Shoulder Therapeutic Surgery in Bath

Summary

The shoulder is a highly mobile ball and socket joint relying heavily on stabilising muscles (the rotator cuff) for its control and function.

Two of the most common shoulder conditions are subacromial impingement and frozen shoulder. These are assessed using your symptoms, examination and imaging as appropriate.

There are several non-surgical treatments but if these have failed to resolve your symptoms the surgical options should be explored, which will vary depending on your condition.

Typically after surgery, you will have some discomfort in the shoulder, neck or arm, however, regular analgesia will be provided to help manage this. You will require a sling for one to seven days depending on the procedure.

Your shoulder movement and function will be limited by discomfort, stiffness or weakness for at least a few weeks but can continue for up to several months postoperatively. You should gradually progress your movement and function, guided by the ‘safe zones’, ‘pacing’ and ‘soreness rules’ techniques detailed in this booklet.

Regular rehabilitation exercises at home, with the guidance of your outpatient physiotherapist, are essential to progression and your long-term outcome.

It can often take between six to nine months before you are able to return to ‘relative’ full function.

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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 joint is surrounded by a tough fiberous sleeve called the capsule which helps hold the joint together.

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 sub-acromial 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.

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Shoulder Conditions

Sub-Acromial Impingement

In this condition, pain is usually felt at the top of the upper arm and around the shoulder as you move your arm into different positions, especially away from your body and overhead. We do not know exactly why some people are more likely to develop this problem but there can be a variety of contributing factors, such as:

• Overuse or repetitive strain, due to poor posture during prolonged computer work or doing work overhead such as DIY or gardening that you don’t commonly do.
• An injury to the shoulder, such as a fall onto it.
• Rotator cuff weakness, tendonopathy, calcific tendonitis, strain or tear.
• Poor muscle control of the shoulder blade.
• Other shoulder conditions, e.g. frozen shoulder.
• These may lead to wear and tear or pinching of the sub-acromial soft tissues, including the rotator cuff tendons, bursa and long head of biceps tendon.

This may then inflame or swell these tissues, increasing the congestion in the sub-acromial space, causing further pain that may occur at night or at rest, and increasing the likelihood of further impingement if the contributing factors are not identified and corrected.

It is the most common shoulder problem. Twenty per cent of people will have symptoms at some point in their lives. It most commonly occurs between the ages of 45–65.

Frozen Shoulder

In this condition there appears to be an inflammatory process leading to fibrosis of the joint capsule, restricting movement especially rotation of the shoulder and causing pain. We don’t know why it occurs, though it often follows injury, a heart attack or stroke and it’s much more common in people with diabetes.

The condition usually resolves itself in time but can take longer than four years. It is typified by three overlapping stages:

Stage 1
‘Painful’ can last 2 – 9 months with increasing pain on movement, progressing to constant pain including at night. Diagnosis in the early stages prior to restriction of movement can be difficult.

Stage 2
‘Freezing’ lasts 4 – 12 months involving stiffening of the shoulder joint to cause a considerable restriction in range of movement. Pain intensity gradual reduces and felt only at the end of range of movement rather than constantly.

Stage 3
‘Thawing’ lasts 12 – 42 months is characterised by the absence of pain except at end of range and increasing shoulder movement and function.

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What are my treatment options?

The initial treatment options are non-surgical including; advice and education into the conditions, painkillers, self-help strategies, physiotherapy and injections.

As you are attending the orthopaedic shoulder clinic, many of these should have already been tried. Meaning you have probably had the problem for some time, or that it is severely affecting your daily life and therefore the surgical options now need to be considered.

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Assessment

What Tests Have To Be Done?

These shoulder conditions are diagnosed from the symptoms you have discussed with your doctor and findings from the examination of your shoulder. An ultrasound scan or MRI may be needed to show the condition of the soft tissues and if the tendon is being pinched in the subacromial space when you are moving your arm. An X-ray may be used to show the condition of the bones in your shoulder and rule out other pathology.

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Surgery

The surgery is performed arthroscopically (where a camera is placed inside the joint) and will include:

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Pre-surgery considerations

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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.

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