experiencing symptoms, particularly pain. Further work is needed to establish high value pathways for this patient group.
Comparison of outcomes following arthroscopic capsular release for idiopathic, diabetic and secondary shoulder adhesive capsulitis: A Systematic Review
2019, Orthopaedics and Traumatology: Surgery and Research
Citation Excerpt :
Massoud et al. reported that 22% of diabetics were unsatisfied and 68% still had limitation in motion after surgical intervention [31]. Studies comparing outcomes in idiopathic and diabetic patients have demonstrated inferior outcomes in diabetic patients after non-operative treatment [10], manipulation under anaesthesia [12,32,33], and arthroscopic release [34]. Jenkins et al. retrospectively compared manipulation under anaesthesia in diabetic and non-diabetic patients and showed that diabetics had a higher return to theatre for unsatisfactory outcomes (36% vs. 15%) [33].
Arthroscopic capsular release for adhesive capsulitis of the shoulder is a treatment option. The present study aimed to investigate the clinical outcomes following arthroscopic capsular release among idiopathic, diabetic and secondary adhesive capsulitis.
Different aetiological groups yield variable outcomes following arthroscopic capsular release.
A literature search was performed using MEDLINE, EMBASE, CINAHL and the Cochrane Database in April 2017. Comparative studies that reported range of motion or functional outcomes following arthroscopic capsular release in patients with adhesive capsulitis were included. A systematic review of the studies was conducted following the PRISMA guidelines.
Six studies met the eligibility criteria. The overall population included 463 patients; 203 idiopathic, 61 diabetic and 199 secondary cases. Of four studies comparing idiopathic and diabetic patients, three reported significantly worse range of movement and function in the diabetic group at various follow up points. No significant difference in function and motion was reported between the idiopathic and secondary groups. Recurrent pain was highest in diabetic patients (26%) compared to idiopathic groups (0%) and the secondary group had a higher rate of revision surgery when compared to the idiopathic group (8.1% vs. 2.4%)
Arthroscopic capsular release has a high success rate regardless of the underlying aetiology. However, diabetic patients are reported to have more residual pain, reduced motion and inferior function compared to idiopathic cases. The rate of revision capsular release is higher among patients with post-surgical adhesive capsulitis when compared to idiopathic cases.
IV, systematic review.
Management of Concomitant Preoperative Rotator Cuff Pathology and Adhesive Capsulitis: A Systematic Review of Indications, Treatment Approaches, and Outcomes
2019, Arthroscopy - Journal of Arthroscopic and Related Surgery
Citation Excerpt :
In particular, this review supports the use of MUA and CR with RC repair in patients with comorbid diabetes, owing to its strength as a risk factor for the development of both idiopathic and postoperative or post-traumatic AC.11,28,29 This review does not suggest the need for substantial technical modifications to be made in performing concomitant RC repair with MUA and/or CR compared with techniques for these interventions previously described in the literature.18,30-36 Arthroscopic RC repair with suture anchors is well explored in this scenario and can be performed with the patient under general anesthesia in the lateral decubitus or beach-chair position.30,31
Concomitant preoperative adhesive capsulitis (AC) and rotator cuff (RC) pathology pose therapeutic challenges in light of contrasting interventional and rehabilitative goals. The purposes of this systematic review were to assess the literature regarding the management and rehabilitation of patients with concomitant RC tears and preoperative AC and to compare overall clinical outcomes between strategies for this common scenario.
In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 3 databases (MEDLINE, Embase, and PubMed) were searched and screened in duplicate using predetermined criteria for studies on the aforementioned patient population. Descriptive statistics are presented.
Of 952 studies, 17 involving 662 shoulders, with a mean age of 59.6 ± 3.5 years, 57.9% female patients, and a mean follow-up period of 18.6 months, were included. Capsular release (CR) (86.1%) and manipulation under anesthesia (MUA) (33.1%) were the most common co-interventions with RC repair. Across studies, mean preoperative American Shoulder and Elbow Surgeons scores ranged from 29.0 to 61.3, visual analog scale scores (pain) ranged from 5.3 to 8.0, and Constant scores ranged from 18.0 to 48.0. Mean postoperative American Shoulder and Elbow Surgeons scores ranged from 76.9 to 92.0, visual analog scale scores (pain) ranged from 0.3 to 2.5, and Constant scores ranged from 72.6 to 93.2. Postoperative rehabilitation comprised abduction braces and passive range of motion immediately postoperatively for mean durations of 5.0 weeks and 5.3 weeks, respectively, followed by active range of motion at a mean of 5.3 weeks and strengthening at 10.9 weeks. Postoperative complications included stiffness, RC retear, instability, glenoid fracture, and superficial infection.
The results of this systematic review support treatment of patients with degenerative RC tears and concomitant AC with a combination of RC repair and MUA, CR, or both MUA and CR. Regardless of the treatment modality, accelerated postoperative rehabilitative protocols are beneficial in preventing postoperative persistence of AC and can be safely used in this scenario without a substantial increase in complication rates compared with patients undergoing RC repair alone with conservative rehabilitation.
Level V, systematic review of Level II, III, IV, and V studies.

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: This study was approved by the Medical Advisory Committee of the BMI Ridgeway Hospital.

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ShoulderThe outcome of manipulation under general anesthesia for the management of frozen shoulder in patients with diabetes mellitus

Hypothesis

Materials and methods

Results

Conclusion

Section snippets

Materials and methods

Results

Discussion

Conclusion

Disclaimer

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Shoulder capsulitis in type I and type II diabetic patients: association with diabetic complications and related diseases

Ann Rheum Dis

Periarthritis of the shoulder and diabetes mellitus

Ann Rheum Dis

The pathology of frozen shoulder. A Dupuytren-like disease

J Bone Joint Surg Br

The role of surgery in frozen shoulder

J Bone Joint Surg Br

The shoulder: rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa

Questionnaire on the perceptions of patients about shoulder surgery

J Bone Joint Surg Br

The Oxford Shoulder Score revisited

Arch Orthop Trauma Surg

The effects of diabetes on outcome after hip fracture

Bull Hosp Jt Dis

Shoulder
The outcome of manipulation under general anesthesia for the management of frozen shoulder in patients with diabetes mellitus