Frozen shoulder

Amar Rangan and colleagues1Rangan A Brealey SD Keding A et al.Management of adults with primary frozen shoulder in secondary care (UK FROST): a multicentre, pragmatic, three-arm, superiority randomised clinical trial.Lancet. 2020; 396: 977-989Summary Full Text Full Text PDF PubMed Scopus (14) Google Scholar presented their findings from a multicentre, pragmatic, three-arm, superiority randomised controlled trial designed to compare early structured physiotherapy of frozen shoulder with manipulation under anaesthesia and arthroscopic capsular release.1Rangan A Brealey SD Keding A et al.Management of adults with primary frozen shoulder in secondary care (UK FROST): a multicentre, pragmatic, three-arm, superiority randomised clinical trial.Lancet. 2020; 396: 977-989Summary Full Text Full Text PDF PubMed Scopus (14) Google Scholar All options were found to be clinically equivalent; however, there was a higher risk of complications with arthroscopic capsular release than with manipulation under anaesthesia. Manipulation was the most cost-effective option.1Rangan A Brealey SD Keding A et al.Management of adults with primary frozen shoulder in secondary care (UK FROST): a multicentre, pragmatic, three-arm, superiority randomised clinical trial.Lancet. 2020; 396: 977-989Summary Full Text Full Text PDF PubMed Scopus (14) Google Scholar We have a few comments regarding the study design and some of the conclusions. First, this trial did not include the option of shoulder hydrodilatation for adhesive capsulitis. The investigators mentioned a UK-based survey from 2010,2Dennis L Brealey S Rangan A Rookmoneea M Watson J Managing idiopathic frozen shoulder: a survey of health professionals' current practice and research priorities.Shoulder Elbow. 2010; 2: 294-300Crossref Scopus (23) Google Scholar in which only 60 (6%) of 1042 responders offered hydrodilatation. Furthermore, they stated that its effectiveness was inconclusive. We agree that, at that point, the survey showed only a few surgeons offering this procedure; however, nowadays, we feel that hydrodilatation is a standard treatment option in almost all hospitals, across the UK and worldwide.3Elnady B Rageh EM Hussein MS et al.In shoulder adhesive capsulitis, ultrasound-guided anterior hydrodilatation in rotator interval is more effective than posterior approach: a randomized controlled study.Clin Rheumatol. 2020; 39: 3805-3814Crossref PubMed Scopus (0) Google Scholar, 4Gallacher S Beazley JC Evans J et al.A randomized controlled trial of arthroscopic capsular release versus hydrodilatation in the treatment of primary frozen shoulder.J Shoulder Elbow Surg. 2018; 27: 1401-1406Summary Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 5Paruthikunnan SM Shastry PN Kadavigere R Pandey V Karegowda LH Intra-articular steroid for adhesive capsulitis: does hydrodilatation give any additional benefit? A randomized control trial.Skeletal Radiol. 2020; 49: 795-803Crossref PubMed Scopus (3) Google Scholar Thus, it is of paramount clinical importance to include patients receiving hydrodilatation and to compare their outcomes with those of patients receiving the treatment options included in this trial. Second, all but one patient in the manipulation and physiotherapy group had steroid injection, whereas in the arthroscopic capsular release group only some patients had steroid injection at the discretion of each surgeon.This difference could be a source of potential bias because it can affect or even alter outcomes, especially within the first 6 months. Additionally, some patients in the arthroscopic capsular release group had an additional operation, such as posterior capsular release or subacromial decompression, which could also influence outcomes. Finally, an important question that needs to be further addressed is how any improvement noted after treatment was verified as the result of the treatment alone and not due to a natural resolution of frozen shoulder over time, given that this is a self-limiting condition that can resolve in an average of 15 months (range 4–36 months).6Vastamäki H Kettunen J Vastamäki M The natural history of idiopathic frozen shoulder: a 2- to 27-year followup study.Clin Orthop Relat Res. 2012; 470: 1133-1143Crossref PubMed Scopus (78) Google Scholar Comments from the investigators on these findings would facilitate deeper understanding of the results of the trial. We declare no competing interests. Management of adults with primary frozen shoulder in secondary care (UK FROST): a multicentre, pragmatic, three-arm, superiority randomised clinical trialAll mean differences on the assessment of shoulder pain and function (OSS) at the primary endpoint of 12 months were less than the target differences. Therefore, none of the three interventions were clinically superior. Arthoscopic capsular release carried higher risks, and manipulation under anaesthesia was the most cost-effective. Full-Text PDF Open AccessFrozen shoulder – Authors' replyWe thank Georgios Mamarelis and Dimitrios Moris for their interest in the UK FROST trial data1. As we reported,1 hydrodilatation was being used in only a few centres when we designed the UK FROST trial, which meant that it was not feasible to include hydrodilatation as a trial intervention. Although we acknowledge that hydrodilatation seems to be used more widely nowadays, the evidence to support its use remains scarce. There is also uncertainty as to what constitutes hydrodilatation because there is considerable variation in how it is delivered. Full-Text PDF