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Capsular Shrinkage


What is it?

Capsular Shrinkage is an Arthroscopic surgical procedure where the loose ligaments and capsule of the joint are (physiologically) tightened usinga specialradiofrequency heating probe.


VAPR Radiofrequency Probe

Who is it for?

  • It is indicated for people with very loose shoulder joints causing problems of dislocations or subluxations, where there has been no major trauma to cause the 'looseness'. This is known as  a Loose Shoulder or Atraumatic Instability (sometimes known as Multidirectional Instability (MDI))

  • It is not suitable for people who have had a major injury causing the dislocation and have no capsular looseness. These patients require a repair of the torn structures ( Bankart repair ) (see Shoulder Instability ).

  • Occasionally throwing, overhead athletes also develop looseness of the shoulder due too repetitive straining of the ligaments and capsule. These athletes may also benefit from a capsular shrinkage procedure.

 

How does it work?

It was previously thought that capsular shrinkage should burn the tissue and promote scar formation, thus the technique developed a bad reputation. It has also been used for the incorrect indications in the past, thus poor results. However modern thermal capsular shrinkage techniques, as developed at the Reading Shoulder Unit , manipulate the capsular collagen properties only.

The capsule shrinks approximately 10% of its length at when the special radiofrequency probe is applied.  It is has been shown that the capsular shrinkage acts in several ways to stabilise the shoulder:

    1. Mechanical shortening of the capsule in the area that is stretched, by altering the mechanical properties of the collagen in the ligaments and capsule.   
    2. 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. By re-tensioning the proprioceptors they begin to fire off at lesser degrees of movement, and there is a greater dynamic muscular contribution to shoulder stability

It has been shown that the effects of capsular shrinkage are best when used as part of a good physiotherapy rehabilitation program.Strong shoulder muscles remain the best defence against shoulder dislocation, subluxation, and, thus, instability. Exercises that build up these muscles around the shoulder should be done. Also these muscles need to be trained to work in the correct order again.

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.

Capsular Shrinkage procedure - note the 'shrinkage' response of the tissue to the probe (no burning of the tissue)

(click on the image to see a video clip)
(requires RealPlayer )


Your Operation

You must not eat or drink anything after midnight the day before your surgery. When you wake up following the procedure you will be wearing a sling with a body belt. This may be a standard sling or an External Rotation sling, depending on the procedure performed (see pictures below). The sling should be worn at night and when out and aboutfor 3 weeks. You will then wean off the sling with the aid of your physiotherapist over the next 3 weeks. 
For

more details on Living with a Shoulder Sling CLICK HERE

You should be able to go home the same day as your operation, but may be in hospital overnight. A physiotherapist will see you in hospital to teach you the appropriate exercises. You may also see an occupational therapist to give you advice regarding the use of your arm.


Standard

sling


External Rotation Sling  


 PAIN

A nerve block  is usually used during the surgery. This means that immediately after the operation the shoulder and arm often feel completely numb. This may last for a few hours. After this the shoulder may well be sore and you will be given painkillers to help this whilst in hospital. These can be continued after you are discharged home. Ice packs may also help reduce pain. Wrap crushed ice or frozen peas in a damp, cold cloth and place on the shoulder for up to 15 minutes. Ensuring you cover the wound site with a piece of cling film to keep the area dry.


 THE WOUND

This keyhole operation is usually done through two or three 5mm puncture wounds. There will be no stitches only small sticking plaster strips over the wounds. These should be kept dry until healed. This usually takes 5 to 7 days.

SLEEPING

For the first three weeks your sling must

be worn in bed. Sleeping can be uncomfortable if you try and lie on the operated arm. We recommend that you lie on your back or on the opposite side, as you prefer. Ordinary pillows can be used to give you comfort and support. If you are lying on your side one pillow slightly folded under your neck gives enough support for most people. A pillow folded in half supports the arm in front and a pillow tucked along your back helps to prevent you rolling onto the operated shoulder during the night. If you are lying on your back, tie a pillow tightly in the middle (a "butterfly pillow") or use a folded pillow to support your neck. Place a folded pillow under the elbow of the operated arm to support that.


FOLLOW UP APPOINTMENTS

An appointment will be made for you to see the surgeon or specialist

therapist 3 weeks post-operatively.

DAILY ACTIVITIES

For the first three weeks most activities of daily living for example feeding, dressing, cooking etc must be carried out using your un-operated arm. If appropriate an occupational therapist will be available to give you advice on how to do this.

LEISURE ACTIVITIES

Your physiotherapist and surgeon will advise you when it is safe to resume your leisure activities. This will vary according to your sport and level, as well as the period required to retrain your shoulder muscles with physiotherapy.

Below is a rough guide:

SwimmingBreastroke
Freestyle
6 weeks
3 months
Golf  3 months
Contact SportIncludes rugby, horse riding, football, martial arts, racquet sports, and rock climbing3 months

DRIVING

You will not be able to drive for a minimum of 4 weeks. Your surgeon will confirm when you may begin.

 RETURNING TO WORK

This will depend upon the size of your tear and your occupation. You will need to discuss this with your surgeon.

REHABILITATION PROTOCOL

The physiotherapy rehabilitation protocol will be a specialised Proprioceptive programme and vary according to the type of stabilisation performed. For more details Click Here


Proprioception

Proprioception refers to the body's ability to sense movement within joints and joint position. This ability enables us to know where our limbs are in space without having to look. It is important in all everyday movements but especially so in complicated sporting movements, where precise coordination is essential. This coordinated movement is a result of the normal functioning of the proprioceptive system.

The proprioceptive system is made up of receptor nerves that are positioned in the muscles, joints and ligaments around joints. The receptors can sense tension and stretch and pass this information to the brain where it is processed. The brain then responds by signalling to muscles to contract or relax in order to produce the desired movement.

This system is subconscious, and we don't have to think about the movements or the corrections to movement. Sometimes the reactions take place so fast they are termed reflexive.

Following injury to joints and ligaments the receptors are also damaged, which means the information that is usually sent to the brain is impaired. As a consequence the joint feels odd or just doesn't feel right.

Once a joint has been damaged, or a ligament has been torn or partially torn, there will be a deficit in the proprioceptive ability of the individual. This can leave the person prone to re-injury, or decrease their coordination during sport. Proprioceptive ability can be trained through specific exercises and, in the case of the injured athlete, the improvement can compensate for the loss caused by injury. This has the effect of decreasing the chances of re-injury. Proprioception also helps speed an athlete's return to competition following injury. The exercises should be initiated as soon as possible following injury.


Also See:

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