- 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;
- 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;
- on the average, active forward elevation increased 43 deg, active external rotation increased 25 deg, passive internal
rotation increased eight vertebral levels, and the 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*
SM Griggs et al. 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.
DH Janda, RJ Hawkins. 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;
- the 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;
- three groups consisted of patients who had an idiopathic frozen shoulder, shoulder stiffness after surgery,
or shoulder stiffness after fracture;
- at the time of follow-up, each group had a significant improvement in the scores for pain, patient satisfaction,
and functional activity as well as in the overall outcome score (p < 0.01);
- comparison of the scores among the different groups revealed that all had a similar degree of improvement in
range of motion of the involved shoulder, but patients with postoperative frozen shoulder had significantly (p < 0.05)
lower scores for pain (p < 0.03), patient satisfaction (p < 0.004), and functional activity (p < 0.002) than did those
with idiopathic or post-fracture frozen shoulder;
- 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;
- ref: Arthroscopic Capsular Release for the Treatment of Refractory Postoperative or Post-Fracture Shoulder Stiffness
G. Brian Holloway, MD JBJS (Am) 83:1682-1687 (2001)
- 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;
Recalcitrant chronic adhesive capsulitis of the shoulder. Role of contracture of the coracohumeral ligament and rotator interval in pathogenesis and treatment.
Management of Difficult Shoulder Problems--Symposium: The Frozen Shoulder Diagnosis and Management.
The frozen shoulder. Diagnosis and management.
Frozen shoulder. A long-term follow-up.
Combination treatment for adhesive capsulitis of the shoulder.
Open release in the management of refractory frozen shoulder. DM Kieras, FA Matsen III. Orthop Trans. Vol 15. 1991. p 801-802.
Arthroscopic appearance of frozen shoulder. AM Wiley. Arthrscopy. vol 7, 1991. p 138
Arthroscopic release of postoperative capsular contracture of the shoulder. JP Warner MD et al. JBJS Vol 79-A. No 8. Aug 1997. p 1151.
Operative management of the frozen shoulder in patients with diabetes
