Machine Translated by Google

lile
review article
Treatment of Adhesive
Capsulitis of the Shoulder

Lauren H. Redler, MD
Elizabeth R. Dennis, MS, MD
Abstract
Adhesive capsulitis presents clinically as limited, active and passive
range of motion caused by the formation of adhesions of the
glenohumeral joint capsule. Radiographically, it is thickening of the
capsule and rotator interval. The pathology of the disease, and its
classification, relates to inflammation and formation of extensive scar
tissue. Risk factors include diabetes, hyperthyroidism, and previous
cervical spine surgery. Nonsurgical management includes physical
therapy, corticosteroid injections, extracorporeal shock wave therapy,
calcitonin, ultrasonography-guided hydrodissection, and hyaluronic
acid injections. Most patients will see complete resolution of
symptoms with nonsurgical management, and there appears to be a
role of early corticosteroid injection in shortening the overall duration
of symptoms. Surgical intervention, including manipulation
under anesthesia, arthroscopic capsular release both
limited and circumferential, and the authors' technique are
described in this article. Complications include fracture, glenoid
and labral injuries, neurapraxia, and rotator cuff pathology.
Postoperative care should always include early physical therapy.

articular hydraulic distention to

From the Columbia University Medical
Center, Department of Orthopedics,
Center for Shoulder Elbow and Sports
Medicine, New York, NY.
Neither of the following authors nor
any immediate family member has
received anything of value from or has
stock or stock options held in a
commercial company or institution
related directly or indirectly to the
subject of this article: Dr. Redler and
Dr. Dennis.
J Am Acad Orthop Surg 2019;27:
e544-e554
DOI: 10.5435/JAAOS-D-17-00606
Copyright 2019 by the American
Academy of Orthopedic Surgeons.
Adhesive capsulitisclinically
zen shoulder, (AC), or presents
fro
as equal active and passive range of
motion (ROM), both of which are
limited secondary to the formation of
adhesions of the glenohumeral joint
capsule. An expanding body of liter
ature exists which explores the
various treatment options. This article
reviews the current consensus on
the pathology of the disease, its
classification system, risk factors for
the development of AC, treatment
modalities for nonsurgical
management, and techniques for
optimal surgical intervention.
AC primarily involves contracture
of the joint capsule and the rotator
inter val, which is composed of the
superior glenohumeral interval and
the cor acohumeral ligament (CHL).1 growth factor beta (TGF-b), tumor
In an elegant study, Lee et al2 used intranecrosis factor alpha (TNF-a), and
quantify capsular stiffness by
examining the slope of the elastic
phase of pressure-volume curves.
They determined that the degree of
stiffness of the capsule did not
correlate to patient pain. However,
as expected, the amount of
decreased ROM did cor relate to
capsular stiffness, especially in abduction and
Pathology
The exact pathophysiology of AC is
not completely understood and is
often idiopathic. The main pathology
is thought to involve inflammatory
contracture of the shoulder capsule
with recruitment of inflammatory
cytokines such as transforming

e544 Journal of the American Academy of Orthopedic Surgeons

Copyright © the American Academy of Orthopedic Surgeons. Unauthorized reproduction of this article is prohibited.
Machine Translated by Google

review article
Treatment of Adhesive
Capsulitis of the Shoulder

Lauren H. Redler, MD
Elizabeth R. Dennis, MS, MD
Abstract
Adhesive capsulitis presents clinically as limited, active and passive
range of motion caused by the formation of adhesions of the
glenohumeral joint capsule. Radiographically, it is thickening of the
capsule and rotator interval. The pathology of the disease, and its
classification, relates to inflammation and formation of extensive scar
tissue. Risk factors include diabetes, hyperthyroidism, and previous
cervical spine surgery. Nonsurgical management includes physical
therapy, corticosteroid injections, extracorporeal shock wave therapy,
calcitonin, ultrasonography-guided hydrodissection, and hyaluronic
acid injections. Most patients will see complete resolution of
symptoms with nonsurgical management, and there appears to be a
role of early corticosteroid injection in shortening the overall duration
of symptoms. Surgical intervention, including manipulation
under anesthesia, arthroscopic capsular release both
limited and circumferential, and the authors' technique are
described in this article. Complications include fracture, glenoid
and labral injuries, neurapraxia, and rotator cuff pathology.
Postoperative care should always include early physical therapy.

articular hydraulic distention to

From the Columbia University Medical
Center, Department of Orthopedics,
Center for Shoulder Elbow and Sports
Medicine, New York, NY.
Neither of the following authors nor
any immediate family member has
received anything of value from or has
stock or stock options held in a
commercial company or institution
related directly or indirectly to the
subject of this article: Dr. Redler and
Dr. Dennis.
J Am Acad Orthop Surg 2019;27:
e544-e554
DOI: 10.5435/JAAOS-D-17-00606
Copyright 2019 by the American
Academy of Orthopedic Surgeons.
Adhesive capsulitisclinically
zen shoulder, (AC), or presents
fro
as equal active and passive range of
motion (ROM), both of which are
limited secondary to the formation of
adhesions of the glenohumeral joint
capsule. An expanding body of liter
ature exists which explores the
various treatment options. This article
reviews the current consensus on
the pathology of the disease, its
classification system, risk factors for
the development of AC, treatment
modalities for nonsurgical
management, and techniques for
optimal surgical intervention.
AC primarily involves contracture
of the joint capsule and the rotator
inter val, which is composed of the
superior glenohumeral interval and
the cor acohumeral ligament (CHL).1 growth factor beta (TGF-b), tumor
In an elegant study, Lee et al2 used intranecrosis factor alpha (TNF-a), and
quantify capsular stiffness by
examining the slope of the elastic
phase of pressure-volume curves.
They determined that the degree of
stiffness of the capsule did not
correlate to patient pain. However,
as expected, the amount of
decreased ROM did cor relate to
capsular stiffness, especially in abduction and
Pathology
The exact pathophysiology of AC is
not completely understood and is
often idiopathic. The main pathology
is thought to involve inflammatory
contracture of the shoulder capsule
with recruitment of inflammatory
cytokines such as transforming

e544 Journal of the American Academy of Orthopedic Surgeons

Copyright © the American Academy of Orthopedic Surgeons. Unauthorized reproduction of this article is prohibited.
Machine Translated by Google
interleukins, as well as B-lymphocytes, Figure 1
T-lymphocytes, and macrophages.3
One study examining the histology
of excised CHL found active
fibroblastic proliferation with some
transformation to myofibroblasts,
creating colla gene in the form of a
thick band, similar in appearance to
Dupuytren's dis ease.4 This
transformation to smooth muscle
myofibroblasts is thought to cause
contracture, capsular hyperplasia,
and eventual fibrosis which is
thought to cause reduction in cap
sular volume and stiffness, ultimately
restricting motion.3 In summary, AC
appears to start as an inflammatory
reaction with associated synovitis
that progresses to fibrotic contracture of the shoulder capsule.
classification
As previously described by Neviaser
and Neviaser,5,6 AC is classified
into four stages based on arthroscopic
and histologic appearance of the
joint capsule, following progression
from capsular inflammation to fibrosis
(Figure 1). Stage 1, “the pre-
adhesive stage,” is described as
proliferation of the fibroblasts without
formation of adhesions. Patients
have full ROM but report pain, often
at night. Stage 2, “acute adhesive
synovitis,” is characterized by hy
pertrophy of the synovium and early
formation of adhesions, often in the
inferior capsular fold. Patients begin
to have mild loss of ROM with pain.
Stage 3, “the maturation stage,” is
marked by the transition from
synovitis to fibrosis. The axillary fold
is often adhered to the capsule.
ROM comes markedly reduced, but
often patients are in less pain than
in the earlier stages. Stage 4, “the
chronic stage,” is characterized by
severe loss of ROM and dense
fibrotic adhesions. Of note, stage 4
patients can have minimal pain,
except when their ROM is forcibly
moved past the restraints of their fibroticincapsule.
June 15, 2019, Vol 27, No 12
Copyright © the American Academy of Orthopedic Surgeons. Unauthorized reproduction of this article is prohibited.
Lauren H. Redler, MD and Elizabeth R. Dennis, MS, MD
Pathologic phases of AC. Schematic describing the overlapping nature of
inflammation and scar tissue formation, forming the breakdown of the three
clinical phases of AC. A comparison is made with four phases previously
described by Neviaser and Hannafin. AC = adhesive capsulitis. (Reproduced
with permission from Neviaser AS, Hannafin JA: Adhesive capsulitis: A review
of current treatment. Am J Sports Med 2010;38(11):2346-2356.)
In describing AC to patients, the with AC often reveals capsular and
senior author finds it helpful to break CHL thickening, poor capsular
the progression down into three distension, extracapsular contrast
clinical phases based on the over leak age, and synovial hypertrophy
lapping nature of inflammation and and scar tissue formation at the
scar tissue formation as described rotator interval8 (Figure 2). MRI
by Neviaser and Hannafin7 (Figure 1) . findings on T2 fat-suppressed
Phase 1 involves only inflammation, sequences in a study of 103 patients
characterized by capsular pain with with AC cor related with pain
sudden shoulder motion, usually in intensity, ROM, and clinical stage.
a functional range (not extremes), Anterior extracapsular edema was
but patients do not yet have restricted associated with degree of external
ROM. Often, only patients who have rotation and abduction. Joint capsule
suffered AC on the contralateral side edema in the axillary recess was
present this early. Phase 2 involves associated with loss of external
both inflammation and scar tissue rotation. Joint capsule thickness was
formation. Patients classically have associated with pain intensity.
pain and restricted ROM. This is the Findings of joint capsule edema and
most common phase at presentation. obliteration of the sub coracoid fat
Phase 3 is distinguished by the triangle were more common in the
resolution of inflammation. Patients early stages of AC, whereas capsular
have profound loss of motion but thickness markedly increased in later stages.9
often no longer have pain.
Risk Factors
Diagnostic Imaging
The prevalence of AC is 2% to 5%,
Radiographs are classically normal and it occurs more commonly in
patients with AC. MRI in patients women and patients with diabetes.2 Other
e545
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Shoulder Adhesive Capsulitis

Figure 2

MRI evidence of adhesive capsulitis. Coronal MRI showing a normal thickness capsule in the axillary pouch (A), coronal
MRI
* showing a thickened capsule and contracted axillary pouch (B), and axial MRI showing scarring of the rotator interval (C).
= axillary pouch/capsule, RI = rotator interval

risk factors include hyperthyroidism; hazard ratio of 1.22 compared with stiffness or stiffness requiring capsule
previous shoulder, breast, or cervical the control group, hence concluding release in 3.3% of patients.15 Another
spine surgery; and rarely, that hyperthyroidism was an study by Huberty et al16 on 489
immunizations. In a case-controlled independent risk factor for developing AC.12 patients who underwent RCR found
study of 208 patients with type 2 A great deal of research has symptomatic postoperative stiffness
diabetes mellitus (DM) versus 200 explored the incidence of AC in in 4.9% of patients. Further analysis
matched control subjects, 13% of patients who previously had shoulder revealed that it was most common in
patients in the diabetes group had AC surgery. Results are mixed but range workers compensation patients
versus 1.5% of patients in the control from 5% to 11% prevalence of the (8.6%), patients younger than 50
group (P , 0.01). Of all the patients development of AC after shoulder years (8.6%), those with coexisting
who suffered from AC, those with dia surgery. In a prospective cohort study calcific tendinitis (16.7%), those with
betes were younger than those of 505 patients undergoing elective partial articular-sided tendon avulsions
without. Additionally, the incidence of shoulder surgery, AC was identified (13.5%), and those with concomitant
AC in the diabetes group was in 11% of the patients at their 6-month labral tears (11.0%).16 In a study of
associated with how long they had follow-up and was more common in 345 patients, Namdari and Green17
been diabetic and had poor blood women than in men (15% versus found that 47 patients with preoperative
glucose control (P , 0.05).10 Like 8%).13 In a retrospective analysis of stiffness had persistent stiffness after
wise, in a meta-analysis of 18 stud 200 patients who underwent RCR, of which only 3 required cap
ies, patients with diabetes were five arthroscopic subacromial sular release.
times more likely than control subjects decompression with or without distal
to have AC. From this, the overall clavicle excision, the incidence of AC Patients with upper extremity trauma
prevalence of AC in patients with was 5.21% versus 5.71%.14 Ages can also have resultant stiffness or
diabetes was estimated at 13.4%, between 46 and 60 years and previous posttraumatic stiffness (PTS) which
whereas the prevalence of DM in diagnosis of AC in the contralateral has been theorized to progress along
patients with AC was 30%. Of note, side were statistically significant. risk a similar pathway to AC. In a study of
comparison of prevalence in patients factors for the development of sec 73 patients undergoing open reduction
using insulin versus other treatments ondary AC. It was concluded that the internal fixation (ORIF) for proximal
showed no notable difference.11 risk of developing AC after arthro humerus fractures, Clavert et al18
In a prospective, population-based, scopic débridement is just over 5% found that PTS developed in 4.1% of
7-year cohort study of one million and not markedly affected by whether or not the distal
patients. clavicle
In a study byisLancaster
excised. et
participants using the Longitudinal Also, several studies have looked al19 on 64 patients with PTS after
Health Insurance Database 2005 in at the incidence of AC after rotator upper limb trauma, manipulation
Taiwan, of 4,472 patients with cuff repair (RCR). A meta-analysis of under anesthesia (MUA) was a
seven studies on stiffness after
hyperthyroidism, 162 patients experienced successful intervention for improv ing
AC, giving a statistically significant arthroscopic RCR found resistant ROM and Oxford Shoulder

e546 Journal of the American Academy of Orthopedic Surgeons

Copyright © the American Academy of Orthopedic Surgeons. Unauthorized reproduction of this article is prohibited.
Machine Translated by Google
Scores. The improvement in ROM after
MUA was similar to that observed in
patients who underwent MUA for
idiopathic AC.
AC has been documented in 10% of
patients after breast cancer sur gery.20
The incidence was higher in the patients
aged 50 to 59 years and in those who
underwent mastectomy (with or without
reconstruction) com pared with those
who underwent lumpectomy.
Again using the Longitudinal Health
Insurance Database 2005 in Taiwan,
patients who underwent surgery for a
cervical herniated disk disease had a
markedly higher risk (1.66) of
developing oping shoulder capsulitis in
6-month follow-up compared with
patients who received conservative therapy only.
Last, though not surgical, worth
mentioning is a case study of 3 cases
of acute onset of AC after pneumococcal extracorporeal shock wave therapy
and influenza vaccines.22
Treatment Options
Nonsurgical Management Many
options are available for proving the
pain, ROM, and functional scores in
patients with newly diagnosed AC or in
those who wish to avoid surgery.
Treatment should be geared toward the
phase of AC (Figure 3). Oral anti-
inflammatory drugs, either nonsteroidal
(NSAIDs) or a short tapered course of
corticosteroids (particularly helpful in
patients with very severe pain), can be
helpful in reducing patients' symptoms,
enough to make physical therapy (PT)
tolerable. This point needs to be
stressed–medications will not relieve
their pain completely but are instead
being used so they can effectively
participate in PT. Nar cotics do not have
a role in the nonsurgical management
of AC. In addition to the mainstays of
non surgical management with PT, oral
anti-inflammatories, and cortisone
injections, other modalities include
June 15, 2019, Vol 27, No 12
Copyright © the American Academy of Orthopedic Surgeons. Unauthorized reproduction of this article is prohibited.
Lauren H. Redler, MD and Elizabeth R. Dennis, MS, MD
Figure 3
Treatment
algorithm based on pathologic phases of adhesive capsulitis. MUA =
twenty-one
manipulation under anesthesia
In patients with AC, a notable decrease
(ECSWT), calcitonin pharmacotherapy, in shoulder pain at 6 weeks was
ultrasonography-guided hydrodissection, observed.24 These results were main
and hyaluronic acid (HA) injections. A held at 12 weeks but were no longer
recent systematic review graded various notable at 26 weeks. No difference
nonsurgical interventions based on existed between the group who received
study scientific rigor and level of intra-articular corticosteroid injection
evidence.23 Therapeutic exercises and and the group who received a combined
mobilization were strongly recommended intra-articular and rotator interval
for reducing pain and improving ROM injection. In a meta-analysis, nine
and function in patients with stage 2 randomized controlled trials for 453
and 3 AC. Corticosteroid injections patients were analyzed.25 From 6 to up
were most effective in early AC. to 26 weeks postintervention, no
superiority was noted in favor of either
Acupuncture with therapeutic ex ercises steroid injection or PT for functional
was moderately recommended for pain improvement. However, steroid injection
relief, improving ROM and function. did provide more improvement in
Continuous passive motion was passive external rotation for 26 weeks.
recommended for short-term pain relief Last, in a study of 106 patients, four
but not for improving ROM or function. injections with cortico steroid with or
Ultrasonography for pain relief or for without distension given during 8 weeks
improving ROM or function was not were better than PT alone.26 However,
recommended. in the long term no difference was
shown, suggesting that natural healing
Corticosteroid Injections Intra- takes place regardless of intervention.
articular corticosteroid injections
decrease pain in early stages of AC. In Despite these findings, intra-articular
a double-blind, placebo-controlled ran steroid injections do seem to have a
domized study of ultrasonography role in patients with AC. In a
guided intra-articular and rotator interval retrospective longitudinal study of 339
corticosteroid injections in 122 patients with AC, all patients who
e547
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Shoulder Adhesive Capsulitis
were unresponsive to at least 1 month
of conservative treatment under went
ultrasonography-guided cortico steroid
injection, and all outcomes, at
both 1 month and 12 months, were
better when the amount of time in pain
before injection was shorter.27 There
fore, this group concluded that early
injection improves outcomes of AC at
both short- and long-term follow-ups.
They feel that if pain persists despite
conservative management, injection in
the early time frame helps shorten the
natural history of AC.
A remarkable amount of research also
existed into the best technique for injection
of the glenohumeral joint and
whether ultrasonography guidance
you have a role to play. In a randomized
controlled study of ultrasonography guided
injections versus blind intra articular
injections, improvements in
pain, ROM, and functional scores
were observed in the ultrasonography
guided group at 1 and 4 weeks, but
these findings were not statistically
significant.28 In a prospective ran domized
study of 42 patients, signed to determine
the ideal position
for glenohumeral injection, no difference
was found in the joint space
window available for injection with
the patient in three different positions
(palm on thigh, hand on op posite
shoulder, and hanging arm
position), but injections given in all
three positions yielded statistically
significant improvement in pain and
ROM.29
Extracorporeal Shock Wave
Therapy
In a prospective randomized with trolled
study of 40 patients treated
with ECSWT versus oral steroids,
Chen et al30 showed notable improvement
in Constant Shoulder Score
and ROM by the fourth week and
statistically significant improvement
in ADL function by the sixth week in
patients treated with ECSWT. in a
systematic review of 19 trials (1,249
e548
Copyright © the American Academy of Orthopedic Surgeons. Unauthorized reproduction of this article is prohibited.
participants), the use of ECSWT in
general did not generate any additional
adverse events compared with
that in the control groups in all
studies.31 Importantly, ECSWT has
been shown to improve functional
outcomes in patients with diabetes
and may therefore be a desirable
alternative to corticosteroids for this
patient population who are not ideal
candidates for corticosteroid injections
because of the effect on their
blood glucose control.10
Calcitonin
A double-blind randomized con trolled
trial of 64 patients with AC
compared intranasal calcitonin to see
their placebo for 6 weeks along with PT
and NSAIDs.32 At 6 weeks, shoulder
pain, ROM, and functional scores
were markedly improved in the cal citonin
group.
Calcitonin is a polypeptide hormone
secreted from parafollicular
cells of the thyroid. It has been used
for the management of the complex
regional pain syndrome, rheumatoid
arthritis, and bone tumors for its
analgesic properties. Although its
pathophysiology is not completely
understood, it is thought to decrease
the systemic inflammatory response
and stimulate the release of endorphins.
Calcitonin primarily acts to
inhibit osteoclast function and has
been shown to stabilize and some times
increase bone density. The
previously mentioned study used calcitonin
in the form of an intranasal spray, but
both this form and intramuscular injections
have been shown to have low
adverse effect profiles (facial flushing,
nasal irritation/sneezing, rhinitis) and
long-term therapy with calcitonin has
been shown to be safe, without serious
adverse effects.32
In the setting of AC, calcitonin
therapy is thought to be effective
augmentation for pain control. The current
dose recommendation is 200 U
(1 puff) daily. At our institution, one
Journal of the American Academy of Orthopedic Surgeons
inhaler (a 30-day supply) costs $115
to $120. This form of therapy is
derived from salmon, so it is contraindicated
in patients with salmon
allergies.32
Ultrasonography–guided
Hydrodistention
Ultrasonography-guided hydro distention
has been shown to be effective in patients
with AC in the short
term, but no difference has been found
in long-term relief between hydrodistention
and intra-articular steroid
injection.33 In a prospective randomized
controlled study of 121 patients
with AC, patients were randomized
between hydrodistention with joint
manipulation under an interscalene
block and treatment with an intra-articular
corticosteroid injection.34
Hydrodistention combined with joint
manipulation under an interscalene
block provided earlier pain relief and
restoration of shoulder ROM and
function compared with single intra
articular corticosteroid injection in
patients with AC; however, at 12
months no difference existed between
the two groups.34 A randomized con
trolled study of 64 patients with
refractory AC who received capsule
preserving hydrodistention with
corticosteroid versus a standard intra
articular corticosteroid showed nota ble
improvement in both the groups
in shoulder pain and disabilities
index score and visual analogue scale
(VAS) for pain but no difference
between the two groups.35
Hyaluronic Acid Injections
HA injections in combination with
corticosteroid injections and PT have
been shown to have excellent results
for complete resolution of AC.36 In a
systematic review by Lee et al,37 four
randomized controlled studies were
Identified encompassing 273 participants
with 278 shoulders. Two tri als compared
intra-articular HA
injections versus conventional ther apy,
whereas two studies looked at
Machine Translated by Google
HA injections in addition to conventional
therapy. In all the four studies, no
difference existed in pain or shoulder
function/disability outcomes with or
without HA. In another study, 52
patients underwent a treatment protocol
of HA and anesthetic periarticular and
intra-articular injections, followed by a
specific program of capsule and muscle
stretching.36 Of the 52 patients, 50
(96%) had complete recovery of ROM,
therefore concluding that a combined
pharmacologic and rehabilitation
approach was effective in resolving
pain and improving ROM in patients
with idiopathic AC.
Surgical Intervention
Indications
When nonsurgical management,
including NSAIDs, PT, and injections,
has failed to provide relief of symptoms
by 9 to 12 months, surgical intervention
is indicated. In a retrospective review
of 105 patients at our own institution
with resolution of AC, 89.5% resolved
with nonsurgi cal management,
including 17 of 19 patients with
diabetes.38 Patients who required
surgery were younger (aged 51 years
versus 56 years in the nonsurgical
group). No difference was found in
sex. Of the patients who underwent
nonsurgical management, all received
NSAIDs, 52.4% received PT with no
corticosteroid injection, and 37.1%
received at least one injection. Patients
who had resolution of symptoms with
nonsurgical man agement alone
averaged approximately 3.8 months
of treatment, whereas those who
required surgery endured more than 1
year of nonsurgical management
(average, 12.4 months).38 Arthroscopic
assessment of
the glenohumeral jo int often
demonstrates extensive synovitis and
an erythema tous, injected capsule
(Figure 4).
Arthroscopic synovectomy and cir
cumferential capsulotomy have been
June 15, 2019, Vol 27, No 12
Copyright © the American Academy of Orthopedic Surgeons. Unauthorized reproduction of this article is prohibited.
Lauren H. Redler, MD and Elizabeth R. Dennis, MS, MD
shown to have long-lasting
improvement ment in ROM and pain
relief. However, in many studies MUA
has been shown to be equivalent to
capsular release in relief of clinical symptoms.39
Manipulation Under Anesthesia
Alone Versus Arthroscopic
Capsular Release A
prospective study of 26 patients looked
at whether arthroscopic shoulder
capsular release decreased the
duration of symptoms compared with
a nonsurgical home therapy program.
Patients randomized to the surgical
group underwent arthroscopic capsular
release and MUA.
Immediately after surgery, they began
the same stretching program as the
nonsurgical group. No statistically
significant difference existed between
the groups.40
Similarly, a systematic review of 22
studies compared outcomes between
patients treated with MUA, capsular
release, or a combination of both.39
Of the study participants, 60% were
women and the median age was 52
years (24 to 91 years). Minimal diff
ferences existed in the median changes
in abduction, flexion, and external
rotation ROM, and final constant score
between the MUA and capsular release
groups. These authors there fore
concluded that little benefit may be
there for a capsular release instead of,
or in addition to, an MUA.39
Alternatively, many studies have
shown remarkable effectiveness of
arthro scopic release for the
management of AC.3 Le Lievre and
Murrell41 showed maintained
improvement in ROM, pain, and
function at 7 years for a group of 43
patients treated with arthroscopic capsularinterval
With respect to the technique of
arthroscopic release, limited anterior
capsular release with controlled MUA
has been shown to yield statistically
significant improvement in both pain
and function modules of the Oxford
Shoulder Score and ROM at 6-month
Figure 4
Intraoperative arthroscopic image
showing erythematous injected
capsule. * = synovitis and adhesions,
BT = biceps tendon, G = glenoid,
HH = humeral head
follow up. Some feel that the addition
of a posterior capsule release is
essential to regain internal rotation,
but this has not been shown to make
a notable difference in outcomes.42
These findings support the concept
that arthroscopy provides a minimally
invasive technique to directly visualize
the anatomy and pathologic tissue in
patients with AC under the same anes
thetic burden as MUA with optimal and
better controlled outcomes.43
Limited Capsular Release Versus
Circumferential Release As
mentioned earlier, various techniques
exist for managing the capsu lotomy
and rotator interval. Some authors
advocate for avoidance of an inferior
release to limit axillary nerve injury.44
A retrospective study of 52 patients
who underwent arthroscopic capsular
release compared various techniques,
such as joint débridement, rotator
release.opening, CHL release, various
capsulotomies (anterior, posterior ,
inferior, and anterior-inferior), or
subscapularis tenotomy.43 All patients
had improvement in pain and ROM.
Patients who underwent inferior
capsulotomy as part of their release (n
= 20) had the best results.43
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Shoulder Adhesive Capsulitis
Figure 5
Intraoperative arthroscopic image
showing release of the rotator
*interval and anterior capsule.
= opened rotator interval, BT =
biceps tendon, G = glenoid, HH =
humeral head, SS = subscapularis
Lafosse et al45 recently described
the 360-capsular release technique
in which the subacromial space is
entered laterally, the rotator interval
is opened from the outside in, and
a 360 cap sular release and biceps
tenotomy is performed. All patients
reported excellent improvement in
ROM and pain scores, and no
complications were present, including deep to subscapularis tendon along
axillary nerve injury, fracture, or infection.45
Author's Preferred
technique
The senior author prefers an inter
scalene block for sustained
postoperative pain control combined
with a general anesthetic, including
paralysis, to ensure that a gentle
MUA can be accomplished without
undue force. Our capsular release
method incorporates an anterior,
ante roinferior, and posterior capsular arm, which decreases the risk of
release, with extension inferiorly to
the level of the infraspinatus and
release of the rotator interval. We
begin using a posterior working
portal where the rotator interval is
released working around the labrum
superiorly to the biceps laterally (Figure capsule.
e550
Copyright © the American Academy of Orthopedic Surgeons. Unauthorized reproduction of this article is prohibited.
Figure 6
Intraoperative arthroscopic image
showing release of the posterior
capsule. * = ablating device
releasing posterior capsule through
original posterior portal, HH =
humeral head, IS = infraspinatus
muscle fibers, PL = posterior labrum
taken to release all adhesions to
help lateralize the humeral head and
improve working space. The superior
glenohumeral interval and CHL are
released within the rotator interval.
Next, we identify the subscapularis
and free up its posterior surface. The
anteroinferior capsule is released
with any component of contracted
middle glenohumeral ligament and
inferior glenohumeral ligament
circumferentially to the 5 o'clock position.
Next, an anterior working portal is
used to perform a posterior capsule
release, working inferiorly using in
fraspinatus fibers as landmark of
adequate release (Figure 6).
During the MUA, the anterior and
posterior releases propagate toward
each other and connect inferiorly. It
is vital to grasp the patient's arm
proximally to create a short lever
fracture. The first step is forward
elevation of the arm to 180. This
serves to release the inferior capsule A small percentage of patients who
in the axillary fold. Next, with the arm have been treated surgically for AC
adducted, the shoulder is externally
rotated to release the anterior
5). Care Then,
is cross-body adduction successful.46 In a group of 730 patients who
Journal of the American Academy of Orthopedic Surgeons
is performed to release the inferior
postero capsule. Next, the arm is
brought into abduction. In abduction,
with scapular stabilization by an
assistant, the glenohumeral joint is
first maximally externally rotated (to
continue release of the anterior
capsule) and then maximally
internally rotated (to release the
posterior capsule). We document
the patient's forward elevation,
external rotation at the side, internal
rotation at 90 abduction, and straight
abduction with the camera to provide
the patient and his or her therapist
with photos of the improved ROM
(Figure 7). After the manipulation, a
repeat arthroscopic assessment is
performed to confirm circumferential release.
Last, an assessment of the
subacromial space is always
performed. Impingement signs are
not applicable on physical examination
in patients with AC, and a large
subacromial spur with extensive
subacromial bursitis is often
encountered. A standard subacromial
decompression with acromioplasty
is performed if warranted by
intraoperative findings. Postoperatively,
all patients have portable AP, lateral,
and axillary radiographs in the post
anesthesia care unit to ensure no
fractures are present. Postoperative
multimodal pain management is
used, including acetaminophen 1000
mg three times daily for 7 days,
gabapentin 300 mg three times daily
for 3 days, diazepam 5 mg as needed
for muscle spasm, and oxycodone 5
to 10 mg as needed for pain. With
this regimen, we have found that
patients require fewer narcotics and therefore can av
Recalcitrant Adhesive
capsulitis
continue to have symptoms. Repeat
MUA has been shown to be
Machine Translated by Google

Lauren H. Redler, MD and Elizabeth R. Dennis, MS, MD

underwent MUA for AC, 141 required Figure 7

additional MUA. Improve ment was
seen after a second MUA, regardless
of the outcome of the initial MUA and
of the time of recurrence.46 Patients
with type 1 diabetes mellitus were at
a 38% increased risk of requiring a
repeat MUA, compared with the 18%
increased risk of the group as a
whole (P , 0.0001).

Postoperative Protocol
PT should start as soon as possible
in the postoperative setting. An inter
scalene block or catheter can provide
analgesia to allow for immediate
post op ROM. Mariano et al47
showed that a continuous interscalene
block provides greater pain relief,
allowing for minimization of opioid
use, im provement in sleep quality,
and overall increase in patient
satisfaction compared with a single
application regional block.47
However, inter scalene blocks are
not without their own set of risks;
Cases of reversible radial neurapraxia
and phrenic nerve paralysis have been reported.43
The PT protocol focuses on
achieving ing (for nonsurgical care) Post-capsular release examination under anesthesia showing increased range
or maintaining (postoperatively) a of motion. A, Forward elevation. B, External rotation at the side. C, External
rotation at 90 abduction. D, Internal rotation at 90 abduction. We find it best to
functional ROM by slow, sustained stretching.
write these numbers on the drapes next to the preoperative values for proper
PT prescriptions are shown in Figure documentation and case dictation.
8, A (nonsurgical) and Figure 8, B
(surgical). Patients are encouraged
to do daily stretching, including wall released from follow-up care once cuff pathology. Arthroscopic capsu
walking for forward elevation (Figure they have achieved pain-free ROM lar release, while improving out
9, A), doorway stretch for external that is acceptable to them. comes in management of AC,
rotation (Figure 9, B), and modified At minimum, this includes the ability introduces its own unique set of
sleeper stretch for internal rotation to perform activities of daily living potential complications, including
(Figure 9, C). Patients often find independently. Patients are advised axillary nerve injury and rarely the
stretching in the shower to be more to return for evaluation if pain during development of complex regional
successful because of the heat. functional ROM returns or they note pain syndrome.48
Postoperatively, a sling is only used a recurrence of restricted ROM. In a prospective trial, arthroscopic
for comfort for a few days and must assessment after MUA revealed
be discontinued for 1 week. Patients multiple potential iatrogenic
are encouraged not to sleep in the Complications complications, such as superior labral
sling. Patients are also advised that tears, partial tears of the subscapularis,
they may be more comfortable Complications from MUA range from anterior labral detachments, and
sleeping on an incline for the first fractures, glenoid and labral injuries, tears of the middle glenohumeral
week after surgery. Patients are neurapraxia, and rotator ligament.49 Case reports have documented gle

June 15, 2019, Vol 27, No 12 e551

Copyright © the American Academy of Orthopedic Surgeons. Unauthorized reproduction of this article is prohibited.
Machine Translated by Google

Shoulder Adhesive Capsulitis

Figure 8 proximal humerus fractures and

axillary nerve neurapraxia.43
These results support the use of
arthros copy to directly visualize
tissues and prevent iatrogenic
injury that can occur with blind MUA.

Summary
AC occurs in up to 5% of the
population, more often in women
and patients with diabetes, and its
etiology is still unknown. The
pathology of the disease seems to
be related to a combination of
inflammation and active fibroblastic
proliferation, with transformation of
myofibroblasts leading to extensive
scar tissue formation. Based on
the natural history of the disease,
early corticosteroid injection has a
role in shortening the overall
duration of symptoms. Patients
should be counseled that NSAIDs
and corticosteroid injections do not
cure the problem; they simply
make the PT, which is imperative
for recovery, more comfortable to
endure. For patients with diabetes
who may have undue metabolic
disarray from corticosteroid
injection, ECSWT may have a role
in symptom relief. Most patients
will see complete resolution of
symptoms with non surgical
management. When surgical
intervention is required, the ideal
technique should include both
ante rior and posterior capsular
release as well as rotator interval
release specifically including
release of the CHL. When combined
with a gentle MUA, circumferential
capsular release is possible without
risking injury to the axillary nerve.
Early PT is essentially
postoperatively. An interscalene
block can be used to provide
Physical therapy prescription for (A) nonsurgical management of adhesive enhanced pain relief. To avoid
capsulitis and (B) postoperative treatment. It is important to note the side complications, aggressive MUA
involved and the current range of motion.
should be avoided, care must be taken with inferio

e552 Journal of the American Academy of Orthopedic Surgeons

Copyright © the American Academy of Orthopedic Surgeons. Unauthorized reproduction of this article is prohibited.
Machine Translated by Google

Lauren H. Redler, MD and Elizabeth R. Dennis, MS, MD

Figure 9

Home stretching exercises. Stretches area held for 30 seconds, relax, and repeated 3 times. Wall-walking to stretch the
inferior capsule and increase forward elevation (A), doorway external rotation stretch to stretch the anterior capsule (B),
and modified sleeper stretch to stretch the posterior capsule and increase internal rotation (C).

the post-anesthesia care unit to assess
for fracture.
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