CHA P T E R 10
Arthroscopic Treatment of
Internal Impingement
The term internal impingement was initially used by Walch8
to describe contact of the undersurface of the rotator cuff
with the posterior superior labrum in the abducted and
externally rotated position. Jobe5 described progressive
internal impingement due to repetitive stretching of ante-
rior capsular structures as the primary cause of shoulder
pain in overhead athletes. Our treatment of disability in
the throwing shoulder is predicated on the inciting lesion
being an acquired contracture of the posteroinferior
capsule.2 The posteroinferior capsular contracture alters
the biomechanics of the joint and leads to a progressive
pathologic cascade observed in the disabled throwing
shoulder.
Due to repetitive overuse, throwers are susceptible
to the development of posterior shoulder muscle fatigue
and weakness, including the scapular stabilizers and
rotator cuff. Posterior muscle weakness leads to failure to
counteract the deceleration force of the arm during the
follow-through phase of throwing. In the healthy throw-
ing shoulder, a glenohumeral distraction force of up to 1.5
times body weight is generated during the deceleration
phase of the throwing motion. This distraction force is
counteracted by violent contraction of the posterior
shoulder musculature at ball release, which protects the
glenohumeral joint from abnormal forces and prevents
development of pathologic changes in response to these
forces. In the presence of posterior muscle weakness, as
seen initially in the disabled thrower, the distraction force
becomes focused on the area of the posterior band of the
inferior glenohumeral ligament (PIGHL) complex because
of the position of the arm in forward flexion and adduction
during the follow-through phase of throwing. Fibroblastic
ch010-X3447.indd 87
Matthew T. Boes, MD
Craig D. Morgan, MD
thickening and contracture of the PIGHL zone occur as
a response to this distraction stress (Fig. 10-1A and B).
PIGHL contracture causes a shift of the glenohumeral
contact point posteriorly and superiorly in the abducted
and externally rotated position4 (Fig. 10-1C). This shift
allows clearance of the greater tuberosity over the postero-
superior glenoid rim, enabling hyperexternal rotation
(unlike normal internal impingement). In addition, the
posterosuperior shift causes a relaxation of the anterior
capsular structures, which manifests as anterior “pseudol-
axity” and allows even further hyperexternal rotation
around the new glenohumeral rotation point (Fig.
10-1D).
High-level throwing athletes need to achieve extreme
external rotation of the humerus in the late cocking phase
to maximize the throwing arc in order to generate maximal
velocity at ball release. This maneuver creates an abnormal
and posteriorly directed force vector on the superior
labrum through the long head of the biceps tendon as well
as torsion at the biceps anchor. With repetitive stress in
the hyperexternally rotated position, the labrum fails and
“peels back” from the glenoid rim medially along the pos-
terior superior scapular neck. Failure of rotator cuff fibers
in this position can occur through abrasion but, more
important, due to twisting and shear failure, which is most
pronounced on the articular side of the cuff tendons.
Tension failure may ultimately occur in the anterior
capsule, causing anterior instability that in our view is a
tertiary event and has been erroneously identified as the
primary lesion in the disabled thrower.
The collection of symptoms observed in the disabled
throwing shoulder has been termed the dead arm
87
10/17/2007 2:01:17 PM
 Surgical Techniques for Shoulder Instability

A B
Neutral ABER

SGHL

MGHL

IGHL
PIGHL

C
Figure 10-1 A, Diagram showing location of posterior inferior capsular contracture in the area of the PIGHL complex. B, Arthroscopic image from the posterior
portal with the camera directed inferior to view posterior inferior capsular contracture. C, Diagram showing biomechanical effect of posterior inferior capsular
contracture. In the abducted–externally rotated (ABER) position, the glenohumeral (GH) contact point is shifted posterosuperior, causing tension on the biceps
anchor. IGHL, inferior glenohumeral ligament; MGHL, middle glenohumeral ligament; SGHL, superior glenohumeral ligament.

88

ch010-X3447.indd 88 10/17/2007 2:01:19 PM


D
Figure 10-1, cont’d D, Diagram showing relative anterior laxity as a result of
the posterosuperior shift of the glenohumeral contact point.
syndrome. Essentially, the athlete is unable to throw with
premorbid velocity and control because of pain and sub-
jective discomfort in the shoulder. Five pathologic com-
ponents contribute to symptoms in the dead arm
syndrome:
1. Posterior muscle weakness, demonstrated by scapular
asymmetry
2. PIGHL contracture, the inciting lesion; manifested as
a glenohumeral internal rotation deficit (GIRD) in
the throwing shoulder versus the nonthrowing
shoulder
3. Superior labral anterior-posterior (SLAP) tear, type
II, typically the anterior and posterior or posterior
subtype (the “thrower’s SLAP”)6
4. Rotator cuff failure, generally partial undersurface
and, occasionally, full-thickness tearing in the
posterosuperior cuff; and
5. Anterior instability (anterior capsular attenuation
or capsulolabral injury), in approximately 10% of
cases.
Preoperative Considerations
History
Typical History
● Vague “tightness” in the shoulder
● “Difficulty getting loose”
● Loss of throwing velocity over previous season
ch010-X3447.indd 89
Arthroscopic Treatment of Internal Impingement
10
Figure 10-2 Right-hand dominant thrower with significant posterior scapular
muscle weakness and resultant scapular asymmetry. Corresponding superior
and inferior scapular angles and medial scapular border are marked for
comparison.
● Pain with throwing, particularly in late cocking phase,
when the peel-back phenomenon occurs
Symptoms
● Pain, usually posterior superior; described as “deep” in
the shoulder
● Mechanical symptoms: painful clicking and popping.
These occur after actual injury to the superior labrum
or the “SLAP event.”
Physical Examination
Inspection
● Both exposed shoulder girdles are inspected from
behind.
● Note asymmetry in both shoulder height and scapular
position.
● The superior and inferior medial scapular angles are
marked as a visual reference.
● Dropped position of the acromion and elevation of the
inferomedial angle of the scapula from the chest wall
signify scapular protraction and antetilt and are
evidence of scapular muscle weakness (Fig. 10-2).
Palpation
● Posterosuperior joint line: superior labral
pathology
● Coracoid: protraction of the scapula forces the
coracoid into a more lateral position and places
89
10/17/2007 2:01:24 PM
 Surgical Techniques for Shoulder Instability
tension on the pectoralis minor tendon, causing
tenderness at its insertion.
● Superior scapular angle: scapula infera places tension
on the levator scapula muscle insertion, causing
similar tenderness.
Range of Motion
● Measurements are made in the supine position with
the scapula stabilized by anterior pressure on the
shoulder against the examining table. A goniometer is
used with carpenter’s level bubble chamber attached.
● The arm is abducted 90 degrees to the body, scapular
plane; internal rotation and external rotation are
measured from a vertical reference point
(perpendicular to floor) (Fig. 10-3).
● The throwing shoulder is compared with the
nonthrowing shoulder.
● Internal rotation, external rotation, total motion arc,
and GIRD of the throwing shoulder versus the
nonthrowing shoulder are recorded.
A reveal bone abnormalities (e.g., Bennett lesion)
B mechanical symptoms as described earlier with pathologic
Figure 10-3 Measurement of glenohumeral rotation. The scapula is
stabilized with posteriorly directed pressure by the examiner against the
table to prevent scapulothoracic motion. True glenohumeral internal (A) and
external (B) rotation is recorded from a vertical reference point.
90
ch010-X3447.indd 90
Specificity of clinical tests for type II SLAP tears in
these athletes has been determined.6
● Modified Jobe relocation test: specific for posterior
SLAP lesions (the thrower’s SLAP)
● Speed test and O’Brien test: specific for anterior
SLAP tears
The Jobe relocation test is performed by placing the
arm in maximal abduction and external rotation. Throwers
with a posterior SLAP tear will experience pain in this
position as a result of the unstable biceps anchor falling
into the peel-back position. The discomfort is relieved
with a posteriorly directed force to the front of the shoul-
der, which has been shown under direct arthroscopic visu-
alization to reduce the labrum into the normal position.1
Factors Affecting Surgical Planning
● Patients with long-standing GIRD may require a
selective posteroinferior quadrant capsulotomy. As
outlined later, response to a period of focused internal
rotation stretches determines the need for a posterior
capsulotomy.
● Extreme hyperexternal rotation (>130 degrees) is
associated with attenuation of anterior
capsuloligamentous structures. This finding occurs in
approximately 10% of all disabled throwers. Patients
with this amount of scapular stabilized external
rotation require anterior capsular suture plication. We
do not perform thermal capsulorrhaphy.
Imaging
Radiographs
● Anteroposterior, scapular lateral, and axillary views to
Magnetic Resonance Arthrography
● The intra-articular administration of contrast material
allows better resolution of labral pathology and
partial-thickness tearing of the rotator cuff.
● Abduction–external rotation views are best for
visualization of undersurface rotator cuff tears in
throwers.
Indications and Contraindications
Arthroscopic evaluation and treatment are indicated for
throwing athletes who present with a history of pain and
findings on magnetic resonance arthrography. Once the
pathologic cascade has progressed to actual injury to labral
and cuff structures, regaining premorbid function is not
possible without surgical repair of these structures.
10/17/2007 2:01:25 PM
 Arthroscopic Treatment of Internal Impingement

Table 10-1 Recommended Instruments for Arthroscopic Treatment of

Pathologic Processes in the Throwing Shoulder

Instrument Use

Camera
30-degree lens

Shoulder arthroscopy set

(Arthrex)
Arthroscopic rasp Labral detachment
Arthroscopic elevator

Arthroscopic cannulas
8 mm Anterior working portal
10
5 mm Anterior accessory portal

Motorized shaver Débridement

Full-radius blade (Stryker)
Figure 10-4 Glenohumeral internal rotation or sleeper stretches. The patient
Motorized burr Preparation of glenoid rim
lies on the involved side to minimize scapulothoracic motion. The opposite
hand provides steady internal rotation pressure. Protective hood; SLAP bur
(Stryker)

Arthroscopic bovie Posterior capsulotomy

Patients start internal rotation “sleeper stretches” Long handle, hook tip
preoperatively for assessment of the extent of PIGHL con- (Linvatec)
tracture (Fig. 10-4). In general, 90% of patients with severe
BioSuture Tak anchors Labral fixation
GIRD (>25 degrees) are able to decrease their internal
(Arthrex)
rotation deficit to less than 20 degrees with 10 to 14 days
No. 1 PDS suture SLAP fixation
of focused stretching. The remaining 10% are stretch
Free suture: capsular plication
“nonresponders” and are generally older athletes with
long-standing GIRD and substantial thickening of the Lasso suture passer device Suture passage: superior
posteroinferior capsule. In these patients, a posteroinferior (Arthrex) labrum
capsulotomy is indicated to increase internal rotation at Right-angled
the time of surgery.
BirdBeak suture retrievers Suture passage
Contraindications to the procedure are similar to
(Arthrex)
those for other elective arthroscopic shoulder procedures,
45-degree Posterior superior labrum
such as infection and concomitant medical illness.
22-degree Anterior superior labrum

Suture passer set (e.g., Suture passage

Spectrum)
Surgical Planning Straight Longitudinal rotator cuff tear
45-degree curved hook Capsular plication
Before the procedure is begun, it is important to have all (left and right)
anticipated instruments and materials needed for the
surgery available and on the surgical field so that the pro-
cedure can be performed without unnecessary intraopera-
tive delays (Table 10-1). Efficient performance of the
procedure will avoid the dreaded scenario of attempting Surgical Technique
an arthroscopic repair in the distended, “watermelon”
shoulder that can severely compromise the quality of the Anesthesia and Positioning
surgery. This cannot be overemphasized. As a general
guideline, the type of repair described here should be Patients are administered general anesthesia after place-
accomplished in 20 to 40 minutes, depending on the asso- ment of an intrascalene nerve block that greatly assists
ciated pathologic processes. Superior labral tears in throw- with postoperative pain control.
ers may be associated with rotator cuff and anterior We perform all arthroscopic repairs in the lateral
capsulolabral pathology. Treatment of these associated decubitus position. Positioning is controlled with a beanbag
pathologic processes must be anticipated at the time of brought to the level of the axilla. The operative extremity
surgery. is secured in 30 to 40 degrees of abduction by a pulley

91

ch010-X3447.indd 91 10/17/2007 2:01:26 PM

 Surgical Techniques for Shoulder Instability

device with 10 pounds hung to counterweight the arm. Examination

The patient is administered antibiotic prophylaxis for
skin flora, and the skin is painted with povidone-iodine
(Betadine).
Surgical Landmarks, Incisions,
and Portals
Repairs in throwing athletes are performed through the
following portals:
● Posterior: viewing portal
● Anterior: main working portal; anchor placement in
anterior labrum, knot tying
● Posterolateral (portal of Wilmington): anchor
placement and suture passage in posterior labrum
(Fig. 10-5)
● Anterosuperior: accessory portal; viewing and suture
passage in anterior labrum or capsule (depending on
associated pathologic changes)
The posterolateral border of the acromion is marked,
and a posterior portal is established approximately 2 cm
medial and 2 or 3 cm inferior to the corner of the acro-
mion. The blunt camera trocar is directed through the
posterior capsule just above the level of the equator of the
humeral head. Both the anterior portal and the portal of
Wilmington are established by an outside-in technique
with an 18-gauge spinal needle.
Diagnostic Arthroscopy and Surgical Tactic
Routine diagnostic arthroscopy is performed to ensure
that all portions of the joint are inspected and no patho-
logic lesion is overlooked. In the disabled throwing shoul-
der, areas requiring particular attention include
● Superior labrum and biceps anchor
● Rotator cuff insertion
● Anterior labrum and capsuloligamentous structures
● Posterior capsule
Evidence of labral injury must be assessed carefully
as findings may be subtle (Box 10-1). An assessment
is quickly made of the pathologic areas to be addressed,
and a plan is made for the completion of the repair
(Box 10-2).
Provocative Tests
Drive-Through Sign
Before other cannulas or instruments are introduced, an
assessment is made of laxity in the joint by testing for
the drive-through sign. In a normal shoulder, capsular
Box 10-1 Arthroscopic Findings Consistent with Labral Injury or an Unstable
Biceps Anchor

Labral Injury
● Frayed labral edge

● Adjacent capsular irritation

● Disruption of the smooth articular contour of the glenoid rim

Unstable Biceps Anchor

● Superior labral sulcus >5 mm
● Displaceable biceps root

● Positive peel-back test result

● Presence of drive-through sign

1cm Box 10-2 Recommended Sequence for Arthroscopic Repairs in Throwing

1cm Shoulders with Multiple Pathologic Sites

1. Anterior inferior capsulolabral disruption (if present)

2. Posterior portion SLAP tear

3. Anterior portion SLAP tear

4. Anterior inferior capsular attenuation (if present)

5. PIGHL contracture (if present)

Figure 10-5 Diagram showing location for posterolateral portal or portal of
Wilmington. A spinal needle is used for specific localization. 6. Rotator cuff tear (if present)

92

ch010-X3447.indd 92 10/17/2007 2:01:27 PM


restraints prevent passage of the arthroscope from poste-
rior to anterior at the midlevel of the humeral head or
sweeping of the scope from superior to inferior along the
anterior glenoid rim. The drive-through sign may be
present in patients with a SLAP tear because of pseudolax-
ity from the loss of labral continuity around the glenoid
rim.7
Peel-back Test
The peel-back test is performed by removing the arm from
traction and placing it into the abducted and externally
rotated position. With a posterior SLAP lesion, the labrum
can be observed to fall medially along the glenoid neck
during this maneuver (Fig. 10-6). Anterior SLAP lesions
will have a negative result of the peel-back test. After
assessment of the biceps anchor, the probe is used to assess
the undersurface of the rotator cuff and to estimate depth
of partial-thickness tears, to determine the stability of the
A B
Figure 10-6 Photographs and corresponding arthroscopic views during dynamic peel-back test. A, The superior labrum is reduced in neutral position. B, When
the shoulder is placed in abduction–external rotation, superior labral instability is revealed, with the labrum falling posteriorly and medially along the scapular
neck.
ch010-X3447.indd 93
Arthroscopic Treatment of Internal Impingement
anterior inferior labrum, and to identify any redundancy
in the anterior capsule.3
Specific Steps (Box 10-3)
1. Placement of Secondary Portals
An 8-mm cannula is used as a primary anterior working
portal. An 18-gauge spinal needle is used to localize
the cannula so that it can accommodate all necessary
repairs, including anterosuperior anchor placement in the
labrum and tying of posterosuperior anchor sutures. The 10
cannula is readied near the skin surface, the spinal needle
is used as a guide to the proper insertion angle, the spinal
needle is withdrawn, and the cannula is inserted. An acces-
sory 5-mm anterior portal may be placed, depending on
the location of associated pathologic lesions requiring
treatment.
93
10/17/2007 2:01:28 PM
 Surgical Techniques for Shoulder Instability

Box 10-3 Surgical Steps

1. Placement of secondary portals

2. Probing of intra-articular structures

3. Intra-articular débridement

4. Preparation of superior labral bone bed

5. Anchor placement, suture passage, and knot tying

6. Dynamic assessment of repair

7. Treatment of associated pathology

2. Probing of Intra-Articular Structures

A probe is introduced in the anterior cannula for more
careful assessment of stability of intra-articular structures.
Normally, a sublabral sulcus with healthy-appearing artic- A
ular cartilage can be seen extending up to 5 mm beneath
the labrum. An unstable biceps root can easily be displaced
with the probe medially along the glenoid neck3 (Fig. 10-7;
see also Box 10-1).

3. Intra-Articular Débridement
A full-radius blade motorized shaver is used to gently
débride loose and frayed tissue to prevent snagging of
tissue with joint motion or potential loose bodies.

4. Preparation of Superior Labral Bone Bed

An arthroscopic rasp is used to completely separate any
remaining attachments in the injury area. A rasp is used
because there is less risk of causing intra-substance injury B
in the labrum than with an elevator. On occasion, some
Figure 10-8 A and B, An arthroscopic burr with protective hood to prevent
inadvertent damage to the labrum is used to remove a small amount of
cortical bone on the superior glenoid to make a bleeding bone bed for
subsequent repair.

tenuous attachments from the labrum may be present

Figure 10-7 Superior labrum and biceps anchor are gently probed to identify
evidence of injury or instability.
medially, but the biceps anchor is still unstable. In
these cases, we routinely complete the lesion by removing
these loose attachments before repair. All loose soft
tissue is removed from the repair site carefully with the
shaver.
An arthroscopic burr is then used to remove carti-
lage along the superior glenoid rim to make a bleeding
bone bed for labral repair (Fig. 10-8). This step is crucial
to allow subsequent healing of the labrum back to the
glenoid rim. We prefer a burr with a protective hood
that is specifically designed to prevent damage to labral
tissue during this step (SLAP burr-Stryker Endoscopy,
San Jose, CA). No suction is used while the burr is on to
ensure that tissue is not inadvertently sucked into the
instrument.

94

ch010-X3447.indd 94 10/17/2007 2:01:34 PM


5. Anchor Placement, Suture Passage, and Knot Tying
The portal of Wilmington is used for posterior anchor
placement. Only small-diameter instruments are passed
through this portal. No cannulas are placed in this portal
to prevent damage to the rotator cuff tendons. A spinal
needle again is used to localize the portal, which is approx-
imately 1 cm anterior and 1 cm lateral to the posterolateral
acromial margin (see Fig. 10-5). The angle of approach for
the portal must provide for orientation of the anchor
insertion device at 45 degrees to the glenoid rim to ensure
solid anchor placement. We prefer to use a biodegradable,
tap-in type anchor for superior labral repair (Bio-Suture
Tak; Arthrex, Inc., Naples, Fla).
After skin incision, the Spear guide (3.5 mm; Arthrex)
is brought into the joint through the portal of Wilmington
as described previously for anterior cannula placement.
The guide enters medial to the musculotendinous junction
of the infraspinatus with minimal damage given its small
diameter. The number of anchors to be placed is somewhat
subjective but must be sufficient to neutralize peel-back
forces.3 The Spear guide is brought immediately onto the
glenoid rim in the area of the previously prepared bone
bed. The sharp obturator is removed after proper localiza-
tion, and a hole is drilled for anchor insertion. The angle of
approach of the Spear guide must be meticulously main-
tained during drilling and subsequent anchor placement to
ensure adequate fixation in the bone. We insert anchors
until the hilt of the anchor insertion handle abuts the
handle of the Spear guide. Gentle twisting in line with the
anchor is often needed to remove the insertion handle in
dense bone (Fig. 10-9). The Spear guide is removed, and
both ends of the suture are brought through the anterior
cannula using a looped grasper instrument.
Figure 10-9 After localization with a spinal needle, the Spear guide is
introduced into the shoulder through the portal of Wilmington for anchor
placement on the posterior superior glenoid rim. The Spear guide is
introduced into the joint medial to the rotator cable and in the muscular
portion of the cuff. Because of its relatively small diameter (3.5 mm), this
causes minimal damage to the rotator cuff.
ch010-X3447.indd 95
Arthroscopic Treatment of Internal Impingement
For passage of a suture limb through the labrum, we
use a small-diameter, pointed suture-passing device with a
wire loop (Lasso Suture Passer; Arthrex). The passing
device is brought through the portal of Wilmington
without a cannula (again to minimize cuff damage) and
into the joint through the muscle rent made by the Spear
guide (Fig. 10-10A and B). The passer is brought through
the labrum from superior to inferior, achieving a solid bite
of labral tissue, and carefully advanced over the rim to the
glenoid face. The wire loop is extended and brought out
the anterior cannula (Fig. 10-10C). Next, the suture limb
that is closest to the labrum at the anchor site is identified 10
and passed through the wire loop outside the cannula. The
wire loop and suture lasso are then carefully removed from
the portal of Wilmington, and one of the suture limbs is
brought through the labrum and out the portal (Fig. 10-
11A). The suture limbs around the anchor are carefully
observed as the suture is passed to ensure that no tangling
has occurred. Next, the suture that has been passed
through the labrum and is now out the portal of Wilming-
ton is brought out the anterior cannula and becomes the
post limb of the arthroscopic knot (Fig. 10-11B). Posterior
anchors are tied through the anterior portal either medial
or lateral to the biceps tendon. Additional suture anchors
are placed posterior or anterior to the biceps anchor until
it is secure. Posterior anchors are most easily placed
through the portal of Wilmington as described before.
Anterior anchors may be placed through the anterior
cannula. Although we prefer the lasso suture passer for
passing sutures, BirdBeak suture retrievers (Arthrex) may
alternatively be used, depending on the surgeon’s prefer-
ence. The 45-degree BirdBeak is ideal for passing sutures
in the posterior labrum through the anterior superior
cannula; the 22-degree BirdBeak works well for the ante-
rior labrum.
6. Dynamic Assessment of Repair
After labral repair, the peel-back and drive-through signs
are again assessed to confirm that they are negative and
that the pathologic process has been corrected. The peel-
back maneuver can be performed for dynamic assessment
of whether forces at the biceps anchor have been neutral-
ized (Fig. 10-12). The drive-through sign is performed to
assess for additional anterior laxity that may require cor-
rection by capsular plication techniques.
7. Treatment of Associated Disease
We generally perform a mini-plication in the anterior
capsule when there is a persistent drive-through sign, evi-
dence of anterior capsular tissue attenuation, or more than
130 degrees of external rotation in the 90-degree abducted
position. The anterior capsular tissue to be plicated is first
abraded with a rasp or “whisker” shaver. Capsular redun-
dancy is then obliterated by suturing a lateral portion of
the capsule to the glenoid labrum. The amount of tissue
plicated depends on the amount of redundancy observed
95
10/17/2007 2:01:40 PM
 Surgical Techniques for Shoulder Instability

A A

B B
Figure 10-11 A, The wire loop is carefully retracted to pass a suture limb
through the labrum and out the portal of Wilmington. B, A looped suture
grasper is then used to retrieve this suture limb out the anterior cannula,
where it becomes the post limb for the arthroscopic knot. To prevent
“snagging” or capturing of the biceps tendon with suture, perform all passage,
retrieval, and tying of sutures on one side of the biceps or the other.

C
Figure 10-10 A and B, The right-angled suture-passing device, which is also
small diameter, is brought along the same trajectory and through the same
muscle rent made by the Spear guide. C, The superior margin to the labrum
is pierced with the device, a firm bite of labral tissue is captured, and the
pointed device is gently advanced onto the glenoid face. The wire loop is
deployed and retrieved from the anterior cannula for passage of the labral
post suture.

Figure 10-12 After anchor placement and knot tying, the dynamic peel-back
maneuver is performed again to confirm stable fixation of the biceps anchor.
96

ch010-X3447.indd 96 10/17/2007 2:01:42 PM


on arthroscopic examination (Fig. 10-13). Rarely, a dis-
crete capsulolabral avulsion in the anteroinferior glenoid
needs to be repaired as described elsewhere in this text.
A posteroinferior capsulotomy is performed in
patients who are selective stretch nonresponders. The
response to stretching is assessed preoperatively as out-
lined earlier. A posterior capsular release is rarely required
as part of the treatment of the disabled throwing shoulder.
However, for restoration of full motion, the procedure is
indicated for patients who display little or no response to
stretching. Arthroscopic findings consistent with a patho-
Figure 10-13 If anterior capsular redundancy exists, a suture mini-
plication is performed with No. 1 PDS suture. A, Diagram of mini-plication
technique. B, The tissue is gently abraded to promote healing.
C, Starting inferiorly, a lateral bite of capsular tissue is captured with the
suture device. D, The capsular tissue is advanced medially up onto the
glenoid rim and secured to the anterior labrum.
D
ch010-X3447.indd 97
Arthroscopic Treatment of Internal Impingement
logic posteroinferior capsular contracture include inferior
recess restriction and a thickened PIGHL complex, which
can be up to ½-inch thick in some cases (Fig. 10-14).
Biopsy of the capsule in these cases reveals hypocellular
and disorganized fibrous scar tissue similar in appearance
to end-stage adhesive capsulitis.
Posteroinferior capsular release may be performed
by one of two methods:
1. Scope in the anterior portal and instrumentation in
the standard posterior portal; or
10
97
10/17/2007 2:01:50 PM
 Surgical Techniques for Shoulder Instability

E F
Figure 10-13, cont’d E, Once the suture is passed, the amount of capsular redundancy is assessed before knot tying, and adjustments are made as needed.
F, Subsequent sutures are placed advancing superiorly along the anterior labrum until the anterior capsular redundancy is obliterated.

SGHL

MGHL

IGHL

PIGHL

A
Figure 10-14 A, Diagram showing location of the posterior inferior capsulotomy. B, Arthroscopic photograph from the posterior portal with the camera directed
inferiorly shows thickening around the PIGHL and inferior recess restriction.

2. Scope in the standard posterior portal and
instrumentation in the posterosuperior portal
(portal of Wilmington).
We prefer method 2 as it allows better direct visualization
of the capsule during release.
The procedure is performed with electrocautery in
a nonparalyzed patient. During the capsulotomy, any
twitching of the shoulder musculature will alert the
surgeon that the procedure is being performed too
close to the axillary nerve, thus placing the nerve at
risk for injury. If this occurs, the capsulotomy should be

98

ch010-X3447.indd 98 10/17/2007 2:01:55 PM

 Arthroscopic Treatment of Internal Impingement

moved to a more superior or medial portion of the

capsule or abandoned altogether if no safe zone can be
found. A hooked-tip arthroscopic bovie (meniscal
bovie; Linvatec, Largo, Fla) with a long shaft is used.
The capsulotomy is full thickness and made ¼-inch
peripheral to the labrum in the posterior inferior
quadrant (6-o’clock to 3- or 9-o’clock). A sweeping
technique is used to gently section progressively
deeper layers of the capsule under direct visualization
(Fig. 10-15). The capsulotomy typically results in a 50- to
60-degree increase in internal rotation immediately
(Fig. 10-16).
Postoperative Considerations
Follow-up
All procedures are performed on an outpatient basis.
Patients are typically seen 1 day after surgery for dressing
change. At 1 week, sutures are removed, and self-directed
range of motion is begun under specific guidelines. Patients
are seen at regular intervals during the rehabilitation phase
to monitor progress with motion and to advance therapy
as appropriate. 10

A B

Figure 10-15 A, A hooked-tip long-stem arthroscopic bovie is used to perform

a full-thickness capsulotomy just adjacent to the posterior inferior labrum.
B, Gentle sweeping motions divide the capsule under direct vision.
C, Completed posterior inferior capsulotomy.
C

99

ch010-X3447.indd 99 10/17/2007 2:02:00 PM

 Surgical Techniques for Shoulder Instability

Biceps strengthening is begun at 8 weeks. Continue

daily sleeper stretches indefinitely.
● 4 months: Interval throwing program is started on
level surface. Stretching and strengthening are
continued with emphasis on posterior inferior capsular
stretching.
● 6 months: Pitchers start throwing full-speed,
depending on progression in interval throwing
program. Continue daily sleeper stretches indefinitely.
● 7 months: Pitchers are allowed full-velocity throwing
from the mound. Continue daily sleeper stretches
indefinitely.

A
Complications

Complications are similar to those of other procedures

involving arthroscopic shoulder reconstruction, including
a rare incidence of infection, failed repair, painful adhesion
formation, and stiffness. Physicians and therapists working
with throwing athletes must be vigilant for the develop-
ment of postoperative shoulder stiffness through regular
follow-up and a directed therapy program. All athletes are
instructed to continue daily internal rotation stretches
indefinitely to prevent recurrence of the pathologic cascade
that will place stress on the repair.

B Results
Figure 10-16 A, Preoperative internal rotation. B, Internal rotation
immediately after posterior inferior capsulotomy. A gain of 50 to 60 degrees In 182 baseball pitchers (one third professional, one third
of internal rotation can be expected immediately intraoperatively.
college, one third high-school) treated during an 8-year
period, 92% resumed pitching at the preinjury perfor-
mance level or better. UCLA scoring averaged 92% excel-
Rehabilitation
lent results at 1 year and 87% excellent results at 3 years.
Pitchers undergoing posteroinferior capsulotomy had an
● Immediate: Passive external rotation with arm at the
average GIRD reduction of 31 degrees at 6 months and 30
side (not in abduction); flexion and extension of the
degrees at 2 years and an average increase in fastball veloc-
elbow. Patients undergoing posterior inferior
ity of 11 mph at 1 year after the procedure. Results of
capsulotomy begin internal rotation sleeper stretches
GIRD reduction for patients treated with SLAP repair
on postoperative day 1.
with capsular stretching and SLAP repair with capsulot-
● Weeks 1 to 3: Pendulum exercises. Passive range of omy are shown with combined UCLA scores in Tables
motion is begun with a pulley device in forward 10-2 to 10-4.
flexion and abduction to 90 degrees. Shoulder shrugs
and scapular retraction exercises are begun in the
sling. The sling is worn when the arm is not out for Table 10-2 GIRD reduction SLAP Repair with Posteroinferior Capsular
exercises. Stretching*

● Weeks 3 to 6: The sling is discontinued after 3 weeks. Preoperative 1 Year 2 Years

Passive range of motion is advanced to full motion in
GIRD (average degrees) 46 13 15
all planes. Sleeper stretches are started in patients not
undergoing capsulotomy. TMA (throwing shoulder) 120 148 146
● Weeks 6 to 16: Stretching and flexibility exercises are TMA (nonthrowing shoulder) 158 160 159
continued. Passive external rotation stretching in
abduction is begun. Strengthening for rotator cuff, *In 164 baseball pitchers.
GIRD, glenohumeral internal rotation deficit; TMA, total motion arc.
scapular stabilizers, and deltoid is initiated at 6 weeks.

100

ch010-X3447.indd 100 10/17/2007 2:02:05 PM

 Arthroscopic Treatment of Internal Impingement

Table 10-3 GIRD Reduction of SLAP Repair with Posterior Inferior Table 10-4 UCLA Scores for Results of SLAP Repair with Capsular Stretching
Capsulotomy* or Capsulotomy*

Preoperative 1 Year 2 Years 1 Year (182) 2 Years (124) 3 Years (86)

GIRD (average degrees) 42 12 12 Excellent 92% 90% 87%

TMA (throwing shoulder) 114 147 147 Good 8% 10% 13%

TMA (nonthrowing shoulder) 158 160 157 Fair 0% 0% 0%

*In 18 baseball pitchers. Poor 0% 0% 0%

GIRD, glenohumeral internal rotation deficit; TMA, total motion arc.
*In 182 baseball pitchers.

PEARLS AND PITFALLS
Physical Examination
● The shoulder girdle must be stabilized against the examination table
when GIRD measurements are made. Failure to do so will lead to
erroneously high values because of scapulothoracic motion.
Positioning and Set-up
● The lateral decubitus position offers a better view of the superior
labrum and approach for suture passage because gravity causes
superior recess tissue to fall away.
● Repairs are done with use of a pressure device (set at 60 mm Hg) both
to widen the field of view and to limit bleeding for better visualization.
Significant distention of the soft tissues around the shoulder is
possible and must be avoided as it makes manipulation of cannulas
and instruments through the tissues difficult and can compromise the
procedure.
Steps to Avoid Operating in the Distended Shoulder
● Have an efficient surgical tactic in place.
● Turn the pump off, if necessary, to pause.
● Make sure that cannulas stay in the joint once they are passed through
the capsule.
● Have sufficient arthroscopic skill, including suture passage and knot
tying.
● Work expeditiously.
Suture Anchors
● For SLAP repair, we now rethread anchors with No. 1 PDS suture, which
is resorbable and avoids pain from prominent knots of permanent
10
suture material, as has been our observation with knots in the superior
labrum.
Suture Passage
● Tangling of the suture limbs can occur during suture passage and can
make sliding of sutures difficult for knot tying. This problem is easily
corrected when there is slack in the sutures, so pass the limbs slowly
under careful observation to allow corrections.
● When a looped suture-passing device is employed, use one cannula for
passing the device and another cannula to retrieve it and thread the
suture; otherwise, tangling of sutures will occur. When both sutures are
in a cannula that has the best angle of approach for suture passage,
use a BirdBeak to penetrate the tissue and retrieve a suture through
the same cannula to avoid tangling.
● Have an assistant hold and stabilize the cannulas during suture
passage and shuttling or the cannulas will end up out of the joint.
Knot Tying
● Knots must be tied through cannulas (not percutaneously through
tissue); otherwise, tissue will become stuck in the knot and prevent
sliding and tightening.
● Multiple variations of knot tying are possible. It is important to be
proficient with one sliding and one nonsliding knot. We prefer the
Duncan loop with a two-hole knot pusher (Arthrex) as it is easily tied,
and the two-hole knot pusher allows untwisting of knots during tying.
Peel-Back Test
● A spring-gated carabiner device can be used to link the arm holder with
the pulley system so that the arm can be detached during the
procedure for this maneuver.

References
1. Burkhart SS. Arthroscopically-observed dynamic pathoanatomy in
the Jobe relocation test. Presented at the symposium on SLAP lesions,
18th open meeting of the American Shoulder and Elbow Surgeons;
Dallas, Texas; February 16, 2002.
2. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoul-
der: spectrum of pathology. Part I: Pathoanatomy and biomechanics.
Arthroscopy 2003;19:404-420.
3. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoul-
der: spectrum of pathology. Part II: Evaluation and treatment of
SLAP lesions in throwers. Arthroscopy 2003;19:531-539.
4. Grossman MG, Tibone JE, McGarry MH, et al. A cadaveric model of
the throwing shoulder: a possible etiology of superior labrum ante-
rior-to-posterior lesions. J Bone Joint Surg Am 2005;87:824-831.
5. Jobe CM. Posterior superior glenoid impingement: expanded spec-
trum. Arthroscopy 1995;11:530-537.
6. Morgan CD, Burkhart SS, Palmeri M, et al. Type II SLAP lesions:
three subtypes and their relationship to superior instability and
rotator cuff tears. Arthroscopy 1998;14:553-565.
7. Panossian VR, Mihata T, Tibone JE, et al. Biomechanical analysis of
isolated type II SLAP lesions and repair. J Shoulder Elbow Surg
2005;14:529-534.
8. Walch G, Boileau J, Noel E, et al. Impingement of the deep surface
of the supraspinatus tendon on the posterior superior glenoid
rim: an arthroscopic study. J Shoulder Elbow Surg 1992;1:238-
243.

101

ch010-X3447.indd 101 10/17/2007 2:02:07 PM