Shoulder Stabilisation Surgery in Bath
Mr Chambler has been a Consultant Orthopaedic Surgeon in the United Kingston for the past 13 years. He qualified from St Mary’s Hospital Medical School, part of Imperial College London. Embarking on his surgical career, his interest soon became Orthopaedics and in particular shoulder and elbow surgery, being awarded his Masters of Surgery degree in this area by the University of London in 2000.
He gained his Shoulder & Elbow Fellowship with Professor Carr in Oxford and has since been awarded travelling fellowships by the British Elbow & Shoulder Society within the United Kingdom and Europe as well as to the world renowned Mayo Clinic in the United States of America.
Shoulder Conditions
The shoulder is a highly mobile ball and socket joint relying heavily on the labrum for its stability and the stabilising muscles (the rotator cuff) for its control and function.The shoulder can become unstable, causing apprehension, subluxations and dislocations to occur causing pain and dysfunction of the shoulder. There are several reasons this may occur and is assessed using your symptoms, examination and imaging as appropriate.The type of instability will determine if it is best treated with surgery or the non-surgical options. Typically after surgery you will have some discomfort in the shoulder, neck or arm, however regular analgesia will be provided to help manage this. Your shoulder movement and function will need to be limited, using a sling for three to six weeks (depending on several factors) to allow the repair to heal. Function, including driving and work will also be restricted initially. Regular rehabilitation exercises at home are essential to progression and your long-term outcome. These should be gradually progressed along with your movement and function, guided by your outpatient physiotherapist and the ‘safe zones’, ‘pacing’ and ‘soreness rules’ techniques detailed in this booklet. It can often take between four to nine months before you are able to return to ‘relative’ full function.
Shoulder anatomy
The main shoulder joint, the glenohumeral joint (GHJ) is a ball and socket joint, providing a very wide range of movement. It is formed by a ball on the top of your arm bone (humeral head) and a shallow socket (glenoid) which is part of the shoulder blade.
The glenoid is made deeper by a fiberous cartilage called the labrum and the joint is surrounded by a tough fiberous sleeve called the capsule which helps hold the joint together. Together, these structurally aid shoulder stability.
Above the ball and socket joint is a ligament which is attached to a bony prominence (the acromion) on the top for your shoulder blade. This forms an arch over the shoulder joint.
This area above the shoulder joint and below the arch is known as the subacromial space.
To move your shoulder and control the positions of the ball on the socket, you have a group of muscles and tendons known as the rotator cuff.
They attach from the shoulder blade onto the top of the humeral head, passing through the subacromial space. One of these tendons (supraspinatus) sits in the middle of the subacromial space. A small fluid lining, called the bursa cushions this tendon from the under surface of the arch.
Shoulder Conditions
Shoulder Instability
1. Traumatic
The capsule-labral complex is damaged by a major injury or repetitive trauma (such as throwing action). The most common instability is at the front (anterior) called a Bankart lesion.
Other lesions that may occur include;
Posterior Bankart lesion – back of the shoulder instability
SLAP lesion – (Superior Labral Anterior to Posterior) or a tear at the top of the labrum, front to back, involving the attachment of the long head of the biceps (LHB) tendon.
HAGL tear – (Humeral Avulsion of Glenohumeral ligament)
Bony Bankart – a fragment of bone breaks off with the Bankart tear
Hill-Sachs Lesion – a dent in the back of the humeral head which occurs during the dislocation as the humeral head impacts against the front of the glenoid.
2. Atraumatic
The patterning of muscular control around the shoulder becomes unbalanced resulting in the humeral head being displaced upon the glenoid.
What are my treatment options?
The decision to proceed to surgery can be a very complex one, dependent on multiple variables that you will need to discuss with your consultant before deciding the best treatment option for you.
Basic guidelines are; if you have had a significant episode of traumatic instability causing structural damage you will most likely benefit from surgical stabilisation. Atraumatic, muscular patterning instability is rarely appropriate for surgery.
Assessment
What Tests Have To Be Done?
These shoulder conditions are diagnosed from the symptoms you have discussed with your doctor and findings of the examination of your shoulder. A magnetic resonance arthrogram (MRA) will be performed. Other investigations may be performed, such as a computer tomography (CT) scan, electromyography’s (EMG’s), or evaluation under anesthetic (EUA) & arthroscopy if indicated.
Surgery
If you do require surgery, there are various ways the shoulder can be stabilised depending on the type of lesion and direction of instability.
Pre-surgery considerations
Appendix
Post-Operative Exercises
All exercises should be performed out of the sling, three to four times per day once the nerve block has worn off and should not cause any significant increase in pain. Use the ‘safe-zones’, ‘pacing’ and ‘soreness rules’ to guide the progression of your range of movement and repetitions as guided by your outpatient Physiotherapist. If you have any concerns regarding the exercises please call the hospital.
Gentle mobility exercises to be performed while using the sling to avoid your joints stiffening up:
1. Neck – bend your head forwards, to each side and turn to look over each shoulder 4–5 times.
2. Shoulder blades – roll your shoulder blades forwards and backwards 4–5 times. Sometimes the operated side can be stiffer and harder to control, do them in front of the mirror to help perform them evenly.
3. Elbow – bend your elbow up and down 4–5 times, then with your elbow at 90° turn your hand over and over 4–5 times.
4. Wrist and hand – bend your wrist up and down 4–5 times, then stretch your fingers out and make a fist 4–5 times.
Specific shoulder exercises to be performed up until you see your outpatient Physiotherapist:
5. Shoulder passive forward flexion
Lean forwards allowing your arms to gentle come away from your body.
Not into pain. Try to avoid your shoulder blade ‘hitching’ up (arrow). Hold for three. Try to avoid your shoulder blade ‘hitching’ up (arrow). Hold for three seconds and stand back up. Repeat 4–5 times
6. Shoulder passive external rotation
Use your non-operated arm to gentle guide your operated arm outwards.
Not into pain. Hold for three seconds and bring your hands back to the start. Try to avoid your body turning, your shoulder blade dropping backwards or your upper arm coming away from the side of your body. Repeat 4–5 times.
Note: If you have had a frozen shoulder release, exercises 5 and 6 should be performed every hour as tolerated, in order to maximise the range of movement.
