Hi guys, this is Alan Curtis from Boston. I wish I was with you there in Chicago, but in this day and age, this is the new abnormal. So I'm coming to you from Boston and we're going to talk today about managing the stiff shoulder. These are my disclosures. So if you do a lot of shoulder surgery, you know that dealing with someone with lack of motion can be challenging and difficult on the patient, and sometimes it's a long arduous course. Adhesive capsulitis can present in two different ways. Basically, it can be primary, which is idiopathic global inflammation of the capsule resulting in loss of motion. Or it can be secondary, which is post-surgical or post-traumatic. Frozen shoulder usually presents with a primary insidious onset. It almost sneaks up on the patient. It's more common in females than it is in males. The most common time to see this is in the 40 to 60-year-old age group. Sometimes and more often than not, it can involve the non-dominant arm. Other factors that come into play is if the patient has diabetes, thyroid disease, autoimmune disorders, or breast cancer. In the normal joint, the volume into articular is about 25 millimeters. In adhesive capsulitis, it can fall to about 5 to 10 millimeters in this inferior space in the axillicum, completely scarring, as is shown here on the right. Stages of adhesive capsulitis. In stage one, this is really increasing vague radiating pain, usually well-tolerated, except for at night, it starts to wake the patient up. They start to have end-range sharp pain. That is, if they reach quickly, they get a zing, like if something falls off the shelf, they can almost remember and cringe when they reach for it. Generally, we see loss of terminal internal rotation than external rotation. Forward flexion is still pretty good in stage one. In stage two, this is the freezing stage. This is when it really gets significant. These patients complain of almost acute symptoms and acute synovitis. They have pain at rest, and motion pain is significant. They're miserable, and they can't sleep. In stage three, this is the maturation phase, there's less pain at rest, but they have stretch pain, and they have global loss of motion. There is severe stiffness in all planes, and this is often when these patients will present to you in the office. In stage four, this is the thawing stage. This is a chronic period, it can last up to two years, marked by slow resolution of symptoms and slow resolution and increase in motion, and in 30% of cases, there can be residual loss of function and motion, and in diabetes, it can be worse. So basically, no one wants to wait that long, so the workup when the patients present is to get the history. It's usually innocuous minor trauma. They complain of night pain, and often some problems with dressing, especially reaching behind their back. On exam, they have lack of rotation early, and then flexion loss late. They can really cheat to get up into the, reaching into the overhead by arching their back and extending their scapula. On exam, active and passive range of motion are essentially equal. Strength can be within normal limits, although uncomfortable, these patients are usually not that weak, unlike with rotator cuff tears. Radiology, x-rays are usually normal. You want to rule out arthritis, of course, because that would be the other cause of stiffness in the shoulder. MRIs can be misdiagnostic. In essence, sometimes these patients are told they have partial cuff tears, impingement, labeled tears, slap lesions, when the problem is they have adhesive capsulitis. A week doesn't go by that I don't have someone come in for a second opinion who have been told they need surgery, they have adhesive capsulitis on exam, and a slap lesion on their MRI, and they've been told they need that repair. So be wary of the misdiagnostic MRI. Treatment. Early on, if they're not that bad, any inflammatory is icing in physical therapy, with the caveat that it's all about stretching, no strengthening. Strengthening actually makes these patients worse. Sometimes I'll try a MedDraw dose pack, but more often than not, we really go to an intra-articular cortisone shot under either fluoroscopy or ultrasound guidance. It's more accurate, and especially in these stiff, painful shoulders, you want to make sure it's intra-articular, otherwise it's not going to work. We did a study back in 2005 looking at 100 sequential patients with significant adhesive capsulitis. We had one radiologist inject all of them under fluoroscopy, 80% resolved with one shot, another 10% needed a second shot, and only 10% ultimately went on to have surgery, and even then, these were much easier releases than they would have been early on. So now if they fail two cortisone shots, and usually we wait two months between them, we'll move forward with surgery, and what I usually like to do is manipulate in the forward flexion plane in an effort to break up the inferior capsule. That makes getting into the joint easier, and also means you don't have to do as much work inferiorly. So the setup that you're doing in the lateral decubitus position is a little less abduction is good because it doesn't tether inferiorly, and then when you come in with your spinal needle, stay a little bit higher and in line with the glenoid. You can't cheat laterally like you usually do because it's hard to get into the shoulder. Be careful on entry because you don't want to damage the cartilage. Irrigate out the hematoma from the manipulation, and then find the biceps. These shoulders, it can be hard to see, so make sure you take your time and work toward the front. And then I start by just debriding any label fraying, bicep fraying, and I basically move in and find the interval. It can be difficult. The interval can be completely scarred in, so you can't even see the subscapularis. I start out by releasing the superior glenohumeral ligament so that I can see the subscap, and then I come down, I release the middle glenohumeral ligament, preserving the subscapularis as you're seeing here on the right. I'll then move down inferiorly to the five o'clock position, releasing the top of the inferior glenohumeral ligament down to the five position. I don't usually have to go too much beyond that because the manipulation is taking care of it. And if you do have to go inferiorly, stay near the glenoid rim because the axillary nerve is right there. This is from a study we did a few years ago where this is a left shoulder looking from anterior to posterior, and you can see the subscapularis there to the right that I'm moving out of the way, and that's the axillary nerve that bifurcates at the five o'clock position. The main branch goes out through the quadrangular space, and at six o'clock, it stays about 18 millimeters away from the glenoid. But the posterior branch to the teres minor comes a little bit closer to about 12 millimeters away, so that's actually the branch more at risk. So be wary when you go down inferiorly. I rarely go into the posterior capsule now. If I have to do anything posteriorly, I just release a little bit of the posterior inferior glenohumeral ligament. I avoid completely releasing the posterior capsule because you lose that tether effect. You create a floating shoulder, and rarely does it make much of a difference postoperatively. Subacromial work should be avoided, maybe a brisectomy at most, but I try to avoid decompressions and repairs in the stiff shoulder because, of course, these patients have a much harder time recovering. I remanipulate at completion of the operation. But the real caveat here is to be selective in your releases and avoid the just global release. It's actually not necessary, and you can avoid complications like this. This is a 60-year-old woman I saw three months after she had a release after a stiff shoulder from a rotator cuff repair. She wasn't doing very well in therapy. She only got out to neutral. She had three months of therapy and then came in for a second opinion. This is the x-ray that I got in the office. You can see she has a locked anterior inferior dislocation with complete hibernation of the glenoid, and she had to go on to have a reverse. So I caution you about overdoing it. Shoulders are not forgiving. Postoperatively, no sling is really required. You encourage use in motion early. Start PT early. And it's all about stretching. I don't really start any strengthening until they have about 80% of their motion back. And it usually takes about three to six months to completely plateau. But if the pain is better and the motion is improving, these patients are very satisfied. So what about the stiff postoperative shoulder? So my practice is a little unusual, and about half the people I see have had prior surgery. So the most common problem after surgery that doesn't go well is pain and weakness, loss of motion, and loss of function. And how often do you hear this phrase, especially in the work comp population, all I want is my life back. So when you're dealing with a postoperative stiff shoulder, the workup is to review the operative notes and the PT notes and see what would you have done differently. Focus on the true pain points and listen to the patient. What is really bothering them? Compare passive and active range of motion, but it's not usually global loss of motion. They're all stiff, but the stiffness is usually due to whatever the operation was. So you can really pick that out, and that guides you if you have to do further surgical intervention. So glucose and subacrylamide adhesion is the most common problem after prior surgery, affecting usually around 10% of patients. It can be due to over-mobilization. If the patient's diabetic, they tend to get stiff. If they have preoperative adhesive capsulitis, no matter what you do, they're going to be stiff postoperatively, and you have to really address that early. And then this, too much is done. Shoulders should never be shotgun. They are a very unforgiving joint, so be selective and do the operation that needs to be done, but don't overdo it and do unnecessary operations like just arbitrarily doing an AC joint resection and a cuff repair because they have arthritis on their MRI. Only do it if it's really part of the problem. Stiffness and pain factors. In another study, we looked at failed slaps back in 09, and so what we found was that if a patient had had a labral repair in the over 40 group, and especially if they had surgery such as a cuff repair, they were bound to get stiff postoperatively. If they had arthritis in a labral repair, if they had adhesive capsulitis in a labral repair, they did poorly, and if they had the absence of instability symptoms, and we see this a fair amount, in that active woman in their 30s who works out a lot, she gets a positional bursitis from poor posture. Yes, under exam, she has a drive-thru sign, she has a little bit of a sulcus, but it's not her complaint. It's more of a bursal problem, so if these patients wake up with an instability procedure, they do quite poorly. Bad decisions equal bad results, so be wary. Subacromial pain stiffness factors that we've seen, a acromial scar formation happens early, so after a cuff repair or a decompression, if there's bleeding, the bleeding almost acts like glue, and if it hurts, they don't move, so they immobilize the shoulder and it stiffens up quite quickly. If you do a cuff repair and you put them in a pillow brace, be careful if you do a decompression as well, because all a tendon knows is they want to heal to expose bone, so if a patient sits in an abductive position after a cuff repair, they'll heal to the humerus, but they'll also heal to the undersurface of the acromion, and I've seen that quite often. This is a subacromial space in a patient that had a cuff repair eight months ago, so you can see, it really doesn't go away that carefully. If they had impingement, had a decompression done, see that it was adequate and that it's nice and smooth. If they've had prior surgery, if they have prominent knots or hardware, that's going to be a cause of postoperative scarring in the subacromial space as well. Treatment options, just like in primary adhesive capsulitis, I'll usually do a guided interarticular inversal cortisone shot under ultrasound, or if they've had a prior cuff repair, I'll do it under fluoroscopy with a radiologist with an orthogram, because that way, I get basically a free check on the rotator cuff. If you have to do surgery on these individuals, basically, when I get into the joint, I want to debride the labrum in the joint, of course, remove any implants that are causing clicking and pain, as you can see here, this is a 52-year-old pipefitter who woke up with an instability repair after having no symptoms of instability, and then selective release of adhesions based on your exam and your findings at the time of surgery. Atenodesis for biceps pathology or prior slap repairs works very well, and then if necessary, repair the cuff. Obviously, if you can avoid doing any type of surgery that puts this patient back in a sling, that is a better outcome. In the subacromial space, if they've had prior surgery, as you see here, entry can be tough as the rotator cuff scars to the acromion, and there's no landmarks. So basically, you want to come in at mid-acromion, pointing to the back of the AC joint. Find and feel the bone, and then stay on bone. Bone is home here, and you want to peel the scarred cuff off the acromion, just let it fall down, and then you can see the prominent knots there. This had been a prior open cuff repair and decompression, so that's significant scar tissue. And so you want to triangulate off the mid, work toward the front, and preserve the arch as much as possible. So, in summary, it's important to stay with the least invasive approach when dealing with these patients who have had a long, arduous course and are not doing well. Avoid surgery if you can, and if you do surgery, avoid treating the MRI report. Focus on the patient's needs and specific findings. Less is often better and will lead to a better overall outcome, but in all situations, motion is everything. So, I want to thank you for your attention. I hope you enjoy the weekend, and then just a quick plug, my brother wrote the music to this new movie on Netflix called Over the Moon. It's up for Oscar nomination, and so if your kids are looking for something to do this weekend, tell them to give it a watch, and I hope they enjoy it. So, have a great weekend. Thank you very much.

adhesive capsulitis

shoulder management

cortisone shots

postoperative stiffness

physical therapy