Shoulder Surgery and Physiotherapy
There are many different types of shoulder operations and this page takes a more in depth look at what is involved with each surgical procedure and how physiotherapy can help with recovery and rehabilitation. Our physiotherapy service sees a great number of people who have had shoulder surgery and are in the process of recovering from this surgery. Our home visit physiotherapy service is based in Lichfield and serves surrounding areas such as Sutton Coldfield, Tamworth, Rugeley, Walsall and Cannock.
Also know by the acronym SAD, a sub acromial decompression is a fairly common orthopaedic procedure used to help with shoulder pain that is not responding to physiotherapy and conservative management. To understand the operation it is necessary to know a small bit of anatomy - the shoulder joint consists of two bones the humerus (upper arm bone) and the scapula (shoulder blade). It is a ball and socket joint consisting of the head of humerus (ball) and the glenoid fossa of the scapula (socket part) and is more formally known as the gleno-humeral joint (GHJ), securing the ball into the socket are 4 important muscles called the rotator cuff muscles which consist of supraspinatus, infraspinatus, teres minor and subscapularis. The tendon of supraspinatus in particular is very important in terms of shoulder pain and surgery as on its way to the head of humerus (ball) it passes through a confined space at the top of the scapula called the sub acromial space. This is a very small area and inside is a bursa (jelly filled sac that reduces friction) and above the tendon is a lip of bone called the sub acromial arch.
Sometimes due to friction or irritation/overload of the supraspinatus tendon or the bursa patients will experience pain coming from this area, this is commonly diagnosed as shoulder impingement and is initially treated with rest, anti-inflammatories and physiotherapy. Now for the majority of patients this will result in complete recovery, however for some patients this will not be enough and they will need surgery - in this case a sub-acromial decompression. This involves an arthroscopy (this will usually be a day case and not involve an overnight stay) and here the surgeon will commonly shave some of the bone of the acromial arch off (in order to relieve pressure on the supraspinatus tendon) and usually will remove the sub acromial bursa as this is commonly very inflamed and a source of pain. Recovery from this operation despite being a day operation will be lengthy and will involve a large amount of physiotherapy after an initial period of rest for a week or so depending upon the surgeon's recommendations.
Initially the goal of physiotherapy will be to restore normal range of movement, this can be achieved by some gentle manual therapy from your physiotherapist and a home exercise program designed by your physiotherapist. Once normal range of motion is achieved and pain has become more settled your physiotherapist will prescribe a strengthening program of exercises and may use more intensive manual techniques to relieve any muscle tension around the scapula. In general you would need to expect a lengthy period of many months to make a full recovery.
Rotator Cuff Repair
As described above there are 4 extremely important muscles called the rotator cuff (obviously there are many other muscles but these are commonly injured). Their primary role is to secure the head of humerus (ball) into the glenoid fossa (socket) and help with rotation of the shoulder (hence their name). Sometimes the tendon of supraspinatus (near where it inserts into the head of humerus) becomes worn and frayed, this may be because of age or overload.
When this happens patients will often experience pain on raising their arm out to the side and above their head. If the tendon becomes worn too much then it can rupture completely and will (dependent upon age) need re-attaching. Rotator cuff repairs can vary from complete rupture of the tendon and re-attachment to a small repair of the tendon after it has frayed and worn. Again these are usually done arthroscopically and will mostly be day case surgery.
With a full rupture of the tendon however the recovery process is much longer than that of a sub-acromial decompression as it is necessary to allow a significant period of time for the tendon to be securely attached to the joint and not rupture again. Initially as with all shoulder surgery the goal is to slowly re-establish range of motion - however if you have had a rupture of the tendon then you will need to avoid some movements of the shoulder initially (your surgeon will give clear instructions about this). Physiotherapy will be a key part of your recovery and ideally you will have access to ongoing physiotherapy throughout the recovery process. Once your surgeon has removed any restrictions on movement then you will need to build up strength throughout the full range of motion of your shoulder, you should expect this to be a lengthy process (6months - 1year).
Around the glenoid fossa (socket) is a piece of fibro-cartilage that serves to enlarge the socket part of the joint and improve the stability and fit of the head of humerus. It is also the attachment point for several tendons and is subject to considerable stresses. Occasionally it can be torn or injured - this would usually be done by overhead throwing activities - bowlers or javelin throwers being particularly susceptible, it can also occur due to trauma most notably in shoulder dislocation after which it is very likely that the labrum will have been damaged. Labral tears in general are likely to require surgery as the cartilage does not repair itself very well and often causes considerable pain in particular positions. There are various types of labral tears and surgical procedures but the most common one is called a SLAP tear. As with the arthroscopic procedures described above it is usually only a day operation but again will involve an extensive recovery process with physiotherapy being a key part of this process.
This is a fairly rare operation and is done as open surgery (i.e. not arthroscopically), there are a couple of reasons that shoulder replacements are usually done - firstly a large fracture that disrupts the integrity of the joint sufficiently to make repairing the joint not viable, secondly osteoarthritis of the joint that is giving the patient significant pain that is not manageable with conservative treatment and physiotherapy. This is a major operation and it is reasonable to expect an extended stay in hospital in order to recover from the surgery. Once released and at home you will be wearing a shoulder sling to support the shoulder for at least 3 weeks and will require intensive and ongoing physiotherapy for a significant period. Certainly recovery can continue for up to a period of 2 years and you will need a large amount of ongoing guidance from your physiotherapist as to how to improve the strength and stability of your shoulder.
ThreeSpires Physiotherapy offers patients who have undergone shoulder surgery a method of gaining easy access to regular and intensive physiotherapy at home. With our physiotherapy service patients are able to receive the optimum amount of physiotherapy per week at home thus maximising their potential for making a good recovery. If you have had shoulder surgery through the NHS then it is often the case that you will not receive the ideal number of sessions of physiotherapy. Our physiotherapists can supplement this NHS physiotherapy provision and help you to make recover better.
Due to the complexity of shoulder surgery and the shoulder joint itself, the need to clearly determine any protocols from the surgeon and the lengthy assessment process; treatment sessions are 1 hour for all sessions including follow ups. It is our experience that this extended period of time allows for a much greater benefit and response to therapy and is especially beneficial for patients who are in significant pain and benefit from a slower and more progressive approach to rehab.