Manipulation under anaesthesia and arthroscopic capsular release are options for selected patients whose disability remains unacceptable after an appropriate non-operative pathway. Neither should be presented as an inevitable next stage of frozen shoulder.
The 503-participant UK FROST trial found no clinically important superiority at 12 months among early structured physiotherapy with steroid injection, manipulation under anaesthesia, and arthroscopic capsular release. Surgery carried more serious adverse events; choice therefore depends on the individual, service setting and informed preference.
Manipulation under anaesthesia
During MUA, the anaesthetised shoulder is moved through range to disrupt capsular restriction. It is less invasive than arthroscopic release but is not risk-free. Reported complications include fracture, dislocation, cuff or labral injury and nerve injury, although serious events are uncommon in experienced services.
Arthroscopic capsular release
ACR uses keyhole surgery to divide selected contracted parts of the capsule under direct vision, usually followed by manipulation. It permits inspection and treatment of some coexisting pathology but involves surgical, anaesthetic and post-operative risks. UK FROST found small statistical differences favouring ACR at 12 months, but these did not meet the prespecified threshold for clinical importance.
Who might be considered?
Referral is generally considered when diagnosis is secure, symptoms remain substantially limiting, reasonable non-operative options have been discussed or tried, and the patient understands both the natural history and procedural trade-offs. “Failure” should not be defined by a rigid number of weeks alone. Severity, trajectory, work, sleep, comorbidity and preference all matter.
Post-procedure care
Procedures create an opportunity to use newly available movement; they do not remove the need for recovery planning. The plan should cover analgesia, wound or injection-site care, early comfortable movement, function, graded loading and warning signs. Rehabilitation intensity must be balanced against tissue irritability and surgical instructions.
- Document an early baseline after the procedure.
- Restore useful movement rather than chase maximal range at every session.
- Progress active control and strength as pain and healing permit.
- Escalate promptly for fever, wound concerns, unexpected neurological symptoms, severe unremitting pain or suspected fracture/dislocation.
How to communicate the evidence
A procedure may help an individual considerably even when group-level differences are modest. Equally, improvement after surgery does not prove that surgery was the only route to improvement. Shared decision-making should use absolute expectations, risks, recovery demands and alternatives—not simply the label “refractory”.