The main indication for manipulation under anesthesia is primary idiopathic frozen shoulder. It is important to distinguish between this and post-traumatic stiffness, which does not usually respond well to manipulation. The ideal time for manipulation of the frozen shoulder is at the stage when night pain is decreasing but the stiffness has reached a maximum. Physiotherapy at this stage usually makes the shoulder more painful but is of course invaluable immediately after the manipulation and possible injection.

Technique

The patient lies supine under general anesthesia with the head resting on a head ring, and if the patient is being manipulated on a trolley, the stretcher pole is removed from the affected side. The surgeon should stand at the head end of the table with one hand stabilizing the scapula in the resting position. The surgeon’s other hand should then be placed in the patient’s axilla such that the surgeon’s forearm is resting against the whole of the inside of the patient’s arm.

First, abduction is taken to the patient’s free limit, and then the patient is forcibly abducted while the scapula is maintained down in the anatomic position. The scapula must not move at any stage. This maneuver will rupture the inferior capsule. The shoulder is then forcibly adducted such that the affected elbow is pushed in front of the patient’s chin to rupture the posterior capsule. Finally, forcible external rotation and internal rotation are added, but great care is taken here because it is during these final rotation maneuvers that a spiral fracture can be caused.

Postoperative Management

For the first few days, daily physiotherapy (possible home physiotherapy) is encouraged, and a home exercise program is begun whereby the patient is asked to put the shoulder through the maximum range of movements, stretching to extremes at least three times a day. The patient should have been prewarned that this may be a very uncomfortable procedure. Majority of patients undergo physiotherapy as outpatients.

Although the shoulder may have been manipulated through a full range of movements under anesthesia, this is rarely gained immediately after recovery and it takes several weeks to regain the full range of motion. Recovery from this procedure can be extremely variable. However, if the shoulder gives with one definite snap during the manipulation, then a good result is usually achieved quite quickly.

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