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Capsular Shrinkage / Capsular Plication

Indications:

• Atraumatic Instability
• As part of a Bankart repair for traumatic instability
• May also be for Internal Impingement (Thrower's Shoulder)

It is used specifically for shoulders where capsular stretching appears to be the major source of the problem. We do not to use it in shoulders that have a large Bankart defect or a fractured glenoid lip.

It is thought that the capsular shrinkage acts in several ways to stabilise the shoulder. Mechanical shortening of the capsule in the area that is stretched.   Tightening the proprioceptive sensor feedback mechanism. In the same way that you would use strapping around the shoulder to increase skin sensory input we can improve the shoulder proprioception by tightening the capsule. As this procedure is done arthroscopically and nothing has been incised or stitched, there is no need to wait to start post-operative physiotherapy. However there is some concern about temporary weakness of the capsule round about 3-6 weeks and hence stretching to regain motion has no part in the early post-operative phase.  As soon as pain allows proprioceptive physiotherapy is started. The early results are encouraging but approximately one – third can stretch out with time. It may be necessary to repeat the procedure at a later date if this were to happen. This particular group of patients are difficult to treat even by open surgery and the results of heat shrinkage stabilisation appeared to be comparable. The technique we use was developed by the Reading Shoulder Unit, where most of the research and clinical studies were done in developing this technique.

Protocol

• Scapular stabiliser programme
• Gleno-humeral control exercises
• Check core stability
• Submaximal isometric rotator cuff exercises

Post op
Out patient physiotherapy is arranged prior to discharge.
An appointment is made at the shoulder unit for 3 weeks post-op.

Patients are in a sling for pain relief but the aim is to remove this between 1 and 5 days.

The patient is encouraged to use the arm functionally and active assisted and active range of movement exercises are given. The patient should be instructed not to push the shoulder or stretch to end of range as the capsule remains weak for the first 6 weeks following the procedure.

Aims of Physiotherapy

Improve scapula and glenohumeral stability
Restore normal scapula humeral rhythm
Improve shoulder proprioception
Retain functional mobility of the shoulder with avoidance of stretching into end of range.

Emphasis should be on control and proprioceptive re-education not regaining range of motion. In these patients avoid any passive mobilisation until 6 weeks.

This should include:

• Scapular stabiliser programme.
• Gleno-humeral control exercises.
• Correction movement pattern.
• No combined external rotation/abduction.
• Proprioceptive re-education.

Return to Functional Activities

Patients should avoid contact sports for 3 months, but precision sports e.g. racquet sports can be useful for improving proprioception.
Any overhead activities should be avoided until the patient has adequate scapula control and cuff strength below shoulder height.

For more information please contact therapists@shoulderdoc.co.uk

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