Immediately following the Oolo-Austin Trigenics (MCD) Capsular Dissection operation to resolve adhesive capsulitis frozen shoulder, patients have many questions. One of the biggest questions is always whether or not what is experienced in the days and weeks after the operation is normal. Is it normal to still have pain? If some pain still exists, when will it go away? Is it normal to still have some restriction of movement in certain positions? Is it normal to have pain in the arm, hand or neck? Is it normal to still have some difficulty putting the arm up behind the back or bending the forearm back with the elbow bent, etc.? Our clinical studies indicate that 50% of our patients no longer have any pain 1 month after the operation and almost all MCD patients no longer have any pain at 3 months post-op.
The first night following the MCD non-surgical operation for adhesive capsulitis frozen shoulder is the MOST critical time for patients in ensuring maximum success. It is also the most difficult night and the most painful night. If a post-op MCD patient is able to clearly follow their instructions to wake up hourly without fail and perform their prescribed MCD shoulder recovery exercises exactly as instructed, their improvement and recovery will proceed well.
To do this, however, is often not easy for some patients especially if they are especially pain sensitive. After Dr. Austin Oolo has conducted the MCD operation, he will bring the patients arm well up above their head. The end range of approximately 10-20 degrees of this restored motion will often be quite painful to do but, when you are there in the recovery room with the doctor, you will repeatedly move it into this range. A straight line will be drawn up your arm when it is up fully and you and your support person will be told to ensure that you get it back fully to this point at least twice per hour.
Many patients will return to see Dr. Austin Oolo for the post-op follow up the next day being slightly discouraged because, over the course of the night, they felt they were not able to get it to the same end range and that they have lost some of the motion they gained with the operation. The main reason usually cited for this finding is that they felt like it was too painful to put it into the final end range.
Because we are obviously all programmed to equate pain with doing damage we are all naturally afraid of doing things that are painful. Left to their own devices on the night following the MCD operation, with the effect of the medication having dissipated, patients will often begin to think that something went wrong or that the pain they often experience doing their exercises is not normal. As a result, they may shy away from performing the exercises, as they have been instructed, to the end range.
If patients do not reach into their end range on the first night post-op, they will definitely begin to lose that range and will not be moving as fully the next day as they were immediately after the operation.
The patients who have this happen often come in the next day, pleased with the significant improvement they have gained but still slightly discouraged that they have lost a bit of the end range. Fortunately, the capsule will not have had enough time to re-attach and reform the adhesions so Dr. Austin Oolo always re-restores the final end range again for those patients in the follow up. This will show them that they can still achieve this range and quickly restores their confidence again to really do the exercises completely. Dr. Austin Oolo will also re-assure these patients that pain for them during their exercises is normal initially and that they will need to make sure they actually work into the pain ranges and do the exercises fully and as regularly as prescribed.
Each and every case of frozen shoulder adhesive capsulitis is different but there are some general observations we have made over the last decade. Although a small number of patients surprisingly have no pain the day after the operation, most do still have some pain for a period of time following the procedure during their healing and recovery phase. Many have no pain at all other than when they reach the end ranges of movement during their post-op MCD recovery exercises while others still experience various forms and locations of pain for some time after the MCD operation.
It is important to note that the pain MCD patients experience after the MCD operation is a usually a different pain to the pain they experienced from the adhesive capsulitis when their shoulder was still frozen before the MCD operation. This is because, after the adhesions are separated and motion restored with the MCD operation, the shoulder joint is no longer severely impacted and swollen meaning that the pain originating specifically from the capsulitis (swollen capsule) will be gone or largely reduced. Any remaining pain will actually be mostly coming from any associated muscles, tendons and tissues, in and attaching to the shoulder joint, which are damaged, swollen or still in a state of repair. These other involved tissues and physical structures will still need some rehabilitative exercise and/or therapy, post-op MCD, to restore them to normal and, therefore, eliminate the pain which originates from them. The good news is that, once motion of the shoulder joint has been largely restored with the MCD operation, rehabilitation of the associated shoulder tissues will finally be possible. When the shoulder joint is still frozen these tissues cannot and will not heal regardless of how much physical therapy is applied or exercise done. Following the MCD operation, with motion restored, your shoulder will finally be given the green light to fully heal.
Post-op MCD patients just need to be aware that the recovery process and healing will sometimes still take a number of weeks or even a few months so they need to have patience!
It is important for those considering the MCD operation, to know that, if motion is not restored and their shoulder joint remains frozen for months or years, these underlying shoulder conditions will usually also deteriorate and actually worsen. In addition, the actual shoulder joint itself, will deteriorate and permanently degenerate, more and more, the longer the joint remains completely or partially immobilized. It is, therefore, critically important to have the full range of shoulder motion restored as soon as possible after the onset of the adhesive capsulitis. The MCD non-surgical operation is the world’s first and only method of immediately restoring shoulder joint range of motion safely and effectively with a near 100% success rate.
For the majority who still have some pain for some time following the operation will find that the residual post-op MCD pain is quite different to the adhesive capsulitis pain. As already stated, residual post-op soft tissue pain can last for days, weeks or even a few months depending on the case and how many underlying conditions may preside. The overall post-op pain our patients experience, however, is usually considerably less than it was before the procedure. If it is still quite intense, it means that there are still some unresolved issues in the shoulder tissues which will require exercise, therapy and time to resolve. Again, be patient. You will get better and it will still be much faster than if you went for any other therapy.
Many patients with later stages of adhesive capsulitis no longer have severe or constant pain and only have pain if they move suddenly beyond their restricted range of motion or if they hit their arm on something. Most patients clearly note, however, that they are finally able to sleep without pain already the first night after the procedure and in that pain no longer wakes them up. This is a big breakthrough for many of our patients as so many have lost months or years of sleep because night-time is when their pain is usually the worst due to increased swelling at night.
It is logical that pain will still exist following the MCD operation when one considers that much of the pain comes from inflammation and that internal joint tissue has been physically separated. Consider having a surgical operation performed where tissues are cut externally and internally. It is expected to have pain for some weeks or even months after orthopaedic surgery where tissues need to heal and function needs to be restored during the post-op rehabilitation period. The MCD operation is like undergoing surgery without being cut open from the outside. The MCD non-surgical approach, however, is much better in that, because the body remains closed from the outside, the recovery is much faster.
Following the MCD operation, the length of time for complete recovery and the length of time with residual pain depends on many factors such as the severity of the adhesive capsulitis, the consistency of the patients’ connective tissue, how long the shoulder has been frozen as well as complications from pre-existing conditions associated with the adhesive capsulitis frozen shoulder.
The most common post-op residual pain location is in the side shoulder muscle (deltoid) about a third of the way down the arm where this muscle joins into the arm bone (humerus). There will be a hard lump of tissue about the size of a large denomination coin. Because the upper arm shoulder bone (humerus) is virtually hanging in space and only held in place by the suction effect of the rotator cuff and shoulder capsule, there will be a continual stress on the deltoid, especially where it joins into the humerus part way down the upper arm. The constant contraction stress will cause a physical change in the consistency of the deltoid muscle especially at the insertion point on the humerus (deltoid tuberosity). The deltoid muscle tendon at this point becomes fibrotic meaning that the tissue physically hardens and becomes less pliable. This contracted and hardened fibrotic deltoid tendon will be irritated constantly with the static load in attempting to hold the shoulder in place and every time the shoulder is moved causing inflammation and pain. This point of pain, and associated pain down the middle of the deltoid muscle, will often be the last pain to dissipate and disappear in cases of adhesive capsulitis and frozen shoulder impingement syndrome. The muscle will slowly soften and again become more pliable and less painful over time as the shoulder is repeatedly raised and lowered with the muscle moving through its full contraction and relaxation range. Careful stripping massage through this muscle knot in an upward direction toward the shoulder joint with laser treatment is useful in expediting the resolution of this pain. Even with some physiotherapy and soft tissue treatment for this problem, it is not uncommon for the mid deltoid muscle point pain to last for 1, 2 or even 3 months in severe cases. Again, be patient as this scenario is quite common in those suffering with adhesive capsulitis and frozen shoulder impingement syndrome. It will improve!
Pain in the front of the shoulder is also quite common in association with frozen shoulder. Usually it will be either point pain at the top front of the shoulder bone and/or pain down the inside groove of the front of the upper arm and shoulder at the inside border of the front shoulder muscle (anterior deltoid). This pain will be due to the often pre-existing condition referred to as tendonitis (tendon inflammation). In the case of front shoulder pain it will almost always be due to a tendonitis from strain micro-tear injury with resulting chronic inflammation of either the biceps tendon or the supraspinatous tendon. Frequently, with cases of adhesive capsulitis frozen shoulder, patients have MRI radiographs which show that there is inflammation and also often partial thickness tears of shoulder muscle tendons with the biceps and supraspinatous being the most common. (This finding does not interfere with or prevent the MCD non-surgical operation from being performed.)
The biceps tendon is a very long tendon coming up from the elbow which functions in raising the humerus up in front of the body (shoulder flexion). The biceps muscle will usually be both weak and short when it is involved. Neurological re-strengthening of the biceps will have been
conducted both before and after the MCD operation in the pre and post-op Trigenics treatments. When the biceps is chronically contracted in cases of adhesive capsulitis frozen shoulder it will need to be functionally lengthened following the re-opening of the shoulder joint with the MCD procedure. The most effective method of functional muscle lengthening is the Trigenics Myoneural Lengthening (TL) Treatment Protocol for the biceps. This treatment protocol will usually be performed post-op after the MCD operation on the same day or in the next day’s follow-up visit. (Some soft tissue treatment carefully performed in a way similar to the deltoid stripping technique may also be needed to address physical fibrotic changes of the biceps as well.)
The supraspinatous tendon is a shorter tendon originating from underneath the upper trapezius muscle at the top of the shoulder blade and upper back. This important shoulder muscle is one of the 4 rotator cuff muscles which, together, act to hold the humerus up in place. The supraspinatous muscle also initiates raising the arm up from the side. It also pushes the top of the humerus down as the arm is being raised so as to create more space at the top of the shoulder joint. This important action makes sure that there is enough room in the joint so that the shoulder bones do not hit together when the arm is raised above shoulder height. Inflammation and accompanying weakness of the supraspinatous muscle tendon (tendonitis) will respond best to application of the Trigenics Myoneural Strengthening Treatment Protocol with accompanying physiotherapy modalities (laser, ultrasound) and home exercise post-op MCD. Fibrotic physical alteration of the muscle texture/consistency which feel like painful lumps in the muscle and tendon, will also possibly require some soft tissue massage-like techniques to be applied carefully.
Depending on severity of damage, pain in the front of the shoulder from bicipital or supraspinatous tendonitis can last for 6-12 weeks post-op MCD even with rehabilitative treatment so this also requires patience and attention.
Pain in the top of the shoulder joint will usually be created from a shoulder impingement syndrome and/or an inflammation of the padding or bursa between the bones and the muscles (bursitis).
This means that there will be less physical room inside the shoulder joint when the arm is raised causing increased pressure and pinching of the tendons between the shoulder bones. This pinching pressure can be quite painful and prevent a person without adhesive capsulitis from being able to raise their arm up above the horizontal to put it up high and reach back without pain. This means that, even with the shoulder joint re-opened and mobilized with the MCD procedure, when a pre or co-existing impingement syndrome and/or bursitis is present, patients may still experience a lot of pain toward the end ranges of motion. Some continued pain or restricted end-range motion following the MCD procedure, therefore, does not mean that the MCD operation was not a success.
It almost always means that the patients pre-existing impingement condition has been exposed and still exists following the MCD procedure. In these cases, the affected patients will certainly need to attend for post-op care after the 2-4 week recovery period. Bursitis is very persistent as there is very little blood supply to the bursa meaning that healing of this condition can take a very long time. Patients with shoulder bursitis without adhesive capsulitis can take up to 6 months to heal so it can be quite intractable and also requires patience.
Pain in the back of the shoulder will usually be caused by inflammation and sometimes partial tearing and contraction of the shoulder rotator cuff muscles which originate on the shoulder blade and which turn the arm and shoulder outward (infraspinatous, teres minor). Patients with these muscles affected will often have weakness in turning their arm outward and tightness in the back of the shoulder when they try to reach across to the other side of their body with their affected arm elbow bent.
This condition responds well to Trigenics myoneural post-op treatment and will improve over the coming weeks following the MCD procedure with a specific follow-up Trigenics exercise provided to these patients.
Pain deep in the shoulder up into the arm pit is usually caused by tearing or inflammation of the 4th rotator cuff muscle (subscapularis) which the deepest muscle and which rotates the arm outward. Like the other shoulder muscles affected in this way, the subscapularis will respond and heal over the coming weeks following the MCD procedure using Trigenics, physiotherapy modalities and exercise.
Some patients will still experience pain in the elbow and forearm for some time after the MCD procedure. Pain on the inside of the elbow joint is usually due to contracture and shortening of the biceps muscle and tendons which frequently occurs in association with adhesive capsulitis frozen shoulder. If the biceps muscle was slightly damaged with micro-tears and inflammation (bicipital tendonitis) there will be more pain in one or both ends of the biceps at the shoulder or the elbow.
If the pain is on the outside of the elbow, it usually means that there was some strain or injury to the triceps muscle and tendon at its attachment on the bump of your elbow. (Remember that injury often occurs without the person knowing it has happened because it takes 3 full days before the inflammation peaks and pain begins in many cases. This is why so many people claim they can’t remember hurting their shoulder.)
Hand numbness at night is also a frequent complaint. Usually this complaint will have already surfaced before the shoulder became frozen but sometimes is shows up during the existence of the adhesive capsulitis frozen shoulder.
When the hand is numb during sleep hours, it pretty much always indicates that there is compression of nerves in the region of the neck.
The nerve compression usually occurs in 1 or more areas with there being 3 primary sites:
1) The holes where the nerves exit from between the vertebrae,
2) The area above the inside portion of the collar bone and
3) the spinal canal.
If the source of compression is due to closing of the holes between the spinal bones in the lower neck, it is usually due to degeneration of the spinal disc between the 5th and 6th neck vertebrae. This, in turn is usually due to reversal of the normal neck curvature in a way that the head is held too far forward. This is extremely common in cases of adhesive capsulitis frozen shoulder. In these cases, it will be very important for the frozen shoulder patient to attend to a chiropractor, osteopath or physiotherapist who has training in structural neck curve correction treatment. Non-surgical spinal disc decompression therapy is also often quite effective in increasing disc height and space between the vertebrae. Some spinal manipulation is also helpful. Either way, this structural aberration needs to be addressed in order to prevent further shoulder problems from developing.
On the day of the MCD operation, Dr. Austin Oolo will perform some specialized neck muscle reprogramming treatment to the muscles of the neck to start the structural correction. He may also elect to perform osteopathic manipulation procedures on the neck vertebrae to initiate restoration of movement such that pressure on the discs and exiting nerves is lessened.
If the lower arm and hand pain originates from compression of nerves above the collar bone, it is due to contraction of the muscles on the front and side of the lower neck called the scalenes. This is also common with adhesive capsulitis and causes the nerves which carry messages to the shoulder, arm and hand to be compressed between the muscles and the first rib. This condition is called Thoracic Outlet Syndrome or TOS. At night when the body is at rest and the blood slows down, the water pools more and this increases water retention in the tissues and inflammation.
Increased swelling causes increased pressure on the nerves. When this occurs, the lower regions where the nerves deliver messages do not receive transmission and feeling is lost causing â€œnumbnessâ€ in the hands and fingers. Special treatment of the scalene muscles using Trigenics myoneural muscle reprogramming protocols will be performed before and after the MCD procedure in order to begin to functionally lengthen the scalene muscle to take pressure off of the nerves.
If the nerve pressure is coming from the closure or stenosis of the spinal canal, you will be referred to and orthopaedic surgeon as this must be treated using less conservative measures. This scenario is not very common.