AAOS Symposium Complex Shoulder Disorders: Evaluation and ... · rotator cuff tear involving the...

Complex Shoulder Disorders:Evaluation and Treatment

Abstract

Evaluation of patients with shoulder disorders often presentschallenges. Among the most troublesome are revision surgery inpatients with massive rotator cuff tear, atraumatic shoulderinstability, revision arthroscopic stabilization surgery, adhesivecapsulitis, and bicipital and subscapularis injuries. Determiningfunctional status is critical before considering surgical options in thepatient with massive rotator cuff tear. When nonsurgical treatmentof atraumatic shoulder stability is not effective, inferior capsularshift is the treatment of choice. Arthroscopic revision of failedarthroscopic shoulder stabilization procedures may be undertakenwhen bone and tissue quality are good. Arthroscopic release isindicated when idiopathic adhesive capsulitis does not respond tononsurgical treatment; however, results of both nonsurgical andsurgical treatment of posttraumatic and postoperative adhesivecapsulitis are often disappointing. Patients not motivated to performthe necessary postoperative therapy following subscapularis repairare best treated with arthroscopic débridement and bicepstenotomy.

In 1972, Neer1 hypothesized that ro-tator cuff pathology was the result

of impingement by the anterolateralacromion on the rotator cuff and thattreatment should consist of removalof this portion of the acromion andthe accompanying coracoacromialligament. Over the past 30 years, im-provements in diagnostic imaging mo-dalities, such as magnetic resonanceimaging (MRI) and arthroscopicshoulder evaluation, have resulted in asignificant change in the way in whichorthopaedic surgeons evaluate andtreat rotator cuff pathology as well asother common shoulder disorders.Despite these advances, there is still anincomplete understanding and a gen-eral lack of consensus among even themost experienced orthopaedic sur-geons regarding treatment of complexshoulder conditions.

Revision rotator cuff surgery is oneof the most challenging conditionsfor orthopaedic surgeons. A com-plete history and physical examina-tion, along with careful evaluation ofdiagnostic studies, are required be-fore considering whether surgery is avalid option for the patient with amassive rotator cuff tear. Physical ex-amination findings and radiographictesting also can aid in determiningthe proper course of treatment.

Common causes of failed arthro-scopic shoulder stabilization surgeryinclude recurrence of instability, fail-ure to detect associated injuries pre-operatively, technical errors intra-operatively, and implant failure.Careful clinical evaluation and se-lected diagnostic studies, particularlythose allowing for evaluation of theosseous anatomy, are important to

Pietro M. Tonino, MD, MBA

Christian Gerber, MD

Eiji Itoi, MD

Giuseppe Porcellini, MD

David Sonnabend, MD

Gilles Walch, MD

Dr. Tonino is Associate Professorand Chief of Sports Medicine,Loyola University Medical Center,Maywood, IL. Dr. Gerber isProfessor and Chairman,Department of Orthopedics,University of Zurich, Balgrist,Switzerland. Dr. Itoi is Professor andChair, Department of OrthopaedicSurgery, Tohoku University Schoolof Medicine, Sendai, Japan.Dr. Porcellini is Chief of Unit ofShoulder and Elbow Surgery,Cattolica, Italy. Dr. Sonnabend isProfessor of Orthopaedics andTraumatic Surgery, University ofSydney, New South Wales,Australia. Dr. Walch is Director,Centre Orthopédique Santy, Lyon,France.

Reprint requests: Dr. Tonino,Department of Sports Medicine,Loyola University Medical Center,2160 South First Avenue, Maywood,IL 60153.

J Am Acad Orthop Surg 2009;17:125-136

Copyright 2009 by the AmericanAcademy of Orthopaedic Surgeons.

AAOS Symposium

March 2009, Vol 17, No 3 125

avoid recurrence of this condition.Adhesive capsulitis of the shoulder

may be idiopathic or may present asa result of immobilization or reducedmotion resulting from either injuryor the trauma of surgery. Carefulpreoperative evaluation of range ofglenohumeral motion helps in per-forming a more selective capsular re-lease of the shoulder. Patient motiva-tion is a crucial factor in determiningthe best method for treating lesionsof the anterosuperior rotator cuff

and the biceps tendon. Repair can bedone open or arthroscopically.

Massive Rotator Cuff Tear

Surgical management of massive rota-tor cuff tear is difficult, and results areoften disappointing. To aid in determin-ing which patients may benefit from re-constructive surgery, those with massiverotator cuff tears are classified as highor low functional demand. Further dis-tinction is made between patients whohave severe pain and those who are rel-atively pain-free. The size of the tearand the quality of the remaining rota-tor cuff are then assessed; patients arefurther subdivided into those with rep-arable or irreparable tears and thosewith or without pseudoparalysis (Fig-ure 1).

Prior to attempting repair of amassive rotator cuff tear, it is helpfulto determine whether the primaryproblem is pain or function. Whenthe primary complaint is pain, thepatient is asked whether he or she issatisfied with the current strengthand function of the extremity. If theanswer is yes, the patient is classifiedas low functional demand, and re-construction is not considered. Sucha patient is initially treated with sub-acromial injections; if this treatmentis not successful, subacromial dé-bridement with biceps tenotomy isconsidered.2 Patients who are notsatisfied with the strength and func-

tion of the injured shoulder are clas-sified as high functional demand. Inthese patients, the following condi-tions suggest that the tear is irrepara-ble: (1) The examiner maximally ex-ternally rotates the arm in adductionor at 90° of abduction, and the pa-tient is unable to hold this positionactively.3,4 (2) The patient exhibitschronic pseudoparalysis during at-tempts to elevate the arm, with dy-namic anterior subluxation of theshoulder occurring when anterior el-evation is attempted. (3) The patienthas coexistent deltoid injury.

The extent of pain and the presenceor absence of pseudoparalysis also helpdetermine appropriate treatment usingthe following criteria: (1) Rotator cuffreconstruction is preferred for the pa-tient with pain and a tear that can berepaired using arthroscopic or opentechniques.5 (2) Arthroscopic sub-acromial débridement with bicepstenotomy is preferred for the patientwith an irreparable tear who doesnot have pseudoparalysis.2 (3) Sub-coracoid transposition of the pecto-ralis major muscle is recommendedfor the patient with a painful, irrepa-rable isolated subscapularis tear.6

(4) Partial repair and latissimus dorsitransfer is preferred for the patientwith an irreparable posterosuperiorrotator cuff tear (intact subscapu-laris) who demonstrates weakness,but not pseudoparalysis, irrespectiveof whether pain is present.7 (5) A re-

Dr. Tonino or a member of his immediate family has stock or stock options held in Regeneration Technologies. Dr. Gerber or amember of his immediate family serves as a board member, owner, officer, or committee member of the Swiss Society ofOrthopaedic Surgery; is affiliated with the publication Shoulder and Elbow Surgery; has received royalties from Zimmer; serves as apaid consultant to Storz; and has received research or institutional support from Zimmer Medacta. Dr. Sonnabend or a member of hisimmediate family serves as a paid consultant to DePuy; and has received research or institutional support from DePuy and Zimmer.Dr. Itoi or a member of his immediate family is affiliated with the publication American Journal of Sports Medicine; has receivedroyalties from Alcare; is a member of a speakers’ bureau or has made paid presentations on behalf of Alcare, DePuy, Eli Lilly,Johnson & Johnson, Merck, Mitek, Novartis, Pfizer, Smith & Nephew, and Wyeth; and has received research or institutional supportfrom Alcare and Smith & Nephew. Dr. Walch or a member of his immediate family serves as a board member, owner, officer, orcommittee member of the Société Française de Chirurgie Orthopédique, the European Society of Shoulder and Elbow Surgery, andthe Société Française d’Arthroscopie, and is an ASES corresponding member; is affiliated with the publication Journal of Shoulderand Elbow Surgery; and has received royalties from and has received nonincome support (such as equipment or services),commercially derived honoraria, or other non-research–related funding (such as paid travel) from Tornier. Neither Dr. Porcellini nor amember of his immediate family has received anything of value from or owns stock in a commercial company or institution relateddirectly or indirectly to the subject of this article.

Preoperative photograph of a 65-year-old woman with a massiverotator cuff tear involving thesupraspinatus, infraspinatus, andteres minor muscles, associatedwith pseudoparalysis of elevationand of external rotation in the rightarm. Elevation was limited to 60°,and the arm fell into internalrotation with any attempt to elevateit anteriorly.

Figure 1

Complex Shoulder Disorders: Evaluation and Treatment

126 Journal of the American Academy of Orthopaedic Surgeons

verse (inverse) prosthesis is preferredfor irreparable tears in patients withchronic pseudoparalysis.8

Determining the functional statusof the shoulder and performing care-ful examination with preoperativeclinical testing are critical steps be-fore considering surgical options inthe patient with a massive rotatorcuff tear. This approach leads to im-proved patient satisfaction and helpsto avoid failure of revision rotatorcuff surgery.

Atraumatic ShoulderInstability

One of us (E.I.) classifies shoulder in-stability based on whether instabilityoccurs in the midrange or at the end-range of motion. Although the amountof shoulder laxity present in themidrange varies by individual, thepatient with atraumatic or midrange in-stability typically demonstrates exces-sive midrange laxity of the glenohu-meral joint.9 In these individuals,repetitive translation of the humeralhead out of the glenoid with normalactivities may eventually damage thecapsuloligamentous structures of theshoulder.10,11 End-range instability,often associated with an acute trau-matic event or with repetitive mi-crotrauma, occurs at the limits ofshoulder motion, when the capsule istensioned in an attempt to maintainshoulder stability.

When the arm hangs freely at theside in the absence of muscular con-traction, the negative intra-articularpressure of the shoulder maintainsthe humeral head within the gle-noid.12 The rotator interval, which isthe only portion of the shoulder jointin which the thin capsule is not cov-ered and reinforced by the musculo-tendinous portions of the rotatorcuff, acts as a pressure absorber bydimpling in when the pressure be-comes negative and by bulging out

when the pressure is positive.13 Theeffectiveness of the shoulder in main-taining this negative pressure de-pends on capsular thickness, volume,and elasticity.14 In the patient withatraumatic instability, the capsule isoften thin and the joint volume isenlarged.15-17 As a result, the pressureresponsiveness is diminished, andshoulder stability may be compro-mised. With the arm in full elevation,or with inferior traction of the arm,normal shoulders demonstrate asharp increase in negative intra-articular pressure, which increaseslinearly as the arm is pulled inferior-ly.12,18 This adaptive response is lessefficient in patients with shoulder in-stability.12,19,20

The normal ratio of humeral toscapular motion on arm elevation is2:1.21 This ratio is higher in patientswith atraumatic instability becauseof imbalance between the shoulderand the parascapular musculature,which results in less scapular abduc-tion relative to the humerus.22 Scapu-lar abduction helps prevent inferiortranslation of the glenohumeraljoint.23 When the arm hangs freely atthe side, the height of the glenoid rimthat the humeral head has to over-ride is much less with the scapula inadduction than with the scapula inabduction (Figure 2).

In a patient with atraumatic insta-bility of the shoulder, the scapulamay be adducted with the arm at theside, which aggravates the inferiordisplacement of the humeral head.When the arm is in motion, muscularcontraction produces forces that re-sult in compression of the humeralhead against the glenoid fossa. Theeffect of the muscular activity in con-cert with the concavity of the shoul-der to maintain stability is termedthe “concavity-compression” effect.24

Muscle force imbalance betweenshoulder agonists and antagonists,as well as generalized muscularweakness, is observed in patients

with atraumatic shoulder instability.Weakness is typically present in bothinternal and external rotators but ismost significant in internal rota-tors.25 Despite muscular contractionin these patients, the humeral head isnot centered on the glenoid.26

The ratio of the dislocation forceto the compressive force is known asthe stability ratio.27 The stability ra-tio of normal shoulders is 50% to60% in the superior-inferior direc-tion and 30% to 40% in theanterior-posterior direction.28 The ra-tio is higher in the superior-inferiordirection because inferiorly, the la-brum is thickest and its attachmentmost rigid.29

The glenoid has a deep concavity inthe superior-inferior direction and ashallow concavity in the anterior-posterior direction. In the patient withatraumatic instability, the glenoid issometimes hypoplastic,16,30,31 and ret-roversion may be increased.11,16 Thestability ratio is lower with a shal-low, retroverted glenoid, particularlyin the inferoposterior direction. Onplain radiographs with the arm in el-evation, humeral head slipping maybe observed,16 and the center of thehumeral head may be translated pos-teriorly or inferiorly.32

Anteroposterior radiographdemonstrating scapular adduction.

Figure 2

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In addition to being detectable bythe sulcus sign and the anteroposte-rior drawer test, atraumatic laxitycan be clinically detected by the hy-perabduction test.33 The latter is theonly quantitative test that measuresthe length of the inferior capsule.The shoulder angle of abduction ismeasured while scapular motion isprevented. The normal shoulder hasa hyperabduction angle of 85° to90°. In the patient with an elongatedinferior capsule, this angle may ex-ceed 105°.

Plain radiographs are taken withthe arm hanging by the side with andwithout weights. Normally, the hu-meral head subluxates only when aweight is applied; in the patient withatraumatic instability, subluxationmay occur even without the applica-tion of weight. With the arm in anelevated position, the humeral headmay subluxate in a posterolateral di-rection because of a hypoplastic gle-noid.16 Computed tomography (CT)and MRI scans are helpful in evalu-ating retroversion and dysplasia ofthe glenoid. Magnetic resonance ar-thrography often reveals enlargedjoint capacity and a widened rotatorinterval.

Although nonsurgical treatment ofatraumatic shoulder instability witha supervised rehabilitation programis effective in only 66% to 85% ofpatients, it should be attempted be-fore surgical treatment is consid-

ered.25,34 Strengthening exercises toimprove scapular abduction are im-portant and should include bothisometric and isotonic exercises withresistance bands. Wall push-up exer-cises are also useful to strengthen thescapular stabilizers.25,34 A scapularband helps support the scapula frombehind, in addition to controlling ex-cessive adduction of the scapula (Fig-ure 3). This band has been shown toimprove the effectiveness of scapularstabilization exercises.25 When non-surgical treatment of atraumaticshoulder instability is not successfulafter 6 months, surgical treatmentshould be considered.

Capsular redundancy is alwayspresent; thus, inferior capsular shiftis the treatment of choice to decreasecapsular volume. This shift is effec-tive because it reduces the capsularvolume and increases the responsive-ness of pressure to external load.35

Surgical closure of the rotator inter-val is thought to increase the rein-forcement of the capsule in this loca-tion and reduces midrange instabilitywithout affecting end-range instabili-ty.36

The failure rate of isolated capsu-lorrhaphy with or without rotatorinterval closure is 6% to 14%37-39

and may be related to the concomi-tant presence of glenoid dysplasia.40

Preoperative imaging is essential,and osteotomy may be required ifimaging reveals glenoid dysplasia or

increased glenoid retroversion. In thepatient with dysplasia, glenoid con-cavity can be increased with eitherglenoid osteotomy16 or capsulolabralaugmentation.8 Studies have indi-cated that 15% of patients with vol-untary posterior subluxation requireglenoid osteotomy in addition to acapsular procedure.41 Glenoid osteot-omy has resulted in an increase inthe stability ratio of up to 34%42 andin capsulolabral augmentation up to25%.43 In the experience of one of us(E.I.), the need for glenoid osteotomyis relatively low.

Failed ArthroscopicShoulder StabilizationSurgery

Recurrence of instability is one of themain complications of arthroscopicstabilization of the shoulder.44 Fail-ure of both open and arthroscopicstabilization surgery is reported to bebetween 7% and 19%.45 The clinicalexamination helps in determiningpossible causes of recurrent disloca-tion. Failure to diagnose the type ofinstability during the initial surgerymay lead to possible failure ofthe primary stabilization procedure.Subscapularis pathology may alsolead to failure of shoulder stabiliza-tion procedures; this muscle shouldbe carefully examined in patientswho have failed stabilization surgery.

Plain radiographs may reveal tech-nical errors that occurred during theinitial procedure, such as poor place-ment or loosening of suture anchorsor other fixation devices (Figure 4).Magnetic resonance arthrographyaids in evaluating anterior labral re-pair and may reveal pathology thatwas not appreciated during the stabi-lization procedure, such as a humeralavulsion of the glenohumeral liga-ment, posterior or superior injuries,and associated rotator cuff lesions.46

CT scans are useful in determining

Posterior (A) and anterior (B) views of a scapular band.

Figure 3



whether failure is the result of boneloss of the glenoid or of osseous de-fects of the humerus.47,48

The ideal candidate for revisionsurgery is the patient with traumaticunidirectional instability with a re-pairable Bankart lesion and good-quality capsular tissue.49 Patientswith seizure disorders, scapular dys-kinesia, multidirectional instability,and voluntary dislocators are typi-cally not optimal surgical candidates.For these patients, nonsurgical treat-ment should be maximized before al-ternatives are considered.

Arthroscopic revision surgery is thetreatment of choice for the patient inwhom failure is the result of an inad-equately healed Bankart lesion. Ar-throscopic revision surgery also ispreferred when preoperative evalua-tion indicates the presence of otherassociated conditions (eg, superiorlabral tear or lesion) that can best beaddressed with arthroscopic visual-ization and treatment. Diagnostic ar-throscopy should be considered evenwhen open treatment has been se-lected for the revision surgery be-cause associated lesions that havenot been apparent on preoperativeevaluation may be diagnosed andtreated appropriately (Figure 5).

Open revision shoulder stabiliza-tion surgery is considered when cap-sular quality is insufficient to alloweffective arthroscopic stabilization.In addition to capsular procedures,open surgery is often chosen becauseit allows for procedures such as theBristow-Laterjet,49 which helps ad-dress osseous deficiency of the gle-noid. Open procedures are also help-ful when capsular laxity isaccompanied by lesions of the sub-scapularis and, more recently, incases in which cartilage restorativeprocedures can be performed to ad-dress humeral head chondral defects.

Failure of implants inserted duringarthroscopic stabilization may resultin significant chondral injury. Re-

moval of these implants may requireopen exposure of the shoulder if ar-throscopic removal cannot be per-formed.

Rehabilitation should be carefullyperformed following the initial shoul-der stabilization procedure and follow-ing a revision procedure. It is importantfor the patient to regain external rota-tion because loss of this motion maylead to adhesive capsulitis. However,external rotation, both in adductionand abduction, should be avoided un-til 4 to 5 weeks postoperatively to avoidinjuring the repaired capsuloligamen-tous structures. Restoration of scapu-lar musculature is also critical becausescapular dyskinesia may result in unsat-isfactory results even when anatomicshoulder joint lesions have been appro-priately addressed during surgery.

The treatment approach of one ofus (G.P.) begins with arthroscopicsurgery following an intrascaleneblock and general anesthesia. Thepatient is oriented in a modified lat-eral decubitus position, with theshoulder in 70° of abduction and 25°of forward flexion, with traction of5 kg. A standard posterior viewing

portal is used; an anterosuperior por-tal is created with an inside-out tech-nique, and an anteroinferior portal iscreated with an outside-in technique.

The glenoid is carefully inspectedand is compared with preoperativeCT scans. Its size and shape are de-termined and measured with the as-sistance of a calibrated probe. In thepresence of >20% osseous loss of theglenoid, the Bristow-Laterjet proce-dure is used.

If a protruding fixation device isfound, removal is attempted. An un-healed or previously untreated Ban-kart lesion is repaired with two orthree double-loaded bioabsorbabledevices, with adequate tensioning ofthe anterior glenohumeral ligaments.Capsular tensioning of the posteriorband on the inferior glenohumeralligament with capsular plication isalso performed. Repair of a humeralavulsion of the glenohumeral liga-ment can be performed arthroscopi-cally with an auxiliary anterior por-tal at the 5 o’clock position, using ametallic double-loaded suture an-chor. Other disorders, such as rota-tor cuff tears and biceps lesions, arealso treated during the arthroscopicprocedure.

Anteroposterior radiograph of ashoulder redislocation afterarthroscopic stabilization. Theupper anchor (white arrow) is toomedial on the glenoid neck, andthe lower anchor (black arrow) isloose in the joint.

Figure 4

Arthroscopic image demonstratingjoint destruction after failedarthroscopic stabilization.Symptoms were the result of aprominent metallic anchor.

Figure 5


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One of us (G.P.) performs theBristow-Laterjet procedure in abeach-chair position. A vertical inci-sion is made from the tip of the pal-pable coracoid to the axilla. Thecephalic vein is shifted laterally, withthe deltoid muscle and the pectoralisshifted medially. The coracoid is thenidentified and the conjoined tendonretracted medially. A 3-cm verticaland 3-cm horizontal (superior por-tion) L-shaped incision is made inthe subscapularis tendon. The ten-don is then retracted medially, anddébridement is performed on the gle-noid neck to remove any scar tissue.The coracoid process is resected witha 90° saw and is positioned in linewith the articular cartilage immedi-ately below the equatorial line ofthe glenoid surface. Normally, one4.5- × 40-mm malleolar screw isused with a washer to affix the cora-coid to the glenoid rim. The subscap-ularis is repaired with nonabsorbablesutures.

Postoperatively, arthroscopic revi-sion repairs are treated with a shoul-der immobilizer for 3 weeks. The pa-tient then begins assisted passivemobilization, avoiding external rota-tion. After 5 weeks, the patient be-gins active exercises in a pool andpassive mobilization in external rota-tion. The patient treated with theBristow-Laterjet procedure beginspassive mobilization of the shoulderat 2 weeks postoperatively in thescapular plane; at 4 weeks, passivemobilization in external rotation isallowed. Active exercises in the poolare permitted after the 5th week.

At 8 weeks postoperatively, pa-tients whose repairs were done ar-throscopically and those who weretreated with the Bristow-Laterjetprocedure are advanced to strength-ening exercises. Patients in the lattergroup are allowed to participate incontact sports at 3 months, whereaspatients treated arthroscopically can-

not do so until 5 months postopera-tively.

Arthroscopic revision of failed ar-throscopic stabilization procedurescan be undertaken when bone andtissue quality are good. For the pa-tient with significant glenoid defi-ciency, the Bristow-Laterjet proce-dure is preferred.

Idiopathic andPostoperative AdhesiveCapsulitis

Idiopathic adhesive capsulitis is anintrinsic process involving the gleno-humeral capsule, primarily the cora-cohumeral ligament.50 This conditionmust be distinguished from posttrau-matic adhesive capsulitis, an extrin-sic process that may be seen follow-ing injury or shoulder surgery andthat results in scarring between tissuelayers of the shoulder.

Idiopathic adhesive capsulitis typi-cally presents insidiously in patientsbetween ages 40 and 60 years. Thedisease process has been described ashaving three phases: freezing, frozen,and thawing.51-54 It has been associ-ated with systemic diseases such asdiabetes, thyroid disease, and hyper-lipidemia. The incidence of this con-dition is also higher in patients withDupuytren contracture and Peyroniedisease as well as in patients whohave undergone cardiac surgery andcervical spine procedures.55

There is no consensus regardingthe pathophysiology of idiopathicadhesive capsulitis. Myofibroblastssimilar to those seen in Dupuytrencontracture have been identified bysome investigators.56 Cytokines suchas transforming growth factor-β,platelet-derived growth factor, andhuman growth factor have beenidentified in the early inflammatoryphase. Metalloproteinases and theirinhibitors are altered in variousphases of the disease.56,57

Postoperative or posttraumatic ad-hesive capsulitis typically occurs fol-lowing immobilization or reducedmotion associated with the traumaof surgery or injury. Procedures thatinvolve exposure of the deltopectoralinterval, particularly when they in-clude tightening of the anterior gle-nohumeral capsule, are associatedwith an increased risk of contracture.Both glenohumeral and scapulotho-racic ranges of motion are decreased.Significant fibrosis is most com-monly identified in the area of thecoracohumeral ligament, in the inter-val between the base of the coracoidand the top of the subscapularis, be-tween the conjoined tendon and thesubscapularis, and between the rota-tor cuff and the overlying acromionand deltoid muscle in the scapu-lothoracic region.

Physical examination is helpful indetermining the site of the most in-volved capsule. Anterosuperior tight-ness (ie, tightness of the cora-cohumeral ligament and rotatorinterval) limits external rotation inadduction, while anteroinferior con-tracture (ie, of the inferior glenohu-meral ligament) limits external rota-tion in abduction. Posterior tightness(ie, of the posterior capsule) limitscross-body adduction and internalrotation. Loss of passive external ro-tation in adduction is the most sensi-tive test for adhesive capsulitis.

Serologic testing for patients withadhesive capsulitis should include acomplete blood count, determinationof C-reactive protein level, erythro-cyte sedimentation rate (to detectsepsis or malignancy), fasting bloodglucose level, and fasting lipid pro-file. Radiographic examination, in-cluding an outlet view, is essential torule out conditions such as a lockedglenohumeral dislocation, chondrol-ysis, calcific tendinitis, and failure offixation in patients who have under-gone surgical procedures.

The goal of treatment of idiopathic



adhesive capsulitis is to reduce dis-comfort and improve mobility. Inmost patients who are not diabetic,there is normally a gradual and al-most complete return of movementand eventual absence of pain.51,58 Inthe early phase, inflammation isgreatest and treatment is sympto-matic, consisting of pain manage-ment and restriction of activities.58

Passive stretching is counterproduc-tive in this stage and is particularlypainful. Intra-articular steroid injec-tions of the glenohumeral joint maybe effective. Anterior and superiorsteroid injections are technically eas-ier than a posterior approach, andsteroid injection by a radiologist un-der fluoroscopic control can also beconsidered. Injections should be lim-ited to no more than three per6-month period.

Passive stretching is more effectiveonce the severe pain of the initial in-flammatory phase has diminished. Hy-drodilatation has also been shown to beeffective in this phase of treatment.59

Historically, manipulation under an-esthesia was often considered thetreatment of choice for this con-dition, but arthroscopic capsularrelease is now increasingly pre-ferred.60,61 Examination under anes-thesia before commencing surgery is

important because it helps to identifythe specific capsular structures in-volved in adhesive capsulitis (Fig-ure 6).

Arthroscopic capsular release canbe performed in the beach-chair orlateral decubitus position. Becausethe capsule is thickened and theintra-articular space is diminished,special care is required to avoid pen-etration of the posterior humeralhead during the arthroscopic instru-mentation on arthroscope insertion.Addition of epinephrine to the ar-throscopic irrigation fluid helps pro-vide better visualization. When ade-quate visualization of the anteriorcapsule is not possible, an inside-outtechnique may be necessary to insertan anterior cannula. Care should betaken to mark bony landmarks be-fore initiating the arthroscopic pro-cedure and to remain lateral to thecoracoid while passing instrumenta-tion during the inside-out technique.

An electrocautery instrument is es-sential, and it is often the only in-strument required for successful sur-gical treatment of adhesive capsulitis(Figure 7). Initial débridement withthe electrocautery device should fo-cus on débriding tissue in the area ofthe rotator interval. The superiorborder of the subscapularis should

be identified (Figure 8). Initial dé-bridement is limited to the area supe-rior to the subscapularis and inferiorto the long head of the biceps, withresection of the coracohumeral andsuperior glenohumeral ligaments.Not only should the capsule be di-vided, but a portion should be re-moved or ablated to avoid early re-currence of this condition. Divisionof rotator interval tissue should con-tinue until the lateral base of thecoracoid can be visualized. The re-maining anterior capsule is then di-vided from proximal to distal until

The upper border of thesubscapularis should be identifiedto avoid injury to this structureduring débridement of the rotatorinterval.

Figure 8

Photograph demonstrating preoperative examination under anesthesia.Limitation of external rotation is one of the most common findings withadhesive capsulitis.

Figure 6

Intraoperative arthroscopic imagedemonstrating use of anelectrocautery device duringcapsular release in a patient withadhesive capsulitis.

Figure 7


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the inferior pole of the glenoid isreached. This completes the anteriorrelease.

The arthroscope is then moved tothe anterior portal, and the posteriorcapsule is divided. Great care shouldbe taken during the electrosurgicaldivision of the posterior capsule be-low the equator of the glenoid, andthe instrument should be directed to-ward the glenoid to avoid injury tothe axillary nerve. Some surgeonsrecommend avoiding removal of themost inferior portion of the posteriorcapsule because of the potential forinjury to the axillary nerve.

Arthroscopic instruments are thenremoved, and range of motion is as-sessed. If external rotation is still re-stricted, a gentle but firm manipula-tion is performed to achieve thedesired range of external rotation, inboth adduction and abduction.

The assessment of posttraumaticand/or postoperative loss of motiondiffers from that for idiopathic cap-sulitis. This condition is often ac-companied by scarring and adhe-sions between tissue layers as a resultof surgical disruption of these struc-tures and postoperative bleeding.Early aggressive mobilization is ofteneffective in reducing these adhesions.

Prior to a recommendation of sur-gical management of posttraumaticor postoperative capsulitis, the causeof stiffness should be identified. Thepatient should be advised that surgi-cal release is done with the intent toimprove mobility rather than toachieve a normal range of motion.

Surgical intervention for postoper-ative capsulitis may involve both ar-throscopic and open releases. Thesite of capsular release is determinedby physical examination. The mostlikely sites of postoperative scarringshould also be determined. Arthro-scopic release is often done when thesubacromial space or the capsule isthe primary site of pathology. Whenscarring extends to the region be-

tween the coracoid and the con-joined tendon and subscapularis,open releases are often more effec-tive. For restriction in motion causedby contracture of the subscapularis,open release or lengthening of thesubscapularis or arthroscopic tenot-omy may be required.

Isolated contracture of the coraco-humeral ligament can be released ar-throscopically or through a smalldeltoid-splitting incision placed lat-eral to the coracoid. When intra-articular biceps adhesions are en-countered, arthroscopic release isindicated. The tendon may be re-leased or, if necessary, its intra-articular portion excised. Tenodesisis usually not performed becausepostoperative therapy is aggressiveand may disrupt the surgical recon-struction. Scarring between the baseof the coracoid and the superior mar-gin of the subscapularis may extendwell medially. Release in this regionmay endanger the axillary nerve andthus should be performed cautiously.This is particularly the case follow-ing surgical procedures that use adeltopectoral approach. In thesecases, scarring may cause the nerveto displace more laterally than nor-mal, and the nerve may be found tocourse over the anterior and inferiorglenohumeral capsule rather than theglenoid neck.

When scarring between the sub-scapularis and underlying glenoidneck (and joint capsule) is suspected,this tissue plane can be accessed digi-tally over the top of the subscapu-laris, but it is probably best reachedby division and possible elongationof the subscapularis tendon. This al-lows for circumferential release ofthe subscapularis similar to that per-formed with soft-tissue release forshoulder arthroplasty. One centime-ter of lengthening of the subscapu-laris will result in 15° to 20° of addi-tional external rotation.

Postoperative mobilization should

be immediate, aggressive, and pro-longed. Continuous passive motionmachines may be helpful, and familymembers can assist in mobilizationof the shoulder.

Idiopathic and posttraumatic cap-sulitis are unique conditions that re-quire different assessments and treat-ment. The prognosis for idiopathiccapsulitis is good, irrespective ofwhether the patient is diabetic. Ini-tially, nonsurgical treatment shouldbe undertaken and should includeintra-articular steroid injection, pas-sive mobilization (after acute painhas subsided), and a home exerciseprogram. If this is not effective, ar-throscopic release is indicated. Post-traumatic or postoperative capsulitisis caused by pathologic soft-tissuescarring and contracture and may re-spond to early, aggressive stretching.Surgical release for this type of cap-sulitis is technically demanding, re-habilitation is difficult, and results oftreatment, whether surgical or non-surgical, are often disappointing.

Injuries of theSubscapularis and LongHead of the Biceps

Subscapularis tears are often associ-ated with lesions of the long head ofthe biceps, rotator interval, or su-praspinatus tendon.62-64 Tears may becomplete or partial, involving onlythe superior portion of the subscapu-laris tendon.65

Biceps instability is commonly as-sociated with subscapularis tears(Figure 9). Disruption or distensionof the ligamentous pulley of thebiceps tendon occurs, resulting infraying of the medial aspect of thetendon. Partial tears of the subscapu-laris may result in dislocation of thetendon, which then comes to rest onthe lesser tuberosity. Complete sub-scapularis rupture may be associatedwith intra-articular medial disloca-



tion of the biceps tendon. Finally,with disruption of the rotator inter-val, the tendon may dislocate extra-articularly and come to rest on theanterior surface of an intact subscap-ularis.

The patient who sustains a tear ofthe subscapularis typically recalls atraumatic episode associated withrupture of the tendon. Forced exter-nal rotation or extension of a par-tially abducted arm is a typicalmechanism of injury.66 In the olderpatient, acute dislocation of theshoulder may be accompanied by atear of the subscapularis.67 Degenera-tive tears may also occur, similar towhat is encountered with tears of theposterosuperior rotator cuff ten-don.65

Physical examination findings inthe patient with subscapularis tearmay include increased passive exter-nal rotation with the arm at the side,weakness on internal rotation, a pos-itive lift-off test (Figure 10), and apositive belly-press test66,68,69 (Figure11). Radiographs are typically nega-tive, although avulsions of the lessertuberosities have been reported.70,71

Shoulder arthrography may demon-strate biceps dislocation or sublux-ation, suggesting rupture of the sub-scapularis. CT arthrography andmagnetic resonance arthrography arethe tests of choice to diagnose partialor complete ruptures of the sub-

scapularis.72-74 In addition to detect-ing subscapularis injuries, CT andMRI scans reveal the extent of atro-phy and fatty infiltration of the sub-scapularis.75 The extent of fatty infil-tration is of particular importanceand is a significant prognostic factor

in assessing the likelihood of success-ful repair of the tendon.76,77

Several factors determine the typeof treatment needed for tears of thesubscapularis. Patient motivation isimportant. Those who are not moti-vated to perform the type of postop-

Classification of dislocations of the long head of the biceps. A, Intra-articular dislocation with an intact anterior fascia(complete rupture of the subscapularis). B, Intra-articular dislocation with complete rupture of the subscapularis.C, Dislocation within the subscapularis fibers, with displacement medial to the lesser tuberosity. D, Extra-articulardislocation over an intact subscapularis, with disruption of the rotator interval.

Figure 9

The lift-off test is positive when the patient cannot hold the hand off the back.A, Standing position. B, Negative test. C, Positive test.

Figure 10

Belly-press test. A, Standing position. B, Negative test: the patient can resistthe examiner. C, Positive test: the patient flexes the wrist and extends theelbow.

Figure 11


March 2009, Vol 17, No 3 133

erative therapy needed followingsubscapularis repair are best treatedwith arthroscopic débridement andbiceps tenotomy.78

The presence of concomitant irrep-arable posterosuperior rotator cuff,Goutallier grade III or higher fattyinfiltration of the subscapularis, andfixed anterior subluxation of the hu-meral head may contraindicate sub-scapularis repair.76,79,80 Pectoralis ma-jor transfer may be used to treat theyoung, motivated patient with an ir-reparable tear of the subscapularisfor whom nonsurgical treatment hasbeen unsuccessful.81

Full passive mobility should be ob-tained prior to subscapularis repair.This repair may be accomplished withopen or arthroscopic techniques. Mostrepairs can be achieved with an antero-superior deltoid-splitting approach.82

The deltopectoral approach can beused for more retracted tears.69 Allrepairs are accompanied by a bicepstenodesis.83

Summary

Despite improvements in imagingmodalities and surgical techniques,treatment of complex shoulder con-ditions remains challenging. Revisionrotator cuff surgery is among themost challenging, but other condi-tions include failed arthroscopicshoulder stabilization surgery, idio-pathic and traumatic adhesive capsu-litis, and lesions of the anterosupe-rior rotator cuff and biceps tendon.A complete patient history and thecareful evaluation of preoperative di-agnostic tests are essential in deter-mining proper means of treatment.

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