Posterior Capsular
Contracture of the Shoulder
H. Gregory Bach, MD Abstract
Posterior capsular contracture is a common cause of shoulder pain
Benjamin A. Goldberg, MD
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,
Dr. Bach is Resident, Department of rotator cuff tear. Management involves regaining internal rotation
Orthopaedic Surgery, University of
such that the loss of internal rotation is not greater than the
Illinois Chicago, Chicago, IL. Dr.
increase in external rotation. In the athlete who fails nonsurgical
Goldberg is Assistant Professor,
management, a selective posteroinferior capsulotomy can improve
Department of Orthopaedic Surgery,
University of Illinois Chicago, and
motion, reduce pain, and prevent further shoulder injury.
Senior Attending Surgeon, Division of
Orthopaedic Surgery, Cook County
Hospital, Chicago.
lassic impingement in the impingement syndrome and posteri-
Cshoulder involves pain on for- or capsular contracture may present
None of the following authors or the
departments with which they are ward flexion that is localized over with pain on forward elevation, only
affiliated has received anything of value the supraspinatus insertion on the in the presence of posterior capsular
from or owns stock in a commercial greater tuberosity.1-4 Although asso- contracture would the patient be ex-
company or institution related directly or
ciated loss of internal rotation has pected to present with objectively
indirectly to the subject of this article:
been described, the pain may be in- decreased internal rotation.6
Dr. Bach and Dr. Goldberg.
dicative of a posterior capsular con- In a cadaveric study, posterior
tracture; loss of motion is not com- capsular contracture was shown to
Reprint requests: Dr. Goldberg,
mon with impingement.2 The alter normal glenohumeral kinemat-
Department of Orthopaedic Surgery,
original description of impingement ics, resulting in increased anterosu-
University of Illinois Chicago, 835 S
syndrome did not mention a capsu- perior translation of the humeral
Wolcott Avenue, M/C 844, Chicago, IL
lar contracture limiting motion. Ad- head during shoulder flexion.7 This
60612.
ditionally, the morphology of the can cause a form of nonoutlet im-
J Am Acad Orthop Surg 2006;14:265-
coracoacromial arch does not re- pingement as the humeral head
277
strict internal rotation of the shoul- translates toward the coracoacromi-
der. Thus, in impingement syn- al arch8,9 (Figure 1). Harryman et al7
Copyright 2006 by the American
drome, there should be normal demonstrated that in vitro posterior
Academy of Orthopaedic Surgeons.
shoulder motion.5 Although both capsular shortening results in limit-
Volume 14, Number 5, May 2006 265
Posterior Capsular Contracture of the Shoulder
Figure 1
A, A shortened posterior capsule causing obligate anterosuperior translation of the humeral head during forward flexion,
resulting in nonoutlet impingement (inset images). Top, Normal resting arm position. Bottom, Posterior capsule contracture.
B, When the capsule is of normal length (top and bottom), the humeral head remains centered on the glenoid during forward
elevation and subacromial impingement does not occur (inset images). (Adapted with permission from Ticker JB, Beim GM,
Warner JJP: Recognition and treatment of refractory posterior capsular contracture of the shoulder. Arthroscopy
2000;16:27-34.)
ed internal rotation and flexion. postoperative, such as after a poste- the posteroinferior aspect of the cap-
Although adhesive capsulitis (ie, rior capsular shift for posterior insta- sule.15,16 Posteroinferior contracture
frozen shoulder) may present with bility. However, procedures per- most likely occurs in response to the
limited internal rotation, it is con- formed to manage a variety of stress loads associated with the
sidered to be a separate and different shoulder conditions, including clas- follow-through motion in throw-
condition.9-14 Patients with adhesive sic impingement, may result in pos- ing.16 After ball release, the arm
capsulitis frequently have pain with terior capsular contracture. In our moves ahead of the body and exerts
shoulder flexion as well as com- experience, idiopathic and posttrau- a large distraction force of approxi-
plaints that resemble those of im- matic contractures typically do well mately 750 N (approximately 80%
pingement symptoms; however, re- with nonsurgical treatment; postop- of the pitcher s weight),17 which acts
stricted range of motion (ROM) in all erative contracture often requires on the posteroinferior capsule.16 Be-
planes is usually present. surgical release of the posterior cap- cause the shoulder is internally ro-
There are three basic types of pos- sule to restore motion and improve tated in follow-through, the inferior
terior capsular contracture: (1) idio- pain.8 part of the posterior capsule is rotat-
pathic, with the patient unable to re- Posterior capsular contracture ed into a more posterocentral posi-
member any prior trauma; (2) also may occur in the overhead tion, where it more directly resists
posttraumatic, typically after a low- throwing athlete, especially in base- the distraction force of follow-
energy event, which may be misdi- ball pitchers.15,16 In these athletes, through.16 The reactive force of the
agnosed as a muscle strain; and (3) however, the contracture involves shoulder musculature produces a
266 Journal of the American Academy of Orthopaedic Surgeons
H. Gregory Bach, MD, and Benjamin A. Goldberg, MD
compressive load to resist this dis- through nonoutlet mechanisms;
Figure 2
traction force. The shoulder capsule they are not related to the acromial
is then subjected to repetitive high morphology.9,19
loads that cannot be completely re- Harryman et al7 experimentally
sisted by muscle forces.16 This repet- shortened the posterior portion of
itive tensile loading of the posteroin- the shoulder capsule in seven cadav-
ferior capsule could cause the eric specimens. They confirmed that
capsular hypertrophy that is so com- tightening of the posterior capsule
mon in the throwing athlete.16 results in limited internal rotation,
cross-body movement, and flexion of
the shoulder.7 Additionally, the au-
Anatomy
thors demonstrated that posterior
The shoulder is a synovial joint with capsule tightening caused a signifi-
a capsule comprising four supporting cant increase in anterior translation
layers: (1) the deltoid and pectoralis of the center of the humeral head
major muscles, (2) the clavipectoral during both shoulder flexion (P
fascia and conjoined tendon (short < 0.01; from a mean of 3.79 to 7.27
head of the biceps and coracobrachi- mm) and cross-body movement (P
alis), (3) the deep layer of the subdel- < 0.01; from a mean of -0.14 to 6.63
Effect of asymmetric tightening of the
toid bursa and rotator cuff muscles, mm).7 This anterior translation oc-
shoulder capsule. Rotating the humeral
and (4) the glenohumeral joint cap- curred earlier in the arc of motion in
head produces tension in the tissues
sule and coracohumeral ligament.18 the study specimens than it did in a
of a surgically tightened capsule,
The shoulder capsule contains an ex- shoulder with a posterior capsule of
causing translation in a direction
tracellular matrix that is composed normal length.7 Tightening of the
opposite to the tight-tissue constraint.
primarily of type I collagen, with
This constraint opposes loads and posterior capsule also resulted in sig-
displacement that are directed toward
lesser amounts of types II and III.19 nificant superior translation of the
itself and acts to translate the humeral
The highly ordered crystalline ar- humeral head with flexion (P < 0.05;
head on the glenoid in a direction away
rangement of collagen in the extend- from a mean of 0.35 to 2.13 mm). As
from itself. This mechanism of
ed conformation provides an ana- a result, the convex humeral head
translatory motion is referred to as the
tomic structural basis for its and bursal side of the rotator cuff are
capsular constraint mechanism.
viscoelastic properties.19 forced against the undersurface of
(Adapted with permission from
The posterior capsule originates the concave coracoacromial arch,
Harryman DT II, Sidles JA, Clark JM,
from the posterior capsulolabral which may cause compression of the
McQuade KJ, Gibb TD, Matsen FA III:
complex and extends from the poste- cuff because the humeral head can-
Translation of the humeral head on
rior origin of the biceps tendon to not remain centered in the glenoid2
the glenoid with passive glenohumeral
the inferior aspect of the glenoid.19 motion. J Bone Joint Surg Am (Figure 3).
1990;72:1334-1343.)
At the inferior aspect of the shoulder Gerber et al21 reported that poste-
joint is the inferior glenohumeral rior capsular plication significantly
ligament (IGHL) complex.20 This limits internal rotation. The authors
complex is bounded by an anterior performed a posterior capsulorrha-
Pathoanatomy
band and a posterior band that per- phy by surgically plicating one half
form like a hammock to support the With experimental tightening of the the circumference of the capsule
humeral head with the arm in ab- shoulder capsule, there is abnormal from the 6 o clock to the 12 o clock
duction.20 The posterior capsule, translation of the humeral head dur- position. At 0° of abduction, posteri-
which blends with the tendinous ing glenohumeral rotation.7,19 The or capsulorrhaphy limited internal
portion of the posterior aspect of the translation occurs in the opposite di- rotation by 21.5°, or 48.2% of inter-
rotator cuff, limits posterior transla- rection of the capsular tightening.7 nal rotation (P < 0.00001).21 At 45°
tion when the arm is forward flexed, This mechanism of translational of abduction, posterior plication
adducted, and internally rotated.19 motion is referred to as the capsular limited internal rotation by 27.2°,
Additionally, the posterior capsule constraint mechanism7 (Figure 2). or 69.7% of internal rotation (P
becomes taut in various positions of Injury to this mechanism may lead < 0.0007).21 At 90° of abduction, pos-
flexion and internal rotation and can to instability, articular damage, and terior capsulorrhaphy limited inter-
limit excessive flexion and internal symptoms of impingement.19 The nal rotation by 21°, or 68.2% of in-
rotation.7 impingement symptoms occur ternal rotation (P < 0.0022).21
Volume 14, Number 5, May 2006 267
Posterior Capsular Contracture of the Shoulder
head on the glenoid face of approxi-
Figure 3
mately 4.4 mm following posteroin-
ferior capsular plication.16
Mechanically, the IGHL complex
may be represented by two domi-
nant structural components that
function as interdependent cables
the anterior band and the posterior
band.16 These primary passive con-
straints of the glenohumeral joint
develop tension reciprocally and
equally as the shoulder internally
and externally rotates in the 90° ab-
ducted position.16 This defines the
allowable envelope of motion of the
shoulder, in much the same way
that the four-bar linkage model de-
A, Normal capsular laxity allows the humeral head to remain centered during fines allowable knee motion based
elevation. B, Tightness of the posterior capsule may create obligate anterosuperior
on cruciate restraints.16
translation with shoulder flexion. (Adapted with permission from Matsen FA III,
With external rotation of the hu-
Lippitt SB, Sidles JA, Harryman DT II: Practical Evaluation and Management of the
merus about its central contact
Shoulder. Philadelphia, PA: WB Saunders, 1994, p 40.)
point on the glenoid, the cables
tighten and develop tension equally
of loss of internal rotation, 26° to as they assume an oblique course
Posterior Capsular
58°).16 In another study, high-level across their allowable envelope of
Contracture in the
tennis players were followed pro- motion16 (Figure 4, A). When the
Overhead Throwing
spectively for 2 years. One group per- posterior cable is shortened, as in
Athlete
formed daily posterior inferior cap- posteroinferior capsule contracture,
In the overhead throwing athlete, sular stretching to minimize GIRD, it acts as a tether, shifting the gleno-
the posteroinferior capsule may de- whereas the control group did not humeral contact point posterosupe-
velop a contracture that causes a loss stretch.16 Over the 2-year study peri- riorly during combined abduction
of internal rotation.15,16 Gleno- od, those who stretched increased and external rotation because the
humeral internal rotation deficit internal rotation and total rotation shortened posterior cable reaches its
(GIRD) is the loss in degree of gleno- compared with the control group; maximum elongation before the an-
humeral internal rotation of the additionally, the stretching group terior cable maximally elongates.16
throwing shoulder compared with had a 38% decrease in the incidence The anterior band continues to al-
the nonthrowing shoulder.15,16 The of shoulder problems.16 Finally, low external rotation anteriorly, re-
first recognition of the relationship among 22 major league pitchers who sulting in posterosuperior transla-
of GIRD with shoulder dysfunction were manually stretched daily dur- tion on the humeral head16 (Figure 4,
in the throwing athlete was in ing the 1997, 1998, and 1999 profes- B). With the posterosuperior shift of
1991.16 In this study, 39 professional sional baseball seasons, there were the arc of motion of the greater tu-
baseball pitchers identified at spring reportedly no innings lost, no intra- berosity, it ceases to abut the usual
training as having d"25° of total inter- articular shoulder pathology, and no segment of the posterosuperior gle-
nal rotation (GIRD), with loss of in- surgical procedures.16 noid in combined abduction and ex-
ternal rotation e"35°, were followed Posteroinferior capsular contrac- ternal rotation, allowing additional
for a single season.16 Sixty percent of ture in the overhead throwing ath- external rotation to be obtained.16
these pitchers developed shoulder lete results in translation of the hu- The peel-back mechanism is a dy-
problems requiring them to stop meral head on the glenoid.15,16 A namic phenomenon that has been
pitching during the study period.16 recent study investigated the observed arthroscopically in over-
Similarly, in a series of 38 arthro- amount of translation both before head throwers with SLAP lesions.16,22
scopically proven symptomatic type and after posteroinferior capsular The peel-back, which occurs with
II superior labrum anterior-posterior plication in cadaveric shoulders the arm in the cocked position of ab-
(SLAP) lesions in overhead athletes, tracked with electromagnetic sen- duction and external rotation, is
significant GIRD was found in all af- sors.16 The authors documented a caused by the force effect of the bi-
fected shoulders (average, 33°; range posterosuperior shift of the humeral ceps tendon as its vector shifts to a
268 Journal of the American Academy of Orthopaedic Surgeons
H. Gregory Bach, MD, and Benjamin A. Goldberg, MD
Figure 4
A, With abduction and external rotation, the two inferior glenohumeral ligament cables, set obliquely across the shoulder,
reciprocally and equally develop tension. Inset, The greater tuberosity of the humerus has a well-defined circular arc (dotted
line) before it contacts the posterior glenoid. B, When the posterior cable (PIGHL) shortens (contracted posterior band), the
glenohumeral contact point shifts posterosuperiorly, and (inset) the allowable arc of external rotation (before the greater
tuberosity contacts the posterior glenoid) increases significantly (dotted lines). AIGHL = anterior inferior glenohumeral ligament,
PIGHL = posterior inferior glenohumeral ligament (Adapted with permission from Burkhart SS, Morgan CD, Kibler WB: The
disabled throwing shoulder: Spectrum of pathology. I: Pathoanatomy and biomechanics. Arthroscopy 2003;19:404-420.)
more posterior position in late cock- the biceps force vector as well as a is not well-anchored to the glenoid,
ing.16,22 During arthroscopy, the bi- twist at the base of the biceps ten- this posteriorly directed torsional
ceps tendon can be seen to assume a don, transmitting a torsional force to
force causes the humeral head and
more vertical and posterior angle, the posterior superior labrum16,22 superior labrum to rotate medially
which produces a posterior shift in (Figure 5). When the superior labrum
over the corner of the glenoid on-
to the posterosuperior scapular
Figure 5
neck.16,22
Acquired posteroinferior capsular
contracture is the primary pathology
that initiates a pathologic cascade,
climaxing in the late-cocking phase
of throwing.16 At that point, the shift
in the glenohumeral contact point
causes maximal shear stress on the
posterosuperior labrum at exactly
the time when the peel-back mech-
anism produces its maximum tor-
sional effect on the posterosuperior
labrum, putting the shoulder in a
vulnerable situation.16,23 The in-
Superior view of the biceps and labral complex of the left shoulder in the resting
creased shear forces at the biceps
position (A) and in the abducted, externally rotated position (B) demonstrating the
tendon insertion and the posterosu-
peel-back mechanism as the biceps vector shifts posteriorly (arrows). (Adapted with
perior labral attachment cause both
permission from Burkhart SS, Morgan CD, Kibler WB: The disabled throwing
structures to begin to fail at their at-
shoulder: Spectrum of pathology. I: Pathoanatomy and biomechanics. Arthroscopy
tachments, producing a posterior
2003;19:404-420.)
SLAP lesion.16 The SLAP lesion
Volume 14, Number 5, May 2006 269
Posterior Capsular Contracture of the Shoulder
al side, assuming the latter is with-
Figure 6
out pathology.
Harryman et al7 advocated mea-
suring adduction in the horizontal
plane in the sitting or standing pa-
tient because these positions mini-
mize any effect of chest or body rota-
tion.7 This measurement is accurate
assuming that the sides have similar
scapulothoracic motion and humer-
al lengths. Maximal cross-body ad-
duction is the minimal distance
from the antecubital fossa to the
contralateral acromion when the
arm is adducted horizontally across
the body25 (Figure 7). This is repeat-
ed for the contralateral shoulder, and
the measurements are compared.
External rotation of the shoulder
Torsional overload with repetitive twisting of rotator cuff fibers occurring at the
in adduction (0° of abduction) and in
articular surface of the rotator cuff, the most common location of cuff failure in the
90° of abduction is expected to be
throwing athlete. (Adapted with permission from Burkhart SS, Morgan CD, Kibler
nearly symmetric compared with
WB: The disabled throwing shoulder: Spectrum of pathology. I: Pathoanatomy and
the contralateral side. Posterior cap-
biomechanics. Arthroscopy 2003;19:404-420.)
sular contracture should be differen-
tiated from adhesive capsulitis,
magnifies the shift and instability the back, and flexion.2 Symptoms in- which usually presents with global
problem and can lead to the dead clude pain and difficulty with sleep- loss of motion. Thus, patients with
arm syndrome.15 ing as well as in reaching both across adhesive capsulitis would be expect-
Damage to the rotator cuff also the body and up the back (eg, to fas- ed to have significantly diminished
may contribute to problems in the ten a brassiere).2 ROM measure- external rotation and, usually, more
throwing shoulder. The increased ments during physical examination pronounced loss of flexion of the
external rotation of the shoulder may confirm the diagnosis of poste- shoulder than is encountered in pa-
may cause abrasion and tearing of rior capsular contracture by identify- tients with posterior capsular con-
the rotator cuff against the postero- ing loss of internal rotation, cross- tracture.
superior glenoid, resulting in dam- body adduction, and, to a lesser The Neer impingement sign is
age to the cuff.16 An even greater ad- extent, forward flexion while main- elicited by the examiner s elevating
verse effect of excessive external taining external rotation. Both ac- the shoulder with one hand while
rotation on the rotator cuff is that it tive and passive ROM must be mea- preventing scapular rotation.3 Neer
allows repetitive twisting of the ro- sured because pain may limit the thought that this maneuver caused
tator cuff fibers, which can lead to patient s ability to actively maxi- the greater tuberosity to impinge
torsional overload and shear failure mally rotate the shoulder internally against the acromion, thus produc-
of the cuff fibers. With the arm in to the physical limits of ROM. ing pain in patients with impinge-
the abducted, externally rotated po- The physician will notice that ment.3 However, shoulder flexion
sition, the greatest shear stresses in passive internal rotation is asym- frequently causes pain in many other
the cuff will be at their attachment metric compared with the normal shoulder conditions; therefore, ante-
on the articular side, the location of side. Internal rotation in 90° of ab- rior impingement pain must be con-
cuff failure in the throwing ath- duction is assessed with the patient sidered nonspecific. The Neer im-
lete16 (Figure 6). supine, and side-to-side differences pingement test is positive when pain
are noted. The physician should ex- with shoulder flexion is eliminated
amine the seated patient for internal after injection of 10 mL of 1.0%
Clinical Assessment
rotation (the distance to the most lidocaine into the subacromial space
With posterior capsular contracture, cephalad spinous process to which beneath the anterior acromion.3
the shoulder is limited in its range of the patient can apply the thumb).24 The Hawkins impingement sign
internal rotation in abduction, cross- There is usually asymmetry in mo- is positive when shoulder flexion to
body adduction, internal rotation up tion compared with the contralater- 90°, combined with internal rotation
270 Journal of the American Academy of Orthopaedic Surgeons
H. Gregory Bach, MD, and Benjamin A. Goldberg, MD
and horizontal adduction, produces
Figure 7
pain.1 The physician must rule out
acromioclavicular pathology, which
also may cause pain during horizon-
tal shoulder adduction. However,
the patient with posterior capsular
tightness also would be expected to
test positive for the Hawkins im-
pingement sign because the internal
rotation stretches the posterior cap-
sule. With impingement, subjective
pain may be located anteriorly or an-
terolaterally, whereas with posterior
capsular tightness, the pain is often
posterior and reproduced with rota-
tions that stretch the posterior cap-
sule. In addition, the patient with
posteroinferior capsule contracture
reports a sense of posterior tight-
ness.15
The arthroscopic impingement
test may be observed from the later-
al portal while flexing the shoulder
anterior to the scapular plane
through an arc of motion of 140° and
observing the relationship of the hu-
meral head to the acromion.26 In the
Maximal cross-body adduction is the minimal distance from the antecubital fossa to
normal shoulder, the rotator cuff
the contralateral acromion when the arm is adducted horizontally across the body.
passes under the acromion, and the
(Adapted with permission from Matsen FA III, Lippitt SB, Sidles JA, Harryman DT II:
interval between the acromion and
Practical Evaluation and Management of the Shoulder. Philadelphia, PA: WB
rotator cuff is maintained in all posi-
Saunders, 1994, p 21.)
tions. Patients diagnosed with poste-
rior capsular contracture were ob-
served to have superior translation shoulder has normal rotational kine- tightness.2 Physician- or therapist-
of the humeral head during flexion, matics without any form of glenohu- supervised patient-directed posterior
with the rotator cuff contacting the meral instability throughout the capsular stretching is effective.2 The
undersurface of the acromion, there- throwing cycle.23 However, when the patient performs gentle stretches
by diminishing the subacromial GIRD exceeds the external rotation five times per day2 (Figure 8). Each
space.8 However, after posterior cap- gain (ERG) (GIRD:ERG ratio >1), the stretch is performed until the patient
sule release, the kinematics of the shoulder may be at risk because of feels a pull against the shoulder
shoulder can be restored and the sub- posterosuperior shift of the glenohu- tightness, but not to the point of
acromial space maintained.8 meral rotation point with abduction pain.2 Each stretch is performed for 1
Several authors recommend and external rotation during the late minute; thus, the patient invests ap-
screening the overhead throwing cocking phase.23 The risk of struc- proximately 30 minutes per day
athlete for posteroinferior capsular tural injury is directly proportional stretching.2 Obvious improvement
contracture at the beginning of and to the increase in the GIRD:ERG commonly occurs within the first
during each season.16,23 This is be- ratio.23 month, but 3 months may be re-
cause posteroinferior capsule con- quired to completely eliminate the
tracture is the primary condition condition.2 Patients with chronic
Nonsurgical
that initiates the pathologic cascade painful loss of internal rotation that
Management
to a SLAP lesion and the subsequent is unresponsive to nonsurgical treat-
development of dead arm syn- In the absence of weakness or a prior ment may be candidates for arthro-
drome.16,23 As long as the GIRD is surgical procedure, nonsurgical man- scopic capsular release.
less than or equal to its external ro- agement is usually successful for The healthy throwing shoulder
tation gain, the healthy throwing the patient with posterior capsular has normal rotational kinematics;
Volume 14, Number 5, May 2006 271
Posterior Capsular Contracture of the Shoulder
These athletes may be treated with
Figure 8
sleeper stretches.16,23 The athlete lies
on one side with the shoulder in 90°
of flexion and the elbow in 90° of
flexion.23 The shoulder is passively
internally rotated by pushing the
forearm toward the table around a
fixed elbow, which acts as the pivot
point23 (Figure 9). The loss of internal
rotation usually can be improved to
an acceptable level over 2 weeks
with a compliant posteroinferior
capsule stretching program using
sleeper stretches.16
Ten percent of throwers do not re-
spond to stretching; these patients
tend to be older elite pitchers who
have been throwing for years and
have chronic long-standing symp-
toms.16 It is extremely unusual for
high school and college pitchers to
be nonresponsive to stretching; rare-
ly have these younger pitchers need-
ed selective posteroinferior capsu-
lotomy.16 Baseball pitchers and other
throwing athletes who have been
stretch nonresponders may be con-
sidered for arthroscopic release of
the posteroinferior capsule.23
Surgical Management
Arthroscopic Posterior
Capsule Release
General anesthesia, an inter-
scalene block, or an interscalene
catheter may be used with arthro-
scopic posterior capsule release.27,28
Warner et al24,29 and Ticker et al8 ad-
vocate regional anesthesia to im-
prove postoperative control of pain,
thereby allowing intensive physical
therapy in the immediate postoper-
Patient-directed posterior capsular stretching. A, Stretching in overhead reach
ative period. An interscalene block
using the opposite arm as the therapist. B, Stretching in overhead reach using the
using 30 mL of 0.5% bupivacaine
progressive forward lean to apply a gentle elevating force to the arm. C, Stretching
in internal rotation using a towel to apply a gentle stretching force. D, Stretching with a 1:200,000 concentration of
in cross-body reach using the opposite arm as the therapist. (Adapted with
epinephrine provides adequate intra-
permission from Matsen FA III, Lippitt SB, Sidles JA, Harryman DT II: Practical
operative anesthesia and, frequently,
Evaluation and Management of the Shoulder. Philadelphia, PA: WB Saunders,
>6 hours of postoperative analge-
1994, pp 46-49.)
sia.24,29 Patients with an interscalene
block can have repeat interscalene
however, when the GIRD exceeds with posteroinferior capsule contrac- blocks in the morning of postopera-
the ERG, the shoulder becomes vul- ture and symptomatic loss of inter- tive days 1 and 2, thereby allowing
nerable to further injury.16 Approxi- nal rotation respond to a posteroinfe- the patient and physical therapist to
mately 90% of all throwing athletes rior capsule stretching program.16 perform morning and afternoon ses-
272 Journal of the American Academy of Orthopaedic Surgeons
H. Gregory Bach, MD, and Benjamin A. Goldberg, MD
Figure 9
Focused posterior inferior capsular stretches. A, In the sleeper stretch, the patient is side lying with the scapula stabilized
against a wall, the shoulder flexed 90°, and the elbow flexed 90°. Passive internal rotation to the arm is applied by the
nondominant arm to the dominant wrist. B, The roll-over sleeper stretch is the same as the sleeper stretch, except that the
shoulder is flexed only 50° to 60° and the patient rolls forward 30° to 40° from vertical side lying. C, For the cross-arm stretch,
the patient stands with the shoulder flexed 90°; passive adduction is applied by the uninvolved arm to the involved elbow. This
primarily stretches the posterior musculature to a greater degree than the posterior inferior capsule. D, In the doorway stretch,
the shoulder is abducted 90° and internally rotated. The elbow is flexed 90° with the elbow on the edge of an open doorway. The
patient leans forward and inferior to apply an inferior capsular stretch to the shoulder. (Reproduced with permission from
Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. I: Pathoanatomy and
biomechanics. Arthroscopy 2003;19:404-420.)
sions of passive ROM, in addition to tively.24,27,29 Patients also may self- anterosuperior portal to visualize
the self-assisted exercises done by administer analgesia through an the posterior portion of the glenohu-
the patient.24,29 intravenous pump.24,29 meral joint.24 The posterior part of
To achieve regional anesthesia Warner et al24 developed a tech- the capsule has been found to be
and postoperative analgesia through nique for posterior capsule release thickened and shortened in all pa-
an interscalene catheter, a continu- for isolated loss of internal rotation. tients with posterior capsular con-
ous infusion of 0.25% bupivacaine at After diagnostic arthroscopy with tracture.8,24 An electrocautery device
a rate of 6 mL per hour can be ad- the patient in the beach chair posi- is then placed through the posterior
ministered for 48 hours postopera- tion, the arthroscope is placed in the portal cannula.24 The capsule is di-
Volume 14, Number 5, May 2006 273
Posterior Capsular Contracture of the Shoulder
tissue, similar to stretching a rubber
Figure 10
band, rather than by the discrete im-
provement of motion seen after an-
terior capsule release.24
Arthroscopic Selective
Posteroinferior
Capsulotomy
When the posteroinferior aspect
of the capsule is tight, as may occur
in the overhead throwing athlete, a
selective posteroinferior capsuloto-
my may be performed. The capsular
contracture is located in the postero-
inferior quadrant of the capsule in
the zone of the posterior band of the
IGHL complex.16 The capsulotomy
is made 0.25 inches away from the
labrum from the 9 o clock position
to the 6 o clock position.16 Typical
arthroscopy findings in these pa-
tients include a severely contracted
and thickened posteroinferior recess
in the zone of the posterior band of
the IGHL complex.16 In most pa-
tients, the capsule in this zone is e"6
mm thick.16 After selective postero-
inferior capsulotomy, the patient
can expect an immediate 65° in-
crease in glenohumeral internal ro-
tation.16
Arthroscopic posterior capsule release in a right shoulder with the humeral head
removed. The posterior capsule is released along the glenoid rim, and the electro-
Postoperative
cautery device is introduced through the posterior portal. The arthroscope is intro-
Management
duced through the anterior-superior portal. (Adapted with permission from Ticker
JB, Beim GM, Warner JJP: Recognition and treatment of refractory posterior cap-
Warner et al24,29 recommend passive
sular contracture of the shoulder. Arthroscopy 2000;16:27-34.)
motion with both morning and after-
noon sessions on the first postoper-
vided beginning just posterior to the An arthroscopic shaver is then in- ative day. In addition, the physical
biceps tendon origin on the superior serted to remove the ragged edges of therapist should instruct the patient
glenoid rim at approximately the 11 the capsule in order to clearly iden- in self-assisted motion exercises. Pa-
o clock position and continuing infe- tify the capsular edge and rotator tients were discharged after the after-
riorly to approximately the 8 o clock cuff muscle.8 A shaver creates a wid- noon session on the second postoper-
position24 (Figure 10). The posterior er gap in the resected capsule to help ative day.24,29 For the first 2 weeks,
capsule is divided adjacent to the avoid recurrence.8 Extending the re- the authors recommend daily super-
glenoid rim because the rotator cuff lease into the inferior aspect of the vised therapy 5 days per week in ad-
muscles at this level are superficial axillary pouch exposes the axillary dition to a home-exercise program
to the capsule.24 If there were addi- nerve to injury by either thermal or consisting of pulley and cane-
tional lateral division of the capsule, electrical energy.31 assisted motion in all planes. For the
the tendons of the rotator cuff would After removing the arthroscope, next 4 weeks, the patient should at-
be at risk for injury because they are gentle manipulation completes the tend supervised therapy three times
conjoined with the capsule.11,30 The release of any remaining capsular fi- per week.24,29 The home exercise pro-
depth of the capsular division is bers to restore internal rotation and gram can be advanced during this
complete when the muscle fibers of flexion.24 Motion usually is im- time.8 After 6 weeks, the rehabilita-
the rotator cuff are visible.24 proved through a gradual yielding of tion may be individualized according
274 Journal of the American Academy of Orthopaedic Surgeons
H. Gregory Bach, MD, and Benjamin A. Goldberg, MD
to the patient s progress.8,24,29 11 to 35 months). There were no pingement may occur because of dy-
Warner et al24,29 recommend postoperative complications, and namic translation of the humeral
against using a sling for support at posterior instability was not ob- head anteriorly and superiorly.7
any time, and they encourage the pa- served postoperatively. The average Loss of motion after posterior cap-
tient to use the operated arm for ac- preoperative internal rotation in ab- sular shift for instability is a rare
tivities of daily living as soon as pos- duction was 10° (range, -10° to 40°) occurrence.34-37 Ticker et al8 reported
sible after surgery. Strengthening is for the involved side compared with that some of their patients with iso-
begun as soon as postoperative pain 58° (range, 50° to 80°) for the con- lated refractory posterior capsule
and active shoulder motion al- tralateral side.8 Postoperative inter- contracture had undergone a prior
low.24,29 Patients are encouraged to nal rotation in abduction increased posterior capsule shift procedure. All
attempt to swim in a pool between 2 by an average of 37° (range, 30° to of the other patients reported a spe-
and 4 weeks after the operation.24,29 50°) to an average motion of 47° cific event that they described as a
In our experience, posterior cap- (range, 30° to 80°), which was statis- traction injury to the affected arm.
sule contracture release may be per- tically significant (P < 0.01).8 In for- Surgical procedures performed to
formed as an outpatient procedure ward flexion, the average preopera- manage a variety of conditions, in-
with good results. Close follow-up is tive motion for the involved cluding classic impingement, may
necessary to ensure patient compli- shoulder was 133° (range, 95° to be a factor in posterior capsular con-
ance with shoulder-stretching and 150°) and for the noninvolved shoul- tracture. In the series of Ticker et
ROM exercises. The physical thera- der, 156° (range, 150° to 170°).8 For- al,8 five of nine patients (56%) had
py program, including stretching and ward flexion improved an average of undergone prior procedures; in all of
ROM, should be familiar to these pa- 15° (range, -20° to 45°) to an average these cases, the prior surgical ap-
tients because they would have had motion of 148° (range, 130° to proaches had failed.
physical therapy before considering 160°).8 Although there was a trend All patients in the series of Warner
surgery (Figure 8). toward gains in forward flexion, they et al24 and Ticker et al8 had a con-
In the throwing athlete, the gain in were not statistically significant tracted and thickened posterior cap-
internal rotation must be maintained compared with preoperative val- sule at the time of arthroscopy. Ac-
by an immediate postoperative inter- ues.8 cording to Burkhart et al,16 in most
nal rotation stretching program in or- cases, the capsule in this zone is
der to prevent the capsulotomy gap e"6 mm thick. It is unclear why the
Discussion
from closing during healing.16 Sleeper posterior capsule undergoes this pro-
stretches are performed beginning Posterior capsular contracture is typ- cess, whereas the anterior capsule is
postoperative day 1.32 ically a painful condition associated spared. Matsen et al2 reported that
with loss of internal rotation and this condition is a common result of
horizontal adduction. In addition, injury to the rotator cuff. Ticker et al8
Postoperative Results
forward flexion may be reduced be- postulated that, in the cases of injury
Warner et al24 reported good results cause of altered glenohumeral kine- associated with a traction mecha-
with arthroscopic posterior capsule matics. This occurs because a short- nism, trauma to the posterior capsule
release for isolated loss of internal ened posterior capsule may result in may result in localized and excessive
rotation in five patients. The func- anterosuperior translation of the hu- scarring. In patients who underwent
tion of all shoulders was graded ac- meral head during flexion, with sub- a posterior capsular shift procedure,
cording to the 100-point Constant sequent nonoutlet impingement.9 either the posterior capsule was over-
and Murley scoring system.33 The Ticker et al8 noted the presence of tightened or there was excessive scar-
Constant and Murley score im- subacromial bursitis in all cases, ring with subsequent collagen short-
proved a mean of 20 points (range, 5 lending further support for this non- ening in this region after the repair.
to 35).24 Mean improvement in inter- outlet form of impingement. Their Several cases have been reported
nal rotation in abduction was 42° treatment included removing in- of successful open posterior capsule
(range, 30° to 60°; P < 0.005); with flamed bursal tissue without an acro- release performed after posterior cap-
the arm in adduction, mean im- mioplasty. Normal ROM of the sular shift.38 However, an open pos-
provement in internal rotation was shoulder without objective physical terior capsule release may produce
four spinous-process levels (range, 1 evidence and normal strength is usu- injury to the rotator cuff, thereby im-
to 10 levels; P < 0.05).24 ally consistent with a diagnosis of peding rehabilitation. Warner et al24
Ticker et al8 reported on arthro- impingement syndrome. Pain caused determined that an arthroscopic pro-
scopic posterior capsule release in by posterior capsular tightness is not cedure can release as much capsule
nine patients, with average postoper- a result of direct pathology of the as an open release; other authors8 re-
ative follow-up of 19 months (range, coracoacromial arch. However, im- port that arthroscopic posterior cap-
Volume 14, Number 5, May 2006 275
Posterior Capsular Contracture of the Shoulder
12. Lusardi DA, Wirth MA, Wurtz D,
sule release with subacromial bur- tural injury directly proportional to
Rockwood CA Jr: Loss of external ro-
sectomy is a reliable management the increase in the GIRD:ERG ratio.
tation following anterior capsulorrha-
option with minimal morbidity. When sleeper stretches fail to treat
phy of the shoulder. J Bone Joint Surg
Pain control after closed manipu- the GIRD to an acceptable level,
Am 1993;75:1185-1192.
lation for adhesive capsulitis is crit- stretch nonresponders may be con-
13. Neviaser RJ, Neviaser TJ: The frozen
ical.10,13,39 Similarly, Warner et al29 sidered for arthroscopic posteroinfe- shoulder: Diagnosis and manage-
ment. Clin Orthop Relat Res 1987;
report that postoperative analgesia is rior capsulotomy.
223:59-64.
an essential part of the rehabilitation
14. Ogilvie-Harris DJ, Biggs DJ, Fitsialos
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duces the need for narcotics while
Shoulder injuries in overhead ath-
allowing aggressive passive ROM in
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