Shoulder

Arthroscopic Arthrolysis & Manipulation Under Anaesthetic

Why the shoulder requires manipulation under anaesthetic

The shoulder can become inflamed and tight. This is commonly known as 'frozen shoulder'. Often the process can start without apparent cause. Sometimes the pain and tightness follows a minor accident/injury, or after an operation. 'Frozen shoulder' appears to be associated with diabetes, particularly insulin dependent diabetes. It can be a problem for 12 to 24 months, sometimes even longer.

Generally it has two main phases. The first phase is of increasing pain and stiffness. In the second phase the problem is mainly of stiffness. Normally it resolves with time. Treatment is initially to reduce pain and then to increase movement in the second phase. If physiotherapy fails to improve movement then arthroscopy and manipulation under anaesthetic (MUA) may be offered.

About your arthroscopy and manipulation under anaesthetic (MUA)

The aim of the operation is to try and increase the range of movement in your shoulder. The operation is done partly by keyhole surgery or 'arthroscopy'. A water/salt solution is pumped into the joint. This is known as 'distension'. It aims to stretch or distend the capsule. The tight capsule and ligaments are then released or removed. Finally the joint will be forcefully stretched in outward, upward and twisting movements to try and regain maximum movement in the ball and socket joint.

This is usually done under general anaesthetic but it may be able to be done by regional anaesthesia (i.e. just your arm is 'put to sleep', you are still awake). Please discuss this with the consultant.

What are the risks and complications?

All operations involve an element of risk. We do not wish to over-emphasise them but feel that you should be aware of them before and after your operation. Please make sure you discuss any concerns with the doctors/consultant.

The risks include:

• Complications relating to the anaesthetic such as sickness, nausea or rarely cardiac, respiratory or neurological. (Less than 1% each, i.e. less than one person out of one hundred)
  
  
• Infection. These are usually superficial wound problems. Occasionally deep infection may occur after the operation. (Less than 1%)
  
  
• The operation does not succeed in improving the pain or movement in your shoulder. (Up to 30%)
  
  
• Damage to nerves and blood vessels around the shoulder. (Less than 1%)
  
  
• The upper arm bone breaking. (Less than 1%)

Questions that we are often asked

Will it be painful?

It is quite normal for there to be an increase in pain initially after this operation. You will be given pain-killers to help reduce the discomfort. A prescription for continued pain medication will be given to you for your discharge home. If you require further medication after these are finished, please visit your General Practitioner (GP).

You may find ice packs over the area helpful. Use a packet of frozen peas, placing a piece of wet paper towel between your skin and the ice pack. Until it is healed, also use a plastic bag to protect the wound from getting wet. Leave on for 10 to 15 minutes and you can repeat this several times a day. This would be first choice if the joint feels warm and inflamed. However if this does not help (and the joint is not warm), try heat over the area by using a hot water bottle.

Try and keep the level of pain down so that you can tolerate moving the shoulder

Do I need to wear a sling?

When you are in hospital your arm may be placed in a special sling (Bradford sling) which supports your arm away from your side. For home, you are given a sling for comfort only. Do not feel you have to use it. Remember this operation has been done to try and increase movement, so do not keep your arm in the sling for long periods without doing regular exercises. Discard the sling when you feel able. Try to rest with your arm supported out to the side, in front of you or behind your head (see pictures below).
To begin with you may need to rest with a pillow/towel under your elbow.

Also at night, if you lie on your back, you may find placing a thin pillow or rolled towel under your upper arm helpful.

If you lie on your painful side, try a pillow (or two) in front of you, it will stop your arm flopping foward.

Do I need to do exercises?
Yes definitely! The exercises are designed to try and maintain any increased movement achieved at surgery. You will be shown exercises to move your shoulder and you need to continue with these at home, straight away!

Outpatient physiotherapy will be arranged to start as soon as possible. If you have not got an appointment within 1 week, phone the hospital and ask for the physiotherapy department.

You will start an exercise programme to gradually regain movements and the exercises will be changed as you progress.

You will need to get into the habit of doing regular daily exercises at home for several months. They will enable you to gain maximum benefit from your operation.

A selection of exercises are shown at the back of this booklet.

What do I do about the wound and the stitches?

You will not have any stitches, only small sticking plaster strips over 1 or 2 small wounds. Keep the wounds dry until they are healed, which is normally within 5-7 days. Usually the dressings will be removed at 7 days by the nurse at your G.P surgery or by a district nurse. You can shower/wash and use ice packs, but protect the wound with cling film or a plastic bag. Avoid using spray deodorants, talcum powder or perfumes near or on the scar.

When do I return to the clinic

This is usually arranged for approximately 4 - 6 weeks after your discharge from hospital to check how you are progressing. Please discuss any queries or worries you have at this time. Appointments are made after this as necessary. Occasionally pain and stiffness may return at this stage and a repeat Cortisone injection maybe necessary. On very rare occasions a repeat MUA is needed.

Are there things that I should avoid doing?

The only thing to avoid is keeping the shoulder still! Although you may not like taking tablets, try to keep the level ofpain down and exercise regularly to keep the joint moving.Remember you can also try using ice packs or heat (hot waterbottle will do fine). In addition rest with the arm supported awayfrom your side.

How I am likely to progress?
This can be divided into 2 phases.

Phase 1. Getting over the 'operation pain'

The initial increase in pain for the first few weeks may affect your ability to do everyday activities, especially if your dominant hand (right if you are right handed) is the side of the operation. However we appreciate that you may have been having problems before your operation.

Try and use your arm for daily activities, particularly if the joint feels stiff more than painful. Even though the shoulder is painful, you need to try and do regular exercises. Outpatient physiotherapy will normally start as soon as possible. Take medication and use ice/heat to try and keep the pain level down.

Phase 2. Regaining everyday movements

The pain from the operation should gradually lessen and you will be able to exercise more frequently and vigorously. Normally the change in movement will occur within 4-6 weeks of the operation.

Research shows that the results are variable. Some movements improve, others may not change. Sometimes the twisting movements do not greatly improve (e.g. putting your hand behind your back).

Even though regaining perfect movement is unlikely, you may find that even small gains may improve your ability to do everyday activities. Unfortunately, the results may be less good if you have diabetes, but this is not always the case.

When can I return to work?

This will depend on the type of work you do. If you have a desk-type job you will probably be off work for a week. However, if you are involved in lifting or manual work you may not be able to do these for 2 weeks. Please discuss any queries with the physiotherapist or hospital doctor.

When can I drive?

Normally within a week or two of the operation. Check you can manage all the controls. It is also advisable to start with short journeys. The seat-belt may be uncomfortable initially but your shoulder will not be harmed by it.

In addition, check your insurance policy. You may need to inform the insurance company of your operation.

When can I participate in leisure activities?

Your ability to start these will be dependent on the range of movement and strength that you have in your shoulder following the operation. Nothing is forbidden! Please discuss activities that you are interested in with your physiotherapist or consultant. Start with short sessions, involving little effort and gradually increase.

You can try movements in water as soon as the wounds are healed. Doggy paddle or breast stroke may be easier initially. You can exercise the rest of your body immediately. Try and regain the natural 'swing' of your arm as you walk.

Exercises

Use pain-killers and/or ice packs/heat to reduce the pain before you exercise.

It is normal for you to feel aching, discomfort or stretching sensations when doing these exercises. However, if you experience intense and lasting pain (e.g. more than 30 minutes) reduce the exercises by doing them less forcefully or less often. If this does not help, discuss the problem with the physiotherapist.

Certain exercises may be changed or added for your particular shoulder. Do short frequent sessions (e.g. 5-10 minutes, 4 times a day)rather than one long session.

Gradually increase the number of repetitions you do. Aim for the repetitions that your therapist advises, the numbers stated here are rough guide-lines.

Get into the habit of doing them! Good luck.

Please note: all pictures are shown for the right shoulder unless specified.

1. Lying, or sitting or standing, elbow to your side.
Hand starts near your stomach. Take hand away from stomach, elbow in. This twists the shoulder joint. Can support/add pressure with a stick held between your hands. Repeat 10 times.

2. Stand. Leaning well forwards.
Let your arm hang down. Swing arm a) forwards and backwards. b) side to side c) round in a circle Repeat 10 times.

3. Lying on your back, knees bent, feet flat on the bed/floor.
Support your operated arm with the other arm and lift it up overhead. Do not let your back arch. Repeat 5-10 times.

Repeat this movement but with your elbows bent. Hands holding elbows (like 'Russian dancing'). Aim to stretch elbows overhead. Do not let your back arch. Repeat 5-10 times.

4. Kneeling on all fours.
Keep your hands still and gently sit back towards your heels. Repeat 5-10 times

5. Standing facing a wall.
Place a tea towel or duster between hand and wall. Slide hand up wall. Try and keep your shoulder down. Repeat 5-10 times.

6. Sit or stand
Try and set up a pulley system with the pulley or ring high above you. Pull down with your unoperated arm to help lift the operated arm up. Repeat 10 times

7. Sit or stand.
Hold a stick or umbrella between hands. Keep shoulder down and push operated hand out to the side. Try not to move your body. Repeat 5-10 times

8. Standing with arms behind your back.

Grasp the wrist of your operated arm and:
a) gently stretch hand towards the opposite buttock
b) slide your hands up your back.
Repeat 5 times.

9. Use a towel in the other hand to stretch it.
Repeat 5 times.

10. Lying on back, knees bent and feet flat.
Place hands behind neck or head, elbows up towards the ceiling. Let elbows fall outwards. Repeat 5 times

11. Stand or sit.
Take hand of your operated arm across body towards opposite shoulder. Give gentle assistance from your other arm. Repeat 5 times.

Who to contact if you are worried or require further information?

If your wound changes in appearance, weeps fluid or pus or you feel unwell with a high temperature, contact your GP.

If you have a query about exercises or movements, contact the Physiotherapy department where you are having treatment if you have already started.

We would like to thank the Nuffield Orthopaedic Centre especially Professor Andrew Carr for allowing us to reproduce this information. This has then been modified to suit local patients needs taking into account varying clinical practice. Help and feedback was given from people who have had a Shoulder MUA.

Mr Shantanu Shahane FRCS (Orth)

The One Health Group - Sheffield Limited