This website is under development - The information contained on this site is for guidance only and is not intended for self diagnosis or self treatment. This will not replace professional medical advice or consultation. Always seek the professional advice of a qualified health care provider like your doctor or specialist before embarking on any treatment. If you have a problem please consult your doctor or specialist.
Investigations
If symptoms do not settle with simple measures including physiotherapy or injections, then your GP may refer you to a specialist. After examination, investigations like x-ray and sometimes ultrasound scan may be requested if not done earlier. These investigations usually give adequate information about the bone, joint and tendon structures around the shoulder and in the case of frozen shoulder are likely to be normal. Therefore, frozen shoulder is diagnosed by exclusion of other conditions.
Operation
The aim of the surgical intervention is to free up the joint by releasing the scar tissue and initiating normal healing response rather than the relentless ineffective healing process. This can be achieved by either manipulation under anaesthesia or by physically cutting the scar tissue by arthroscopic technique.
During manipulation, the scar tissue is simply ‘broken’ by sequentially taking the arm into different ranges of movements following a safe and well destabilised sequence. Risks are low but it avoided if the stiffness is severe or if the x-ray suggests poor bone quality. If simple manipulation is done, one may miss any pathology inside the joint - like early arthritis or cartilage lesion.
The surgical release is usually performed as a day case procedure under general anesthetic. One may supplement this with a nerve block at neck or using local anaesthetic around the wound and inside the joint. To perform the operation, you will be turned to your ‘good-side’ such that the affected sided in on the top. Gentle traction will be applied to the arm to help the pass various instruments needed to perform the operation.
The shoulder joint is visualized by introducing the telescope via a small stab incision in the back of the shoulder. Sterile
saline is pumped into the shoulder under pressure to distend the joint. To assess the inside of the shoulder, a further stab incision may be placed in the front of the shoulder.
In an active frozen shoulder, one would get a ‘red-carpet’ welcome with aggressively inflamed tissues covering the normal tendons. In a burnt out stage, the normal tendon structures are completely covered with very thick scar tissue which sometimes can be as thick as 1 cm!. The biceps tendon can also be completely covered in this scar tissue. The joint itself can be very tight and moving instruments can be very difficult. Also the joint volume will be low due to scar tissue formation. .
The scar tissue is sequentially released to expose the normal tendons. This is achieved with alternative use of the diathermy probe and small cutting tool call ‘punch’. The gap between the top and the front tendon is cleared and biceps tendon is also released. Capsular release is carried out in a circumferential fashion to release the joint. To watch a video of this click this link. Usually, I resist the temptation to use any type of instrument at the lower most portion of the joint to avoid damage to the nerve. Occasionally the joint may require a gentle stretching at the end to release the inferior scar tissue at the end of the operation.
It is very important that there is very good continuous flow of cold saline to keep the temperature inside the shoulder as low as possible. This is achieved by using an outflow cannula and using a fluid pump to control the flow of the saline.
The wound is closed with sutures and water resistant dressing is applied. This is covered with a further layer of pressure dressing. Following the release, I do not place the arm in a sling and strongly encourage active exercises from the first day. You will be given information regarding wound care and information regarding various exercises you need to do. Physiotherapy will be arranged if required.
Red carpet welcome inside the joint
Biceps tendon stuck down
Release started with electric ablation probe
Rotator interval released with exposure of corocoid
| Ultrasound scans |
| MRI scans |
| A S D + D C E |
| Impingment syndrome - Picture |