Watchful Waiting versus Physical Therapy for Frozen Shoulder: Randomized Trial Compares Nonoperative Treatment Options

A watchful waiting (WW) approach for management of adhesive capsulitis, or frozen shoulder, delivered similar outcomes at 1 year compared with the use of physical therapy (PT), with a lower cost burden, according to results from a randomized trial. The findings were presented at the AAOS 2024 Annual Meeting by Bilal Sohail Siddiq, BS, medical student at the University of Tennessee Health Science Center in Memphis. The study was co-authored by Scott D. Martin, MD, director of the sports medicine fellowship at Massachusetts General Hospital and head physician for the New England Patriots.

“Shoulder adhesive capsulitis afflicts 2 percent to 5 percent of the general population and can greatly impede quality of life and even cause long-term disability. Although PT is often touted as a useful treatment, there was a lack of clinical evidence for this treatment modality over any other, such as WW,” Mr. Siddiq told AAOS Now. “This study was done to investigate any superiority in PT versus WW and also to assess whether the economic burden of PT on patients is justified.”

The study included 61 shoulder patients treated at a single center. Thirty-one patients were randomized to the WW group, and 30 were assigned to the PT group. The PT group underwent a standard PT regimen for adhesive capsulitis. Patients in both groups received corticosteroid injections on an as-needed basis. The WW group was regularly observed with no further medical intervention. The primary outcome was American Shoulder and Elbow Surgeons (ASES) score. Secondary outcomes included patient value, which was defined as the 12-month ASES score divided by healthcare costs; Disabilities of the Arm, Shoulder, and Hand (DASH) score; and visual analog scale (VAS) pain scores. Outcomes were assessed at 6 weeks, 3 months, 6 months, and 12 months.

Overall, patients in both treatment groups improved to nearly full shoulder function with limited pain. “Patients from both the PT and WW groups improved significantly at each time point for all patient-reported outcome measures (PROMs) investigated,” Mr. Siddiq reported. “However, there were no significant differences in PROM scores between treatment modalities at any time point.”

All PROMs improved significantly from baseline levels at each timepoint in both treatment groups (all P <0.05). there were no differences in improvement in ases, dash, or vas scores at 6 weeks, 3 months, 6 months, or 12 months (all>P >0.05) between the treatment groups.

Additionally, costs incurred with PT were significantly higher than costs in the WW group. “PT patients incurred 10.0 times higher costs and achieved only 16.9 percent of the patient value,” Mr. Siddiq noted.

The mean difference in costs between the PT and WW groups was $1,635.67 (95 percent confidence interval [CI], 967.19–2,304.15; P <0.001). the normalized mean difference in patient value for the pt group was –146.97 (95% ci, –207.47 to –86.47;>P <0.001). the authors noted that these results were consistent across all sensitivity analyses.

The clinical takeaway from these findings, Mr. Siddiq said, is that WW “is a comparable treatment to PT in terms of clinical improvement as measured by PROMs, but superior in that patients incur lower costs and thus higher value. Thus, WW is the overall higher-value treatment modality for the conservative management of adhesive capsulitis of the shoulder.”

Regarding limitations, Mr. Siddiq noted that the study did not evaluate the impact of each treatment modality on active and passive range of motion, “which some studies suggest are improved by PT in the short term.” However, range-of-motion outcomes are captured in the DASH and ASES questionnaires, he added.

Additionally, the study did not capture “intangible” costs associated with each treatment, such as health-related quality of life and psychosocial factors. Mr. Siddiq called for future studies to extend these findings and compare the benefits of WW and more invasive treatments.

Mr. Siddiq’s coauthors of “Watchful Waiting Achieves Higher Value Than Physical Therapy for the Treatment of Idiopathic Frozen Shoulder: A Prospective Randomized Controlled Trial” are Scott D. Martin, MD; Nathan J. Cherian, MD; Christopher Thomas Eberlin, MD; Michael Peter Kucharik, MD; Stephen M. Gillinov, AB; Paul Fawzi Abraham, MD; Mark Nazal, MD, MPH; William Conaway, MD; and Michael C. Dean, BA.

Rebecca Araujo is the managing editor of AAOS Now. She can be reached at raraujo@aaos.org.