From the Guidelines
The shoulder capsule may remain stiff and tight after arthroscopic capsular release surgery due to inadequate post-operative rehabilitation, as evidenced by the lack of high-quality studies on physical therapy following shoulder arthroplasty 1. The primary reason for this stiffness is the healing process, which involves inflammation and scar tissue formation, potentially recreating tightness even after surgical release. Inadequate post-operative rehabilitation is another major factor, as patients need consistent physical therapy to maintain the range of motion achieved during surgery. Typically, a structured rehabilitation program should begin within 24-48 hours after surgery and continue for 3-6 months, including:
- Passive stretching
- Active-assisted exercises
- Eventually strengthening exercises Pain management is crucial during this period, often requiring medications like NSAIDs (ibuprofen 400-600mg three times daily or naproxen 500mg twice daily) for 1-2 weeks, along with occasional short-term opioids for breakthrough pain, as seen in other rehabilitation protocols 1. Some patients may benefit from corticosteroid injections if inflammation persists. Additionally, individual factors such as age, pre-existing conditions like diabetes, prolonged immobilization before surgery, and genetic predisposition to excessive scar formation can contribute to persistent stiffness. The biological process of capsular healing involves fibroblast activity and collagen deposition, which can lead to adhesions if not properly managed through consistent stretching and movement during the recovery period. It is essential to prioritize a well-structured rehabilitation program to minimize the risk of persistent stiffness and optimize outcomes after arthroscopic capsular release surgery.
From the Research
Possible Reasons for Persistent Stiffness
- The shoulder capsule may still be stiff and tight after arthroscopic capsular release surgery due to various factors, including the etiology of the stiffness, the effectiveness of the surgical procedure, and the presence of complications or reoperations 2, 3, 4, 5, 6.
- According to a study published in 2021, shoulder stiffness after total shoulder arthroplasty is a difficult pathology to treat, with high rates of complications and reoperations after capsular release 2.
- Another study from 2008 found that arthroscopic capsular release can improve range of motion and alleviate pain in patients with posttraumatic stiff shoulders, but the gain in range of motion may be lost over time 3.
- A 2023 study suggested that the etiology of the frozen shoulder may play a role in the outcome of arthroscopic capsular release, with better functional outcomes expected when the etiology is idiopathic 4.
Complications and Reoperations
- Complications such as stiffness, infection, subscapularis rupture, and glenoid loosening can occur after arthroscopic capsular release, which may contribute to persistent stiffness 2, 5.
- Reoperations may be necessary in some cases, which can also affect the outcome of the surgery 2, 5.
- A study from 2011 noted that postoperative shoulder stiffness is often resistant to nonsurgical management, and surgical release of scar tissue and adhesions may be necessary 5.
Effectiveness of Arthroscopic Capsular Release
- Arthroscopic capsular release can be an effective treatment for frozen shoulder, with significant improvements in range of motion and pain relief 3, 4, 6.
- A 2014 study found that arthroscopic capsular release can provide rapid improvement in pain and a marked improvement in range of motion in patients with idiopathic frozen shoulder 6.
- However, the effectiveness of the procedure may depend on various factors, including the etiology of the stiffness and the presence of complications or reoperations 2, 3, 4, 5, 6.