Arthroscopic release of adhesive capsulitis

Improved range of motion after manipulation under anesthesia versus physiotherapy for stage two frozen shoulder: a randomized controlled trial

Background

Frozen shoulder (FS) is a common cause of shoulder pain and stiffness. Conservative treatment is sufficient for the majority of patients with long-term recovery of shoulder function. Manipulation under anesthesia (MUA) is known as a well-established treatment option if conservative treatment fails. It is unknown whether MUA does indeed shorten the duration of symptoms or leads to a superior outcome compared to conservative treatment. The objective of the current trial is to evaluate the effectiveness of MUA followed by a physiotherapy (PT) program compared to a PT program alone in patients with stage 2 FS.

Methods

A prospective, single-center randomized controlled trial was performed. Patients between 18 and 70 years old with stage 2 FS were deemed eligible if an initial course of conservative treatment consisting of PT and intra-articular corticosteroid infiltration was considered unsatisfactory. Patients were randomized, and data was collected with an online data management platform (CASTOR). MUA was performed by a single surgeon under interscalene block, and intensive PT treatment protocol was started within 4 hours after MUA. In the PT group, patients were referred to instructed physiotherapist, and treatment was guided by tissue irritability. The primary outcome was the Shoulder Pain and Disability Index (SPADI) score. Secondary outcomes were pain, range of motion (ROM), Oxford Shoulder Score, quality of life, and ability to work.

Results

In total, 82 patients were included, 42 in the PT group and 40 in the MUA group. There was a significant improvement in SPADI, Oxford Shoulder Score, pain, ROM, and quality of life in both groups at 1-year follow-up. SPADI scores at three months were significantly improved in favor of MUA. MUA showed a significantly bigger increase in anteflexion and abduction compared to PT at all points of follow-up. No significant differences between both groups were found for all other parameters. No fractures, dislocations, or brachial plexus injuries occurred in this trial.

Conclusion

MUA in stage 2 FS can be considered safe and results in a faster recovery of ROM and improved functional outcome, measured with SPADI scores, compared to PT alone in the short term. After 1 year, except for slightly better ROM scores for MUA, the result of MUA is equal to PT.

The S2e Guideline on Shoulder Stiffness

The clinical picture of "frozen shoulder" is still poorly understood. In order to present the current state of knowledge on aetiology, diagnosis, and treatment, and to provide recommendations for the professional groups involved, a working group was formed by the DGOU and the DVSE to create a German language, evidence-based guideline, which was published in 2022 by the AWMF. The following summarises the development and the most important results.

Effect of surgical timing in outcomes in Hispanic patients after arthroscopic capsular release in diabetic and idiopathic adhesive capsulitis

Background

Adhesive capsulitis of the shoulder is a painful and debilitating condition. While the majority of patients improve with conservative treatment, those who do not improve require surgery such as arthroscopic capsular release (ACR) for symptom relief. However, there is limited literature regarding the optimal timeframe to proceed with surgery.

Methods

This retrospective cohort evaluated 134 Hispanic patients who underwent ACR for the treatment of adhesive capsulitis. Patients were divided into an early and a delayed treatment group that included all patients. Patients were then divided into diabetic and idiopathic subgroups. Early vs. delayed treatment outcomes (forward flexion, external rotation, Visual Analog Scale pain scores, and recurrence requiring reoperation) were assessed in all patients and in each subgroup.

Results

No statistically significant differences were found between the early and delayed release groups in postoperative forward flexion, external rotation, pain intensity scores, and recurrence requiring reoperation at 1 month, 3 months, and 6 months of follow-up in the all-patient group. In the idiopathic frozen shoulder subgroup, no significant differences were observed in postoperative forward flexion, external rotation, pain intensity scores, and recurrence requiring reoperation at 1 month, 3 months, and 6 months of follow-up. In the diabetic frozen shoulder subgroup, no significant differences were observed in postoperative forward flexion, external rotation, pain intensity scores, and recurrence requiring reoperation at 1 month and 6 months of follow-up visits.

Conclusions

There was no difference in outcomes following ACR for adhesive capsulitis between patients who underwent early release vs. delayed release. There were no significant differences in outcomes between early and delayed arthroscopic release in patients with a history of diabetes mellitus.

Adhesive Capsulitis

Adhesive capsulitis, colloquially known as "frozen shoulder," is a relatively common disorder, affecting approximately 2% to 5% of the general population. The incidence may be higher as the condition can be relatively mild and self-limited and thus many patients who experience it may never present for treatment. It involves a pathologic process of gradual fibrosis of the glenohumeral joint that leads to limited active and passive range of motion, contracture of the joint capsule, and shoulder pain.

Frozen shoulder

Frozen shoulder is a common debilitating disorder characterized by shoulder pain and progressive loss of shoulder movement. Frozen shoulder is frequently associated with other systemic conditions or occurs following periods of immobilization, and has a protracted clinical course, which can be frustrating for patients as well as health-care professionals. Frozen shoulder is characterized by fibroproliferative tissue fibrosis, whereby fibroblasts, producing predominantly type I and type III collagen, transform into myofibroblasts (a smooth muscle phenotype), which is accompanied by inflammation, neoangiogenesis and neoinnervation, resulting in shoulder capsular fibrotic contractures and the associated clinical stiffness. Diagnosis is heavily based on physical examination and can be difficult depending on the stage of disease or if concomitant shoulder pathology is present. Management consists of physiotherapy, therapeutic modalities such as steroid injections, anti-inflammatory medications, hydrodilation and surgical interventions; however, their effectiveness remains unclear. Facilitating translational science should aid in development of novel therapies to improve outcomes among individuals with this debilitating condition.

Post-surgical physiotherapy in frozen shoulder: A review

Despite its prevalence, the optimal management of frozen shoulder is unclear. A range of conservative measures are often undertaken with varying degrees of success. In cases of severe and persistent symptoms, release procedures which could include any combination of manipulation under anaesthetic, arthroscopic capsular release or hydrodilatation are frequently offered, none of which has been shown to offer superior outcome over the others. When surgical release is performed a period of rehabilitation is normally recommended but no best practice guidelines exist resulting in considerable variations in practice which may or may not directly affect patient outcome. During this narrative review, we hypothesise that these differing responses to treatment (both conservative and surgical options) are potentially the result of different causal mechanisms for frozen shoulder and may also suggest that post-release rehabilitation may need to take this into account.

The correlation between shoulder pathologies and sleep disorders

OBJECTIVE

To assess and characterize the correlation between shoulder pathologies and sleep disturbances.

METHODS

Participants enrolled into this case-control study were divided into two groups: patients with an established clinical diagnosis of active shoulder pathology (study group), and patients without any shoulder pathology (control group). All patients completed the Insomnia Severity Index (ISI) questionnaire, in addition to questions related to participant demographics, health status, medication, and other known insomnia risk factors.

RESULTS

A total of 98 patients were included (46 in the study group and 52 controls). Mean ISI score was significantly higher (indicating more severe insomnia) in the study group versus control group (t[96] = -9.67), even after correcting for confounders (t[53.1] = -8.61). Additionally, in patients with shoulder pathology, those with comorbidities experienced more sleep disturbances than those without comorbidities (β = 0.36). Lastly, the shoulder pathology group was at a higher risk of having sleep disturbances compared with controls (relative risk 4.86, 95% confidence interval 2.24, 10.55).

CONCLUSIONS

Sleep disturbances are more common among patients with shoulder pathologies. Comorbidities and a shorter duration of pathology may predict more severe sleep disturbances.

Arthroscopic release in adhesive capsulitis of the shoulder: a retrospective study with 2 to 6 years of follow-up

Background

This study aimed to evaluate the response rate to arthroscopic release treatment in adhesive capsulitis of the shoulder (ACS) for patients with refractory to conservative treatment.

Methods

In this retrospective study, 51 patients (age mean, 49.1±5.6 years) with unilateral adherent capsule underwent arthroscopic releasing surgery for the shoulder capsule. Etiologies of the ACS in 30 patients were idiopathic: 10 patients were affected after surgery and 11 patients following trauma. The patients were evaluated in terms of shoulder function, satisfaction rate, pain intensity, and joint range of motion (ROM) based on a Constant score, a Simple Shoulder Test, the visual analog scale, and four movements, respectively.

Results

The mean Constant score before surgery was 48.2±3.5 and reached 74.4±6 and 77.0±6.3 at 6 months and the final follow-up, respectively (p<0.001). The mean scores of pain intensity, a Simple Shoulder Test, and ROM showed significant improvement at all follow-ups (p<0.001). Sex, age, and diabetes did not have any significant effect on patient recovery. However, patients who experienced ACS after surgery had poorer results than others at all follow-up points.

Conclusions

Arthroscopic releasing surgery of the shoulder in patients with ACS refractory to conservative treatment produces rare complications and an effective injury response. It seems that patients suffering ACS following surgery have a weaker response to the treatment.

Clinical Management of Arthrofibrosis: State of the Art and Therapeutic Outlook

* Arthrofibrosis is a pathologic condition that is characterized by excessive periarticular scar-tissue formation. Arthrofibrosis may occur secondary to injury, surgical trauma, hemarthrosis, or infection, or it may occur idiopathically.* The pathogenesis of arthrofibrosis is incompletely understood but involves the dysregulation of normal reparative pathways, with transforming growth factor-beta (TGF-[beta]) as a principal mediator.* Current treatment options for arthrofibrosis primarily involve physiotherapy, operative manipulation, and surgical debridement, all with imperfect results.* Currently, there are no pharmacologic treatment options for arthrofibrosis. This has prompted increased investigational interest in the development of antifibrotic intra-articular therapies.

Clinical outcomes of arthroscopic pan-capsular release with or without entire coracohumeral ligament release for patients with frozen shoulder

Background

We aimed to retrospectively determine the effects of arthroscopic pan-capsular release with or without entire coracohumeral ligament (CHL) release and diabetes mellitus (DM) in patients with frozen shoulder (FS).

Methods

The study included 34 patients (20 male and 14 female patients) who underwent arthroscopic pan-capsular release without entire CHL release (group 1) and 26 patients (6 male and 20 female patients) who underwent entire CHL release for FS (group 2). Patients with a minimum of 12 months of follow-up were included, and range of motion (ROM) and the shoulder rating scale of the University of California at Los Angeles (UCLA) scoring system were evaluated.

Results

In group 2, external rotation and hand-behind-the-back (HBB) ROMs were significantly increased compared with group 1 at the final follow-up (external rotation, 53.1° ± 15.2° vs. 41.3° ± 20.5° [P = .044]; HBB level, T6 [interquartile range, T5-T9] vs. T11 [interquartile range, T8-L4] [P < .001]). Total UCLA scores and UCLA scores for pain (9.2 ± 1.5 vs. 10.0, P = .003), function (8.5 ± 1.4 vs. 10.0, P < .001), and active forward flexion (4.6 ± 0.6 vs. 4.9 ± 0.2, P < .011) were significantly greater in group 2 at the final follow-up. Patients without DM tended to have greater recovery of forward flexion and HBB ROMs and better total, pain, and function UCLA scores compared with those with DM. In group 2, there were no significant differences in ROMs and UCLA scores between the patients with DM and those without DM.

Conclusion

Arthroscopic entire CHL release is an essential treatment option for FS patients to regain ROMs and function and to reduce pain.

Convalescence after arthroscopic capsular release in frozen shoulder

Introduction

To determine if arthroscopic capsular release (ACR) shortens duration of illness in frozen shoulder (FS) in comparison to the depicted natural course of 30.1 months and to identify risk factors for persisting complaints.

Materials and methods

A consecutive group of 71 shoulders in 70 patients with mean age of 54 (37-74) years with FS were treated by ACR and enrolled in our study with follow-up investigation at 1, 3, 6 and finally 32 (19-49) months postoperatively.

Results

Patients had complaints for 8 (3-60) months preoperatively. 8 shoulders (11%) were classified as primary and 63 (89%) shoulders as secondary type FS. 6 patients were lost to follow-up. Relative Constant score increased significantly from 31% before surgery to 103% at last follow-up. 55 patients (85%) achieved subjective remission after 7 (1.5-18) months, postoperatively. Overall duration of illness was 16 (5-72) months. All patients with primary FS achieved remission and all patients with persisting symptoms had secondary FS.

Conclusion

Duration of illness was shortened by more than 12 months compared with the natural time course defined by Reeves. Secondary FS, especially ac-joint pathologies, previous surgery, diabetes and more than 12 months preoperative illness duration were identified as risk factors for persisting complaints. Hypothesis of worse outcome in secondary FS was confirmed.

Outcomes of Arthroscopic Capsular Release in the Beach-Chair Versus Lateral Decubitus Position: A Systematic Review

Background:

Arthroscopic capsular release (ACR) for the treatment of adhesive capsulitis of the shoulder can be performed in either the beach-chair (BC) or lateral decubitus (LD) position.

Purpose:

To determine the clinical outcomes and recurrence rates after ACR in the BC versus LD position.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed by searching PubMed, Embase, and the Cochrane Library databases for studies reporting clinical outcomes of patients undergoing ACR in either the BC or LD position. All English-language literature from 1990 through 2017 reporting on clinical outcomes after ACR with a minimum 3-month follow-up were reviewed by 2 independent reviewers. Recurrence rates, range of motion (ROM) results, and patient-reported outcome (PRO) scores were collected. Study methodological quality was evaluated using the modified Coleman Methodology Score (MCMS).

Results:

A total of 30 studies (3 level 1 evidence, 2 level 2 evidence, 4 level 3 evidence, 21 level 4 evidence) including 665 shoulders undergoing ACR in the BC position (38.1% male; mean age, 52.0 ± 3.9 years; mean follow-up, 35.4 ± 18.4 months) and 603 shoulders in the LD position (41.8% male; mean age, 53.0 ± 2.3 years; mean follow-up, 37.2 ± 16.8 months) were included. There were no significant differences in overall mean recurrence rates between groups (BC, 2.5%; LD, 2.4%; P = .81) or in any PRO scores between groups (P > .05). There were no significant differences in improvement in ROM between groups, including external rotation at the side (BC, 36.4°; LD, 42.8°; P = .91), forward flexion (BC, 64.4°; LD, 79.3°; P = .73), abduction (BC, 77.8°; LD, 81.5°; P = .82), or internal rotation in 90° of abduction (BC, 40.8°; LD, 45.5°; P = .70). Significantly more patients in the BC group (91.6%) underwent concomitant manipulation than in the LD group (63%) (P < .0001). There were significantly more patients with diabetes in the LD group (22.4%) versus the BC group (9.6%) (P < .0001).

Conclusion:

Low rates of recurrent shoulder stiffness and excellent improvements in ROM can be achieved after ACR in either the LD or BC position. Concomitant manipulation under anesthesia is performed more frequently in the BC position compared with the LD position.

Arthroscopic release for frozen shoulder: Does the timing of intervention and diabetes affect outcome?

Purpose

To evaluate the effect of timing of arthroscopic release and manipulation under anesthesia for frozen shoulder in patients with diabetes and non-diabetes.

Methods

One hundred and twenty-seven patients with frozen shoulder were included in the study. Each patient was assigned to: 1) one of four groups according to the duration from symptom onset to surgery (group A: ≤3 months; group B: 3–6 months; group C: 6–12 months; group D: >12 months), 2) diabetic or nondiabetic group. The outcomes were measured by shoulder range of motion (ROM), Disabilities of the Arm, Shoulder, and Hand (DASH) score, American Shoulder and Elbow Surgeons (ASES) Shoulder score, the period of pain relief, overall duration of disease, and satisfaction.

Results

All the patients got great improvement in shoulder ROM (P < .0001) after arthroscopic surgery, but there was no statistical difference in the pre-operative and post-operative shoulder ROM between the four groups and between diabetic and nondiabetic groups. The overall duration of disease was mean 55.4~68.7 weeks, which demonstrated much shorter disease course compared with nature course.

Improvement were also seen in shoulder ROM at one week to one month, and the period of total pain relief was at a mean time of 3.7 to 3.8 weeks. There were higher ASES Shoulder score in group B than in group C (P = 0.02) and higher DASH score in diabetic group in short term follow-up.

Conclusions

Arthroscopic release provides effective and rapid improvements to shoulder motion and function, unrelated to the timing of surgery, in patients with frozen shoulder. The diabetic patients do not have functional outcomes as good as the nondiabetic patient at short-term follow-up.

Factors Affecting the Outcomes of Arthroscopic Capsular Release for Idiopathic Adhesive Capsulitis

Background:

Arthroscopic capsular release has been shown to provide excellent short- and long-term outcomes in patients with idiopathic frozen shoulder. Some surgeons delay surgery in the belief that operating in the early stages of adhesive capsulitis results in a poorer prognosis. However, it is unclear which factors, particularly the stage of the disorder, affect the surgical outcome of this procedure.

Hypothesis:

Patients who undergo capsular release during the early symptomatic stage of idiopathic adhesive capsulitis would have less improvement in range of motion compared with those who undergo surgery at a later stage.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A total of 189 shoulders with idiopathic adhesive capsulitis that underwent arthroscopic capsular release were evaluated. All patients completed a L’Insalata questionnaire and had their range of motion and strength tested prior to surgery and at 1, 6, and 12 weeks and 6 months post–capsular release. Post hoc, patients were grouped by whether they had symptoms lasting <10 months (shorter symptoms group; n = 131) or ≥10 months (longer symptoms group; n = 38). Multiple linear regression analysis was performed to determine which preoperative factors were independently associated with a favorable outcome.

Results:

Patients in the shorter symptoms group were more restricted prior to surgery than were those in the longer symptoms group (mean ± SEM: external rotation, 17° ± 2° vs 27° ± 4° [P = .04]; abduction, 78° ± 3° vs 92° ± 6° [P = .04]; internal rotation, S3 ± 1 vs S1 ± 1 [P = .03]). The shorter symptoms group had greater postoperative improvement in internal rotation (from S3 ± 1 preoperatively to T12 ± 1 vertebral levels) compared with the longer symptoms cohort (from S1 ± 1 to L2 ± 1) (P = .02).

Conclusion:

Patients with a frozen shoulder and a duration of symptoms <10 months made greater improvements in internal rotation and had similar final results for flexion, abduction, and external rotation following arthroscopic capsular release when compared with patients who had a longer duration of symptoms, so there is no reason to delay surgery.

Comparison of outcomes following arthroscopic capsular release for idiopathic, diabetic and secondary shoulder adhesive capsulitis: A Systematic Review

INTRODUCTION

Arthroscopic capsular release for adhesive capsulitis of the shoulder is a treatment option. The present study aimed to investigate the clinical outcomes following arthroscopic capsular release among idiopathic, diabetic and secondary adhesive capsulitis.

HYPOTHESIS

Different aetiological groups yield variable outcomes following arthroscopic capsular release.

MATERIALS AND METHODS

A literature search was performed using MEDLINE, EMBASE, CINAHL and the Cochrane Database in April 2017. Comparative studies that reported range of motion or functional outcomes following arthroscopic capsular release in patients with adhesive capsulitis were included. A systematic review of the studies was conducted following the PRISMA guidelines.

RESULTS

Six studies met the eligibility criteria. The overall population included 463 patients; 203 idiopathic, 61 diabetic and 199 secondary cases. Of four studies comparing idiopathic and diabetic patients, three reported significantly worse range of movement and function in the diabetic group at various follow up points. No significant difference in function and motion was reported between the idiopathic and secondary groups. Recurrent pain was highest in diabetic patients (26%) compared to idiopathic groups (0%) and the secondary group had a higher rate of revision surgery when compared to the idiopathic group (8.1% vs. 2.4%) DISCUSSION: Arthroscopic capsular release has a high success rate regardless of the underlying aetiology. However, diabetic patients are reported to have more residual pain, reduced motion and inferior function compared to idiopathic cases. The rate of revision capsular release is higher among patients with post-surgical adhesive capsulitis when compared to idiopathic cases.

LEVEL OF EVIDENCE

IV, systematic review.

Chronic adhesive capsulitis (Frozen shoulder): Comparative outcomes of treatment in patients with diabetes and obesity

Despite an abundance of information about frozen shoulders, larger prospective studies on the outcomes of intervention are limited. The purpose of our study was to assess the functional and clinical outcomes with a further aim to analyse the independent effects of diabetes and BMI. A prospective cohort study of all 210 primary frozen shoulders over a 12 - month period was analysed. The Oxford Shoulder score was used to assess functional outcomes before and after interventions. Further demographic data was collected. The effect of interventions including steroid injections, arthroscopic release and manipulation was analysed. 54% patients responded to intra-articular steroid injections. Patients with recalcitrant symptoms (46%) had an arthroscopic release. Failure of initial injection therapy was higher in diabetes [70%] than non-diabetes [44%] patients. After surgery, the Oxford shoulder score improved from a mean of 41.6 to 27.2 at 3 months [p < 0.05]. 85% of patients had satisfactory resolution of symptoms with external rotation improving from a mean of 10.5 ° to 61.3 ° [p < 0.05]. There was no statistical significance in outcomes of patients with BMI of >_30 and <30. Understanding the outcomes of surgical intervention is important in counselling patients with frozen shoulder. We found that patients with diabetes had higher failure rates of conservative management and increasing needs for multiple surgery but complete resolution of symptoms can still be achieved and that BMI status in isolation was not a predictor of poorer outcome.

Arthrofibrosis and large joint scarring

Large joint arthrofibrosis and scarring, involving the shoulder, elbow, hip, and knee, can result in the loss of function and immobility. The pathway of joint contracture formation is still being elucidated and is due to aberrations in collagen synthesis and misorientation of collagen fibrils. Novel antibodies are being developed to prevent arthrofibrosis, and current treatment methods for arthrofibrosis include medical, physical, and surgical treatments. This article describes the biology of joint contracture formation, along with current and future pharmacologic, biologic, and medical interventions.

Clinical Outcome after Arthroscopic Capsular Release for Adhesive Capsulitis of the Shoulder

Background

This study was undertaken to evaluate the outcome of the arthroscopic capsular release for adhesive capsulitis of the shoulder.

Methods

This study retrospectively investigated thirty shoulders in 29 patients who presented with recalcitrant adhesive capsulitis and underwent arthroscopic treatments. Other than typical findings of adhesive capsulitis, combined pathologies in the glenohumeral joint and subacromial space were evaluated by arthroscopy. Clinical evaluations were performed using the Constant’s score and ranges of motion (ROM) at preoperative, 6 months postoperatively and at the final follow-up.

Results

Our study included 17 women and 12 men with a mean age of 53.8 years (range, 34–74). Mean follow-up duration was 24 months (range, 12–40 months). Assessment of combined pathologies revealed that partial rotator cuff tear of less than 25% thickness, was most common (overall 83.3%; with bursal 57% and articular 23%). Subacromial synovitis and adhesion were also frequent (53.3%). The Constant score and ranges of motion significantly improved at the final follow-up, compared with preoperative levels. However, clinical results at 6 months postoperatively were found to be significantly inferior to those observed at the final follow-up (p≤0.001 for all factors). Functional impairment was the major complaint in 59.3% patients at the 6 months follow-up.

Conclusions

Although arthroscopic capsular release yielded favorable outcome at the mean 24 months follow-up, pain and motion limitations at 6-month postoperatively persisted in more than 50% of our patients. While combined pathologies were commonly encountered during arthroscopy, although their effects on surgical outcome in adhesive capsulitis remains unclear in this study.

The effectiveness of conservative and surgical treatment for shoulder stiffness: a systematic review of current literature

INTRODUCTION

Currently, no therapeutic intervention is universally accepted, and the most effective management for restoring motion and diminishing pain in patients with shoulder stiffness has yet to be defined. This systematic review analyses outcomes of conservative and surgical interventions to treat shoulder stiffness.

SOURCE OF DATA

A systematic review of literature according to the PRISMA guidelines was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, Ovid and Google Scholar databases using various combinations of the keywords 'shoulder', 'shoulder stiffness', 'stiff shoulder', 'conservative', since inception of databases to June 2018 was performed.

AREAS OF AGREEMENT

Shoulder stiffness could be treated with conservative means including nonsteroidal anti-inflammatory medications, corticosteroid injections, or transcutaneous electrical nerve stimulation, manipulation under anaesthesia, and arthroscopic capsular release.

AREAS OF CONTROVERSY

No therapeutic intervention is universally accepted, and the most effective management to restore motion and diminish pain in patients with shoulder stiffness has yet to be defined.

GROWING POINTS

The rate of failure after treatment for stiff shoulder is higher in the surgical group than in the conservative group.

AREAS TIMELY FOR DEVELOPING RESEARCH

There is insufficient evidence to establish whether surgical or conservative management is the best choice to manage shoulder stiffness. Prospective, randomized studies are needed to establish whether surgical or conservative management produce a clinically relevant difference in functional outcome.

Effect of nonoperative concomitant intraarticular pathologies on the outcome of arthroscopic capsular release for adhesive capsulitis of the shoulder

OBJECTIVE

The aim of this study was to investigate whether coexistent intraarticular lesions are negative prognostic factors for the results of arthroscopic capsular release in frozen shoulder patients.

METHODS

Seventy-two patients who met inclusion criteria and underwent arthroscopic capsular release between March 2011 and August 2015 for the frozen shoulder were retrospectively evaluated. The patients were divided into two groups according to existence of concomitant intraarticular pathologies detected during arthroscopy. Preoperative and postoperative functional results were assessed with Constant score and shoulder ranges of motion; and the amount of pain was evaluated using visual analog scale (VAS).

RESULTS

Group I consisted of 46 patients (mean age 47.2 years and mean follow-up 26 months) without concomitant shoulder pathologies and group II consisted of 26 patients (mean age 48.6 years and mean follow-up 15 months) with coexistent lesions (SLAP lesions, n = 8; SLAP and partial rupture of the RC, n = 4; SLAP, partial rupture of RC and impingement, n = 10; SLAP and impingement, n = 2; and AC arthritis and impingement, n = 2). Preoperatively, the mean ranges of forward flexion (p = 0.221), abduction (p = 0.065), internal rotation (p = 0.564), Constant (p = 0.148) and VAS (p = 0.365) scores were similar between the groups. After a minimum 12 months of follow-up, all patients significantly improved but no statistically significant difference was detected in the mean ranges of forward flexion (152 vs 150; p = 0.902), abduction (137 vs 129; p = 0.095), external rotation (45 vs 40; p = 0.866), internal rotation (5 vs 5 point; p = 0.474), Constant (82 vs 82.3; p = 0.685) and VAS (1.2 vs 1.2; p = 0.634) scores between the groups.

CONCLUSION

The presence of concomitant shoulder pathologies does not appear to affect the clinical outcomes in patients undergoing arthroscopic capsular release for frozen shoulder.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

MID-LONG TERM RESULTS OF MANIPULATION AND ARTHROSCOPIC RELEASE IN FROZEN SHOULDER

OBJECTIVE

Surgical treatment options should be discussed in cases of frozen shoulder, which is usually treated in a conservative manner. In this study, we evaluated the efficacy of manipulation and arthroscopic release in cases of frozen shoulder which resisted conservative treatment.

METHODS

A total of 32 patients who underwent manipulation and arthroscopic capsular release in 34 shoulders were included in the study. The average follow-up period was 49.5 months (range: 24-90 months). No reason for onset could be found in 8 (25%) patients, who were classified as primary frozen shoulder; twenty-four (75%) patients were classified as secondary frozen shoulder due to underlying pathologies. The average pre-operative complaint period was 11 months (range: 3-24 months). After arthroscopic examination, manipulation was performed first, followed by arthroscopic capsular release. The range of motion in both shoulders was compared before the procedure and in the last follow-up visit. Constant and Oxford classifications were used to assess functional results, and the results were assessed statistically.

RESULTS

Patient values for passive elevation, abduction, adduction-external rotation, abduction-external rotation, and abduction-internal rotation increased in a statistically significant manner between the preoperative assessment and follow-up evaluation (p<0.01). The average change of 47.97±21.03 units observed in the patients' values obtained in the control measurements against the pre-op Constant scores was determined to be statistically significant (p<0.01). According to the Oxford classification, 29 shoulders were sufficient.

CONCLUSION

Successful results can be obtained with arthroscopic release performed after manipulation in patients with frozen shoulder resistant to conservative treatment. Level of Evidence IV, Case Series.

Adhesive Capsulitis of the Shoulder. Is there Consensus Regarding the Treatment? A Comprehensive Review

Background:

Adhesive capsulitis of the shoulder (ACS) is a common self-limiting condition characterized by disabling pain and restricted movements. Its pathophysiology is poorly understood, clinically it is characterized by stages of pain and stiffness, and finally often patients never recover fully. However, there is no consensus about available methods of treatment for ACS. The aims of this paper are to discuss and develop issues regarding approaches to management in ACS in the stages of it.

Methods:

A review of the literature was performed and guidelines for the treatment of that clinical entity for doctors and health care professionals are provided.

Results:

Anti-inflammatory medications, steroid and/or hyaluronate injections and physiotherapy is the mainstay of conservative management either alone in the first stages or in combination with other treatment modalities in the later stages. Next line of treatment, involving minor to moderate intervention, includes suprascapular nerve block, distension arthrography and manipulation under anaesthesia. In order to avoid complications of “blind intervention”, arthroscopic capsular release is gradually more commonly applied, and in recalcitrant severe cases open release is a useful option.

Conclusion:

Various modalities of conservative management and gradually more surgical release are applied. However, often clinicians choose on personal experience and training rather than on published evidence.

Thawing frozen shoulder by steroid injection

BACKGROUND

Frozen shoulder is not an uncommon disorder, and steroid injection into the glenohumeral (GH) joint is one of the most well-known approaches for the frozen shoulder. However, their results have been varied with beneficial effects or no additional advantage. With the understanding about the pathological changes taking place in frozen shoulder and the biomechanics involved, we wanted to evaluate the short- and long-term efficacy of steroid injection by a novel three-site (NTS) injection technique and compare it with the single-site injection (SSI).

MATERIAL AND METHODS

This was a prospective study with 85 patients including all stages and randomized into two groups. SSI group received steroid injection through posterior approach. NTS group received the same dose of steroid in diluted doses at three sites (posterior capsule, subacromial and subcoracoid). Second sitting was repeated after 3 weeks. Both groups had received the same physiotherapy. The patients were evaluated by CONSTANT score at initial, 3 week, 6 week and 6 month.

RESULTS

NTS group patients had significant pain relief and early improvement in activities of daily living ( p < 0.005). Both groups had improvement in shoulder movements but with NTS group, early near-normal scores were attained and sustained after 6 months. About 43% in SSI group could not attain near-normal levels and had relapses.

CONCLUSION

The three-site approach to steroid instillation in frozen shoulder is a safe method and provides early recovery and better improvement in shoulder function with less relapses.

Short-term outcomes after arthroscopic capsular release for adhesive capsulitis

BACKGROUND

Little is known about the short-term temporal outcomes of an arthroscopic capsular release for adhesive capsulitis (frozen shoulder). Specifically, it is not known how immediate the improvements are and how quickly patients return to normal function after an arthroscopic release.

METHODS

The study included 140 shoulders in 133 patients with idiopathic adhesive capsulitis who underwent a complete arthroscopic release of the shoulder capsule, performed by a single surgeon in a day surgery setting. Patient-reported pain and shoulder function were evaluated with the use of Likert scales, and an independent examiner assessed shoulder strength and range of motion preoperatively and at 1 week, 6 weeks, 12 weeks, and 24 weeks postoperatively.

RESULTS

Arthroscopic capsular release resulted in immediate improvements in pain, functional outcomes, and range of motion (P < .0001). External rotation increased from 21° ± 17° (mean ±  standard deviation) to 76° ± 17° at 1 week. Passive range of shoulder motion improved at 1 week, deteriorated slightly at 6 weeks, and then continued to improve at 12 and 24 weeks. Before surgery, 38% of patients reported that they "always" experienced extreme pain. This proportion reduced to 30% (P < .0001) at 1 week postoperatively and 2% (P < .0001) at 24 weeks postoperatively. There were no complications.

CONCLUSIONS

Patients who underwent an arthroscopic capsular release for idiopathic adhesive capsulitis experienced significant reductions in pain, improvements in range of motion, and improvements in overall shoulder function in the first postoperative week. These immediate improvements in pain and function continue to improve at 6, 12, and 24 weeks postoperatively.

Does chondrolysis occur after corticosteroid-analgesic injections? An analysis of patients treated for adhesive capsulitis of the shoulder

BACKGROUND

Clinical studies using continuous infusions of local anesthetics and basic science studies that model injections of local anesthetics have shown chondrotoxicity. However, clinical studies do not exist that have assessed for the risk of chondrolysis in nonarthritic joints exposed to single or intermittent corticosteroid or analgesic injections. Currently, there are no data available to guide the clinician on the safety of using these injections in clinical practice.

MATERIALS AND METHODS

A retrospective review of patients treated for adhesive capsulitis of the shoulder with at least 1 intra-articular injection of a corticosteroid and anesthetic was performed. The inclusion criteria were a diagnosis of adhesive capsulitis and a minimum 2-year follow-up. Prospective follow-up was performed to obtain patient-determined outcome scores, range of motion, and radiographs to determine the presence of chondrolysis.

RESULTS

Fifty-six patients with a mean age of 52.5 ± 7.2 years were enrolled at a mean follow-up of 54 months. The mean number of injections performed was 1.5 ± 0.7 (range, 1-4). At final follow-up, the mean Western Ontario Osteoarthritis of the Shoulder score was 91.4% ± 14.2%; Disabilities of the Arm, Shoulder and Hand score, 6.7 ± 9.6; Shoulder Pain and Disability Index score, 7.4 ± 11.4; and Single Assessment Numeric Evaluation score, 92.7% ± 10.1%. The Shoulder Activity Score was 8.3 ± 4.7. Passive and active forward elevation, external rotation, internal rotation, and cross-body adduction showed no significant differences compared with the unaffected contralateral shoulder. There was no radiographic evidence of chondrolysis in any patient.

CONCLUSIONS

This study did not show chondrolysis in patients treated with an intra-articular corticosteroid and local anesthetic for adhesive capsulitis. The findings of this study do not support the cessation of using intra-articular analgesic-corticosteroid injections for the treatment of adhesive capsulitis.

LEVEL OF EVIDENCE

Level IV; Case Series; Treatment Study.

Shoulder proprioception - lessons we learned from idiopathic frozen shoulder

Background

Of all the most frequent soft tissue disorders of the shoulder, idiopathic frozen shoulder (IFS) offers the greatest potential for studying proprioception. Studies concerning the presence of proprioception dysfunctions have failed to determine the potential for spontaneous healing of passive shoulder stabilizers (anterior and posterior capsule, middle and inferior gleno-humeral ligaments), its relationship with passive (PJPS) and active (AJPS) shoulder proprioception for internal and external rotation (IR, ER), as well as the isokinetic muscle performance of the internal and external rotators. This study investigates these dependencies in the case of arthroscopic release of IFS.

Methods

The study group comprised 23 patients (average aged 54.2) who underwent arthroscopic release due to IFS and 20 healthy volunteers. The average follow-up time was 29.2 months. The Biodex system was used for proprioception measurement in a modified neutral arm position and isokinetic evaluation. The results were analysed using the T-test, Wilcoxon and interclass correlation coefficient. P-values lower than 0.05 were considered significant.

Results

Statistically significant differences were found between involved (I) and uninvolved (U) shoulders only in the cases of PJPS and AJPS, peak torque, time to peak torque and acceleration time for ER (p < 0.05). No statistically significant difference was noted between PJPS IR and PJPS ER or between AJPS IR and AJPS ER (p > 0.05) for the U shoulders.

Conclusions

The anatomical structure of anterior (capsule, middle and anterior band of inferior gleno-humeral ligament) and posterior (capsule and posterior band of inferior gleno-humeral ligament) passive shoulder restraints has no impact on the difference in PJPS values between ER and IR in a modified neutral shoulder position. The potential for spontaneous healing of the anterior and posterior passive shoulder restraints influences PJPS recovery after arthroscopic release of IFS. ER peak torque deficits negatively affect AJPS values. PJPS and AJPS of ER and IR can be measured with a high level of reproducibility using an isokinetic dynamometer with the arm in a modified neutral shoulder position. Differences greater than 15 % for PJPS and >24 % for AJPS for ER and IR can be helpful for future studies as baseline data for identification of particular passive and active shoulder stabilizers at risk.

Intra-articular injection, subacromial injection, and hydrodilatation for primary frozen shoulder: a randomized clinical trial

BACKGROUND

The aim of this prospective randomized study was to compare the efficacy of 3 injection methods, intra-articular injection, subacromial injection, and hydrodilatation (HD), in the treatment of primary frozen shoulder.

METHODS

Patients with primary frozen shoulder were randomized to undergo intra-articular injection (n = 29), subacromial injection (n = 29), or HD (n = 28). Evaluations using a visual analog scale for pain, Simple Shoulder Test, Constant score, and passive range of shoulder motion were completed before treatment and 1 month, 3 months, and 6 months after treatment.

RESULTS

Among the 3 injection methods for primary frozen shoulder, HD resulted in a greater range of motion in forward flexion and external rotation, a lower visual analog scale score for pain after 1 month, and better outcomes for all functional scores after 1 month and 3 months of follow-up. However, there were no significant differences in any clinical outcomes among the 3 groups in the final follow-up at 6 months.

CONCLUSIONS

Although HD yielded more rapid improvement, the 3 injection methods for primary frozen shoulder resulted in similar clinical improvement in the final follow-up at 6 months.

Corticosteroid Injections Accelerate Pain Relief and Recovery of Function Compared With Oral NSAIDs in Patients With Adhesive Capsulitis: A Randomized Controlled Trial

BACKGROUND

Intra-articular corticosteroid injection is a common therapy for adhesive capsulitis, but there is a lack of prospective randomized controlled studies analyzing the efficacy of single injections applied blindly to accelerate improvement in pain and function.

HYPOTHESIS

In patients with adhesive capsulitis, a single intra-articular corticosteroid injection without image control applied before the beginning of a physical therapy program will accelerate pain relief and recovery of function compared with oral nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 74 patients with primary adhesive capsulitis in the freezing stage were randomized to receive either intra-articular injections with betamethasone or oral NSAIDs. Clinical outcome was documented at baseline and after 2, 4, 8, and 12 weeks and comprised a visual analog scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) Shoulder Score, the abbreviated Constant-Murley score, and the abbreviated Disabilities of the Arm, Shoulder and Hand (QuickDASH) score for function. Passive range of motion was measured with a goniometer.

RESULTS

Patients treated with corticosteroid injections achieved faster pain relief compared with control patients during the first 8 weeks after treatment (P < .001). However, no significant difference in pain was observed among the groups at final follow-up. Likewise, shoulder function and motion improved significantly in both groups at all follow-up points. Shoulder function scores and most motion parameters improved faster in the injection group up to week 8 (P < .001). Again, no significant differences in function or motion were seen at final follow-up.

CONCLUSION

In patients with adhesive capsulitis, a single corticosteroid injection applied without image control provides faster pain relief and earlier improvement of shoulder function and motion compared with oral NSAIDs.

Limited capsular release and controlled manipulation under anaesthesia for the treatment of frozen shoulder

BACKGROUND

In light of recent interest in the cost-effectiveness of the treatment options available for frozen shoulder, we aimed to determine the results of limited anterior capsular release and controlled manipulation under anaesthesia (MUA) in the treatment of primary frozen shoulder in terms of patient-related outcomes measure, range of motion and re-intervention rates.

METHODS

This single-surgeon series included prospectively collected data on all patients undergoing capsular release with MUA from March 2011 until June 2013, with a minimum follow-up of 6 months from the index procedure. Outcome measures included pre- and postoperative Oxford Shoulder Score (OSS), range of motion and need for re-intervention.

RESULTS

Fifty-four procedures were performed in 52 patients. Mean age 50 years (range 42 years to 59 years); male: female ratio = 11: 41. There was a highly statistically significant improvement in both pain and function modules of the OSS (p < 0.005) and range of motion (p < 0.005) at 6 months. The median postoperative score was 41 from a maximum of 48 points, with an average mean improvement of 24 points. Seventeen patients were diabetics. There was no significant difference in pre-operative and postoperative OSS or range of motion between the diabetic group and the non-diabetic groups. No patients required surgical re-intervention.

CONCLUSIONS

A combination of limited capsular release and MUA for the treatment of primary frozen shoulder is a safe and effective procedure resulting in marked improvement in pain, function and range of motion.

Arthroscopic treatment of refractory adhesive capsulitis of the shoulder

OBJECTIVE

to evaluate the results of arthroscopic treatment of refractory adhesive capsulitis of the shoulder associated as for improved range of motion after a minimum follow up of six years.

METHODS

from August 2002 to December 2004, ten patients with adhesive capsulitis of the shoulder resistant to conservative treatment underwent arthroscopic surgery. One interscalene catheter was placed for postoperative analgesia before the procedure. All were in Phase II, with a minimum follow up of two years. The mean age was 52.9 years (39-66), predominantly female (90%), six on the left shoulder. The time between onset of symptoms and surgical treatment ranged from six to 20 months. Four adhesive capsulitis were found to be primary (40%) and six secondary (60%).

RESULTS

the preoperative mean of active anterior elevation was 92°, of external rotation was 10.5° of the L5 level internal rotation; the postoperative ones were 149°, 40° and T12 level, respectively. Therefore, the average gain was 57° for the anterior elevation, 29.5° for external rotation in six spinous processes. There was a significant difference in movements' gains between the pre and post-operative periods (p<0.001). By the Constant Score (range of motion), there was an increase of 13.8 (average pre) to 32 points (average post).

CONCLUSION

the arthroscopic treatment proved effective in refractory adhesive capsulitis of the shoulder resistant to conservative treatment, improving the range of joint movements of patients evaluated after a minimum follow up of six years.

Arthroscopic treatment of adhesive capsulitis of the shoulder with minimum follow up of six years

OBJECTIVE

To evaluate the results of the arthroscopic treatment of adhesive capsulitis of the shoulder with six to nine years of follow up.

METHODS

From August 2002 to December 2004, ten patients underwent arthroscopic capsular release for adhesive capsulitis refractory to conservative treatment. An interscalene catheter was used for postoperative analgesia, before the procedure. All were in stage II, with a minimum follow up of six years. The mean age was of 52.9 years old (range, 39 to 66), with female predominance (90%) and six left shoulders. The time between the onset of symptoms and surgery varied from six to 20 months. There were four patients in the primary form (40%) and six in the secondary (60%).

RESULTS

In the preoperative evaluation, the mean active anterior elevation was 92°, 10.5° of external rotation, and internal rotation level L5. Postoperatively, the mean active elevation was 149°, 40° of external rotation and internal level T12, respectively. Thus, the average gains were 57° in forward active elevation, 29.5° in external rotation and six spinous processes, these values being statistically significant (p <0.001). According to the Constant functional score (arc of movements), the value increased from 13.8 (preoperative mean) to 32 points (postoperative mean).

CONCLUSION

Arthroscopic treatment of adhesive capsulitis of the shoulder refractory to conservative treatment allows effective gain of range of motion of this joint.

Comparative outcome of arthroscopic release for frozen shoulder in patients with and without diabetes

Our aim was to compare the outcome of arthroscopic release for frozen shoulder in patients with and without diabetes. We prospectively compared the outcome in 21 patients with and 21 patients without diabetes, two years post-operatively. The modified Constant score was used as the outcome measure. The mean age of the patients was 54.5 years (48 to 65; male:female ratio: 18:24), the mean pre-operative duration of symptoms was 8.3 months (6 to 13) and the mean pre-operative modified Constant scores were 36.6 (standard deviation (sd) 4.6) and 38.4 (sd 5.7) in the diabetic and non-diabetic groups, respectively. The mean modified Constant scores at six weeks, six months and two years post-operatively in the diabetics were 55. 6 (sd 4.7), 67. 4 (sd 5.6) and 84. 4 (sd 6.8), respectively; and in the non-diabetics 66.8 (sd 4.5), 79.6 (sd 3.8) and 88.6 (sd 4.2), respectively. A total of 15 (71%) of diabetic patients recovered a full range of movement as opposed to 19 (90%) in the non-diabetics. There was significant improvement (p < 0.01) in the modified Constant scores following arthroscopic release for frozen shoulder in both groups. The results in diabetics were significantly worse than those in non-diabetics six months post-operatively (p < 0.01) with a tendency towards persistent limitation of movement two years after operation. These results may be used when counselling diabetic patients for the outcome after arthroscopic treatment of frozen shoulder.

[Arthroscopic release for shoulder stiffness]

OBJECTIVE

Arthroscopic capsular release for refractory shoulder stiffness to recreate active and passive shoulder joint mobility.

INDICATIONS

Adhesive capsulitis of the shoulder (primary and secondary frozen shoulder) after receiving at least 3 months of conservative treatment.

CONTRAINDICATIONS

Boney-related stiffening of the shoulder joint, joint infection, freezing phase of the primary frozen shoulder and shoulder stiffness after reconstructive surgery.

SURGICAL TECHNIQUE

Opening of the lower shoulder joint capsule over a gentle unidirectional manipulation under general anesthesia. A diagnostic arthroscopy in lateral position with extension of the arm is then performed. The release is completed with incision of the ventral and the dorsal part of the capsule under arthroscopic control.

POSTOPERATIVE MANAGEMENT

While still in the operation room, the anesthetist places an interscalene brachial plexus catheter, thus, delivering the best possible analgesia. This enables full range of active and passive movement of the shoulder joint for at least 3 days. Outpatient continuation of physiotherapy with anti-inflammatory and analgesic medication.

RESULTS

The literature shows good functional results with age- and gender-related Constant scores greater than 75 %. Our retrospective inquiry of 37 cases with a mean follow-up of 40 months confirms this outcome. The disease duration was shortened by arthroscopic release. Ability to work was achieved after a mean of 1.9 months; treatment ended 3.6 months after operation. In 10 cases with secondary shoulder stiffness, residual symptoms remained.

Increased blood flow in the anterior humeral circumflex artery correlates with night pain in patients with rotator cuff tear

BACKGROUND

Night pain is a particularly vexing symptom in patients with rotator cuff tear. It disturbs sleep and decreases quality of life, and there is no consensus regarding its etiology. Based on arthroscopic surgical observations of synovitis around the rotator interval or capsule surface in rotator cuff tear, we hypothesized that blood flow from the artery feeding the capsule increases blood supply to the synovium. This study aimed to investigate the relationship between blood flow and night pain using pulse Doppler ultrasonography.

METHODS

A series of 47 consecutive patients with rotator cuff tear was evaluated. The peak systolic velocity and resistance index of blood flow in the ascending branch of the anterior humeral circumflex artery were evaluated using pulse Doppler ultrasonography. We also investigated 20 normal shoulders in healthy volunteers. The peak systolic velocity and resistance index were compared between affected and unaffected sides in patients and between dominant and nondominant sides in controls.

RESULTS

Anterior humeral circumflex artery peak systolic velocity and resistance index did not differ between sides in control subjects or in patients with rotator cuff tear without night pain. However, anterior humeral circumflex artery peak systolic velocity and resistance index did differ significantly between sides in patients with rotator cuff tear with night pain.

CONCLUSIONS

This study revealed anterior humeral circumflex artery hemodynamics in patients with rotator cuff tear and normal subjects using Doppler ultrasonography. Night pain, particularly involving aching, appears to be related to the hemodynamics. These findings suggest that investigating the hemodynamics of patients with rotator cuff tear with night pain may lead to greater understanding of the etiology of this symptom.

Short-term results of transcatheter arterial embolization for abnormal neovessels in patients with adhesive capsulitis: a pilot study

BACKGROUND

Neovessels and accompanying nerves are possible sources of pain. We postulated that transcatheter arterial embolization of abnormal neovessels would relieve pain and symptoms in patients with adhesive capsulitis.

METHODS

Adhesive capsulitis was treated by transcatheter arterial embolization in 7 patients. Adverse events, changes in visual analog scale scores for night pain and overall shoulder pain, and changes in range of motion and American Shoulder and Elbow Surgeons scores were assessed at 1 week and at 1, 3, and 6 months after the procedure.

RESULTS

Abnormal neovessels were identified at the rotator interval in all patients. No major or minor adverse events were associated with the procedures. Transcatheter arterial embolization rapidly decreased nighttime pain scores from 67 ± 14 mm to 27 ± 14 mm at 1 week after the procedure, with further improvement at 1 and 6 months (6 ± 8 mm and 2 ± 5 mm, respectively). The American Shoulder and Elbow Surgeons score significantly improved from 17.8 ± 4.5 to 39.8 ± 12.0, 64.3 ± 13.9, and 76.2 ± 4.4 at 1, 3, and 6 months, respectively.

CONCLUSION

All patients with adhesive capsulitis had abnormal neovessels at the rotator interval. Transcatheter arterial embolization was feasible, relieved unrelenting pain, and restored shoulder function.

Clinical outcomes do not support arthroscopic posterior capsular release in addition to anterior release for shoulder stiffness: a randomized controlled study

BACKGROUND

Arthroscopic capsular release is an effective treatment for shoulder stiffness, yet its extent is controversial.

PURPOSE

To compare the clinical outcomes of arthroscopic capsular release in patients with and without posterior extended capsular release for shoulder stiffness.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Between January 2008 and March 2011, 75 patients who underwent arthroscopic capsular release for shoulder stiffness were enrolled and randomized into 2 groups. In group I (n = 37), capsular release was performed, including release of the rotator interval and anterior and inferior capsule. In group II (n = 38), capsular release was extended to the posterior capsule. The American Shoulder and Elbow Surgeons score, Simple Shoulder Test, visual analog scale for pain, and range of motion (ROM) were used for the evaluation before surgery and at 3, 6, and 12 months after surgery and at the last follow-up.

RESULTS

Preoperative demographic data of age, sex, symptom duration, and clinical outcomes showed no significant differences (P > .05). The average follow-up was 18.4 months. Both groups showed significantly increased ROM at the last follow-up compared with preoperative ROM (P < .05). At the last follow-up, no statistical differences were found (P > .05) between groups I and II in American Shoulder and Elbow Surgeons score (91.3 vs. 79.5), Simple Shoulder Test (83.3 vs. 83.3), and visual analog scale (1.5 vs. 2.2). There were also no statistical differences between the 2 groups at the last follow-up (P > .05) in ROM: forward flexion, 145.2° vs. 143.3°; external rotation with 90° of abduction, 88.1° vs. 86.2°; external rotation at side, 88.9° vs. 82.9°; and internal rotation, 9.1° vs. 8.3°.

CONCLUSION

Posterior extended capsular release might not be necessary in arthroscopic surgery for shoulder stiffness.

A blinded, randomized, controlled trial assessing conservative management strategies for frozen shoulder

BACKGROUND

There is little evidence for the optimal form of nonoperative treatment in the management of frozen shoulder. This study assesses the efficacy of current physiotherapy strategies.

METHODS

All primary care referrals of frozen shoulder to our physiotherapy department were included during a 12-month period. Of these referrals, 17% met the inclusion criteria for primary idiopathic frozen shoulder. The 75 patients were randomly assigned to 1 of 3 groups: group exercise class, individual physiotherapy, and home exercises alone. A single independent physiotherapist, who was blinded to the treatment groups, made all assessments. Range of motion, Constant score, Oxford Shoulder Score, Short Form 36, and Hospital Anxiety and Disability Scale (HADS) outcome measures were performed at baseline, 6 weeks, 6 months, and 1 year.

RESULTS

The exercise class group improved from a mean Constant score of 39.8 at baseline to 71.4 at 6 weeks and 88.1 at 1 year. There was a significant improvement in shoulder symptoms on Oxford and Constant scores (P < .001). This improvement was greater than with individual physiotherapy or home exercises alone (P < .001). The improvement in range of motion was significantly greater in both physiotherapy groups over home exercises (P < .001). HADS scores significantly improved during the course of treatment (P < .001). The improvement in HADS anxiety score was significantly greater in both physiotherapy intervention groups than in home exercises alone.

CONCLUSIONS

A hospital-based exercise class can produce a rapid recovery from a frozen shoulder with a minimum number of visits to the hospital and is more effective than individual physiotherapy or a home exercise program.

Arthroscopic capsular release for idiopathic frozen shoulder with intra-articular injection and a controlled manipulation

INTRODUCTION

The aim of this prospective study was to assess the immediate and long-term effectiveness of arthroscopic capsular release in a large cohort of patients with a precise and isolated diagnosis of stage II idiopathic frozen shoulder.

METHODS

All patients underwent a preoperative evaluation. Patients with secondary frozen shoulder and those with concurrent pathology at arthroscopy were excluded. This left 136 patients with a stage II arthroscopically confirmed idiopathic frozen shoulder. At each postoperative attendance, a record was made of pain, function and range of motion. At 12 months, the Oxford shoulder score was calculated, and pain and range of motion were assessed.

RESULTS

Fifty per cent achieved good pain relief within a week and eighty per cent within six weeks of arthroscopic capsular release. The mean preoperative visual analogue scale pain score was 6.6 and the mean postoperative score was 1.0. The mean time to achieving good pain relief was 16 days following surgery. No patient could sleep through the night prior to surgery while 90% reported having a complete night's sleep at a mean of 12 days after surgery. The mean postoperative Oxford shoulder score was 38/48 and the mean improvement was 19.2.

CONCLUSIONS

This large series demonstrates that arthroscopic capsular release is a safe procedure, with rapid improvement in pain and a marked improvement in range of motion.

Improvement in quality of life after arthroscopic capsular release for contracture of the shoulder

There is little published information on the health impact of frozen shoulder. The purpose of this study was to assess the functional and health-related quality of life outcomes following arthroscopic capsular release (ACR) for contracture of the shoulder. Between January 2010 and January 2012 all patients who had failed non-operative treatment including anti-inflammatory medication, physiotherapy and glenohumeral joint injections for contracture of the shoulder and who subsequently underwent an ACR were enrolled in the study. A total of 100 patients were eligible; 68 underwent ACR alone and 32 had ACR with a subacromial decompression (ASD). ACR resulted in a highly significant improvement in the range of movement and functional outcome, as measured by the Oxford shoulder score and EuroQol EQ-5D index. The mean cost of a quality-adjusted life year (QALY) for an ACR and ACR with an ASD was £2563 and £3189, respectively.

ACR is thus a cost-effective procedure that can restore relatively normal function and health-related quality of life in most patients with a contracture of the shoulder within six months after surgery; and the beneficial effects are not related to the duration of the presenting symptoms.

Cite this article: Bone Joint J 2013;95-B:942–6.

Assessment of the results from arthroscopic surgical treatment of adhesive capsulitis

Objective: Describe the outcomes of patients with adhesive capsulitis treated with arthroscopic surgical procedure. Methods: Between January and September of 2009, 9 patients (10 cases) underwent arthroscopic surgical release. There were 4 male (one bilateral) and 5 female patients. Their mean age was 51 years (27-63). The time from onset of symptoms to the surgical procedure averaged 23.4 months (6-38). Preoperative assessment was based on the UCLA and Constant score. ROM was evaluated with one week and six months of surgery. Results: According to UCLA shoulder score (p < 0.01) it increased from preoperatively (6-14) to 31.6 postoperatively (26-35) and the Constant (p < 0.01) from 20 (13-27) to 79.2 (66-91). ROM improved significantly, with mean passive elevation changing from 89° (80-100°) preoperatively to 150° postoperatively with one week and 153° with six months, mean passive external rotation changing from 12.5° (0-30°) preoperatively to 46° (one week) and 56° (six months) postoperatively, and passive internal rotation from L5 (T12-gluteus) to T11 (one week) and T9 (six months). There was not statistical significance of the duration of the disease and the postoperative result. Conclusion: This study shows that the surgical treatment of adhesive capsulitis with arthroscopic capsular release and manipulation appears to be a safe procedure that results in pain relief and functional gain.

Long-term outcomes after arthroscopic capsular release for idiopathic adhesive capsulitis

BACKGROUND

One management strategy for the treatment of idiopathic adhesive capsulitis, or frozen shoulder, is arthroscopic capsular release. While there are long-term data regarding nonoperative treatment and good short-term outcomes following a release for idiopathic adhesive capsulitis, little is known about the outcomes five years or more after arthroscopic capsular release.

METHODS

Patients with idiopathic adhesive capsulitis treated with a circumferential arthroscopic capsular release of the glenohumeral joint by a single surgeon were assessed with use of patient-reported pain scores, shoulder functional scores with use of a Likert scale, and shoulder range of motion at the preoperative evaluation and at one, six, twelve, twenty-four, and fifty-two weeks and a mean of seven years after surgery.

RESULTS

At a mean follow-up of seven years (range, five through thirteen years), forty-three patients (forty-nine shoulders) had significant improvement with regard to pain frequency and severity, patient-reported shoulder function, stiffness, and difficulty in completing activities compared with the findings at the initial presentation (p < 0.001) and the one-year follow-up evaluation (p < 0.01 to p < 0.001). Shoulder motion also improved (p < 0.001) and was comparable with that of the contralateral shoulder. There were no complications.

CONCLUSIONS

Patients with idiopathic adhesive capsulitis treated with an arthroscopic capsular release had early significant improvements in shoulder range of motion, pain frequency and severity, and function. These improvements were maintained and/or enhanced at seven years. In contrast to results reported for nonoperative treatment, shoulder range of motion at seven years was equivalent to that in the contralateral shoulder.

Arthroscopic arthrolysis for recalcitrant frozen shoulder: a lateral approach

PURPOSE

The purpose of this study was to evaluate a new all-arthroscopic technique in the management of recalcitrant globally stiff frozen shoulders. This adopts an initial extra-articular approach followed by intra-articular entry to perform a 360° capsular release.

METHODS

Ten patients with global adhesive capsulitis were prospectively evaluated. All patients had not improved after undergoing a minimum of 6 months of physiotherapy, and 5 received intra-articular injections of steroids. The mean age was 47 years (range, 33 to 56 years). Patients were examined preoperatively and postoperatively for range of motion. A Constant score and visual analog scale score for pain were recorded. We described an all-arthroscopic technique by entering the subacromial space laterally and opening the rotator interval from the outside in, followed by a complete 360° capsular release and biceps tenotomy.

RESULTS

The mean follow-up was 42 months (range, 18 to 90 months), and the mean Constant score improved from 21 to 72 (P < .01). Preoperative abduction improved from a mean of 40° to 165°, elevation improved from 55° to 175°, and external rotation improved from 6° to 58°. The visual analog scale pain score improved from 7 to 1.6, and all patients reported an excellent outcome after surgery. There were no complications particularly regarding axillary nerve injury, fracture, or infection.

CONCLUSIONS

This study shows a combined extra-articular and intra-articular approach that is controlled and anatomic and achieves excellent results that were maintained at the midterm. The technique permits anatomic debridement of the rotator interval, enabling excellent intra-articular access, a circumferential capsular release, and biceps tenotomy. There were no complications, and no manipulations were required, which pose a risk of creating soft-tissue lesions, fractures, or dislocations. We recommend this 360° capsular release technique for releasing globally stiff shoulders where the surgeon is experienced in arthroscopy.

Miniopen coracohumeral ligament release and manipulation for idiopathic frozen shoulder

In the management of idiopathic frozen shoulder, manipulation under anaesthesia is known to have serious potential complications including fractures and intra-articular injuries. Arthroscopy is a safer treatment modality but requires special instruments, experience, and involves added cost. The aim of this work was to study the use of miniopen Coracohumeral ligament release and manipulation of the shoulder as a safe and simple method of treating idiopathic frozen shoulder that could be performed as a quick procedure under short duration anaesthesia obtaining a significant improvement of shoulder function while avoiding complications that are feared to occur with the use of manipulation under anaesthesia. Miniopen Coracohumeral ligament release is performed through a 3-cm incision. The Coracohumeral ligament is divided, and then the shoulder is manipulated without undue force. A case series including fifteen patients (19 shoulders) with idiopathic frozen shoulder operated by this technique is described. Miniopen Coracohumeral ligament release and manipulation is a quick procedure that may be performed under short duration anaesthesia obtaining a significant improvement of shoulder function meanwhile avoiding complications that are feared to occur with the use of manipulation under anaesthesia.

Frozen shoulder

Frozen shoulder is commonly encountered in general orthopaedic practice. It may arise spontaneously without an obvious predisposing cause, or be associated with a variety of local or systemic disorders. Diagnosis is based upon the recognition of the characteristic features of the pain, and selective limitation of passive external rotation. The macroscopic and histological features of the capsular contracture are well-defined, but the underlying pathological processes remain poorly understood. It may cause protracted disability, and imposes a considerable burden on health service resources. Most patients are still managed by physiotherapy in primary care, and only the more refractory cases are referred for specialist intervention. Targeted therapy is not possible and treatment remains predominantly symptomatic. However, over the last ten years, more active interventions that may shorten the clinical course, such as capsular distension arthrography and arthroscopic capsular release, have become more popular. This review describes the clinical and pathological features of frozen shoulder. We also outline the current treatment options, review the published results and present our own treatment algorithm.