Managing the stiff (frozen) shoulder

Effects of comorbidities on the outcomes of manipulation under anesthesia for primary stiff shoulder

These authors sought to assess how comorbidities influence the recovery speed and clinical outcomes after manipulation under anesthesia (MUA) in 281 primary stiff shoulders. They divided patients into the control (n . 203), diabetes mellitus (DM)(n . 32), hyperlipidemia (n . 26), and thyroid disorder (n . 20) groups. The mean HbA1c (normal range: 4.5%-5.6%) of the DM group was 7.3%.  Among the 32 diabetic patients, 24 (75%) had HbA1c ≥ 6.5%. 

MUA was considered if all four criteria were met:

(1) limited passive ROM compared with the opposite normal shoulder (passive glenohumeral motion is 20 or less of forward flexion with holding down the scapula by the surgeon, and movements are made mainly using the scapulothoracic motion); 

(2) pain and stiffness persisted for at least 3 months and did not respond to sufficient conservative treatment;

(3) stiff shoulder is in the frozen stage; and 

(4) normal shoulder x-rays.

MUA was performed as an outpatient procedure under interscalene regional anesthesia with the patient in the supine position. With one hand stabilizing the scapula, the range of glenohumeral movement was assessed and recorded. To avoid iatrogenic injuries such as humeral fracture, the surgeon performed manipulation by holding the patient’s arm between the shoulder and elbow with the other hand to form a short lever arm. The shoulder was manipulated sequentially through a range of forward flexion, abduction, external rotation, cross-body adduction, and internal rotation. The procedure was followed by immediate physical therapy.

A successful MUA was defined as achieving the ROM for the passive forward flexion and external rotation at the side within 15 degrees and internal rotation to the posterior within 3 spinal levels compared with the normal contralateral side.

Significant improvements in range of motion (ROM) and clinical scores at 3 months after MUA were observed in all groups. 

Significant differences in ROM among the 4 groups were also observed during follow-up. The DM group had significantly lower ROM values, even at 3 months after MUA, compared with the control group.  The ROM recovery speed after MUA was slowest in the DM group, followed by the thyroid disorder, hyperlipidemia, and control groups.

Most (90.6%) of the DM group experienced late recovery. The proportion of nonsuccessful MUA was higher in the DM and thyroid disorder groups than that in the control and hyperlipidemia groups.

One case of spiral humeral fracture occurred after MUA while rotating the arm externally during this study. No other complications occurred. 

During follow-up, there were no statistically significant differences among groups regarding the visual analog scale, University of California at Los Angeles shoulder, and Constant scores.

Comment: We have found manipulation under anesthesia to be useful for refractory shoulder stiffness in patients without glenohumeral arthritis or osteopenia. We use a short (5 minute) general anesthetic coupled with complete muscle paralysis achieved with succinylcholine.  This has been a safe and effective procedure for patients with refractory idiopathic frozen shoulder and for shoulders with refractory post operative stiffness.

In the photo below, one anesthesiologist (upper left) is providing oxygen ventilation while another (upper right) is administering the intravenous succinylcholine. To avoid the risk of humeral fracture (such as the one reported in this paper) or cuff injury, we manipulate in flexion, cross body adduction, and abduction, but not in rotation.

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

Follow on twitter: Frederick Matsen (@shoulderarth)

Shoulder stiffness and glucose control

The relationship between the incidence of adhesive capsulitis and hemoglobin A1c

These authors determined a "cumulative" HbA1c, that uses HbA1c values over time to estimate the total disease burden that the patient experiences over a period. They evaluated whether a correlation existed between cumulative HbA1c levels in diabetic patients and the prevalence of frozen shoulder using a retrospective review of  patients from a single institution for which HbA1c values were available. The exclusion criteria were age younger than 18 years, HbA1c levels greater than 15, and patients who had 1 year or less of single or consecutively recorded HbA1c levels. A total of 24,417 patients met the inclusion criteria.

They found that cumulative HbA1c was positively associated with adhesive capsulitis.  The effect size of cumulative HbA1c on adhesive capsulitis was significant; for each unit of time that the HbA1c level was greater than 7, there was a 2.77% increase in the risk of adhesive capsulitis.

Comment: The mechanism of joint stiffness in individuals with abnormal sugar metabolism is thought to be non-enzymatic gycosylation, causing abnormal cross links between collagen fibers resulting in increased stiffness. 

Surgeons performing surgical releases for stiff diabetic shoulders often note increased thickness and toughness of the capsular tissue. Surgeons attempting to manage diabetic stiff shoulders with manipulation are often frustrated for the same reason.

This paper would have been stronger if the authors had provided the diagnostic criteria used for making the diagnosis of adhesive capsulitis (if indeed these criteria were standardized across the practice) and if they had performed a multivariate analysis that included all the data they collected: patient age, sex, BMI, length of time over which the HbA1c data were collected (range, 12-207 months), thyroid status, and insulin dosage at the time of diagnosis. 

In any event, this study reminds us that, in addition to its effect on surgical complications, glycemic control may affect the success of procedures designed to improve shoulder motion, including shoulder arthroplasty. 

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Information about shoulder exercises can be found at this link.

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Can a stiff shoulder be loosened up with arthroscopic surgery?

Arthroscopic Management of the Stiff Shoulder

These authors have conducted a most thorough review of the application of arthroscopy to the management of the stiff shoulder.

Their bullet points are:

➢ Shoulder stiffness affects a diverse population of patients suffering a decrease in function and shoulder pain. Arthroscopic management of this debilitating spectrum of pathology is a safe and effective course of action in cases recalcitrant to nonoperative therapy.

➢ Arthroscopic management of the stiff shoulder has been reported to be effective in the treatment of stiffness due to adhesive capsulitis, birth palsy, stiffness in the setting of rotator cuff tears, and osteoarthritis in the posttraumatic patient, in the postoperative patient, and in the throwing athlete.

➢ Arthroscopic management is most effective in treating the stiff shoulder in the setting of adhesive capsulitis recalcitrant to nonoperative therapy or posttraumatic stiffness. Results are more guarded in the treatment of postoperative stiffness.

➢ Excessive force and trauma to the shoulder, including fracture of the humerus, can be avoided with a 360° capsular release for shoulder stiffness rather than manipulation under anesthesia.

Comment: A post about evaluating a shoulder for stiffness is shown here. Critically they point out the difference between idiopathic frozen shoulder (classically defined as a functionally important limitation of passive and active range of motion in the absence of prior surgery, injury, congenital defects and x-ray abnormalities) from the myriad of other potential causes of shoulder stiffness (e.g. birth defects, glenohumeral arthritis, post-surgical stiffness, etc).  See this link. The former is usually very responsive to management because the rest of the joint is normal. The other causes of stiffness may be addressed by arthroscopic releases, but the effectiveness of releasing the capsule may be limited by joint surface, bony, and other pathologies.

Finally, the authors point to the importance of a complete capsular release and complete muscle relaxation so that minimal force is applied when the shoulder is manipulated.

It is nice that the authors credit the contributions of our late partner, Doug Harryman, to the application of arthroscopy to the management of the stiff shoulder. See this link.

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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Stiff shoulders with cuff tears - what does this teach us?

Rotator Cuff Lesions in Patients with Stiff Shoulders: A Prospective Analysis of 379 Shoulders.


These authors use MRI to investigate the prevalence of rotator cuff lesions in a a series of 379 patients with stiff shoulders (excluding those with traumatic etiology, diabetes, or radiographic abnormalities).

Group 1 included 89 shoulders with severe and global loss of passive motion (≤100° of forward flexion, ≤10° of external rotation with the arm at the side, and internal rotation not more cephalad than the L5 level).  91% of these patients had an intact rotator cuff and 9% had a partial-thickness rotator cuff tear

Group 2 included 290 shoulders with severe but not global loss. 44% of these patients had intact cuffs, 17% had partial thickness tears and 39% had full thickness tears.

Group 3 included 179 shoulders with mild to moderate limitation. 35% of these had intact cuffs, 16% ha partial thickness tears, and 50% had full thickness tears.

The results are easier to see in this chart we prepared from their data

The authors concluded that shoulder stiffness with severe and global loss of passive range of motion is not commonly associated with full-thickness rotator cuff tears, although some stiff shoulders may have a partial-thickness tear. 

Comment: To us the real take home message is that shoulders with full-thickness cuff tears can have mild, moderate or severe stiffness. This stiffness may be as much a contribution to the patient's loss of comport and function as the tear itself. If a cuff repair is attempted on a stiff shoulder, there is a real risk that the stiffness will be exacerbated as a result of the surgical tightening and the post operative protection of the repair. 

We often use the smooth and move procedure (see this link) in chronic degenerative tears and failed prior repair attempts. This is a procedure that does not attempt to repair the cuff, but instead includes a lysis of adhesions and a manipulation under anesthesia, followed by immediate post-operative full passive motion stretching exercises. Prior to the manipulation we are often impressed by the amount of stiffness in these shoulders. We are also impressed by the rapid recovery of function and comfort after this procedure that treats the stiffness but not the cuff defect.

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Click here to see the new Rotator Cuff Book

Consultation for those who live a distance away from Seattle.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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Propionibacterium and frozen shoulder

Association between Propionibacterium acnes and frozen shoulder: a pilot study

These authors studied 10 patients undergoing arthroscopic release for stage II idiopathic frozen shoulder, each of which had aerobic cultures of two biopsies of tissue taken from the affected shoulder joint capsule at the time of surgery and biopsies of subdermal fat after standard Chlorhexidine preparation of the skin. Eight of the 10 patients had positive findings on extended culture in their shoulder capsule and, in six of these, Propionibacterium was present.

Comment: What was especially interesting to us about this article was (1) the high rate with which Propionibacterium was recovered from the fat and (2) the high degree of correlation between the percent of fat cultures positive for Propionibacterium and the percent of capsular cultures positive for Propionibacterium; see our graph of their data below. The correlation coefficient was .84.

These data once again show that standard surgical skin preparation does not sterilize the subdermal fat and that shoulders with Propionibacterium in the fat are likely to have it in the joint.

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You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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Effects of Glycemic Control on Prevalence of Diabetic Frozen Shoulder - JBJS

Effects of Glycemic Control on Prevalence of Diabetic Frozen Shoulder was recently published by JBJS.

It is well known that individuals with diabetes are at increased risk of having a frozen shoulder and that frozen shoulders in these individuals are often more difficult to manage with therapy or with surgery. These authors sought to answer the question of whether control of the diabetes was related to the development of frozen shoulder. They reviewed 201,513 diabetic patients and found 1150 with a diagnosis of frozen shoulder. There was no significant relationship between HbA1c level and the prevalence of frozen shoulder. The frequency of frozen shoulder was almost twice as high in insulin-dependent patients than non-insulin-dependent diabetic patients. The incidence of frozen shoulder was also higher in those taking oral hypoglycemic drugs than those who were not. It was also more common for those who had had diabetes for 10 or more years. The prevalence of end-stage diabetic manifestations was increased in patients with frozen shoulder as compared with those without frozen shoulder.

These data suggest that the severity of the diabetes, but not the degree of diabetic control, and the incidence of frozen shoulder are closely related.

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Shoulder arthritis and rotator cuff articles from Sept issue of the JBJS - cuff muscle function, frozen shoulder

The September issue of JBJS contains an article by Mannaya et al entitled "evaluation of in vivo rotator cuff muscle function after acute and chronic detachment of the supraspinatus tendon".
The authors used a rat model to show that repaired supraspinatus tears had less endurance and generated less force than normal rotator cuff tendon. The loss of function was more severe when the tear was 12 weeks old than when the tear was 4 weeks old. They also found that increased tension in the repair (as may result from the fact that with tendon loss it is necessary to stretch the muscle to reach the attachment point) leads to inferior function. The message is that in acute tears, earlier repair of rotator cuff tears, before tendon loss occurs, is likely to lead to better functional results. Of course this does not mean that there is a hurry in repairing long standing chronic atraumatic cuff tears, as we've stated previously in this blog.

There is also an interesting article on adhesive capusulitis or 'frozen shoulder'. This is a systematic review of the literature which concludes that the existing publications show no significant difference in the long-term results of management of this condition with (a) intra-articular steriod injection, (b) manipulation under anesthesia, (c) intra-articular local anesthetic, (d) intra-articular saline injection, (e) oral steriods and  (f) physical therapy.
Basically, all treatments led to improvement in comfort and function. Perhaps this is a self limited condition that gets better with time, regardless of treatment. The authors do caution, however, that the methodology of the studies comparing treatments is 'poor', so that there may be differences that would be detected by better quality studies.
In my practice I consider manipulation under anesthesia and complete muscle relaxation for patients with refractory stiff shoulders who have normal x-rays, good quality bone, and no prior injury or surgery.

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Revision surgery for failed shoulder replacement arthroplasty due to glenoid component failure, Part 11

What if a failed shoulder arthroplasty is associated with instability, that is,  unwanted translation of the humeral head on the glenoid?  Such a shoulder requires a careful  history, examination, and radiographs.  The physical examination of strength in isometric internal rotation with the arm against the abdomen, isometric elevation of the internally rotated arm, and isometric external rotation of the neutrally rotated arm at the side as well as expert shoulder ultrasound can evaluate the integrity of the subscapularis, supraspinatus, and infraspinatus, respectively.  High quality and appropriately oriented anteroposterior and axillary radiographs will reveal the glenohumeral relationship (including the superior/inferior and anteroposterior relationship of the center of the humeral head and the center of the glenoid), the integrity of the tuberosities, the orientation of the glenoid and much about the type and position of the humeral component.  If knowledge of the humeral version is essential, it may be necessary to perform an examination under fluoroscopy, noting the rotational position of the arm that places the humeral neck in greatest profile. 
In terms of treatment options, here are some to consider.


Subscapularis deficiency may not be reconstructable.  If there is good quality muscle and tendon a repair may be possible after a complete release of the medial muscle and tendon.  A hamstring autograft may be useful for extending the tendon length.  

If the glenoid component is in excessive anteversion, its intrinsic balance stability angle does not provide anterior stability due to its misalignment with the net humeral joint reaction force (determined principally by the scapular origin of the scapulohumeral muscles). This etiology of anterior instability is suspected when there is minimal resistance to the anterior load and shift test.  The diagnosis of glenoid component anteversion can be made by examination of a true axillary view of the joint.  The glenoid centerline normally projects out the anterior scapular neck at the centering point.  In the anteverted glenoid, the glenoid centerline projects down the scapular body or behind it.  When anterior instability is associated with glenoid anteversion, reorientation of the prosthetic glenoid centerline is usually indicated.  Because the anterior glenoid lip of a polyethylene component is usually worn by the recurrent instability, the prosthesis often needs to be changed.  Thus, the revision is accomplished either by removal of the prosthetic component and performance of a properly oriented non-prosthetic glenoid arthroplasty or by reinsertion of a glenoid component with its centerline in proper orientation with the scapula. 

If the anterior glenoid bone stock is deficient, an iliac crest bone graft may be secured to the anterior glenoid and then reamed either for a non-prosthetic glenoid arthroplasty or to fit the back of the glenoid prosthesis.

If the glenoid component is in excessive retroversion, its intrinsic balance stability angle does not provide posterior stability.

Clinically, the shoulder will demonstrate diminished resistance to posterior load and shift and instability on cross body adduction.  On the axillary radiograph, the glenoid centerline is seen to project through the bony glenoid more anteriorly than the normal centering point.  As for glenoid anteversion, correction may include re-establishing the normal glenoid centerline and then performing corrective reaming for a non-prosthetic or prosthetic glenoid arthroplasty.

At times it may be necessary to use a posterior bone graft, but it is challenging to obtain secure fixation of the graft to the host glenoid bone.

If there is insufficient glenoid bone for a reconstruction and if an iliac crest autograft cannot be performed because of insufficient quality bone stock to which it can be anchored, a glenoidectomy can be considered as a salvage procedure.  In this procedure the residual glenoid is resected down to the level of the scapular spine.  An appropriately sized humeral head prosthesis is inserted to articulate with the glenoid neck, the scapular spine and the base of the coracoid.

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Revision surgery for stiff shoulder replacement arthroplasty - our approach, Part 3

Before embarking on a surgical revision to regain motion, it is important to determine the cause of the residual stiffness.  Previous operative notes are reviewed to discover if the joint was intentionally tightened and if so how this was carried out.  Particular note is made of whether the subscapularis was advanced lateral to the bicipital groove and whether thermal or laser capsular cauterization was carried out.  Excellent anteroposterior and axillary radiographs are needed to exclude bony or articular causes of shoulder stiffness.  The location of hardware and other implants is determined.

Prior to prepping and draping the shoulder, the ranges of flexion, cross body adduction, internal and external rotation in 90 degrees of abduction, and external rotation at the side as well as the excursion on posterior drawer testing are recorded for both shoulders.

The surgical procedure is performed sequentially, with the range of motion being reexamined after each step of the release.  When the desired range is achieved, the procedure may be concluded. The initial step is to completely free the humeroscapular motion interface.

Any prominent suture, suture anchors, hardware, bone or soft tissue is resected from the proximal humerus to assure smooth passage within the coracoacromial arch.  A nerve-to-nerve release is performed.

The second step is to incise the coracohumeral ligament from around the coracoid process.

Next the subscapularis is identified. and incised from its humeral attachment, preserving maximal length.  A 360-degree release of the subscapularis and anterior capsule is carried out, assuring that the subscapularis moves freely with respect to the coracoid, the glenoid lip, the inferior capsule and the axillary nerve.

In this release the anterior capsule is incised just lateral to the labrum, leaving the labrum on the bony glenoid to maintain the glenoid concavity.  After the release, the subscapularis should have a nice ‘bounce’ when traction is applied to it.  Recall that if the subscapularis is to allow a range of rotation of 115 degrees (two radians) it must have an excursion of twice the radius of the humeral head.  Thus, if a humeral head has a radius of 25 mm, a subscapularis excursion of 50 mm will allow a 115-degree range of internal and external rotation.

After this complete release, additional subscapularis lengthening is rarely needed.  However, if additional lengthening of the subscapularis tendon is needed, an inside-out coronal plane Z-plasty is considered if there is adequate thickness of the capsule and tendon. Sometimes a hamstring autograft is used to robustly connect the subscapularis to the lesser tuberosity with additional tendon length.  It must be noted, however, that adding tendon length does not increase the functional excursion of the muscle.

If the long head tendon of the biceps does not slide freely in the bicipital groove, the adhesions in the groove are released.  If freedom cannot be achieved, the tendon is incised at its insertion to the supraglenoid tubercle and tenodesed to the proximal humerus in its groove.

The next step is, while protecting the axillary nerve with the non-dominant index finger, to release the inferior capsule from the inferior glenoid labrum.

Inserting a humeral head retractor into the joint and rotating its inferior aspect away from the glenoid puts the inferior capsule under tension, facilitating this release.  The anterior and posterior bands of the inferior glenohumeral ligament are released.  Exposure of the origin of the long head of the triceps signals a complete release.

The articular aspect of the joint is inspected and any bony prominences that potentially block motion are resected.  Note is made of the condition of the glenoid and humeral joint surfaces.

Finally, the posterior capsule is released from the posterior glenoid labrum. The capsule is placed under tension by rotating the humeral head retractor away from the glenoid, first inferiorly and then superiorly.

At the conclusion of the procedure, the shoulder is put through a full range of motion.  The subscapularis tendon is closed robustly to the lesser tuberosity so that immediate, postoperative motion maintaining exercises can be implemented.

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