Review Question - QID 219891

This 42-year-old continues to experience pain and limitations in range of motion secondary to adhesive capsulitis, which is refractory to physical therapy. She is indicated for arthroscopic capsular release, which includes the release of the rotator interval/Structure D (Answer 4).

Adhesive capsulitis is a relatively uncommon entity, most often seen in female patients with endocrine disorders (diabetes, hypothyroidism). The classic finding of the condition includes loss of motion in both active and passive motion, with loss of external rotation often the earliest and most common finding. The entity can be broken down into multiple stages, which include the freezing, frozen, and thawing stages. The initial stage is characterized by pain, followed by loss of motion until its gradual return. Collectively, the entire duration of symptoms can take up to two years, but on average, it takes 3-6 months. This creates a conundrum from a therapeutic standpoint in terms of when to intervene, as the mainstay of treatment for the condition is nonoperative with physical therapy and serial corticosteroid injections. Nonetheless, surgical intervention is appropriate following 3-6 months of therapy, with manipulation under anesthesias and arthroscopic capsular releases. The latter intervention involves releasing the rotator interval, as well as the coracohumeral ligament, as part of a circumferential capsular release in order to improve range of motion..

Drs. Dennis and Redler provide an overview of adhesive capsulitis, detailing the pathology, classifications, diagnostic imaging, risk factors, and treatments. The authors note the pathology appears to be related to a combination of inflammation and active fibroblastic proliferation. For treatment, the authors believe corticosteroid injections are effective in decreasing the overall duration of symptoms, and that most patients will see complete resolution of their symptoms without surgical treatment. When surgical treatment is indicated, the authors suggest gentle manipulation under anesthesia, followed by a circumferential capsular release, beginning with the rotator interval.

Levine et al. detail the efficacy of nonoperative management of adhesive capsulitis by performing a retrospective review of 98 patients (105 shoulders) with adhesive capsulitis. They noted an 89.5% resolution rate, with an average duration of symptoms being 3.8 months (+/- 3.6 months). In those who required surgical intervention, nonoperative treatment lasted 12.4 months (+/- 12.1 months) but noted large increases in range of motion, with an average increase of 46 degrees in forward flexion and 33 degrees in external rotation. The authors conclude the majority of patients can successfully undergo nonoperative treatment; however, surgery can successfully improve range of motion when indicated.

Figure A represents coronal T2 imaging of a right shoulder illustrating a contracted capsule with loss of the axillary recess. Figure B is a T2-weighted sagittal image representing a diagram of the rotator cuff/glenohumeral joint anatomy.

Incorrect Answers:
Answer 1/Structure A: this represents the subscapularis
Answer 2/Structure B: this represents the supraspinatus
Answer 3/Structure C: this represents the biceps tendon
Answer 5/Structure E: this represents the infraspinatus