Arthroscopic Capsular Release for the Treatment of Stiff Shoulder Pathology

Chapter 30


Arthroscopic Capsular Release for the Treatment of Stiff Shoulder Pathology








The diagnosis of shoulder stiffness, also termed frozen shoulder or adhesive capsulitis, is one of exclusion. It is a clinical syndrome characterized by painful restricted passive and active range of motion. It is associated with night pain and pain with activities.1–5 This clinical entity has been difficult to classify and follows an unpredictable clinical course.1,3,6,7 Etiologic factors in the pathophysiology of the disease include idiopathic causes, posttraumatic conditions, diabetes, and postsurgical factors; the condition can arise even as a consequence of prolonged impingement syndrome.4,5,8–11 It appears that susceptible shoulders respond to an insult in a common pathway of expression. This is a glenohumeral synovitis. If this process continues unabated, the capsule will become thickened and disorganized in its collagen structure and actually become contracted.12,13 The time course of the process and recovery is unpredictable. The true cause, diagnostic criteria, pathophysiology, treatment methods, and natural history of this condition are under debate and investigation.1,4–8,14–16 There are patients who do not respond to time, proper therapy, injections, or anti-inflammatory medications and who are profoundly affected by the shoulder stiffness. These patients can be offered an arthroscopic capsular release.



Preoperative Considerations




Physical Examination


Adhesive capsulitis, or frozen shoulder, is a limitation of motion without an obvious clinical reason for the loss of motion such as arthritis or previous fracture of the shoulder. Thus a comprehensive examination of the shoulder and cervical spine needs to be performed. The examiner should evaluate passive motion and active motion in forward elevation in the plane of the scapula, external rotation at the side, and internal rotation. In a painful shoulder, internal rotation behind the back can be painful. It is helpful to evaluate internal rotation with the arm abducted in the scapular plane approximately 40 degrees and then let the forearm drop toward the floor. The rotation can be seen and measured, and the early movement of the scapula can easily be seen in patients with posterior capsular involvement. The affected side should always be compared with the unaffected side. Inspection for atrophy around the shoulder girdle should be done. Evaluation for acromioclavicular (AC) joint pain, impingement-type pain, and cervical radicular symptoms must be done. In this step-wise fashion the examiner can determine the motion planes that are involved, and any contributing factors to the loss of motion and pain patterns. It can be helpful to do differential injections around the shoulder to determine pathologic locations and contributions. A subacromial injection of anesthetic can eliminate subacromial pain and allow the examiner to evaluate the shoulder with that area temporarily “eliminated” as a pain generator. An injection in the glenohumeral joint itself can eliminate glenohumeral pain. This can allow the examiner to evaluate shoulder motion again with pain eliminated. If the motion is remarkably improved, it may not be a true shoulder stiffness problem. However, most of the time the injections help the pain aspect but the range of motion is not improved, confirming a diagnosis of stiffness.



Imaging


Plain radiographs will evaluate conditions such as arthritis of the glenohumeral joint, calcific tendonitis, and subacromial impingement. A true anteroposterior (AP) view of the glenohumeral joint, an axillary view, and an outlet view should be performed. Magnetic resonance imaging (MRI) can evaluate for rotator cuff pathology, but in a true adhesive capsulitis picture, MRI will exclude other pathology. Bone scan, computed tomography (CT), and electromyography are rarely necessary for the evaluation of frozen shoulder. Arthrography with limited joint volume was at one time felt to be a gold standard–type test,3 but it is not necessary for the diagnosis of shoulder stiffness if a proper history is obtained and a proper physical examination is performed. Another diagnostic test can be physical therapy. A patient who does not respond to or who actually gets worse with a therapy program designed specifically for shoulder stiffness can be a candidate for arthroscopic capsular release.






Surgical Technique



Anesthesia and Positioning


By definition there is restricted range of motion of the shoulder; thus there is small joint volume, and small movements can help intra-articular exposure. For this reason the preference is for the beach chair position with the arm free. The lateral position with the arm in traction will restrict ability to rotate the shoulder during the procedure, and traction will not open up the stiff joint. A combined anesthetic technique is preferred. A scalene regional block for intraoperative and postoperative pain relief is preferred. A general anesthetic can then be used. If the patient is going to be admitted for therapy, an in-dwelling scalene catheter can be used for prolonged pain control. The surgeon should choose the option based on the patient, the anesthesia experience, and surgeon experience.


The patient is placed in the beach chair position with a small towel roll under the medial border of the scapula. The landmarks of the scapular spine, acromion, and coracoid are marked out after standard preparation and draping. An assessment of motion is made with the patient under anesthesia (Fig. 30-1). No manipulation is performed at this time. It would create bleeding within the glenohumeral joint and make for a more difficult procedure.


Related posts:

Open Repair of Posterior Shoulder Instability Autologous Chondrocyte Implantation in the Knee Arthroscopic Rotator Cuff Repair: Double-Row Techniques Surgical Treatment of Posterolateral Instability of the Elbow Primary Repair of Osteochondritis Dissecans in the Knee Arthroscopic Meniscus Repair: All-Inside Technique

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Sep 11, 2016 | Posted by in SPORT MEDICINE | Comments Off on Arthroscopic Capsular Release for the Treatment of Stiff Shoulder Pathology

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