
==== Front
Interv Pain Med
Interv Pain Med
Interventional Pain Medicine
2772-5944
Elsevier

S2772-5944(23)00097-3
10.1016/j.inpm.2023.100265
100265
Original Article
Comparative efficacy of ultrasound-guided combined suprascapular and axillary nerve block with suprascapular nerve block alone in patients with frozen shoulder: A prospective, double-blinded randomized, single-centre trial
Kumar Sanjay a
Khuba Sandeep sandeepkhuba@gmail.com
a∗
Gautam Sujeet a
Agarwal Anil a
Chatterjee Arindam a
Goyal Nitin a
Mishra Prabhakar b
a Department of Anaesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
b Department of Biostatistics and Health Informatics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
∗ Corresponding author. sandeepkhuba@gmail.com
28 6 2023
9 2023
28 6 2023
2 3 10026523 5 2023
9 6 2023
12 6 2023
© 2023 The Authors
2023
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Background

Frozen shoulder is a troublesome disease of the shoulder joint. It leads to marked disability because of pain with restriction of active and passive movement of the joint. We aimed to determine and compare the efficacy of combined suprascapular and axillary nerve blocks with suprascapular nerve block alone for the treatment of frozen shoulder pain.

Methodology

A total of 61 patients with frozen shoulder included in the study underwent ultrasound-guided combined suprascapular and axillary nerve block (n ​= ​31) and suprascapular nerve block (n ​= ​30). All the patients were assessed for visual analogue scale (VAS) pain (0-10), simple pain score (0-5), total pain score (0-9), range of motion (abduction, external rotation, and internal rotation) of the affected shoulder joint at baseline and post-procedure at 7 days, 1 month, 3 months, 6 months, and 12 months.

Result

There was a significant improvement in VAS pain score, simple pain scores, total pain scores and range of motion of the affected shoulder joint in both groups at all time points as compared to the baseline. However, in the combined nerve block group the VAS scores, simple and total pain scores, abduction, and internal rotation were significantly better at 6 months, 3 months, 6 months, and 12 months, respectively.

Conclusion

The combined block provided faster and superior pain relief and improvement in function.

Keywords

Adhesive capsulitis
Axillary nerve block
Chronic pain
Frozen shoulder
Local anaesthetic Nociceptive pain
Shoulder pain
Suprascapular nerve block
==== Body
pmc1 Introduction

Frozen shoulder or adhesive capsulitis is a troublesome disease of the shoulder joint. It leads to marked disability because of pain with restriction of active and passive movement of the joint. Its prevalence is around 2–5% in the general population, more commonly affecting patients with age 40–70 years, diabetes mellitus, stroke, and local shoulder pathology [1,2]. A variety of treatment modalities are offered for pain relief including the use of physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), intra-articular steroids, manipulation under anaesthesia and surgical capsular repair with limited success [3].

The sensory innervation of the shoulder joint consists of the suprascapular, axillary, lower subscapular, and lateral pectoral nerve [Fig. 1] However, the majority of sensory innervation is provided by the suprascapular and axillary nerve [4]. The blockade of the sensory supply of a chronic painful joint lead to improvement in its pain relief and function. Suprascapular nerve block has been observed to lead to improvement in pain and function of chronic shoulder pain of varied etiology [5]. The various studies reported beneficial effects of suprascapular nerve block for 3–6 months in patients with shoulder pain [6,7]. We hypothesized that the blockade of two nerves innervating a joint is better than a single nerve to improve pain and function. So, the present study aims to determine and compare the efficacy of ultrasound-guided combined suprascapular and axillary nerve block with suprascapular nerve block alone for the treatment of pain and function of the shoulder joint in frozen shoulder patients.Fig. 1 Nerve supply of shoulder joint.

Fig. 1

2 Materials & methods

2.1 Study design and setting

This prospective, double-blinded, randomized, single-center, interventional study was conducted after approval by the institutional ethical committee with reference number PGI/BE/408/2017 dated 11 May 2017. This study is registered with the clinical trial registry of India with registration number CTRI/2018/05/014083. The patients suffering from frozen shoulder attending the Pain Clinic, Department of Anaesthesiology were recruited to the study according to the following inclusion and exclusion criteria.

2.2 Inclusion criteria

• Age 18–60 years

• History of complaint >6 weeks

• Second and third stages of shoulder capsulitis

• Restricted shoulder movement in at least 2 planes including abduction, external rotation, and internal rotation.

• Written informed consent obtained.

2.3 Exclusion criteria

• Systemic inflammatory disease (including rheumatoid arthritis and osteoarthritis, polymyalgia rheumatica)

• Glenohumeral joint arthritis

• Tumor

• Contraindications to needle insertion like coagulopathy, allergy to local anaesthetic.

• Pregnancy

• Acute trauma, fracture of the shoulder

2.4 Group allocation

The patients after satisfying the inclusion criteria were allocated to one of two groups according to a computer-generated random number table. The patients were blinded to the group allocation. One group was the “SA” group in which both suprascapular and axillary nerves were blocked. The other group was the “S” group in which only the suprascapular nerve was blocked, and sham needling was done for the axillary nerve.

2.5 Trial treatment

A single physician performed the procedures on all the patients. Written informed consent was taken from all the patients. The procedures were performed under standard American Society of Anesthesiologists (ASA) monitoring. Intravenous access was obtained before beginning the procedure. The procedure was performed with the patient in the sitting position with the clinician standing behind. The shoulder area was prepared aseptically with chlorhexidine and povidone-iodine solution. The high frequency (6–13 ​MHz) linear probe of the ultrasound machine (M-Turbo, Fujifilm Sonosite, USA) was used for both suprascapular and axillary nerve block.

2.6 Suprascapular nerve block technique

The USG probe was placed in a transverse plane to visualize the suprascapular notch [Fig. 2]. The suprascapular artery and the transverse scapular ligament were visualized in the suprascapular notch. A 2–3 ​ml of 1% lignocaine was infiltrated into the skin and subcutaneous tissue. A 22 ​G, 10 ​cm Quincke spinal needle was inserted from medial to lateral direction in the “in-plane technique” towards the suprascapular notch [Fig. 3]. 5 ​ml of 0.25% bupivacaine along with Triamcinolone acetonide (Kenacort, Abbott, India) (10 ​mg in SA group and 20 ​mg in S group) was deposited in the suprascapular notch to block the suprascapular nerve [Fig. 3]Fig. 2 Suprascapular nerve block.

Fig. 2

Fig. 3 Local Anaesthetic spread.

Fig. 3

2.7 Axillary nerve block technique

The USG probe was placed on the posterior surface of the humerus and scanned in its long axis along a horizontal line that crosses the midpoint of a line joining the anterior aspect of the acromion and the inferior angle of the scapula (Fig. 4). This allowed a short axis view of the circumflex artery and the axillary nerve traversing the posterior aspect of the neck of the humerus (Fig. 5). 5 ​ml of 0.25% bupivacaine with 10 ​mg of Triamcinolone acetonide was injected adjacent to the artery in SA group and 5 ​ml of normal saline in S group (Fig. 6). After the procedure, the patients were shifted to post anaesthesia recovery room. The patients were observed and discharged after 2 ​h (see ).Fig. 4 Axillary nerve block.

Fig. 4

Fig. 5 Short axis view of the circumflex artery and the axillary nerve.

Fig. 5

Fig. 6 Local anaesthetic Spread.

Fig. 6

Fig. 7 Consort flow diagram.

Fig. 7

2.8 Outcome

All the patients were assessed for Pain (VAS), total pain score (combination of simple pain score, radiation, and sleep disturbance score) and active range of movement of the shoulder joint at baseline and post-procedure at 7 days, 1, 3, 6 and 12th months. Patients graded their sleep disturbance and radiation/spread of pain using a nominal scale shown in Table 1. The first column will be the simple pain score and the sum of the 3 columns was recorded as the total pain score [5]. All the assessment was done by a third observer who was blinded to the allocation group of the patients. The active range of abduction, internal rotation and external rotation was measured using goniometry. All the assessment of outcome measures was done by the same physician.Table 1 Range of scores and corresponding intensity.

Table 1Score	Simple pain score	Radiation	Sleep disturbance	
0	None	None	None	
1	Mild, intermittent	To elbow	Mild	
2	Mild, constant	To wrist	Moderate	
3	Moderate	To hand	Severe	
4	Severe			
5	Very severe			

2.9 Sample size estimation

Assuming a 35% difference in pain reduction between suprascapular and axillary nerve block (SA) and suprascapular nerve block (S) study groups, pain reduction in SA and S groups was assumed to be 85% and 50%. At minimum two-sided 95% confidence interval and 80% power of the study, the estimated sample size in SA and S groups was 26 (in each group). Finally in this study, 31 and 30 patients were included in SA and S groups respectively. The sample size was estimated using software Power analysis and sample size version −16 (PASS-16, NCSS, LLC, USA).

2.10 Statistical analysis

Continuous variables were presented in mean (95% Confidence interval) along with median (interquartile range) whereas categorical variables were presented in frequency and percentage. To compare between SA and S groups, the Chi-square test was used to compare the female proportions whereas the independent samples t-test was used to compare the mean age. Mann Whitney U test was used to compare the Pain Scores and other quantitative measurements including ordinal data. Friedman test was used to test the change in the repeated scores over the follow-up time. A linear mixed model was used to test the association between study groups (SA and S) and repeated Scores measured at time points (Baseline, 7 days, 1 month, 3 months, 6 months, and 12 months). Adjacent and Cumulative bar diagrams were used to compare the measurements between the groups. P value ​< ​0.05 was considered statistically significant. Statistical package for social sciences, version 23 (SPSS 23, IBM, Chicago, USA) was used for data analysis.

3 Results

In the present study, 61 patients were included, of them, 31 were in suprascapular and axillary nerve block (SA) and 30 in suprascapular nerve block (S) (Fig. 7). The Mean and median age of the study patients was 53.75 and 52 years (Range: 34-78). 55.7% of the participants were females. There was no significant difference in mean age (54.32 ​± ​11.04 vs 53.17 ​± ​12.04, p ​= ​0.697) and female sex (58.1% vs 53.3%, p ​= ​0.710) between SA and S groups.

In both groups (SA and S), the intervention was given and reduction in VAS score, Simple pain score (P) and Total pain score (TP) were measured at Baseline, 7 days, 1 month, 3 months, 6 months and 12 months and association of pain reduction between study groups and time points were assessed.

The VAS score, Simple pain score (P) and Total pain score (TP) showed a reduction over time in both groups. For the VAS score, the reduction was evident in the SA as well as S group but there was a more rapid reduction observed in the SA group as compared to the S group and it was significantly lower at 7 days, 1 month, 3 months and 6 months (p ​< ​0.05 each) however, it was statistically equal at baseline and 12 months (p ​> ​0.05 each). The linear mixed model showed that there was a significant association between the study groups (SA and S) and the reduction in VAS pain score during the follow-up time (p ​< ​0.05). [Table 2, Fig. 8].Table 2 Association of the Study Groups and change in Score of VAS and simple pain score between time points.

Table 2Variable's	SA (n ​= ​31)	S (n ​= ​30)	P value	
Mean (95% CI)	Median (Q1, Q3)	Mean (95% CI)	Median (Q1, Q3)	
VAS_Baseline (0)	76.8(73.6,79.8)	80(70,80)	77(73.8,80)	80(70,80)	0.874	
VAS_7 days	27.7(23.6,31.9)	25(20,30)	37(33.7,40.7)	40(30,50)	0.001	
VAS_1 month	22.3(19.4,25.2)	20(20,30)	33.3(28.3,38)	30(27.5,50)	0.001	
VAS_3 months	13.9(11.3,16.5)	10(10,20)	24.3(21,27.3)	30(20,30)	0.001	
VAS_6 months	4.8(2.9,6.8)	0(0,10)	12(9.3,14.7)	10(10,20)	0.001	
VAS_12 months	4.2(2.6,6)	0(0,10)	6.2(4,8.3)	7.5(0,10)	0.244	
P_baseline	4.1(3.9,4.3)	4(4,4)	4(3.8,4.2)	4(4,4)	0.825	
P_7 days	1.8(1.6,2.1)	2(1,2)	2.4(2.2,2.7)	3(2,3)	0.003	
P_1 month	1.4(1.3,1.6)	1(1,2)	2.1(1.8,2.3)	2(1,3)	0.001	
P_3 months	1(0.8,1.1)	1(1,1)	1.6(1.4,1.8)	2(1,2)	<0.001	
P_6 months	0.5(0.3,0.7)	0(0,1)	0.6(0.4,0.7)	1(0,1)	0.521	
P_12 months	0.4(0.2,0.5)	0(0,1)	0.5(0.3,0.7)	0.5(0,1)	0.256	
CI: Confidence Interval, Q1 ​= ​First Quartile, Q3 ​= ​Third Quartile.

Linear Mixed model used (p ​= ​0.001 for VAS, p ​= ​0.013 for P).

Friedman test for repeated measurements (p ​< ​0.05 for each measurement of VAS and P). Mann Whitney U test between S and SA. p ​< ​0.05 significant.

VAS: Visual Analogue Scale.

P: Simple Pain Score.

Fig. 8 Distribution of the VAS pain score during the follow up between baseline, 7 days, 1 month, 3 months, 6 months, and 12 months.

Fig. 8

For the Simple pain score (P), the more rapid reduction was observed in the SA group as compared to the S group and it was significantly lower at 7 days, 1 month and 3 months (p ​< ​0.05 each) but statistically equal at baseline, 6 months, and 12 months (p ​> ​0.05 each). The linear mixed model showed a significant association between the study groups and a reduction in pain scores during the follow-up time (p ​< ​0.05). [Table 2, Fig. 9].Fig. 9 Distribution of the simple pain score during the follow up between baseline, 7 days, 1 month, 3 months, 6 months, and 12 months.

Fig. 9

For the Total pain score, a more precipitous reduction was observed in the SA group as compared to the S group and it was significantly lower at 7 days, 1 month and 3 months (p ​< ​0.05 each) but statistically equal at baseline, 6 months, and 12 months (p ​> ​0.05 each). The linear mixed model indicated a significant association between the study groups and a reduction in total pain score during the follow-up time (p ​< ​0.05). [Table 3, Fig. 10].Table 3 Association of the Study Groups and change in TP Score between Six time points.

Table 3Variable's	SA (n ​= ​31)	S (n ​= ​30)	P value	
Mean (95% CI)	Median (Q1, Q3)	Mean (95% CI)	Median (Q1, Q3)	
TP_baseline	8.5(8.1,8.9)	9(8,9)	8.6(8.3,8.9)	9(8,9)	0.706	
TP_7 days	4.3(3.9,4.7)	4(3,5)	4.9(4.5,5.2)	5(4,6)	0.023	
TP_1 month	2.7(2.5,3)	3(2,3)	3.6(3.3,4)	3.5(3,4)	<0.001	
TP_3 months	2.1(1.9,2.3)	2(2,2)	2.7(2.5,2.9)	3(2,3)	<0.001	
TP_6 months	1.5(1.3,1.7)	1(1,2)	1.6(1.4,1.7)	2(1,2)	0.521	
TP_12 months	1.4(1.2,1.5)	1(1,2)	1.5(1.3,1.7)	1.5(1,2)	0.256	
CI: Confidence Interval, Q1 ​= ​First Quartile, Q3 ​= ​Third Quartile.

Linear Mixed model used (p ​= ​0.011 for TP).

Friedman test for repeated measurements (p ​< ​0.05 for each measurement of TP).

Mann Whitney U test between S and SA. P ​< ​0.05 significant.

Fig. 10 Distribution of the total pain score during the follow up between baseline, 7 days, 1 month, 3 months, 6 months, and 12 months.

Fig. 10

Similarly, for the radiation of pain (RAD pain) score and sleep disturbance score (SL), a reduction trend was evident in the SA as well as S groups with almost similar reduction in each of the two groups. RAD score was statistically equal at all time points (p ​> ​0.05 each). Similar results were also observed for sleep disturbance score (SL) where except at one month, rest of the time points, score was statistically equal. Linear mixed model showed that there was no significant association between the study groups and reduction in RAD pain score and SL score during the follow up time (p ​> ​0.05 each). [Table 4].Table 4 Association of the Study Groups and change in RAD and SL Score between Six time points.

Table 4Variables	SA (n ​= ​31)	S (n ​= ​30)	p value	
Mean (95% CI)	Median (Q1, Q3)	Mean (95% CI)	Median (Q1, Q3)	
RAD_baseline	2.7(2.6,2.9)	3(2,3)	2.8(2.7,2.9)	3(3,3)	0.593	
RAD_7 days	1.4(1.3,1.6)	1(1,2)	1.5(1.3,1.7)	1(1,2)	0.712	
RAD_1 month	1.1(1,1.2)	1(1,1)	1.1(1,1.2)	1(1,1)	0.973	
RAD_3 months	1(1,1)	1(1,1)	1(1,1)	1(1,1)	0.999	
RAD_6 months	1(1,1)	1(1,1)	1(1,1)	1(1,1)	0.999	
RAD_12 months	1(1,1)	1(1,1)	1(1,1)	1(1,1)	0.999	
SL_baseline	1.8(1.6,2)	2(1,2)	1.8(1.5,2)	2(1,2)	0.956	
SL_ 7 days	1(1,1)	1(1,1)	1(1,1)	1(1,1)	0.999	
SL_1 month	0.2(0.1,0.4)	0(0,0)	0.5(0.4,0.7)	1(0,1)	0.014	
SL_3 months	0.1(0,0.2)	0(0,0)	0.1(0,0.3)	0(0,0)	0.657	
SL_6 months	0(0,0)	0(0,0)	0(0,0)	0(0,0)	0.999	
SL_12 months	0(0,0)	0(0,0)	0(0,0)	0(0,0)	0.999	
CI: Confidence Interval, Q1 ​= ​First Quartile, Q3 ​= ​Third Quartile.

Linear Mixed model used (p ​= ​0.902 for RAD, p ​= ​0.168 for SL).

Friedman test for repeated measurements (p ​< ​0.05 for each measurement of VAS and P). Mann Whitney U test between S and SA. P ​< ​0.05 significant.

Score of the Abduction angle (ABD), Internal rotation angle (IR) and External rotation angle (ER) were assessed at baseline, 7 days, 1 month, 3 months, 6 months, and 12 months. The measurements showed an increasing trend from baseline to all follow up time points. In ABD, score was significantly higher in SA group at 7 days, 1, 3 and 6 months (p ​< ​0.05) but statistically equal at baseline and 12 months (p ​> ​0.05). [Fig. 11]. In Internal rotation angle (IR), except at baseline rest of the time points, score of SA group was significantly higher as compared to S group. [Fig. 12]. In External rotation angle (ER) group, at the 3 months, score was significantly higher in SA group as compared to S group whereas rest of the time points, score was statistically equal (p ​> ​0.05) [Fig. 13]. Linear mixed model showed that there was significant association between the study groups (SA and S) and increment of ABD and IR scores individually (each p ​< ​0.05) whereas no association was observed for ER measurements. [Table 5, Table 6].Fig. 11 Distribution of the ABD score during the follow up between baseline, 7 days, 1 month, 3 months, 6 months, and 12 months.

Fig. 11

Fig. 12 Distribution of the IR score during the follow up between baseline, 7 days, 1 month, 3 months, 6 months, and 12 months.

Fig. 12

Fig. 13 Distribution of the ER score during the follow up between baseline, 7 days, 1 month, 3 months, 6 months, and 12 months.

Fig. 13

Table 5 Association of the Study Groups and change in ABD and IR Score between Six time points.

Table 5Variables	SA (n ​= ​31)	S (n ​= ​30)		
Mean (95% CI)	Median (Q1, Q3)	Mean (95% CI)	Median (Q1, Q3)	p value	
ABD_baseline	94.5(87.4,101.3)	100(80,110)	88.7(81,96.3)	80(77.5,110)	0.268	
ABD_ 7 days	129.7(118.6,139.5)	130(130,130)	118.3(110.7,126.3)	120(100,130)	0.003	
ABD_1 month	151.4(138.1,161.8)	160(126,180)	135(127.3,143.3)	120(120,152)	<0.001	
ABD_3 months	167.4(159.7,173.9)	180(160,180)	151.3(144,159.7)	150(140,180)	0.004	
ABD_6 months	180(180,180)	180(180,180)	175.3(172,178)	180(175,180)	0.005	
ABD_12 months	179.1(178.7,179.5)	180(180,180)	178.2(176.5,179.7)	180(180,180)	0.402	
IR_baseline	35.5(31.9,39)	30(30,40)	35.7(32.7,38.7)	30(30,40)	0.945	
IR_7 days	56.8(51.6,61.9)	60(50,70)	43.7(39.7,47.7)	40(30,60)	0.001	
IR_1 month	71.3(67.4,75.2)	70(60,80)	57.3(52.7,61.3)	60(40,60)	<0.001	
IR_3 months	83.6(80,86.8)	90(80,90)	77.7(73.3,81.7)	80(70,90)	0.018	
IR_6 months	90(90,90)	90(90,90)	81.7(78.3,84.7)	80(80,90)	<0.001	
IR_12 months	90(90,90)	90(90,90)	85.8(84,87.5)	90(80,90)	<0.001	
CI: Confidence Interval, Q1 ​= ​First Quartile, Q3 ​= ​Third Quartile.

Linear Mixed model used (p ​= ​0.004 for ABD, p ​< ​0.001 for IR).

Friedman test for repeated measurements (p ​< ​0.05 for each measurement of ABD and IR). Mann Whitney U test between S and SA. p ​< ​0.05 significant.

Table 6 Association of the Study Groups and change in ER Score between Six time points.

Table 6Variables	SA (n ​= ​31)	S (n ​= ​30)	p value	
Mean (95% CI)	Median (Q1, Q3)	Mean (95% CI)	Median (Q1, Q3)	
ER_baseline	44.5(41,48.1)	40(40,50)	44.3(40.3,48.3)	45(30,50)	0.952	
ER_7 days	69.4(63.9,74.2)	70(60,80)	62.3(56.3,69.3)	60(40,82.5)	0.123	
ER_1 month	82.6(78.1,86.4)	90(70,90)	76.7(71.7,81.3)	80(60,90)	0.080	
ER3_3 months	88.6(86.5,90.3)	90(80,90)	81(76.3,85.3)	90(70,90)	0.016	
ER_6 months	90(90,91)	90(90,90)	90(90,91.2)	90(90,90)	0.967	
ER_12 months	90(90,91)	90(90,90)	90(90,91.2)	90(90,90)	0.967	
CI: Confidence Interval, Q1 ​= ​First Quartile, Q3 ​= ​Third Quartile.

Linear Mixed model used (p ​= ​0.087).

Friedman test for repeated measurements (p ​< ​0.05 for each measurement of ER). Mann Whitney U test between S and SA. p ​< ​0.05 significant.

4 Discussion

This study shows that combined suprascapular and axillary nerve block leads to better improvement in pain and function of shoulder joint in initial 6 months than suprascapular nerve block alone. However, after 6 months both combined and suprascapular nerve block are similar in terms of pain relief and functional improvement.

The suprascapular nerve innervates the posterior glenohumeral capsule, subacromial bursa, coracoacromial, and acromioclavicular ligament. The axillary nerve supply sensory innervation to inferior portion of anterior and posterior glenohumeral capsule [8]. The suprascapular nerve block has been observed to lead to improvement in chronic shoulder pain for 3–6 months [[5], [6], [7]]. Consistent with earlier studies, this study observed similar improvement in pain scores for up to 12 months with both combined and suprascapular nerve block. However, the pain relief was significantly better for up to 6 months with combined block. So anaesthetic block of two nerves offers faster pain relief as compared to single nerve block.

We observed significant improvement in sleep at 1 month with combined block than suprascapular nerve block alone. After 1-month similar improvement in radiation of pain and sleep disturbance was there with both combined and suprascapular nerve block over all time periods as compared to the baseline. The pain relief achieved with nerve blocks led to improvement in sleep. Cho et al. [9] observed the association of shoulder pain with sleep disturbance. They found 81.5%. prevalence of sleep disturbance in patients with shoulder pain of more than 3 months duration. They also observed that the sleep disturbance co-related with intensity of shoulder pain rather than duration. In our experience, combined suprascapular and axillary nerve block provides faster improvement in sleep as compared to suprascapular nerve block alone.

The normal range of motion of shoulder joint for abduction, internal rotational, and external rotation is 0–180°, 0–90°, and 0–90°, respectively. The frozen shoulder is characterized by pain and stiffness in the shoulder joint. The average range of motion of abduction, internal rotation, and external rotation have been observed to be 98-degree, 18°, and 33° in shoulder joints of patients with frozen shoulder [10]. The baseline average abduction, internal rotation, and external rotation angle of the patients included in this study were observed to be 91.63, 35.57, and 44.42°, respectively. It has been observed that in patients of adhesive capsulitis, external rotation is more severely affected followed by abduction and then internal rotation [11]. We observed significant increase in shoulder movement after combined or suprascapular nerve block alone for up to 12 months as compared to the baseline. In our experience, the combined block provided faster improvement in external rotation, abduction, and internal rotation for up to 3, 6 and 12 months, respectively.

The frozen shoulder is managed conservatively with the use of non-steroidal anti-inflammatory drugs, physiotherapy modalities, exercises, oral or intra-articular corticosteroids and hydrodilatation. The operative treatment involved manipulation under anaesthesia and open or laparoscopic capsular release [12]. The conservative management has been found to be successful in 90% of the patients [13]. The use of intra articular steroid early in the course of the disease has been found to lead to short term improvement in pain relief and function of the shoulder joint [14]. The patients who did not get adequate relief after 3–6 months of conservative management are offered surgical interventions. However surgical interventions have less favorable outcome as compared to conservative management [15]. There is also increased risk of damage to normal tissue as presence of adhesions make it difficult to differentiate between normal and abnormal tissue [16]. There is still disagreement regarding universal treatment for the management of pain and disability of the shoulder in patients of frozen shoulder [17].

The suprascapular nerve block with local anaesthetic with steroid has been shown to lead to improvement in pain and function of the joint in frozen shoulder patients for up to 3 months [5]. The pulsed radiofrequency treatment of suprascapular nerve has also been shown to result in benefit of up to 6 months in patients of chronic shoulder pain [17]. The combined suprascapular and axillary nerve block has been found safe and effective for perioperative anaesthesia and analgesia in patients undergoing arthroscopic shoulder surgery [18]. In a case report described by Rothe et al. [19], the isolated axillary nerve block had resulted in excellent pain relief in chronic shoulder pain after a fracture of tubercle of humerus. In this study we have demonstrated the efficacy of combined suprascapular and axillary nerve block for improvement in pain and function of the shoulder joint in frozen shoulder patients.

This study concludes that the combined suprascapular and axillary nerve block provided better pain relief and functional improvements compared to suprascapular nerve block alone during the initial follow up period of 3–6 months; however, both combined and suprascapular nerve block alone are comparable in the later part of follow up. As the risk associated with an additional ultrasound guided axillary nerve block is minimal, we suggest that both axillary and suprascapular nerve block should be offered to the patients of frozen shoulder for better initial pain management.

5 Limitations of the study

We assessed only pain, quality of sleep and improvement in range of motion of the joint. A multidimensional assessment score like the Shoulder Pain and Disability Index (SPDI) would have been much better to assess the quality of the life of the patients. We have included patients up to the age of 60 years only in our study. The inclusion of patients older than 60 years would have enhanced generalizability of our study results. We followed up our patients for up to 12 months so more studies with longer follow up may be done in future to know the long-term benefit of these nerve blocks. This is a single center trial; a multicenter trial may be warranted to confirm the findings of our study. So further studies may be required to improve upon limitations posed by our study.

Funding

None.

Declaration of generative AI and AI-assisted technologies in the writing process

The authors declare that no artificial intelligence tools were used during preparation of manuscript.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
==== Refs
References

1 Manske R.C. Prohaska D. Diagnosis and management of adhesive capsulitis Curr Rev Musculoskelet Med 1 3–4 2008 Dec 180 189 19468904
2 Hand C. Clipsham K. Rees J.L. Carr A.J. Long-term outcome of frozen shoulder J Shoulder Elbow Surg Am Shoulder Elbow Surgeons 17 2 2008 231 236
3 Le H.V. Lee S.J. Nazarian A. Rodriguez E.K. Adhesive capsulitis of the shoulder: review of pathophysiology and current clinical treatments Shoulder Elbow 9 2 2017 Apr 75 84 28405218
4 Tran J. Peng P.W.H. Agur A.M.R. Anatomical study of the innervation of glenohumeral and acromioclavicular joint capsules: implications for image-guided intervention Reg Anesth Pain Med 44 2019 452 458
5 Shanahan E.M. Ahern M. Smith M. Wetherall M. Bresnihan B. FitzGerald O. Suprascapular nerve block (using bupivacaine and methylprednisolone acetate) in chronic shoulder pain Ann Rheum Dis 62 5 2003 400 406 12695149
6 Jones D.S. Chattopadhyay C. Suprascapular nerve block for the treatment of frozen shoulder in primary care: a randomized trial Br J Gen Pract 49 438 1999 39 41 10622015
7 Sá Malheiro N. Afonso N.R. Pereira D. Oliveira B. Ferreira C. Cunha A.C. Efficacy of ultrasound guided suprascapular block in patients with chronic shoulder pain: retrospective observational study Rev Bras Anestesiol 70 1 2020 15 21
8 Laumonerie P. Dalmas Y. Tibbo M.E. Robert S. Faruch M. Chaynes P. Bonnevialle N. Mansat P. Sensory innervation of the human shoulder joint: the three bridges to break J Shoulder Elbow Surg 29 12 2020 e499 e507 32712453
9 Cho C.H. Jung S.W. Park J.Y. Song K.S. Yu K.I. Is shoulder pain for three months or longer correlated with depression, anxiety, and sleep disturbance? J Shoulder Elbow Surg 22 2 2013 222 228 22738644
10 Rundquist P.J. Anderson D.D. Guanche C.A. Ludewig P.M. Shoulder kinematics in subjects with frozen shoulder Arch Phys Med Rehabil 84 10 2003 1473 1479 14586914
11 Cyriax J. Textbook of orthopedic medicine seventh ed. Diagnosis of soft tissue lesions vol. 1 1978 Macmillan Publishing New York
12 Cho C.H. Bae K.C. Kim D.H. Treatment strategy for frozen shoulder Clin Orthop Surg 11 3 2019 Sep 249 257 31475043
13 Levine W.N. Kashyap C.P. Bak S.F. Ahmad C.S. Blaine T.A. Bigliani L.U. Nonoperative management of idiopathic adhesive capsulitis J Shoulder Elbow Surg 16 5 2007 569 573 17531513
14 Challoumas D. Biddle M. McLean M. Millar N.L. Comparison of treatments for frozen shoulder: a systematic review and meta-analysis JAMA Netw Open 3 12 2020 e202958
15 Longo U.G. Ciuffreda M. Locher J. Buchmann S. Maffulli N. Denaro V. The effectiveness of conservative and surgical treatment for shoulder stiffness: a systematic review of current literature Br Med Bull 127 1 2018 111 143 30137234
16 Grant J.A. Schroeder N. Miller B.S. Carpenter J.E. Comparison of manipulation and arthroscopic capsular release for adhesive capsulitis: a systematic review J Shoulder Elbow Surg 22 8 2013 1135 1145 23510748
17 Ergonenc T. Beyaz S.G. Effects of ultrasound-guided suprascapular nerve pulsed radiofrequency on chronic shoulder pain Med Ultrason 20 4 2018 461 466 30534653
18 Checcucci G. Allegra A. Bigazzi P. Gianesello L. Ceruso M. Gritti G. A new technique for regional anesthesia for arthroscopic shoulder surgery based on a suprascapular nerve block and an axillary nerve block: an evaluation of the first results Arthroscopy 24 6 2008 689 696 18514113
19 Rothe C. Lund J. Jenstrup M.T. Lundstrøm L.H. Lange K.H. Ultrasound-guided block of the axillary nerve: a case series of potential clinical applications Acta Anaesthesiol Scand 56 7 2012 926 930 22404525
