Frozen Shoulder — Manipulation Without General Anaesthesia?

Polish version

Does manipulation for frozen shoulder have to be performed under general anaesthesia? A new randomised trial suggests that, in carefully selected adults with primary frozen shoulder persisting despite at least 6 months of non-operative treatment, an outpatient procedure under local anaesthesia may be feasible. The study did not demonstrate superiority in its primary endpoint, so the findings are better viewed as evidence of feasibility than as proof of a new standard of treatment.

Why is this study interesting?

Manipulation under anaesthesia is one option for refractory frozen shoulder, but the conventional approach uses an operating theatre and general anaesthesia. The investigators asked whether a similar short-term result could be achieved in an outpatient setting using an ultrasound-guided WALANT protocol—wide-awake local anaesthesia without general anaesthesia.

Question and methodology

This single-centre prospective randomised trial enrolled 72 adults with primary frozen shoulder that persisted despite at least 6 months of conservative treatment. Participants were allocated 1:1 to outpatient manipulation using an ultrasound-guided WALANT protocol or to manipulation under general anaesthesia in the operating theatre.

The primary endpoint was forward shoulder flexion at 4 weeks. The investigators also assessed other ranges of motion, pain, UCLA Shoulder, DASH and Constant–Murley scores, pre-procedure anxiety and early complications. Six participants in the general-anaesthesia group did not complete follow-up; complete-case analysis therefore included 36 patients in the WALANT group and 30 in the general-anaesthesia group.

Results

At 4 weeks, mean forward flexion was 170.6° in the WALANT group and 159.6° after manipulation under general anaesthesia. The between-group difference was 11.0°, but the 95% confidence interval crossed no difference (−0.8° to 22.7°; p=0.068). The prespecified primary endpoint therefore did not show a statistically significant advantage for either strategy.

In secondary analyses, pain, selected motion measures and the Constant–Murley score transiently favoured WALANT during the earlier weeks, but these differences were no longer present at week 4. UCLA Shoulder and DASH scores did not differ between groups. Pre-procedure anxiety was lower in the outpatient group. During the short follow-up, the investigators reported no procedure-related complications, infections, early recurrences or repeat interventions.

Clinical interpretation for an orthopaedic surgeon

The clinically useful message is not that “WALANT is better”. Rather, the trial suggests that, in a specialised setting, ultrasound-guided outpatient manipulation can be technically feasible and can produce short-term outcomes broadly similar to manipulation under general anaesthesia. A potential organisational advantage would be reduced reliance on operating-theatre and anaesthetic resources, but the study did not formally evaluate costs or health-system efficiency.

Patient selection remains central in frozen shoulder. Manipulation is not a first-line treatment for every patient with shoulder stiffness. The decision must take into account symptom duration, response to previous treatment, the clinical diagnosis and the risk of injury during manipulation.

Limitations

• The study was single-centre and included a relatively small number of patients.
• The main follow-up lasted only 4 weeks, so durability of benefit, recurrence and late complications cannot be assessed.
• Six patients were lost to follow-up, all from the general-anaesthesia group, and the reported analysis was based on complete cases.
• The trial was registered retrospectively, an important methodological limitation.
• The prespecified primary endpoint was not statistically significant; favourable differences at earlier time points were secondary findings.

What might this change in practice — and what does the study not prove?

The study supports further evaluation of outpatient frozen-shoulder manipulation without general anaesthesia and may be particularly relevant to centres combining shoulder treatment with interventional ultrasound. It does not establish statistical equivalence between the two methods, does not show a WALANT advantage at 4 weeks and is far too small to assess rare complications reliably.

Back to: Research Updates, Literature and Evidence-Based Medicine

See also: Outpatient and Ultrasound-Guided Procedures

References

1. Konarski W, Poboży T, Hordowicz M, Poboży K, Domańska J. Current concepts of natural course and in management of frozen shoulder: A clinical overview. Orthopedic Reviews. 2020;12(4):8832. DOI: 10.4081/or.2020.8832.
2. Kurtulus T, Bacaksiz T, Maden M, et al. WALANT technique versus general anesthesia in frozen shoulder manipulation: a prospective randomized controlled trial. Journal of Orthopaedic Surgery and Research. Published 6 September 2026. DOI: 10.1186/s13018-026-07169-5.

Educational material for healthcare professionals. It does not constitute an individual therapeutic recommendation.

Content prepared by: Tomasz Poboży - orthopaedic surgeon.