Abstract
The shoulder has the greatest range of motion of any joint in the human body. It is also subject to significant stiffness from conditions such as adhesive capsulitis or stiffness after trauma or surgery. Physical therapy is the mainstay of management, but surgical intervention is sometimes needed. Surgery entails closed manipulation but also arthroscopic capsular release and release of adhesions in the subacromial space. Care needs to be exercised with manipulation to avoid fracture, and care needs to be exercised with capsular release to avoid axillary nerve injury.
Keywords
adhesive capsulitis, stiffness, ankylosis, axillary nerve, contracture release, manipulation, capsular release
There are three basic conditions that produce shoulder stiffness and are amenable to arthroscopic treatment: idiopathic adhesive capsulitis, posttraumatic stiffness, and postoperative stiffness. The treatment of the stiff, osteoarthritic shoulder is discussed in Chapter 7 .
Idiopathic adhesive capsulitis is widely believed to be a painful but self-limited condition that resolves between 6 months and 2 years. Recent reports suggest that although most patients improve, many have some residual limitations of movement. Fortunately, this residual loss of motion is generally not functionally disabling and is often unnoticed. However, those who suffer from disabling pain are often unwilling to wait for their condition to resolve and inquire about operative treatment. Shoulder stiffness in diabetic patients seems to cause greater pain, more profound stiffness, and is more refractory to nonoperative treatment than in their nondiabetic counterparts. The impairment from posttraumatic stiffness can often be correlated to the severity of the trauma. Postoperative stiffness can be the result of excessive scarring in the area of surgery (subacromial adhesions after rotator cuff repair, anterior glenohumeral capsule contracture after a Bankart procedure), but profound glenohumeral joint contracture can be seen after surgery that does not violate the capsule ( Figs. 6.1–6.3 ).
Release of the capsular contracture or subacromial adhesions can be done in open fashion. However, the arthroscopic technique offers the great advantage of allowing release of intra-articular, subacromial, and subdeltoid adhesions without dividing the subscapularis for glenohumeral adhesions and without creating more adhesions from the open incision. Active range of motion can be started immediately after surgery without concern for tendon repair failure or wound dehiscence.
Literature Review
Arthroscopic treatment is generally successful, with the degree of improvement related to the patient’s underlying condition. Ogilvie-Harris, Harryman, and Warner have published landmark articles describing their results.
Warner reported on 23 patients with idiopathic adhesive capsulitis treated with arthroscopic release. In that study, the Constant score improved an average of 48 points. Flexion improved a mean of 49 degrees; external rotation, 45 degrees; and internal rotation by eight spinous processes. Harryman documented patient satisfaction, improved function, and pain relief in a diabetic population, although the improvement in range of motion was not as great as that seen in patients with idiopathic adhesive capsulitis.
Literature Review
Arthroscopic treatment is generally successful, with the degree of improvement related to the patient’s underlying condition. Ogilvie-Harris, Harryman, and Warner have published landmark articles describing their results.
Warner reported on 23 patients with idiopathic adhesive capsulitis treated with arthroscopic release. In that study, the Constant score improved an average of 48 points. Flexion improved a mean of 49 degrees; external rotation, 45 degrees; and internal rotation by eight spinous processes. Harryman documented patient satisfaction, improved function, and pain relief in a diabetic population, although the improvement in range of motion was not as great as that seen in patients with idiopathic adhesive capsulitis.
Clinical Presentation
Patients with all types of adhesive capsulitis present with painful, limited shoulder motion. Pain at night interferes with sleep. Routine activities of daily living that require reaching overhead or behind the back are difficult and painful. Rapid movements cause especially severe pain. Most patients either recall a trivial antecedent injury or cannot identify an inciting event. Patients demonstrate restricted passive and active motion, with the degree of motion loss dependent on the timing of presentation. Radiographs are usually normal, but mild osteopenia due to disuse may be present.
Diagnosis
A number of other shoulder conditions that produce painful, limited motion can be eliminated by patient history, physical examination, and radiographic evaluation. Patients with rotator cuff tears present with passive motion greater than active motion, weakness on manual muscle testing, and abnormal magnetic resonance images or arthrograms. In patients with osteoarthrosis, plain radiographs depict loss of the glenohumeral joint space ( Fig. 6.4 ). Patients with posttraumatic stiffness may have malunited fractures, and those with postoperative stiffness may have internal fixation devices that interfere with motion.
It is important to obtain a thorough history that ascertains prior trauma or shoulder difficulties. Patients should also be asked about diabetes and thyroid dysfunction. Evaluate and record passive range of motion in elevation, abduction, and external rotation (in adduction with the arm at the side and in maximal allowable abduction). Measure internal rotation as the vertebral level to which the patient can reach with the extended thumb. Behind-the-back internal rotation is usually decreased, but it is occasionally close to normal because internal rotation measured in this manner includes not only glenohumeral movement but also scapulothoracic motion. With prolonged shoulder stiffness, scapulothoracic motion may increase to compensate for the loss of glenohumeral rotation. For this reason, the scapula should be stabilized with one hand and the arm abducted with the other. Range of motion is compared with the contralateral shoulder. Muscle strength in forward flexion and external rotation may be recorded, but it is often decreased due to pain, so it may not be helpful.
Indications for Surgery
As a general principle, we consider operation if the patient has persistent pain and stiffness after 6 months of appropriate nonoperative care. Even then, the patient makes the choice to proceed with surgery. There is no rigid definition of what constitutes stiffness that is significant enough to consider surgery, but we consider severe stiffness as 0 degrees of external rotation and less than 30 degrees of abduction. Moderate stiffness is defined as a decrease of 30 degrees in either plane compared with the contralateral shoulder. If stiffness persists, but pain has diminished after 6 months, nonoperative care can be continued for an additional 2 months in case the decrease in pain indicates that the stiffness is about to resolve or “thaw” spontaneously. If there is no improvement in the range of motion 2 months later, surgery is considered. Of note, it seems that external rotation is an important predictor of success or failure of nonoperative treatment. If external rotation remains at neutral or worse 4 to 6 months after the start of nonoperative treatment, earlier operative intervention is advisable.
Limitations of Arthroscopic Surgery
Relative contraindications to arthroscopic treatment apply mainly to patients with postoperative and posttraumatic stiffness. Patients who have had instability surgery with subscapularis takedown or shortening may develop profound soft tissue contracture. The contracture in these patients is typically extra-articular between the subscapularis and the conjoined tendon. Often, adhesions can be identified between the subscapularis and the conjoined tendon when the arthroscope is placed in the lateral subacromial portal. If this area cannot be well-visualized, open release may be a necessary addition to an arthroscopic glenohumeral joint release. Patients with mildly malunited fractures of the greater tuberosity or proximal humerus can be treated arthroscopically, but those with badly malunited fractures or internal fixation require open release, removal of hardware, and fracture osteotomy, as indicated (see Fig. 6.3 ).
Patients in the inflammatory or contracting phase of idiopathic adhesive capsulitis should not undergo operation because the surgery may accelerate the contracture or simply not be as effective. Once the range of motion has stabilized and is not improving, surgery can be considered. Heterotopic ossification and myositis ossificans are also a contraindication to arthroscopic release ( Fig. 6.5 ).
Operative Technique ( )
Examination Under Anesthesia
The patient is given a regional block for postoperative pain control and then placed under general anesthesia. After the induction of anesthesia, examine both shoulders for range of motion in elevation, abduction, and external rotation in adduction. Place the shoulder in maximal abduction, and record internal and external rotation.
Manipulation
A gentle closed manipulation is attempted first ( Figs. 6.6–6.11 ). It is difficult to quantify gentle as it depends on the patient’s habitus. For a thin 60-year-old female with osteopenia, minimal force is applied, and it is better to err on the side of less manipulation and focus on the arthroscopic capsular release. For a more robust younger male, a little more force can be applied. The order of application of force is important. Force is applied gradually and first in forward flexion. This avoids torsional forces that may result in a spiral fracture, and it avoids stress on the acromion. Often the release of adhesions or the tearing of the capsule can be felt and heard. If the motion improves with forward flexion, the arm can then be manipulated in abduction. Internal and external rotation in adduction and abduction are done last and may not need to be done at all if the motion improved with the manipulation in forward flexion and abduction. The specific order of motion is important because external rotation and internal rotation involve torsional stresses and may cause a spiral fracture to the humerus. If the shoulder does not respond to abduction and elevation, we do not attempt any rotational movements and proceed directly to arthroscopy. Regardless of whether the motion is improved, we generally still proceed with an arthroscopy to ensure that all adhesions have been released and to release any that remain.
