Capsular Releases for Shoulder Stiffness: Considerations for Treatment and Rehabilitation

Capsular Releases for Shoulder Stiffness: Considerations for Treatment and Rehabilitation

Jacqueline Munch, MD

Andrea Tychanski, PT, DPT, ATC, CSCS

Sarah E. McLean, PT, MSPT

Samuel Arthur Taylor, MD

Scott Alan Rodeo, MD

Dr. Munch or an immediate family member has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research–related funding (such as paid travel) from Acumed and Arthrex. Dr. Rodeo or an immediate family member has stock or stock options in Rotation Medical and Ortho RTI (not paid consultant to Ortho RTI). Also—consultant to Joint Restoration Foundation. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Taylor and Dr. Tychanski.


Frozen shoulder, or adhesive capsulitis, is a common cause of loss of both active and passive shoulder motion. Originally described by Duplay in 1872, Codman and Neviaser lent the terms “frozen shoulder” and then “adhesive capsulitis” to this condition. Idiopathic adhesive capsulitis presents in the absence of any underlying shoulder pathology, trauma, or systemic condition. Risk factors for idiopathic adhesive capsulitis include female sex, diabetes, thyroid disease, or other autoimmune disease, age over 40 years, stroke, and cardiopulmonary disease. Frozen shoulder can also be a significant cause of delay and difficulty in reestablishing shoulder range of motion (ROM) in the postoperative or posttraumatic setting. The precise cause of this condition remains unknown, but our understanding of the pathologic process has improved substantially.

In the absence of any surgery or known trauma, idiopathic adhesive capsulitis generally manifests as a gradual onset of global shoulder pain and stiffness. This global loss of motion is in contrast to directional capsular tightness, as in the case of the throwing shoulder (in which the posterior capsule is typically tight, due to adaptive changes secondary to repetitive high-velocity external rotation [ER]) or an iatrogenic motion loss such as that seen in the setting of an overly tight anterior instability repair, such as the now-defunct Putti Platt procedure.

Pain associated with adhesive capsulitis is typically constant in the early period. Patients have trouble sleeping, and find particular difficulty with activities involving reaching to the extremes of their motion, including overhead or behind the back. Rapid shoulder movement—a vigorous handshake or unexpected “bump,” for instance—often causes particularly severe pain. In the early presentation, before there is severe loss of motion, the condition is often confused with rotator cuff or impingement syndromes. Patients can avoid pain by minimizing or avoiding movements that cause pain.

As our understanding of the pathogenesis of adhesive capsulitis has improved, the process has been divided into four typical stages. In stage 1, adhesive capsulitis, which typically lasts for about 3 months, patients note pain with active and passive motion, and progressive limitation of shoulder motion in all directions. If pain is controlled or eliminated (such as by injection or nerve block), examination will demonstrate minimal loss of passive motion. The glenohumeral joint has diffuse synovitis on arthroscopic examination, and microscopic examination demonstrates a normal capsule, with a hypertrophic synovium.

In stage 2, or “freezing” adhesive capsulitis, from 3 to 9 months from the onset of symptoms, patients continue to suffer from pain with active and passive motion, but experience true loss of passive range of motion (PROM) as well as limited glenohumeral translation that can be demonstrated on physical examination. Pathologic evaluation reveals synovitis as in stage 1, but with additional scarring and changes in the glenohumeral capsule.

Patients in stage 3, or “frozen” adhesive capsulitis, from 9 to 15 months from the onset of symptoms, have relief of pain except at the extremes of motion, but continue to suffer from significant limitation of active range of motion (AROM) and PROM. The capsule is dense and shows global volume loss. Histologic evaluation demonstrates a synovium that is no longer hypervascular, but the capsule has fibroblastic scarring (Figure 4.1).

Stage 4 adhesive capsulitis is called the “thawing” phase, which can last from 15 to 24 months after the onset of symptoms. During this time, patients have diminishing pain, and gradually regain their ROM.

The diagnosis of adhesive capsulitis is made primarily based on history and physical examination, with imaging studies utilized mainly to rule out other known causes of shoulder pain and stiffness, such as rotator cuff disease, osteoarthritis, or
calcific tendinitis. Plain radiographs may demonstrate disuse osteopenia, and depending on the stage in which the imaging is obtained, MRI may show a thickened capsule with loss of overall intra-articular volume.

Figure 4.1 MRIs demonstrating global contraction of the axillary pouch with scarring of the glenohumeral ligaments, consistent with stage 3 adhesive capsulitis. Arrows indicate the thickened and scarred glenohumeral ligaments/capsule.

Surgical Procedure: Arthroscopic Capsular Release with Manipulation under Anesthesia

Postoperative Rehabilitation

Patients are referred immediately to PT, in order to maintain the ROM that was obtained intraoperatively. Focused rehabilitation after capsular release is essential to restore function and achieve patient goals. As this surgical procedure is indicated and performed on patients who have failed conservative measures, it is important to consider that a patient may be frustrated with the process and the prospect of more PT. Patient education on the importance of regaining ROM in a timely manner is critical to the success of this procedure.

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Oct 13, 2018 | Posted by in ORTHOPEDIC | Comments Off on Capsular Releases for Shoulder Stiffness: Considerations for Treatment and Rehabilitation

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