Posterior Capsular Contracture of the Shoulder...Posterior Capsular Contracture of the Shoulder...

Posterior CapsularContracture of the Shoulder

AbstractPosterior capsular contracture is a common cause of shoulder painin which the patient presents with restricted internal rotation andreproduction of pain. Increased anterosuperior translation of thehumeral head occurs with forward flexion and can mimic the painreported with impingement syndrome; however, the patient withimpingement syndrome presents with normal range of motion.Initial management of posterior capsular contracture should benonsurgical, emphasizing range-of-motion stretching with the goalof restoring normal motion. For patients who fail nonsurgicalmanagement, arthroscopic posterior capsule release can result inimproved motion and pain relief. In the throwing athlete, repetitiveforces on the posteroinferior capsule may cause posteroinferiorcapsular hypertrophy and limited internal rotation. This may bethe initial pathologic event in the so-called dead arm syndrome,leading to a superior labrum anteroposterior lesion and, possibly,rotator cuff tear. Management involves regaining internal rotationsuch that the loss of internal rotation is not greater than theincrease in external rotation. In the athlete who fails nonsurgicalmanagement, a selective posteroinferior capsulotomy can improvemotion, reduce pain, and prevent further shoulder injury.

Classic impingement in theshoulder involves pain on for-

ward flexion that is localized overthe supraspinatus insertion on thegreater tuberosity.1-4 Although asso-ciated loss of internal rotation hasbeen described, the pain may be in-dicative of a posterior capsular con-tracture; loss of motion is not com-mon with impingement.2 Theoriginal description of impingementsyndrome did not mention a capsu-lar contracture limiting motion. Ad-ditionally, the morphology of thecoracoacromial arch does not re-strict internal rotation of the shoul-der. Thus, in impingement syn-drome, there should be normalshoulder motion.5 Although both

impingement syndrome and posteri-or capsular contracture may presentwith pain on forward elevation, onlyin the presence of posterior capsularcontracture would the patient be ex-pected to present with objectivelydecreased internal rotation.6

In a cadaveric study, posteriorcapsular contracture was shown toalter normal glenohumeral kinemat-ics, resulting in increased anterosu-perior translation of the humeralhead during shoulder flexion.7 Thiscan cause a form of nonoutlet im-pingement as the humeral headtranslates toward the coracoacromi-al arch8,9 (Figure 1). Harryman et al7

demonstrated that in vitro posteriorcapsular shortening results in limit-

H. Gregory Bach, MD

Benjamin A. Goldberg, MD

Dr. Bach is Resident, Department ofOrthopaedic Surgery, University ofIllinois–Chicago, Chicago, IL. Dr.Goldberg is Assistant Professor,Department of Orthopaedic Surgery,University of Illinois–Chicago, andSenior Attending Surgeon, Division ofOrthopaedic Surgery, Cook CountyHospital, Chicago.

None of the following authors or thedepartments with which they areaffiliated has received anything of valuefrom or owns stock in a commercialcompany or institution related directly orindirectly to the subject of this article:Dr. Bach and Dr. Goldberg.

Reprint requests: Dr. Goldberg,Department of Orthopaedic Surgery,University of Illinois–Chicago, 835 SWolcott Avenue, M/C 844, Chicago, IL60612.

J Am Acad Orthop Surg 2006;14:265-277

Copyright 2006 by the AmericanAcademy of Orthopaedic Surgeons.

Volume 14, Number 5, May 2006 265

ed internal rotation and flexion.Although adhesive capsulitis (ie,

frozen shoulder) may present withlimited internal rotation, it is con-sidered to be a separate and differentcondition.9-14 Patients with adhesivecapsulitis frequently have pain withshoulder flexion as well as com-plaints that resemble those of im-pingement symptoms; however, re-stricted range of motion (ROM) in allplanes is usually present.

There are three basic types of pos-terior capsular contracture: (1) idio-pathic, with the patient unable to re-member any prior trauma; (2)posttraumatic, typically after a low-energy event, which may be misdi-agnosed as a muscle strain; and (3)

postoperative, such as after a poste-rior capsular shift for posterior insta-bility. However, procedures per-formed to manage a variety ofshoulder conditions, including clas-sic impingement, may result in pos-terior capsular contracture. In ourexperience, idiopathic and posttrau-matic contractures typically do wellwith nonsurgical treatment; postop-erative contracture often requiressurgical release of the posterior cap-sule to restore motion and improvepain.8

Posterior capsular contracturealso may occur in the overheadthrowing athlete, especially in base-ball pitchers.15,16 In these athletes,however, the contracture involves

the posteroinferior aspect of the cap-sule.15,16 Posteroinferior contracturemost likely occurs in response to thestress loads associated with thefollow-through motion in throw-ing.16 After ball release, the armmoves ahead of the body and exertsa large distraction force of approxi-mately 750 N (approximately 80%of the pitcher’s weight),17 which actson the posteroinferior capsule.16 Be-cause the shoulder is internally ro-tated in follow-through, the inferiorpart of the posterior capsule is rotat-ed into a more posterocentral posi-tion, where it more directly resiststhe distraction force of follow-through.16 The reactive force of theshoulder musculature produces a

Figure 1

A, A shortened posterior capsule causing obligate anterosuperior translation of the humeral head during forward flexion,resulting in nonoutlet impingement (inset images). Top, Normal resting arm position. Bottom, Posterior capsule contracture.B, When the capsule is of normal length (top and bottom), the humeral head remains centered on the glenoid during forwardelevation and subacromial impingement does not occur (inset images). (Adapted with permission from Ticker JB, Beim GM,Warner JJP: Recognition and treatment of refractory posterior capsular contracture of the shoulder. Arthroscopy2000;16:27-34.)

Posterior Capsular Contracture of the Shoulder

266 Journal of the American Academy of Orthopaedic Surgeons

compressive load to resist this dis-traction force. The shoulder capsuleis then subjected to repetitive highloads that cannot be completely re-sisted by muscle forces.16 This repet-itive tensile loading of the posteroin-ferior capsule could cause thecapsular hypertrophy that is so com-mon in the throwing athlete.16

Anatomy

The shoulder is a synovial joint witha capsule comprising four supportinglayers: (1) the deltoid and pectoralismajor muscles, (2) the clavipectoralfascia and conjoined tendon (shorthead of the biceps and coracobrachi-alis), (3) the deep layer of the subdel-toid bursa and rotator cuff muscles,and (4) the glenohumeral joint cap-sule and coracohumeral ligament.18

The shoulder capsule contains an ex-tracellular matrix that is composedprimarily of type I collagen, withlesser amounts of types II and III.19

The highly ordered crystalline ar-rangement of collagen in the extend-ed conformation provides an ana-tomic structural basis for itsviscoelastic properties.19

The posterior capsule originatesfrom the posterior capsulolabralcomplex and extends from the poste-rior origin of the biceps tendon tothe inferior aspect of the glenoid.19

At the inferior aspect of the shoulderjoint is the inferior glenohumeralligament (IGHL) complex.20 Thiscomplex is bounded by an anteriorband and a posterior band that per-form like a hammock to support thehumeral head with the arm in ab-duction.20 The posterior capsule,which blends with the tendinousportion of the posterior aspect of therotator cuff, limits posterior transla-tion when the arm is forward flexed,adducted, and internally rotated.19

Additionally, the posterior capsulebecomes taut in various positions offlexion and internal rotation and canlimit excessive flexion and internalrotation.7

Pathoanatomy

With experimental tightening of theshoulder capsule, there is abnormaltranslation of the humeral head dur-ing glenohumeral rotation.7,19 Thetranslation occurs in the opposite di-rection of the capsular tightening.7

This mechanism of translationalmotion is referred to as the capsularconstraint mechanism7 (Figure 2).Injury to this mechanism may leadto instability, articular damage, andsymptoms of impingement.19 Theimpingement symptoms occur

through nonoutlet mechanisms;they are not related to the acromialmorphology.9,19

Harryman et al7 experimentallyshortened the posterior portion ofthe shoulder capsule in seven cadav-eric specimens. They confirmed thattightening of the posterior capsuleresults in limited internal rotation,cross-body movement, and flexion ofthe shoulder.7 Additionally, the au-thors demonstrated that posteriorcapsule tightening caused a signifi-cant increase in anterior translationof the center of the humeral headduring both shoulder flexion (P< 0.01; from a mean of 3.79 to 7.27mm) and cross-body movement (P< 0.01; from a mean of −0.14 to 6.63mm).7 This anterior translation oc-curred earlier in the arc of motion inthe study specimens than it did in ashoulder with a posterior capsule ofnormal length.7 Tightening of theposterior capsule also resulted in sig-nificant superior translation of thehumeral head with flexion (P < 0.05;from a mean of 0.35 to 2.13 mm). Asa result, the convex humeral headand bursal side of the rotator cuff areforced against the undersurface ofthe concave coracoacromial arch,which may cause compression of thecuff because the humeral head can-not remain centered in the glenoid2

(Figure 3).Gerber et al21 reported that poste-

rior capsular plication significantlylimits internal rotation. The authorsperformed a posterior capsulorrha-phy by surgically plicating one halfthe circumference of the capsulefrom the 6 o’clock to the 12 o’clockposition. At 0° of abduction, posteri-or capsulorrhaphy limited internalrotation by 21.5°, or 48.2% of inter-nal rotation (P < 0.00001).21 At 45°of abduction, posterior plicationlimited internal rotation by 27.2°,or 69.7% of internal rotation (P< 0.0007).21 At 90° of abduction, pos-terior capsulorrhaphy limited inter-nal rotation by 21°, or 68.2% of in-ternal rotation (P < 0.0022).21

Figure 2

Effect of asymmetric tightening of theshoulder capsule. Rotating the humeralhead produces tension in the tissuesof a surgically tightened capsule,causing translation in a directionopposite to the tight-tissue constraint.This constraint opposes loads anddisplacement that are directed towarditself and acts to translate the humeralhead on the glenoid in a direction awayfrom itself. This mechanism oftranslatory motion is referred to as thecapsular constraint mechanism.(Adapted with permission fromHarryman DT II, Sidles JA, Clark JM,McQuade KJ, Gibb TD, Matsen FA III:Translation of the humeral head onthe glenoid with passive glenohumeralmotion. J Bone Joint Surg Am1990;72:1334-1343.)

H. Gregory Bach, MD, and Benjamin A. Goldberg, MD


Posterior CapsularContracture in theOverhead ThrowingAthlete

In the overhead throwing athlete,the posteroinferior capsule may de-velop a contracture that causes a lossof internal rotation.15,16 Gleno-humeral internal rotation deficit(GIRD) is the loss in degree of gleno-humeral internal rotation of thethrowing shoulder compared withthe nonthrowing shoulder.15,16 Thefirst recognition of the relationshipof GIRD with shoulder dysfunctionin the throwing athlete was in1991.16 In this study, 39 professionalbaseball pitchers identified at springtraining as having ≤25° of total inter-nal rotation (GIRD), with loss of in-ternal rotation ≥35°, were followedfor a single season.16 Sixty percent ofthese pitchers developed shoulderproblems requiring them to stoppitching during the study period.16

Similarly, in a series of 38 arthro-scopically proven symptomatic typeII superior labrum anterior-posterior(SLAP) lesions in overhead athletes,significant GIRD was found in all af-fected shoulders (average, 33°; range

of loss of internal rotation, 26° to58°).16 In another study, high-leveltennis players were followed pro-spectively for 2 years. One group per-formed daily posterior inferior cap-sular stretching to minimize GIRD,whereas the control group did notstretch.16 Over the 2-year study peri-od, those who stretched increasedinternal rotation and total rotationcompared with the control group;additionally, the stretching grouphad a 38% decrease in the incidenceof shoulder problems.16 Finally,among 22 major league pitchers whowere manually stretched daily dur-ing the 1997, 1998, and 1999 profes-sional baseball seasons, there werereportedly no innings lost, no intra-articular shoulder pathology, and nosurgical procedures.16

Posteroinferior capsular contrac-ture in the overhead throwing ath-lete results in translation of the hu-meral head on the glenoid.15,16 Arecent study investigated theamount of translation both beforeand after posteroinferior capsularplication in cadaveric shoulderstracked with electromagnetic sen-sors.16 The authors documented aposterosuperior shift of the humeral

head on the glenoid face of approxi-mately 4.4 mm following posteroin-ferior capsular plication.16

Mechanically, the IGHL complexmay be represented by two domi-nant structural components thatfunction as interdependent cables—the anterior band and the posteriorband.16 These primary passive con-straints of the glenohumeral jointdevelop tension reciprocally andequally as the shoulder internallyand externally rotates in the 90° ab-ducted position.16 This defines theallowable envelope of motion of theshoulder, in much the same waythat the four-bar linkage model de-fines allowable knee motion basedon cruciate restraints.16

With external rotation of the hu-merus about its central contactpoint on the glenoid, the cablestighten and develop tension equallyas they assume an oblique courseacross their allowable envelope ofmotion16 (Figure 4, A). When theposterior cable is shortened, as inposteroinferior capsule contracture,it acts as a tether, shifting the gleno-humeral contact point posterosupe-riorly during combined abductionand external rotation because theshortened posterior cable reaches itsmaximum elongation before the an-terior cable maximally elongates.16

The anterior band continues to al-low external rotation anteriorly, re-sulting in posterosuperior transla-tion on the humeral head16 (Figure 4,B). With the posterosuperior shift ofthe arc of motion of the greater tu-berosity, it ceases to abut the usualsegment of the posterosuperior gle-noid in combined abduction and ex-ternal rotation, allowing additionalexternal rotation to be obtained.16

The peel-back mechanism is a dy-namic phenomenon that has beenobserved arthroscopically in over-head throwers with SLAP lesions.16,22

The peel-back, which occurs withthe arm in the cocked position of ab-duction and external rotation, iscaused by the force effect of the bi-ceps tendon as its vector shifts to a

Figure 3

A, Normal capsular laxity allows the humeral head to remain centered duringelevation. B, Tightness of the posterior capsule may create obligate anterosuperiortranslation with shoulder flexion. (Adapted with permission from Matsen FA III,Lippitt SB, Sidles JA, Harryman DT II: Practical Evaluation and Management of theShoulder. Philadelphia, PA: WB Saunders, 1994, p 40.)



more posterior position in late cock-ing.16,22 During arthroscopy, the bi-ceps tendon can be seen to assume amore vertical and posterior angle,which produces a posterior shift in

the biceps force vector as well as atwist at the base of the biceps ten-don, transmitting a torsional force tothe posterior superior labrum16,22

(Figure 5). When the superior labrum

is not well-anchored to the glenoid,this posteriorly directed torsionalforce causes the humeral head andsuperior labrum to rotate mediallyover the corner of the glenoid on-to the posterosuperior scapularneck.16,22

Acquired posteroinferior capsularcontracture is the primary pathologythat initiates a pathologic cascade,climaxing in the late-cocking phaseof throwing.16 At that point, the shiftin the glenohumeral contact pointcauses maximal shear stress on theposterosuperior labrum at exactlythe time when the peel-back mech-anism produces its maximum tor-sional effect on the posterosuperiorlabrum, putting the shoulder in avulnerable situation.16,23 The in-creased shear forces at the bicepstendon insertion and the posterosu-perior labral attachment cause bothstructures to begin to fail at their at-tachments, producing a posteriorSLAP lesion.16 The SLAP lesion

Figure 4

A, With abduction and external rotation, the two inferior glenohumeral ligament cables, set obliquely across the shoulder,reciprocally and equally develop tension. Inset, The greater tuberosity of the humerus has a well-defined circular arc (dottedline) before it contacts the posterior glenoid. B, When the posterior cable (PIGHL) shortens (contracted posterior band), theglenohumeral contact point shifts posterosuperiorly, and (inset) the allowable arc of external rotation (before the greatertuberosity contacts the posterior glenoid) increases significantly (dotted lines). AIGHL = anterior inferior glenohumeral ligament,PIGHL = posterior inferior glenohumeral ligament (Adapted with permission from Burkhart SS, Morgan CD, Kibler WB: Thedisabled throwing shoulder: Spectrum of pathology. I: Pathoanatomy and biomechanics. Arthroscopy 2003;19:404-420.)

Figure 5

Superior view of the biceps and labral complex of the left shoulder in the restingposition (A) and in the abducted, externally rotated position (B) demonstrating thepeel-back mechanism as the biceps vector shifts posteriorly (arrows). (Adapted withpermission from Burkhart SS, Morgan CD, Kibler WB: The disabled throwingshoulder: Spectrum of pathology. I: Pathoanatomy and biomechanics. Arthroscopy2003;19:404-420.)



magnifies the shift and instabilityproblem and can lead to the deadarm syndrome.15

Damage to the rotator cuff alsomay contribute to problems in thethrowing shoulder. The increasedexternal rotation of the shouldermay cause abrasion and tearing ofthe rotator cuff against the postero-superior glenoid, resulting in dam-age to the cuff.16 An even greater ad-verse effect of excessive externalrotation on the rotator cuff is that itallows repetitive twisting of the ro-tator cuff fibers, which can lead totorsional overload and shear failureof the cuff fibers. With the arm inthe abducted, externally rotated po-sition, the greatest shear stresses inthe cuff will be at their attachmenton the articular side, the location ofcuff failure in the throwing ath-lete16 (Figure 6).

Clinical Assessment

With posterior capsular contracture,the shoulder is limited in its range ofinternal rotation in abduction, cross-body adduction, internal rotation up

the back, and flexion.2 Symptoms in-clude pain and difficulty with sleep-ing as well as in reaching both acrossthe body and up the back (eg, to fas-ten a brassiere).2 ROM measure-ments during physical examinationmay confirm the diagnosis of poste-rior capsular contracture by identify-ing loss of internal rotation, cross-body adduction, and, to a lesserextent, forward flexion while main-taining external rotation. Both ac-tive and passive ROM must be mea-sured because pain may limit thepatient’s ability to actively maxi-mally rotate the shoulder internallyto the physical limits of ROM.

The physician will notice thatpassive internal rotation is asym-metric compared with the normalside. Internal rotation in 90° of ab-duction is assessed with the patientsupine, and side-to-side differencesare noted. The physician should ex-amine the seated patient for internalrotation (the distance to the mostcephalad spinous process to whichthe patient can apply the thumb).24

There is usually asymmetry in mo-tion compared with the contralater-

al side, assuming the latter is with-out pathology.

Harryman et al7 advocated mea-suring adduction in the horizontalplane in the sitting or standing pa-tient because these positions mini-mize any effect of chest or body rota-tion.7 This measurement is accurateassuming that the sides have similarscapulothoracic motion and humer-al lengths. Maximal cross-body ad-duction is the minimal distancefrom the antecubital fossa to thecontralateral acromion when thearm is adducted horizontally acrossthe body25 (Figure 7). This is repeat-ed for the contralateral shoulder, andthe measurements are compared.

External rotation of the shoulderin adduction (0° of abduction) and in90° of abduction is expected to benearly symmetric compared withthe contralateral side. Posterior cap-sular contracture should be differen-tiated from adhesive capsulitis,which usually presents with globalloss of motion. Thus, patients withadhesive capsulitis would be expect-ed to have significantly diminishedexternal rotation and, usually, morepronounced loss of flexion of theshoulder than is encountered in pa-tients with posterior capsular con-tracture.

The Neer impingement sign iselicited by the examiner’s elevatingthe shoulder with one hand whilepreventing scapular rotation.3 Neerthought that this maneuver causedthe greater tuberosity to impingeagainst the acromion, thus produc-ing pain in patients with impinge-ment.3 However, shoulder flexionfrequently causes pain in many othershoulder conditions; therefore, ante-rior impingement pain must be con-sidered nonspecific. The Neer im-pingement test is positive when painwith shoulder flexion is eliminatedafter injection of 10 mL of 1.0%lidocaine into the subacromial spacebeneath the anterior acromion.3

The Hawkins impingement signis positive when shoulder flexion to90°, combined with internal rotation

Figure 6

Torsional overload with repetitive twisting of rotator cuff fibers occurring at thearticular surface of the rotator cuff, the most common location of cuff failure in thethrowing athlete. (Adapted with permission from Burkhart SS, Morgan CD, KiblerWB: The disabled throwing shoulder: Spectrum of pathology. I: Pathoanatomy andbiomechanics. Arthroscopy 2003;19:404-420.)



and horizontal adduction, producespain.1 The physician must rule outacromioclavicular pathology, whichalso may cause pain during horizon-tal shoulder adduction. However,the patient with posterior capsulartightness also would be expected totest positive for the Hawkins im-pingement sign because the internalrotation stretches the posterior cap-sule. With impingement, subjectivepain may be located anteriorly or an-terolaterally, whereas with posteriorcapsular tightness, the pain is oftenposterior and reproduced with rota-tions that stretch the posterior cap-sule. In addition, the patient withposteroinferior capsule contracturereports a sense of posterior tight-ness.15

The arthroscopic impingementtest may be observed from the later-al portal while flexing the shoulderanterior to the scapular planethrough an arc of motion of 140° andobserving the relationship of the hu-meral head to the acromion.26 In thenormal shoulder, the rotator cuffpasses under the acromion, and theinterval between the acromion androtator cuff is maintained in all posi-tions. Patients diagnosed with poste-rior capsular contracture were ob-served to have superior translationof the humeral head during flexion,with the rotator cuff contacting theundersurface of the acromion, there-by diminishing the subacromialspace.8 However, after posterior cap-sule release, the kinematics of theshoulder can be restored and the sub-acromial space maintained.8

Several authors recommendscreening the overhead throwingathlete for posteroinferior capsularcontracture at the beginning of andduring each season.16,23 This is be-cause posteroinferior capsule con-tracture is the primary conditionthat initiates the pathologic cascadeto a SLAP lesion and the subsequentdevelopment of dead arm syn-drome.16,23 As long as the GIRD isless than or equal to its external ro-tation gain, the healthy throwing

shoulder has normal rotational kine-matics without any form of glenohu-meral instability throughout thethrowing cycle.23 However, when theGIRD exceeds the external rotationgain (ERG) (GIRD:ERG ratio >1), theshoulder may be at risk because ofposterosuperior shift of the glenohu-meral rotation point with abductionand external rotation during the latecocking phase.23 The risk of struc-tural injury is directly proportionalto the increase in the GIRD:ERGratio.23

NonsurgicalManagement

In the absence of weakness or a priorsurgical procedure, nonsurgical man-agement is usually successful forthe patient with posterior capsular

tightness.2 Physician- or therapist-supervised patient-directed posteriorcapsular stretching is effective.2 Thepatient performs gentle stretchesfive times per day2 (Figure 8). Eachstretch is performed until the patientfeels a pull against the shouldertightness, but not to the point ofpain.2 Each stretch is performed for 1minute; thus, the patient invests ap-proximately 30 minutes per daystretching.2 Obvious improvementcommonly occurs within the firstmonth, but 3 months may be re-quired to completely eliminate thecondition.2 Patients with chronicpainful loss of internal rotation thatis unresponsive to nonsurgical treat-ment may be candidates for arthro-scopic capsular release.

The healthy throwing shoulderhas normal rotational kinematics;

Figure 7

Maximal cross-body adduction is the minimal distance from the antecubital fossa tothe contralateral acromion when the arm is adducted horizontally across the body.(Adapted with permission from Matsen FA III, Lippitt SB, Sidles JA, Harryman DT II:Practical Evaluation and Management of the Shoulder. Philadelphia, PA: WBSaunders, 1994, p 21.)



however, when the GIRD exceedsthe ERG, the shoulder becomes vul-nerable to further injury.16 Approxi-mately 90% of all throwing athletes

with posteroinferior capsule contrac-ture and symptomatic loss of inter-nal rotation respond to a posteroinfe-rior capsule stretching program.16

These athletes may be treated withsleeper stretches.16,23 The athlete lieson one side with the shoulder in 90°of flexion and the elbow in 90° offlexion.23 The shoulder is passivelyinternally rotated by pushing theforearm toward the table around afixed elbow, which acts as the pivotpoint23 (Figure 9). The loss of internalrotation usually can be improved toan acceptable level over 2 weekswith a compliant posteroinferiorcapsule stretching program usingsleeper stretches.16

Ten percent of throwers do not re-spond to stretching; these patientstend to be older elite pitchers whohave been throwing for years andhave chronic long-standing symp-toms.16 It is extremely unusual forhigh school and college pitchers tobe nonresponsive to stretching; rare-ly have these younger pitchers need-ed selective posteroinferior capsu-lotomy.16 Baseball pitchers and otherthrowing athletes who have beenstretch nonresponders may be con-sidered for arthroscopic release ofthe posteroinferior capsule.23

Surgical Management

Arthroscopic PosteriorCapsule Release

General anesthesia, an inter-scalene block, or an interscalenecatheter may be used with arthro-scopic posterior capsule release.27,28

Warner et al24,29 and Ticker et al8 ad-vocate regional anesthesia to im-prove postoperative control of pain,thereby allowing intensive physicaltherapy in the immediate postoper-ative period. An interscalene blockusing 30 mL of 0.5% bupivacainewith a 1:200,000 concentration ofepinephrine provides adequate intra-operative anesthesia and, frequently,>6 hours of postoperative analge-sia.24,29 Patients with an interscaleneblock can have repeat interscaleneblocks in the morning of postopera-tive days 1 and 2, thereby allowingthe patient and physical therapist toperform morning and afternoon ses-

Figure 8

Patient-directed posterior capsular stretching. A, Stretching in overhead reachusing the opposite arm as the therapist. B, Stretching in overhead reach using theprogressive forward lean to apply a gentle elevating force to the arm. C, Stretchingin internal rotation using a towel to apply a gentle stretching force. D, Stretchingin cross-body reach using the opposite arm as the therapist. (Adapted withpermission from Matsen FA III, Lippitt SB, Sidles JA, Harryman DT II: PracticalEvaluation and Management of the Shoulder. Philadelphia, PA: WB Saunders,1994, pp 46-49.)



sions of passive ROM, in addition tothe self-assisted exercises done bythe patient.24,29

To achieve regional anesthesiaand postoperative analgesia throughan interscalene catheter, a continu-ous infusion of 0.25% bupivacaine ata rate of 6 mL per hour can be ad-ministered for 48 hours postopera-

tively.24,27,29 Patients also may self-administer analgesia through anintravenous pump.24,29

Warner et al24 developed a tech-nique for posterior capsule releasefor isolated loss of internal rotation.After diagnostic arthroscopy withthe patient in the beach chair posi-tion, the arthroscope is placed in the

anterosuperior portal to visualizethe posterior portion of the glenohu-meral joint.24 The posterior part ofthe capsule has been found to bethickened and shortened in all pa-tients with posterior capsular con-tracture.8,24 An electrocautery deviceis then placed through the posteriorportal cannula.24 The capsule is di-

Figure 9

Focused posterior inferior capsular stretches. A, In the sleeper stretch, the patient is side lying with the scapula stabilizedagainst a wall, the shoulder flexed 90°, and the elbow flexed 90°. Passive internal rotation to the arm is applied by thenondominant arm to the dominant wrist. B, The roll-over sleeper stretch is the same as the sleeper stretch, except that theshoulder is flexed only 50° to 60° and the patient rolls forward 30° to 40° from vertical side lying. C, For the cross-arm stretch,the patient stands with the shoulder flexed 90°; passive adduction is applied by the uninvolved arm to the involved elbow. Thisprimarily stretches the posterior musculature to a greater degree than the posterior inferior capsule. D, In the doorway stretch,the shoulder is abducted 90° and internally rotated. The elbow is flexed 90° with the elbow on the edge of an open doorway. Thepatient leans forward and inferior to apply an inferior capsular stretch to the shoulder. (Reproduced with permission fromBurkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. I: Pathoanatomy andbiomechanics. Arthroscopy 2003;19:404-420.)



vided beginning just posterior to thebiceps tendon origin on the superiorglenoid rim at approximately the 11o’clock position and continuing infe-riorly to approximately the 8 o’clockposition24 (Figure 10). The posteriorcapsule is divided adjacent to theglenoid rim because the rotator cuffmuscles at this level are superficialto the capsule.24 If there were addi-tional lateral division of the capsule,the tendons of the rotator cuff wouldbe at risk for injury because they areconjoined with the capsule.11,30 Thedepth of the capsular division iscomplete when the muscle fibers ofthe rotator cuff are visible.24

An arthroscopic shaver is then in-serted to remove the ragged edges ofthe capsule in order to clearly iden-tify the capsular edge and rotatorcuff muscle.8 A shaver creates a wid-er gap in the resected capsule to helpavoid recurrence.8 Extending the re-lease into the inferior aspect of theaxillary pouch exposes the axillarynerve to injury by either thermal orelectrical energy.31

After removing the arthroscope,gentle manipulation completes therelease of any remaining capsular fi-bers to restore internal rotation andflexion.24 Motion usually is im-proved through a gradual yielding of

tissue, similar to stretching a rubberband, rather than by the discrete im-provement of motion seen after an-terior capsule release.24

Arthroscopic SelectivePosteroinferiorCapsulotomy

When the posteroinferior aspectof the capsule is tight, as may occurin the overhead throwing athlete, aselective posteroinferior capsuloto-my may be performed. The capsularcontracture is located in the postero-inferior quadrant of the capsule inthe zone of the posterior band of theIGHL complex.16 The capsulotomyis made 0.25 inches away from thelabrum from the 9 o’clock positionto the 6 o’clock position.16 Typicalarthroscopy findings in these pa-tients include a severely contractedand thickened posteroinferior recessin the zone of the posterior band ofthe IGHL complex.16 In most pa-tients, the capsule in this zone is ≥6mm thick.16 After selective postero-inferior capsulotomy, the patientcan expect an immediate 65° in-crease in glenohumeral internal ro-tation.16

PostoperativeManagement

Warner et al24,29 recommend passivemotion with both morning and after-noon sessions on the first postoper-ative day. In addition, the physicaltherapist should instruct the patientin self-assisted motion exercises. Pa-tients were discharged after the after-noon session on the second postoper-ative day.24,29 For the first 2 weeks,the authors recommend daily super-vised therapy 5 days per week in ad-dition to a home-exercise programconsisting of pulley and cane-assisted motion in all planes. For thenext 4 weeks, the patient should at-tend supervised therapy three timesper week.24,29 The home exercise pro-gram can be advanced during thistime.8 After 6 weeks, the rehabilita-tion may be individualized according

Figure 10

Arthroscopic posterior capsule release in a right shoulder with the humeral headremoved. The posterior capsule is released along the glenoid rim, and the electro-cautery device is introduced through the posterior portal. The arthroscope is intro-duced through the anterior-superior portal. (Adapted with permission from TickerJB, Beim GM, Warner JJP: Recognition and treatment of refractory posterior cap-sular contracture of the shoulder. Arthroscopy 2000;16:27-34.)



to the patient’s progress.8,24,29

Warner et al24,29 recommendagainst using a sling for support atany time, and they encourage the pa-tient to use the operated arm for ac-tivities of daily living as soon as pos-sible after surgery. Strengthening isbegun as soon as postoperative painand active shoulder motion al-low.24,29 Patients are encouraged toattempt to swim in a pool between 2and 4 weeks after the operation.24,29

In our experience, posterior cap-sule contracture release may be per-formed as an outpatient procedurewith good results. Close follow-up isnecessary to ensure patient compli-ance with shoulder-stretching andROM exercises. The physical thera-py program, including stretching andROM, should be familiar to these pa-tients because they would have hadphysical therapy before consideringsurgery (Figure 8).

In the throwing athlete, the gain ininternal rotation must be maintainedby an immediate postoperative inter-nal rotation stretching program in or-der to prevent the capsulotomy gapfrom closing during healing.16 Sleeperstretches are performed beginningpostoperative day 1.32

Postoperative Results

Warner et al24 reported good resultswith arthroscopic posterior capsulerelease for isolated loss of internalrotation in five patients. The func-tion of all shoulders was graded ac-cording to the 100-point Constantand Murley scoring system.33 TheConstant and Murley score im-proved a mean of 20 points (range, 5to 35).24 Mean improvement in inter-nal rotation in abduction was 42°(range, 30° to 60°; P < 0.005); withthe arm in adduction, mean im-provement in internal rotation wasfour spinous-process levels (range, 1to 10 levels; P < 0.05).24

Ticker et al8 reported on arthro-scopic posterior capsule release innine patients, with average postoper-ative follow-up of 19 months (range,

11 to 35 months). There were nopostoperative complications, andposterior instability was not ob-served postoperatively. The averagepreoperative internal rotation in ab-duction was 10° (range, −10° to 40°)for the involved side compared with58° (range, 50° to 80°) for the con-tralateral side.8 Postoperative inter-nal rotation in abduction increasedby an average of 37° (range, 30° to50°) to an average motion of 47°(range, 30° to 80°), which was statis-tically significant (P < 0.01).8 In for-ward flexion, the average preopera-tive motion for the involvedshoulder was 133° (range, 95° to150°) and for the noninvolved shoul-der, 156° (range, 150° to 170°).8 For-ward flexion improved an average of15° (range, −20° to 45°) to an averagemotion of 148° (range, 130° to160°).8 Although there was a trendtoward gains in forward flexion, theywere not statistically significantcompared with preoperative val-ues.8

Discussion

Posterior capsular contracture is typ-ically a painful condition associatedwith loss of internal rotation andhorizontal adduction. In addition,forward flexion may be reduced be-cause of altered glenohumeral kine-matics. This occurs because a short-ened posterior capsule may result inanterosuperior translation of the hu-meral head during flexion, with sub-sequent nonoutlet impingement.9

Ticker et al8 noted the presence ofsubacromial bursitis in all cases,lending further support for this non-outlet form of impingement. Theirtreatment included removing in-flamed bursal tissue without an acro-mioplasty. Normal ROM of theshoulder without objective physicalevidence and normal strength is usu-ally consistent with a diagnosis ofimpingement syndrome. Pain causedby posterior capsular tightness is nota result of direct pathology of thecoracoacromial arch. However, im-

pingement may occur because of dy-namic translation of the humeralhead anteriorly and superiorly.7

Loss of motion after posterior cap-sular shift for instability is a rareoccurrence.34-37 Ticker et al8 reportedthat some of their patients with iso-lated refractory posterior capsulecontracture had undergone a priorposterior capsule shift procedure. Allof the other patients reported a spe-cific event that they described as atraction injury to the affected arm.Surgical procedures performed tomanage a variety of conditions, in-cluding classic impingement, maybe a factor in posterior capsular con-tracture. In the series of Ticker etal,8 five of nine patients (56%) hadundergone prior procedures; in all ofthese cases, the prior surgical ap-proaches had failed.

All patients in the series of Warneret al24 and Ticker et al8 had a con-tracted and thickened posterior cap-sule at the time of arthroscopy. Ac-cording to Burkhart et al,16 in mostcases, the capsule in this zone is≥6 mm thick. It is unclear why theposterior capsule undergoes this pro-cess, whereas the anterior capsule isspared. Matsen et al2 reported thatthis condition is a common result ofinjury to the rotator cuff. Ticker et al8

postulated that, in the cases of injuryassociated with a traction mecha-nism, trauma to the posterior capsulemay result in localized and excessivescarring. In patients who underwenta posterior capsular shift procedure,either the posterior capsule was over-tightened or there was excessive scar-ring with subsequent collagen short-ening in this region after the repair.

Several cases have been reportedof successful open posterior capsulerelease performed after posterior cap-sular shift.38 However, an open pos-terior capsule release may produceinjury to the rotator cuff, thereby im-peding rehabilitation. Warner et al24

determined that an arthroscopic pro-cedure can release as much capsuleas an open release; other authors8 re-port that arthroscopic posterior cap-



sule release with subacromial bur-sectomy is a reliable managementoption with minimal morbidity.

Pain control after closed manipu-lation for adhesive capsulitis is crit-ical.10,13,39 Similarly, Warner et al29

report that postoperative analgesia isan essential part of the rehabilitationprogram after arthroscopic release ofposterior capsule contracture. Inter-scalene anesthesia is reportedly safeand well tolerated. It significantly re-duces the need for narcotics whileallowing aggressive passive ROM inthe immediate postoperative peri-od.10,27,28,39

Summary

In patients with suspected shoulderimpingement, careful examinationof passive and active motion in allplanes is necessary to diagnose pos-terior capsule contracture. In pa-tients with limited internal rotationwith or without limited flexion, atherapy program directed at improv-ing motion in the deficient planesshould be instituted. When nonsur-gical management fails and painfullimitation of motion persists, arthro-scopic posterior capsule release withsubacromial bursectomy is a reliabletreatment with minimal morbidity.Postoperative physical therapy isimperative for both maintaining mo-tion that has been gained intraoper-atively and providing maximumshoulder function.

In the overhead throwing athlete,several authors recommend screen-ing for posteroinferior capsular con-tracture at the beginning of and dur-ing each season because it caninitiate a pathologic cascade to aSLAP lesion and, subsequently, todead arm syndrome. The healthythrowing shoulder has normal rota-tional kinematics without any formof glenohumeral instability through-out the throwing cycle as long as itsGIRD is less than or equal to itsERG. However, when the GIRD ex-ceeds the ERG, the shoulder be-comes vulnerable for risk of struc-

tural injury directly proportional tothe increase in the GIRD:ERG ratio.When sleeper stretches fail to treatthe GIRD to an acceptable level,stretch nonresponders may be con-sidered for arthroscopic posteroinfe-rior capsulotomy.

References

Evidence-based Medicine: Levels IIIand IV case series are reported but noprospective randomized series.

Citation numbers printed in boldtype indicate references publishedwithin the past 5 years.

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