Indications for Manipulation Under Anaesthesia (MUA)

1. Adhesive Capsulitis (Frozen Shoulder) - PRIMARY INDICATION

• Ideal timing is when night pain is decreasing but stiffness has reached its maximum - typically the "thawing" phase (Stage 3)
• Primary idiopathic frozen shoulder responds better than secondary (post-traumatic) stiffness
• In a randomised trial, MUA with steroid injection, arthroscopic capsular release, and structured physiotherapy were equivalently effective - MUA carries a lower risk profile than surgery (Goldman-Cecil Medicine)
• If the shoulder gives with one definite snap during manipulation, a good outcome is likely; a slow, plastic give-way predicts poorer results and risk of re-freezing

2. Post-Traumatic Stiffness

• Intraarticular adhesions
• Fibrosis of surrounding soft tissues
• Both mechanisms together

3. Post-Operative Joint Stiffness

• Total Knee Arthroplasty (TKA): Standard indication is knee ROM < 70° or flexion contracture > 15° at 6-8 weeks post-op. Timing is critical - MUA should generally be performed within 3 months of surgery while scar tissue is still "plastic" and before it fully matures. After this window, arthroscopic lysis of adhesions may be needed instead.
• Quadricepsplasty: If 90° of flexion is not obtained by 3 months, gentle MUA may be required (Campbell's Operative Orthopaedics, 15th Ed.)
• Other reconstructive procedures (unicondylar, tricompartmental, patellofemoral arthroplasties)

4. Arthrofibrosis

• Flexion contracture >10°
• Active flexion <120°, or
• Requiring MUA or arthroscopic lysis of adhesions

5. Persistent Loss of ROM Despite Conservative Treatment

• Physiotherapy and structured exercise programmes
• Corticosteroid injections
• Hydrotherapy / hydrodilatation
• Adequate time for natural resolution

Summary Table

Important Contraindications (for clinical completeness)

• Osteoporosis / elderly, frail patients - risk of fracture (proximal humerus, femoral shaft)
• Insulin-dependent diabetes - frozen shoulder often re-freezes within 2-3 weeks
• Post-irradiation fibrosis - risk of brachial plexus traction injury
• Acute inflammatory arthritis - active infection (septic arthritis)
• Unhealed fractures at or near the joint
• Malaligned / oversized prosthetic components - MUA will fail, surgical revision needed
• Complex Regional Pain Syndrome (CRPS) in active phase - surgery/manipulation must be delayed

Contraindications of Manipulation Under Anaesthesia (MUA)

ABSOLUTE CONTRAINDICATIONS

1. Active Infection

• Manipulation of an infected joint risks haematogenous spread of bacteria, converting localised infection into systemic sepsis
• Mechanical disruption of the joint capsule can disseminate organisms into surrounding tissues and the bloodstream
• Active infection also invalidates the purpose of MUA - any ROM gained will be lost as the infection progresses
• MUA must be deferred until infection is fully treated and resolved, confirmed by normalised inflammatory markers (CRP, ESR, WBC)

2. Recent Fracture (Unhealed / Healing Fracture)

• Applying forceful passive motion across a fracture site risks re-displacement, malunion, or non-union
• The fracture callus at early healing stages has insufficient tensile and compressive strength to withstand manipulation forces
• A pathological fracture (through tumour or severely osteoporotic bone) can occur at the fracture site or at a distant weakened site
• The fracture must be radiologically confirmed to have healed before MUA is considered
• Exception: Cervical spine dislocations - MUA can be used for pure dislocation reduction, but fracture-dislocations are a contraindication to closed manipulation (success rate drops from ~90% to ~22%, with high risk of neurological injury)

3. Severe Osteoporosis

• Osteoporotic bone has severely reduced bone mineral density, making it highly susceptible to fracture under the lever-arm forces generated during MUA
• At the shoulder, the proximal humerus and humeral shaft are at particular risk - fracture of the surgical neck of humerus is a well-documented complication
• At the knee, the distal femur and proximal tibia (especially post-arthroplasty) can fracture
• The elderly, frail patient represents a high-risk group even without a formal osteoporosis diagnosis
• Previous vertebral compression fractures require that the affected spinal segments are completely avoided
• DEXA scanning should be considered pre-operatively in at-risk patients (post-menopausal women, long-term steroid users)

4. Bone Tumours (Primary or Metastatic)

• Both primary bone tumours (e.g., giant cell tumour, osteosarcoma) and metastatic lesions weaken cortical and trabecular bone structure
• MUA can precipitate a pathological fracture through the tumour site
• Tumour involvement may be occult - pre-procedure imaging (X-ray, MRI, bone scan) is mandatory to rule out underlying bone lesions, especially in patients with known malignancy or unexplained bone pain
• The forceful nature of MUA can also disrupt tumour capsule integrity, potentially facilitating local spread

5. Joint Instability

• MUA is designed to increase ROM by breaking adhesions and stretching contracted capsule/periarticular tissue
• In an already unstable joint (e.g., ligamentous laxity, failed reconstruction, malaligned prosthesis), further stretching of stabilising structures risks worsening instability, subluxation or dislocation
• Causes of instability that must be identified pre-procedure:
  • Ligament rupture (MCL, ACL, rotator cuff tears)
  • Malaligned or oversized prosthetic components (a mechanical cause of stiffness - MUA will fail and potentially damage the implant)
  • Neuromuscular instability (stroke, upper motor neurone lesion causing muscle rigidity)
• MUA will not correct mechanical causes of stiffness - surgical revision is required instead

6. Uncontrolled Bleeding Disorders

• MUA by its nature ruptures adhesions and tears contracted capsular tissue - this is how it achieves ROM gains
• In patients with uncontrolled coagulopathies (haemophilia A/B, thrombocytopenia, patients on anticoagulants without bridging), this tearing produces uncontrolled haemarthrosis
• Haemarthrosis itself causes:
  • Severe pain and swelling that undoes any ROM gain
  • A secondary fibrotic response as blood organises within the joint - worsening the original pathology
  • Pressure necrosis of articular cartilage with prolonged accumulation
• Bleeding disorders must be controlled and corrected (e.g., factor replacement in haemophilia, INR normalisation) before MUA

7. Acute Inflammatory Arthritis

• In active inflammatory arthritis, synovium is highly vascular, oedematous and friable - manipulation can cause significant synovial haemorrhage and rupture
• The periarticular bone is often osteoporotic due to the inflammatory process and disease-modifying drug effects (steroids), increasing fracture risk
• Pannus formation in RA can erode articular cartilage and subchondral bone, increasing susceptibility to fracture and joint destruction
• MUA during an acute flare can trigger a severe post-procedure inflammatory response that worsens pain and swelling
• Inflammatory arthritis must be in remission before MUA is considered; even then, it remains a relative contraindication

RELATIVE CONTRAINDICATIONS

Summary: Why Each Contraindication Matters

Active infection      → Sepsis risk + no durable ROM gain
Recent fracture       → Displacement / non-union / pathological fracture
Severe osteoporosis   → Iatrogenic fracture (proximal humerus, distal femur)
Bone tumour           → Pathological fracture + tumour spread
Joint instability     → Worsening subluxation / mechanical cause of stiffness
Bleeding disorder     → Haemarthrosis → secondary fibrosis
Acute inflammatory    → Synovial rupture + bone fragility + post-MUA flare

Contraindications of MUA: Absolute vs. Relative

ABSOLUTE CONTRAINDICATIONS

RELATIVE CONTRAINDICATIONS

Quick Reference Summary

ABSOLUTE - NEVER proceed:
  ✗ Active infection
  ✗ Unhealed / recent fracture
  ✗ Severe osteoporosis
  ✗ Bone tumour
  ✗ Joint instability (mechanical)
  ✗ Uncontrolled bleeding disorder
  ✗ Acute inflammatory arthritis flare
  ✗ Neurovascular compromise
  ✗ Fracture-dislocation

RELATIVE - Optimise first, then reassess:
  ~ IDDM (frozen shoulder)
  ~ Advanced age / frailty
  ~ Post-irradiation fibrosis
  ~ Active CRPS
  ~ Controlled coagulopathy
  ~ Neurological rigidity
  ~ Uncontrolled systemic disease
  ~ Spinal compression fracture history
  ~ RA/inflammatory arthritis in remission
  ~ Post-traumatic shoulder stiffness

Precautions After MUA

IMMEDIATE POST-PROCEDURE (Recovery Room - First Few Hours)

1. Monitoring and Safe Discharge

• Patient is monitored in the recovery room until fully awake and haemodynamically stable
• If a nerve block was used (common for shoulder/knee MUA), the limb will be numb for several hours - the patient must not bear weight or use the limb unsupported until sensation returns
• Do NOT discharge until the patient can demonstrate basic mobility and has adequate pain control
• Arrange for someone to accompany the patient home - driving is not permitted on the day of the procedure

2. Early Mobilisation

• Mobilisation should begin as soon as possible - within a few hours of recovery from anaesthesia for lower limb MUA (knee)
• For knee MUA: aim to be walking (with or without aids) the same day
• Early movement is the single most important precaution - the longer the joint remains still, the faster adhesions reform

3. Pain Management - Immediate

• Expect moderate to significant pain and soreness as anaesthesia wears off - this is normal
• Prescribed analgesia must be taken regularly and as directed, not just when pain becomes severe
• Common regimens: NSAIDs (e.g., ibuprofen/diclofenac) + paracetamol +/- short-course opioids
• Adequate analgesia is not just for comfort - it enables the patient to comply with physiotherapy. Undertreated pain = poor exercise compliance = adhesion re-formation

FIRST 24-48 HOURS

4. Ice Therapy (Cryotherapy)

• Apply ice (wrapped in a damp towel - never direct contact) to the affected joint for 10-15 minutes every 3-4 hours
• Reduces post-procedure swelling, haemarthrosis, and pain
• For knee MUA: elevate the limb on pillows while icing to reduce swelling further
• Do NOT apply heat in the first 48 hours - it increases blood flow and worsens swelling

5. Elevation

• For lower limb MUA (knee, ankle): elevate the limb above the level of the heart when resting
• Reduces oedema and haemarthrosis accumulation in the joint
• Important particularly in the first 48-72 hours

6. Rest vs. Movement Balance

• Rest for the first 24 hours from strenuous activity, but NOT complete immobilisation
• Gentle active ROM exercises should begin within the first day
• Complete rest is contraindicated - it defeats the purpose of the procedure

FIRST WEEK

7. Physiotherapy - Begin Early

• Physiotherapy must begin within 1 week to 10 days of the procedure (ideally Day 1 for inpatients)
• For knee MUA: ward physiotherapist teaches exercises before discharge; outpatient physiotherapy is arranged immediately
• For shoulder MUA: physiotherapy is "invaluable immediately after the manipulation" (Shoulderdoc) - the window of capsular laxity post-MUA must be exploited
• Early physiotherapy goals:
  • Maintain and consolidate the ROM gained during MUA
  • Reduce muscle guarding and spasm
  • Begin gentle active-assisted exercises

8. Home Exercise Programme (HEP)

• Patient must be provided with a written, clearly explained home exercise programme before discharge
• Exercises must be performed multiple times daily (typically 3-5 sessions per day)
• Compliance with HEP is the most important determinant of long-term outcome
• Common exercises include: pendulum exercises (shoulder), heel slides and straight-leg raises (knee), active ROM in all planes

9. Continuous Passive Motion (CPM) Machine

• Used primarily after knee MUA - some surgeons routinely prescribe CPM for 2-3 days post-procedure
• CPM provides continuous, controlled passive movement through the joint while the patient rests
• Prevents adhesion re-formation during sleep/rest periods when active exercises are not being performed
• Not universally prescribed - practice varies by surgeon

WEEKS 2-6

10. Progressive Rehabilitation - Phased Approach

11. Avoid High-Impact Activities

• No running, jumping, contact sports, or heavy lifting until cleared by the surgeon and physiotherapist
• High-impact loading of a joint that has just had adhesions disrupted can cause re-injury or haemarthrosis

12. Heat Therapy (After 48-72 hours)

• After the initial 48-72 hours, heat therapy can be introduced to aid soft tissue extensibility before exercises
• Warm shower/bath or a heat pack applied for 10-15 minutes before a physiotherapy session improves tissue pliability and exercise tolerance

13. Anti-Inflammatory Medication

• Continue NSAIDs as prescribed for the first 1-2 weeks to reduce ongoing post-procedure inflammation
• Patients on long-term steroids or with inflammatory arthritis need rheumatology input to optimise anti-inflammatory cover

ONGOING PRECAUTIONS

14. Watch for Warning Signs - Report Immediately

15. Corticosteroid Injection (Shoulder MUA)

• A corticosteroid injection into the glenohumeral joint is commonly given at the time of MUA or immediately post-procedure
• Acts to suppress the inflammatory response in the disrupted capsule, reducing the risk of rapid re-freezing
• Particularly important in diabetic patients (though outcomes remain guarded)

16. Avoid Re-Freezing / Adhesion Re-Formation

• The most common reason MUA fails is inadequate post-procedure rehabilitation
• Even if full ROM is achieved in theatre, it can be lost within days without aggressive physiotherapy
• In frozen shoulder: if the shoulder has a "plastic, slow give-way" pattern during manipulation (rather than a definite snap), the risk of re-freezing is high and the patient must be strongly motivated and compliant
• Repeat MUA may be required in some cases

17. Return to Work and Driving

• Sedentary work: typically 1-2 weeks
• Manual/physical work: guided by physiotherapist, typically 4-6 weeks
• Driving: only when the patient can perform an emergency stop or shoulder check safely and comfortably - usually 2-4 weeks depending on the joint involved
• Formal clearance from the surgeon is required before returning to driving

Summary

IMMEDIATE      → Monitor, early mobilise, pain control, nerve block awareness
FIRST 48H      → Ice + elevation, regular analgesia, gentle ROM exercises
WEEK 1         → Physiotherapy starts, HEP compliance, CPM if prescribed
WEEKS 2-6      → Progressive strengthening, functional rehab, no high-impact loading
ONGOING        → Watch for warning signs, avoid re-freezing, corticosteroid if indicated

Precautions After MUA

1. Begin Physiotherapy Immediately

• The disrupted capsule and adhesions begin reforming within hours of MUA
• The window of capsular laxity created by the procedure is narrow - physiotherapy must exploit it urgently
• For inpatients (knee MUA post-TKR): the ward physiotherapist assesses and teaches exercises before the patient is discharged the same day
• For shoulder MUA: physiotherapy is described as "invaluable immediately after the manipulation" - delay directly predicts re-freezing
• Physiotherapy should start within 24-48 hours at the latest; outpatient referral must be arranged at the time of discharge, not retrospectively

• Passive and active-assisted ROM exercises in all planes
• Soft tissue mobilisation and joint mobilisation techniques
• Electrotherapy modalities: ultrasound, TENS, and electrostimulation to reduce pain and facilitate movement
• Heat therapy (after 48 hours) before sessions to improve tissue extensibility
• Manual therapy by the physiotherapist to maintain and build on intraoperative gains

2. Maintain Gained ROM

• ROM achieved on the operating table is the ceiling at the time of the procedure - it cannot exceed what was achieved intraoperatively
• Without active maintenance, this gain reduces rapidly as oedema, haemarthrosis, and nascent scar tissue contract the joint back
• The most common cause of MUA failure is failure to maintain the ROM gained - not the procedure itself

• Active ROM exercises performed 3-5 times daily targeting the full range achieved intraoperatively
• Monitor ROM at every physiotherapy session and compare to intraoperative measurements
• A Continuous Passive Motion (CPM) machine may be used (particularly for knee MUA) during rest periods - keeps the joint moving passively when the patient is not actively exercising
• Corticosteroid injection at the time of shoulder MUA reduces capsular re-inflammation that drives re-contraction
• Hydrotherapy/pool therapy is useful once the wound is healed - buoyancy reduces pain during ROM exercises and allows fuller movement

• Knee MUA: aim to achieve and maintain >90° flexion within 4-6 weeks
• Shoulder MUA: progressive restoration of elevation, external and internal rotation

3. Ice if Soreness Occurs

• Post-MUA soreness and swelling are expected - the capsule and periarticular tissue have been forcibly stretched and partially torn
• Unmanaged swelling causes pain, restricts movement, and actively promotes re-adhesion formation
• Ice (cryotherapy) is a simple, effective, readily available analgesic and anti-inflammatory tool

• Wrap ice pack or bag of frozen peas in a damp towel - never apply ice directly to skin (risk of ice burn/frostbite)
• Apply for 10-15 minutes at a time
• Can be repeated every 3-4 hours as needed
• For knee MUA: combine icing with elevation of the limb above the level of the heart to further reduce swelling
• Do NOT use heat in the first 48 hours - heat vasodilates, worsens oedema and haemarthrosis; heat is appropriate only after the initial inflammatory period has settled (typically 48-72 hours post-procedure)
• Ice before physiotherapy sessions controls post-exercise soreness; ice after sessions reduces exercise-induced swelling

4. Avoid Aggressive Loading Initially

• The tissues around the joint (capsule, ligaments, peri-articular muscles) have been mechanically disrupted - they need time to consolidate
• Aggressive loading immediately post-MUA can cause:
  • Re-tear of healing capsular tissue
  • Haemarthrosis (bleeding into the joint) from disrupted vasculature
  • Fracture at osteoporotic sites subjected to impact loading
  • Wound dehiscence in post-TKR patients
  • Severe pain that impairs compliance with the rehabilitation programme

• Running, jumping, stair climbing with heavy loads, contact sports, heavy resistance training
• Weight-bearing through an unstable or painful joint without appropriate aids
• Passive stretching applied with excessive force by a third party

• Low-load, high-repetition active ROM exercises
• Gentle closed-chain exercises (e.g., mini-squats, heel slides) progressed slowly
• Walking with aids initially if lower limb MUA was performed, weaning to unassisted walking as tolerated
• Progressive loading is introduced in Phase 2 (weeks 2-5) once baseline ROM is consolidating and pain is controlled
• Formal return to sport/heavy manual work: only after physiotherapist and surgeon clearance, typically 4-6 weeks minimum

5. Follow Home Programme Regularly

• Formal physiotherapy sessions are typically 2-3 times per week - the remaining time is managed by the patient at home
• The home exercise programme (HEP) fills the gap between supervised sessions and is responsible for the majority of daily ROM work
• Compliance with HEP is the single strongest predictor of long-term success after MUA - more so than the MUA procedure itself
• A patient who attends physiotherapy diligently but does not exercise at home will re-adhere

• Exercises should be performed 3-5 times per day, every day, not just on physiotherapy days
• Brief, frequent sessions are more effective than one long daily session for maintaining joint mobility
• A short warm-up (heat pack or warm shower) before HEP improves tissue extensibility and reduces pain during exercises

• Patient should keep a simple ROM diary - recording daily flexion/extension angles using a goniometer or visual estimation
• This is reviewed at each physiotherapy session
• Plateau or regression in ROM at home is a red flag - may indicate adhesion re-formation requiring escalation (repeat MUA or arthroscopic lysis of adhesions)

Summary Overview