Interventions for adhesive capsulitis: systematic review and network meta-analysis of randomised controlled trials
BMJ · 4 Nov 2026
† Impact is the editorial-priority score. All scores are out of 100. Clinical is how far this paper should move patient care if its methods hold up; it does not measure the size of a treatment benefit.
Why it matters
Frozen shoulder is a common clinic and exam topic, and this review shows that the evidence behind most of its many treatments is weak, short-term, and unable to rank options definitively.
The evidence
This network meta-analysis pooled 189 randomised trials (12,988 adults, 59 treatments) to compare everything from physiotherapy and injections to manipulation under anaesthesia for frozen shoulder (adhesive capsulitis). Most trials were small, single-centre, mostly from Asia, and at high risk of bias (about 71% for pain). Only a few findings reached moderate certainty: shockwave therapy probably reduces short-term pain, and manipulation under anaesthesia (with or without a steroid injection) probably improves short-term flexion compared with usual care. Most other effects, mid-term outcomes, and safety remain uncertain.
A coherent primary effect estimate is unavailable. Clinical relevance does not estimate treatment benefit.
Why this rigour score?
Network meta-analysisDesign starting point: 53
Raised the score
- Prospectively registered+5.1
- Pools randomised trials+5.1
Lowered the score
No negative adjustments recorded.
Methods at a glance
Recorded assessment- Comprehensive literature searchMet
- Risk of bias assessedMet
- Bias considered in synthesisMet
- Publication bias assessedMet
- Study exclusions justifiedMet
- Prospective registrationMet
Not reported does not mean not done. Checks have different weights; this is not a count of boxes ticked.
See the full score breakdown
- Study design starting point
- 53
- Prospectively registered
- +5.1
- Pools randomised trials
- +5.1
- Comprehensive literature search
- +3.4
- Risk of bias assessed in the included studies
- +3.4
- Risk of bias carried into the synthesis
- +2.5
- Excluded studies listed and justified
- +1.7
- Publication bias assessed
- +2.5
- Final rigour score rounded
- 77 / 100
Study design sets the starting point and a ceiling of 90. Recorded methods then adjust the score. Points are shown to one decimal place; the final score uses unrounded values.
Checklist from the stored appraisal. “Not met” describes the recorded criterion; it does not always produce a deduction. This overview supports reading the full study.
How the clinical score was reached
The question: 7/9. Three judgements of how much it matters to patients, which decision it informs and how closely it fits their care.
Patient consequence: moderate (2/3). A patient-experienced outcome of real but smaller or shorter-lived importance: early pain or function, speed of recovery, return to sport or work, minor complications, satisfaction, or a validated score at a short time point.
Decision relevance: moderate (2/3). Bears on a real decision, but indirectly: an association or risk factor that informs counselling or surveillance, a subgroup or secondary analysis, one component of a pathway, or a comparison that leaves out a main alternative.
Applicability: moderate (3/3). A recognisable practice population, but with a notable restriction: narrow eligibility, a single expert surgeon or centre, or an unusual protocol that would need adapting. Applicability only subtracts for a real mismatch, so moderate counts in full.
What it found: Points one way (×0.86). A verdict without a usable interval, a clear result from a trial the paper itself calls underpowered, or a review whose certainty is low or unrated.
The design ceiling: 94. The most a network meta-analysis can score here, however relevant its question and clear its answer.
Clinical = 94 × 7/9 × 0.86 = 63.
For journal club
1.Given moderate certainty that shockwave therapy reduces pain at three months, how would you counsel a patient in the painful freezing stage who is weighing shockwave therapy against a corticosteroid injection?
2.When should a patient with persistent stiffness be offered manipulation under anaesthesia rather than continued physiotherapy, given that the flexion benefit is shown only in the short term?
Original publication title
Interventions for adhesive capsulitis: systematic review and network meta-analysis of randomised controlled trials