Frozen Shoulder (Capsular Release)

You are fed up with the problems in your life caused by the lack of movement in your shoulder and have decided you’d like to have surgery to get it moving more quickly.

This is what happens.

Your surgery is done as a day-case and under a general anaesthetic.

Do I have to have a general anaesthetic?

Yes you do is the simple answer and there are very good reasons why. A modern general anaesthetic is a very different thing from one given even 15 years ago and nearly all my patients wake up very quickly with no pain and no sickness and often asking ‘when am I having my surgery?’.   The general anaesthetic also makes my life a lot easier because I don’t have to worry about you moving about during the operation and the anaesthetist has good control of your blood pressure.

You don’t just have the general anaesthetic though. It is very important that you don’t have any pain after the surgery and to ensure that happens the anaesthetist gives you an inter-scalene block. This is a very specialist technique whereby local anaesthetic is injected around the nerves at the base of the neck and that makes the whole arm go numb. What happens is that the injection is done first in the anaesthetic room and then you will be moved into the recovery area while we wait and make sure your arm is completely dead. That usually takes half an hour or so and once we are happy that your shoulder is numb the anaesthetist will give you the general anaesthetic and I do the operation.

What happens in the operation?

The first thing I do is make sure the shoulder is really frozen by moving it around and measuring how much movement you have. The keyhole operation is done through two small holes less than 1cm long – one at the back of the shoulder and one at the front. I then look around inside the gleno-humeral joint (the ball and socket) and make sure there are no other problems (arthritis, torn tendons etc) before cutting the capsule and releasing the shoulder. The two holes are closed with stitches, sticky plasters are applied and then I tie your arm up over your head in a sling!

And afterwards?

The important thing is to get the arm moving as soon as possible after the surgery. Now, because of the inter-scalene block, you won’t be able to lift up the bad arm so we get you to use your good hand to move the bad one (now also a good one!)  right up over your head till it hits the pillow behind you and right out to the side doing 10 of each every 15 minutes till you are discharged.

So I get it moving and you keep it moving. As the movement and feeling return you can start moving it under it’s own steam. The physiotherapist will see you before you go home and show you some exercises to get you started (see, I told you they came in very useful at the right time!). Out-patient physiotherapy should have been organised to start a few days after the surgery.

When can I drive, go back to work, play sports?

By 24 hrs after your surgery you should have a much, much better shoulder than you started out with and, basically, you can use it as much as you like straight away. It is going to be sore for up to a month but that shouldn’t stop you.

Driving? As soon as you feel confident and that may only be a day or two.

Return to work is also as soon as you like and because we don’t put any limits on what we allow you to do after the surgery, it doesn’t really matter what your job is. You do need to find time for some physiotherapy though and make time in your day to do your exercises as well.

And the same thing applies for sports. You should probably stay out of the swimming pool for 3 or 4 days to allow the wounds to start to heal. If you are a keen swimmer it is a great exercise for the shoulder but just use good waterproof plasters over the cuts until the stitches come out.

How long do I have to do the physiotherapy for?

You will need to do your own exercises until your shoulder movement has returned completely to normal and it could take up to 6 months to get that last 5%. Formal outpatient physiotherapy is usually for 8 – 12 sessions but that varies on how well you are doing and how much your insurance company lets you have.

Will my shoulder be 100% back to normal?

Now that is a very good question and the answer is a bit different from the surgeon’s perspective to the patients. What do I mean by that? Surely 100% is 100%? Well yes it is if you measure things scientifically and accurately. Because your shoulder had been so stiff and such a problem, if you get to 90% of normal after the surgery that can often seem to be fully normal because it isn’t that often in the day you actually stretch the shoulder all the way up, out or back so you may not realise there is still a little last bit of movement to get back.

It can be quite easy to get into a comfort zone around that 90% mark because you can do pretty much everything without any problems but it is well worthwhile really going for it in the first few months to try and hit 100%.

Does it always work?

Good question and the answer is….no. Well, let me qualify that. At the end of the surgery you will always have better movement than when you started and in 99% of cases the movement will be normal. You will be able to see that for yourself because your arm will be up over your head and either the physio or I will demonstrate that full range to you by moving the arm around for you. However not everyone keeps all the movement.

In about 5% of cases you do keep it all and by 2 weeks you are pretty much back to normal and wonder why you waited so long to decide about having the surgery.

At the other end of the spectrum about 5% will freeze right back to where they started.  This is nothing whatsoever to do with how much you did or did not exercise the arm. This is something in your system that is simply telling me to leave you alone and let the shoulder defrost in its own sweet time – which it inevutably will.  People with diabetes and thyroid problems tend to have a higher rate of this happening and it also occurs if we inadvertently operate before the shoulder has fully frozen. This is obviously very frustrating and, occasionally, we might have another go but usually this means – leave me alone.

So in the middle we have the 9 out 0f 10 cases where I get the full range for you and, for a couple of days it all feels wonderful. But then it looks like it is starting to freeze up again and you get a bit anxious. This is normal and the shoulder does tighten up a bit but it doesn’t freeze right back up again. It stops, scratches it’s head, has a think and decides. ‘You know what? I don’t want to freeze up again. Let’s hit the defrosting mode.’ So, with a couple of months of hard work, the movement all (or nearly all) comes back.

You must also remember that there are two elements to the loss of movement – the capsular thickening which is the true ‘frozen’ bit (primary tihgtness) and the bit I can deal with surgically but there is also a significant element of global tendon tightening around the shoulder (secondary tightness) and that is the bit that takes the time to stretch out. Its a bit like stretching out a tight hamstring or a stiff back – it will have tightened up a lot during the freeze simply because the capsular tightening will have prevented the shoulder moving so has to be stretched out over a good few months.

I describe it this way: for some people we do get you all the way across the finish line but for most we get you an awful lot nearer it.

Frozen Shoulder is a very common condition but there is a constant problem with getting the diagnosis correct so many people are told the do when they don’t and vice versa. This confusion has lead to a vast array of treatments being proposed to cure it but these are nearly all healing some other condition. It is the view of the shoulder specialist community that either you leave it to defrost by itself or you have surgery because that thick capsule isn’t going to release with water injections or exercise.