PHYSICAL THERAPY GUIDELINES FOR

POSTOPERATIVE MANAGEMENT OF ARTHROSCOPIC

CAPSULAR RELEASE

GENERAL GOALS:

• Maximize pain-free range of motion

• Restore normal scapulo-humeral rhythm
• Maximize functional use of the upper extremity

GENERAL INFORMATION:

This is arthroscopic surgery performed for either primary or secondary adhesive capsulitis
that has been refractory to conservative management. This procedure releases capsular
adhesions with the overall goal of restoring gleno-humeral mobility. This surgery does not
usually involve joint or muscle reconstructions; thus, the postoperative precautions are
secondary to pain only. In cases where a capsular release is done in conjunction with other
surgical procedures such as rotator cuff repair physical therapy is modified according to the
surgeon’s guidelines to protect the healing tissues. Along with releases to the capsule, these
procedures involve releases of the rotator cuff interval and the inferior and superior
glenohumeral ligaments. Occasionally the subacromial space debridement is also
performed if adequate ROM cannot be obtained after release of the capsular adhesions. This
procedure is reported to result in near normal ROM as compared to the contra lateral,
uninvolved shoulder. Gains in functional scores, pain and patient satisfaction are also
reported to be significant with lesser scores for patients with postoperative adhesive
capsulitis than those status post fracture or idiopathic adhesive capsulitis.

www.docmartin.at

© 2006 The General Hospital Corporation d/b/a Massachusetts General Hospital

X\ptshare folder\outpatient folder/shoulderguidelines\postoperative management of arthroscopic capsular release

Revised 03/21/06
- Page -1-
GENERAL INTERVENTION:

• Patients are typically treated while in the hospital by Physical Therapy and their
outpatient therapy is initiated immediately following hospital discharge. [Adequate
pain control is considered imperative for full participation in Physical Therapy
especially in the early postoperative period.]
• Outpatient Physical Therapy treatment is typically done three to five times a week
during the first two postoperative weeks. Frequency of therapy diminishes over the
subsequent weeks as progress dictates. There is no consensus on the scientific basis to
determine optimal frequency of postoperative Physical therapy visits. Thus, patients
are followed at a frequent necessary to attain their goals.
• Patients always have a full home exercise program to be done daily.
• Intervention should not be forceful or painful to the point of exacerbating symptoms,
such as muscle guarding and swelling
• Intensity and duration of exercise is based on:
a. Extent of pain
b. Need for frequent/short duration periods of exercise
c. Degree of associated impairments of strength, musculoskeletal length, and normal
timing of shoulder complex
• Patients in this group may benefit from a pre-operative physical therapy visit
• Typically, a sling is not utilized in the postoperative phase

SPECIFIC INTERVENTION BY PHASE:

• The intervention progresses with consideration of patient’s specific impairments that
are identified in the physical therapy examination. The rehabilitation process is
generally divided into three general phases based on tissue reactivity and pain.
• Intervention may not include all the components listed below, as programs are
designed, based on each patient’s particular needs.

Phase I: PROM/AAROM
Phase II: AROM
Phase III: Strengthening/Endurance phase

© 2006 The General Hospital Corporation d/b/a Massachusetts General Hospital

X\ptshare folder\outpatient folder/shoulderguidelines\postoperative management of arthroscopic capsular release

Revised 03/21/06
- Page -2-
 PHASE I:

• 0 - 3 to 4 Weeks
• PROM/AAROM

• If pain and effusion decrease readily, and if range of motion progresses rapidly, then this
phase may be shortened and the patient progressed to the active range of motion phase
more quickly.

SPECIFIC GOALS:

• Maximize gleno-humeral range of motion

• Improve muscular extensibility
• Decrease pain and muscle guarding
• Empower the patient to manage their home program successfully

SPECIFIC PRECAUTIONS:

• No forceful or painful range of motion

JOINT MOBILITY PATIENT EDUCATION

• Joint range of motion/capsular mobilization within
patient tolerance in all planes of motion
• Encourage exercise in a pool, if possible
• Ice/modalities to manage soft tissue swelling, if
needed
• Normalize extensibility of the periscapular and
gleno-humeral musculature with manual therapy
techniques, such as soft tissue mobilization
• Explain normal shoulder mechanics and patient
pathophysiology, goals of surgical intervention and
general postoperative rehabilitation course
• Educate the patient regarding pain management,
which may include medication and ice
• Emphasize that interventions performed in the clinic
are meant to augment the home exercise program
• Home exercise program is advised to be done in
frequent, short duration sessions throughout the day
• Encourage use of arm for activities of daily living
• Encourage a normal arm swing during gait

© 2006 The General Hospital Corporation d/b/a Massachusetts General Hospital

X\ptshare folder\outpatient folder/shoulderguidelines\postoperative management of arthroscopic capsular release

Revised 03/21/06
- Page -3-
 PHASE II: AROM phase

• Starts at approximately 4 weeks; the duration of this phase may vary depending on
patient’s availability to achieve normal scapulo-humeral rhythm.

SPECIFIC GOALS:

• Restore full gleno-humeral joint mobility

• Normalize scapulo-humeral rhythm
• Return patient to normal functional usage of the arm

PATIENT EDUCATION JOINT MOBILITY

• Emphasize the need for continued efforts to maintain
extensibility of the joint and soft tissue
• Stress the use of the arm for activities of daily living
and independent activities of daily living as much as
possible within their limits of comfort
• Continue with joint range of motion and capsular
mobilization within patient tolerance in all planes of
motion, as well as combined planes
• Home exercise program to continue to advance
mobility and improve muscle length is continues at
least twice a day
• Continue exercise in water or pool, if possible

NEUROMUSCULAR CONTROL

• Improve timing of the shoulder girdle musculature to

normalize scapulo-humeral rhythm
• Increase muscle strength for rotator cuff and
periscapular muscles

© 2006 The General Hospital Corporation d/b/a Massachusetts General Hospital

X\ptshare folder\outpatient folder/shoulderguidelines\postoperative management of arthroscopic capsular release

Revised 03/21/06
- Page -4-
 Phase III:

• Timing of initiation of this phase depends on achievement of full AROM with normal scapulo-
humeral rhythm. Strengthening is not started until there are minimal complaints of pain with
ROM of the shoulder (generally within 6 weeks after surgery)

Specific Goals:

• Return patient to normal functional usage of the arm, including sports and recreational activities.

PATIENT EDUCATION JOINT MOBILITY

• Discuss with patient a realistic progression to sports • Address residual gleno-humeral/scapulo-thoracic and
and hobby activities. trunk mobility impairments

NEUROMUSCULAR CONTROL

• Increase strength and endurance for rotator cuff and

periscapular muscles
• Introduce sports and recreational activities as
mobility, strength endurance and motor performance
improves.

© 2006 The General Hospital Corporation d/b/a Massachusetts General Hospital

X\ptshare folder\outpatient folder/shoulderguidelines\postoperative management of arthroscopic capsular release

Revised 03/21/06
- Page -5-
REFERENCES:

Berghs B, Sole-Molins X, Bonker T. Arthroscopic release of the adhesive capsulitis. J Shoulder Elbows
Surg. March/April 2004; 180-185.

Castellarin G, Ricci M, Vendorw, et al. Manipulation and arthroscopy under general anesthesia and early
rehabilitative treatment for frozen shoulders. Arch Phys Med Rehabil.. 2004 Aug; 85(8); 236-40.

Diwan D, Murrel G. An Evaluation of the Effects of the Extent of Capsular Release and of Postoperative
Therapy on the Temporal Outcomes of Adhesive Capsulitis. The Journal of Arthroscopic and Related
Surgery, 2005 Sept; 21;1105-113.

Holloway GB, Schenk T, Williams GR, Ramsey ML, Ianotti JP. Arthroscopic capsular release for the
treatment of refractory postoperative or post fracture shoulder stiffness. J Bones Joint Surg. AM. 2004
Nov; 83-A(11); 1682-87.

Junji I, Katsumasa T. Early and Long-Term Results of Arthroscopic Treatment for Shoulder Stiffness. J.
Shoulder Elbow Surg. 2004; 13:174-9.

Klinger HM, Otte S, Baums MH, Haerer T. Early arthroscopic release in refractory shoulder stiffness.
Arch Orthrop Trauma Surg. 2002 May; 122(4); 200-3.

Nicholson GP. Arthroscopic capsular release for stiff shoulders: effect of etiology on outcomes.
Arthroscopy. 2003 Jan; 19(1); 40-9

Warner JJ, Answorth A, Marks PH, Wong P. Arthroscopic release for chronic refractory adhesive
capsulitis of the shoulder. J Bone Joint Surg. 1997; 79(8): 1151-8.

© 2006 The General Hospital Corporation d/b/a Massachusetts General Hospital

X\ptshare folder\outpatient folder/shoulderguidelines\postoperative management of arthroscopic capsular release

Revised 03/21/06
- Page -6-