medicina
Article
Arthroscopic Pan-Capsular and Transverse Humeral Ligament
Release with Biceps Tenodesis for Patients with Refractory
Frozen Shoulder
Chih-Hao Chiu 1,2,3, *, Huan Sheu 2,3,4 , Poyu Chen 1,5,6 , Dan Berco 7 , Yi-Sheng Chan 2,3,8
and Alvin Chao-Yu Chen 1,2,3
Citation: Chiu, C.-H.; Sheu, H.; Chen,
P.; Berco, D.; Chan, Y.-S.; Chen,
A.C.-Y. Arthroscopic Pan-Capsular
and Transverse Humeral Ligament
Release with Biceps Tenodesis for
Patients with Refractory Frozen
Shoulder. Medicina 2022, 58, 1712.
https://doi.org/10.3390/
medicina58121712
Academic Editors: Umile Giuseppe
Longo and Vicenzo Denaro
Received: 31 October 2022
Accepted: 21 November 2022
Published: 23 November 2022
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Copyright: © 2022 by the authors.
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This article is an open access article
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Attribution (CC BY) license (https://
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4.0/).
Medicina 2022, 58, 1712. https://doi.org/10.3390/medicina58121712
1 Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
2 Bone and Joint Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
3 Comprehensive Sports Medicine Center (CSMC), Linkou Chang Gung Memorial Hospital,
Taoyuan 333, Taiwan
4 Department of Orthopedic Surgery, Taoyuan Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
5 Department of Occupational Therapy, Graduate Institute of Behavioral Sciences, College of Medicine,
Chang Gung University, Taoyuan 333, Taiwan
6 Healthy Aging Research Center, Chang Gung University, Taoyuan 333, Taiwan
7 Department of Electronics Engineering and Program in Nano-Electronic Engineering and Design,
Chang Gung University, Taoyuan 333, Taiwan
8 Department of Orthopedic Surgery, Keelung Chang Gung Memorial Hospital, Keelung 204, Taiwan
* Correspondence: joechiu0115@cgmh.org.tw
Abstract: Arthroscopic capsular release allows direct visualization and release of inflamed tissues in
refractory frozen shoulder. The reticular neural network in the long head of the biceps tendon (LHBT)
and nerve endings of the transverse humeral ligament (THL) might be responsible for shoulder
pain. We hypothesized that patients with painful refractory frozen shoulder benefited from pan-
capsular release, THL release, and LHBT tenodesis. The LHBT tenodesis decreased the possibility
of LHBT instability. The balance of the shoulder joint was maintained after such extensive release.
From October 2013 to June 2019, patients with painful refractory frozen shoulder were enrolled
consecutively at the same institute. All patients received arthroscopic pan-capsular, THL release, and
suprapectoral LHBT tenodesis with a minimum of 2-year follow-up. Preoperative and postoperative
shoulder range of motion (ROM), pain visual analog scale (PVAS), subjective shoulder value (SSV),
constant score, LHBT score, acromio-humeral distance (AHD), and critical shoulder angle (CSA)
were recorded. In total, 35 patients with an average age of 53.1 ± 9 years were enrolled. The average
follow-up period was 24 ± 1.5 months. Forward elevation improved from 105.1◦ ± 17◦ to 147◦ ± 12◦
(p < 0.001), external rotation improved from 24.1◦ ± 13.3◦ to 50.9◦ ± 9.7◦ (p < 0.001), and internal
rotation improved from L3 to T9 (p < 0.001), respectively, at final follow-up. PVAS improved from
7.3 ± 1.1 to 1.8 ± 0.6 (p < 0.001), constant score from 23.4 ± 11 to 80.7 ± 5.2 (p < 0.001), and SSV
from 27.7 ± 10.5 to 77.4 ± 3.8, respectively, at follow-up. No differences were found in AHD and
CSA after surgery (p = 0.316, and p = 0.895, respectively). Patients with painful refractory frozen
shoulder benefited from pan-capsular and THL release. A radiographically balanced shoulder joint
was maintained even after such extensive release.
Keywords: refractory frozen shoulder; capsular release; transverse humeral ligament; biceps tenodesis
1. Introduction
Frozen shoulder is an inflammatory disease with spontaneous onset impairing gleno-
humeral motion [1], and it is often regarded as a self-limiting disease that resolves within a
range of 1 to 3 years. However, 20 to 50% of patients have been reported to still have long-
lasting symptoms in various studies [2,3]. First-line treatments for frozen shoulder include
analgesia, physiotherapy [4], intra-articular corticosteroid injection [5], hydrodilation [6],
https://www.mdpi.com/journal/medicina
Medicina 2022, 58, 1712 2 of 11

and manipulation under anesthesia. Arthroscopic capsular release, although safe and
effective, is only reserved for shoulders refractory to conservative treatment measures [7].
When compared to manipulation under anesthesia and hydrodilation, arthroscopic capsu-
lar release allows for the direct visualization and release of the tightened coracohumeral
ligament (CHL), thickened rotator interval (RI), and contracted capsule to ensure adequate
release [8]. Patients who received arthroscopic capsular release showed a significantly
higher Oxford shoulder score at 6 months than those receiving hydrodilation [9]. Several
other groups reported quick and long-lasting pain relief effects after arthroscopic capsular
release [7,10].
However, there is still controversy regarding the extent of release in refractory frozen
shoulder. Ogilvie-Harris et al. advocated the inferior posterior capsular release in resistant
frozen shoulder [11]. Chen et al. concluded that the extended release of the posterior inferior
glenohumeral ligament (IGHL), along with anterior capsular structures, improved range
of motion (ROM) more rapidly within the first 3 months postoperatively [12]. Hagiwara
et al. published their surgical technique of arthroscopic CHL release and considered this
procedure essential and reliable for regaining full ROM for frozen shoulder [13]. On the
other hand, frozen shoulder often presents with diffuse shoulder pain followed by gradual
loss of both active and passive ROM, which made it difficult to evaluate the bicipital
groove area because of the close anatomical proximity of the structures in the anterior
shoulder [14]. The chronic inflammation of synovium causes mechanical impingements
in capsular tissue around the bicipital groove [15], and adhesions within a tenosynovial
compartment of the long head of the biceps tendon (LHBT). LHBT also had a reticular
neural network containing sensory and sympathetic neurotransmitters presented around
the tendon. Not only the nociception, but the neurotransmitters within had pivot roles in
the vasoregulation and immunomodulation of neurogenic inflammation [16]. Additionally,
transverse humeral ligaments (THL) demonstrated myelinated and unmyelinated free
nerve endings, suggesting a potential role as a pain generator of anterior shoulder pain [17].
There is a paucity of literature evaluating the role of capsular and THL release and
LHBT treatment in refractory frozen shoulder. The purpose of this study is to report our
result of arthroscopic pan-capsular and THL release with LHBT tenodesis for patients
with refractory frozen shoulder. We hypothesized that patients with a painful refractory
frozen shoulder could be benefited from pan-capsular release, THL release, and LHBT
tenodesis. The associated LHB tenodesis could decrease the possibility of LHBT instability.
The balance of the shoulder joint could be maintained even after such extensive release and
LHBT tenodesis.

2. Materials and Methods

2.1. Patient Enrollment
From October 2013 to June 2019, patients with refractory frozen shoulder were en-
rolled in this retrospective study. The written informed consent was obtained from all
participants enrolled in this study. The inclusion criteria of refractory frozen shoulder
involved moderate-to-severe shoulder pain [18] around the bicipital groove with no im-
provement after conservative treatments, such as local steroid injections or physiotherapies,
for at least six months, and limited ROM of the shoulder with anterior elevation being
up to 130◦ , external rotation up to 50◦ , and internal rotation up to L5 [19]. The exclusion
criteria included radiological signs of fracture, glenohumeral arthritis, previous LHBT
tenodesis/tenotomy, and concomitant rotator cuff tear with more than 50% of footprint
involvement. All enrolled patients received arthroscopic pan-capsular and THL release
with suprapectoral LHBT tenodesis at the entry of the bicipital groove (top-of-the-groove
tenodesis) with a double-loaded anchor. The authors explained the methods to all par-
ticipants enrolled in this study. All surgeries were performed by a single surgeon in the
same institute. This study was approved by the Institutional Review Board of the author’s
institutes (IRB 201900352B0).
Medicina 2022, 58, 1712 3 of 11

2.2. Outcome Assessment

Preoperative demographic data included sex; age; involvement of the dominant
arm; duration of pain; number of previous injections; and underlying diseases, such
as diabetes, breast cancer, thyroid dysfunction, cancer, and previous traumatic history.
Degrees of passive maximum forward elevation and external rotation were measured
by a goniometer. Internal rotation was measured by the vertebral spinous process that
could be reached with the tip of the patient’s thumb and was converted into contiguously
numbered groups: T1-12 to 1-12, L1-5 to 13–17, buttock to 18, and greater tubercle of
the proximal femur to 19 [20]. All patients had preoperative X-ray, ultrasonography
exam, and magnetic resonance imaging (MRI) to evaluate the conditions of the rotator
cuff, labrum, capsules, and LHBT. The ultrasonography was performed in consensus by
two independent observers: one musculoskeletal radiologist and one orthopedic surgeon
different from the operating surgeon. All the ultrasonography scans were performed using
a Medison ACCUVIX V20 machine with 7.5–13 MHz linear array transducer (Medison
America, Inc., Cypress, CA, USA). Standard scanning techniques and positions were used
as described in previous studies [21,22]. The OMERACT US definitions for tenosynovitis,
synovitis, synovial hypertrophy, and effusion were applied [23]. The criteria for biceps
tendinosis were defined as the presence of an increased Doppler signal, plus one of the
following features: (1) thickening of the biceps tendon; (2) evidence of synovial thickening
of more than 3 mm; (3) evidence of fluid collection in the biceps tendon sheath of more
than 3 mm; and (4) splitting and hypoechoic change in the biceps tendon or a negative
Doppler signal but with two of the above mentioned features, as previously described [24].
Constant score [25], pain visual analog scale (PVAS), subjective shoulder value (SSV) [26],
ROM, O’Brien test, speed tests, and tenderness over the LHBT were investigated before the
operation and at final follow-up.
For radiological evaluation, the patients were evaluated preoperatively using a stan-
dardized radiographic examination (a true anteroposterior (AP) radiograph with the arm in
neutral rotation). The acromio-humeral distance (AHD) was measured in millimeters on the
AP radiograph. The critical shoulder angle (CSA) was measured between a line connecting
the inferior with the superior border of the glenoid fossa and another connecting the inferior
border of the glenoid with the most inferolateral point of the acromion [27]. Two indepen-
dent assessors assessed the AHD and CSA preoperatively and 2-year postoperatively.
The ultrasound scan for the LHBT and rotator cuff integrity was performed preopera-
tively and at final follow-up. LHBT were obtained in longitudinal and axial planes with
the forearm in supination and the elbow in 90◦ of flexion. The anatomic failure of tenodesis
was determined when the LHBT fibers were not traced longitudinally in the intertubercular
groove [28]. A finding of a rotator cuff tear was defined when there was a focal defect
extending from the bursal to the humeral side of the tendon or complete non-visualization
of the tendon [29].

2.3. Surgical Technique

All patients were placed in the beach chair position under general anesthesia with
interscalene block. ROM of the involved shoulder was examined in light force to rule out
patients with a pseudo-frozen shoulder [30]. Clinically, we found some included patients
with frozen shoulders revealed decreased ROM during consultation because of muscle
guarding and pain misdiagnosed with a frozen shoulder but had better mobility under
anesthesia. Manipulation was avoided to decrease the incidence of complications, such
as fractures of the humerus [31]. Traction device was not used to facilitate intra-operative
shoulder ROM to see if there was residual stiffness after release.

2.4. Intra-Articular Release

The diagnostic arthroscopy with a 30◦ arthroscope (1488 Full HD; Stryker, San Jose,
CA, USA) was firstly introduced from the standard posterior portal. Then, an anterior
portal was made with an outside-in technique using a 23-gauge needle. The trajectory of the
 fractures of the humerus [31]. Traction device was not used to facilitate intra-operative
shoulder ROM to see if there was residual stiffness after release.
Medicina 2022, 58, 1712 4 of 11
2.4. Intra-Articular Release
The diagnostic arthroscopy with a 30° arthroscope (1488 Full HD; Stryker, San Jose,
CA, USA) was firstly introduced from the standard posterior portal. Then, an anterior
needle
portal was parallel
was made withto an
theoutside-in
glenoid and the percutaneous
technique entrance
using a 23-gauge was
needle. lateral
The to theofcoracoid.
trajectory
Inthe
this approach,
needle we could
was parallel to themake
glenoidsureand thethe
radiofrequency wand reached
percutaneous entrance the bottom
was lateral to the of the
shoulder
coracoid.joint without
In this damaging
approach, we could cartilages
make sure of the
thehumeral head orwand
radiofrequency glenoid. The the
reached LHBT and
superior
bottom oflabrum were joint
the shoulder examined
without bydamaging
the probe to see ifofthere
cartilages was instability
the humeral or tear. Lots of
head or glenoid.
The LHBT and
synovium fluidsuperior
was oftenlabrum wereextravasate
found examined byfrom the probe to see if there
the bicipital waswhen
groove instability
pulling the
or tear.medially
LHBT Lots of synovium fluid was
with a probe often found
(Figure 1A). The extravasate
CHL and from the bicipital
superior groove when
glenohumeral ligament
pulling the LHBT medially with a probe (Figure 1A). The CHL and
(SGHL) were also cut to make sure there was no proximal impingement of the LHBT when superior glenohumeral
ligament
exiting the(SGHL)
groove.were also cut
If there to adhesion
was make sure between
there wasthe no proximal
LHBT and impingement of the of the
the undersurface
LHBT when exiting the groove. If there was adhesion between the LHBT and the
supraspinatus, the release was performed until the LHBT could slide freely. The rotator
undersurface of the supraspinatus, the release was performed until the LHBT could slide
interval was always covered by thick and erythematous synovium and fibrous tissues, as
freely. The rotator interval was always covered by thick and erythematous synovium and
well as neovascularization, in refractory frozen shoulder. Thorough release of RI (Figure 1B)
fibrous tissues, as well as neovascularization, in refractory frozen shoulder. Thorough
was performed with1B)
release of RI (Figure thewasradiofrequency
performed withwand until there was
the radiofrequency wand nountil
scarthere
tissuewasbetween
no the
subscapularis and coracoid. The medial glenoid humeral ligament
scar tissue between the subscapularis and coracoid. The medial glenoid humeral ligament (MGHL) was cut when
impingement
(MGHL) was cut waswhen
found during subscapularis
impingement was found excursion. The radiofrequency
during subscapularis excursion. The wand was
then extended downward
radiofrequency wand was then around the 6downward
extended o’clock position
around to therelease theposition
6 o’clock anteriortoband of
release
the IGHL theuntil
anterior band of part
the muscle the IGHL
of theuntil the muscle was
subscapularis part revealed
of the subscapularis
(Figure 1C). wasThen, the
revealed (Figure
arthroscopy was1C). Then,tothe
shifted thearthroscopy
anterior portalwas shifted
and theto the anterior portal wand
radiofrequency and thefrom the
radiofrequency
posterior portal.wand
Thefrom the posterior
shoulder was manuallyportal. Thekeptshoulder was manually
in 45 degrees kept in
abduction 45 neutral
and
degrees abduction and neutral rotation because the axillary nerve
rotation because the axillary nerve moved farther away than in the neutral arthroscopic moved farther away
than in the neutral arthroscopic setup position [32]. The release of the middle and
setup position [32]. The release of the middle and posterior band of IGHL was performed
posterior band of IGHL was performed as close as possible to the glenoid rim because the
as close as possible to the glenoid rim because the axillary nerve is closer to the humeral
axillary nerve is closer to the humeral insertion of the capsule [33]. Posteriorly, the release
insertion of the capsule [33]. Posteriorly, the release should involve the most superior band
should involve the most superior band of the posterior IGHL until the long head of the
oftriceps
the posterior
tendon wasIGHL until the (Figure
confirmed long head 1D).ofIfthe triceps
partial tendonsupraspinatus
articular was confirmed (Figure 1D).
tendon
Ifavulsion
partial articular supraspinatus tendon avulsion (PASTA) <50%
(PASTA) <50% of footprint involvement was found during the scope exam, it of footprint involvement
was
wouldfound during the
be debrided andscope exam,
left alone it would
without repair.be debrided and left alone without repair.

Figure 1. Surgical
Figure 1. technique
Surgical technique to to release
release right
right refractory
refractory frozenfrozen shoulder.
shoulder. (A) Viewing
(A) Viewing from posterior
from posterior
portal of right
portal rightshoulder. LotsLots
shoulder. of synovium fluid (arrow)
of synovium fluid extravasated from the bicipital
(arrow) extravasated from groove when groove
the bicipital
pulling
when the LHBT
pulling medially
the LHBT with a with
medially probe. (B) Thorough
a probe. release of
(B) Thorough rotator
release of interval with a with a
rotator interval
radiofrequency wand. (C) The radiofrequency wand was extended downward around the 6 o’clock
radiofrequency wand. (C) The radiofrequency wand was extended downward around the 6 o’clock
position to release the anterior band of the inferior glenohumeral ligament. (D) Viewing from anterior
portal with the radiofrequency wand introduced from posterior portal. The posterior IGHL should
be released until the long head of the triceps was seen. (E) Viewing from anterolateral portal in
the subacromial space. The greater and lesser tuberosities were used to define the location of the
LHBT and transverse humeral ligament. (F) Two tissue layers of transverse humeral ligament were
all released. The LHBT was pulled medially to reveal the bicipital groove. Any scar, adhesion,
abrasive osteophyte, and loose bodies should be removed at this time. AIGHL, anterior band of
inferior glenohumeral ligament; B, LHBT; BG, bicipital groove; G, glenoid; GT, greater tuberosity;
HH, humeral head; LT, lesser tuberosity; PIGHL, posterior band of inferior glenohumeral ligament;
RI, rotator interval; SSC, subscapularis; SSP, supraspinatus; THL, transverse humeral ligament.
Medicina 2022, 58, 1712 5 of 11

2.5. THL Release

After intra-articular release, the scope was shifted to subacromial space viewing from
the lateral portal. An anterolateral portal was also made to facilitate subacromial release.
Coracoacromial ligament (CAL) was preserved and acromioplasty was not performed.
After debridement of subacromial bursitis, the shoulder was put in an abduction–external
rotation position to see the anterior portion of the extra-articular shoulder joint. The LHBT
was easily located by probing the bicipital groove or pulling medially out of the groove
through the anterior portal. Greater and lesser tuberosity could be used to define the
location of LHBT (Figure 1E). Viewing from the anterolateral portal, THL was released
with a radiofrequency wand introduced from the anterior portal. The lateral border of the
opened rotator interval provided a good reference to start the release distally along with
the anatomy of the LHBT. Two tissue layers of the THL were all released. Then, the LHBT
was pulled medially to reveal the bicipital groove (Figure 1F). Any scar, adhesion, abrasive
osteophyte, and loose bodies should be removed at this time.
Following the release, a double-loaded suture anchor was inserted at the junction of
the bicipital groove and humeral head cartilage. One lasso loop and one simple stitch from
the same suture were passed through LHBT and fixed with 7 knots. The other suture was
passed through the LHBT in the same way 5 mm proximal to the first knot to secure the
LHBT. Finally, the fixed LHBT was cut at the level of the LHBT anchor. Care should be
taken not to leave an intra-articular huge stump.

2.6. Postoperative Care

All patients had sling protection for the initial 2 weeks right after the surgery. Then,
an aggressive rehabilitation program began with passive ROM exercises from 2 to 6 weeks
postoperatively. This was followed by active-assisted ROM exercises from 6 to 12 weeks
under the supervision of physical therapists in the hospital or self-stretches at home. All
patients had follow-up consultations at 2 weeks, 6 weeks, 6 months, and 2 years after
surgery. An ultrasonography exam was performed at the final follow-up to see the integrity
of the rotator cuff and LHBT by the first author, who had more than 10 years of experience
in surgery and ultrasonography.

2.7. Statistical Analysis

All statistical analyses were performed with IBM SPSS 25.0 for Mac (SPSS Inc., Armonk,
NY, USA). Continuous data were described by means and standard deviations. Paired
t-tests were used to analyze the difference between pre- and postoperative outcome scores
for constant score, PVAS, SSV, ROM, AHD, and CSA, respectively. Two-tailed p values of
less than 0.05 were considered significant. An a priori power analysis was conducted to find
the minimum sample needed to detect a difference in the preoperative and postoperative
PVAS, SSV, ROM, AHD, and CSA. With alpha = 0.05, power set at 80%, and a standard
deviation of 10, a minimum of thirty-three patients in each group was needed [34].

3. Results
The author performed 112 arthroscopic capsular releases for frozen shoulders. Of them,
20 patients were excluded because LHBT tenotomy was performed during the surgery and
another 31 patients were excluded due to having only pan-capsule release without LHBT
treatment. A total of 26 patients failed to attend the minimum requirement of at least a
2-year follow-up consultation, leaving 35 patients enrolled in the study (Figure 2).
 The author performed 112 arthroscopic capsular releases for frozen shoulders. Of
them, 20 patients were excluded because LHBT tenotomy was performed during the
surgery and another 31 patients were excluded due to having only pan-capsule release
without LHBT treatment. A total of 26 patients failed to attend the minimum requirement
Medicina 2022, 58, 1712 of at least a 2-year follow-up consultation, leaving 35 patients enrolled in the study (Figure 6 of 11
2)

Figure 2. Study flow chart.

3.1.
Figure 2. Cohort
Study Demographics
flow chart.
The study included 19 men (54%) and 16 women (46%), with a mean age of 53.1 ± 9
3.1. Cohort
(mean Demographics
± standard deviation) years (range, 36–74 years). The mean duration of symptoms
The
was 9.9 ±included
study 2.3 months19 men (54%)
(range, 6–12and 16 women
months). (46%),
Of the with a mean
35 operated age of 15
shoulders, 53.1 ± 9 were
(43%)
(mean on± standard
the right deviation)
side and 20years
(57%)(range,
were on 36–74 years).
the left. The of
A total mean duration
30 patients of symptoms
(86%) were right hand
was 9.9dominant, and 5(range,
± 2.3 months (14%) 6–12
had left-hand
months).dominance. The average
Of the 35 operated number15of(43%)
shoulders, injection
were (steroid,
on the hyaluronic
right side andacid, platelet-rich
20 (57%) were onplasma,
the left.etc.) before
A total of 30the index(86%)
patients surgery
werewas ± 2.1. The
5.2hand
right
patient
dominant, anddemographic
5 (14%) had data were listed
left-hand in Table 1.The average number of injection
dominance.
(steroid, hyaluronic acid, platelet-rich plasma, etc.) before the index surgery was 5.2 ± 2.1.
Table 1.
The patient Patient demographics.
demographic data wereData are presented
listed in Table 1.as mean ± SD; PASTA, partial articular supraspina-
tus tendon avulsion; SLAP, superior labrum anterior posterior tear.
Table 1. Patient demographics. Data are presented as mean ± SD; PASTA, partial articular
No. SLAP,
supraspinatus tendon avulsion; of Patients
superior labrum anterior posterior tear. 35
Age, y 53.1 ± 9
No.male:
Sex, of Patients
female, n 35
19:16
DominantAge,hand,y right: left 53.130:5± 9
Surgical side,female,
Sex, male: right: left
n 15:20
19:16
Duration of pain, month 9.9 ± 2.3
Dominant hand, right: left 30:5
Number of previous injections 5.2 ± 2.1
Surgical side, right:
Mean follow-up, month left 15:20
24 ± 1.5
Duration of pain,
Underlined diseasemonth
(%) 9.9 ± 2.3
NumberDiabetes mellitus
of previous injections 5 (14.3)
5.2 ± 2.1
Cancer month
Mean follow-up, 2 (5.7)
24 ± 1.5
Thyroid dysfunction 0
Underlined disease (%)
Previous trauma 4 (11.4)
Diabetes
Intra-operative finding othermellitus
than frozen shoulder (%) 5 (14.3)
Cancer
PASTA lesion 82 (22.9)
(5.7)
Biceps pulley
Thyroid dysfunctiontear 2 (5.7)
0
SLAP tear 1 (2.8)
Previous trauma 4 (11.4)
Intra-operative finding other than frozen shoulder (%)
3.2. Range of MotionPASTA lesion 8 (22.9)
After the surgery,
Biceps all patients
pulley tear experienced significant improvement
2 (5.7) in active ROM.
Preoperative forward elevation ranged from 105.1 ◦ ± 17◦ (mean ± standard deviation),
SLAP tear 1 (2.8)
and this increased to 147◦ ± 12◦ (p < 0.001) at final follow-up (Figure 3A). External rotation
improved
3.2. Range from 24.1◦ ± 13.3◦ to 50.9◦ ± 9.7◦ (p < 0.001) (Figure 3B), and internal rotation
of Motion
improved from 15.2 ± 2 (L3) to 8.6 ± 1.6 (T9) (p < 0.001) at final follow-up (Figure 3C).
 After the surgery, all patients experienced significant improvement in active ROM.
After the surgery, all patients experienced significant improvement in active ROM.
Preoperative forward elevation ranged from 105.1° ± 17° (mean ± standard deviation), and
Preoperative forward elevation ranged from 105.1° ± 17° (mean ± standard deviation), and
this increased to 147° ± 12° (p < 0.001) at final follow-up (Figure 3A). External rotation
this increased to 147° ± 12° (p < 0.001) at final follow-up (Figure 3A). External rotation
improved from 24.1° ± 13.3° to 50.9° ± 9.7° (p < 0.001) (Figure 3B), and internal rotation
Medicina 2022, 58, 1712 improved from 24.1° ± 13.3° to 50.9° ± 9.7° (p < 0.001) (Figure 3B), and internal rotation
7 of 11
improved from 15.2 ± 2 (L3) to 8.6 ± 1.6 (T9) (p < 0.001) at final follow-up (Figure 3C).
improved from 15.2 ± 2 (L3) to 8.6 ± 1.6 (T9) (p < 0.001) at final follow-up (Figure 3C).

Figure 3. Preoperative and postoperative range of motion. (A) Forward elevation improved from
Figure 3. Preoperative
3.±Preoperative andand postoperative
postoperative range
range of motion.
of motion. (A)(A) Forward
Forward elevation improved
elevation from
Figure
105.1° 17° to 147° ± 12°. (B) External rotation improved from 24.1° ± 13.3° to 50.9° ±improved from
9.7°. (C) Internal
105.1°
◦ ± 17°
◦ to 147°
◦ ± 12°. ◦(B) External rotation improved from 24.1° ± 13.3° to 50.9° ± 9.7°. (C) Internal
105.1 ± 17
rotation improved ± 1215.2
to 147 from . (B)
± 2 External
(L3) to 8.6rotation improved
± 1.6 (T9). * p valuefrom 24.1 ± 13.3 to 50.9 ± 9.7◦ .
< 0.001. ◦ ◦ ◦
rotation improved from 15.2 ± 2 (L3) to 8.6 ± 1.6 (T9). * p value < 0.001.
(C) Internal rotation improved from 15.2 ± 2 (L3) to 8.6 ± 1.6 (T9). * p value < 0.001.
3.3. Functional Assessment
3.3.3.3. Functional
Functional Assessment
Assessment
Before their operation, all patients had pain during the movement, positive O’Brien
Before their
Before operation,allall patients had pain during
thethe movement, positive O’Brien
test, speedtheir
tests,operation,
and tenderness patients had
over the pain
LHBT. during movement,
The preoperative PVASpositive
was 7.3O’Brien
± 1.1 and
test,
test, speed
speed tests,and
tests, andtenderness
tendernessover overthe
the LHBT.
LHBT. The preoperative
preoperative PVAS
PVAS was
was7.37.3±±1.11.1
and
improved to 1.8 ± 0.6 (p < 0.001) at the final follow-up. The constant score improved from
improved to 1.8 ± 0.6 (p < 0.001) at the final follow-up. The constant score
and improved to 1.8 ± 0.6 (p < 0.001) at the final follow-up. The constant score improvedimproved from
23.4 ± 11 to 80.7 ± 5.2 (p < 0.001), and SSV improved from 27.7 ± 10.5 to 77.4 ± 3.8 (p < 0.001),
23.423.4
from ± 11±to11
80.7 ± 5.2±
to 80.7 (p5.2
< 0.001), and SSV
(p < 0.001), andimproved from 27.7
SSV improved from± 10.5
27.7 to
± 77.4
10.5±to3.8 (p <±0.001),
77.4 3.8
respectively, at final follow-up (Figure 4).
(p respectively, at final follow-up
< 0.001), respectively, (Figure 4).
at final follow-up (Figure 4).

Figure
Figure 4. 4. Preoperative
Preoperative andand postoperative
postoperative functional
functional assessment.
assessment. (A)(A) PVAS
PVAS decreased
decreased from
from 7.37.3 ± 1.1
± 1.1
Figure 4. Preoperative and postoperative functional assessment. (A) PVAS decreased from 7.3 ± 1.1
to to 1.8
1.8 ± ±0.6.
0.6. (B)
(B) Constant
Constant score
score improved
improved from
from 23.4
23.4±±1111toto
80.7 ± 5.2.
80.7 ± (C) (C)
5.2. SSVSSV
improved
improvedfromfrom
to 1.8 ± 0.6. (B) Constant score improved from 23.4 ± 11 to 80.7 ± 5.2. (C) SSV improved from 27.7 ±
27.7 ±
10.5
± to 77.4
to±±77.4
3.8. PVAS,
3.8. pain visual analog
visualscale; SSV,scale;
subjective shoulder value. * p value < 0.001.
27.710.5 10.5
to 77.4 3.8. ±
PVAS, PVAS,
pain pain
visual analog analog
scale; SSV, subjective
SSV, subjective shoulder
shoulder value. value.
* p value * p
< 0.001.
value < 0.001.
3.4. Image Assessment
3.4. Image Assessment
3.4. Image
All Assessment
patients had thickened CHL and capsular thickening in the axillary recess on
All patients had thickened CHL and capsular thickening in the axillary recess on
All patients MRI.
preoperative had thickened
EffusionCHL and capsular
around the LHBT thickening
was in the axillaryobserved
commonly recess on pre-from
preoperative MRI. Effusion around the LHBT was commonly observed from
operative MRI. Effusion
ultrasonography around
and MRI the LHBT
before surgery.was commonly
There were no observed from
significant ultrasonography
differences between
ultrasonography and MRI before surgery. There were no significant differences between
and MRI beforeand
preoperative surgery. There were
postoperative AHD no significant
(9.5 ± 2.1 vs.differences
10 ± 1.8, pbetween preoperative
= 0.316) and CSA (38.3and ± 5.8
preoperativeAHD
postoperative and postoperative
(9.5 ± 2.1 vs. AHD
10 ± (9.5p±=2.1
1.8, vs. 10
0.316) ± 1.8,
and CSA p =(38.3
0.316)
± andvs.
5.8 CSA (38.3
38.2 ± ± 5.8
5.4,
vs. 38.2 ± 5.4, p = 0.895) (Figure 5). On ultrasound evaluation at final follow-up, one (5.7%)
p= vs. 38.2 ±
0.895) had 5.4,
(Figurep = 0.895)
5). of (Figure
Ontheir 5).
ultrasound On ultrasound
evaluation evaluation at final
at final follow-up, follow-up, one (5.7%)
patient a retear LHBT with Popeye deformity; no rotatoronecuff(5.7%)
tear morepatient
than
hadpatient had
a retear a retear of
of their LHBT their LHBT
with(22.9%) with
PopeyePASTA Popeye
deformity; deformity;
noremainedno rotator
rotator cuff cuff
tear more tear more than
than under
50%
50% was diagnosed. The eight lesions unchanged in sizes
was50% was diagnosed.
diagnosed. The eight
The eight (22.9%)
(22.9%) PASTA PASTA lesions
lesions remained
remained unchanged
unchanged in sizes
in sizes under
under
ultrasound examination.
ultrasound examination.
ultrasound examination.
 Medicina 2022, 58, x FOR PEER REVIEW 8 of 11
Medicina 2022, 58, 1712 8 of 11

Figure 5. Preoperative and postoperative image assessment. (A) Preoperative AHD was 9.5 ± 2.1,
Figure 5. Preoperative and postoperative image assessment. (A) Preoperative AHD was 9.5 ± 2.1,
and postoperative AHD was 10 ± 1.8, p = 0.316. (B) Preoperative CSA, 38.3 ± 5.8, and postoperative
and postoperative AHD was 10 ± 1.8, p = 0.316. (B) Preoperative CSA, 38.3 ± 5.8, and postoperative
CSA, 38.2±±5.4,
CSA,38.2 5.4,p p==0.895.
0.895.AHD,
AHD,acromio-humeral
acromio-humeraldistance;
distance;CSA,
CSA,critical
criticalshoulder
shoulderangle,
angle,Pre-OP,
Pre-OP,
preoperative; Post-OP, postoperative.
preoperative; Post-OP, postoperative.
4. Discussion
4. Discussion
Our study revealed that patients with refractory frozen shoulder and pain benefited
Our study revealed
from pan-capsular release,thatTHLpatients
release,with and refractory
LHB tenodesis. frozenInshoulder
addition,and thepain benefited
radiological
from pan-capsular release, THL release, and LHB tenodesis.
parameters, such as AHD and CSA, did not change after surgery, implying a radiographic In addition, the radiological
parameters,
balanced such joint
shoulder as AHD wasand CSA, dideven
maintained not change
after such after surgery,release.
extensive implying a radiographic
Frozen shoulder
balanced shoulder joint was maintained even after
is an inflammatory disease with spontaneous onset impairing all the directions of gleno-such extensive release. Frozen
shouldermotion
humeral is an inflammatory
[1]. It is oftendiseaseregarded withasspontaneous
a self-limiting onset impairing
disease all the directions
that resolves within
3 of glenohumeral
years. However, variousmotion studies
[1]. It ishave
oftenshownregarded as aoutcomes
inferior self-limiting anddisease
long-lastingthat resolves
symp-
within 3 years. However, various studies have shown inferior
toms with conservative treatments [35,36]. When conservative treatment failed, Smith et al. outcomes and long-lasting
symptoms
found that 50% withand conservative
80% of patients treatments
had good [35,36]. Whenwithin
pain relief conservative treatment
1 and 6 weeks failed,
of arthro-
Smith et al. found that 50% and 80% of patients had good
scopic capsular release [7]. Le Lievre et al. observed all patients had improvement in pain relief within 1 and 6 weeks
of arthroscopic
pain frequency and capsular release
severity, [7]. Le Lievre
shoulder function, et al. observed
and ROM at allapatients
long-term hadfollow-up
improvement of
7 in pain[10].
years frequency
On theand other severity,
hand, LHBT shoulder function,
is also a commonand ROM source at of
a long-term
pain in the follow-up
shoulder,of
7 years
and [10]. difficult
it is often On the other hand, clinically
to identify LHBT is also whena LHBT
common source of
pathology pain inwith
coexists the ashoulder,
frozen
and it is Intra-articularly,
shoulder. often difficult to Hagiwara
identify clinically when LHBT
et al. reported pathology
the presence coexists withcapsule
of superomedial a frozen
shoulder.
and the LHBT Intra-articularly,
adhesion with Hagiwara
synovitis in etdiabetic
al. reported the presence
patients of superomedial
with decreased ROM [13]. capsule Extra-
and the LHBT
articularly, Tayloradhesion with synovitis
et al. demonstrated thatin 47%diabetic patients symptomatic
of chronically with decreased ROMhad
patients [13].
hidden extra-articular
Extra-articularly, TaylorLHBT lesions,
et al. such as adhesion,
demonstrated that 47% LHBT instability,
of chronically stenosis, abrasive
symptomatic patients
osteophyte,
had hiddenLHBT partial tear,
extra-articular and loose
LHBT lesions, bodies.
such as Among them,LHBT
adhesion, 45% of patients with
instability, an
stenosis,
intra-articular
abrasive osteophyte,LHBT lesionLHBTalso had tear,
partial hidden andtunnel
loose lesions
bodies. extra-articularly.
Among them, 45% High levels
of patients
ofwith
inflammatory cytokines,
an intra-articular LHBT degenerative
lesion also mediators,
had hiddenand nociceptive
tunnel molecules were also
lesions extra-articularly. High
observed within the bicipital groove [37], causing pain
levels of inflammatory cytokines, degenerative mediators, and nociceptive molecules in the shoulder and warranting
release.
were also Soifer et al. identified
observed within theneurofilaments
bicipital groove and peripheral
[37], causing nerves
pain inwithin
the shoulderthe LHBT, and
tendon
warrantingsheath, and THL
release. Soiferin et
14 al.
cadaveric
identified shoulders [38]. Snow
neurofilaments andetperipheral
al. demonstrated
nerves within two
tissue layers intendon
the LHBT, THL. Neurohistological
sheath, and THL staining
in 14 revealed
cadaveric the presence
shoulders of free
[38]. nerve
Snow endings
et al.
indemonstrated
both layers, which suggests
two tissue layersTHL has a Neurohistological
in THL. potential role as a shoulder pain generator
staining revealed [17].
the presence
Therefore, we enrolled patients with painful refractory frozen shoulders
of free nerve endings in both layers, which suggests THL has a potential role as a shoulder who failed conser-
vative
pain treatment
generatorand [17].performed
Therefore, not weonlyenrolled
pan-capsule release
patients intra-articularly
with but also frozen
painful refractory THL
release extra-articularly to avoid inadequate treatment for
shoulders who failed conservative treatment and performed not only pan-capsule releasesuch complicated situations. A
proximal LHBT tenodesis was also performed to prevent LHBT
intra-articularly but also THL release extra-articularly to avoid inadequate treatment for instability after the exten-
sive
suchrelease, including
complicated the whole
situations. RI, SGHL,LHBT
A proximal and THL, whichwas
tenodesis provides soft tissueto
also performed restraint
prevent
for LHBT stability. In our result, only one (2.8%) patient
LHBT instability after the extensive release, including the whole RI, SGHL, and had retear or dislocation of fixed
THL,
LHBT
whichat provides
follow-up.soft A total
tissue of restraint
97.2% of patients
for LHBT had healed LHBT
stability. In ourinsideresult,bicipital
only one groove.
(2.8%)
We did
patient had not repair
retear the PASTA
or dislocation of lesion
fixed LHBTwhen at it follow-up.
involved less thanof50%
A total 97.2% of ofthe foot-
patients
print. One reason is that most
had healed LHBT inside bicipital groove. studies suggest PASTA repair when there is greater than
50% of the tendon footprint and tendon thickness involved [39]. The other reason is, as
We did not repair the PASTA lesion when it involved less than 50% of the footprint.
Ueda et al. demonstrated, shoulder stiffness with severe and global loss of passive ROM
One reason is that most studies suggest PASTA repair when there is greater than 50% of
is not associated with full-thickness rotator cuff tears, although some patients may have
a partial-thickness tear [40]. We choose not to repair the PASTA lesion because it may
Medicina 2022, 58, 1712 9 of 11

be irrelevant to the clinical condition of our patient group. Our results proved that the
pan-capsular release without PASTA repair did not significantly change the AHD and CSA
of the treated shoulder at final follow-up.
In our study, we preferred THL release to relieve the anterior shoulder pain and
suprapectoral LHBT tenodesis to prevent LHBT instability because of the extensive release
of RI and SGHL. There are plenty of debates about where to fix the LHBT. Sanders et al.
reported a higher revision rate for proximal arthroscopic tenodesis than distal (35.7% vs.
2.7%). However, patients in their group of proximal tenodesis had a lower revision rate
(2.4%) when the bicipital sheath was released, compared to those not released (13.4%) [14].
When comparing the result of proximal versus distal tenodesis, Lutton et al. demonstrated
that 2 of the 5 patients with tenodesis within the upper half of the bicipital groove had
persistent pain at the tenodesis site, requiring further debridement surgery, while the other
12 patients with tenodesis in the lower half of the groove or shaft were free of symptoms [41].
Our study echoed their results by releasing the THL to avoid the unwanted bicipital groove
pain after the LHBT tenodesis. Additionally, we wanted to prevent the complications
of subpectoral LHBT tenodesis, such as brachial plexus injury [42], musculocutaneous
nerve palsy [43], and proximal humeral fractures [44]. Since the LHBT was well-fixed by
two sutures, we encourage our patients to move aggressively after the surgery. This may
contribute to our good results showing significant improvement in all directions of ROM
and functional movement.
There were limitations of this study. First, this was a retrospective study and as such
had inherent bias. The second limitation was the indication of the surgery. Most patients
with frozen shoulder respond well to conservative treatments. Therefore, we only enrolled
patients with refractory frozen shoulders who failed plenty of injections and physiotherapy.
Additionally, patients with diabetes did not respond as well toward surgical release as
patients without diabetes [45]. In such patients, the author prefers LHBT tenotomy to
tenodesis. Further study should focus on these patients to see if they would have lesser,
equivalent, or improved outcomes with either arthroscopic pan-capsular release alone, or
an arthroscopic pan-capsular release with an LHBT tenotomy. Only 14.3% in our patient
cohort had diabetes under good medical control and received LHBT tenodesis. Further
study should focus on the role of LHB tendonitis in frozen shoulder and how to treat it,
along with pan-capsular release as the close anatomical proximity of LHBT at the anterior
shoulder, which makes it “difficult to define, difficult to treat and difficult to explain” as
Earnest Codman described [46]. Third, we lacked a control group of either no surgery or
pan-capsular release without LHBT treatments, which would have allowed us to compare
the groups to determine if this would alter the surgeon’s practice decisions.

5. Conclusions
Patients with refractory frozen shoulder and pain benefited from pan-capsular and
THL release. A balanced shoulder joint was maintained even after such extensive release.

Author Contributions: Conceptualization, C.-H.C. and H.S.; methodology, C.-H.C. and P.C.; software,
D.B.; validation, Y.-S.C. and A.C.-Y.C.; formal analysis, C.-H.C.; investigation, H.S.; resources, C.-H.C.;
data curation, C.-H.C.; writing—original draft preparation, H.S.; writing—review and editing, C.-
H.C.; visualization, C.-H.C.; supervision, C.-H.C.; project administration, C.-H.C.; funding acquisition,
C.-H.C. All authors have read and agreed to the published version of the manuscript.
Funding: This research was funded by “Chang Gung Memorial Hospital, grant number CM-
RPG5K0092” and “Taiwan Minister of Science and Technology, grant number MOST 111-2628-
B-182A-016-”.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki and approved by the Institutional Review Board of Chang Gung Medical Foundation
Institutional Review Board, IRB 201900352B0.
Informed Consent Statement: Written informed consent has been obtained from the patients to
publish this paper.
Medicina 2022, 58, 1712 10 of 11

Data Availability Statement: Not applicable.

Acknowledgments: The authors gratefully thank Taiwan Minister of Science and Technology and
Linkou Chang Gung Memorial Hospital for financial support of this study (Grant: MOST 111-2628-B-
182A-016-, CMRPG5K0092).
Conflicts of Interest: The authors declare no conflict of interest.

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