OTSR - 2026-07-10 - Journal Article; Review
Manipulation Under Anesthesia With vs Without Intra-Articular Corticosteroid Injection for Frozen Shoulder: A Systematic Review and Meta-analysis.
Boutros M, Awad G, Smadi Z, Tarabay PDB, Rached RB, Elhassan B
Topics
Key Takeaway
Adding intra-articular corticosteroid to MUA significantly improves external rotation recovery (MD=6.90°, 95% CI 5.05–8.75°) but confers no significant benefit in pain, forward flexion, abduction, or internal rotation in the overall pooled analysis.
Summary Depth
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Summary
This systematic review and meta-analysis asked whether adding intra-articular corticosteroid to MUA improves outcomes versus MUA alone across pain and five ROM planes. Pooled analysis of 5 studies showed no significant difference in pain (p=0.35), FF (p=0.12), abduction (p=0.28), or IR (p=0.25), but a significant ER advantage with steroid (MD=6.90°, p<0.001). RCT-only sensitivity analysis confirmed the ER benefit (MD=7.73°, p<0.001) and additionally identified a significant FF advantage (MD=9.05°, p=0.004).
Key Limitation
The meta-analysis pools only 5 heterogeneous studies without reporting total patient N, and corticosteroid type, dose, timing relative to MUA, and anesthesia technique are not standardized across included studies, limiting the ability to define an optimal injection protocol.
Original Abstract
BACKGROUND
Adhesive capsulitis is a common cause of shoulder pain and stiffness, and manipulation under anesthesia (MUA) is frequently used when conservative therapy fails. Corticosteroid injections are often added peri-procedurally to reduce inflammation and potentially enhance recovery, but the magnitude and consistency of their benefit remain unclear.
METHODS
A systematic search of PubMed, Scopus, Cochrane Library, and Google Scholar was performed through December 2025. Three randomized trials (RCTs) and two observational cohorts met inclusion criteria. Primary outcomes included VAS for pain and range of motion in forward flexion (FF), abduction, external rotation (ER), and internal rotation (IR). Pooled analyses including all studies were performed, followed by sensitivity analyses restricted to RCTs.
RESULTS
No significant differences were observed between MUA with versus without corticosteroid injection for pain (p = 0.35), FF (p = 0.12), abduction (p = 0.28), or IR (p = 0.25). However, corticosteroid use was associated with a significant improvement in ER (MD = 6.90; 95% CI 5.05-8.75; p < 0.001). In sensitivity analyses restricted to RCTs, ER remained significantly improved (MD = 7.73; 95% CI 5.26-10.21; p < 0.001), abduction and IR remained non-significant (p > 0.05), and FF became significantly greater in the steroid group (MD = 9.05; 95% CI 2.84-15.25; p = 0.004).
CONCLUSION
Adding an intra-articular corticosteroid injection to MUA was associated with improved ER recovery, while offering no significant advantage in pain relief or most other motion planes in the overall pooled analysis. Sensitivity analysis of RCTs supported the robustness of the ER finding and suggested a possible benefit for FF, although this should be interpreted cautiously. These findings support selective corticosteroid use when ER recovery is a primary goal, while MUA without corticosteroid injection remains a reasonable alternative. Further studies should evaluate standardized steroid protocols, phase-specific indications, and long-term functional outcomes.
LEVEL OF EVIDENCE
II.