Arthroscopic Capsular Release for the Stiff Shoulder

Anup A. Shah

Laurence D. Higgins

Jon J. P. Warner

INDICATIONS/CONTRAINDICATIONS

Primary adhesive capsulitis refers to a condition in the shoulder in which the capsule becomes inflamed, hypertrophic, and shortened, with the result being decreased intra-articular volume and capsular compliance (1). These changes limit glenohumeral rotation in all planes, leading to global loss of active and passive motion. Potential causes of adhesive capsulitis have been extensively studied and include immunologic, endocrine, and inflammatory factors. It is often associated with systemic disorders such as diabetes mellitus, hypothyroidism, and ischemic heart disease (2).

Secondary or acquired shoulder stiffness by definition has a known cause. Acquired shoulder stiffness is most commonly encountered after surgery or trauma, often during prolonged immobilization (3, 4, 5, 6). Acquired shoulder stiffness can result from intra-articular and/or extra-articular pathology, distinguishing itself from primary adhesive capsulitis where the pathology is solely intra-articular.

The management of shoulder stiffness has been controversial since Codman first coined the term “frozen shoulder.” Current potential treatments include stretching exercises, with or without formal physical therapy, pain medication, judicious use of intra-articular injections, closed manipulation under anesthesia, and open surgical release. With advanced surgical techniques and instrumentation, arthroscopic capsular release has now become a widely utilized option in patients with shoulder stiffness refractory to conservative management. This method was initially described in the 1990s by several surgeons (3, 7, 8).

Indications

Surgical treatment is indicated when a prolonged trial of physical therapy (stretching), injections, and other modalities have failed to restore motion and alleviate pain. Conservative treatment is considered unsuccessful when stiffness and pain persist. Additionally, it is important to attempt to determine the location of the soft-tissue contracture (intra-articular vs. extra-articular, anterior vs. posterior, etc.) as this procedure is most beneficial for specific intra-articular capsular contractures.

There is no consensus as to the limits or duration of physical therapy before deciding that surgical management should be undertaken. The literature reports a time frame from 3 to 36 months (2, 3, 4, 5, 8, 9). Secondary causes of shoulder stiffness, such as posttraumatic and postsurgical stiffness, are often refractory to conservative measures, and thus, the surgeon must differentiate between primary and secondary adhesive capsulitis. Stiffness resulting from surgery such as a rotator cuff repair or trauma without bony deformity can often resolve after one year, and therefore, surgical release may be indicated after 9 to 12 months. In general, a patient who has plateaued on an adequate rehabilitation program of at least 8 weeks or for whom the exercise program is not able to be tolerated because of uncontrollable pain would appear to be a good candidate for surgical release of the intra-articular contracture.

We discourage closed manipulation under anesthesia as this procedure often requires a large force to break the contracted capsular tissue. With this manipulation, the surgeon risks fracture and its subsequent need for immobilization. Precise control of those structures released appears to be a more attractive option than the lack of control of which structures are torn, which invariably accompanies closed manipulation. Arthroscopic capsular release enables the surgeon to identify and selectively release the capsule based on the patient’s pathology.

Contraindications

Arthroscopic capsular release is primarily indicated for patients with isolated capsular contractures, while open release is more appropriate for stiffness resulting from trauma or prior open surgical procedures where an extra articular component is a factor contributing to stiffness. Patients with contractures of the extra-articular soft tissues (after procedures such as a Bristow, Putti-Platt, or Latarjet procedure) are not appropriate candidates for arthroscopic capsular release. The capsule, subscapularis, and extra-articular tissues (such as subdeltoid, subacromial, subcoracoid, and rotator interval adhesions) are involved (10, 11). Open surgical release of these adhesions is required and potential lengthening procedures of the capsule and subscapularis may be indicated.

In rare instances, the glenohumeral joint may be so contracted that introduction of the arthroscope may not be possible or inadequate visualization may occur secondary to poor portal placement. Additionally, uncontrolled bleeding during introduction of the scope or prior manipulation (intentional or unintentional during prepping and draping) can occur. In these cases, the procedure should be converted to an open release.

A unique contraindication of arthroscopic capsular release is in the setting of instability with stiffness. This paradoxical situation is seen in instances where the patient’s multidirectional instability was treated with a unidirectional repair (i.e., Bankart or Putti-Platt procedure) that does not resolve instability but limits external rotation. When this is the case, a formal open anterior capsular release is recommended combined with a revision capsular shift. The details of this procedure are beyond the scope of this chapter and have been described in other reports (12, 13).

Lastly, in cases of acute onset of stiffness, if severe pain is a major component of the patient’s complaint in adhesive capsulitis, surgical treatment should not be considered at that time. Surgery during this stage of the disease may exacerbate his or her pain level and motion loss with further injury to the capsule (1, 2). We recommend an intra-articular steroid injection without physical therapy for 3 weeks to decrease the inflammation and then start physical therapy with a skilled therapist.

Capsular release in the presence of osteoarthritis is controversial. If the humeral head remains round and congruent to the glenoid, arthroscopic capsular release can alleviate pain as capsular contracture is thought to be a pain generator in addition to the arthritis (14, 15). However, if there is deformity at the glenohumeral joint, shoulder arthroplasty is the treatment of choice.

PREOPERATIVE PLANNING

A detailed history and physical examination are essential for proper treatment of the stiff shoulder. Most patients describe their shoulder pain as gradual without a specific mechanism of injury or traumatic event. Most have attempted prolonged physical therapy without improvement in motion. Conversely, acquired shoulder stiffness occurs after a specific event either after surgery or trauma and the resulting prolonged immobilization. The cause, surgery or trauma, must be determined as treatment may vary. This is especially true in fracture cases where bony incongruity exists and capsular release would not be indicated.

Additionally, prior open anterior instability procedures may require a formal open release as well. Often the subscapularis has been shortened or tethered and cannot be adequately visualized with arthroscopy. Therefore, an open release and possible lengthening may be required.

Patients who develop a stiff shoulder after rotator cuff surgery may also have a reruptured cuff. This scenario can affect decision making and the surgeon may consider a staged repair: capsular release to improve motion, followed by rotator cuff repair.

Medical comorbidities such as diabetes and other endocrine disorders should be considered as these are known risk factors for the development of adhesive capsulitis.

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