Surgical release for stiff frozen shoulders: Surgery to remove scar tissue and release contractures can lessen pain and improve function for stiff shoulders that have not responded to rehabilitation or physical therapy.
Last updated Wednesday, January 26, 2005
Figure 1 - Axillary nerve Figure 2 - Subscapularis lengthening Figure 3 - "360 degree" release Figure 4 - Releasing the inferior capsule sharply while a finger protects the axillary nerve Figure 5 - Releasing the posterior capsule up to the origin of biceps tendon at the supraglenoid tubercle Figure 6 - Continuous passive motion machine Figure 7 - Sample empty progress chart Figure 8 - Sample progress chart Figure 9 - Two-year follow-up data Introduction
This is the information which might be shared with patients as they
consider a surgical release for shoulder stiffness. Before it can be
applied to a specific clinical situation, however, it needs to be
tailored to the patient, the problem, and the surgeon.Home exercise program Most patients with stiff shoulders can improve their comfort and function with a home exercise program.
Your doctor may consider an open surgical release for the few stiff
shoulders which do not improve with a persistent effort at the
exercises.Purpose The purpose of the surgical release is to cut through the adhesions,
scar tissue, and other structures that may be interfering with the
motion of your shoulder.Alternatives to surgery This procedure is purely elective. The alternatives are to continue with the exercises or to accept the current range of motion.Risks Open release is a surgical operation; as such it carries some risks.
These include the risk of anesthesia, infection, nerve injury, blood
vessel injury, excessive looseness and instability of the shoulder,
persistent or increased shoulder stiffness, fracture, increased pain,
or the need for repeat surgery.After the surgery After surgery, it is essential that you resume the stiff shoulder exercises so that adhesions will not have an opportunity to reform.
While an experienced surgeon can loosen the shoulder at surgery, you
are the only person who can maintain the motion during the healing
period. These exercises will need to be continued for up to a year
after your surgery. If you have concerns about your ability to carry
out this important aspect of your treatment, please discuss this with
your doctor before you undertake surgery.
You are likely to be in the hospital until your exercise program is
well launched. At the time of discharge your doctor will encourage you
to be physically active and to avoid narcotic and sleeping medications.
You will be unable to drive for at least two weeks after this
procedure, so you should make appropriate provisions for getting around
during this time. Who should consider surgery Open surgical release is considered for informed, consenting patients
if the manipulation is not indicated or successful in reestablishing
motion in a stiff shoulder. The patient's role in the recovery process
is emphasized.
The type of stiffness dictates the surgical approach to the refractory stiff shoulder.Usual approach We usually approach a post-surgical stiff shoulder through an
incision that provides access to the previous surgical site. This is
because the densest adhesions and scar are usually located beneath the
surgical incision. The idiopathic frozen shoulder is reached through a
deltopectoral approach, which allows access to the rotator interval,
the motion interface, the subscapularis, and the glenohumeral joint
capsule. The surgical release is analogous in many ways to the
subscapularis and capsule release performed during a glenohumeral
arthroplasty.
We proceed sequentially through a series of distinct stages of
shoulder release, reassessing the range of motion after each stage. We
continue through these stages until the desired motion is obtained. Stage one Re-establishment of the humeroscapular motion interface: Our in vivo
MRI studies demonstrated that there is normally a substantial excursion
at the humeroscapular motion interface. In post-surgical and
post-traumatic stiff shoulders, adhesions or "spot welds" are common
between the deltoid, acromion, coracoacromial ligament, coracoid, and
coracoid muscles on one hand and the rotator cuff and humerus on the
other. These spot welds can virtually eliminate motion at the
interface. Thus, each area of the interface needs to be smooth and free
of adhesions for the shoulder to achieve its normal range. At times the
motion interface can be obscured and difficult to identify.
In the "totally stuck shoulder" we start under the acromion, knowing
that it is part of the outer aspect of the motion interface. Dissecting
beneath the acromion and coracoacromial ligament with a knife, we can
free the subjacent cuff tissue. By rotating the humerus internally and
externally during this step of the dissection we continue the
dissection under the coracoacromial arch to the coracoid. Then the
sharp dissection proceeds beneath the coracoid and coracoid muscles,
freeing the subjacent subscapularis muscle.
Adhesions between the coracoid muscles and the subscapularis cause a
major limitation of external rotation owing to the magnitude of
interfacial motion here. It must be remembered that the brachial
plexus, especially the musculocutaneous and axillary nerves, are close
by and vulnerable. Thus we stay lateral to the coracoid muscles (the
"safe side") dissecting on the surface of the subscapularis as it is
externally rotated, rather than diving medial to the coracoid muscles
(the "suicide").
In a similar manner, sharp dissection continues laterally from the
acromion to reestablish the motion interface between the deltoid and
the rotator cuff. Again, the nerve supply, in this case the branches of
the axillary nerve, lie in the motion interface. We avoid them by
keeping our sharp dissection on the superficial aspect of the rotator
cuff and proximal humerus. If the dissection enters the deltoid muscle,
its nerve supply, the axillary nerve, is at risk. Stage two Opening the rotator interval: As our cadaver research has demonstrated,
tightness at the rotator interval can substantially restrict the range
of glenohumeral motion. We release the rotator interval by sharply
dissecting the subscapularis and supraspinatus tendons free from their
moorings to the base of the coracoid. We verify the completeness of
this release by passing a blunt elevator between the tendons on both
sides of the coracoid process.Stage three Reestablishment of subscapularis length and excursion: The
subscapularis and anterior capsule may be contracted and scarred,
particularly after previous anterior shoulder injury or surgery. We
perform a coronal plane "Z" lengthening of the subscapularis tendon and
capsule using a step cut. We cut the superficial lateral aspect of the
tendon at the lesser tuberosity near the long head of the biceps. We
then split the tendon medially in the coronal plane. Finally, we
complete the medial aspect of the cut by transecting the remaining
tendon and capsule adjacent to the glenoid labrum. At the conclusion of
the procedure we will suture the lateral end of the superficial flap to
the medial end of the deep flap.
Each centimeter of subscapularis lengthening gained by the step cut
increases external rotation by approximately 20 degrees. Prior to the
closure, we perform a "360 degree" release of the subscapularis tendon
from the coracoid muscles anteriorly, the axillary nerve below, the
capsule and scapular neck posteriorly and the coracoid above. This
release should reestablish the normal "bounce" and excursion of the
subscapularis. Stage Four Release of the capsule: Capsular tightness is the major component of an
idiopathic frozen shoulder, but it may also be a major component of
post-traumatic and post-surgical stiff shoulders. In the surgical
release, we section the tight capsular tissue just lateral to the
glenoid labrum. The capsule can be released selectively or
circumferentially according to the pattern of stiffness. A
circumferential capsular release can be started anterosuperiorly, then
carried down the anterior glenoid. We release the inferior capsule
sharply while a finger protects the axillary nerve. We expose the
origin of the triceps from the infraglenoid tubercle with this release.
We insert a humeral head retractor into the joint and twist it slightly
to tension the posterior inferior capsule so that it can be safely
sectioned. By twisting the retractor a little more with each bit of
posterior capsular release, we can safely release the posterior capsule
up to the origin of biceps tendon at the supraglenoid tubercle. The
lengthened subscapularis tendon is then sutured to the capsule attached
to the lesser tuberosity.Adequate release The hallmarks of an adequate release are:
- translation of the humeral head on the posterior drawer test of at least 1.5 centimeters,
- a "scarecrow" test demonstrating almost 90 degrees of internal
rotation of the arm elevated 90 degrees in the zero degree thoracic
plane,
- at least 45 degrees external rotation with the arm at the side, and
- total elevation of the arm to at least 140 degrees.
Continuous passive motion and exercise As soon as the procedure is completed, we place the arm in
continuous passive motion. Early motion achieves several goals. It
prevents formation of adhesions or scarring during the critical early
healing period. It also demonstrates to the patient that the shoulder
can and should be moved immediately. Finally, early movement seems to
increase the comfort, speed, and completeness of motion recovery. The
use of the continuous passive motion after surgery is greatly
facilitated by a brachial plexus block for the surgical procedure. This
type of anesthesia can give 12 to 18 hours of post-operative
anesthesia, allowing the awake patient the opportunity to observe the
increase in motion gained by the procedure without experiencing early
post-operative pain.
On the first day after surgery, the patient resumes the stiff shoulder exercises.
Each day the patient is in the hospital, we plot the range of elevation
(overhead reach) and rotation on charts posted in the patient's
hospital room. These charts (see figures) provide positive
reinforcement for the patient's progress.
Ideally, before discharge the patient can demonstrate comfortable
assisted motion to 140 degrees of elevation, 40 degrees of external
rotation, internal rotation until able to reach T12 with the thumb, and
cross body adduction comparable to the normal side. The wall charts
reflect these discharge goals. With this program, the patient becomes
the center of the treatment team and is motivated to continue the
exercises after discharge.
The two-year follow-up data for twelve patients having open surgical
release for refractory frozen shoulders are encouraging (see figure).
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