Arthroscopic Capsular Release
The shoulder joint has a capsule (or thickened ligament) that surrounds the head of the Humerus (the ball) and the Glenoid (the socket). The purpose of the capsule is to act as a restraint to dislocation at the extremes of movement therefore improving the stability of the joint. When this joint capsule becomes inflamed it is commonly termed a ‘Frozen Shoulder’ or Adhesive Capsulitis. This is an extremely painful condition that also produces a marked restriction in movement in all directions, can make any activity of daily living problematic and can severely disrupt sleep.
The causes of a frozen shoulder are still largely unknown, it can happen following a traumatic fall or injury, shoulder surgery, or a prolonged immobilisation. It can often be associated with diabetes, and there are many for whom there is no explanation at all.
There are 3 phases to frozen shoulder. Phase 1 is the ‘Inflammatory phase’. This phase is associated with the onset of pain and marked stiffness and can last 6 months or more. Phase 2 then begins as the initial very painful inflammatory phase settles. Often a somewhat marked restriction will remain making daily activities such as reaching behind or out in front very difficult. This second phase may last many months.
A frozen shoulder will usually spontaneously resolve and a full recovery can be made 95% of the time but this can take 18 months or more in some cases. A capsular release or Manipulation under Anaesthetic (MUA) are surgical procedures that aim to substantially speed up the recovery of a frozen shoulder, or help those patients with severe pain. These treatments do not provide an instant cure, but usually provide a good return to function and a marked decrease in pain within the first 3 months. The remaining restriction to movement can remain for 3 or more months after this.
The recovery process: what to expect and recovery
A capsular release involves making 2/3 small holes in the shoulder and releasing the capsule surgically. A manipulation involves forcibly moving the capsule under anaesthetic. A nerve block can be used in anaesthetics that can render the arm numb for up to 24 hours or more.
These procedures can be painful initially and physiotherapy is essential to help achieve the early goals of rehabilitation following surgery.
The early goals of rehabilitation are to:
- keep the pain controlled
- ensure that movement is maintained as best as possible.
- keep expectations realistic.
- Pain should be controlled with prescription drugs. On leaving the ward you will be given a 5-day prescription, after this time you may be able to downgrade to over the counter analgesics which can be discussed with the pharmacist or you may need to visit your GP to continue with the prescription drugs. Ice can be used at home as a useful adjunct or alternative.
- Pain control is essential as it allows you to do your exercises regularly. The importance of regular exercises cannot be overstated. Following these procedures the capsule needs to be able to heal, if the shoulder isn’t adequately moved during this period then the healing process occurs in a restricted range and you will take longer to reach a full resolution. The exercises need to be done ‘little and often’ and it is worth remembering why you are doing them; to ensure that during the painful stage we maintain as much movement as possible. The number and how often you will have to do these exercises depends on your pain tolerance.
The recovery process; milestones
- Driving - you may begin driving approximately 1 week after your operation or when you feel comfortable
- Returning to work - this will be dependent on your occupation. If you are in a sedentary role you may feel happy to resume work after 1 week, however if your job involves heavy lifting or using your arm at shoulder height, you may require longer
- Functional range of movement achieved at 4 – 6 weeks
- Sleeping – you should feel comfortable sleeping and tablets are no longer required by 3 months, or earlier in some cases.
Your physiotherapist will aim to see you in the first week following your surgery, to ensure you are exercising to the right level. Depending on your progress at this point will determine how regularly you will need to be seen by a physiotherapist.