• An examination is performed under anesthesia with the patient supine before he or she is turned to the lateral decubitus position.

• Particular attention should be paid for evidence of internal rotation deficit and/or anterior or posterior instability.

• We prefer the lateral decubitus position, but the procedure also can be done with the patient in the beach-chair position.

• All bony prominences are carefully padded, including the greater trochanter, fibular head, and elbow. An axillary roll is placed under the down axilla.

• Approximately 10 lb of traction is applied to the operative limb.

• The arm should be in ˜15 degrees of forward flexion and 45 degrees of abduction.

• The glenohumeral joint is insufflated with 60 cc of normal saline.

• If performed appropriately, the shoulder should internally rotate.

• A posterior portal is created ˜2 cm inferior and medial to the posterolateral corner of the acromion.

• If a posterior release is planned, this portal can be shifted laterally to give a better approach to the posterior capsule.

• The anterior portal is placed just lateral to the coracoacromial (CA) ligament, which should be marked as a line connecting the coracoid to the anterolateral corner of the acromion.

• Accessory portals can be used depending on individual pathology.

• An intra-articular diagnostic arthroscopy is performed. It is important to evaluate the shoulder from both the posterior and anterior portals.

• Commonly seen pathologies with internal impingement

• Glenohumeral internal rotation deficit

• Bennett lesion

• Posterior, partial-thickness rotator cuff tears

• Superior labrum anterior and posterior (SLAP) tears

• Posterosuperior labral tears

• If an internal rotation deficit exists and has been refractory to physical therapy, a posterior capsular release is performed.

• The release is done with the arthroscope in the anterior portal, using the posterior portal as the working portal.

• If there is difficulty obtaining an appropriate angle for the capsulotomy, a second accessory posterior portal can be made.

• The surface landmark for this portal usually is lateral to the standard posterior portal and should provide a steeper angle to the glenoid/capsule.

• The capsulotomy is largely posteroinferior and should start at the 10 o’clock position and extend down to the 6:30 o’clock position. The capsulotomy should be adjacent to the margin of the labral tissue with a small cuff of capsular tissue intervening. The posterior band of the inferior glenohumeral ligament (IGHL) should be released and marks the inferiormost extent of the release (Fig. 8-1A and B).

• We typically begin the capsulotomy with a shaver and proceed until we see muscular fibers. The inferior capsulotomy can be performed with a meniscal biter to avoid injury to deeper structures, including the axillary nerve.

• Bennett lesions often can be identified on plain radiographs (Fig. 8-2A).

• It is controversial as to whether this represents a traction osteophyte from the posteroinferior capsule or the triceps attachment.

• Excision is performed when the patient has posterior symptoms or evidence of an internal rotation deficit for which nonoperative management has failed.

• A capsular release is performed as described above.

• The lesion often can be palpated with a probe or shaver through the capsule and typically is located adjacent to the posteroinferior margin of the glenoid (Fig. 8-2B).

• Excision is done with the arthroscope in the anterior portal. If there is difficulty visualizing the lesion, a 70-degree scope can be used or an accessory portal can be made (Fig. 8-2C). If the accessory portal is created, the arthroscope can be introduced through the standard posterior portal with the accessory portal as the working portal.

• The bony prominence is excised, and a smooth margin is created at with the remainder of the glenoid. We typically perform this with a shaver. The inferior margin often is confluent with the inferior scapular neck. Care must be taken not to create a divot in the neck. The triceps attachment may need to be elevated to determine the true extent of the lesion and to fully excise it.