Treatment of a stiff shoulder after posterior capsulorrhaphy. A report of three cases

Posterior capsular contracture of the shoulder

Posterior capsular contracture is a common cause of shoulder pain in which the patient presents with restricted internal rotation and reproduction of pain. Increased anterosuperior translation of the humeral head occurs with forward flexion and can mimic the pain reported with impingement syndrome; however, the patient with impingement syndrome presents with normal range of motion. Initial management of posterior capsular contracture should be nonsurgical, emphasizing range-of-motion stretching with the goal of restoring normal motion. For patients who fail nonsurgical management, arthroscopic posterior capsule release can result in improved motion and pain relief. In the throwing athlete, repetitive forces on the posteroinferior capsule may cause posteroinferior capsular hypertrophy and limited internal rotation. This may be the initial pathologic event in the so-called dead arm syndrome, leading to a superior labrum anteroposterior lesion and, possibly, rotator cuff tear. Management involves regaining internal rotation such that the loss of internal rotation is not greater than the increase in external rotation. In the athlete who fails nonsurgical management, a selective posteroinferior capsulotomy can improve motion, reduce pain, and prevent further shoulder injury.

A 4-portal arthroscopic stabilization in posterior shoulder instability

The purpose of this study was to present an arthroscopic stabilization technique with 4 portals for posterior instability used in 11 patients (13 shoulders). There were 7 male and 4 female patients. All patients had an arthroscopic labral suture with anchors and capsular plication with 4 portals. The follow-up period averaged 34 months. No complication or recurrence of instability was noted. A moderate loss of range of motion was noted in 4 shoulders and moderate pain in 2 shoulders. All patients were satisfied. According to the literature, the rate of recurrence of instability is currently lower than 12% when a labral suture and capsular plication are performed. Our results for pain and range of motion are similar to those described in recent publications. However, we think that the 4-portal technique allows a facilitated access to the posteroinferior part of the glenoid and reduces the rate of postoperative instability.

Recognition and treatment of refractory posterior capsular contracture of the shoulder

SUMMARY

Limitation of internal rotation has been reported in conjunction with impingement syndrome of the shoulder. A group of 9 patients was identified who had discrete, painful loss of internal rotation associated with refractory impingement syndrome. The duration of symptoms averaged 18 months (range, 11 to 33 months), and all patients failed a course of physical therapy specifically addressing loss of internal rotation. Six patients reported traction as the mechanism of injury, and 3 developed motion loss and pain following a posterior capsular shift procedure. All patients underwent arthroscopy, and were observed to have a thickened posterior capsule. An arthroscopic release of the posterior capsule improved motion in all patients, with substantial relief of pain. At an average of 19 months follow-up (range, 11 to 35 months), internal rotation in 90 degrees of abduction improved from 10 degrees preoperatively to 47 degrees postoperatively, and there were no complications related to the procedure. We conclude that chronic loss of internal rotation secondary to posterior capsular contracture may be an explanation for refractory pain in some patients with an initial diagnosis of impingement syndrome. This condition appears to be amenable to arthroscopic posterior capsular release.