Is it safe for the cuff to perform a full circumferential arthroscopic capsular release for frozen shoulder? A systematic review.

BACKGROUND

Frozen shoulder causes prolonged pain and restricted range of motion (ROM), with many patients requiring surgery when conservative treatment fails. Arthroscopic capsular release (ACR) is a common intervention, but the optimal extent of release-particularly the safety of superior capsule release and risk of iatrogenic rotator cuff tears-remains controversial. The purpose of this systematic review is to evaluate the clinical effects of releasing the superior capsule of the shoulder as part of a full circumferential ACR, specifically evaluating the rate of postoperative rotator cuff tears.

METHODS

A systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. MEDLINE, EMBASE, and Web of Science were searched. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized controlled trials (RoB 2.0) and the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tools. Included studies reported on frozen shoulder patients treated with circumferential ACR, with or without superior capsule release. Postoperative outcomes-ROM, functional scores, and complications like cuff tears-were extracted. A minimum follow-up of 1 year was required. Procedures including superior capsule release were classified as full circumferential ACR only when they included a superior capsule release; otherwise, they were considered limited ACR.

RESULTS

Forty-five studies with 1,921 patients (mean age 51.8 years, 59.1% female) met the inclusion criteria. Only 2 randomized controlled trials and 8 prospective studies were included, along with 35 retrospective studies, which generally exhibited a low to moderate risk of bias. Twenty-one studies (46.7%) used full circumferential and 24 (53.3%) used limited ACR. ROM and functional scores improved across all groups, with comparable outcomes between techniques. Only 3 postoperative cuff tears (0.16%) were reported-all in the full circumferential ACR group. However, postoperative imaging was reported in only 2 studies.

CONCLUSION

Full circumferential ACR, including superior capsule release, does not present a higher risk of rotator cuff tears, though the low incidence and limited imaging data suggest underreporting.