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Adhesive Capsulitis of the Shoulder

- Discussion:
    - refers to a condition in which the shoulder capsule becomes contracted and thickened;
    - patients note a dramatic decrease in shoulder ROM;
    - in many cases there is spontaneous resolution after 1-3 years and motion is re-gained;
    - associated disorders:
          - cervical spondylosis
          - hypothyroidism
                 - ref: Prevalence of hypothyroidism in patients with frozen shoulder
          - diabetes mellitus
                 - these patients may have a worse prognosis than patients w/o diabetes;
                 - ref: Comparative outcome of arthroscopic release for frozen shoulder in patients with and without diabetes
    - diff dx:
          - polymyalgia rhematica: this condition is usually associated w/ elevated sed rate;
          - pancoast tumor
          - posterior dislocation
                 - prior to making the diagnosis of frozen shoulder be sure to rule the possibility of a chronic locked posterior dislocation;
          - ref: Tumors masked as frozen shoulders: a retrospective analysis

- Physical Exam:
    - physical exam helps identify which portion of the capsule is most affected;
    - see: stabilizers of the shoulder;
    - external rotation w/ arm adducted: tests for contracture of the antero-superior portion of the capsule;
    - external rotation w/ arm abducted: tests for contracture of the antero-inferior portion of the capsule;
    - internal rotation: tests for contracture of posterior capsule;

- Radiographs:
    - may show osteopenia second to disuse;
    - arthrography:
           - demonstrates marked contracture of joint capsule and obliteration of the axillary fold;
           - look for lack of dye filling the bicipital sheath;

- Labs:
    - ERS and CRP are useful to rule an inflammatory arthritis or polymyalgia rhematica

- Non Operative Treatment:
    - involves NSAIDS/steroids, intra-articular steroid injection, and physical therapy;
    - in the report by Griggs SM, et al. (2000), the authors followed 75 consecutive patients (77 shoulders) with phase-II idiopathic
           adhesive capsulitis;
           - patients were treated with use of a specific four-direction shoulder-stretching exercise program and evaluated prospectively;
           - mean duration of follow-up was 22 (range, twelve to forty-one months);
           - 64 (90 percent) of the patients reported a satisfactory outcome
           - 7 (10 %) were not satisfied with the outcome, and 5 (7 %) underwent manipulation and/or arthroscopic capsular release;
           - active forward elevation increased 43 deg, active external rotation increased 25 deg, passive IR increased eight vertebral levels,
                     and glenohumeral rotation arc at 90 deg of abduction increased 72 deg (p < 0.00001);
           - patients with more severe pain and functional limitations before treatment had relatively worse outcomes;
           - the authors recommend at least 3 months of PT prior to making any considerations for surgery;
    - references:
           - Thawing the frozen shoulder: the "patient" patient.        
           - Idiopathic Adhesive Capsulitis. A Prospective Functional Outcome Study of Nonoperative Treatment  
           - Nonoperative management of idiopathic adhesive capsulitis.

- Manipulation under Anesthesia:
    - does not allow for a controlled release of pathologic tissue;
    - complete muscle paralysis is essential;
    - hazards: humeral fracture may occur from excessive torque (external rotation);
    - first attempt to recover external rotation w/ the arm adducted, and then move on to recovering flexion and external
            rotion and abduction;
    - be sure to hold the arm as proximally as possible inorder to minimize the lever arm on the humerus (which lessens the
            chance of humeral fracture);
    - some surgeons feel that a successful manipulation requires two or three audible "pops" before the procedure is complete;
    - reference:
            - Shoulder manipulation in patients with adhesive capsulitis and diabetes mellitus: a technical note.

- Arthrscopic Release:
    - indicated for patients who have not improved after 4 months of PT;
    - contra-indicated in patients who have contracture due to an extra-articular etiology;
    - preop exam includes an assessment of shoulder external rotation in both adduction and abduction;
    - a gentle manipulation prior to portal placement will help open shoulder joint and will facilitate trocar insertion;
    - arthroscopic portal placement:
           - anterior portal is placed just beneath the biceps;
    - biceps tendon:
           - in many cases, there is scarring around the biceps tendon, which requires release or tenodesis; 
           - ref: Dynamic movement of the long head of the biceps tendon in frozen shoulders
    - anterior release:
           - prior to performing capsular release, ensure that the subscapular tendon is well demarcated (inorder to avoid transecting the
                       tendon) and to demarcate the 5 o'clock position of the capsule (below which lies the axillary nerve);
                       - be aware that the axillary nerve crosses underneath the inferior portion of the glenoid capsule;
                       - damage to the axillary nerve is minized by keeping the arm in adduction during the release;
           - scarring may distort the usual features of these structures;
           - if the subscapularis cannot be distinguished from the capsule then the case needs to be converted to an open release;
           - arthroscopic electrocautery tip is used to divide the anterior capsular scar just beneath the supraspinatus tendon (just
                     below the biceps);
           - release of the rotator interval and coracohumeral ligament is especially important for patients who have loss of external
                     rotation in adduction;
           - the electrocautery disection is continued down to the superior border of the subscapularis;
           - scarring of the rotator interval is responsible for loss of external rotation in adduction;
           - external rotation (in adduction) is retested and re-manipulated;
           - if the shoulder lacks external rotation in abduction, then the glenoid capsule overlying the subscapularis muscle should
                    be divided;
           - at the end of the procedure, a gentle shoulder manipulation can be performed to gain even more motion;
           - at this point, re-test internal rotation;
           - if internal rotation is lacking, then switch the portals and arthroscopically release the posterior capsule;
           - references:
                    - Recalcitrant chronic adhesive capsulitis of the shoulder. Role of contracture of the coracohumeral ligament and rotator interval in pathogenesis and treatment.
                    - Is the extended release of the inferior glenohumeral ligament necessary for frozen shoulder?

    - posterior release:
           - switch the portals over a 4 mm Steinman pin;
           - use cautery to release the posterior capsule adjacent to the glenoid rim, just posterior to the biceps;
           - by staying adjacent to the glenoid, there is less chance of damaging the rotator cuff;
           - following capsular release, attempt a gentle closed manipulation;
           - Holloway GB, et al (2001), the authors evaluated the results of arthroscopic capsular release in three different groups of
                    patients with shoulder contracture refractory to nonoperative management and manipulation under anesthesia;
                    - at time of follow-up, each group had a significant improvement in scores for pain, satisfaction, and function and
                            overall outcome score (p < 0.01);
                    - concluded that arthroscopic capsular release was as effective for improving range of motion in patients with postoperative
                            contracture of the shoulder as it was in patients with idiopathic and post-fracture contracture;
           - references:
                   - Arthroscopic Capsular Release for the Treatment of Refractory Postoperative or Post-Fracture Shoulder Stiffness.  
                   - Posterior Arthroscopic Capsular Release in Frozen Shoulder
                   - Outcomes Dont Support Arthroscopic Posterior Capsular Release in Addition to Anterior Release for Shoulder Stiffness.
                   - Arthroscopic treatment of rotator cuff tears with shoulder stiffness: a comparison of functional outcomes with and without capsular release.

- Open Release:
    - indicated for failure of arthroscopic release to improve motion and for extra-articular contractures;
    - performed through a deltopectoral approach;
    - z plasty lengthening of the subscapularis and anterior capsule
    - references:
           - Open release in the management of refractory frozen shoulder. Kieras DM and Matsen FA. Orthop Trans. 1991;15:801-802.

The frozen shoulder. Diagnosis and management.
Frozen shoulder. A long-term follow-up.
Combination treatment for adhesive capsulitis of the shoulder.
Arthroscopic appearance of frozen shoulder.     
Arthroscopic release of postoperative capsular contracture of the shoulder.   
Operative management of the frozen shoulder in patients with diabetes
Is the extended release of the inferior glenohumeral ligament necessary for frozen shoulder?

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