anesthesia to record the amount of stiffness in forward elevation, axial rotation with the arm at the side and elevated, and horizontal abduction. In the typical case, the shoulder has global tightness, and we will plan to perform a 270° release, sparing only the superior joint capsule.
TABLE 8-1 SELECTED RELEASES OF CONTRACTED GLENOHUMERAL LIGAMENTS AND CAPSULE MAY BE INDICATED WHEN SPECIFIC LOSSES OF SHOULDER RANGE OF MOTION ARE PRESENT
A 47-year-old right hand-dominant woman injured her left shoulder lifting a box overhead at work at a warehouse. She heard a pop and has had lateral shoulder pain with progressive stiffness over the last 9 months.
Nonoperative treatment failed to give her relief. Her SST score was 2, and she stated that her shoulder was 20% normal. Recently, her right shoulder has also been hurting because of overuse and has begun to be stiff.
She has been on light duty since the injury for her warehouse job, but she has been able to continue working at her second job as an office assistant without limitations. She smokes one-half pack per day of cigarettes.
FIGURE 8-1 Preoperative active forward elevation (A), external rotation (B), and internal rotation (C), with the left shoulder being affected with adhesive capsulitis.
FIGURE 8-2 Exam under anesthesia in forward elevation (A), internal rotation (B), and external rotation (C) confirms that significant glenohumeral joint stiffness is present.
Active and passive ROM were equal with forward elevation to 130°, external rotation to 20° with the arm at the side, external rotation to 40° with the arm abducted, internal rotation to L5 and internal rotation to 0° with the arm abducted (Figs. 8-1 and 8-2).
5/5 strength in abduction, internal, and external rotation.
Negative bear hug and belly press tests. No AC joint tenderness.
X-rays were unremarkable with a type 1 acromion.
MRI showed only subacromial bursitis without biceps, labral, or rotator cuff pathology (Fig. 8-3).
The glenohumeral joint space was very tight on diagnostic arthroscopy, but no chondromalacia, biceps, labral, or cuff pathology could be found. Synovitis was minimal. The subacromial space showed minimal bursitis without abrasive wear of the bursal cuff or the CA arch (Fig. 8-4).
In certain patients with idiopathic adhesive capsulitis, it is tempting to avoid surgery and perform isolated manipulation under anesthesia without capsular
release. Our philosophy is that arthroscopy with capsular release should always be done for the surgical treatment of the stiff shoulder, as this has several benefits. First, arthroscopy allows identification and treatment of additional sources of pathology that might have been missed on preoperative workup. Second, we have been referred patients who had iatrogenic injuries during isolated shoulder manipulation under anesthesia. Arthroscopic release allows for a controlled disruption of the offending capsuloligamentous structures (Fig. 8-5). Third, postmanipulation arthroscopy allows the surgeon to reexamine the shoulder and document that no iatrogenic injury has occurred (Fig. 8-5).
Fourth, incision of the capsule likely provides some pain relief via capsular denervation.
A controlled manipulation of the shoulder under anesthesia should always follow the arthroscopic capsular release, as this breaks up any remaining adhesions that might restrict postoperative motion (Fig. 8-6). Additionally, manipulation addresses thixotropy of muscle fibers that might be chronically shortened and fibrotic after disuse.
This patient had no pain or imaging findings to suggest symptomatic AC joint arthritis. Since the anatomy of the subacromial space, biceps, and labrum appeared to be nearly normal, no other concomitant procedures were performed (e.g., distal clavicle excision, biceps tenotomy, or subacromial decompression).
Postoperatively, the patient had a dramatic improvement in pain and active range of motion, even as early as postop day 3 (Fig. 8-7).
Many surgeons have a tendency to “write off” frozen shoulder patients, the idea being that they don’t improve with any treatment, surgical or nonsurgical. Our experience is the opposite, namely, that with a technically well-done arthroscopic capsular release and manipulation, these patients tend to improve dramatically quite quickly after surgery and that they tend to be very grateful.
A 27-year-old RHD laborer who injured his left shoulder falling directly onto the shoulder at work. He had no instability event or symptoms.
He was treated with benign neglect initially, but after he had continued pain, he went to physical therapy for range of motion and strengthening. After 6 months of failed nonoperative treatment, he was referred for a surgical opinion.
He had been unable to return to full work duties or sports.
Marked AC joint tenderness without deformity or instability. Active and passive forward elevation 150°, external rotation to 45°, internal rotation to the greater
trochanter. With the arm at 90° abduction, internal rotation was to 0°.
No strength deficits.
Negative belly press and bear hug tests. Positive dynamic labral shear test. Positive Speed test. Negative anterior apprehension.
FIGURE 8-7 Active forward elevation (A), internal rotation (B), and external rotation (C) on postoperative day 3 is much improved and essentially pain-free. The patient was very thankful for such a dramatic improvement in her symptoms.
X-rays showed no significant AC joint injury or arthrosis.
MRI showed no Bankart lesion, only slight AC joint degenerative changes and distal clavicle increased T2 signal (Fig. 8-8).
FIGURE 8-8 Axial (A) and sagittal (B) MRI images demonstrate distal clavicle edema, but no labral tear was seen (C).
Unexpected labral pathology is commonly encountered during shoulder arthroscopy. It can be difficult to decide which labral lesions require repair. In this case, because of the age of the patient, concomitant Hill-Sachs lesion, no degenerative changes of the joint or labrum, we decided that the labral lesion was most likely a traumatic tear and might be one source of the patient’s persistent pain.
Unexpected labral lesions represent a potential pitfall in shoulder arthroscopy. If a degenerative labrum is repaired as if were a traumatic lesion, especially with a capsulolabral shift, postoperative stiffness may result. The location of an abnormal-appearing labrum can also be a key to management. Except in the case of anterior instability, we routinely ignore anatomical variant or degenerative-appearing labra from 12 to 3 o’clock (right shoulder). In this example, even
though the tear was presumed to be a pain generator, we did not advance the capsulolabral complex onto the face of the glenoid or superiorly (Fig. 8-10). We ignored the labral detachment superior to the 9 o’clock position.
An advantage of shoulder arthroscopy is the ability to address pathology in any part of the shoulder. Selective capsular releases, as in this case, are occasionally required to address a specific range of motion deficit (e.g., posterior capsular release for loss of internal rotation, Fig. 8-11).
The correct course of postoperative activity restrictions and rehabilitation after a unique case such as this one may be difficult to discern. For this patient, we chose sling immobilization for 6 weeks with only a forward bend for passive shoulder range of motion (pendulum exercises). Our philosophy over the years has been to prioritize the protection of surgical repairs, and that with arthroscopic repair, postoperative stiffness unresponsive to physical therapy is unusual.
We make the decision to perform arthroscopic distal clavicle excision (Fig. 8-12) based primarily on patient history and clinical examination. When a patient reports superior shoulder pain and has consistent tenderness over the AC joint, we consider the decision to perform distal clavicle excision fairly straightforward. When done technically well, the procedure carries little risk and has been very successful in our hands for treating AC joint pain.
FIGURE 8-10 Three-anchor knotless labral repair with LabralTape and 2.9-mm BioComposite PushLock anchors (Arthrex, Naples, FL) as seen from posterior (A) and anterosuperolateral (B) viewing portals. G, glenoid; H, humeral head.
An active and independent 70-year-old right hand-dominant woman fell from a standing height and struck her right shoulder sustaining a minimally displaced fracture of the greater tuberosity.
After a 1-week period of sling wear for pain control, she started a program of supervised physical therapy with gentle, patient-directed passive range of motion.
At 2 months, her fracture was well healed but she had significant stiffness and continued pain with attempted use of the arm.
At 4 months, she had experienced no improvement after continued physical therapy for stiffness and a corticosteroid injection.
FIGURE 8-11 A selective posterior capsular release was performed to treat internal rotation preoperative stiffness in this patient. H, humeral head; G, glenoid; L, posterior labrum; P, posterior capsule.
FIGURE 8-13 Grashey injury (A) and preoperative (B) x-rays show a minimally displaced greater tuberosity fracture that healed uneventfully.
Active and passive ROM were equal with right shoulder forward elevation to 100°, external rotation to 45° with the arm at the side and elevated, and internal rotation to -10° with the arm elevated. Horizontal abduction was to 0°.
4+/5 strength in abduction and external rotation
Negative bear hug and belly press tests. She had no AC joint tenderness.
Injury (A) and preoperative Grashey (B) x-rays showed no displacement of the fracture from the injury with solid healing (Fig. 8-13).
MRI showed healed fracture with supraspinatus tendinosis and degenerative labrum.
Exam under anesthesia confirmed preoperative stiffness (Fig. 8-14).
A type 2 SLAP lesion was found with a displaceable biceps root (Fig. 8-15). The rotator cuff was found to be intact.
This case illustrates several advantages of an arthroscopic approach to shoulder stiffness over performing only a manipulation under anesthesia:
First, this patient had a tremendous amount of thickening of the shoulder capsule and ligaments (Fig. 8-16), a common finding.
Especially in a 70-year-old woman with posttraumatic stiffness, it is likely that this tissue would not have been the weakest link preventing motion. If only a manipulation had been performed, some other tissue would likely have been damaged first (i.e., rotator cuff, bone, or labrum).
Manipulation after release (Fig. 8-19) ensures that muscle fiber fibrosis and shortening (thixotropy) has been addressed and that any remaining capsular adhesions are disrupted.
Postmanipulation arthroscopy allows the surgeon to verify and document that there has been no inadvertent iatrogenic damage to other shoulder structures (Figs. 8-17, 8-18, and 8-20).
An arthroscopic approach allows the surgeon to address other pathology. In this patient, a Type 2 SLAP tear was treated with biceps tenotomy. We perform few tenotomies, but an elderly patient with stiffness is a good indication. Postoperatively, she
was able to aggressively rehab the shoulder without having to protect a tenodesis repair.
A skilled second assistant performing manipulations on the arm greatly facilitates arthroscopy for shoulder stiffness. Often, adducting the arm over an axillary bump will increase the working space in the critical inferior joint space (Fig. 8-21).
FIGURE 8-14 Exam under anesthesia demonstrates stiffness in forward elevation (A), internal rotation (B), and external rotation with the arm abducted (C) and at the side (D).
FIGURE 8-15 A type 2 SLAP tear (A) with a displaceable biceps root (B) without any continuity of the tendon to the supraglenoid tubercle.
FIGURE 8-16 Extremely thick scarring of the rotator interval (A) is released with electrocautery though an anterior portal (B) after biceps tenotomy.
FIGURE 8-17 Anterosuperior 30° arthroscopic view of the inferior capsule (A) during and (B) after capsular release and manipulation.
FIGURE 8-18 Anterosuperior 30° arthroscopic view of the MGHL and subscap (A) before and (B) after capsular release.
FIGURE 8-19 Intraoperative motion after release and manipulation shows large increases in forward elevation (A), internal rotation (B), and external rotation with the arm abducted (C) and at the side (D).
FIGURE 8-20 Lateral portal, 30° arthroscopic view of the bursal supraspinatus tendon, which was intact after capsular release and manipulation.
A 58-year-old right-handed woman presented with 9 months of progressive left shoulder pain and stiffness. Pain at night was predominant.
She had the most difficulty reaching behind her, with relatively preserved ability to reach overhead.
Oral analgesics and NSAIDs had given her no relief, and she had not tried physical therapy.
Active and passive range of motion were equal for the left shoulder: FE = 150°, ER = 40°, IR = L5.
Strength was 5/5 in abduction, ER, IR.
Negative bear hug and belly press tests. Positive AC joint tenderness.
X-rays showed only minimal AC joint degenerative changes.
The patient was unable to undergo MRI because of severe claustrophobia, but CT arthrogram confirmed severely diminished space in the axillary recess and no full-thickness rotator cuff tear (Fig. 8-22).
FIGURE 8-23 The posterior capsule (A) and the rotator interval (B) had synovitis, which likely explains ongoing pain in this patient.
Diffuse synovitis was present intra-articularly, worst at the posterior joint capsule (Fig. 8-23).
The rotator cuff was intact, and there was no glenohumeral chondromalacia.
Many health care providers (primary care physicians, physical therapists, surgeons) do not recommend patients for a surgical opinion or for surgery while pain is the predominant symptom in adhesive capsulitis (“pain-predominant” disease).
Unfortunately, many patients continue to have significant pain despite lengthy periods of nonoperative treatment. Our experience is that a well-done arthroscopic capsular release (Fig. 8-24) followed by manipulation provides excellent relief of pain and restoration of shoulder motion for these patients.
A 53-year-old right-handed chef presented with 2 years of left shoulder pain, unresponsive to subacromial corticosteroid injection and physical therapy.
She took an oral NSAID daily for her pain, but this helped minimally. She stated that she could not take any time off of work.
Full range of motion of the left shoulder: FE = 170°, ER = 45°, IR = T7
5/5 strength in abduction, IR, and ER
Positive Neer and Hawkins tests
Shoulder radiographs showed a mature-appearing calcific deposit at the posterosuperior rotator cuff (Fig. 8-25).
Diagnostic ultrasound demonstrated an intact rotator cuff with a calcific deposit in the supraspinatus tendon.
Since the patient stated that she could not have any time off work or comply with any restrictions of her arm, ultrasound-guided barbotage of the lesion was offered. This scenario has become more common in our practices, and we now typically reserve surgery for
chronic calcific tendinitis for patients who fail ultrasound-guided barbotage.
The procedure was performed in the office with local anesthetic using live ultrasound with an in-plane approach to the lesion (Fig. 8-26).