title: Effect of capsular release in the treatment of shoulder stiffness concomitant with rotator cuff repair: diabetes as a predisposing factor associated with treatment outcome.
abstract: BACKGROUND
  In spite of the high prevalence of shoulder stiffness during rotator cuff repair, optimal management remains unclear.
  
  
  OBJECTIVE
  To identify the effect of capsular release during rotator cuff repair on the outcomes of patients with both shoulder stiffness and a rotator cuff tear, based on subgroup analyses.
  
  
  METHODS
  Cohort study; Level of evidence, 3.
  
  
  METHODS
  Forty-nine consecutive patients (mean age, 61.5 ± 8.3 years) were enrolled who underwent arthroscopic repair of a small- to large-sized full-thickness rotator cuff tear and manipulation for concomitant shoulder stiffness (passive forward flexion ≤120°, external rotation at the side ≤45°). The first 21 consecutive patients underwent manipulation alone to treat stiffness; the second 28 consecutive patients underwent capsular release with manipulation. Among the 49 patients, 25 showed severe stiffness (forward flexion ≤100°, external rotation at the side ≤30°; 11 in the first series and 14 in the second series), and 15 had diabetes mellitus (30.6%; 6 in the first series and 9 in the second series). Shoulder range of motion was measured 6 weeks, 3 months, 6 months, and 1 year postoperatively and at final follow-up visit. Simultaneously, functional outcome was evaluated by visual analog scale for pain, American Shoulder and Elbow Surgeons score, Constant score, and muscle strength ratio (involved/uninvolved), and cuff integrity was assessed ultrasonographically at least 1 year postoperatively.
  
  
  RESULTS
  All range of motion measurements, functional scores, and muscle strength ratios significantly improved postoperatively regardless of the treatment method of stiffness. No outcome measure differed significantly between patients who did and did not undergo capsular release, regardless of the severity of stiffness, except for a temporary improvement in external rotation at side 3 months postoperatively in favor of those who underwent capsular release in cases with severe stiffness. Among patients with diabetes mellitus however, those who underwent capsular release showed greater improvement in forward flexion after 3 months and 1 year and in external rotation at the side for all time points (all P < .05), except for 6 weeks postoperatively; these patients also had a significantly higher final American Shoulder and Elbow Surgeons score (P = .03). Of 21 patients who underwent manipulation alone and of 28 who underwent capsular release and manipulation, 2 and 1 developed retears, respectively.
  
  
  CONCLUSIONS
  Both manipulation and capsular release with manipulation significantly improved range of motion and produced satisfactory functional outcomes. The outcomes did not differ between treatment methods for stiffness regardless of the severity of stiffness. In patients with diabetes mellitus however, capsular release at the time of rotator cuff repair seems to be beneficial, especially for external rotation and final postoperative function.
authors: Seok Won Chung, Department of Orthopaedic Surgery, Konkuk University School of Medicine, Konkuk University Medical Center, 120-1 Neungdong-ro (Hwayang-dong Gwangjin-gu, Seoul 143-729, Korea. smilecsw@gmail.com).
authors: Jin-Young
authors: JY
authors: Park
authors: Seok Won
authors: SW
authors: Chung
authors: Zulkifli
authors: Z
authors: Hassan
authors: Jin-Young
authors: JY
authors: Bang
authors: Kyung-Soo
authors: KS
authors: Oh
mesh_terms: D000328:Adult; D015331:Cohort Studies; D003920:Diabetes Mellitus / Q000503:physiopathology*; D005260:Female; D006801:Humans; D057913:Joint Capsule Release / Q000379:methods*; D007592:Joint Diseases / Q000503:physiopathology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D053580:Muscle Strength / Q000502:physiology; D026201:Musculoskeletal Manipulations; D010147:Pain Measurement; D016059:Range of Motion, Articular / Q000502:physiology; D012307:Risk Factors; D012399:Rotation; D017006:Rotator Cuff / Q000503:physiopathology / Q000601:surgery*; D000070636:Rotator Cuff Injuries; D012785:Shoulder Joint / Q000503:physiopathology / Q000601:surgery*; D016896:Treatment Outcome
keywords: capsular release; diabetes; manipulation; rotator cuff tear; shoulder stiffness