Frozen shoulder (Adhesive capsulitis) has been defined as a condition characterized by both active and passive loss of motion. Zuckerman et al further classified Frozen shoulder into primary and secondary groups. Primary or idiopathic frozen shoulder has by definition no clear cause. The initial treatment consists of conservative management with NSAID, Physiotherapy, intra-articular steroids or saline and in some instances manipulation under anaesthesia. Once in a while there are cases which are refractory to conservative treatment and manipulation under anaesthesia has its risks like fractures and rotator cuff tears. Arthroscopic capsular release of stiff shoulders has been done providing excellent functional outcome and reproducible results.

1. Arthroscopic Anterior Capsular Release for Idiopathic Frozen
Shoulder

2. Arthroscopic anterior capsular release for idiopathic frozen
shoulder
Abheek Kar
ABSTRACT
Introduction: Frozen shoulder (Adhesive capsulitis) has been defined as a condition characterized by both active
and passive loss of motion. Zuckerman et al further classified Frozen shoulder into primary and secondary groups.
Primary or idiopathic frozen shoulder has by definition no clear cause. The initial treatment consists of conservative
management with NSAID, Physiotherapy, intra-articular steroids or saline and in some instances manipulation under
anaesthesia. Once in a while there are cases which are refractory to conservative treatment and manipulation under
anaesthesia has its risks like fractures and rotator cuff tears. Arthroscopic capsular release of stiff shoulders has been
done providing excellent functional outcome and reproducible results.
Aim: The purpose of this study was to prospectively evaluate the efficacy of arthroscopic anterior capsular release for
patients with refractory idiopathic adhesive capsulitis.
Methods: 26 patients (sixteen males, ten females) with a mean age of 58.4 years (range; 44-72 years) were followed
up at our institution. Arthroscopic anterior capsular release was done using two portals. Synovectomy was done using
a shaver and capsular release was done using radiofrequency ablator.
Results: The functional outcome was evaluated using ASES (American Shoulder and Elbow Society) and Constant
and Murley scoring system. At 12 months, mean improvement in ASES score was 38 points and Constant and Murley
score was 40.5 points. Out of 26 patients 22 said that they would recommend the procedure to someone
Copyright © 2012, Indraprastha Medical Corporation Ltd. All rights reserved.
Keywords: Frozen shoulder, Refractory idiopathic adhesive capsulitis, Intra-articular steroids
INTRODUCTION AND AIM
Frozen shoulder (Adhesive capsulitis) has been defined as
a condition characterized by both active and passive loss
of motion. Zuckerman et al further classified1
frozen
shoulder into primary and secondary groups. Primary or
idiopathic frozen shoulder has by definition no clear cause.
Secondary frozen shoulder has intrinsic causes (fractures,
tendonitis, rotator cuff tears or degenerative arthritis),
extrinsic causes (Parkinsonism, cervical radiculopathy,
cardiovascular accidents and head injuries) and systemic
causes (Diabetes mellitus, thyroid dysfunction and
myositis).
Primary (Idiopathic) frozen shoulder goes through three
stages. The freezing phase (from few weeks up to 9 months),
frozen phase (3e12 months) and thawing phase (5e26
months). The initial treatment consists of conservative
management with NSAID, Physiotherapy, intra-articular
steroids or saline and in some instances manipulation under
anaesthesia.
Once in a while there are cases which are refractory to
conservative treatment and manipulation under anaesthesia
has its risks2
like fractures and rotator cuff tears. Manipula-
tion also doesn’t treat the primary pathology in this condi-
tion, which is synovitis. Arthroscopic capsular release of
stiff shoulders has been done providing excellent functional
Consultant, Shoulder and Sports Medicine Unit, Apollo Gleneagles Hospitals, Kolkata 700054, India.
email: abheekkar@gmail.com
Received: 30.7.2012; Accepted: 13.8.2012; Available online 27.8.2012
Copyright Ó 2012, Indraprastha Medical Corporation Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.apme.2012.08.007
Apollo Medicine 2012 December
Volume 9, Number 4; pp. 303e306
Original Article

3. outcome and reproducible results. The purpose of this study
was to prospectively evaluate the efficacy of arthroscopic
anterior capsular release for patients with refractory idio-
pathic adhesive capsulitis.
METHODS
Between January 2009 and February 2011, 26 patients
(sixteen males, ten females) with a mean age of 58.4 years
(range; 44e72 years) were followed up at our institution.
The mean duration between the onset of symptoms and
surgery was 6.2 months. All patients had tried conservative
treatment including intra-articular steroids, physical therapy
and 14 patients had undergone manipulation under anaes-
thesia prior to Arthroscopy. All the patients had severe night
pain, stiffness and restricted usage of the arm for day to day
activities. Exclusion criteria included diabetes mellitus,
trauma, arthritis, thyroid dysfunction, cervical radiculopathy,
cerebro-vascular accident, cardiac surgery and major
systemic illness. Radiographs were unremarkable. The
surgery was done under general anaesthesia in beach chair
position. Hypotensive anaesthesia (mean BP e 90 mmHg)
was used along with Artho-pump to minimize intra-articular
bleeding and facilitate clear visualization. At first the poste-
rior portal is made. To facilitate entry of the arthroscopy
trocar and cannula into the tight joint some saline may be
injected into the joint to distend it. Also the posterior portal
is 0.5 cm higher than the usual posterior portal. Entry into
the joint is made using a blunt trocar to avoid joint damage.
The anterior portal is also made high up, just supero-lateral
to the coracoid process close to the biceps tendon. A
5.5 mm plastic cannula is used for smooth passage of instru-
ments through the anterior portal. The first step of the surgery
Fig. 1 Synovectomy of the rotator interval and superior
capsule.
Fig. 2 Release of superior, middle and inferior gleno-humeral
ligaments and capsule using the radiofrequency probe.
Fig. 3 After the complete release, the shiny subscapular is
tendon can be seen.
Table 1 Chart showing the improvement in the range of
motion.
304 Apollo Medicine 2012 December; Vol. 9, No. 4 Kar

4. is removal of the synovitis of the rotator interval using
a motorized shaver (3.5 mm) (Fig. 1). The next step is the
capsular release using the radio frequency ablation device.3
The release is done of the capsule along with the superior,
middle and inferior gleno-humeral ligaments3
(Fig. 2). The
probe should be close to the glenoid edge when it reaches
inferiorly to avoid injuring the axillary nerve. The tendon
of subscapularis should be seen clearly after the release
(Fig. 3). Post-operative pain relief was given using routine
analgesics depending on the pain score of the patient. Post-
operative physiotherapy was done for a period ranging
from 3 to 12 weeks. All patients were discharged on the
evening of the surgery or the next morning .The functional
outcome was evaluated using ASES (American Shoulder
and Elbow Society) and Constant and Murley scoring
system.
RESULTS
All the patients showed significant improvement in the
range of motion (Table 1) and relief of pain in the imme-
diate post-operative period. At 12 months, mean improve-
ment in ASES score was 38 points and Constant and
Murley score was 40.5 points. The complications in our
series were, two transient axillary nerve paraesthesias
(which resolved within three days), excessive swelling of
the joint due to fluid extravasations in all the cases (which
subsided within 24 h) and one patient developed anterior
portal superficial infection (which subsided with regular
dressings and antibiotics). None of the patients had any
instability post-operatively. Out of 26 patients 22 said
that they would recommend the procedure to someone.
CONCLUSIONS
Arthroscopic release showed promising results with reliable
increase in range of motion, early relief of symptoms and
consequent early return to work (Fig. 4). It is sufficient to
perform anterior release only2
without the need for poste-
rior release as there was no residual internal rotation stiff-
ness and pain during follow up. Arthroscopic anterior
capsular release is highly recommended in properly
selected patients. It should be done in mid stage of the
disease (frozen state). Post-operative physiotherapy is
extremely important.
CONFLICTS OF INTEREST
The author has none to declare.
Fig. 4 Restoration of normal joint function at 2 months follow up.
Arthroscopic anterior capsular release Original Article 305

5. REFERENCES
1. Zuckerman JD, Rokito A. Frozen shoulder: a consensus defini-
tion. J Shoulder Elbow Surg. 2011 Mar;20(2):322e325. Epub
2010 Nov 4.
2. Beaufils P, Prévot N, Boyer T, et al. Arthroscopic release of the
glenohumeral joint in shoulder stiffness: a review of 26 cases.
French Society for Arthroscopy. Arthroscopy. 1999 JaneFeb;
15(1):49e55.
3. Musil D, Sadovský P, Stehlík J, Filip L, Vodicka Z.
Arthroscopic capsular release in frozen shoulder syndrome.
Acta Chir Orthop Traumatol Cech. 2009 Apr;76(2):
98e1032.
306 Apollo Medicine 2012 December; Vol. 9, No. 4 Kar

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