Capsular Release for Frozen Shoulder Protocol

Immediate Post-surgery

Waking up
Most patients feel dizzy and tired for a few hours after the surgery. You can simply sleep it off. Some patients may feel nausea and even experience some vomiting as well, but with modern anaesthesia, this is very much less common, and should not last more than 2-3 hours.

Pain
You should not be feeling much pain at all, when you wake up from the surgery. This is due to the indwelling block which you will have, administered by the anaesthetist. The pain control provided by the block will allow you to commence shoulder range of movement (ROM) exercises immediately after the surgery.

Many patients will also experience weakness and numbness in the arm. This is also due to the block. Please do not be alarmed because you will regain the strength and sensation in the arm fully once the block has been removed and the drugs used in the block has worn off.

It might take 8 – 36 hours for the effects of the block to wear off completely. It is advisable to take oral pain medications before the block is removed. This is to ensure that pain relief is adequate for you to continue working on your shoulder ROM even after the block stopped.

Wounds and dressings
There will be a bulky dressing over the shoulder which can be removed either on the same day (at night) or the next morning. You will find small waterproof dressings (the size of 2 band-aids placed side by side) underneath the bulky dressing. You can take a shower, but please do not take baths or soak in water until the wounds are well healed.

Stitches
Stitches used may or may not need removal after 12-14 days. This is on a case-by-case basis. But if required, this can be quickly and easily done at ours or any doctor’s office.

Going home and medications
Most patients go home from hospital after 2 – 3 days. This is so that the block can be adjusted. Ideally, the block should be tweaked such that you continue to have movements (though weakened) in your arm, but experience no pain so that you can commence and do ROM exercises as soon as possible after the surgery.

After the block is removed, you will be discharged with pain medications, which you should take on a regular basis for the first week or two. This will allow you to continue to do the exercises as frequently as you can manage without feeling too much discomfort.

Antibiotics are not usually required, unless there are some concerns with regards to increased infection risks like a eczema over the skin, pimples around the area, previous tendency to get infections etc.

Arm sling
Most patients will wear a simple sling for 1 – 2 weeks. Do not be alarmed if you feel you need to wear the sling longer for comfort. You may remove the sling at any time.  

Movements
It is of utmost importance to commence movement and physiotherapy as soon as possible. That means starting it on the same day as the surgery if possible. Some patients may be feeling too drowsy to start physiotherapy on the same day. In that case, starting the next day is acceptable, though my preference is to start earlier.

Initial follow up schedule:
For a typical patient, the timeline is usually:

• Return home on the 2nd or 3rd day after the surgery. Eg if surgery is done on Monday, you can return home on Wednesday or Thursday. For patients who are reluctant to stay in hospital for that long, there is an option of returning home the next day, but you will need to return home with the block in place and carry a small bottle containing the anaesthetic drug for the block.

The small bottle will slowly release the anaesthetic drug via a small tube in the neck. The tube is less than 1mm in diameter and can be easily removed in the clinic when it is no longer required. This is known as an indwelling block with balloon pump.

• Review in clinic on post-operative day (POD) 7 for first dressing change (this is advised because the hot and humid weather in Singapore often makes the skin under the dressing irritated)

• Review in clinic on POD 12 – 14 for removal of stitches and dressing. A water-resistant spray will be applied so you can shower over the healed wound without needing anymore dressings.

• Physiotherapy should be ongoing upon discharge. If this is too troublesome, patients can certainly do their stretches on their own at home though this does require some discipline!

will be a bulky dressing over the shoulder which can be removed either on the same day (at night) or the next morning. You will find small waterproof dressings (the size of 2 band-aids placed side by side) underneath the bulky dressing. You can take a shower, but please do not take baths or soak in water until the wounds are well healed.

Stitches
Stitches used may or may not need removal after 12-14 days. This is on a case-by-case basis. But if required, this can be quickly and easily done at ours or any doctor’s office.

Going home and medications
Most patients go home from hospital either later on the same day of the surgery, or the next morning. You will be discharged with pain medications, which many patients may not even take! But if you have pain, do not be worried about taking pain medications.

The pain medications prescribed are simple, non-addictive ones which will not cause problems in the future. Antibiotics are not usually required, unless there are some concerns with regards to increased infection risks like a eczema over the skin, pimples around the area, previous tendency to get infections etc.

Arm sling
Most patients will wear a simple sling for 1 – 2 weeks. You may remove the sling and rest the arm at your side, as long as you do not try to externally rotate your arm beyond neutral (i.e wrist and hand pointing directly forwards, with your elbow flexed at 90°).

I generally do not strictly require patients to wear the arm slings all the time. I also allow patients to sleep without their arm slings, although patients and their parents/ spouses know themselves best.

So if they are particularly “violent” sleepers, wearing the arm sling for the first couple of weeks when they sleep is certainly not a bad idea!

Movements
Please do not place your arm up and externally rotated (like how you would if you were going to throw a ball hard, or if a burglar shouted “hands up” behind you!). Please also avoid externally rotating your shoulder beyond neutral (as described above).

With regards to other movement, you may go ahead and move your shoulder and arm within comfort levels. But as a guide, try not to lift your arm up beyond 90° to your body.

Initial follow up schedule
For a typical patient, the timeline is usually:

• Return home either on same day of surgery or the next morning
• Review in clinic on post-operative day (POD) 5 for first dressing change (this is advised because the hot and humid weather in Singapore often makes the skin under the dressing irritated)
• Review in clinic on POD 12 – 14 for removal of stitches and dressing. A water-resistant spray will be applied so you can shower over the healed wound without needing anymore dressings.
• Physiotherapy can commence at any time. If patients have more discomfort in the surrounding muscles, they can often get some relief with physiotherapy. But if they would rather allow wounds to heal and give the shoulder some time to settle down before commencing physiotherapy, it is also reasonable. I usually start patients on physiotherapy about 2 weeks after the surgery.

Recovery Post-Surgery

Most patients will have dramatic improvement in the movements in their shoulder immediately. There is usually some reduction in the movements after a few days as the body reacts with scar formation. But with regular stretching and physiotherapy, you can expect to have sustained dramatic improvement in your shoulder movements.

There will also be dramatic improvement in pain, and this is often evident right from the start, as the block will alleviate post-surgical pain. Full recovery may take up to 3 months.

Week 0 – 1: (Goal: Pain control, healing of wounds, keep moving!)

• Arm sling is optional. Most patients will use one for a week or two, for comfort and usually only while standing or walking.
• Keep moving and stretching the shoulder!
• Ensure that you frequently flex and extend your elbow, wrist and fingers to avoid swelling of the extremity.
• Periodic icing of the shoulder will also help to reduce swelling and soreness.

Week 1 – 12: (Goal: Regain passive and passive ROM)

• Keep working on ROM.
• As your ROM improves, add strength training as tolerated.

Week 3 – 4: (Goal: Commence strength training)

• Work on regaining full ROM in the shoulder.
• Commence progressive external rotation.
• Commence progressive strength training of the shoulder including rotator cuff strength training.
• Continue to avoid Thrower’s position.

Month 3-6: (Goal: Achieve full active ROM and start work on strength)

• Gradual return to normal daily activities.

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