Review Question - QID 1832

This patient has adhesive capsulitis. The primary treatment is nonoperative with a gentle home stretching program, as this is a self-limited process that can take up to 18 months to resolve. If arthroscopic capsular release is attempted, the most common complication is recurrent stiffness.

Infection, instability, impingement syndrome, recurrent stiffness, and axillary nerve injury are all potential complications of arthroscopic capsular release for the treatment of adhesive capsulitis. However, recurrent stiffness is the most common complication and can be mitigated by immediate early motion and physical therapy with no sling usage. Continuous passive motion machines may be considered as an adjunct. Pain control is important, and regional anesthesia techniques can be helpful in the perioperative period.

Pollock et al. treated 30 shoulders with arthroscopic release for resistant adhesive capsulitis and achieved satisfactory results in 25 (83%). Those with diabetes fared more poorly, with satisfactory results in only 64%.

Yoon et al. randomized 66 patients to receive either subacromial injection, intra-articular injection or hydrodilatation (HD) for treatment of adhesive capsulitis. They found that HD patients had less pain and better function at one month and three months but there were no differences among groups at 6 months. They concluded that HD offered more rapid improvement, but that the three injection techniques offered similar benefits at final follow up.

Sun et al. performed a systematic review and meta-analysis of eight randomized, controlled trials of the effects of intra-articular corticosteroid injection for frozen shoulder. Patients who received injection had less pain and more passive external rotation and abduction at all time points studied (up to 26 weeks). They concluded that steroid injection was a safe and effective treatment for frozen shoulder, resulting in pain relief, functional improvement and increased range of motion at 4-6 weeks, 12-16 weeks and 24-26 weeks post-intervention.

Incorrect Answers
Answer 1: Routine use of prophylactic antibiosis is recommended but infection is not as common as stiffness.
Answers 2 and 5: Iatrogenic injury to nerve or tendon should be carefully avoided but stiffness is more common.
Answer 3: NSAIDs may be useful for controlling post-operative pain and inflammation and therefore secondarily prevent recurrent stiffness but are less critical than motion and therapy.