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Year |
2001 |
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Question Number |
246. |
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Category |
Select |
Question
A 32 yr old woman reports right shoulder pain and has difficulty with overhead activities. History reveals that she underwent an open anterior labral repair and capsular shift to treat anterior glenohumeral instability 3 years ago. Examination reveals tenderness over the anterior shoulder, active and passive total elevation of 120 and external rotation of 30. Shoulder strength is normal. Plain radiographs are normal. Physical therapy failed to provide relief. Tx should now consist of:
a. Arthroscopic acromioplasty
b. Biceps tenodesis
c. Open subscapularis lengthening and capsular release.
d. Humeral head replacement
e. Derotational humeral osteotomy
Figures
Answer (click for answer)
Answer: C
The complaints listed above are the result of a tight subscapularis muscle. This is a common problem after anterior shoulder repair due to contracture and scar tissue. Loss of external rotation after an anterior procedure for instability is a problem due to the resulting alterations in the biomechanics of the shoulder leading to osteoarthritic changes over time. In the study listed below, they found that after releasing the subscapularis, each pt (n=10) had less shoulder pain and an average increase of 27 degrees of external rotation. Guidelines for treatment of the complaints listed in the question include: NSAIDs, and PT consisting of rotational strengthening and ext rot stretching for mild pain; with a trial of the above recommendations for moderate pain, but if conservative tx fails—release of the subscapularis. If this release does not improve function and pain control, then a shoulder arthroplasty should be considered.
Reference: Macdonald PB, Hawkins RJ, Fowler PJ, Miniaci A: Release of the subscapularis for internal rotation contracture and pain after anterior repair for recurrent anterior dislocation of the shoulder. JBJS 1992; 74:734-737.