JBJS | Arthroscopic Release for Chronic, Refractory Adhesive Capsulitis of the Shoulder*

The Journal of Bone & Joint Surgery, Volume 78, Issue 12

Articles | December 01, 1996

Arthroscopic Release for Chronic, Refractory Adhesive Capsulitis of the Shoulder*

JON J. P. WARNER, M.D.†; ANSWORTH ALLEN, M.D.‡; PAUL H. MARKS, M.D., F.R.C.S.(C)§; PATRICK WONG, M.D.¶, PITTSBURGH, PENNSYLVANIA

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Investigation performed at the Shoulder Service, Center for Sports Medicine, University of Pittsburgh, Pittsburgh

The Journal of Bone & Joint Surgery. 1996; 78:1808-16

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Abstract

Idiopathic adhesive capsulitis usually responds to gentle physical therapy or, if that fails, to closed manipulation with the patient under anesthesia. In some patients, however, loss of motion may be refractory to either of these treatments and an operative release may be indicated. We are reporting on the technique and results of arthroscopic capsular release as a new alternative for the management of such patients. During a three-year period, we managed twenty-three patients who had idiopathic adhesive capsulitis that had failed to respond to physical therapy or closed manipulation. These patients had an arthroscopic anterior capsular release and received forty-eight hours of intensive physical therapy as inpatients. During the physical therapy, the patients received an interscalene regional analgesic with use of repeated nerve blocks or with a continuous infusion through an interscalene catheter. This was followed by a supervised outpatient physical-therapy program. Six patients also had an arthroscopic acromioplasty for the treatment of impingement. There were no complications related to any of the procedures.At a mean of thirty-nine months (range, twenty-four to sixty-four months) after the arthroscopic procedure, the improvement in the score of Constant and Murley averaged 48 points (range, 13 to 77 points). The mean improvement in motion was 49 degrees (range, 0 to 105 degrees) for flexion; 42 degrees (range, 10 to 80 degrees) and 53 degrees (range, 0 to 100 degrees) for external rotation in adduction and abduction, respectively; and eight spinous-process levels (range, three to fourteen levels) and 33 degrees (range, 30 to 60 degrees) for internal rotation in adduction and abduction, respectively. These gains in motion were all significant (p < 0.01) compared with the preoperative values and were within a mean of 7 degrees of the values for the contralateral, normal shoulder.We concluded that, in patients who have loss of motion that is refractory to closed manipulation, arthroscopic capsular release improves motion reliably with little operative morbidity.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

Idiopathic adhesive capsulitis affecting the glenohumeral joint is believed to be a self-limited condition and can usually be treated successfully with physical therapy^{7,11,12,14,18,22,26,27,29,31,49-51,55,57}. Some patients may, however, be unwilling to wait the one to three years often required for the resolution of symptoms^{12,25,27,28,31,55}. Furthermore, some studies have demonstrated long-term residual pain and limitation of motion in most patients after non-operative treatment^{2,5,6,31,49-51}. For these reasons, when little motion has been gained despite a prolonged supervised physical-therapy program, some authors have recommended closed manipulation with the patient under anesthesia^{13,21,28,38,39,41,42,47,49,57}. Although successful for some patients^{13,42,47,49,51}, manipulation has been associated with complications such as humeral fracture, neural injury, and dislocation of the shoulder^10,25,30. For some patients who have failed to gain mobility after manipulation, an open soft-tissue release has been suggested, often in association with lengthening of the subscapularis^{14,23,25,36,37,42,46}. This approach is associated with the morbidity of an extensive operative dissection and with the need to protect the repair of the subscapularis during initial postoperative motion.

While some authors have suggested that arthroscopy is not useful in either the diagnosis or the treatment of a stiff shoulder^38,39,41,42, others have recommended its use to help to delineate abnormalities, to document the results of closed manipulation, and to assist in distention of the contracted joint capsule^{3,19,44,48,53,56}. Moreover, some investigators have proposed arthroscopically guided sectioning of the contracted capsule as a treatment for adhesive capsulitis^14,48. During a three-year period, we prospectively evaluated the efficacy of arthroscopic release for patients who had chronic, refractory adhesive capsulitis. The purpose of the current paper is to describe the results of this treatment.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Shoulder Service, Center for Sports Medicine, Department of Orthopaedic Surgery, University of Pittsburgh, 4601 Baum Boulevard, Pittsburgh, Pennsylvania 15213.

‡Sports Medicine and Shoulder Service, The Hospital for Special Surgery, Affiliated with The New York Hospital-Cornell University Medical College, 535 East 70th Street, New York, N.Y. 10021.

§Orthopaedic and Arthritis Hospital, 43 Wellesley Street, East Toronto, Ontario MYY 1H1, Canada.

¶Department of Orthopaedics, Northwest Private Hospital, Brickport Road, Burnie, Tasmania 7320, Australia.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Shoulder Service, Center for Sports Medicine, Department of Orthopaedic Surgery, University of Pittsburgh, 4601 Baum Boulevard, Pittsburgh, Pennsylvania 15213.

‡Sports Medicine and Shoulder Service, The Hospital for Special Surgery, Affiliated with The New York Hospital-Cornell University Medical College, 535 East 70th Street, New York, N.Y. 10021.

§Orthopaedic and Arthritis Hospital, 43 Wellesley Street, East Toronto, Ontario MYY 1H1, Canada.

¶Department of Orthopaedics, Northwest Private Hospital, Brickport Road, Burnie, Tasmania 7320, Australia.

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Figs. 1-A, 1-B, and 1-C: Drawings showing the operative technique for the anterior capsular release. Fig. 1-A: As the anterosuperior portion of the capsule (the rotator interval region) is released, the humeral head moves laterally and inferiorly, allowing the arthroscope to be introduced farther into the joint.

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Fig. 1-B With division of the thickened anterosuperior portion of the capsule, the subscapularis (Sc.) tendon is defined. I.G.H.L. = inferior glenohumeral ligament region of the capsule and G. = glenoid.

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Fig. 1-C The anteroinferior portion of the capsule can also be divided if necessary.

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Fig. 2 Graph showing the Constant and Murley^8,9 scores, expressed as the mean and the standard deviation, for the patients who had an anterior capsular release. The difference between the preoperative and postoperative scores is significant (p < 0.001).

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Figs. 3-A through 3-E: Graphs showing the preoperative and postoperative ranges of motion, expressed as the mean and the standard deviation, for the patients who had an anterior capsular release. The differences are significant (p < 0.001). Fig. 3-A: Flexion.

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Fig. 3-B External rotation in adduction.

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Fig. 3-C Internal rotation in adduction.

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Fig. 3-D External rotation in abduction.

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Fig. 3-E Internal rotation in abduction.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Selection of Patients

From September 1990 through December 1994, 107 patients were evaluated at the Shoulder Service of the University of Pittsburgh because of stiffness of the shoulder. Twenty-six of these patients had loss of motion after an operative procedure, and the remaining eighty-one had loss of motion after trivial trauma such as a minor fall or with no identifiable etiology. These eighty-one patients were thought to have idiopathic adhesive capsulitis as they had lost both active and passive motion in all planes without a known cause¹⁴.

All eighty-one patients were managed with a supervised physical-therapy program for at least four months. After completion of the program, forty-eight patients noted that the pain had decreased and the motion had improved to the point where they were comfortable sleeping at night and they could perform all of their daily work and recreational activities with slight or no limitations. Although we did not have an absolute criterion for acceptable improvement of motion in these patients, all achieved motion to within 80 per cent of that of the contralateral, normal extremity. The remaining thirty-three patients continued to have loss of both active and passive motion as well as pain for a mean duration of twelve months (range, four to forty-eight months), despite a supervised physical-therapy program that averaged six and one-half months (range, four to twelve months). All thirty-three patients had an attempted closed manipulation under anesthesia, and ten of them had demonstrable improvement in motion and decreased pain.

In the remaining twenty-three patients, motion did not improve after manipulation under anesthesia. They had an arthroscopic release, and they form the basis of this study. The mean age of these patients was forty-eight years (range, twenty-seven to seventy-three years). Seven right and sixteen left shoulders were involved, in eleven men and twelve women.

Clinical Assessment

All twenty-three patients were evaluated both preoperatively and postoperatively by the senior one of us (J. J. P. W.), and they also answered a questionnaire about their symptoms. Both active and passive motion were assessed goniometrically. Flexion and external rotation in adduction (0 degrees of abduction) and abduction (90 degrees), as well as internal rotation in abduction (90 degrees), were assessed with the patient supine. Active internal rotation was assessed with the patient seated and was measured as the most cephalad spinous process to which the patient could apply the thumb. Preoperatively, flexion averaged 91 degrees (range, 52 to 120 degrees); external rotation, 10 degrees (range, -10 to 30 degrees) in abduction and 28 degrees (range, 0 to 60 degrees) in abduction; and internal rotation, the fourth lumbar level (range, the greater trochanter to the eighth thoracic level) in adduction and 10 degrees (range, -5 to 30 degrees) in abduction.

The function of all shoulders was graded according to the 100-point scoring system of Constant and Murley^8,9. This system combines assessments of subjective symptoms and objective findings. Pain is given a maximum of 15 points, with 15 representing no pain and 0, severe, constant pain. Activities of daily living are assigned a maximum of 20 points. Flexion, abduction, external rotation, and internal rotation are each given a maximum of 10 points (total, 40 points). Pain-free motion of the shoulder is given 25 points, and marked weakness is assigned 0 points.

Six patients had painful flexion, which suggested concomitant impingement. This diagnosis was confirmed by a positive impingement sign, as described by Neer³² or by Hawkins and Hobeika¹⁷, and a positive impingement test³². The Neer impingement sign is considered positive when the examiner causes pain by elevating the humerus with one hand while depressing the scapula with the other hand. The impingement sign of Hawkins and Hobeika is considered positive when flexion to 90 degrees combined with internal rotation and horizontal adduction produces pain. An impingement test is considered positive when pain with elevation of the shoulder is eliminated after an injection of fifteen milliliters of 1 per cent Lidocaine (xylocaine) into the sub-acromial space through a posterior approach.

Standard radiographs were made in the anteroposterior and axillary planes. For the six patients who had pain in the anterosuperior portion of the shoulder with active flexion, special radiographs of the acromion (a supraspinatus outlet radiograph^1,35 and a caudal tilt radiograph⁴⁵) were made in order to define the supraspinatus outlet. These patients were found to have either a type-II (curved) or a type-III (hooked) acromion according to the classification of Bigliani et al.¹

Some patients who were referred to us had had either an arthrogram or a magnetic resonance image made; neither had demonstrated any intrinsic abnormality of the shoulder. These studies were not performed routinely for all of our patients.

Finally, videotaped documentation of the function and the range of motion of the shoulder both preoperatively and postoperatively was available for all patients. All operative findings and procedures were recorded on videotape and photographs as well.

Operative Technique

Anesthesia and Postoperative Analgesia

Six patients had general anesthesia, ten had an interscalene block, and five had an interscalene catheter^4,24. There were no complications related to the interscalene block or to placement of the catheter. At the beginning of the series, we were concerned that the amount of postoperative pain was limiting the effectiveness of physical therapy and was necessitating the use of a large amount of analgesics with narcotics. Consequently, we began to use an interscalene block of 0.5 per cent bupivacaine with 1:200,000 epinephrine for anesthesia and postoperative analgesia. This not only gave adequate anesthesia for the procedure but also gave about five to six hours of postoperative analgesia. As the patients were admitted to the hospital for forty-eight hours so that immediate passive range-of-motion exercises could be performed, postoperative analgesia was an essential part of the rehabilitation program. Therefore, the patients who had an interscalene block for anesthesia had repeat blocks with use of 0.5 per cent bupivacaine with 1:200,000 epinephrine on the morning of the first and second postoperative days. This provided excellent analgesia well into the afternoon of each day and allowed the therapist to perform both a morning and an afternoon session of passive motion.

Toward the end of the series, we began to use an interscalene catheter to provide both anesthesia and postoperative analgesia⁴. The patients received a continuous infusion of 0.25 per cent bupivacaine at a rate of six milliliters an hour for forty-eight hours. All patients also had self-administered (patient-controlled) analgesia through an intravenous pump that was set to administer one milligram of morphine every eight minutes as needed, to a maximum of thirty milligrams in four hours.

Anterior Capsular Release

The passive range of motion was first recorded after induction of anesthesia. A gentle closed manipulation was attempted for each patient^14,42; twenty-three had a hard block to motion, especially in external rotation.

Arthroscopy was performed with the patient seated in an upright beach-chair position⁵⁴. An 18-gauge spinal needle was introduced posteriorly into the joint. As the humeral head was compressed tightly into the glenoid, this needle had to be inserted carefully over the humeral head in order to enter the joint. Sterile saline solution was then injected; however, the volume of the contracted joint usually permitted no more than ten milliliters. As it may be difficult to place the spinal needle into the contracted, small joint, it is important to confirm its intra-articular position by observing a retrograde flow of fluid out of the needle when the syringe is removed. Inflation of the joint with fluid was also helpful as increased fluid pressure pushed the humeral head away from the glenoid and reduced the risk of injury to the cartilage when the arthroscope was inserted.

The arthroscope was introduced carefully into the joint, after the spinal needle had been oriented over the humeral head. Correct intra-articular placement of the arthroscope was confirmed by backflow of fluid out of the arthroscopic sheath. At this point, it was possible to see only the anterosuperior region of the joint. An 18-gauge spinal needle was then inserted anteriorly so that it entered the joint just underneath the biceps tendon. The needle was then replaced with a seven-centimeter arthroscopic shoulder cannula (Linvatec, Concept Arthroscopy, Largo, Florida). A 4.5-millimeter motorized shaver (full radius resector; Linvatec, Concept Arthroscopy) was used to debride the joint of inflamed synovial and scar tissue through the anterior portal. An arthroscopic electrocautery device with a hooked tip (Linvatec, Concept Arthroscopy) was then placed through the anterior cannula, and the anterior capsular scar just underneath the biceps tendon was divided. Division of the capsule was in its mid-portion and proceeded from superior to inferior until the interval between the superior border of the subscapularis tendon and the anterior border of the supraspinatus tendon (the rotator interval region of the capsule¹⁵) was encountered (Figs. 1-A and 1-B). As the thickened capsular tissue was divided, the rotator interval opened and the joint became more mobile, with the humeral head moving inferiorly and laterally. This allowed the arthroscope to be inserted farther into the joint anteriorly and inferiorly. After this region had been released fully and the tendon of the subscapularis was seen to be freely mobile with external rotation of the arm, the arthroscopic instruments were removed and a gentle manipulation was performed.

In eighteen patients, release of the rotator interval region of the capsule restored external rotation of the adducted shoulder without any need for manipulation. A gentle closed manipulation was performed to restore motion in other planes.

In five patients, although release of the rotator interval restored external rotation in adduction the patient continued to have limitation of external rotation in abduction. These patients were found to still have a thick, contracted anterior portion of the capsule distal to the level of the proximal border of the subscapularis tendon. This portion of the capsule was then divided with the electrocautery device down to the anteroinferior portion of the glenoid (Fig. 1-C), and the shoulder was manipulated to regain external rotation in abduction.

Additional Procedures

In the six patients who had had pain in the anterosuperior portion of the shoulder preoperatively and whom we considered to have concomitant impingement, arthroscopy of the subacromial space demonstrated an inflamed bursa and a prominent anteroinferior portion of the acromion. These patients had an arthroscopic acromioplasty in addition to the arthroscopic capsular release. None of the twenty-three patients had any other notable intra-articular findings.

Postoperative Treatment

On the morning of the first postoperative day, passive motion was begun by a physical therapist, with stretching in all planes limited only by the patient's intolerance to pain. Therapy sessions were in both the morning and the afternoon, and the patient was also instructed in self-assisted motion exercises. Analgesia was provided with the methods described earlier.

The patients were discharged on the afternoon of the second postoperative day, after the second physical-therapy session of that day. For the first two weeks, they attended daily sessions of supervised physical therapy and performed a home-exercise program consisting of pulley and cane-assisted motion in all planes. This was then reduced to supervised therapy two or three times a week for the next four weeks, after which the program was individualized according to each patient's progress. Patients were not given a sling support at any time, and they were encouraged to use the affected extremity for activities of daily living as soon as possible after the operation. Strengthening was begun as soon as pain and active motion of the shoulder allowed. Patients were encouraged to try to swim in a pool between two to four weeks after the operation.

Statistical Analysis

Statistical analysis was performed with use of a t test for paired samples (SPSS [Statistical Package for the Social Sciences Release] 5.0 for VAX/VMS; SPSS, Chicago, Illinois). Postoperative motion was compared with preoperative motion and with that of the contralateral, asymptomatic shoulder. The preoperative and postoperative scores of Constant and Murley^8,9 were also compared.

Results

Introduction | Materials and Methods | Results | Discussion | References

The mean duration of follow-up was thirty-nine months (range, twenty-four to sixty-four months). There were no complications related to the operation.

Arthroscopy revealed a thick, shortened anterosuperior portion of the capsule in all twenty-three patients (Figs. 1-A, 1-B, and 1-C). Fourteen patients also had marked synovitis. Six patients had subacromial bursitis and a prominent anterior portion of the acromion. No patient had abnormalities of the articular cartilage, biceps tendon, or rotator cuff.

The mean improvement in the score of Constant and Murley^8,9 was 48 points (range, 13 to 77 points) (Fig. 2). All patients indicated that they had no pain or only occasional, mild discomfort when using the shoulder forcefully. Nine patients stated that they had participated in sports involving the upper extremity, such as swimming, tennis, golf, and softball, before the problem with the shoulder had begun. After the procedure, seven of these nine patients were able to return to their previous level of participation.

All improvements in range of motion were significant (p < 0.01) (Figs. 3-A, 3-B, 3-C, 3-D through 3-E). Flexion improved a mean of 49 degrees (range, 0 to 105 degrees); external rotation in adduction, a mean of 42 degrees (range, 10 to 80 degrees); external rotation in abduction, a mean of 53 degrees (range, 0 to 100 degrees); internal rotation in adduction, a mean of eight spinous-process levels (range, three to fourteen levels); and internal rotation in abduction, a mean of 33 degrees (range, 30 to 60 degrees). With the numbers available, we could not detect a significant difference between the postoperative range of motion and that of the contralateral, asymptomatic shoulder for flexion, although there remained a small difference (7 ± 9 degrees [mean and standard deviation]; p < 0.05) for external and internal rotation.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Although the etiology of primary adhesive capsulitis remains in question, it is generally believed that the condition is benign and that it has a self-limited course^{7,11,12,18,22,26,27,29,49,52,55,57}. Nevertheless, some studies have shown long-term functional disability^2,5,6,50,51.

The duration of non-operative treatment for adhesive capsulitis has been debated, but most authors have recommended two to six months^{14,25,30,41,42,48}. Neviaser and Neviaser⁴² suggested that patients in whom flexion was still limited to less than 90 degrees and those who had not had any improvement in motion were candidates for closed manipulation. We arbitrarily chose a four-month limit, as many of our patients were unwilling to continue therapy for a longer duration when no gains were being made. Furthermore, we had no specific criterion for loss of motion in order for our patients to have this procedure, although all of our patients had pain and considered the motion of the shoulder to be severely restricted. Forty-eight (59 per cent) of our original group of eighty-one patients responded to a therapy program, while ten of the remaining thirty-three had improvement after closed manipulation^14,42.

Although many of our patients did not have an arthrogram, all patients had limitation of both passive and active motion, indicating that soft-tissue contracture was a limiting factor. Furthermore, while it has been suggested that the arthrographic finding of a contracted axillary pouch is diagnostic of adhesive capsulitis, other authors have not found such a relationship with measured losses of motion^20,40,43.

We excluded all patients who had loss of motion because of an operation or who had had severe trauma such as a fracture, as these conditions may be due to a pathological process that is different than idiopathic adhesive capsulitis^14,33. In addition, many such patients have an extra-articular component to the loss of motion^14,23,48. Because our technique of arthroscopic release is only for capsular lesions, we would expect it to be difficult to improve motion in patients who have an extra-articular component.

Only a few studies have actually documented the technique of measurement and the range of motion in patients who have adhesive capsulitis^2,6,51. Our patients were evaluated prospectively by the same examiner, with use of the same techniques of measurement to assess the range of motion. Furthermore, all patients had videotaped documentation of the preoperative, intraoperative, and postoperative range of motion. Overall function of the shoulder was assessed with use of the scoring system of Constant and Murley^8,9, which has been shown to be a sound method of evaluation for degenerative conditions of the shoulder.

Postoperative control of pain has been shown to be critical to maintenance of gains in motion after closed manipulation for the treatment of adhesive capsulitis^14,42,48. In the current series, although all patients ultimately had improvement it was our impression that regional anesthesia and postoperative analgesia afforded better relief of pain and comfort than general anesthesia and postoperative analgesia with narcotics. We now routinely use an interscalene block or an interscalene catheter and block for both anesthesia and postoperative control of pain. We have found, as have others^4,14,24,48, that this technique is safe and well tolerated and that it usually reduces the need for narcotics while allowing intensive passive range-of-motion therapy in the immediate postoperative period.

For patients who have adhesive capsulitis that remains refractory to closed manipulation, some surgeons have recommended an open release^16,36,37,46. Ozaki et al.⁴⁶, Neer et al.^34,36,37, and others^14,15,48 have pointed out that contracture and scarring of the rotator interval region of the capsule is a major component of refractory adhesive capsulitis of the shoulder. The major capsulo-ligamentous components are the coracohumeral and superior glenohumeral ligaments, and in the normal shoulder these structures are usually elastic and function only to limit excessive external rotation and inferior translation in the adducted arm^{15,16,36,37,46}. Open release of the rotator interval region has been successful in the treatment of chronic, refractory adhesive capsulitis^36,37,46. Occasionally, if the capsular contracture is more extensive, open operative release of the inferior portion of the capsule may be necessary, and in some patients a z-plasty lengthening of the subscapularis and the capsule in the coronal plane is performed^14,23.

Some authors^39,41,43 have thought that arthroscopy is of no diagnostic or therapeutic use in the management of patients who have adhesive capsulitis of the shoulder. Others have thought that it may even be contraindicated because of the risk of iatrogenic chondral injury from insertion of an instrument into a tight shoulder joint^41,42.

Pollock et al.⁴⁸ thought that arthroscopy was useful mainly after closed manipulation to treat concomitant lesions, but they also indicated that arthroscopic sectioning of the coracohumeral ligament might be helpful in some patients who have loss of external rotation that is refractory to non-operative treatment. They were, however, concerned about the risk of injury to the axillary nerve if capsular release was continued more inferiorly than the superior border of the subscapularis tendon. Harryman¹⁴ applied an arthroscopic release technique to a small number of patients who had primary adhesive capsulitis.

Most surgeons have agreed that insertion of an arthroscope into a stiff shoulder with a limited joint volume is difficult^{3,38,39,41,42,56}. Wiley⁵⁶ recommended use of a smaller, 3.8-millimeter arthroscope. We were able to place a standard-size arthroscope into the joint of all of our patients without creating any chondral injuries. We did this by carefully guiding the arthroscope over the humeral head and beginning the division of the capsule in the rotator interval region just underneath the biceps tendon. This allowed the humeral head to gradually move inferiorly and laterally, creating more space for the arthroscope to be inserted into the anterior and inferior portion of the joint.

In all of our patients, we found the rotator interval region of the capsule to be composed of dense, thick, unyielding scar tissue. In eighteen patients, section of the rotator interval region combined with gentle manipulation effectively restored motion in all planes; however, in the remaining five patients, additional division of the remaining anterior portion of the capsule was necessary. Our arthroscopic technique allowed us to perform this extensive release without the extensive dissection that would have been required for an open release; however, even after the release no patient had instability. We believe that this was because of articular compression through the remaining soft-tissue tension around the joint.

In summary, patients who have adhesive capsulitis should be managed non-operatively with a supervised physical-therapy program. While most will have gains in motion and relief of pain to a level where they are satisfied, some will continue to have decreased motion and will be candidates for closed manipulation under anesthesia. In patients in whom closed manipulation fails, arthroscopy offers the added advantage of a precise, controlled capsular release as well as the treatment of concomitant lesions. Manipulation after such a release requires much less force in order to restore motion.

References

Introduction | Materials and Methods | Results | Discussion | References

Bigliani, L. U.; Morrison, D. S.; and |and |April, E. W.: The morphology of the acromion and its relationship to rotator cuff tears. Orthop. Trans.,10: 228, 1986.10228 1986

Binder, A. I.; Bulgen, D. Y.; Hazleman, B. L.; and |and |Roberts, S.: Frozen shoulder: a long-term prospective study. Ann. Rheumat. Dis.,43: 361-364, 1984.43361 1984 [PubMed][CrossRef]

Bradley, J. P.: Arthroscopic treatment for frozen capsulitis. Op. Tech. Orthop.,1: 248-252, 1991.1248 1991 [CrossRef]

Brown, A. R.; Weiss, R.; Greenberg, C.; Flatow, E. L.; and |and |Bigliani, L. U.: Interscalene block for shoulder arthroscopy: comparison with general anesthesia. Arthroscopy,9: 295-300, 1993.9295 1993 [PubMed][CrossRef]

Bulgen, D. Y.; Binder, A. I.; Hazleman, B. L.; Dutton, J.; and |and |Roberts, S.: Frozen shoulder: a prospective clinical study with an evaluation of three treatment regimens. Ann. Rheumat. Dis.,43: 353-360, 1984.43353 1984 [PubMed][CrossRef]

Clarke, G. R.; Willis, L. A.; Fish, W. W.; and |and |Nichols, P. J.: Preliminary studies in measuring range of motion in normal and painful stiff shoulders. Rheumatol. and Rehab.,14: 39-46, 1975.1439 1975 [CrossRef]

Codman, E. A.: The Shoulder: Rupture of the Supraspinatus Tendon and Other Lesions in or about the Subacromial Bursa, pp. 216-224. Malabar, Florida, Robert E. Kreiger, 1984.

Constant, C. R.: Age related recovery of shoulder function after injury. Thesis, University College, Cork, Ireland, 1986.

ConstantC. R., and Murley, A. H.: A clinical method of functional assessment of the shoulder. Clin. Orthop.,214: 160-164, 1987.214160 1987 [PubMed]

Depalma, A. F.: Loss of scapulohumeral motion (frozen shoulder). Ann. Surg.,135: 193-204, 1952.135193 1952 [PubMed][CrossRef]

Grey, R. G.: Brief note. The natural history of "idiopathic" frozen shoulder. J. Bone and Joint Surg.,60-A: 564, June 1978.60-A564 1978

Haggart, G. E.; Dignam, R. J.; and |and |Sullivan, T. S.: Management of the "frozen" shoulder. J. Am. Med. Assn.,161: 1219-1222, 1956.1611219 1956

Haines, J. F., and |and |Hargadon, E. J.: Manipulation as the primary treatment of the frozen shoulder. J. Roy. Coll. Surg.,27: 271-275, 1982.27271 1982

Harryman, D. T., II: Shoulders: frozen and stiff. In instructional Course Lectures, The American Academy of Orthopaedic Surgeons. Vol. 42, pp. 247-257. Rosemont. Illinois, The American Academy of Orthopaedic Surgeons, 1993.

Harryman, D. T., II; Sidles, J. A.; Harris, S. L.; and |and |Matsen, F. A., III: The role of the rotator interval capsule in passive motion and stability of the shoulder. J. Bone and Joint Surg.,74-A: 53-66, June 1992.74-A53 1992

Harryman, D. T., II; Sidles, J. A.; Clark, J. M.; McQuade, K. J.; Gibb, T. D.; and |and |Matsen, F. A., III: Translation of the humeral head on the glenoid with passive glenohumeral motion. J. Bone and Joint Surg.,72-A: 1334-1343, Oct. 1990.72-A1334 1990

Hawkins, R. J., and |and |Hobeika, P. E.: Impingement syndrome in the athletic shoulder. Clin. Sports Med.,2: 391-405, 1983.2391 1983 [PubMed]

Hazleman, B. L.: The painful stiff shoulder. Rheumatol. and Phys. Med.,11: 413-421, 1972.11413 1972 [CrossRef]

Hsu, S. Y., and |and |Chan, K. M.: Arthroscopic distension in the management of frozen shoulder. Internat. Orthop.,15: 79-83, 1991.1579 1991

Itoi, E., and |and |Tabata, S.: Range of motion and arthrography in the frozen shoulder. J. Shoulder and Elbow Surg.,1: 106-112, 1992.1106 1992 [CrossRef]

Janda, D. H., and |and |Hawkins, R. J.: Shoulder manipulation in patients with adhesive capsulitis and diabetes mellitus: a clinical note. J. Shoulder and Elbow Surg.,2: 36-38, 1993.236 1993 [CrossRef]

Kay, N. R.: The clinical diagnosis and management of frozen shoulders. Practitioner,225: 164-177, 1981.225164 1981 [PubMed]

Kieras, D. M., and |and |Matsen, F. A., III: Open release in the management of refractory frozen shoulder. Orthop. Trans.,15: 801-802, 1991.15801 1991

Kinnard, P.; Truchon, R.; St-Pierre, A.; and |and |Montreuil, J.: Interscalene block for pain relief after shoulder surgery. A prospective randomized study. Clin. Orthop.,304: 22-24, 1994.30422 1994 [PubMed]

Leffert, R. D.: The frozen shoulder. In Instructional Course Lectures, The American Academy of Orthopaedic Surgeons. Vol. 34, pp. 199-203. St. Louis, C. V. Mosby, 1985.

Lippmann, R. K.: Frozen shoulder, periarthritis, bicipital tenosynovitis. Arch. Surg.,47: 283-296, 1943.47283 1943

Lloyd-Roberts, G. C., and |and |French, P. R.: Periarthritis of the shoulder. A study of the disease and its treatment. British Med. J.,1: 1569-1571, 1959.11569 1959 [CrossRef]

Lundberg, B. J.: The frozen shoulder. Clinical and radiographical observations. The effect of manipulation under anesthesia. Structure and glycosaminoglycan content of the joint capsule. Local bone metabolism. Acta Orthop. Scandinavica,Supplementum 119: 1969.Supplementum 119 1969

McGraw, J. M., and |and |Turba, J.E.: Frozen shoulder-treatment by arthroscopy and manipulation. Orthop. Trans.,13: 661-662, 1989.13661 1989

McLaughlin, H.: On the "frozen shoulder.". Bull. Hosp. Joint Dis.,12: 383-393, 1951.12383 1951 [PubMed]

Murnagham, J. P.: Frozen shoulder. In The Shoulder, pp. 837-862. Edited by C. A. Rockwood, Jr., and F. A. Matsen. III. Philadelphia, W. B. Saunders, 1990.

Neer, C. S., II: Impingement lesions. Clin. Orthop.,173: 70-77, 1983.17370 1983 [PubMed]

Neer, C. S., II [editor]: Anatomy of shoulder reconstruction. In Shoulder Reconstruction, pp. 1-39. Philadelphia, W. B. Saunders, 1990.

Neer, C. S., II [editor]: Frozen shoulder. In Shoulder Reconstruction, pp. 422-427. Philadelphia, W. B. Saunders, 1990.

Neer, C. S., II, and |and |Poppen, N. K.: Supraspinatus outlet. Orthop. Trans.,11: 234, 1987.11234 1987

Neer, C. S., II; Satterlee, C. C.; Dalsey, R. M.; and |and |Flatow, E. L.: On the value of the coracohumeral ligament release. Orthop. Trans.,13: 235-236, 1989.13235 1989

Neer, C. S., II; Satterlee, C. C.; Dalsey, R. M.; and |and |Flatow, E. L.: The anatomy and potential effects of contracture of the coracohumeral ligament. Clin. Orthop.,28: 182-185, 1992.28182 1992

Neviaser, J. S.: Adhesive capsulitis of the shoulder. A study of the pathological findings in periarthritis of the shoulder. J. Bone and Joint Surg.,27: 211-222, April 1945.27211 1945

Neviaser, J. S.: Adhesive capsulitis of the shoulder. In Instructional Course Lectures, The American Academy of Orthopaedic Surgeons. Vol. 6, pp. 281-291. Ann Arbor, J. W. Edwards, 1949.

Neviaser, J. S.: Arthrography of the Shoulder, pp. 60-66. Springfield, Illinois, Charles C Thomas, 1975.

Neviaser, R. S.: Painful conditions affecting the shoulder. Clin. Orthop.,173: 63-69, 1983.17363 1983 [PubMed]

Neviaser, R. J., and |and |Neviaser, T. J.: The frozen shoulder. Diagnosis and management. Clin. Orthop.,223: 59-64, 1987.22359 1987 [PubMed]

Neviaser, T. J.: Arthrography of the shoulder. Orthop. Clin. North America,11: 205-217, 1980.11205 1980

Ogilvie-Harris, D. J., and |and |Wiley, A. M.: Arthroscopic surgery of the shoulder. A general appraisal. J. Bone and Joint Surg.,68-B(2): 201-207, 1986.68-B(2)201 1986

Ono, K.; Yamamuro, T.; and |and |Rockwood, C. A.: Use of the thirty-degree caudal tilt radiograph in the shoulder impingement syndrome. J. Shoulder and Elbow Surg.,1: 246-252, 1992.1246 1992 [CrossRef]

Ozaki, J.; Nakagawa, Y.; Sakurai, G.; and |and |Tamai, S.: Recalcitrant chronic adhesive capsulitis of the shoulder. Role of contracture of the coracohumeral ligament and rotator interval in pathogenesis and treatment. J. Bone and Joint Surg.,71-A: 1511-1515, Dec. 1989.71-A1511 1989

Parker, R. D.; Froimson, A. I.; Winsberg, D. D.; and |and |Arsham, N. Z.: Frozen shoulder. Part II: Treatment by manipulation under anesthesia. Orthopedics,12: 989-990, 1989.12989 1989 [PubMed]

Pollock, R. G.; Duralde, X. A.; Flatow, E. L.; and |and |Bigliani, L. U.: The use of arthroscopy in the treatment of resistant frozen shoulder. Clin. Orthop.,304: 30-36, 1994.30430 1994 [PubMed]

Quigley, T. B.: Indications for manipulation and corticosteroids in the treatment of stiff shoulders. Surg. Clin. North America,43: 1715-1720, 1963.431715 1963

Reeves, B.: The natural history of the frozen shoulder syndrome. Scandinavian J. Rheumatol.,4: 193-196, 1975.4193 1975 [CrossRef]

Shaffer, B.; Tibone, J. E.; and |and |Kerlan, R. K.: Frozen shoulder. A long-term follow-up. J. Bone and Joint Surg.,74-A: 738-746, June 1992.74-A738 1992

Simmonds, F. A.: Shoulder pain. With particular reference to the "frozen" shoulder. J. Bone and Joint Surg.,31-B(3): 426-432, 1949.31-B(3)426 1949

Uitvlugt, G.; Detrisac, D. A.; Johnson, L. L.; Austin, M. D.; and |and |Johnson, C.: Arthroscopic observations before and after manipulation of frozen shoulder. Arthroscopy,9: 181-185, 1993.9181 1993 [PubMed][CrossRef]

Warner, J. J. P.: Shoulder arthroscopy in the beach-chair position: basic set-up. Op. Tech. Orthop.,1: 147-154, 1991.1147 1991 [CrossRef]

Watson-Jones, R.: Simple treatment of the stiff shoulder. In Proceedings of the British Orthopaedic Association and Scandinavian Orthopaedic Society. J. Bone and Joint Surg.,45-B(1): 207, 1963.45-B(1)207 1963

Wiley, A. M.: Arthroscopic appearance of frozen shoulder. Arthroscopy,7: 138-143, 1991.7138 1991 [PubMed][CrossRef]

Zuckerman, J. D., and Cuomo, F.: Frozen shoulder. In The Shoulder: a Balance of Mobility and Stability, pp. 253-267. Edited by F. A. Matsen, III, F. H. Fu, and R. J. Hawkins. Rosemont, Illinois, The American Academy of Orthopaedic Surgeons, 1994.

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