PROSPECTIVE EVALUATION OF ARTHROSCOPIC
CAPSULAR RELEASE FOR RECALCITRANT FROZEN SHOULDER
San Diego Shoulder Institute 1997
Gregory P. Nicholson, MD
Clinical Assistant Professor of Orthopaedics
Orthopaedics Indianapolis, Inc.
The pathophysiology and time course of frozen shoulder is still
unclear. Few prospective studies documenting the duration of
symptoms and response to treatment are available. A prospective
study of arthroscopic capsular release for adhesive capsulitis
recalcitrant to conservative therapy was undertaken to determine
its efficacy and effect on the time course of the disease process.
Methods: Twenty shoulders (13 female, 7 male) with
an average (avg.) age of 51 (29-72) were evaluated at an avg.
follow-up of 31 months (14-47) after arthroscopic capsular release.
Etiology of shoulder stiffness was idiopathic in 13, traumatic
in 5, and post-surgical in 2. Patients had been symptomatic
for an avg. of 5 months prior to our initial evaluation, and had
been involved in therapy of some type for an avg. of 3 months.
All patients had pain, limitation of motion, functional limitation,
and sleep disturbance. The avg. pre-op values for American Shoulder
Elbow Surgeons (ASES) Score = 43, Simple Shoulder Test (SST)
= 3.2, and Visual Analog Pain Score (VAS) = 6.8. Active motion
averaged: forward elevation (FE) = 80, ER at side = 14, and
IR = buttock. All cases had arthroscopy, complete synovial debridement,
capsular release off the glenoid rim, and rotator interval release
under long-acting scalene block. A 23 hour admission with immediate
physiotherapy was standard.
Results: The avg. post-op active motion was: FE = 164
(+84), avg. ER = 55 (+41), and avg. IR = T11 (+7 segments). These
gains in motion were all statistically significant improvements
(p < 0.05). Post-operatively the avg. ASES Score improved
to 94, and the avg. SST improved to 10.8. Pain relief was the
most dramatic with a decrease in the avg. VAS from 6.8 to 0.2.
These improvements in the scoring parameters were all statistically
significant (p < 0.05). The avg. time to achieve painless
final motion was 3 months (3 wks. - 5 mos.). The avg. duration
of formal therapy was 6 wks. (1-4 months), but patients continued
on a home program for 4 months. There were no recurrences and
The natural history of painful, symptomatic frozen shoulder is
unclear. Controversy exists in the literature over the time course
of the disease, optimal treatment and response to treatment. This
prospective evaluation revealed substantial improvements in motion,
function, and pain in patients undergoing arthroscopic treatment
for frozen shoulder recalcitrant to conservative therapy. The
technique allowed assessment and treatment of frozen shoulder
pathology, and restored pain free function and achieved final
motion within an average of 3 months.
"Descriptive term to indicate a clinical syndrome wherein
the patient has a restricted range of active and passive glenohumeral
motion for which no other cause can be identified."
"However, when specifics as to motion, pathology, and recovery
are sought, there seems to be few answers on review of the literature."
Murnaghan "Frozen Shoulder"
from The Shoulder
- Treatment Options
- Home Therapy 6. Nerve Blocks
- Formal Physical Therapy 7. Closed Manipulation
- Systemic Steroids 8. Open Release
- Intra-Articular Steroids 9. Arthroscopic Release
- Distension Brisement
- Our Definition of Recalcitrant Frozen Shoulder
- Limitation of active and passive range of motion
- Sleep disturbance
- Pain and dysfunction
- At least 6 weeks of therapy without progress
- Symptoms for at least 3 months
- Purpose of Prospective Evaluation
- Determine efficacy of technique to restore motion, function,
and relieve pain
- Document pathology
- Effect on time course of disease process
- How quickly did intervention succeed
- How soon was therapy unnecessary
IV. Operative Technique
- Scalene Block 6. Interval Release
- Beach Chair Position 7. Capsular Release
- Assess Motion 8. Final Motion with Manipulation
- Arthroscopy 9. Bursoscopy
- Synovial Debridement 10. Concominant Conditions
- A/C Pain
V. Technical Tips
Technically Challenging - Be Patient
- Pump for visualization
- Bipolar - control led tissue penetration
- Cautery, cuts, ablates
- Stiff to get into tight spots
- Gelatinous Synovium - debridement with suction shaver
- Mediator of pain?
- Fibrosis of capsule?
- Capsular release
- Release anterior superior capsule and interval first
- Allows mobility to proceed with release inferiorly
- Release at capsulo-labral junction
- Creating a circumferential "sleeve" of capsule released
- The goal is balanced release
- Final motion: gentle lysis of few remaining tethers with
forward elevation, external rotation, internal rotation, abduction
- Evaluate bursa: inflammation, fibrosis
- Concominant conditions
- Bony impingement
- Acromioclavicular arthralgia
- Rotator Cuff status post release
- Variable involvement: etiology dependent
VI. Operative Findings
- Gelatinous synovium
- Long Head of Biceps
- Anterior Inferior capsule
- Posterior Superior recess
- Capsular contracture and thickening
- Humeral head opposed to glenoid
- Glenohumeral ligaments now a "wall" of collagen
- Axillary pouch contracted and with proliferative synovium
- Coracohumeral ligament and interval thickened
- No intra-articular or surface adhesions
- Variable bursal involvement
- Approximately 1/3 of this series involved
- May be etiology dependent
Regardless of etiology all patients manifested extremely
similar synovial and capsular pathology.
- Long acting scalene block
- 23 Hour observation stay
- Allows immediate pain free physical therapy
- Outpatient Physical Therapy
- Three times per week
- Home exercise TID
- Emphasize motion in FE, ER, IR. Motion first, strength later.
VIII. Results of this SERIES
- Table I Assessment Parameters for
Arthroscopic Capsular Release of Frozen Shoulder
(Mean Score Value)
100 Point Scale
|43 (range 17-70)
||94 (range 80-100)|
12 Point Scale
|3.2 (range 0-8)
||10.8 (range 8-12)|
10 Point Scale
|6.8 (range 4-9)
||0.2 (range 0-1)|
All improvements were significant with p < 0.05
using pair-wise t-test comparison analysis.
- Table II
Average Active Motion
|IR||Buttock||(Troch - S1)
IX. Time Course
- Average time to final pain free motion 3 Months (3 weeks
- 5 months)
- Average time in formal physical therapy 6 weeks (1 - 4 months)
Etiology did not effect outcome.
X. Potential Advantages
- Synovial debridement
- Document pathology
- Controlled, balanced capsular and interval release
- Concominant pathology
- Less traumatic manipulation
- Less hemorrhage
XI. Potential Disadvantages
- Technically challenging
- Surgical intervention
XII. Conclusions of this study (at this time)
- Not all frozen shoulders respond to conservative treatment
- Frozen shoulder may represent a common pathologic expression
to a variety of etiologic factors
- This capsular release technique allows for:
- Assessment of pathology
- Balanced release of capsular contracture
- Less traumatic, less bloody manipulation
- Treatment of concomitant conditions
- Provided dramatic pain relief and restoration of function
and motion within any average of three months
- The natural history of this not well understood, stubborn
condition was possibly shortened
- Need for consistent criteria for
- Staging of severity
- Categorization of etiology
to facilitate information exchange
- Current series now 32 patients:
No change in outcome parameters
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