THERMAL ASSISTED CAPSULAR SHRINKAGE

Melanie McNeal, PT, CSCS, CFT

DAVID LINTNER, MD

This protocol is for the patient who has either multi or unidirectional instability resulting in pathologic capsular laxity of the shoulder joint. In this surgery, thermal energy is applied through a heat probe. The effect of the procedure is dependent on the temperature of application, total time heat is applied, age of the patient, mechanical stress placed on patient at time of surgery, and the anatomic location of tissue. It can be used on both the anterior and posterior portions of the capsule, although this protocol will address ant capsular shrinkage only. The tissue involved in the shrinkage usually includes the entire inferior g-h ligament complex and part of the middle g-h ligament. For this reason, positions of ER and Abduction are limited post-op.

Following the procedure, local cell death is followed by a tissue repair response which is initiated as early as the 7^th post-op day. By 4-6 weeks, new collagen molecules and small fibrils are present. This surgery is much less painful post-op than other stabilizing surgeries such as capsular shift. This is due to the high temperature of the heat probe, which damages nerve endings of sensory afferent fibers, acting as an anesthetic on the highly sensory innervated capsule. Because patients do not feel much pain, they tend to want to do too much, too fast. It is important to educate the patient in maintaining proper ROM restrictions to allow tissue healing to occur and to prevent excessive tissue stretching. The decrease in stiffness following surgery is time dependent: by 2 weeks, stiffness is decreased 65%; at 6 weeks, stiffness is decreased 20% and by 12 weeks, tissue stiffness has returned to N pre-op levels.

In addition, this is an arthroscopic procedure. There is less pain, less morbidity, decreased scar tissue, decreased risk of infection, and decreased recovery time when compared to open procedures.

The therapist must take into account the following factors for the post-op patient:

*Did the patient have atraumatic/congenital laxity or traumatic/acquired laxity pre-op? For the congenitally lax patient, a more conservative rehab approach is in order. For the patient with acquired laxity, such as an baseball pitcher, a more aggressive rehab protocol is appropriate.

*What is the patient’s tissue type and status. Examining the uninvolved UE by performing a sulcus test is beneficial in determining if the patient is inherently “tight” or “lax”.

*What is the patient’s response to surgery? ? If the patient has had previous surgeries and is known to scar early, this should be taken into account. The key here is assessing end feel. If a capsular end feel is felt early on in rehab, a more aggressive approach may be in order. Make sure to consult with the physician in this case and voice your concerns. Communication is of utmost importance.

*Was another procedure performed concomitantly with the thermal shrinkage? If so, the more conservative of the two protocols will likely be followed. Other procedures that are commonly performed with thermal shrinkage include SLAP repair, RC debridement, Bankart repair, capsular shift, and/or RCR.

*For the first 4-6 weeks post-op, be careful with stretching because the newly formed collagen tissues are very pliable.

Supine rhythmic stabilization exercises

Scapular stabilization therex – manual resistance

Modalities: Heat prior to Treatment/exercise

Ice following exercise and at night

E-stim and/or US as needed

Notify MD if any abnormal reactions noted or signs of infection detected (fever, nausea, redness, excessive pain)

Patient MUST perform HEP routinely in order for rehab to be successful

Suggestions during rehab:

1. The RC gets a better blood supply when the shoulder is slightly away from the body; therefore, advocate the use of a towel roll under the arm when in a resting position.

2. The RC muscles are very small; therefore, we use lower intensities to isolate each muscle without recruitment from surrounding larger muscles. Focus on hypertrophy initially by high volume (V= Reps X intensity/weight). Following the hypertrophy phase, strength is the focus with lower reps and higher intensities/weight.

THERMAL ASSISTED CAPSULAR SHRINKAGE

PROTOCOL

PHASE ONE (Week 1-2)

In phase one, the general goals are to protect the surgical repair, initiate ROM to prevent adhesions and increase circulation, decrease pain and inflammation, and stress emphasis of HEP.

A sling will be worn for 4 to 6 weeks unless instructed otherwise by Dr. Lintner.

The sling is to be removed 2-3 times/day to perform HEP.

ROM limitations:

Passive and active-assisted ROM ONLY:

Flexion/scaption 0-90° by week 2

ER in scapular plane 0-25° by week 2

IR in scapular plane 0-45° by week 2

Active wrist and elbow full ROM

EXERCISES:

ROM: Pendulums

Rope and pulley – flexion, scaption

AA cane/wand into flexion, ER at 0° and 45°

Seated or supine posterior cuff stretch into horiz adduction

Strength: Hand gripping exercises - putty

Submax pain-free isometrics at 0° abduction all planes (IR, ER, Fl, Ext, Abd)

Modalities: Heat prior to tx

Ice following tx and when needed

PHASE TWO (Week 2-4)

General goals in Phase Two are to gradually restore ROM, initiate active muscle contractions with a focus on regaining proper scapulo-humeral rhythm, begin to train joint proprioception, and continue with HEP.

ROM Limitations/goal:

Flexion/elevation 135° by week 4

ER in scapular plane 50° by week 4

IR in scapular plane Full ROM by week 4

At week 4, can initiate IR/ER at 90° abduction

EXERCISES:

ROM: Continue with AAROM exercises from Phase One – pulley, cane/wand

Initiate towel IR stretch if needed

Posterior capsule stretch

G-H joint mobilizations can be initiated emphasizing post and inf glides. Should be pain-free and in loose/open packed position.

Passive stretching should be performed following mobilizations.

Strength: IR/ER with theraband using towel roll between upper arm and thorax

Side-step holding t-band at neutral IR/ER for isometric resistance

Sidelying ER against gravity, adding weight as able within ROM limits

Biceps and Triceps with theraband

Rhythmic stab progressing from supine to sidelying to partial sitting to standing as tolerated

Scapular strengthening therex including seated rows, shrugs, PNF patterns with manual resistance

Modalities: Heat prior to tx

Ice following tx and when needed

PHASE THREE (Week 4-6)

Goals in this phase are to continue to protect the healing connective tissue, stress importance of adherence to ROM guidelines, perform HEP, and gradually increase strength and ROM.

ROM goals:

Flexion/elevation 160° by week 6

ER at 90° abduction 80° by week 6

IR at 90° abduction 70° by week 6

EXERCISES

ROM: Continue with cane/wand, pulley as before

Towel for IR

Progress post cuff stretch and IR stretch to sidelying position

Continue with Grade II and III g-h jt and scapular mobilizations if needed to gain ROM

Strength: UBE

Progress theraband exercises by color, sets, repetitions

Initiate standing dumbbell routine – flexion, scaption, empty can, deceleration

Push-up progression – wall, counter, table, knees, regular – emphasize push-up with plus

Dynamic hug with sports cord or theraband

Cable column or T-band biceps, triceps, seated rows, scapular

punches

T-band or manual PNF patterns

Modalities: Ice following exercise

PHASE FOUR (Week 6-12)

The goals in this phase are to restore full active ROM, progress strengthening and scapular stabilization exercises, and initiate more functional drills into rehab program.

ROM goals:

Full ROM all planes by 12 weeks

EXERCISES:

ROM: Continue with previous exercises to gain full ROM

May need to add chicken wing stretch for ER

Mobilizations may be more aggressive if needed

Strength: Continue with previous T-band and C. column exercises

Continue with db therex increasing sets, reps, and intensity (up to 7 lbs)

Initiate T-band ER at 90/90 position – slow and fast reps

Initiate prone db therex including scaption at 130° with thumb up, horiz abduction with thumb up, extension with palm down, ER

Week 8:

Initiate two-handed plyometrics including ball toss –chest pass, OH pass, diagonals

Week 10:

Progress to one-handed plyos including ball toss, ball on wall

Eccentric RC strengthening using plyoball, deceleration tosses, T-band

Biodex – isokinetics for IR/ER beginning in modified neutral position, progress to 90/90 position in scapular plane

Large muscle exercises including shoulder press, lat pull-downs, bench press – do not allow elbow to extend past plane of thorax

Modalities: Ice as needed

PHASE FIVE (Week 12-24)

Goals include regaining full functional strength, implementing functional or sports specific training, and establishing a progressive gym program for continued strengthening and endurance training.

*Continue as needed with ROM exercises

*For high school athletes: at 12 weeks, passive ER should be 100-105°; allow the athlete to gain the rest on his own.

*For college/pro athletes: at 12 weeks, active ER should be 100-105° and passive ER should be 110-115° - allow the rest to come on its own

*Initiate interval throwing program at wk 12-16 – consult with physician first

*Initiate sports specific/functional training

*At week 12, do a biodex test at 180°/sec and 300°/sec. – goal is for strength to be at 80% of unaffected side

*Expected Biodex results: ER/IR ratio at 180°/sec: male–66; female- 71

Peak T/BW range for ER at 180°/sec: male11-15; female 8-12

Peak T/BW range for IR at 180°/sec: male 17-23; female 13-17

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