Open Capsular Release
Frozen shoulder may occur as a primary phenomenon or secondarily in conjunction with fractures, rotator cuff tears, arthritis of the glenohumeral joint, metabolic disorders (diabetes, hypothyroidism), prolonged immobilization, myocardial infarction, stroke, and autoimmune disorders. Treatment of the stiff shoulder without recognition and treatment of concomitant pathology will yield suboptimal results and an increased risk of recurrence.
The natural history of the primary frozen shoulder is one of gradual, spontaneous improvement. The disease will frequently resolve over a course of 1 to 3 years through a combination of medical modalities and physical therapy. Three phases of frozen shoulder have been described: (1) pain; (2) stiffening; and (3) thawing. Patients are often left with mild, permanent residual loss of motion. Disuse osteopenia in the setting of long-term adhesive capsulitis may be noted on shoulder radiographs. This may mimic the clinical picture of reflex sympathetic dystrophy (RSD). Patients will frequently present having had either one injection or a course of rehabilitation with their primary care practitioner. Primary frozen shoulder will present insidiously, causing the patient to limit the use of the affected arm. Secondary frozen shoulder will frequently require more aggressive treatment including arthroscopic or open surgical procedures. Intraarticular steroids are useful in treating early adhesive capsulitis, as there appears to be an active inflammatory phase early in the disease process. Consideration may be given to subacromial injection to differentiate subacromial from glenohumeral pathology. Prevention of recurrent adhesive capsulitis often requires a rigorous course of daily stretching exercises.
1. Closed manipulation is contraindicated because of:
a. Osteopenia (increased risk of fracture during manipulation)
b. Recent arthrotomy and/or subscapularis repair
2. Arthroscopic release contraindicated.
3. Arthroscopic release has been attempted once without success.
4. Extraarticular contracture (do not attempt closed manipulation) (Figs. 33–1A,B,C).
1. During early phases of disease process when there is extreme pain and acute loss of motion.
2. Inflammatory phase: surgery during this period may be associated with high rate of failure/recurrence.
1. A thorough cervical spine exam.
2. Document bilateral arc and range of active and passive motion in forward elevation, abduction, and plane of the scapula.
3. Document passive glenohumeral motion in both sitting and supine positions.
4. Document range of motion in the plane of the scapula and compare it to the contralateral shoulder. Include forward flexion, external and internal rotation, abduction, extension, and cross-body abduction.
5. Document the number of vertebral levels of loss of internal rotation between shoulders.
6. Examination of strength is integral, as well as determination of which motions and at what point pain is precipitated.
7. Differentiate adhesive capsulitis from impingement syndrome.
8. Document range of motion after injection, if given.
1. Standard radiographs include anteroposterior, outlet, and axillary views.
2. Injections of corticosteroid and lidocaine can help differentiate pain location.
3. To exclude other pathology, magnetic resonance imaging, computed tomography, or bone scans may be considered.
Special Considerations: Diabetes Mellitus and Adhesive Capsulitis
1. Do not immobilize these patients postinjury or postoperatively.
2. May see active and passive stiffness in several joints concomitantly.
3. Prescribe daily stretching exercises.
4. More common with insulin-dependent diabetes (IDDM) type I (36% incidence type I, 10 to 20% type II).
5. Type I DM more resistant than type II to nonoperative modalities.
6. Capsular contracture occurs most commonly in rotator interval.
7. Patients with long-term IDDM and adhesive capsulitis do not respond well to physical therapy and/or manipulation under anesthesia.
Patient and Equipment Position
1. Beach chair position.
2. Arm is prepped free.
3. Deltopectoral approach.