Considering Key hole surgery of the shoulder?
The shoulder joint is a complex joint. It consists of a large ball at the top of the arm bone (the ‘humerus’) which is joined to a small shallow socket which is part of the shoulder blade. Sitting above the ball is a roof, formed by a bony part of the shoulder blade at the back (the ‘acromion’) and a ligament at the front. The space in between the ball and the roof is called the sub acromial space, see picture. The rotator cuff muscles, which help to move the arm and keep the ball sitting in the correct position on the socket, pass through the sub-acromial space. A fluid filled sac (the ‘bursa’) sits on top of these tendons to cushion them from the bony roof. When the arm is lifted to shoulder height, the sub-acromial space narrows, in positions above and below this the sub-acromial space is much larger.
What is rotator cuff related shoulder pain?
Rotator cuff related shoulder pain (RCRSP) is the medical name for pain coming from the sub-acromial space; you may have heard it called ‘impingement’. It is very common and affects 1 in 5 people at some point in their life, most commonly in middle age, and often in people who do repetitive work than you've not done for some time.
RCRSP is often due to inflammation of the rotator cuff tendons and bursa, though there are many possible causes. Once swollen and inflamed the tendons cause pain, commonly when elevating the arm at shoulder height.
Why does it happen?
The tendons of the rotator cuff are susceptible to wear and tear. With a period of increased demand (e.g. painting the ceiling, washing the windows or pruning the hedge) it can be enough to trigger off a process of inflammation, swelling and pain. Sometimes arthritis in the joint between the collar bone and shoulder blade – the acromioclavicular joint or ACJ – can contribute to shoulder pain.
Did you know?
The shoulder is one of the most complex joints of the body. It relies heavily on muscular strength to enable it to function.
Did you know?
Smoking significantly increases the time it takes for your body to heal and recover after an injury. It can also make us more sensitive to pain.
Did you know?
In most cases, shoulder pain can settle with a mix of rest and exercise.
How do I know if I need surgery?
Many of the common problems associated with shoulder pain can be managed with a combination of exercise, activity modification and medication. If you have not already done so, talk to a Physiotherapist who will be able to guide you towards the best type of exercise that is most suited to you. Remember that any exercise needs time to take effect.
If you have had a fracture, osteoarthritis or there has significant tear in the shoulder muscles, then that represents a structural change to your shoulder This means we can't always expect it to behave in the same way it used to. The treatments available may aim to help you manage and reduce symptoms, not fully take it away.
Alongside Subacromial Decompression, you may have surgery to:
Fix / repair torn muscles (rotator cuff)
Fix / repair the labrum
Remove excess calcium
Debride (shave) the Acromioclavicular joint (ACJ)
If you have tried exercise, activity modification and medication and are still unable to manage the pain, an X-ray may be taken of the shoulder to look at the amount of change that has happened.
It is important to remember that everyone is different and the amount of change we see on an X-ray does not equal the amount of pain or discomfort we experience. You may also have an Ultrasound scan. This helps us understand the condition of the soft tissue (muscles) in the shoulder. Again, it's important to remember that it can be normal to find age related changes on a scan that are not always causing us pain.
You may be offered an injection into the shoulder joint to help settle the pain. The injection contains a powerful anti-inflammatory (steroid) which can help to settle stiffness, pain and swelling. Injections are best used alongside graded exercise, as the stronger you can get the shoulder to be, the longer the injection can last. You can only have 1 injection every 12 weeks. This limitation is to help prevent further damage to the shoulder.
We know that most shoulder pain will settle if its given the right about of rest and exercise. If you have not done so already, try some of the basic shoulder exercises below. It will take time to build up the strength around the shoulder. If you are unsure what you should be doing, speak to a Physiotherapist.
If you have tried all of the options and you have signs of inflammation or tears on a scan, then you may be referred to an Orthopaedic Consultant. The decision to have surgery should not be taken lightly. It is important to discuss everything with your family, friends, healthcare professionals and Doctor. The decision usually revolves around how much your shoulder is impacting YOU and YOUR daily life. If you are unsure of this impact, try the Oxford Shoulder Questionnaire here
Advice from a Shoulder Consultant
Mr Charlie Talbot talks about Subacromial Decompression (ASD) Surgery
What is arthroscopic sub acromial decompression?
Arthroscopic subacromial decompression (ASD) is performed for patients who have a painful shoulder that has not resolved with non-surgical treatments. The operation helps to prevent the bones and tendons in the shoulder rubbing against each other when the arm is raised. The procedure involves removing the inflamed bursa, cutting the ligament and shaving some bone (from the acromion) to create more space for the tendons to move freely. This, combined with rest and exercise can help to reduce your shoulder pain.
People with ACJ pain may also be listed for an ACJ resection – a procedure to shave some bone from the end of the collar bone. This is performed by keyhole (arthroscopic) surgery, as a day case procedure
What are the risks?
Wound infection - rare and usually involves the skin. Occasionally a deep infection can occur, the risk is less than 1%.
Stiffness – shoulders can become stiff after shoulder surgery. Around 5% of patients develop stiffness that normally resolves with physiotherapy.
Nerve injury – there is a very small risk to nerves around the shoulder. The risk is less than 1%.
On-going pain – 5-20% of patients will have some on-going discomfort / pain after surgery.
Anesthetic - This is the medication used to put you to sleep for the operation. You should discuss this with the Doctor. It will be different for each patient.
Blood clot - Risk of blood clot in the arm (deep vein thrombosis or DVT) is rare following shoulder surgery. Prevention is by physical means of stockings and pumps in theatre and early mobilisation after surgery (walking). Keeping well hydrated after surgery is also advised (drinking water).
What can I expect?
The first thing to remember is that you are different to everyone else. The speed at which you recover will be very different to everyone else. No two shoulders are the same, and no two operations are the same. You can expect your shoulder to be painful afterwards. You will be given medication and exercise advice to help you with this. For some people, the pain will settle quite quickly. For others, it can take 6-12 months. Try not to compare yourself to others. Your healthcare team should be able to give you a more detailed understanding of how YOU and YOUR shoulder will recover.
So when can I return...
Normally 2 weeks. The law states that the patient should be in complete control of the car, it is their responsibility to ensure this and to inform their insurance company about their surgery.
Up to 6-8 weeks; may need to modify activities for 2-3 months
The hospital will ensure you have the correct medication & pain relief when you go home. This can be different for each patient
Most patients leave hospital the same day. Some patients may need to stay overnight.
2-4 weeks as tolerated
Swimming Breaststroke: As able Freestyle: 12 weeks
Golf: As able Lifting: As able
Racquet sports: Avoid repetitive overhead shots for 3 months
Contact Sport: 3 months