This information has been written to help you gain the maximum benefit after your operation.  It is not a substitute for professional medical care and should be used as guidance in association with advice of the Orthopaedic Clinic and Therapy Department. Individual variations requiring specific instructions not mentioned here may be required.

Shoulder anatomy

The shoulder is a ball and socket joint with a ligament above it forming an arch. The ligament attaches to bony prominences (the ‘acromion’ and ‘coracoid’) on your shoulder blade.

The shoulder joint is surrounded by a deep layer of tendons (the rotator cuff) which pass under the arch. One of these tendons (supraspinatus) commonly becomes worn and painful.  It may swell and rub on the bone, ligament and the bursa (fluid filled sac) above. The bone then may respond to the rubbing and form a bony spur (see diagram below).

Certain movements of the arm reduce the space under the arch, such as when you use or move your arm at shoulder height or above your head. The rubbing causes further swelling of the tendon on the acromion bone.

If the cycle of rubbing and swelling is not broken by time, rest, physiotherapy and cortisone injections, then surgery may be necessary.

Pre-admission clinic

You will be asked to attend a pre-admission clinic before your operation. This is to discuss your past medical history and assess your fitness for anaesthesia. It also allows the hospital to prepare for your surgery and ensure your operation goes as smoothly as possible. It is also a chance for you to ask any questions you may have and alleviate any concerns prior to the surgery.

Please note that neither the surgery nor any other treatment will be done without your agreement (consent). It is your right to refuse treatment at any time, or until you have enough information to feel comfortable about giving your consent.

 

All operations involve an element of risk. We do not wish to over-emphasise them but feel that you should be aware of them before and after your operation. Please discuss these issues with the doctors if you would like further information.

The risks include:

  1. Complications relating to the anaesthetic such as sickness, nausea or rarely cardiac, respiratory or neurological (less than 1% each, i.e. less than one person out of one hundred.)
  2. Infection. These are usually superficial wound problems. Occasionally deep infection may occur many months after the operation (less than 1%).
  3. Persistent pain and/or stiffness in/around the shoulder. 5-20% of patients will still have symptoms after the operation.
  4. Damage to the nerves and blood vessels around the shoulder (less than 1%.)
  5. A need to re-do the surgery is rare. In less than 5% of cases, further surgery is needed within 10 years.

The operation is done by keyhole surgery (‘arthroscopy’). Sub-acromial
decompression involves releasing the ligament from the front of the
acromion, trimming off the under surface of the acromion to remove any bony spurs  and removing the inflamed bursa (see diagram below). This allows the tendon to move more freely and thus break the cycle of rubbing and swelling.

Occasionally the long head of the biceps tendon (LHOB) also becomes damaged and inflamed where it enters the shoulder joint.  In this situation your surgeon may perform a biceps tenotomy—this is where the long head of biceps tendon is released from it’s attachment in the shoulder joint, allowing it to fall down into the upper arm and out of the shoulder joint. As you have another attachment for this muscle this does not normally cause any significant weakness or inconvenience.

It is sometimes required to remove the very end of the collarbone (clavicle) where it meets the acromion to ensure the most space in the arch below it.  This is called an acromioclavicular joint (ACJ) excision. This occasionally requires a small incision to be made over the top of the shoulder. You should still follow the same exercises in this leaflet if  an ACJ excision and/ or long head of biceps tenotomy has been performed.

Will it be painful after the operation? 

Although you will only have small scars, this procedure can be painful due to the surgery performed inside your shoulder. Although the operation is to relieve pain, it may be several weeks until you begin to feel the benefit. It is important that you keep the pain under control with regular pain relief medication. We do not want you to mask the pain but you must be able to feel comfortable. This will allow you to sleep better, complete the exercises and therefore allow the operation to be as successful as possible.

A prescription for continued pain relief medication may be given to you for your discharge home. If you require further medication after these are finished, please contact your general practitioner (GP).

You may have been given an icepack to help relieve the pain and inflammation in your shoulder. Your Physiotherapist or nurse will show you how to place the icepack on the shoulder. Remove the icepack after 15-20 minutes. You may use the icepack every two hours. Do not use the icepack if you experience pain or tingling as a result of the icepack.

What do I do about the wound and the stitches?

Your stitches will need to removed after 10 days. You will need to make an appointment at your own GP surgery for this to be done.

Keep the wound dry until it is healed. Protect the wound with cling film or a plastic bag when washing. If you need to change the dressing take care not to disturb the stitches or pad underneath the dressing. Avoid using spray deodorants, talcum powder or perfumes near or on the wound.

Do I need to wear a sling?

The sling is for comfort only and you can take it on and off as you wish. The body strap is provided for extra support but you do not have to wear it.

Normally the sling is discarded within a week but this is individual for each patient. When you decide to come out of the sling wean yourself from it over a couple of days.

You may find it helpful to wear the sling (with or without the body strap) at night. If you lie on your back to sleep, you may find placing a thin pillow or small rolled towel under your upper arm comfortable.

Alternatively, if you lie on your un-operated side you can rest your arm on pillows placed in front of you.

When do I have a physiotherapy appointment?

You will be seen by a Physiotherapist approximately three weeks after your operation but it may be earlier than this if your shoulder is stiff. This delay allows the discomfort from the operation to reduce and the healing process to be well under way. This will be arranged by the Physiotherapist on the ward. If you would prefer to be seen at a Physiotherapy Department local to you please let the ward Physiotherapist know.

When do I return to the orthopaedic clinic at Yeovil? 

This is usually arranged for approximately three months after your discharge from hospital. Future appointments are made after this as required.

Are there things I should avoid?

There are no restrictions (other than the pain) to movement in any direction. Avoid heavy lifting for at least one week. Do not be frightened to start moving the arm as much as you can. Gradually, the movements will become less painful.

Be aware that activities at or above shoulder height stress the area that has been operated on. Do not do these activities unnecessarily and avoid repetitive overhead activities. Try and keep your arm out of positions which increase pain.

How am I likely to progress?

The discomfort from the operation will gradually lessen over the first few weeks. You should be able to move your arm comfortably below shoulder height by two to four weeks and above shoulder height by six weeks.

Normally the operation is done to relieve pain from your shoulder and this usually happens within six months (for 80-90% of people according to the research). However, there may be improvements for up to one year.

When can I drive?

You can drive as soon as you feel able. This normally is within a week. Check you can manage all the controls and perform an emergency swerve and it is advisable to start with short journeys. It may be required that you inform your insurance company of your procedure to check you are insured.

When can I return to work?

This will depend on the type of work you do and the extent of the surgery. If you have a job involving arm movements close to your body you may be able to return within a week. If you have a heavy lifting job, or one with sustained overhead arm movements, you may require a longer period of rehabilitation. Please discuss this further with the doctors or physiotherapist if you feel unsure.

When can I participate in my leisure activities?

Your ability to start these activities will be dependent on pain, range of movement and strength that you have in your shoulder. Nothing is forbidden, but it is best to start with short sessions involving little effort and then gradually increase the effort or time for the activity.

However, be aware that sustained or powerful overhead movements (eg, trimming a hedge, some DIY, racket sports, etc.) will put stress on the sub-acromial area and may take longer to become comfortable.

Do I need to do exercises?

Yes! You will be shown exercises by the physiotherapist and you will need to continue with the exercises once you go home. They aim to stop your shoulder getting stiff and to strengthen the muscles around your shoulder. The following exercises will help you maintain your movement.

It is important to start the following exercises as soon as you get home. They aim to stop the joint and soft tissues  tightening up and your shoulder getting stiff.

Use pain relief medication and/or ice packs to reduce the pain before you exercise, if necessary. Do short, frequent sessions (eg. five to ten minutes) four times a day rather than one long session.

It is normal for you to feel aching, discomfort or stretching sensations when doing these exercises. However, intense pain or pain that lasts more than 30 minutes after completing the exercise is an indication to change the exercise by doing it less forcefully or less often.

1. Pendulum (shown for left arm)

Lean forwards and let your operated arm hang freely. Start with small
movements and swing your arm:

  1. forwards and backwards
  2. side to side
  3. in circles

Repeat each movement five times

2. Lower trapezius

Sitting or standing. Keep your arms relaxed. Glide your shoulder blades back and downwards. Hold it for 10 seconds. (Do not let your back arch.)

Repeat 10 times.

3. External rotation

Sitting or standing, elbow to your side. Hand near stomach. Take hand away from stomach. (This twists the shoulder joint.)  Can support/add pressure with a stick held between your hands.

Repeat 10 times.

4. Flexion in lying (left shoulder)

Lying on your back on bed/floor. Support your operated arm and lift up overhead. Gradually remove the support.

Repeat 10 times.

5. Flexion in standing

Standing facing a wall, with elbow bent and hand resting against wall. Slide your hand up the wall, aiming to get a full stretch.

Repeat 10 times.

 

Review: 03/20
Ref: 09-18-124