Review Article

Treatment of Adhesive
Capsulitis of the Shoulder

Lauren H. Redler, MD
Elizabeth R. Dennis, MS, MD
Abstract
Adhesive capsulitis presents clinically as limited, active and passive
range of motion caused by the formation of adhesions of the
glenohumeral joint capsule. Radiographically, it is thickening of the
capsule and rotator interval. The pathology of the disease, and its
classification, relates to inflammation and formation of extensive scar
tissue. Risk factors include diabetes, hyperthyroidism, and previous
cervical spine surgery. Nonsurgical management includes physical
therapy, corticosteroid injections, extracorporeal shock wave therapy,
calcitonin, ultrasonography-guided hydrodissection, and hyaluronic
acid injections. Most patients will see complete resolution of
symptoms with nonsurgical management, and there appears to be a
role of early corticosteroid injection in shortening the overall duration of
symptoms. Surgical intervention, including manipulation under
anesthesia, arthroscopic capsular release both limited and
circumferential, and the authors’ technique are described in this
article. Complications include fracture, glenoid and labral injuries,
neurapraxia, and rotator cuff pathology. Postoperative care should
always include early physical therapy.

A dhesive capsulitis (AC), or fro-

From the Columbia University Medical
Center, Department of Orthopedics,
Center for Shoulder Elbow and Sports
Medicine, New York, NY.
Neither of the following authors nor
any immediate family member has
received anything of value from or has
stock or stock options held in a
commercial company or institution
related directly or indirectly to the
subject of this article: Dr. Redler and
Dr. Dennis.
J Am Acad Orthop Surg 2019;27:
e544-e554
DOI: 10.5435/JAAOS-D-17-00606
Copyright 2019 by the American
Academy of Orthopaedic Surgeons.
zen shoulder, clinically presents
as equal active and passive range of
motion (ROM), both of which are
limited secondary to the formation of
adhesions of the glenohumeral joint
capsule. An expanding body of liter-
ature exists which explores the vari-
ous treatment options. This article
reviews the current consensus on the
pathology of the disease, its classifi-
cation system, risk factors for the
development of AC, treatment mo-
dalities for nonsurgical management,
and techniques for optimal surgical
intervention.
AC primarily involves contracture of
the joint capsule and the rotator inter-
val, which is composed of the superior
glenohumeral interval and the cor-
acohumeral ligament (CHL).1 In an
elegant study, Lee et al2 used intra-
articular hydraulic distention to
quantify capsular stiffness by examin-
ing the slope of the elastic phase of
pressure-volume curves. They deter-
mined that the degree of stiffness of the
capsule did not correlate to patient
pain. However, as expected, the
amount of decreased ROM did cor-
relate with capsular stiffness, especially
in abduction and external rotation.
Pathology
The exact pathophysiology of AC is
not completely understood and is
often idiopathic. The main pathol-
ogy is thought to involve inflam-
matory contracture of the shoulder
capsule with recruitment of inflam-
matory cytokines such as transforming
growth factor beta (TGF-b), tumor
necrosis factor alpha (TNF-a), and

e544 Journal of the American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

interleukins, as well as B-lymphocytes,
T-lymphocytes, and macrophages.3
One study examining the histology of
excised CHL found active fibroblastic
proliferation with some transforma-
tion to myofibroblasts, creating colla-
gen in the form of a thick band, similar
in appearance to Dupuytren’s dis-
ease.4 This transformation to smooth
muscle myofibroblasts is thought to
cause contracture, capsular hyperpla-
sia, and eventual fibrosis which is
thought to cause reduction in cap-
sular volume and stiffness, ultimately
restricting motion.3 In summary, AC
appears to start as an inflammatory
reaction with associated synovitis
that progresses to fibrotic contrac-
ture of the shoulder capsule.
Classification
As previously described by Neviaser
and Neviaser,5,6 AC is classified into
four stages based on arthroscopic
and histologic appearance of the
joint capsule, following progression
from capsular inflammation to
fibrosis (Figure 1). Stage 1, “the pre-
adhesive stage,” is described as pro-
liferation of the fibroblasts without
formation of adhesions. Patients
have full ROM but report pain, often
at night. Stage 2, “acute adhesive
synovitis,” is characterized by hy-
pertrophy of the synovium and early
formation of adhesions, often in the
inferior capsular fold. Patients begin
to have mild loss of ROM with pain.
Stage 3, “the maturation stage,” is
marked by the transition of synovitis
to fibrosis. The axillary fold is often
adhered to the capsule. ROM be-
comes markedly reduced, but often
patients are in less pain than in the
earlier stages. Stage 4, “the chronic
stage,” is characterized by severe loss
of ROM and dense fibrotic adhe-
sions. Of note, stage 4 patients can
have minimal pain, except when
their ROM is forcefully moved past
the restraints of their fibrotic capsule.
June 15, 2019, Vol 27, No 12
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Lauren H. Redler, MD and Elizabeth R. Dennis, MS, MD
Figure 1
Pathologic phases of AC. Schematic describing the overlapping nature of
inflammation and scar tissue formation, forming the breakdown of the three
clinical phases of AC. A comparison is made with four phases previously
described by Neviaser and Hannafin. AC = adhesive capsulitis. (Reproduced
with permission from Neviaser AS, Hannafin JA: Adhesive capsulitis: A review of
current treatment. Am J Sports Med 2010;38(11):2346-2356.)
In describing AC to patients, the with AC often reveals capsular and
senior author finds it helpful to break CHL thickening, poor capsular dis-
the progression down into three tension, extracapsular contrast leak-
clinical phases based on the over- age, and synovial hypertrophy and
lapping nature of inflammation and scar tissue formation at the rotator
scar tissue formation as described by interval8 (Figure 2). MRI findings
Neviaser and Hannafin7 (Figure 1). on T2 fat-suppressed sequences in a
Phase 1 involves only inflammation, study of 103 patients with AC cor-
characterized by capsular pain with related with pain intensity, ROM,
sudden shoulder motion, usually in a and clinical stage. Anterior ex-
functional range (not extremes), but tracapsular edema was associated
patients do not yet have restricted with degree of external rotation and
ROM. Often, only patients who have abduction. Joint capsule edema in the
suffered AC on the contralateral side axillary recess was associated with loss
present this early. Phase 2 involves of external rotation. Joint capsule
both inflammation and scar tissue thickness was associated with pain
formation. Patients classically have intensity. Findings of joint capsule
pain and restricted ROM. This is the edema and obliteration of the sub-
most common phase at presentation. coracoid fat triangle were more com-
Phase 3 is distinguished by the res- mon in the early stages of AC, whereas
olution of inflammation. Patients capsular thickness markedly increased
have profound loss of motion but in later stages.9
often no longer have pain.
Risk Factors
Diagnostic Imaging
The prevalence of AC is 2% to 5%, and
Radiographs are classically normal in it occurs more commonly in women
patients with AC. MRI in patients and patients with diabetes.2 Other
e545
Shoulder Adhesive Capsulitis
Figure 2
MRI evidence of adhesive capsulitis. Coronal MRI showing a normal thickness capsule in the axillary pouch (A), coronal MRI
showing a thickened capsule and contracted axillary pouch (B), and axial MRI showing scarring of the rotator interval (C).
* = axillary pouch/capsule, RI = rotator interval
risk factors include hyperthyroidism;
previous shoulder, breast, or cervical
spine surgery; and rarely, immuni-
zations. In a case-controlled study of
208 patients with type 2 diabetes
mellitus (DM) versus 200 matched
control subjects, 13% of patients in
the diabetes group had AC versus
1.5% of patients in the control group
(P , 0.01). Of all the patients who
suffered from AC, those with dia-
betes were younger than those
without. Additionally, the incidence
of AC in the diabetes group was
associated with how long they had
been diabetic and had poor blood
glucose control (P , 0.05).10 Like-
wise, in a meta-analysis of 18 stud-
ies, patients with diabetes were five
times more likely than control sub-
jects to have AC. From this, the
overall prevalence of AC in patients
with diabetes was estimated at 13.4%,
whereas the prevalence of DM in
patients with AC was 30%. Of note,
comparison of prevalence in patients
using insulin versus other treatments
showed no notable difference.11
In a prospective, population-based,
7-year cohort study of one million
participants using the Longitudinal
Health Insurance Database 2005 in
Taiwan, of 4,472 patients with hyper-
thyroidism, 162 patients experienced
AC, giving a statistically significant
e546
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
hazard ratio of 1.22 compared with the
control group, hence concluding that
hyperthyroidism was an independent
risk factor for developing AC.12
A great deal of research has explored
the incidence of AC in patients who
previously had shoulder surgery. Re-
sults are mixed but range from 5% to
11% prevalence of the development of
AC after shoulder surgery. In a pro-
spective cohort study of 505 patients
undergoing elective shoulder surgery,
AC was identified in 11% of the pa-
tients at their 6-month follow-up and
was more common in women than in
men (15% versus 8%).13 In a retro-
spective analysis of 200 patients who
underwent arthroscopic subacromial
decompression with or without distal
clavicle excision, the incidence of AC
was 5.21% versus 5.71%.14 Ages
between 46 and 60 years and previous
diagnosis of AC in the contralateral
side were statistically significant risk
factors for the development of sec-
ondary AC. It was concluded that the
risk of developing AC after arthro-
scopic débridement is just over 5%
and not markedly affected by whether
or not the distal clavicle is excised.
Also, several studies have looked
at the incidence of AC after rotator
cuff repair (RCR). A meta-analysis
of seven studies on stiffness after
arthroscopic RCR found resistant
Journal of the American Academy of Orthopaedic Surgeons
stiffness or stiffness requiring capsu-
lar release in 3.3% of patients.15
Another study by Huberty et al16 on
489 patients who underwent RCR
found symptomatic postoperative
stiffness in 4.9% of patients. Further
analysis revealed that it was most
common in workers compensation
patients (8.6%), patients younger
than 50 years (8.6%), those with
coexisting calcific tendinitis (16.7%),
those with partial articular-sided
tendon avulsions (13.5%), and
those with concomitant labral tears
(11.0%).16 In a study of 345 pa-
tients, Namdari and Green17 found
that 47 patients with preoperative
stiffness had persistent stiffness after
RCR, of which only 3 required cap-
sular release.
Patients with upper extremity trauma
can also have resultant stiffness or
posttraumatic stiffness (PTS) which
has been theorized to progress along
a similar pathway to AC. In a study
of 73 patients undergoing open
reduction internal fixation (ORIF) for
proximal humerus fractures, Clavert
et al18 found that PTS developed
in 4.1% of patients. In a study by
Lancaster et al19 on 64 patients with
PTS after upper limb trauma, manip-
ulation under anesthesia (MUA) was a
successful intervention for improv-
ing ROM and Oxford Shoulder

Scores. The improvement in ROM
after MUA was similar to that
observed in patients who underwent
MUA for idiopathic AC.
AC has been documented in 10%
of patients after breast cancer sur-
gery.20 The incidence was higher in
the patients aged 50 to 59 years and
in those who underwent mastectomy
(with or without reconstruction) com-
pared with those who underwent
lumpectomy.
Again using the Longitudinal Health
Insurance Database 2005 in Taiwan,
patients who underwent surgery for a
cervical herniated disk disease had a
markedly higher risk (1.66) of devel-
oping shoulder capsulitis in 6-month
follow-up compared with patients who
received conservative therapy only.21
Last, though not surgical, worth
mentioning is a case study of 3 cases
of acute onset of AC after pneumo-
coccal and influenza vaccines.22
Treatment Options
Nonsurgical Management
Many options are available for im-
proving the pain, ROM, and func-
tional scores in patients with newly
diagnosed AC or in those who wish
to avoid surgery. Treatment should
be geared toward the phase of AC
(Figure 3). Oral anti-inflammatories,
either nonsteroidal (NSAIDs) or a
short tapered course of cortico-
steroids (particularly helpful in pa-
tients with very severe pain), can be
helpful in reducing patients’ symp-
toms, enough to make physical
therapy (PT) tolerable. This point
needs to be stressed–medications will
not relieve their pain completely but
are instead being used so they can
effectively participate in PT. Nar-
cotics do not have a role in the
nonsurgical management of AC. In
addition to the mainstays of non-
surgical management with PT, oral
anti-inflammatories, and cortisone
injections, other modalities include
June 15, 2019, Vol 27, No 12
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Lauren H. Redler, MD and Elizabeth R. Dennis, MS, MD
Figure 3
Treatment algorithm based on pathologic phases of adhesive capsulitis. MUA =
manipulation under anesthesia
extracorporeal shock wave therapy
(ECSWT), calcitonin pharmacother-
apy, ultrasonography-guided hy-
drodissection, and hyaluronic acid
(HA) injections. A recent systematic
review graded various nonsurgical
interventions based on study scien-
tific rigor and level of evidence.23
Therapeutic exercises and mobiliza-
tion were strongly recommended for
reducing pain and improving ROM
and function in patients with stage 2
and 3 AC. Corticosteroid injections
were most effective in early AC.
Acupuncture with therapeutic ex-
ercises was moderately recommended
for pain relief, improving ROM and
function. Continuous passive motion
was recommended for short-term
pain relief but not for improving
ROM or function. Ultrasonography
for pain relief or for improving ROM
or function was not recommended.
Corticosteroid Injections
Intra-articular corticosteroid injections
decrease pain in early stages of AC. In a
double-blind, placebo-controlled ran-
domized study of ultrasonography-
guided intra-articular and rotator
interval corticosteroid injections in 122
patients with AC, a notable decrease
in shoulder pain at 6 weeks was
observed.24 These results were main-
tained at 12 weeks but were no longer
notable at 26 weeks. No difference
existed between the group who
received intra-articular corticosteroid
injection and the group who received a
combined intra-articular and rotator
interval injection. In a meta-analysis,
nine randomized controlled trials for
453 patients were analyzed.25 From 6
to up to 26 weeks postintervention,
no superiority was noted in favor of
either steroid injection or PT for func-
tional improvement. However, steroid
injection did provide more improve-
ment in passive external rotation by
26 weeks. Last, in a study of 106
patients, four injections with cortico-
steroid with or without distension
given during 8 weeks were better than
PT alone.26 However, in the long term
no difference was shown, suggesting
that natural healing takes place
regardless of intervention.
Despite these findings, intra-articular
steroid injections do seem to have a
role in patients with AC. In a retro-
spective longitudinal study of 339
patients with AC, all patients who
e547
Shoulder Adhesive Capsulitis
were unresponsive to at least 1 month
of conservative treatment under-
went ultrasonography-guided cortico-
steroid injection, and all outcomes, at
both 1 month and 12 months, were
better when the amount of time in pain
before injection was shorter.27 There-
fore, this group concluded that early
injection improves outcomes of AC at
both short- and long-term follow-ups.
They feel that if pain persists despite
conservative management, injection in
the early time frame helps shorten the
natural history of AC.
A notable amount of research also
existed into the best technique for in-
jection of the glenohumeral joint and
whether ultrasonography guidance
has a role to play. In a randomized
controlled study of ultrasonography-
guided injections versus blind intra-
articular injections, improvements in
pain, ROM, and functional scores
were observed in the ultrasonography-
guided group at 1 and 4 weeks, but
these findings were not statistically
significant.28 In a prospective ran-
domized study of 42 patients, de-
signed to determine the ideal position
for glenohumeral injection, no dif-
ference was found in the joint space
window available for injection with
the patient in three different posi-
tions (palm on thigh, hand on op-
posite shoulder, and hanging arm
position), but injections given in all
three positions yielded statistically
significant improvement in pain and
ROM.29
Extracorporeal Shock Wave
Therapy
In a prospective randomized con-
trolled study of 40 patients treated
with ECSWT versus oral steroids,
Chen et al30 showed notable im-
provement in Constant Shoulder Score
and ROM by the fourth week and
statistically significant improvement
in ADL function by the sixth week in
patients treated with ECSWT. In a
systematic review of 19 trials (1,249
e548
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
participants), the use of ECSWT in
general did not generate any addi-
tional adverse events compared with
that in the control groups in all
studies.31 Importantly, ECSWT has
been shown to improve functional
outcomes in patients with diabetes
and may therefore be a desirable
alternative to corticosteroids for this
patient population who are not ideal
candidates for corticosteroid in-
jections because of the effect on their
blood glucose control.10
Calcitonin
A double-blinded randomized con-
trolled trial of 64 patients with AC
compared intranasal calcitonin ver-
sus placebo for 6 weeks along with PT
and NSAIDs.32 At 6 weeks, shoulder
pain, ROM, and functional scores
were markedly improved in the cal-
citonin group.
Calcitonin is a polypeptide hor-
mone secreted from parafollicular
cells of the thyroid. It has been used
for the management of complex
regional pain syndrome, rheumatoid
arthritis, and bone tumors for its
analgesic properties. Although its
pathophysiology is not completely
understood, it is thought to decrease
the systemic inflammatory response
and stimulate the release of endor-
phins. Calcitonin primarily acts to
inhibit osteoclast function and has
been shown to stabilize and some-
times increase bone density. The
aforementioned study used calcitonin
in the form of an intranasal spray, but
both this form and intramuscular in-
jections have been shown to have low
adverse effect profiles (facial flushing,
nasal irritation/sneezing, rhinitis) and
long-term therapy with calcitonin has
been shown to be safe, without seri-
ous adverse effects.32
In the setting of AC, calcitonin
therapy is thought to be an effective
augment for pain control. The cur-
rent dose recommendation is 200 U
(1 puff) daily. At our institution, one
Journal of the American Academy of Orthopaedic Surgeons
inhaler (a 30-day supply) costs $115
to $120. This form of the therapy is
derived from salmon, so it is contra-
indicated in patients with salmon
allergies.32
Ultrasonography–guided
Hydrodistention
Ultrasonography-guided hydro-
distention has been shown to be ef-
fective in patients with AC in the short
term, but no difference has been found
in long-term relief between hydro-
distention and intra-articular steroid
injection.33 In a prospective random-
ized controlled study of 121 patients
with AC, patients were randomized
between hydrodistention with joint
manipulation under an interscalene
block and treatment with an intra-
articular corticosteroid injection.34
Hydrodistention combined with joint
manipulation under an interscalene
block provided earlier pain relief and
restoration of shoulder ROM and
function compared with single intra-
articular corticosteroid injection in
patients with AC; however, at 12
months no difference existed between
the two groups.34 A randomized con-
trolled study of 64 patients with
refractory AC who received capsule-
preserving hydrodistention with
corticosteroid versus a standard intra-
articular corticosteroid showed nota-
ble improvement in both the groups
in shoulder pain and disabilities
index score and visual analogue scale
(VAS) for pain but no difference
between the two groups.35
Hyaluronic Acid Injections
HA injections in combination with
corticosteroid injections and PT have
been shown to have excellent results
for complete resolution of AC.36 In a
systematic review by Lee et al,37 four
randomized controlled studies were
identified encompassing 273 partic-
ipants with 278 shoulders. Two tri-
als compared intra-articular HA
injections versus conventional ther-
apy, whereas two studies looked at

HA injections in addition to conven-
tional therapy. In all the four studies,
no difference existed in pain or
shoulder function/disability outcomes
with or without HA. In another study,
52 patients underwent a treatment
protocol of HA and anesthetic
periarticular and intra-articular
injections, followed by a specific
program of capsule and muscle
stretching.36 Of the 52 patients, 50
(96%) had complete recovery of
ROM, thereby concluding that com-
bined pharmacologic and rehabilita-
tion approach was effective in
resolving pain and improving ROM in
patients with idiopathic AC.
Surgical Intervention
Indications
When nonsurgical management, in-
cluding NSAIDs, PT, and injections,
has failed to provide relief of symp-
toms by 9 to 12 months, surgical
intervention is indicated. In a retro-
spective review of 105 patients at our
own institution with resolution of
AC, 89.5% resolved with nonsurgi-
cal management, including 17 of 19
patients with diabetes.38 Patients
who required surgery were younger
(aged 51 years versus 56 years in the
nonsurgical group). No difference
was found in sex. Of the patients who
underwent nonsurgical management,
all received NSAIDs, 52.4% received
PT with no corticosteroid injection,
and 37.1% received at least one
injection. Patients who had resolution
of symptoms with nonsurgical man-
agement alone averaged approxi-
mately 3.8 months of treatment,
whereas those who required surgery
endured more than 1 year of non-
surgical management (average,
12.4 months).38
Arthroscopic assessment of the
glenohumeral joint often demonstrates
extensive synovitis and an erythema-
tous, injected capsule (Figure 4).
Arthroscopic synovectomy and cir-
cumferential capsulotomy have been
June 15, 2019, Vol 27, No 12
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Lauren H. Redler, MD and Elizabeth R. Dennis, MS, MD
shown to have long-lasting improve-
ment in ROM and pain relief. How-
ever, in many studies MUA has been
shown to be equivalent to capsular
release in relief of clinical symptoms.39
Manipulation Under Anesthesia
Alone Versus Arthroscopic
Capsular Release
A prospective study of 26 patients
looked at whether arthroscopic
shoulder capsular release decreased
the duration of symptoms compared
with a nonsurgical home therapy
program. Patients randomized to the
surgical group underwent arthro-
scopic capsular release and MUA.
Immediately after surgery, they began
the same stretching program as the
nonsurgical group. No statistically
significant difference existed between
the groups.40
Likewise, a systematic review of 22
studies compared outcomes between
patients treated with MUA, capsular
release, or a combination of both.39
Of the study participants, 60% were
women and the median age was 52
years (24 to 91 years). Minimal dif-
ferences existed in the median changes
in abduction, flexion, and external
rotation ROM, and final constant
score between the MUA and capsular
release groups. These authors there-
fore concluded that little benefit may
be there for a capsular release instead
of, or in addition to, an MUA.39
Alternatively, many studies have
shown notable effectiveness of arthro-
scopic release for the management of
AC.3 Le Lievre and Murrell41 showed
maintained improvement in ROM,
pain, and function at 7 years for a
group of 43 patients treated with
arthroscopic capsular release.
With respect to the technique of
arthroscopic release, limited anterior
capsular release with controlled MUA
has been shown to yield statistically
significant improvement in both pain
and function modules of the Oxford
Shoulder Score and ROM at 6-month
Figure 4
Intraoperative arthroscopic image
showing erythematous injected
capsule. * = synovitis and adhesions,
BT = biceps tendon, G = glenoid,
HH = humeral head
follow-up. Some feel that the addition
of a posterior capsule release is essen-
tial to regain internal rotation, but this
has not been shown to make a notable
difference in outcomes.42
These findings support the concept
that arthroscopy provides a minimally
invasive technique to directly visualize
the anatomy and pathologic tissue in
patients with AC under the same anes-
thetic burden as MUA with optimal
and better controlled outcomes.43
Limited Capsular Release Versus
Circumferential Release
As mentioned earlier, various techni-
ques exist for managing the capsu-
lotomy and rotator interval. Some
authors advocate for avoidance of an
inferior release to limit axillary nerve
injury.44 A retrospective study of 52
patients who underwent arthroscopic
capsular release compared various
techniques, such as joint débridement,
rotator interval opening, CHL release,
various capsulotomies (anterior, pos-
terior, inferior, and anterior-inferior),
or subscapularis tenotomy.43 All pa-
tients had improvement in pain and
ROM. Patients who underwent infe-
rior capsulotomy as part of their
release (n = 20) had the best results.43
e549
Shoulder Adhesive Capsulitis
Figure 5
Intraoperative arthroscopic image
showing release of the rotator
interval and anterior capsule.
* = opened rotator interval, BT =
biceps tendon, G = glenoid, HH =
humeral head, SS = subscapularis
Lafosse et al45 recently described
the 360-capsular release technique in
which the subacromial space is entered
laterally, the rotator interval is opened
from the outside in, and a 360° cap-
sular release and biceps tenotomy is
performed. All patients reported
excellent improvement in ROM and
pain scores, and no complications
were present, including axillary nerve
injury, fracture, or infection.45
Author’s Preferred
Technique
The senior author prefers an inter-
scalene block for sustained postop-
erative pain control combined with a
general anesthetic, including paraly-
sis, to ensure that a gentle MUA
can be accomplished without undue
force. Our capsular release method
incorporates an anterior, ante-
roinferior, and posterior capsular
release, with extension inferiorly to the
level of the infraspinatus and release of
the rotator interval. We begin using a
posterior working portal where the
rotator interval is released working
around the labrum superiorly to the
biceps laterally (Figure 5). Care is
e550
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Figure 6
Intraoperative arthroscopic image
showing release of the posterior
capsule. * = ablating device
releasing posterior capsule through
original posterior portal, HH =
humeral head, IS = infraspinatus
muscle fibers, PL = posterior labrum
taken to release all adhesions to help
lateralize the humeral head and
improve working space. The superior
glenohumeral interval and CHL are
released within the rotator interval.
Next, we identify the subscapularis
and free up its posterior surface. The
anteroinferior capsule is released deep
to subscapularis tendon along with
any component of contracted middle
glenohumeral ligament and inferior
glenohumeral ligament circum-
ferentially to the 5 o’clock position.
Next, an anterior working portal is
used to perform a posterior capsule
release, working inferiorly using in-
fraspinatus fibers as landmark of
adequate release (Figure 6).
During the MUA, the anterior and
posterior releases propagate toward
each other and connect inferiorly. It is
vital to grasp the patient’s arm
proximally to create a short lever
arm, which decreases the risk of
fracture. The first step is forward
elevation of the arm to 180°. This
serves to release the inferior capsule
in the axillary fold. Next, with the
arm adducted, the shoulder is exter-
nally rotated to release the anterior
capsule. Then, cross-body adduction
Journal of the American Academy of Orthopaedic Surgeons
is performed to release the postero-
inferior capsule. Next, the arm is
brought into abduction. In abduc-
tion, with scapular stabilization by
an assistant, the glenohumeral joint
is first maximally externally rotated
(to continue release of the anterior
capsule) and then maximally inter-
nally rotated (to release the posterior
capsule). We document the patient’s
forward elevation, external rotation
at the side, internal rotation at 90°
abduction, and straight abduction
with the camera to provide the patient
and his or her therapist with photo-
graphs of the improved ROM (Figure
7). After the manipulation, a repeat
arthroscopic assessment is performed
to confirm circumferential release.
Last, an assessment of the subacromial
space is always performed. Impinge-
ment signs are not applicable on
physical examination in patients with
AC, and a large subacromial spur with
extensive subacromial bursitis is often
encountered. A standard subacromial
decompression with acromioplasty is
performed if warranted by intra-
operative findings. Postoperatively, all
patients have portable AP, lateral, and
axillary radiographs in the post-
anesthesia care unit to ensure no
fractures are present. Postoperative
multimodal pain management is used,
including acetaminophen 1000 mg
three times daily for 7 days, gabapentin
300 mg three times daily for 3 days,
diazepam 5 mg as needed for muscle
spasm, and oxycodone 5 to 10 mg as
needed for pain. With this regimen,
we have found that patients require
fewer narcotics and therefore can
avoid undesirable adverse effects.
Recalcitrant Adhesive
Capsulitis
A small percentage of patients who
have been treated surgically for AC
continue to have symptoms. Repeat
MUA has been shown to be success-
ful.46 In a group of 730 patients who
 Lauren H. Redler, MD and Elizabeth R. Dennis, MS, MD

underwent MUA for AC, 141 Figure 7

required additional MUA. Improve-
ment was seen after a second MUA,
regardless of the outcome of the initial
MUA and of the time of recurrence.46
Patients with type 1 diabetes mellitus
were at a 38% increased risk of
requiring a repeat MUA, compared
with the 18% increased risk of the
group as a whole (P , 0.0001).

Postoperative Protocol
PT should start as soon as possible in
the postoperative setting. An inter-
scalene block or catheter can provide
analgesia to allow for immediate post-
op ROM. Mariano et al47 showed
that a continuous interscalene block
provides greater pain relief, allowing
for minimization of opioid use, im-
provement in sleep quality, and
overall increase in patient satisfaction
compared with a single application
regional block.47 However, inter-
scalene blocks are not without their
own set of risks; cases of reversible
radial neurapraxia and phrenic nerve
paralysis have been reported.43
The PT protocol focuses on achiev-
ing (for nonsurgical care) or maintain- Post-capsular release examination under anesthesia showing increased range
ing (postoperatively) a functional of motion. A, Forward elevation. B, External rotation at the side. C, External
ROM by slow, sustained stretching. rotation at 90° abduction. D, Internal rotation at 90° abduction. We find it best to
write these numbers on the drapes next to the preoperative values for proper
PT prescriptions are shown in Figure 8, documentation and case dictation.
A (nonsurgical) and Figure 8, B (sur-
gical). Patients are encouraged to
do daily stretching, including wall- released from follow-up care once cuff pathology. Arthroscopic capsu-
walking for forward elevation (Fig- they have achieved pain-free ROM lar release, while improving out-
ure 9, A), doorway stretch for external that is acceptable to them. comes in management of AC,
rotation (Figure 9, B), and modified At minimum, this includes the ability introduces its own unique set of
sleeper stretch for internal rotation to perform activities of daily living potential complications, including
(Figure 9, C). Patients often find independently. Patients are advised axillary nerve injury and rarely the
stretching in the shower to be more to return for evaluation if pain during development of complex regional
successful because of the heat. functional ROM returns or they pain syndrome.48
Postoperatively, a sling is only used note a recurrence of restricted ROM. In a prospective trial, arthroscopic
for comfort for a few days and must assessment after MUA revealed multi-
be discontinued by 1 week. Patients ple potential iatrogenic complications,
are encouraged not to sleep in the Complications such as superior labral tears, partial
sling. Patients are also advised that tears of the subscapularis, anterior
they may be more comfortable Complications from MUA range labral detachments, and tears of the
sleeping on an incline for the from fractures, glenoid and labral middle glenohumeral ligament.49 Case
first week after surgery. Patients are injuries, neurapraxia, and rotator reports have documented glenoid and

June 15, 2019, Vol 27, No 12 e551

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Shoulder Adhesive Capsulitis

Figure 8 proximal humerus fractures and

axillary nerve neurapraxia.43 These
results support the use of arthros-
copy to directly visualize tissues and
prevent iatrogenic injury that can
occur with blind MUA.

Summary
AC occurs in up to 5% of the pop-
ulation, more often in women and
patients with diabetes, and its etiol-
ogy is still unknown. The pathology
of the disease seems to be related to a
combination of inflammation and
active fibroblastic proliferation, with
transformation of myofibroblasts
leading to extensive scar tissue for-
mation. Based on the natural history
of the disease, early corticosteroid
injection has a role in shortening the
overall duration of symptoms. Pa-
tients should be counseled that
NSAIDs and corticosteroid injections
do not cure the problem; they simple
make the PT, which is imperative for
recovery, more comfortable to
endure. For patients with diabetes
who may have undue metabolic dis-
array from corticosteroid injection,
ECSWT may have a role in symptom
relief. Most patients will see complete
resolution of symptoms with non-
surgical management. When surgical
intervention is required, the ideal
technique should include both ante-
rior and posterior capsular release as
well as rotator interval release spe-
cifically including release of the
CHL. When combined with a gentle
MUA, circumferential capsular
release is possible without risking
injury to the axillary nerve. Early PT
is essentially postoperatively. An
interscalene block can be used to
provide enhanced pain relief. To
avoid complications, aggressive
MUA should be avoided, care must
Physical therapy prescription for (A) nonsurgical management of adhesive be taken with inferior release, and
capsulitis and (B) postoperative treatment. It is important to note the side all patients should have portable
involved and the current range of motion.
AP, lateral, and axillary imaging in

e552 Journal of the American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Lauren H. Redler, MD and Elizabeth R. Dennis, MS, MD

Figure 9

Home stretching exercises. Stretches area held for 30 seconds, relax, and repeated 3 times. Wall-walking to stretch the
inferior capsule and increase forward elevation (A), doorway external rotation stretch to stretch the anterior capsule (B), and
modified sleeper stretch to stretch the posterior capsule and increase internal rotation (C).

the post-anesthesia care unit to
assess for fracture.
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