- 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;