Manipulation under anaesthesia (MUA) at Cheltenham Hospital

What is manipulation under anaesthesia (MUA)?

Manipulation under anaesthesia is a procedure to improve movement and reduce pain in a stiff joint.

Under anaesthesia, your consultant will deliberately move, or manipulate, the joint beyond the range you can tolerate when awake. This helps loosen tight muscles, tendons, and joints, and break up internal scarring (adhesions) that can form after injury or surgery. MUA is designed to relieve chronic joint pain and stiffness by restoring the joint’s normal mobility.

How does MUA work?

During MUA, you will be asleep under anaesthesia, so you feel nothing while the joint is being moved. Once you are unconscious, your consultant will carefully bend, straighten or rotate the joint through its full possible range of motion. This manipulation is performed more forcefully than you could tolerate awake, which allows the joint capsule and surrounding tissues to stretch beyond their usual limits. As these tissues stretch, tight bands of scar tissue are “broken up” and the joint can move more freely.

The whole process is relatively quick, typically around 20 to 30 minutes in total, and is usually done as an outpatient (day-case) procedure. Once awake, you will have an immediately improved range of motion in the joint, although the joint will feel sore from the stretching.

Which conditions can MUA treat?

MUA is used for joints that are painful and very stiff due to internal adhesions or inflammation. The most common conditions include frozen shoulder (adhesive capsulitis of the shoulder capsule) and stiff knees; for example, stiffness that develops after knee replacement surgery or serious knee injuries.

It can also help other joints, like stiff or painful hip joints, ankles or even elbows. In all these cases, the stiffness comes from scar tissue, muscle spasms or a tight joint capsule. Mostly this procedure is used for knees and shoulders; however, it can be useful for any joint experiencing similar symptoms.

When is MUA recommended?

Doctors typically recommend MUA when a joint remains stiff and painful despite weeks or months of non-surgical treatments. This means you’ve already tried things like physiotherapy, exercise, pain medications or injections without enough improvement.

MUA is often considered for chronic stiffness, for example, if after a shoulder surgery or a knee replacement, you have never regained full motion. According to guidelines, MUA is usually considered if the joint still can’t bend enough after 4 to 12 weeks, and it hasn’t been improving with standard rehab. Your consultant will evaluate your individual situation before deciding if it’s the right option.

What are the benefits of manipulation under anaesthesia?

The main benefits of MUA are improved joint movement and reduced pain. Patients often notice much greater flexibility immediately after MUA, and this often continues to improve with physiotherapy.

Having better range of motion means easier daily activities and, as the treatment is non-invasive (no cutting into the joint), has a much short recovery time than most surgical interventions, and can even can enhance the results of prior surgeries, for example, if knee replacement left you with a stiff knee, MUA can improve the range of motion and allow the replacement to function as intended.

Is MUA right for me?

Candidates typically have chronic joint pain and restricted motion that has not been helped by physiotherapy, medications or injections. The joint stiffness must actually be due to soft tissue tightness and not because of a mechanical block, like a loose bone fragment. Your consultant will evaluate this with examinations and possibly imaging.

Most people with good general health and joint stiffness are candidates, but if you have certain medical conditions, for example, very brittle bones or an active joint infection, MUA may not be safe. Your consultant will weigh up the pros and cons for you.

What to expect during your MUA procedure

The MUA procedure: A step-by-step guide

• Arrival and check-in: On arriving at the hospital and after checking in, our healthcare team will do any preoperative checks and help you get ready for theatre. An anaesthetist will meet you to explain how you will be put to sleep and will fit an IV line for medications and fluids.
• Anaesthesia: Once in the operating room, an anaesthetist will administer the general anaesthetic, and you will quickly fall asleep so as not to feel anything during the procedure.
• Joint manipulation: When you are fully asleep, your consultant will perform the manipulation itself. This involves physically moving the joint through its full range. These movements will be quite forceful, but they are done very carefully to break up scar tissue and stretch tight ligaments or capsule. Your consultant may feel or hear some “give” as adhesions release. Typically, no incisions are made, but sometimes a small needle injection into the joint is given for pain relief.
• Post-procedure pain relief: After the manipulation, you will often receive local anaesthetic into the joint to reduce immediate post-operation pain.
• Recovery: You will then be moved to the recovery area. Nurses will monitor your breathing, pulse and blood pressure as you wake up from anaesthesia. You may initially feel groggy or very sleepy. If a nerve block was used (common for knee procedures), the limb may feel numb or weak for a few hours.
• Going home: Once you are awake, relatively comfortable and able to move the joint (with help), the team will check that it’s safe for you to go home. Because most MUAs are done as day-case procedures, you will usually be discharged the same day. Your consultant will ensure you can walk (if applicable) and that pain is under reasonable control before you leave.
• Pain management: Before you go, the staff will give you pain medication to take at home, and may apply ice or a bandage if needed. They will remind you not to drive after the anaesthetic and to have someone stay with you at home for at least the first night.

Our healthcare team will always be on hand to take you through each step safely and to answer any questions you may have.

Recovery and rehabilitation after manipulation under anaesthesia

Immediately after your MUA

Right after the procedure, expect some immediate soreness and swelling in the treated joint. This is normal because the tissues have just been stretched forcefully. You may notice swelling for a week or two as the joint responds to the manipulation. To manage this, you are advised to rest the joint and to ice the joint in order to help reduce swelling. You can also keep the limb elevated when lying down to further decrease swelling.

It is normal to feel some pain or stiffness when the anaesthetic wears off, so you will be prescribed over-the-counter painkillers to combat this immediately after your treatment and for your initial recovery.

You will be advised not to drive for at least a week, even if you feel able, so you will need someone to take you home and stay with you the first night.

Finally, you will be given physiotherapy exercises and gentle exercises to perform at home to gradually begin introducing more movement back to the joint.

Your recovery timeline

Recovery from MUA varies for each individual and depends on which joint was treated, but a general timeline is:

The importance of physiotherapy

Physiotherapy is crucial after MUA. The manipulation itself is only half the treatment; the other half is the rehabilitation that follows. Without continued exercises, the joint could gradually stiffen again as it heals.

Your physiotherapist will tailor a program of stretches, range-of-motion exercises and strengthening drills specific to your joint and needs.

Evidence and clinical practice both show that patients who actively follow physiotherapy recover much better.

In short, the best outcomes from MUA come when patients are diligent with physiotherapy.

Managing pain and swelling

After MUA, managing discomfort and swelling with simple measures can greatly improve your comfort. The advice is similar to that after other surgeries.

Key steps include:

• Pain medication: Take your prescribed pain relievers regularly, not just when pain peaks. These might include paracetamol, NSAIDs (like ibuprofen), or a short course of stronger painkillers if needed. Staying on top of the pain will allow you to move the joint more easily.
• Ice packs: Applying cold packs to the joint reduces swelling and numbs pain. Use a bag of ice or frozen peas wrapped in a damp towel, and press it lightly against the joint for 10–15 minutes at a time, repeating every few hours as needed. Make sure to protect any dressings or incisions from moisture.
• Elevation: Keep the limb propped up when sitting or lying down. For a knee, lie back and raise your foot on pillows so it’s above heart level. Elevation helps fluid drain away and reduces swelling.
• Rest, but not complete immobility: Rest is important in the first day or two, but you should also gently move the joint periodically. Even slowly straightening or bending the knee a little, or lifting the arm, can prevent fluid build-up. Moving helps pump out swelling and prevents the joint from getting too stiff.

You should follow any specific instructions from your consultant or physiotherapist on icing and activity. Some moderate pain is normal initially, but if the pain suddenly worsens or if you get unusual swelling or numbness, you should contact your consultant.

What are the risks of manipulation under anaesthesia?

The risks of MUA are relatively low, but minor risks can occur as with any procedure involving general anaesthesia.

Common short-term effects include minor soreness, swelling or bruising of the joint after the procedure. This is usually manageable with ice and pain relief.

More serious problems are rare but can include joint or tissue injury. Since the joint is being stretched forcefully, there is a small chance of tearing a ligament. In very uncommon cases, a bone fracture or tendon rupture has occurred during aggressive manipulation. Infection is not a risk from the manipulation itself, as there are no surgical incisions.

How much does manipulation under anaesthesia cost at Nuffield Health?

For pricing information, please get in touch with your local hospital. The hospital or your healthcare team will give you a fixed all-inclusive price for the treatment following your initial consultation.