The Somatic Connection  |   July 2018
Manipulation Under Anesthesia Thaws Frozen Shoulder
Author Notes
  • Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Pomona, California 
Article Information
The Somatic Connection   |   July 2018
Manipulation Under Anesthesia Thaws Frozen Shoulder
The Journal of the American Osteopathic Association, July 2018, Vol. 118, 485-486. doi:
The Journal of the American Osteopathic Association, July 2018, Vol. 118, 485-486. doi:
Web of Science® Times Cited: 2
Tsvieli O, Atoun E, Consigliere P, et al. Manipulation under anaesthetic for frozen shoulder using Codman's paradox: a safe and early return of function. International Orthopaedics (SICOT). 2018;42:339-344. 
Frozen shoulder, or adhesive capsulitis, is often self-limiting over the course of 2 to 3 years, though it can last longer or recur. Osteopathic manipulative treatment has been shown to improve pain and function related to frozen shoulder.1 Manipulation under anesthesia (MUA) has been used for refractory cases by osteopathic physicians.2 However, MUA is not without risks, and potential complications include fractures, dislocations, and nerve injuries. Researchers and surgeons from the United Kingdom aimed to limit complications during MUA by using the Codman paradox, a series of mobilizations that prevent direct rotational torque at the shoulder joint. 
The study assessed 212 consecutive patients (224 shoulders; 85 males [88 shoulders] and 127 females [136 shoulders]) with a mean age of 52.4 years. Of the 224 shoulders, 39 were diabetic frozen shoulders, 62 frozen shoulders resulted from minor trauma or strain, and 123 were idiopathic frozen shoulders. Patients were referred to the study after nonsurgical modalities, including analgesic medication, corticosteroid injections, or physiotherapy, were unsuccessful. All patients received the same MUA with the Codman paradox in the supine position under general anesthesia and interscalene nerve block. 
Patients were evaluated clinically before and after MUA, 3 weeks after MUA, and 3 months after MUA using Constant-Murley functional shoulder score, pain score, range of motion, patient satisfaction, subjective shoulder value, and return to previous activities. After MUA, significant improvement was recorded in all parameters being measured (P<.001) at both 3 weeks and 3 months. In addition, 71% of patients returned to work and full activity at 3 weeks, and 79% returned at 3 months. No fractures, dislocations, nerve injuries, or other adverse effects were reported. 
Although there was no control group and no other manipulation being compared with MUA with the Codman paradox, this study demonstrated significant improvements for all patients with frozen shoulder, regardless of cause. Furthermore, the level of safety and reproducibility reported in this study surpasses previous reports on MUA. A prospective randomized clinical trial comparing other manual therapies, arthroscopic release, and MUA is underway.3 
Knebl JA, Shores JH, Gamber RG, Gray WT, Herron KM. Improving functional ability in the elderly via the Spencer technique, an osteopathic manipulative treatment: a randomized, controlled trial. J Am Osteopath Assoc. 2002;102(7):387-396. [PubMed]
Morey LWJr. Osteopathic manipulation under general anesthesia. J Am Osteopath Assoc. 1973;73(2):116-127. [PubMed]
Brealey S, Armstrong AL, Brooksbank A, et al. United Kingdom Frozen Shoulder Trial (UK FROST), multi-centre, randomised, 12 month, parallel group, superiority study to compare the clinical and cost-effectiveness of early structured physiotherapy versus manipulation under anaesthesia versus arthroscopic capsular release for patients referred to secondary care with a primary frozen shoulder: study protocol for a randomised controlled trial. Trials. 2017;18(1):614. doi: 10.1186/s13063-017-2352-2 [CrossRef] [PubMed]