Stiffness

Literature Review

Arthroscopic treatment is generally successful, with the degree of improvement related to the patient's underlying condition. Ogilvie-Harris, Harryman, and Warner have published landmark articles describing their results.

Warner reported on 23 patients with idiopathic adhesive capsulitis treated with arthroscopic release. In that study, the Constant score improved an average of 48 points. Flexion improved a mean of 49 degrees; external rotation, 45 degrees; and internal rotation by eight spinous processes. Harryman documented patient satisfaction, improved function, and pain relief in a diabetic population, although the improvement in range of motion was not as great as that seen in patients with idiopathic adhesive capsulitis.

Clinical Presentation

Patients with all types of adhesive capsulitis present with painful, limited shoulder motion. Pain at night interferes with sleep. Routine activities of daily living that require reaching overhead or behind the back are difficult and painful. Rapid movements cause especially severe pain. Most patients either recall a trivial antecedent injury or cannot identify an inciting event. Patients demonstrate restricted passive and active motion, with the degree of motion loss dependent on the timing of presentation. Radiographs are usually normal, but mild osteopenia due to disuse may be present.

Diagnosis

A number of other shoulder conditions that produce painful, limited motion can be eliminated by patient history, physical examination, and radiographic evaluation. Patients with rotator cuff tears present with passive motion greater than active motion, weakness on manual muscle testing, and abnormal magnetic resonance images or arthrograms. In patients with osteoarthrosis, plain radiographs depict loss of the glenohumeral joint space ( Fig. 6.4 ). Patients with posttraumatic stiffness may have malunited fractures, and those with postoperative stiffness may have internal fixation devices that interfere with motion.

It is important to obtain a thorough history that ascertains prior trauma or shoulder difficulties. Patients should also be asked about diabetes and thyroid dysfunction. Evaluate and record passive range of motion in elevation, abduction, and external rotation (in adduction with the arm at the side and in maximal allowable abduction). Measure internal rotation as the vertebral level to which the patient can reach with the extended thumb. Behind-the-back internal rotation is usually decreased, but it is occasionally close to normal because internal rotation measured in this manner includes not only glenohumeral movement but also scapulothoracic motion. With prolonged shoulder stiffness, scapulothoracic motion may increase to compensate for the loss of glenohumeral rotation. For this reason, the scapula should be stabilized with one hand and the arm abducted with the other. Range of motion is compared with the contralateral shoulder. Muscle strength in forward flexion and external rotation may be recorded, but it is often decreased due to pain, so it may not be helpful.

Indications for Surgery

As a general principle, we consider operation if the patient has persistent pain and stiffness after 6 months of appropriate nonoperative care. Even then, the patient makes the choice to proceed with surgery. There is no rigid definition of what constitutes stiffness that is significant enough to consider surgery, but we consider severe stiffness as 0 degrees of external rotation and less than 30 degrees of abduction. Moderate stiffness is defined as a decrease of 30 degrees in either plane compared with the contralateral shoulder. If stiffness persists, but pain has diminished after 6 months, nonoperative care can be continued for an additional 2 months in case the decrease in pain indicates that the stiffness is about to resolve or “thaw” spontaneously. If there is no improvement in the range of motion 2 months later, surgery is considered. Of note, it seems that external rotation is an important predictor of success or failure of nonoperative treatment. If external rotation remains at neutral or worse 4 to 6 months after the start of nonoperative treatment, earlier operative intervention is advisable.