REVIEW ARTICLE
Management of Postoperative Shoulder Stiffness
Francesco Franceschi, MD,* Rocco Papalia, MD,* Alessio Palumbo, MD,* Sebastiano Vasta, MD,*
Nicola Maffulli, MD, MS, PhD, FRCS(Orth),w and Vincenzo Denaro, MD*
Abstract: Arthroscopic surgery has become the most popular
treatment to repair rotator cuff tears. Although the exact pre-
valence of postoperative stiffness is unknown, many studies report
an incidence rate of 4% to 15%. Management of postoperative
shoulder stiffness depends on the cause of the stiffness. Non-
operative and operative management modalities are available, but
postoperative shoulder stiffness is often resistant to nonsurgical
management. When conservative treatment fails, surgical release of
the scar tissue and adhesions can be performed both by arthro-
scopic or open surgery. Arthroscopic capsular release is the pre-
ferred technique for capsule contraction and adhesion formation,
as it allows precise and selective debridement of the scar tissue and
division of the shortened and thickened capsule by partial or
extensive capsulectomy.
Key Words: postoperative stiffness, shoulder, capsular release,
manipulative therapy, rehabilitation program, preventing shoulder
stiffness
(Sports Med Arthrosc Rev 2011;19:420–427)
A rthroscopic rotator cuff repair has become the most
popular surgical treatment for rotator cuff pathology
over the last 2 decades, and now provides safe results and
limited rates of failure.1–8 Despite the increasing interest in
arthroscopic procedures, little is known about the compli-
cations of arthroscopic rotator cuff repair,6,9,10 and above
all about postoperative stiffness.11–13 Patients with post-
operative shoulder stiffness report dissatisfaction with pain
management and gradual loss of all planes of shoulder
motion: this is related to postoperative adhesions and
capsular contracture.14 However, it is necessary to differ-
entiate the various conditions leading to postoperative
shoulder stiffness. Four types of stiffness after rotator cuff
repair have been identified 15: (1) stiffness without a retear
of the repaired rotator cuff; (2) stiffness with a retear of the
repaired rotator cuff; (3) stiffness with untreated osteo-
arthritis; and (4) stiffness with nerve or deltoid injury. The
exact prevalence of this problem after rotator cuff repair
has never been studied specifically.14 Brislin et al16 reported
in a case series that stiffness was the most common
complication (23 of 263 patients). Postoperative stiffness
rates range from 4% to 15%,15,16 with a wide range in
incidence depending on the different criteria used to define
From the *Department of Orthopaedic and Trauma Surgery, Campus
Biomedico University of Rome, Rome, Italy; and wCentre for
Sports and Exercise Medicine, Barts and The London School of
Medicine and Dentistry, Mile End Hospital, London E1, England.
Disclosure: The authors declare no conflict of interest.
Reprints: Nicola Maffulli MD, MS, PhD, FRCS(Orth), Centre Lead
and Professor of Sports and Exercise Medicine, Centre for Sports
and Exercise Medicine, Barts and The London School of Medicine
and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1
4DG, England (e-mail: n.maffulli@qmul.ac.uk).
Copyright r 2011 by Lippincott Williams & Wilkins
420 | www.sportsmedarthro.com Sports Med Arthrosc Rev
stiffness.16 Although loss of motion is considered the most
frequent complication after arthroscopic rotator cuff
repair, most studies report excellent outcomes, with good
mobility 1 and 2 years after surgery.12,17,18
RISK FACTORS
Many patient-specific factors are associated with a
higher risk for developing postoperative shoulder stiffness,
including diabetes mellitus, hypothyroidism, infection,
prior keloid formation, arthroscopic evacuation of calcific
deposits from the bursa or rotator cuff tendons, low pain
tolerance, history of complex regional pain syndrome and
chronic pain, and dependent personality.14,15 However, the
role of most of these conditions is still controversial.
Diabetes mellitus has been reported as a great risk factor
for developing limited joint motion.15,19,20 Hsu et al21 and
Ogilvie-Harris et al,22 on the other hand, showed that
diabetes mellitus does not exert a negative effect on the
outcome of the surgical treatment of rotator cuff tears and
its associated stiffness.16,23–26 Early postoperative mobili-
zation with pendulum exercises and passive motion is
recommended to prevent the onset of stiffness,16,23–26
whereas some studies have demonstrated that a period of
immobilization can favor better tissue healing.27,28 In
primary or idiopathic stiff shoulder from adhesive capsu-
litis, cytokines, inflammatory cell products, and platelet-
derived growth factors may have a role as pathogenetic
factors in scar tissue and adhesion formation.29–31 The
same mechanism could be involved in the onset of
postoperative shoulder stiffness21 (Fig. 1).
DIAGNOSIS
The first step in choosing the best treatment option is
to identify the cause of shoulder stiffness. It is necessary to
perform a complete physical examination including an
evaluation of skin sensitivity (to assess nerve injuries),
muscle defects (in case of deltoid dehiscence or injury of the
axillary nerve), occult signs of infections, and referred
problems of the neck, together with impingement and
instability tests also investigating possible residual impinge-
ment syndrome, acromio-clavicular joint disease or biceps
tendon disease.32 Active and passive range of motion
assessment should include flexion, abduction, and internal
and external rotation in adduction and at 90 degrees of
abduction and cross-arm adduction (horizontal flex-
ion).13,33 A detailed history taking can give important
information on the etiology of the stiffness, for example,
prolonged immobilization without passive range of motion
exercises, inadequate postoperative pain control or low
pain threshold, use of inappropriate loads or falls, and
other traumas leading to a retear of rotator cuff tendons. A
subacromial injection of local anesthetic can help in
assessing how much pain influences shoulder mobiliza-
tion.34 Imaging assessments should start with radiographs
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Sports Med Arthrosc Rev  Volume 19, Number 4, December 2011
FIGURE 1. Intra-articular view through an anterior arthroscopic
portal, right shoulder. CT indicates capsule tissue; HH, humeral
head; L, labrum; SS, subscapularis.
including an anteroposterior shoulder view, Grashey view
(anteroposterior glenohumeral joint view), a scapular outlet
view, and an axillary view. Magnetic resonance imaging
arthrography can be useful in determining not only the
presence of capsule contraction but also possible rotator
cuff retears, and the degree of muscle atrophy or fatty
degeneration. However, the presence of artifacts can make
the correct interpretation of the images difficult.35
MANAGEMENT
Management of postoperative stiffness follows the
criteria used for all clinical conditions that lead to limited
range of movement (ROM). Nonsurgical and surgical
treatment options are available to manage a stiff shoulder.
NONSURGICAL MANAGEMENT
Oral Drug Administration and Injection
The first line of treatment is conservative, and only
after failure of conservative measures, should surgery be
considered. Physical therapy programs associated with
aggressive passive stretching and dynamic bracing can be
effective in idiopathic adhesive capsulitis,36 but postoper-
ative shoulder stiffness is often resistant to these modal-
ities.13,15,33,37 Pain and inflammation can be managed with
intra-articular injections of steroids or oral administration
of steroids or nonsteroidal anti-inflammatory drugs. Good
outcomes by these measures may be possible if shoulder
stiffness is diagnosed early.
SURGICAL MANAGEMENT
Surgical management is generally advocated in
patients with a stiff shoulder from intra-articular and
extra-articular scar tissue and adhesion formation, which
responds poorly to nonoperative measures.
Manipulative Therapy
Manipulation should start first with forward flexion
(elevation of the arm in the sagittal plane while the scapula
is stabilized by placing one hand along its axillary border).
The arm is then passively flexed forward in the sagittal
plane to the maximum possible extent. Passive external
rotation is performed at 0 degree of abduction, followed by
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Management of Postoperative Shoulder Stiffness
external rotation at 90 degrees of abduction. The scapula is
manually stabilized at each movement, and rotation of the
shoulder is performed by rotating the humerus at the elbow
level, rather than at the level of the forearm or hand, so as
to protect the elbow ligaments.38,39 All these movements
should be performed gently to prevent fractures of the
humerus.
Arthroscopic Capsular Release
When the stiff shoulder is refractory to manipulative
therapy, it can be dangerous to apply aggressive forces on
the scapulohumeral articulation because of the risk of
humeral fracture, dislocation or rotator cuff retear.40–42
However, although the manipulation could be successfully
performed, outcomes are highly variable, and the gain of
motion and pain reduction may be transient.43–45
Capsular release can be performed both by open or
arthroscopic approaches. Arthroscopic capsular release is
the preferred technique for treating postoperative shoulder
stiffness from capsule contraction and adhesion formation.
It allows precise and selective debridement of scarred
tissues and division of the shortened and thickened capsule
by partial capsulectomy.13,33,37,39,46,47
An arthroscopic procedure also allows evaluation for
the possible presence of other intra-articular and/or
subacromial causes of shoulder stiffness.14,15 Another
advantage is reduced postoperative morbidity due to the
limited dissection involved (Fig. 2).37
The target of the arthroscopic procedure is to release
the posterosuperior and anterosuperior capsule, and the
rotator interval (Figs. 3, 4).15,48,49
Finally, it is important to address the subacromial and
subdeltoid spaces arthroscopically from anterior to poste-
rior, the lateral recesses, and the bursal side of the rotator
cuff extending medially to the acromioclavicular joint and
the scapular spine. Adhesions that restrict motion can be
present in these regions. An arthroscopic shaver and
electrocautery or a radiofrequency device can be used for
lysis of adhesions.15,48
Surgical Technique: Anterior Release50
Both adducted and abducted positions of the shoulder
allow effective safe release of the anterior capsule from the
inferior aspect of the biceps to the inferior glenoid. When it
is impossible to identify the subscapularis, a conversion to
an open approach is mandatory. An electrocautery is
generally used to effectively release the capsulolabral
complex posterior to the subscapularis. The first released
region is the capsule at the rotator interval in which the
adhesive capsulitis could be remarkably thick (Fig. 4). The
releasing process starts just underneath the biceps tendon
and continues to the superior margin of the subscapularis
tendon.13 At times, it is necessary to extend the release to
the base of the coracoid process. Hatch et al51 suggest also
releasing the axillary pouch (the region from approximately
5-o’clock to 7-o’clock position consisting the inferior
glenohumeral ligament complex) when motion loss persists
even after the complete release of the anterior capsule. This
will restore external and internal rotation in abduction and
pure abduction with the arm in neutral position. A release
anterior to the subscapularis is generally not necessary;
also, it should be kept in mind that a release in this area
carries a high risk for neurovascular injuries (axillary
nerve). Arthroscopic acromioplasty is generally not per-
formed because the bleeding bony surface could favor the
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Franceschi et al
FIGURE 2. Gleno-humeral space inflammation after shoulder operative treatment: anterior arthroscopic portal and right shoulder. A,
Rotator interval inflammed. B, Opened anterior-inferior capsular. AIG indicates anteroinferior glenoid; ASL, anterosuperior labrum; CD,
capsule detached; RI, rotator interval; SS, subscapularis.
formation of adhesions. However, Hsu et al21 recommend a
combined procedure of manipulation, lysis of adhesions,
and acromioplasty. Arthroscopy can be performed keeping
the patient in either the beach chair or in lateral position.
FIGURE 3. Interval rotator cuff view through an anterior
arthroscopic portal, right shoulder. HH indicates humeral head;
HS, hypertrophic synovitis; RI, rotator interval; SS, subscapularis.
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Sports Med Arthrosc Rev  Volume 19, Number 4, December 2011
Attention must be paid to introducing the arthroscope in
the glenohumeral space, because the presence of scar tissue
and of fibrotic adhesions can lead to a capsular contraction
and to a markedly reduced joint volume, increasing the risk
for articular injury from forceful insertion of the arthro-
scope (Fig. 5).
Surgical Techniques: Posterior Release50
The release of the posterior capsule is performed by
placing the arthroscope through an anterior portal, whereas
an arthroscopic cannula is placed posteriorly. The release
process starts from the capsule posterior to the biceps tendon
and continues into the region of the posterior labrum. The
posterior release is considered complete when the infra-
spinatus muscle is visible. In this phase, iatrogenic rotator
cuff tendon injury may occur from the posterior confluence
between the capsule and the infraspinatus tendon. Warner
and Greis13 advocate release of the posterior capsule from 11
o’ clock to 8 o’clock (right shoulder) (Fig. 5).
Open Capsular Release
Capsular release can also be performed by open
surgery in patients who have contraindications to arthro-
scopic release or in cases where it fails to restore
motion.13,51,52 The open release can be performed through
the standard deltopectoral or anterosuperior deltoid-split-
ting approach. The first is frequently used because it allows
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Sports Med Arthrosc Rev  Volume 19, Number 4, December 2011 Management of Postoperative Shoulder Stiffness

FIGURE 4. Arthroscopic capsular release through an anterior arthroscopic portal, right shoulder. A, Opening of the rotator interval with
the termal device. B, Cutting the Superior glenohumeral ligament. C, Cutting the middle glenohumeral ligament. D, Cutting the
inferior Anterior-inferior glenohumeral ligaments. AC indicates anterior capsule; CAL, coracoacromial ligament; G, glenoid; HH, humeral
head; MGHL, medial glenohumeral ligament; RI, rotator interval; SS, subscapularis; TD, termal device.

a better access to soft tissues and to intra-articular
structures. The main advantages of the open techniques
are the possibility to lengthen the subscapularis tendon and
to address bony deformity or retained hardware.51
POSTOPERATIVE MANAGEMENT
Anesthetic Therapy
Indwelling interscalene catheters can be effective in
reducing postoperative pain. The indwelling interscalene
catheter can be maintained up to 48 hours, providing a
continuous slow infusion of local anesthetic. This can
provide postoperative pain control, allowing a more
aggressive physical therapy.53 The use of intra-articular
pain pump catheters should be avoided because of the risk
of chondrolysis.54–56
Rehabilitation Program
The target of postoperative care is to restore pain-free
motion. A number of studies have been conducted
evaluating the outcome of arthroscopic capsular release.
The rehabilitation programs are variable among different
investigators (Table 1). There is general agreement37–39,59,62,63
on starting a passive range of motion exercises in the
immediate postoperative period. Strengthening exercises are
recommended to be started as soon as the pain and the
shoulder active motion allow. We advocate physical
therapy twice a day for at least the first 2 postoperative
days, graduating to 3 to 5 times per week for 4 to 6
weeks.37,39,58–63
DISCUSSION
Management of postoperative shoulder stiffness de-
pends on its cause. Stiffness could result from fibrotic
inflammation of the capsule (global or limited), to scarring
and adhesions between the deltoid and the rotator cuff, or
the deltoid and the proximal humerus.24 In addition, retear
of the rotator cuff, excessive tensioning of the rotator cuff
tendons, muscle failure (deltoid avulsion or atrophy), or
nerve injury (brachial plexus, axillary or suprascapular
nerves) must be kept in mind as possible causes of shoulder

FIGURE 5. Results after arthroscopic capsular release through an anterior arthroscopic portal, right shoulder. A, Partial capsular release.
B, Open Interval rotators cuff. AC indicates anterior capsule; C, coracoid; HH, humeral head; MGHL, medial glenohumeral ligament; RI,
rotator interval; SS, subscapularis.

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Franceschi et al Sports Med Arthrosc Rev  Volume 19, Number 4, December 2011

TABLE 1. Postoperative Rehabilitation Programs in Studies Reporting the Outcomes of the Arthroscopic Capsular Release
Study Timing
Nicholson57 Immediately after surgery
Andersen et al38 Immediately after surgery
Elhassan et al58 Immediately after surgery
Harryman et al59 Immediately after surgery
Holloway et al39 Immediately after surgery
Pearsall et al60 First week after surgery
Segmueller et al61 First week after surgery
Warner37 On the first postoperative
day
Gerber et al62 Immediately after surgery
Jerosch63 Immediately after surgery
Timing and Features
of Postoperative Rehabilitation Program
Passive Motion Strengthening Exercise
Three times/wk for the first 3 wk. Then 2 After at least 6 wk
times/wk for the next 3 wk
Continuous passive exercises
supplemented with a CPM machine
applied for 4 hours, twice each day
Supervised physical therapy was
performed 5 days/wk for the first 2 wk
and then usually 3 d/wk for the next 2 wk
Exercises to be performed 5 times a day for
5 min per exercises (5 repetitions of
stretches in forward elevation, external
rotation at the side, internal rotation up
the back, and cross-body adduction)
Assisted passive forward elevation with the Strengthening with use of
patient supine, passive external rotation Therabands is not begun
with the arm by the side, passive external until the patient had
rotation with the arm in abduction, minimal pain with the
assisted passive internal rotation up the range of motion of the
back, and assisted passive cross-body shoulder
adduction
Progressive passive and active-assisted
range of motion exercises including
aquatics
Physiotherapy was conducted 2 to 3 times/
wk for an average of 6 wk
For the first 2 wk, the patients attend daily
supervised physical therapy (passive
range-of-motion exercises and self-
assisted motion exercises) sessions in an
outpatient facility 5 times each week and
performed a home-exercise program.
Then it is reduced to supervised physical
therapy 3 times each week for the next 2
weeks
Passive physical therapy for the first 2 to 4
days after surgery. Successively a
rehabilitation program 3 times weekly
and directed toward regaining passive
range of motion with an emphasis on
anterior elevation is executed
For the first 6 wk, patients performed twice Strengthening of the
a week a supervised physical therapy muscles of the shoulder
sessions in outpatient facilities; begin as soon as
additionally patients perform a home postoperative pain and
exercise program active shoulder motion
allow it

stiffness. Although physical therapy programs with partic-
ular attention to passive stretching and sometimes dynamic
bracing are also effective in the management of primary
shoulder stiffness deriving from adhesive capsulitis,36 the
same measures are often ineffective for the management of
postoperative stiffness.33,37,48
Managing Shoulder Stiffness With Manipulative
Therapy
There are contrasting opinions on manipulative
therapy. Some investigators 38,64 believe that manipulation
with or without anesthesia can be a valid option when drugs
fail. However, there are studies showing that although
manipulation under anesthesia may be useful in idiopathic
adhesive capsulitis, it is generally not helpful in patients
with stiffness after a rotator cuff repair, probably because of
the presence of extra-articular adhesions in addition to
capsular contractures that can be resistant to manipula-
tions.33,37,52
Arthroscopic Capsular Release to Manage the
Stiff Shoulder
Many surgeons13,15,59 consider it appropriate to
surgically approach shoulder stiffness when a 6-month
regimen of conservative measures has failed to restore a
painless shoulder.59 In 30 patients with refractory shoulder
stiffness treated arthroscopically, shoulder motion im-
proved on average 78% on the first day after surgery, and

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Sports Med Arthrosc Rev  Volume 19, Number 4, December 2011
an additional 15% of motion was gained by the time of
discharge from the hospital.59 On comparing the operated
arm with the contralateral, the final motion averaged 93%
of the nonoperated arm. In addition, 73% of patients were
able to sleep comfortably on the affected side and 83% of
patients could raise 1 lb at shoulder height after surgery.
Holloway et al39 evaluated the results of arthroscopic
capsular release in 50 patients with shoulder stiffness
refractory to nonoperative management and manipulation
under anesthesia. Patients were divided into 3 different
groups: idiopathic frozen shoulder, shoulder stiffness after
surgery, and shoulder stiffness after fracture. At a mean of
20 months after arthroscopic capsular release, each group
showed significant improvement in the scores for pain,
patient satisfaction, and functional activity as well as in the
overall outcome score. On comparing the scores among the
3 different groups, all had a similar degree of improvement
in range of motion of the affected shoulder. However, there
was less improvement in the subjective scores for pain,
function, and patient satisfaction in the postoperative
group. Gerber et al62 evaluated 45 stiff shoulders that
underwent arthroscopic capsular release. They demon-
strated improvement in range of motion, pain scores, and
Constant scores. Patients with idiopathic stiff shoulder
improved more than patients with posttraumatic and post-
operative adhesive capsulitis. In contrast, some studies
of arthroscopic release have found no significant differ-
ence between shoulder stiffness of different etiologies.
Nicholson57 managed with arthroscopic capsular release
68 patients with shoulder stiffness secondary to 5 different
etiologies: idiopathic, postsurgical, posttraumatic, diabetic,
and impingement syndrome with secondary stiffness.
Arthroscopic capsular release was effective in relieving pain
and restoring function and motion to comparable levels in
all of them. Tauro12 evaluated the stiffness of the shoulder
in patients with cuff tears that occur before repair to
determine whether preoperative stiffness persists after cuff
repair. Seventy-two patients, divided into 3 groups on the
basis of total ROM deficit, underwent arthroscopic rotator
cuff repair. Arthroscopic evidence of adhesive capsulitis
was found only in 3 patients of the group with the worst
ROM. These patients required a secondary arthroscopic
capsular release. However, the results were generally
satisfactory in all groups. Warner et al47 treated with
arthroscopic capsular release 18 patients with postoperative
shoulder stiffness. In patients who had an anterior or a
combined capsular release, the Constant and Murley score
improved a mean of 43 points; in patients who had a
posterior release, the mean improvement in the Constant
and the Murley score was 20 points. Only 2 patients had
objective and subjective improvement in shoulder motion,
but the pain decreased only slightly after the procedure.
Arthroscopic capsular release is effective with minimum
morbidity in selected patients who have postoperative
stiffness of the shoulder. On comparing arthroscopic
capsular release with manipulation under anesthesia, Hatch
et al51 reported that arthroscopic treatment poses less risk
to damage the repaired rotator cuff tendons; moreover,
arthroscopic release allows to evaluate and treat the intra-
articular compartment and both subacromial and subdel-
toid spaces. Better outcomes in terms of ROM can be
achieved by manipulation performed after adequate arthro-
scopic release. Lower forces when manipulating a shoulder
are required if the adhesions have been surgically released,
and this leads to lower risk of soft and hard tissue damage
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Management of Postoperative Shoulder Stiffness
(repaired rotator cuff tendons, nerves, bone fractures).
Arthroscopic release should be considered before manipu-
lation to allow work in a relatively bloodless surgical field.
Manipulation will cause bleeding, making it difficult to
have a clear vision throughout the arthroscopic procedure.
Ogilvie-Harris et al22 demonstrated that patients managed
with manipulation performed before and afterward arthro-
scopy reached good outcomes as well as patients treated
only with arthroscopic division of the contracted structure
to restore the range of movement. However, the group
underwent only to arthroscopic division had significantly
better pain relief and restoration of function. The use of
passive motion in the early postoperative period is a way to
maintain motion, reducing the potential for adhesion
formation after rotator cuff surgery.9,16,23,24,26
Preventing Stiffness in Patients Who Underwent
Shoulder Arthroscopy
Traditionally, postoperative stiffness has been associ-
ated with open shoulder surgery.25,65,66 However, more
recent studies have also reported stiffness after arthroscopic
procedures.2,9,16
Although early motion may help to reduce the risk of
developing shoulder stiffness, some studies suggest a period of
immobilization to enhance the process of tissue healing.27,28
Brislin et al16 observed an 8.6% incidence of postoperative
stiffness (23 of 268 patients) in patients undergoing arthro-
scopic rotator cuff repair, and all but 2 patients responded to
aggressive physical therapy. Parsons et al67 evaluated 43
patients with full-thickness rotator cuff tears who underwent a
standardized, conservative protocol of full-time sling immo-
bilization without formal therapy for 6 weeks after arthro-
scopic repair. Patients were classified as “stiff” if forward
elevation was less than 100 degrees and external rotation less
than 30 degrees at a follow-up of 6 to 8 weeks, whereas all
others were designated “nonstiff.” Ten patients (23%) were
considered stiff after rotator cuff surgery. However, at 1 year,
there was no difference in mean forward elevation, external
rotation, or internal rotation and in American Shoulder and
Elbow Surgeons Score and Constant and Murley scores
between the stiff and nonstiff groups. Trenerry et al68
demonstrated that patients undergoing arthroscopic evalua-
tion and open decompression with rotator cuff repair showed
no differences in flexion, with restricted ROM at 6 weeks from
surgery. Patients demonstrated a deficit of only 9 degrees in
external rotation compared with the nonstiff group by 76
weeks after surgery. The investigators suggest sling immobi-
lization for 2 days and a 3-month home exercises program.
As shown by these studies, most patients with post-
operative stiff shoulder will improve by a few weeks after
surgery. However, if the stiffness persists, surgery may be
indicated to restore shoulder mobility and to decrease pain.
Anterior or combined anterroposterior capsular arthro-
scopic release associated with an adequate postoperative
pain management and rehabilitation program is the
procedure of choice.
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