All right. Hello, I'm Dr. Holland. I'll be discussing operative management of adhesive capsulitis. I have no conflicts relative to this presentation. So, frozen shoulder is a disabling disease characterized by pain and limited range of motion. This is secondary to decreased interarticular volume, fibrosis, and thickening of the joint capsule. The prevalence of frozen shoulder is about two to five percent in the population. It occurs more frequently in males than females, with a peak incidence between the ages of 40 and 60. About 20 percent occur contralaterally within five years after the initial diagnosis, and primary reoccurrence is rare. Primary frozen shoulder is thought to be idiopathic, however, it's classically associated with diabetes and hypothyroid. Other associations do include heavy tobacco use, Parkinson's, stroke, neck and cardiac surgery, Dupuytren's, hyperlipidemia, trauma, infection, and inflammatory disease. It is often self-limiting and has a natural course of 12 to 24 months. There are three pathologic stages, freezing, frozen, and thawing. The freezing stage lasts between two to six months. It is characterized by rapid loss of range of motion in the shoulder to include external rotation, interrotation, and abduction, followed by a progressive pain to include nocturnal discomfort. The frozen stage would last between four to 12 months, which is characterized by decreasing pain with ADLs, however, continued stiffness. And then lastly, the thawing phase, which can be between five and 24 months, in which you see the patients often report a very little pain and a gradual return of range of motion. The common presentation is not unfamiliar as a shoulder surgeon. This can be similar to those that present initially with rotator cuff disease, chromocovicular issues, subacromial bursitis, or proximal biceps pathology. However, the hallmark with frozen shoulder is a global loss of range of motion, both passive and active. And loss of external rotation at the side is one of the earliest signs. There can also be deltoid atrophy, a limited humeral translation with direct manipulation, lateral rotation of the scapula as the shoulder tries to compensate for that limited motion. Routine imaging can be done in the office to include x-ray, ultrasound, which can show thickened coracohumeral ligament, increased vascularity in the rotator interval, or hypoechoic soft tissues in the rotator interval. And then classically an MRI, which can also again show coracohumeral thickening, decreased axillary volume, and rotator interval tracture. Treatment is important to really engage our primary care colleagues as the underlying condition can be frequently associated with diabetes, thyroid dysfunction, and other things that I had mentioned before. Conservative treatment fortunately is largely successful in most patients. You have that painful stiff shoulder in your office, this is not something that patients want to hear, but it is in fact true and been validated by the literature. Surgery is often considered in more refractory cases. So treatment, physical therapy is the mainstay. Those therapy exercises are really based on the pain intensity. So obviously when patients present with rapidly regressing pain, that pain will be limiting in what they're able to obtain in physical therapy and also their home exercises. So most of those patients, it is suggested that they continue movement, do something with the shoulder. And as the pain subsides, we institute controlled stretching, TENS, and other modalities to help maintain the motion and even improve upon that as we get later in the disease. So incense, helpful early on, well validated in literature. Cortical steroids are beneficial in those early stages in the freezing or early frozen stage. PO steroids as well, favorable to help reduce the pain and increase range of motion. These only have a limited effect, however. Intraarticular, a limited duration, I should say, meaning that they're most effective within the first six weeks of instituting those medications and then the effectiveness sort of diminishes with further time. Intraarticular steroid injections, most commonly used, has been found in the literature, best for short-term pain management and also improve early range of motion. Recommend ultrasound guided if possible. As I mentioned before, one of the hallmarks is decreased joint space. So blindly kind of using the landmarks that we do when a patient comes in for a bursitis, inflammation, flap issues, et cetera, can be much more difficult to kind of pass that blindly. So other modalities described include intraarticular hyaluronate, hydrodilation, which is inflating the shoulder, kind of trying to break up the scar and distend the capsule further, a suprascapular nerve rock, acupuncture, and extracorporeal shockwave therapy. Surgical management, there's no high level evidence regarding optimal timing. It generally considered after six to nine months of failure or severe disabling symptoms. Those options do include MUA, arthroscopic capsule release, and as I mentioned previously, hydrodilation or capsular distension. So manipulation on anesthesia, it's a process where the fibrosa capsule ligament complex is forcibly broken. It is an effective method in those refractory cases in early stage two. There's no high level evidence that is more effective than the natural history of frozen shoulder. Again, a difficult conversation to have to the painful patient who's coming in with a painful stiff shoulder. It must be carefully followed by physical therapy. So manipulating shoulder is not enough to maintain the gains achieved. So the complication rate is overall low. However, the re-intervention rate can be up to 14%. Some complications well known do include humeral shaft fractures, dislocation, rotator cuff and labral tears, nerve injury, and complex regional pain syndrome. Manipulating the shoulder should be avoided in those patients that come in with extreme osteopenia or osteoporosis, patients with prior arthroplasty or even any previous open or instability repair. The MUA does reliably improve the forward reflection and abduction. There continues to be limitations in rotation as surgeons tend to be not as aggressive when performing those type of pepper maneuvers, I should say, forcefully while the patient's asleep. So the technique is described as here. The patient is placed under anesthesia. This can be combined with a nerve block as I mentioned before. You must be sure to stabilize the scapula. This can be either done with your assistant holding the scapula or having the patient supine so the scapula is resting against the surgical table. The upper extremity is held with a short lever arm, so making your arm, position your hands such that hands is more closer to the axilla or mid humerus to shorten that lever arm to avoid a fracture. The shoulders gently moved in flexion, adduction, followed by adduction external rotation and abduction internal rotation. And then lastly, external rotation at the side and cross body abduction. No movement should be forced. If there's excess resistant felt, simply move on to the next maneuver and all movements are repeated until the end range of motion has been achieved. And it's always good to sample the contralateral shoulder prior to instituting this procedure just to see how far you are and so that you know when you get close to kind of what the native motion should be. The post-MUA can be supplemented by injection of a steroid and local anesthetic. However, there's been some studies that showed there's been no outcomes with the addition of that intervention. So the timing, as we talked about before, should be delayed. There's no benefit to any early manipulation. And in fact, this has been found to sort of worsen the outcome and severity of the disease. As I mentioned, no benefit with use of intra-articular steroid injection post-procedure. We do know that diabetics in general, just with other procedures, tend to have a worse outcome. And so this is something just to counsel your patients appropriately, particularly those that have, you know, really uncontrolled diabetes. So this also sort of piggybacks on what I was mentioning before, which is enlisting the help of your primary care provider to get these patients under a medical routine to help tighten up their sugars to avoid prolonged morbidity and recovery. So arthroscopic capsular release is typically the preferred surgical option. It is more controlled and comprehensive than the MUA. It allows you to address the issues with the synovitis, rotator interval, capsule, labrum, cartilage, subacromial space. It also avoids some of those complication risks, fracture that can be seen with the MUA alone. This can be done in either beach chair or lateral. Beach chair have a slight advantage because this is the most commonly approached, a little bit easier for arm positioning than lateral position, but again, no difference in outcome. Indications well-established to include a failure of a well-performed rehab program for six months, failure of at least three steroid injections in a six-month interval, failure of less invasive treatment options for MUA, severe frozen shoulder in patients with diabetes who steroid treatment is contraindicated or in that patient who just wishes for a faster recovery. Surgical anatomy relative to ACR, the anterior shoulder girdle has four anatomic lasers. First two comprised by the capsule, the glenohumeral ligaments and the subscap tendon. The third, which involves a corticohumeral ligament and the fourth, which involves a CA ligament. All four layers trigger pain. However, this corticohumeral ligament is the most responsible for shoulder stiffness. So this is the key target when doing our arthroscopic release. So the lateral position has advantages that it does allow joint space distension. So makes that a little bit easier placing your instruments as opposed to in the beach chair position. It allows improved visualization along the anterior capsule and labrum. Some of the disadvantage includes it can be an unfamiliar setup for some, maybe a little bit more difficult to perform any concomitant subacromial open procedures, and also potential damage to the axillary nerve when releasing down at the six o'clock position inferiorly. So beach chair setup, quite familiar. Identify your landmarks, begin with performing a diagnostic arthroscopy via posterior portal. This can be a little bit tricky as the capsule is thickened, their joint volume is reduced. So tips you can use is to inflate the joint capsule with sterile saline or perform a gentle manipulation just to break up those adhesions and perhaps open the joint space some before beginning your scope. That can be a little bit tricky as well because breaking up those adhesions will make the joint intratically reddened and very bloody, which can also impair your visualization. So just be mindful of that. Establish an anterior portal. This time you can perform a limited synovial debridement. And then the release begins with a sequential release involving the rotator interval, the coracohumeral ligament posterior or superficial to the rotator interval, releasing the MGHL, proceeding inferiorly down to the inferior glenoid about six o'clock. You want to make sure about two millimeters anterior labrum, particularly inferiorly to avoid getting it adjacent to the axillary nerve. So at this time you swap instruments, bring your scope to your anterior portal and establish a posterior portal for placement of your RF wand or arthroscopic baskets. And that posterior capsule is again released from the posterior superior down to inferior. Typically due to visualization that inferior labrum and inferior pouches left alone, that will be later addressed by performing a limited manipulation, which helps kind of break that remaining capsular adhesions. So it can be placed into the subacromial space and any versatile sided or rotator cuff adhesions can be addressed. You can also reassess the CHL and do additional releases as needed at this point. And then once again, the surgery can be augmented with use of intraarticular cortisone, either Kenalog or Deprometrol. Position the patient, establish a posterior portal, establish anterior portal, release the rotator interval, and this can be done using our RF wand. The anterior capsule and MGHL can be released again using RF wand or meniscal baskets. Place your scope anteriorly, establish a posterior portal, and then release your posterior capsule. And then lastly, gently manipulate the arms just to address the capsule that was not released in the axillary fold. So post-procedure, place into a standard arm sling, highly encourage that you inform the patient that this should be discontinued at post-op day one. Therapy is begun immediately. And again, this is the begin active and pass arrangement motion. This is done typically daily for the first two weeks. And depending on the patient response, the patient can be backed down to therapy two to three times a week with home exercises in between. Scapular and rotator cuff reactivation exercises are begun later once you've been able to obtain your near anatomic range of motion. There are some commercially available continuous passive range of motion devices that can be also used post-op again just to maintain your intraoperative gain. And in summary, frozen shoulder is a common condition which causes significant pain and morbidity. There are many treatment options available. There's no consensus which therapeutic option is superior. However, physical therapy and home exercises are the mainstay. Incis and intraarticular steroid injections are augments, which helps to decrease the pain and inflammation and to allow the participants to participate fully in therapy. Patient education and expectations are key. Again, this is a self-limiting disease, typically can resolve on its own between 12 and 24 months. So patients may understand, particularly those that may be apprehensive about surgical interventions, that staying with therapy and some of the adjuvant-enabled range of motion in the shoulder, if that largely fails, can proceed with an arthroscopic capsule release in those refractory cases. Thank you.

adhesive capsulitis

frozen shoulder

operative management

arthroscopic capsular release

post-operative physical therapy