Shoulder manipulation under targeted ultrasound-guided rotator interval block for adhesive capsulitis

Objective

To describe and evaluate the outcome following shoulder manipulation under rotator interval block for the treatment of adhesive capsulitis.

Materials and methods

Patients with adhesive capsulitis referred by our local orthopaedic shoulder surgeons consented to targeted ultrasound-guided injection of the glenohumeral joint via the rotator interval. Inclusion criteria included a failure to respond to conservative treatment and the absence of a full-thickness rotator cuff tear. Twelve millilitres of a mixture of local anaesthetic and steroid was injected into the rotator interval using a 21-gauge needle, with a small volume of the same solution instilled into the subacromial bursa. Following injection, under local anaesthetic block, patients were gently manipulated into abduction, external rotation and internal rotation as far as they could comfortably tolerate. Patients were assessed pre-injection with documented pain scores from 0 to 10 on a visual analogue scale (VAS) and the Oxford Shoulder Score (OSS) questionnaire. Initial follow-up comprised a VAS pain score at 1 h, 24 h and 2 weeks. Clinical review by the referring orthopaedic surgeon was performed at 2 months post-injection. Long-term follow-up involved a VAS pain score and the OSS questionnaire at 5 months.

Results

Forty patients were suitable for inclusion in the study. Twenty-three were female (57.5%) and 17 were male. The mean age was 52 years (range, 31–73 years). Twelve patients were post-operative. The duration of symptoms ranged from 3 months to 18 months. Mean pre-procedure OSS was recorded as 23.3 (range, 4–36). The mean VAS pain score was 7.7 before the procedure (range, 4 – 10), 3.4 at 1 h (range, 0–8), 2.9 at 24 h (range, 0–8), and 1.8 at 2 weeks (range 1–4). Orthopaedic follow-up at an average of 66 days post-injection was recorded in 18 patients. All patients reported initial improvement of their shoulder pain and return to near full range of movement; however, recurrence of adhesive capsulitis symptoms was recorded in 5 patients. One case of rupture of the long head of the biceps tendon was reported, but the patient remained asymptomatic. Long-term follow-up at 5 months was obtained in 31 patients, with a mean OSS of 42 (range, 21–60) and VAS of 2.3 (range, 0–7).

Conclusion

Manipulation under general anaesthesia is a well-recognised treatment for adhesive capsulitis. We report that targeted ultrasound-guided injection of the rotator interval and manipulation of the shoulder under local anaesthetic blockade result in good outcomes in reducing shoulder pain and symptoms of adhesive capsulitis with low recurrence and complication rates.