Hello, I'm Michael O'Brien from Tulane University in New Orleans, and I'm going to be talking to you about the surgical technique for arthroscopic capsular release, how to perform this safely to perform complete range of motion. I want to thank the program chairs for the invitation to present with you. These are my disclosures, which are also listed on the Academy website. As an overview, we're going to be talking about the stiff painful shoulder, the evaluation of the stiff shoulder, most notably adhesive capsulitis, surgical technique for arthroscopic capsular release of the shoulder and the post-operative rehabilitation. By and large, the hallmark of adhesive capsulitis of the shoulder is a loss of both active and passive range of motion. This can start out as very painful and then can become stiff and painless as the adhesive capsulitis develops. Adhesive capsulitis is a disease of the fibroblast. It is hallmarked by fibroblast proliferation, which causes inflammation, capsular thickening and capsular contracture. It generally starts with thickening of the coracohumeral ligament and rotator interval causing loss of external rotation at the side. This leads to a mechanical block to motion. Early on, the chief complaint is really pain. This can start as a very painful condition and then as the disease progresses, it turns into stiffness. Early presentation may just be pain. Late presentation will be stiffness and loss of motion. It's important to note that a very painful tendonitis or subacromial impingement may be an early developing adhesive capsulitis. On physical exam, I think the most important thing is to note a global loss of motion. It's very helpful to show patients a bilateral exam of their loss of motion and elevation, external and internal rotation, comparing the involved shoulder to the uninvolved shoulder. John Fenlon taught me that pain with passive stretch, especially down at the side, can be a hallmark of early adhesive capsulitis. It's stretching that rotator interval and anterior capsule down at the side. The inferior glide test developed by Buddy Savoie is a similar maneuver. It's really an inferior load and shift, so you're stretching that rotator interval and coracohumeral ligament, which causes pain. These maneuvers should not be painful with rotator cuff tendonitis or subacromial impingement. The causes of adhesive capsulitis can be idiopathic, post-traumatic, or post-operative. Post-traumatic will often be from an injury, whether it's a fracture or a strain, or there's prolonged sling wear. Wearing a regular sling, as in this photo here, keeps the arm in internal rotation, causes thickening and scarring of that rotator interval and loss of motion. Post-operative is really more of an arthrofibrosis with post-operative scarring in the glenohumeral joint. The risk factors for adhesive capsulitis, especially idiopathic adhesive capsulitis, are diabetes, thyroid disorder, and female gender. So if someone's coming in and hasn't had recent blood work, I think it's important to check a thyroid panel. I'll check a T3, T4, and a TSH, as well as a hemoglobin A1c to evaluate for any diabetes. You can ask about family history, but if they haven't had blood work in the past year, this can be helpful. We'll get standard radiographs here, which are routinely normal. There's three stages to a frozen shoulder as described by Neviser. The freezing stage, which can be very painful, starts out as pain as the shoulder's getting stiff. The frozen stage, where the pain is subsided, but the shoulder remains stiff, and then the thawing stage. And this whole process, the natural history is it can completely resolve, but it can take up to two years. Neviser also described four different arthroscopic stages that starts out with synovitis, moving on to capsular contracture, and severe scarring. Initial management. I like this photo here because if you've ever treated a patient with adhesive capsulitis, they're never smiling. They're always incredibly painful. So by and large, this will begin with an intra-articular cortisone injection and regimented physical therapy. In all of the studies, really the only thing that has been shown to improve the speed of recovery is an intra-articular steroid injection. I think it's helpful to perform this under ultrasound. Then you wanted to do dedicated physical therapy, and it's really going to focus on stretching and glenohumeral joint mobilizations. The therapy probably has to be three times a week, and you really need to tell your patients they need to do stretching four to times, four to five times a day, every day. Usually I'll give these folks an intra-articular steroid injection, get them going in physical therapy and see them back in six weeks. And they'll either be better or worse. If they report no improvement from a subacromial steroid injection, then it's probably adhesive capsulitis because the injection did not go in the glenohumeral joint. I'll often get an MRI, which is going to show thickening of the rotator interval, as you can see on this top image, and then contracture of the axillary recess, which you can see on the bottom image. The main thing to check on the MRI too, is to make sure they don't have any rotator cuff pathology. Surgery is indicated with a progressive loss of motion or failure to progress. It's been going on for four to six months. Usually when these folks come in, it's already been going on for six or eight weeks. So if you give them an injection and therapy and see them back in six weeks, now they're already pushing four to six months. Diagnostic arthroscopy is going to show a red inflamed joint. So you can see thickening of the rotator interval, redness and erythema in the biceps tendon. The glenohumeral joint is very tight. I perform this in the lateral decubitus position because I think joint distraction helps. And as you start to release down the front, the joint opens up. So I put on 10 pounds of balance suspension. You can see the rotator cuff is normal here. Everything is very red and inflamed and look how thickened that anterior capsule is. So the joint is very tight. We begin with a rotator interval release. So I use electrocautery. You're going to release all of the tissue between the long head of the biceps tendon and the subscap. You want to work down until you see healthy muscle fibers. There is the base of the coracoid there with the conjoined tendon going down distally. I've released a little bit of the coracoacromial ligament here, which generally you want to leave intact. You want to release that entire rotator interval until you see the coracoid and healthy muscle fibers. Next, we'll work our way down the front. I like to use a straight biter for this. Anand Murthy taught me this technique. So you want to develop the plane between the anterior capsule and the subscapularis, and then you'll use your straight biter to release. Right here, we're releasing the middle glenohumeral ligament. You're going to continue to work our way down the front. I like to look back and forth so I can clearly see where the labrum is so I'm safe. I don't want to reset to the labrum. I'm going to use that biter to peel the capsule off of the subscapularis and then continue to release down. Normally, the anterior capsule is just one or two millimeters thick. So as you work your way down, you can see how thickened this inferior capsule and inferior glenohumeral ligament is. So here we're getting into the IGHL. Again, I'm just using that biter to separate the capsular layers to keep me safe. And you want to continue to release until you see healthy muscle fibers of the subscapularis, which we see here. Now we know that we've completely released that capsule. We can look back at the joint, make sure that we're staying out of the labrum and safely release working our way down. I'll switch back and forth between a shaver and the biter. So we'll get the shaver in there to remove any loose debris. I also like to resect a little bit of that anterior capsule so it doesn't immediately scar back down. So there again, I'm looking at the joint. I can see my anterior labrum and I'm going to continue to release down as far as I safely can with this straight biter. You can see how thickened that anterior capsule is here. It's eight to 10 millimeters thick, so very pathologic. That's why these often cannot overcome physical therapy once this capsule has become so scarred in and contracted. So we've got healthy muscle fibers of the subscapularis. You can see down at the bottom of the image, we're starting to get into a little fat and that's going to be the signal for the axillary nerve. So I'll come in with the shaver. I use very little suction. I'm just shaving away the edge of the capsule so it doesn't immediately scar back down. Got healthy muscle fibers there. You can use electrocautery if you get into any bleeders. So we'll continue to release down the front. Once I can no longer safely reach with a straight biter, then I move to a hooked electrocautery. So I like to get the hook under the capsule and then release into the joint. That way I'm not burning down towards the nerve. You can get in between the plane of the muscle and the capsule and then release up. You do this through short pulses so you don't hold the cautery on but do it through short pulses as you release. You can see the fat down at the bottom of the image there. So we're getting close to the axillary nerve. The axillary nerve is usually going to run between that five and six o'clock position. Once you can no longer get any lower, then we'll switch and complete the release down the back. Down the back, I just go from the posterior portal down and connect the dots. So then you can release right along the bottom of the glenoid, releasing that whole inferior capsule. Stay close to the posterior labrum. The axillary nerve is right there. So the axillary nerve is one to two centimeters below the lower border of the glenoid. So you can perform an axillary nerve neuralysis. If indicated, I don't think it's necessary for most procedures. I like to check and make sure the nerve's intact. So there's our axillary nerve. There's the long head of the triceps deep to it. We can see we're about two centimeters below the glenoid. So if you stay immediately below the glenoid, you'll be safe. Finally, it's important to go up into the subacromial space. Here we're viewing from the lateral portal. You want to release any adhesions between the rotator cuff and the acromion. And then it's also important to release the coracohumeral ligament. You cannot fully release the coracohumeral ligament from interarticular. You have to do it from the subacromial space. So again, this is a right shoulder. So there's the glenohumeral joint. There's the subscapularis. There's the coracoid and there's our coracohumeral ligament release. So I'll view from lateral and I'll come in with a cautery from the anterior portal to release the coracohumeral ligament right off of the coracoid that mobilizes your supraspinatus and gives back better external rotation. This was a trick that John Kelly taught me. Finally, I think it's important to do an MUA at the end and check your final range of motion. Always check preoperative and postoperative range of motion. I think taking photos of the arm in this position is helpful for the patient. Then you can tell them, look, your arm goes there now. Now it's up to you to keep it there and stress the importance of physical therapy. Postoperative rehab, I encourage them to get out of the sling early. So I tell them two or three days in the sling and then quit wearing it. They immediately go into physical therapy on postoperative day one to focus on stretching and glenohumeral joint mobilizations. I say no strengthening until four weeks postoperative. The glenohumeral joint mobilizations I think are really the hallmark of rehabilitation before and after surgery for adhesive capsulitis. So how successful is it? This was a meta-analysis published just this year. They looked at 18 articles with 811 shoulders and they actually compared three groups for an arthroscopic capsular release. Group one was an anterior inferior release, group two anterior inferior and posterior release, and group three was a 360 degree release. What these graphs are showing on the right is that group one did better than group three, group two did better than group three, and groups one and two were basically equivocal. So they concluded that a less extensive release may be better. You do not need to do a 360 degree release. You want to be careful releasing across the top anyway because you can damage your rotator cuff. So really I release down the front and then posterior, I go from my posterior portal down to six o'clock and connect the dots. Group two in this release with an added posterior release had better sustained long-term flexion. Thank you very much for your attention.

surgical technique

arthroscopic capsular release

adhesive capsulitis

range of motion

post-operative rehabilitation