PROSPECTIVE EVALUATION OF ARTHROSCOPIC
CAPSULAR RELEASE FOR RECALCITRANT FROZEN SHOULDER

San Diego Shoulder Institute 1997
Gregory P. Nicholson, MD
Clinical Assistant Professor of Orthopaedics
Indiana University
Orthopaedics Indianapolis, Inc.

ABSTRACT

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 no complications.

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.

Frozen Shoulder:

"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

  1. Treatment Options
    1. Home Therapy 6. Nerve Blocks
    2. Formal Physical Therapy 7. Closed Manipulation
    3. Systemic Steroids 8. Open Release
    4. Intra-Articular Steroids 9. Arthroscopic Release
    5. Distension Brisement

  1. Our Definition of Recalcitrant Frozen Shoulder
    1. Limitation of active and passive range of motion
    2. Sleep disturbance
    3. Pain and dysfunction
    4. At least 6 weeks of therapy without progress
    5. Symptoms for at least 3 months

  1. Purpose of Prospective Evaluation
    1. Determine efficacy of technique to restore motion, function, and relieve pain
    2. Document pathology
    3. Effect on time course of disease process
      1. How quickly did intervention succeed
      2. How soon was therapy unnecessary

IV. Operative Technique

  1. Scalene Block 6. Interval Release
  2. Beach Chair Position 7. Capsular Release
  3. Assess Motion 8. Final Motion with Manipulation
  4. Arthroscopy 9. Bursoscopy
  5. Synovial Debridement 10. Concominant Conditions
    1. Impingement
    2. A/C Pain

V. Technical Tips

Technically Challenging - Be Patient

  1. Pump for visualization
  2. Arthrowand
    1. Bipolar - control led tissue penetration
    2. Cautery, cuts, ablates
    1. Stiff to get into tight spots
  3. Gelatinous Synovium - debridement with suction shaver
    1. Mediator of pain?
    2. Fibrosis of capsule?
  4. Capsular release
    1. Release anterior superior capsule and interval first
    2. Allows mobility to proceed with release inferiorly
    3. Release at capsulo-labral junction
    4. Creating a circumferential "sleeve" of capsule released from glenoid
    5. The goal is balanced release
    6. Final motion: gentle lysis of few remaining tethers with forward elevation, external rotation, internal rotation, abduction
  5. Bursoscopy
    1. Evaluate bursa: inflammation, fibrosis
    2. Concominant conditions
      • Bony impingement
      • Acromioclavicular arthralgia
      • Rotator Cuff status post release
    3. Variable involvement: etiology dependent

VI. Operative Findings

  1. Gelatinous synovium
    1. Long Head of Biceps
    2. Anterior Inferior capsule
    3. Posterior Superior recess
  2. Capsular contracture and thickening
    1. Humeral head opposed to glenoid
    2. Glenohumeral ligaments now a "wall" of collagen
    3. Axillary pouch contracted and with proliferative synovium
    4. Coracohumeral ligament and interval thickened
    5. No intra-articular or surface adhesions
  3. Variable bursal involvement
    1. Approximately 1/3 of this series involved
    2. May be etiology dependent

Regardless of etiology all patients manifested extremely similar synovial and capsular pathology.

VII. Aftercare

  1. Long acting scalene block
    1. 23 Hour observation stay
      1. Allows immediate pain free physical therapy
  2. Outpatient Physical Therapy
    1. Three times per week
    2. Home exercise TID
    3. NSAIDS
    4. Emphasize motion in FE, ER, IR. Motion first, strength later.

VIII. Results of this SERIES

  1. Table I Assessment Parameters for

Arthroscopic Capsular Release of Frozen Shoulder

(Mean Score Value)
Pre-Operative Post-Operative
ASES Score

100 Point Scale

43 (range 17-70) 94 (range 80-100)
SST

12 Point Scale

3.2 (range 0-8) 10.8 (range 8-12)
VAS

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.
  1. Table II

Average Active Motion
Pre-Op Post-Op
FE80(40-160) 164(120-180)
ER14(-10 -40) 55(30-80)
IRButtock(Troch - S1) T11(S1-T5)

IX. Time Course

  1. Average time to final pain free motion 3 Months (3 weeks - 5 months)
  2. Average time in formal physical therapy 6 weeks (1 - 4 months)

Etiology did not effect outcome.

X. Potential Advantages

  1. Synovial debridement
  2. Document pathology
  3. Controlled, balanced capsular and interval release
  4. Concominant pathology
  5. Less traumatic manipulation
  6. Less hemorrhage

XI. Potential Disadvantages

  1. Technically challenging
  2. Surgical intervention
  3. Cost

XII. Conclusions of this study (at this time)

  1. Not all frozen shoulders respond to conservative treatment and time
  2. Frozen shoulder may represent a common pathologic expression to a variety of etiologic factors
  3. This capsular release technique allows for:
    1. Assessment of pathology
    2. Balanced release of capsular contracture
    3. Less traumatic, less bloody manipulation
    4. Treatment of concomitant conditions
  1. Provided dramatic pain relief and restoration of function and motion within any average of three months
  2. The natural history of this not well understood, stubborn condition was possibly shortened
  3. Need for consistent criteria for
    1. Definition
    2. Staging of severity
    3. Categorization of etiology
    4. Chronicity

to facilitate information exchange

XIII. Update

  1. Current series now 32 patients:

Idiopathic 18

Trauma 6

Post-Op 6

No change in outcome parameters



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