clinical study the impact of arthroscopic capsular release in … · 2019. 7. 31. · clinical...

Clinical StudyThe Impact of Arthroscopic Capsular Release in Patients withPrimary Frozen Shoulder on Shoulder Muscular Strength

MichaB Waszczykowski1 MichaB Polguj2 and JarosBaw FabiV1

1 Department of Arthroscopy Minimally Invasive Surgery and Sports Traumatology Medical University of Lodz113 Zeromskiego Street 90-549 Lodz Poland

2Department of Angiology Chair of Anatomy Medical University of Lodz 60 Narutowicza Street 90-136 Lodz Poland

Correspondence should be addressed to Michał Waszczykowski mwaszczykowskiwppl

Received 1 April 2014 Revised 30 May 2014 Accepted 10 June 2014 Published 24 June 2014

Academic Editor Sae H Kim

Copyright copy 2014 Michał Waszczykowski et al This is an open access article distributed under the Creative Commons AttributionLicense which permits unrestricted use distribution and reproduction in any medium provided the original work is properlycited

The aim of this study was to evaluate the impact of arthroscopic capsular release in patients with primary frozen shoulder onmuscular strength of nonaffected and treated shoulder after at least two-year follow-up after the surgery The assessment includedtwenty-seven patients who underwent arthroscopic capsular release due to persistent limitation of range of passive and activemotion shoulder pain and limited function of upper limb despite 6-month conservative treatment All the patients underwentarthroscopic superior anteroinferior and posterior capsular release After at least two-year follow-up measurement of muscularstrength of abductors flexors and external and internal rotators of the operated and nonaffected shoulder as well as determinationof range of motion (ROM) and function (ASES) in the operated and nonaffected shoulder was performed Measurement ofmuscular strength in the patient group did not reveal statistically significant differences between operated and nonaffected shoulderThe arthroscopic capsular release does not have significant impact on the decrease in themuscular strength of the operated shoulder

1 Introduction

Frozen shoulder is an inflammatory condition of the shoulderjoint area manifesting with pain and limitation of rangeof passive and active motion in this joint Primary frozenshoulder involving limitation of the joint mobility withoutany apparent cause is the most common form of thecondition Frozen shoulder may also occur after a trauma(posttraumatic frozen shoulder) or surgery in the shoulderarea or be concomitant with diabetes mellitus rheumatoidarthritis or thyroid diseases [1ndash6]

Management of choice involves conservative treatmentNonsteroidal anti-inflammatory drugs oral or intra-articularglucocorticosteroids physical therapy kinesitherapy andforced manipulation under general anaesthesia are applied[3 5 7ndash12] In some 10 of cases indications for surgeryare present Currently arthroscopic capsular release is atreatment of choice in such cases [3 4 13ndash19] Howeverthere are no literature data concerning the impact of suchtreatment on the muscular strength of the operated shoulder

Many data show the improvement of function of the shoulderafter surgical treatment But we still do not know whether itdepends only on improvement of pain-free range of motionor it also correlates with good muscular strength of operatedshoulder We suppose that improvement of function of theshoulder after arthroscopic capsular release depends on goodpain-free range of motion as well as good muscular strengthof the shoulder The purpose of this study is to determinewhether good function of the shoulder after at least two-year follow-up after surgical treatment of frozen shouldercorrelates with good muscular strength

2 Materials and MethodsThe analysis involved 27 patients treated surgically in theyears 2006ndash2010 in theDepartment of Arthroscopy and SportTraumatology Medical University of Lodz due to primaryfrozen shoulderwith at least two-year follow-upThe group of27 patients (27 shoulders) comprised 17 females and 10malesMean age in the whole group was 516 years plusmn 115 (24ndash76)

Hindawi Publishing CorporationBioMed Research InternationalVolume 2014 Article ID 834283 5 pageshttpdxdoiorg1011552014834283

2 BioMed Research International

Inferior capsule release

Subscapularis muscle tendon

Anterior capsule release

Supraspinatus muscle tendon

Infraspinatus muscle tendon

Posterior capsule release

Figure 1 Schema of arthroscopic capsule release of the shoulder

The inclusion criteria for this study were as follows firstepisode of frozen shoulder at least 6-month duration ofpain and limitation of range of motion of the shoulder upto 50 as compared to unaffected shoulder no improve-ment after conservative treatment involving pharmacother-apy (NSAIDs steroids drugs in intra-articular injections) andphysical therapy no history of major trauma of shoulder nosigns of rotator cuff tear (as assessed by MRI or ultrasoundscan) and occasional sports activity The exclusion criteriain this study were as follows history of major trauma of theshoulder partial or full thickness rotator cuff tear currentor former high-level sport activity concomitant diabetesmellitus rheumatoid arthritis osteoarthritis of the shoulderand thyroid diseases All the patients underwent arthroscopiccapsular release of the shoulder joint during their stay inhospital

Following admission to the department limitation ofROM in the affected and nonaffected shoulder joint wasdetermined by means of a goniometer Moreover passivemotion range was assessed in the operation room undergeneral anaesthesia directly before the procedure Beforethe surgery the function of operated shoulder was gradedaccording to ASES (America Shoulder and Elbow Surgeons)score

Arthroscopic capsular release was performed under gen-eral endotracheal anaesthesia with patient in the beach-chairposition with trunk flexed at 60∘ to the lower limbs All thepatients underwent arthroscopic superior anteroinferior andposterior capsular release including interval capsule incision[8 17ndash21] (Figures 1 2 and 3) Then gentle manipulationof the shoulder joint was performed We have always paidattention not to damage subscapularis tendon during anteriorcapsular release (Figure 4)

After at least two-year follow-up after the surgery iso-metric muscular strength of anterior flexors abductors andexternal and internal rotators of the arm was measured(with arm adducted to the trunk and elbow flexed at90∘) Measurements were performed by means of ISOBEX

Figure 2 The arthroscopic view of superior capsule release

Figure 3 The arthroscopic view of anterior capsule release

21 dynamometer (CURSOR AG Bern Switzerland) withcomputer-assisted strength measurement within 5 seconds(Figure 5) The measurements were performed with patientsin standing position Eachmeasurementwas performed threetimes and mean value was calculated Range of motionof the operated and nonaffected shoulder was determinedby means of a goniometer The function of operated andnonoperated shoulder was also graded according to ASES(America Shoulder and Elbow Surgeons) score

BioMed Research International 3

Table 1 The assessment of range of motion function and muscle strength of flexors muscle of the shoulder (FFLX) abductors (ABD) andexternal (ER) and internal rotators (IR) of the operated and healthy shoulder after minimum two-year follow-up

Operated shoulder Healthy shoulder 119875 valueNumber of patients (shoulder) 27Dominantnondominant 1512Mean age (years) 516 (24ndash76)FM 1710Muscular strength (kg)

FFLX 51 52 gt005ABD 50 54 gt005ER 56 61 lt005IR 64 67 gt005

Range of motion (∘) Preop PostopFFLX 819 1663 1721 lt005ABD 608 1475 1534 lt005ER 61 578 642 lt005IR Buttock Th10 Th9 lt005

Function (ASES 0ndash100) 256 912 938 lt005

Figure 4 The arthroscopic view of anterior and superior capsulerelease close to subscapularis muscle tendon

The study protocol was approved by the local bioethicscommittee (Approval number RNN6107KB)

Results were processed statistically by means of StatisticaPL software Analysis of results involved Mann-Whitney testpaired difference test (Wilcoxon rank test) and Friedmantests Nonparametric tests were used for statistical analysisbecause the data did not follownormal distribution accordingto Shapiro-Wilk test

To evaluate the intraobserver and interobserver repeata-bility of dynamometer measurements the strength of abduc-tion of both upper limbs was assessed in 10 healthy volunteerstwice by the same researcher (R11015840 and R110158401015840) and by the secondauthor (R2) Linear regression analysis was used to calculatethe 1198772 value which indicates the level of convergence Thebias was assessed by means of the Bland-Altman plot whichvisualizes the percentage difference between 2 measurements(119910-axis) against their mean (119909-axis)

3 ResultsAssessment of shoulder muscular strength was performedby means of ISOBEX dynamometer for four muscle groupsabductors anterior flexors and external and internal rotators

Figure 5 ISOBEX 21 dynamometer (CURSOR AG Bern Switzer-land)

of the arm Measurement of isometric muscular strength wasperformed for nonaffected and operated shoulder after atleast two-year follow-up after arthroscopic capsular releaseof frozen shoulder No statistically significant differences forarm abductor flexor and internal rotators muscular strengthbetween operated and nonaffected shoulders were found(119875 gt 005) (Table 1) However difference in measuredmuscular strength of external rotators between operated andnonaffected shoulders was approximately 8 and proved tobe statistically significant (119875 lt 005) (Table 1)

We did not notice statistically significant differencesbetween dominant and nondominant sides (119875 gt 005)The differences in muscular strength between dominant andnondominant sides among healthy individuals did not revealstatistical significance (Table 2)

In all the patients after at least two-year follow-upafter the surgery statistically significant improvement withinrange of motion in all the planes (flexion abduction externalrotation and internal rotation) was obtained (119875 lt 005)when compared with the period before the surgery Mobilityof the operated shoulder after two-year follow-up withinanterior flexion abduction and external and internal rotation


Table 2 Differences of muscular strength between body sides

Movement ABD FL ER IR

Mean strength (SD) [kg] Dominant 52 (258) 538 (28) 585 (278) 626 (288)Nondominant 552 (282) 554 (297) 545 (222) 629 (296)

119875 value 035 060 022 089

did not differ significantly as compared to the nonaffected one(Table 1)

The improvement of function of the shoulder afterarthroscopic capsular release was also significant (119875 lt005) according to America Shoulder and Elbow Surgeonsscore (ASES from 256 preoperatively to 912 postoperatively0ndash100) There were no statistical differences in shoulderfunction between operated and nonoperated side accordingto ASES after at least two-year follow-up after the surgery(119875 gt 005) (Table 1)

The power of statistical tests used in this analysis wasassessed to be 80 The intraobserver and interobserverrates of convergence were 1198772 = 0993 and 1198772 = 0995respectively Details concerning limits of convergence andbias are presented in Bland-Altman plots The Bland-Altmanplot and 1198772 value confirm that application of the electricdynamometer is a reliable method for evaluating muscularstrength throughout the range of parameters measured

4 Discussion

This study involved the assessment of impact of arthroscopiccapsular release of frozen shoulder on muscular strength ofthe operated shoulder and comparison of the results obtainedwith nonaffected shoulder Muscular strength of abductorsflexors external rotators and internal rotators of the armwasmeasured We also tried to determine whether good clinicaloutcomes according to ASES score correlated with goodmuscle strength of operated shoulder In the group of patientswith primary frozen shoulder we did not find statisticallysignificant differences inmuscular strength of shoulder whencomparing the operated shoulder with nonaffected one (119875 gt005) We also revealed that improvement of function (ASES119875 lt 005) after arthroscopic capsular release correlatedwith good muscular strength of operated shoulder after two-year follow-up However a small but statistically significantdecrease of muscular strength of external rotators was noted(119875 lt 005) Unfortunately we could not find out why only inthis muscle group did such differences occur It could resultmost likely from the atrophy of the muscle group duringprolonged shoulder dysfunction before the surgery

Recent worldwide studies suggest that arthroscopic cap-sular release is an effective treatment of shoulder contracturesin patients that did not respond to prolonged (months)conservative management [8 17 22ndash24] They all revealedsome improvement in the range of motion and functionThere are not literature data available concerning the assess-ment of shoulder muscular strength following arthroscopicsurgery for frozen shoulder The only paper that partiallyinvolves the issue is a study by Liem et al [25] The authorsanalysed results of measurement of isometric and isokinetic

strengths of external and internal rotators of the arm inpatients after arthroscopic capsular release that additionallyinvolved cutting of intra-articular portion of subscapularistendon However the aim of their study was to evaluate theeffect of cutting of subscapularis tendon on the muscularstrength of rotators as compared to nonoperated shoulderThey did not find statistically significant differences withinthese parameters between operated and nonaffected shoulderin a group of 22 patientsThey also did not notice statisticallysignificant differences between dominant and nondominantsides

Authors of the relevant literature available agree thatsome differences in muscular strength of particular shoul-der muscle groups dominant and nondominant sides mayoccur amounting even to 10 [26 27] However they arenot statistically significant These data are consistent withthose obtained from this study The differences in muscularstrength between dominant and nondominant sides were notstatistically significant (119875 gt 005)

Analysis of the measurements of muscular strength infrozen shoulder patients following arthroscopic capsularrelease suggests that most likely the treatment does notimpact muscular strength of the operated shoulder Howevera small number of individuals included in this study mayprovide a limitation on drawing final conclusions It alsoseems important to analyse shoulder muscular strength insuch patients in early postoperative period to capture itsactual deficit resulting fromprolonged preoperative period ofshoulder dysfunction and to determine optimal rehabilitationprogramme

5 Conclusions

The arthroscopic capsular release most likely does not haveany impact on the decrease in the muscular strength of theoperated shoulder Improvement of global function of theshoulder (ASES) after arthroscopic capsular release corre-lates with good muscular strength of the operated shoul-der Undoubtedly more studies involving higher numberof individuals are needed to confirm this hypothesis andconclusions

Conflict of Interests

The authors declare that they have no conflict of interests

References

[1] B Lundberg ldquoThe frozen shoulderrdquo Acta Orthopaedica Scandi-navica vol 119 pp 5ndash59 1969


[2] M Lubiecki and A Carr ldquoFrozen shoulder past present andfuturerdquo Journal of Orthopaedic Surgery vol 15 no 1 pp 1ndash32007

[3] S Duplay ldquoDe la peri-arthrite scapulo-humerale et des raideursde lrsquoepaule qui en sont la consequencerdquo Archives Generales deMedecine vol 20 pp 513ndash542 1872

[4] E A Codman The Shoulder Rupture of the SupraspinatusTendon and Other Lesions in or about the Subacromial BursaPrivately Printed Boston Mass USA 1934

[5] R J Neviaser ldquoAdhesive capsulitis of the shoulder Diagnosisand managementrdquo Clinical Orthopaedics vol 223 pp 59ndash641987

[6] S M Griggs A Ahn and A Green ldquoIdiopathic adhesive cap-sulitis a prospective functional outcome study of nonoperativetreatmentrdquo Journal of Bone and Joint Surgery A vol 82 no 10pp 1398ndash1407 2000

[7] R Buchbinder J L Hoving S Green S Hall A Forbes and PNash ldquoShort course prednisolone for adhesive capsulitis (frozenshoulder or stiff painful shoulder) a randomised double blindplacebo controlled trialrdquo Annals of the Rheumatic Diseases vol63 no 11 pp 1460ndash1469 2004

[8] J J PWarner A Allen P HMarks and PWong ldquoArthroscopicrelease for chronic refractory adhesive capsulitis of the shoul-derrdquo Journal of Bone and Joint SurgeryA vol 78 no 12 pp 1808ndash1816 1996

[9] RGGrey ldquoThenatural history of ldquoidiopathicrdquo frozen shoulderrdquoJournal of Bone and Joint Surgery A vol 60 no 4 p 564 1978

[10] G C R Hand N A Athanasou T Matthews and A J CarrldquoThe pathology of frozen shoulderrdquo Journal of Bone and JointSurgery B vol 89 no 7 pp 928ndash932 2007

[11] N A Quraishi P Johnston J Bayer M Crowe and A JChakrabarti ldquoThawing the frozen shoulderrdquo Journal of Boneand Joint Surgery B vol 89 no 9 pp 1197ndash1200 2007

[12] S J Thomas C McDougall I D M Brown et al ldquoPrevalenceof symptoms and signs of shoulder problems in people withdiabetes mellitusrdquo Journal of Shoulder and Elbow Surgery vol16 no 6 pp 748ndash751 2007

[13] L B Siegel N J Cohen and E P Gall ldquoAdhesive capsulitis asticky issuerdquoAmerican Family Physician vol 59 no 7 pp 1843ndash1850 1999

[14] F Guler-Uysal and E Kozanoglu ldquoComparison of the earlyresponse to two methods of rehabilitation in adhesive capsuli-tisrdquo SwissMedicalWeekly vol 134 no 23-24 pp 353ndash358 2004

[15] J Jerosch N M Nasef O Peters and A M R Mansour ldquoMid-term results following arthroscopic capsular release in patientswith primary and secondary adhesive shoulder capsulitisrdquoKneeSurgery Sports Traumatology Arthroscopy vol 21 no 5 pp1195ndash1202 2013

[16] J AGrant N Schroeder B SMiller and J E Carpenter ldquoCom-parison of manipulation and arthroscopic capsular release foradhesive capsulitis a systematic reviewrdquo Journal of Shoulder andElbow Surgery vol 22 no 8 pp 1135ndash1145 2013

[17] J J P Warner A A Allen P H Marks and P WongldquoArthroscopic release of postoperative capsular contracture ofthe shoulderrdquo Journal of Bone and Joint Surgery A vol 79 no 8pp 1151ndash1158 1997

[18] H M J Le Lievre and G A C Murrell ldquoLong-term outcomesafter arthroscopic capsular release for idiopathic adhesive cap-sulitisrdquo Journal of Bone and Joint Surgery A vol 94 no 13 pp1208ndash1216 2012

[19] M Waszczykowski and J Fabis ldquoThe results of arthroscopiccapsular release in the treatment of frozen shouldermdashtwo-yearfollow-uprdquo Ortopedia Traumatologia Rehabilitacja vol 12 no3 pp 216ndash224 2010

[20] D J Ogilvie-Harris D J Biggs D P Fitsialos and M MacKayldquoThe resistant frozen shoulder manipulation versus arthro-scopic releaserdquo Clinical Orthopaedics and Related Research vol319 pp 238ndash248 1995

[21] P Beaufils N Prevot T Boyer et al ldquoArthroscopic release of theglenohumeral joint in shoulder stiffness a review of 26 casesrdquoArthroscopy vol 15 no 1 pp 49ndash55 1999

[22] M H Baums G Spahn M Nozaki H Steckel W Schultz andH-M Klinger ldquoFunctional outcome and general health statusin patients after arthroscopic release in adhesive capsulitisrdquoKnee Surgery Sports Traumatology Arthroscopy vol 15 no 5pp 638ndash644 2007

[23] G P Nicholson ldquoArthroscopic capsular release for stiff shoul-ders effect of etiology on outcomesrdquo Arthroscopy vol 19 no 1pp 40ndash49 2003

[24] C Gerber N Espinosa and T G Perren ldquoArthroscopic treat-ment of shoulder stiffnessrdquo Clinical Orthopaedics and RelatedResearch no 390 pp 119ndash128 2001

[25] D Liem F Meier L Thorwesten B Marquardt J Steinbeckand W Poetzl ldquoThe influence of arthroscopic subscapularistendon and capsule release on internal rotation strength intreatment of frozen shoulderrdquo The American Journal of SportsMedicine vol 36 no 5 pp 921ndash926 2008

[26] F Mayer T Horstmann K Rocker H C Heitkamp and HH Dickhuth ldquoNormal values of isokinetic maximum strengththe strengthvelocity curve and the angle at peak torque of andegrees of freedom in the shoulderrdquo International Journal ofSports Medicine vol 15 no 1 pp S19ndashS25 1994

[27] M P Murray D R Gore G M Gardner and L A MollingerldquoShoulder motion and muscle strength of normal men andwomen in two age groupsrdquo Clinical Orthopaedics and RelatedResearch vol 192 pp 268ndash273 1985

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Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom


Inferior capsule release

Subscapularis muscle tendon

Anterior capsule release

Supraspinatus muscle tendon

Infraspinatus muscle tendon

Posterior capsule release

Figure 1 Schema of arthroscopic capsule release of the shoulder

The inclusion criteria for this study were as follows firstepisode of frozen shoulder at least 6-month duration ofpain and limitation of range of motion of the shoulder upto 50 as compared to unaffected shoulder no improve-ment after conservative treatment involving pharmacother-apy (NSAIDs steroids drugs in intra-articular injections) andphysical therapy no history of major trauma of shoulder nosigns of rotator cuff tear (as assessed by MRI or ultrasoundscan) and occasional sports activity The exclusion criteriain this study were as follows history of major trauma of theshoulder partial or full thickness rotator cuff tear currentor former high-level sport activity concomitant diabetesmellitus rheumatoid arthritis osteoarthritis of the shoulderand thyroid diseases All the patients underwent arthroscopiccapsular release of the shoulder joint during their stay inhospital

Following admission to the department limitation ofROM in the affected and nonaffected shoulder joint wasdetermined by means of a goniometer Moreover passivemotion range was assessed in the operation room undergeneral anaesthesia directly before the procedure Beforethe surgery the function of operated shoulder was gradedaccording to ASES (America Shoulder and Elbow Surgeons)score

Arthroscopic capsular release was performed under gen-eral endotracheal anaesthesia with patient in the beach-chairposition with trunk flexed at 60∘ to the lower limbs All thepatients underwent arthroscopic superior anteroinferior andposterior capsular release including interval capsule incision[8 17ndash21] (Figures 1 2 and 3) Then gentle manipulationof the shoulder joint was performed We have always paidattention not to damage subscapularis tendon during anteriorcapsular release (Figure 4)

After at least two-year follow-up after the surgery iso-metric muscular strength of anterior flexors abductors andexternal and internal rotators of the arm was measured(with arm adducted to the trunk and elbow flexed at90∘) Measurements were performed by means of ISOBEX

Figure 2 The arthroscopic view of superior capsule release

Figure 3 The arthroscopic view of anterior capsule release

21 dynamometer (CURSOR AG Bern Switzerland) withcomputer-assisted strength measurement within 5 seconds(Figure 5) The measurements were performed with patientsin standing position Eachmeasurementwas performed threetimes and mean value was calculated Range of motionof the operated and nonaffected shoulder was determinedby means of a goniometer The function of operated andnonoperated shoulder was also graded according to ASES(America Shoulder and Elbow Surgeons) score




















119875 value 035 060 022 089




4 Discussion






5 Conclusions




References


































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of



































119875 value 035 060 022 089




4 Discussion






5 Conclusions




References


































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















clinical study the impact of arthroscopic capsular release in … · 2019. 7. 31. · clinical...

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