Adhesive Capsulitis of the Shoulder
- Discussion:
- refers to a condition in which the shoulder capsule becomes
contracted and thickened;
- patients note a dramatic decrease in shoulder ROM;
- in many cases there is spontaneous resolution after 1-3 years
and motion is re-gained;
- associated disorders:
- cervical spondylosis:
- hypothyroidism;
- diabetes mellitus
- these patients may have a worse prognosis than patients w/o diabetes;
- diff dx:
- polymyalgia rhematica:
this condition is usually associated w/ elevated sed rate;
- pancoast tumor
- posterior
dislocation
- prior to making the diagnosis of frozen shoulder be sure to rule the
possibility of a chronic locked
posterior
dislocation;
- ref: Tumors masked as
frozen shoulders: A retrospective analysis
- Physical Exam:
- physical exam helps identify which portion of the capsule is
most affected;
- see: stabilizers of the
shoulder;
- external rotation w/ arm adducted: tests for contracture of the
antero-superior portion of the capsule;
- external rotation w/ arm abducted: tests for contracture of the antero-inferior portion of the capsule;
- internal rotation: tests for contracture of posterior capsule;
- Radiographs:
- may show osteopenia second to disuse;
- arthrography:
- demonstrates marked
contracture of joint capsule and obliteration of the axillary fold;
- look for lack of dye
filling the bicipital sheath;
- Labs:
- ERS and CRP are useful to rule an inflammatory
arthritis or polymyalgia rhematica
- Non Operative
Treatment:
- involves NSAIDS/steroids, intra-articular steroid injection, and
physical therapy;
- in the report by SM Griggs et al. (JBJS 2000), the authors
followed 75 consecutive patients (77 shoulders)
with phase-II idiopathic
adhesive capsulitis;
- patients were treated with
use of a specific four-direction shoulder-stretching exercise program and
evaluated prospectively;
- mean duration of follow-up
was 22 (range, twelve to forty-one months);
- 64 (90 percent) of the
patients reported a satisfactory outcome
- 7 (10 %) were not
satisfied with the outcome, and 5 (7 %) underwent manipulation and/or
arthroscopic
capsular release;
- active forward elevation
increased 43 deg, active external rotation increased 25 deg, passive IR
increased
eight vertebral levels, and glenohumeral rotation
arc at 90 deg of abduction increased 72 deg (p < 0.00001);
- patients with more severe
pain and functional limitations before treatment had relatively worse outcomes;
- the authors recommend at
least 3 months of PT prior to making any considerations for surgery;
- references:
- Thawing the frozen shoulder: the
"patient" patient. Miller MD. Wirth MA. Rockwood CA Jr.
Orthopedics. 19(10):849-53, 1996 Oct.
- Idiopathic Adhesive Capsulitis. A
Prospective Functional Outcome Study of Nonoperative Treatment
JBJS- Am Volume.
Oct 2000, Vol 82-A, No 10 Page 1398
- Nonoperative
management of idiopathic adhesive capsulitis.
- Manipulation
under Anesthesia:
- does not allow for a controlled release of pathologic tissue;
- complete muscle paralysis is essential;
- hazards: humeral fracture may occur from excessive torque (external rotation);
- first attempt to recover external rotation w/ the arm adducted,
and then move on to recovering flexion and
external rotion and abduction;
- be sure to hold the arm as proximally as possible inorder to
minimize the lever arm on the humerus
(which lessens the chance of humeral
fracture);
- some surgeons feel that a successful manipulation requires two
or three audible "pops" before the procedure is complete;
- references:
- Shoulder manipulation in
patients with adhesive capsulitis and diabetes mellitus: A technical note.
J.
Shoulder Elbow Surg. Vol 2, 1993. p 36-38.
- Arthrscopic Release:
- indicated for patients who have not improved after 4 months of
PT;
- contra-indicated in patients who have contracture due to an
extra-articular etiology;
- preop exam includes an assessment of shoulder external rotation
in both adduction and abduction;
- a gentle manipulation prior to portal placement will help open
shoulder joint and will facilitate trocar insertion;
- arthroscopic portal
placement:
- anterior portal is placed
just beneath the biceps;
- prior to performing capsular release, ensure that the
subscapular tendon is well demarcated (inorder to
avoid transecting the tendon)
and to demarcate
the 5 o'clock position of
the capsule (below which lies the axillary nerve);
- scarring may distort the
usual features of these structures;
- damage to the axillary
nerve is minized by keeping the arm in adduction during the release;
- if the subscapularis
cannot be distinguished from the capsule then the case needs to be converted
to
an open release;
- arthroscopic electrocautery tip is used to divide the anterior
capsular scar just beneath the supraspinatus
tendon (just below the biceps);
- release of the rotator
interval and coracohumeral ligament is especially important for patients who
have
loss of external rotation in adduction;
- the electrocautery
disection is continued down to the superior border of the subscapularis;
- scarring of the rotator
interval is responsible for loss of external rotation in adduction;
- biceps tendon:
- ref: Dynamic movement of the long head of the
biceps tendon in frozen shoulders
- external rotation (in adduction) is retested and
re-manipulated;
- if the shoulder lacks external rotation in abduction, then the
glenoid capsule overlying the subscapularis
muscle should be divided;
- be aware that the axillary
nerve crosses underneath the inferior portion of the glenoid capsule;
- at the end of the procedure, a gentle shoulder manipulation can
be performed to gain even more motion;
- at this point, re-test internal rotation;
- if internal rotation is lacking, then switch the portals and
arthroscopically release the posterior capsule;
- posterior release:
- switch the portals over a
4 mm Steinman pin;
- use cautery to release the
posterior capsule adjacent to the glenoid rim, just posterior to the biceps;
- by staying adjacent to the
glenoid, there is less chance of damaging the rotator cuff;
- following capsular
release, attempt a gentle closed manipulation;
- in the report by GB Holloway et al 2001, the authors evaluated
the results of arthroscopic capsular release
in three different groups of
patients with
shoulder contracture refractory to nonoperative management and manipulation
under anesthesia;
- at time of follow-up, each group had a significant improvement
in scores for pain, satisfaction, and
function and the overall outcome score (p
< 0.01);
- the authors concluded that arthroscopic capsular release was as
effective for improving range of motion
in patients with postoperative
contracture of the shoulder as it was in patients with idiopathic and
post-fracture
contracture;
- references:
- Arthroscopic Capsular Release for the Treatment of Refractory Postoperative or
Post-Fracture
Shoulder Stiffness. Holloway, JBJS (Am) 83:1682-1687
(2001)
- Posterior
Arthroscopic Capsular Release in Frozen Shoulder
- Open Release:
- indicated for failure of arthroscopic release to improve motion
and for extra-articular contractures;
- performed thru a deltopectoral approach;
- z plasty lengthening of the subscapularis and anterior capsule;