Shoulder Stiffness (Adhesive Capsulitis) With A Rotator Cuff Tear: How to Manage


Chapter 28

Shoulder Stiffness (Adhesive Capsulitis) With A Rotator Cuff Tear


How to Manage



Jae Chul Yoo, Jeung Yeol Jeong, and Yeong Seok Lee

Introduction


Most shoulder surgeons recognize that many patients with rotator cuff tear have some shoulder stiffness preoperatively. In general, these patients are managed with a shoulder mobilization program before surgical treatment; however, the ideal treatment for rotator cuff tears with shoulder stiffness remains controversial. Recently, simultaneous early treatment of the stiffness with rotator cuff repair has become popular because of several studies stating that there was no difference in final outcome compared with delayed treatment of the rotator cuff repair.

Procedure


Although there is some debate whether to do manipulation before the arthroscopic capsular release or just do capsular release, our experience shows that most gentle manipulation is not harmful just before arthroscopic surgery. However, on rare occasion one sees some avulsion of the anterior glenoid rim with the labrum. After complete capsular release, especially the anteroinferior capsule (called the inferior glenohumeral ligament [IGHL]), the rotator cuff repair is performed. Rotator cuff repair should be checked in two perspectives: the biceps long head pathology, and subscapularis tendon tear and posterosuperior tear. In this chapter, we discuss some different and crucial aspects of rotator cuff repair and our personal opinions on it.

Patient History



Patient Examination





  1. • Patients with advanced adhesive capsulitis may have lost the natural arm swing that occurs with walking. Moreover, muscle atrophy of the shoulder girdle may be present. As a result of impaired motion in the glenohumeral joint, abnormal scapular movement may be observed with active forward flexion of the affected shoulder.
  2. • A vague, diffuse tenderness over the anterior and posterior shoulder regions could be yielded by palpation. Some authors noted that in adhesive capsulitis, digital pressure on the area of the coracoid process elicits local pain (coracoid pain test) and could be considered as a pathognomonic sign of adhesive capsulitis. This could also be applied to patients with a stiff shoulder and rotator cuff tear.
  3. • Loss of motion with forward flexion, abduction, and external and internal rotation should raise suspicion for typical adhesive capsulitis. The amount of inflammation all over the capsule is depicted in Fig. 28.2. With frozen shoulder, examination of the shoulder typically reveals significant limitation of both active and passive elevation, usually less than 120 degrees.
  4. • As described above regarding global limitation of ROM, when the patient has severe limitation of ROM, no physical examination is useful. All movement that stretches the capsule causes pain. Therefore the impingement test is usually useless. If the patient has mild terminal limitation of ROM, the impingement test result might be positive, and the results of the belly press, bear-hug, and lift-off tests, with the last of these a special test for subscapularis tendon tear, can be positive.
  5. • In this chapter, routine rotator cuff physical examination is not mentioned because it is dealt with in Ch. 5.

Imaging





  1. • Shoulder x-rays are done to rule out glenohumeral arthritis, calcific tendinitis, metastatic disease, or a greater tuberosity fracture that may cause global loss of ROM and severe pain.

  2. image
    FIG. 28.1 The patient shows forward elevation of 100 degrees or less with global limitation of motion. The patient had recent major cardiac surgery (orange circle), which makes frozen shoulder more likely to occur.

  3. • Fig. 28.3 shows osteopenia compared with the contralateral side. One can see clearly the spurs and sclerosis of greater tuberosity (GT) and acromion, indicating severe impingement and partial- or full-thickness rotator cuff tear. Fig. 28.4 shows MRI findings of frozen shoulder which focus mainly on the inferior capsule pouch and thickness.

Treatment Options: Nonoperative and Operative





  1. • For nonoperative treatment, first give a steroid injection prior to rotator cuff surgery, which may relieve severe pain and global limitation of the shoulder to some extent.
  2. • The gentle manipulation can sometimes easily rupture the anterior/anteroinferior capsule (Fig. 28.5). However, it can be skipped if the the capsule is too tight or if the stiffness and rotator cuff tear are caused by secondary stiffness, such as infection or fracture, and so forth. In such case capsular release is done during arthroscopic procedure (Fig. 28.6), because it is too tight due to severe inflammation and chronicity (Fig. 28.7).

Surgical Anatomy



Surgical Indications





  1. • There are still debates about whether to operate on those who have typical frozen shoulder and rotator cuff tear, especially with partial-thickness rotator cuff tear. Some argue that the frozen shoulder should be treated first, and the rotator cuff tear should be dealt with later, whereas others recently advocated otherwise.
  2. • Among the three general groups described below, the surgical indications may differ.


Surgical Technique Setup


Positioning


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Mar 28, 2020 | Posted by in ORTHOPEDIC | Comments Off on Shoulder Stiffness (Adhesive Capsulitis) With A Rotator Cuff Tear: How to Manage

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