Shoulder Capsule Tightening Surgical Procedures

Shoulder capsule surgery is a treatment option for shoulder instability that doesn't improve with more conservative, non-surgical methods.

Shoulder instability can lead to subluxation (coming partially out of the joint) or dislocation of the shoulder joint. This happens when there is too much mobility of the shoulder joint, and the ball can come out of the socket.

In general, there are two categories of shoulder instability:

• Traumatic shoulder instability: The shoulder can come out of the joint when a healthy shoulder joint is pushed too far, causing damage. This occurs most often in sports or due to an injury, such as a fall or a car crash. When the shoulder is forcefully dislocated from the joint, the ligaments or tendons can tear. A Bankart tear is the most common injury after a shoulder dislocation.
• Multidirectional instability (MDI): When the shoulder joint is too loose, it can cause symptoms, even with normal activities. Your shoulder may dislocate or subluxate with simple movements, not necessarily traumatic events. In these situations, instability is the underlying problem, not trauma or injury.

If you have multidirectional instability of the shoulder, you would typically be prescribed nonsurgical treatments, like physical therapy. Often, these treatments will help prevent further episodes of instability by strengthening the muscles surrounding the shoulder to better stabilize the joint. But sometimes therapy isn't unsuccessful, and surgery may be necessary.

Shoulder Capsule Surgery

The shoulder capsule is the envelope that surrounds the shoulder joint. It contains several ligaments, that stabilize the shoulder. Typically, multi-directional instability is associated with lax ligaments and a loose capsule that's described as having pouches.

Surgery for correction of multi-directional instability is aimed at tightening the ligaments and decreasing the overall size of the shoulder capsule.

In general, there are two surgical approaches:

• Traditional surgery happens via a capsular shift, which is an incision over the front of the shoulder.
• Arthroscopic surgery is done through small incisions and the aid of a camera inserted into the joint.

Open Capsular Shift

An open capsular shift is a traditional surgical approach for tightening the shoulder joint. An advantage of this technique is that it's tried and true.

During this procedure:

• An incision is made along the front of the joint.
• The subscapularis muscle in front of the shoulder is detached to allow your surgeon to see inside the joint.
• The shoulder capsule is identified and split
• The bottom part of the shoulder capsule is pulled up, and then the top is pulled down to decrease the volume of the shoulder joint.

With this technique, your surgeon can visualize your shoulder joint and rotator cuff, and can significantly reduce the volume of the shoulder capsule. The downside of this approach is that recovery is longer than with a less invasive method—in part because of the detachment of part of the rotator cuff.

Capsular Plication

A capsular plication is an arthroscopic procedure, which is less invasive than an open procedure. Healing may be faster than with an open procedure.

During an arthroscopic shoulder plication:

• Your surgeon inserts a camera into your shoulder joint,
• Sutures are inserted through small incisions and are used to "grab" part of the shoulder capsule and sew it upon itself to tighten the capsular tissue.

Advantages of this approach include good visibility with the camera and precise placement of the sutures that are used to tighten the shoulder.

Choosing the Best Shoulder Surgery

The best procedure for you might depend on your injury. And sometimes your surgeon might have more experience or a preference for one type of surgical approach over the other.

One type of procedure, a thermal capsular shrinkage — or thermal capsulorrhaphy — should not be performed. This procedure, popular in the 1990s and even into the 2000s, uses a heat probe to cauterize and shrink the capsule of the shoulder. A number of bad outcomes resulted from this surgery, so thermal capsular shrinkage is no longer recommended.