Contact

Rehabilitation

Shoulder surgery can be a daunting experience, but at Spire Dunedin Physiotherapy we are here to guide you through from surgery and what you can to expect, to the physiotherapy process.

Some shoulder surgery you may undergo includes (click on each heading for more information):

Acromioclavicular joint excision

The acromioclavicular joint (ACJ) provides an articulation between the clavicle (collar bone) and the shoulder blade. In some individuals this joint can become problematic and can be a source of pain. In some instances removing this joint can improve the function at the shoulder joint as well as decreasing the pain.

Joint manipulation

The recovery process: what to expect and milestones

Post-operative information

Following this procedure it will be necessary to wear a sling for 1-2 weeks; this is primarily due to the fact that with little muscle bulk covering the area and therefore a slightly limited blood supply, the wound can be slow to heal. This is therefore the priority during the first 10 days after the operation.

The sling needs to be worn throughout the day and during the night also. The sling can be removed for washing and dressing. You will need to avoid actively lifting the arm for the above reasons. Also, in the evening the sling can come off and the arm can be rested on pillows when sitting down, such as to watch television.

Any shoulder operation carries with it certain risks, one of which is shoulder stiffness and in some instances this can lead to a frozen shoulder (capsulitis), therefore during the period of immobilisation, physiotherapy and home exercises are recommended to prevent this complication.

Pain Control

Pain should be controlled with prescription drugs. On leaving the ward you will have a 5-day prescription, after this time you may be able to downgrade to over the counter analgesics which can be discussed with the pharmacist or you may need to visit your GP to continue with the prescription drugs. Ice can be used at home as a useful adjunct or alternative.

Milestones

  • Driving – You may begin driving 1 week after your operation or when you feel comfortable
  • Returning to work – This will be dependent on your occupation, if you are in a sedentary job you may feel happy to resume work after 1 week. However, if your job involves heavy lifting or using your arm at shoulder height, you may require longer
  • Leisure activities – You should avoid sustained, repetitive overhead activities for 3 months
  • Swimming – You may begin breaststroke as soon as it is comfortable for you (ususally approximately 6 weeks). However you should wait 3 months before commencing front crawl
  • Golf – 12-16 weeks post-surgery.

Approximately 3 months after your surgery your symptoms should be 80% better and will continue to improve up to 9 months post operatively.

Find out more about the rehabilitation process

The early goals of rehabilitation

  1. Prevent shoulder stiffness during the initial stages of healing.
  2. Maintain shoulder movement without strong muscle contraction pulling on the wound area.

Exercise Protocol

Weeks 1 – 2:  Sling for 1-2 weeks post-surgery

  • Pendular exercises out of sling
  • Active assisted exercises Flexion, abduction as comfort allows
  • External rotation as comfortable
  • Neck stretches as required
  • Scapula setting in sling.

Weeks 2 – 4: Cease with sling.

  • Continue with active assisted exercises as previous
  • Increase external rotation
  • Introduce hand behind back assisted with walking stick
  • Continue scapula setting and postural awareness.

Weeks 4 – 6:   Increase Active Range of Movement (AROM) as able.

  • Aim for full AROM by 6 weeks
  • Commence light resistance exercises at 6 weeks
  • Flexion, abduction pulls with theraband
  • External rotation with theraband.

Weeks  8 – 12: Focus on increasing cuff power and resistance.

  • Introduce combined movements - external rotation with abduction patterns to 45°, 90°
  • Proprioception exercises with scapula positioning. 

Anterior stabilisation

What causes an unstable shoulder?

Your shoulder joint is surrounded by a capsule, which is thickened in part by very strong ligaments designed to maintain normal joint stability. It is normally very difficult to tear the capsular ligaments, or pull the shoulder out of joint. These type of injuries usually occur when a great deal of force has been applied to the shoulder or arm, e.g. a rugby tackle. This can be described a traumatic dislocation.

Some people naturally have loose shoulder joints, and their shoulder can slip in and out of the joint in more than one direction. This is known as “multi-directional instability”. This can often cause many problems and restrict daily living, as the patient will be afraid their shoulder will come out of the joint if they move their arm in a certain way.

With a severe dislocation the ligaments may become permanently detached from the front of the capsule. This is often described as a Bankart lesion. Your surgery may or may not involve repairing a Bankart lesion.

Shoulder instability is one of the more challenging disorders that orthopaedic surgeons treat. The incredible range of movement your shoulder is capable of is achieved by a balance between the structures that allow motion, along with the structures that stabilise and move the joint, i.e. the tendons, muscle groups and the capsule. Once this balance has been disrupted, it can be challenging to correct without causing excessive tightness or laxity.

How is this treated?

Shoulder instability following a traumatic dislocation can be treated with surgical procedures that are designed to repair and strengthen the ligaments that maintain normal joint stability.

Repairing the torn capsule and ligament back to the bone is called a Bankart repair, and tightening the capsule of the shoulder is called a capsular shift. Both of these procedures can be done using a keyhole technique (arthroscope) or as an open procedure.

Find out more about the recovery process: what to expect and milestones

Post operative information

1 – 2 weeks

  • Day 1 commence with Polysling with body belt attached for 3-4 weeks
  • Finger, wrist and scapular setting exercises
  • Gentle pendular exercises out of sling
  • Assisted elbow flexion and extension
  • Passive flexion as comfortable to 90°
  • Passive external rotation to neutral
  • Postural awareness
  • Return home when comfortable.

2 – 4 weeks

  • Polysling to be removed and weaned off
  • Continue pendular exercises, flexion, extension and circumduction 
  • Commence active assisted exercise as comfortable
  • Active assisted abduction to 60° or more
  • Active assisted external rotation comfortable to neutral
  • Commence proprioceptive exercises (minimal weight bearing below 90°).

6 – 12 weeks

  • Regain scapula and gleno humeral stability
  • Gradually increase your range of movement with active exercise
  • Increase external rotation beyond neutral actively
  • Strengthen rotator cuff
  • Increase proprioception through open and closed chain exercises
  • Progress core stability
  • Ensure and treat posterior capsular tightness if required
  • No abduction exercises with external rotation until 3 months.

Milestones

  • Week 6 – Elevation to pre-operative level
  • Week 12 – Minimum 80% range of external rotation compared to asymptomatic side
  • Normal movement patterns throughout range
  • Driving should be possible after 8 weeks
  • Return to work – light duties as tolerated after 6 weeks, heavy duties at 3 months
  • Swimming – breaststroke at 8 weeks, feestyle at 3 months
  • Golf – 3 months
  • Contact Sports – 6 months, including horse riding, football, martial arts
  • Racquet sports and rock climbing

Find out more about the recovery process: example exercises

Early Phase Shoulder Stabilisation Exercises (Weeks 1 - 2)

Some example exercises are shown below. Your physiotherapist will discuss your options and guide your through how to correctly complete these exercises.

Shoulder pendular exercises

Position:
Step standing. 
With your arm in sling lean your body forward. Support your body weight resting the un-operated arm on a table.

Action:
Gently rock your weight from your front foot to your back foot, enabling the arm to move back and forth using your body weight, rather than your shoulder muscles.

Progress to taking the arm out of the sling, as you feel comfortable.

Passive flexion < 90 (Weeks 1 - 2)

Position:
Lying on your back.

Action:
Hold your operated arm around the wrist using your unoperated arm. Raise both arms up towards your head using your unoperated arm to assist the exercise.

Repetitions:
Complete 6-10 repetitions 3 times per day.

Progress to assisted weeks 2-4

Passive External rotation to neutral (1 - 2 weeks)

Position:
Lying on your back, 
hold a stick or similar object.

Action:
Start with your elbows tucked in at sides of body. Use your un-operated arm to help move the operated arm, by pushing the stick rotating the arm away from body. Keep elbows tucked in. Move the arm no further than midline to protect the repair.

Repetitions:
Complete 6-10 repititions 3 times per day.

Arthroscopic capsular release

The shoulder joint has a capsule (or thickened ligament) that surrounds the head of the Humerus (the ball) and the Glenoid (the socket). The purpose of the capsule is to act as a restraint to dislocation at the extremes of movement therefore improving the stability of the joint. When this joint capsule becomes inflamed it is commonly termed a 'frozen shoulder’ or 'adhesive capsulitis'. This is an extremely painful condition that also produces a marked restriction in movement in all directions, can make any activity of daily living problematic and can severely disrupt sleep.

The causes of a frozen shoulder are still largely unknown, it can happen following a traumatic fall or injury, shoulder surgery, or a prolonged immobilisation. It can often be associated with diabetes, and there are many for whom there is no explanation at all.

There are 3 phases to frozen shoulder. Phase 1 is the ‘Inflammatory phase’. This phase is associated with the onset of pain and marked stiffness and can last 6 months or more. Phase 2 then begins as the initial very painful inflammatory phase settles. Often a somewhat marked restriction will remain making daily activities such as reaching behind or out in front very difficult. This second phase may last many months.

A frozen shoulder will usually spontaneously resolve and a full recovery can be made 95% of the time but this can take 18 months or more in some cases. A capsular release or Manipulation under Anaesthetic (MUA) are surgical procedures that aim to substantially speed up the recovery of a frozen shoulder, or help those patients with severe pain. These treatments do not provide an instant cure, but usually provide a good return to function and a marked decrease in pain within the first 3 months. The remaining restriction to movement can remain for 3 or more months after this.

The recovery process: what to expect and recovery

The procedure

A capsular release involves making 2/3 small holes in the shoulder and releasing the capsule surgically. A manipulation involves forcibly moving the capsule under anaesthetic. A nerve block can be used in anaesthetics that can render the arm numb for up to 24 hours or more.

These procedures can be painful initially and physiotherapy is essential to help achieve the early goals of rehabilitation following surgery.

Recovery

The early goals of rehabilitation are to:

  • keep the pain controlled
  • ensure that movement is maintained as best as possible.
  • keep expectations realistic.

Pain control

  • Pain should be controlled with prescription drugs. On leaving the ward you will be given a 5-day prescription, after this time you may be able to downgrade to over the counter analgesics which can be discussed with the pharmacist or you may need to visit your GP to continue with the prescription drugs. Ice can be used at home as a useful adjunct or alternative.
  • Pain control is essential as it allows you to do your exercises regularly. The importance of regular exercises cannot be overstated. Following these procedures the capsule needs to be able to heal, if the shoulder isn’t adequately moved during this period then the healing process occurs in a restricted range and you will take longer to reach a full resolution. The exercises need to be done ‘little and often’ and it is worth remembering why you are doing them; to ensure that during the painful stage we maintain as much movement as possible. The number and how often you will have to do these exercises depends on your pain tolerance.

The recovery process: milestones

Milestones

  • Driving - you may begin driving approximately 1 week after your operation or when you feel comfortable
  • Returning to work - this will be dependent on your occupation. If you are in a sedentary role you may feel happy to resume work after 1 week, however if your job involves heavy lifting or using your arm at shoulder height, you may require longer
  • Functional range of movement achieved at 4 – 6 weeks
  • Sleeping – you should feel comfortable sleeping and tablets are no longer required by 3 months, or earlier in some cases.

Your physiotherapist will aim to see you in the first week following your surgery, to ensure you are exercising to the right level. Depending on your progress at this point will determine how regularly you will need to be seen by a physiotherapist.

Arthroscopic subacromial decompression

Shoulder impingement syndrome

Shoulder impingement is caused by the tendons of the rotator cuff becoming compressed between the joint and the shoulder blade. This is usually due to a narrowing of the space in which they sit, due to the formation of bony deposits or spurs. The Subacromial space is formed by the part of the shoulder blade, called the Acromium, and the head of the Humerus. Shoulder impingement can become a very painful and inflammatory condition, which can in turn lead to a weakening of the rotator cuff tendons.

The recovery process: the procedure

Arthroscopic decompression - the procedure

This procedure is a minimally invasive technique, which employs ‘keyhole’ surgery, thus enabling a faster recovery. It usually takes approximately 3 months following the surgery, to experience pain relief, and 6-9 months for the end point.

The aim of the procedure is to create more space for the tendons of the Rotator Cuff to pass through. By removing part of the Acromial bone and associated bony spurs, more space is created enabling the tendons to glide more freely.

The recovery process: milestones

Milestones

  • 1 - 2 weeks post operative to be able to return to driving as able
  • 6 weeks – a full range of movement should be possible
  • Lifting, as able
  • Return to sports: swimming - this can take up to 2 months, golf - this usually takes over 3 months, racquet sports - this can take 3 months or more.

Rotator cuff repairs

The muscles around the shoulder girdle can be broadly split into 2 groups:

  1. The movers: These are all the muscles around the shoulder that produce powerful movements such as lifting, i.e. The Pectorals, Latisimus Dorsi, Trapezius, Deltoid, Biceps and Triceps.
  2. The stabilisers: These are needed to control the head of the Humerus (the ball) in the Glenoid (the socket) while the arm is moving, This allows the powerful movers to work efficiently and to minimalise shoulder dysfuctions which can result in pain. The Rotator Cuff is a collective term given to the following muscles: Supraspinatus, Infraspinatus, Subscapularis and Teres Minor that form a strong cuff around the shoulder joint. A muscle becomes a tendon when it inserts into a bone, thus the term muscle and tendon are often synonymous.

The Supraspinatus muscle is the most commonly injured muscle. Its tendon runs under the bone on top of the shoulder and can get squashed between the underside of the shoulder blade and the head of the Humerus (the ball).

Commonly patients notice a loss of power in the arm, changed patterns of movement and often pain, especially at night. The aims of surgery are to try to address these problems, however a full range of movement and normal power is not always achievable. Not all tears are painful and to some extent may be a consequence of ageing; not all tears require surgery.

Shoulder surface replacement (Copeland Surface Replacement)

Osteoarthritis (OA) of the shoulder is a painful condition that can cause a significant loss of function over time. The condition is usually characterised by a loss of the normal smooth surface of the ball and socket joint, which make up the shoulder. The cartilage that usually provides this smooth surface cannot be restored once arthritis has become established, thus the result is a loss of comfort and function of the shoulder, which is difficult to regain.

Surgery: what to expect and the procedure

What to expect from surgery

Joint surface replacement surgery can help to improve the mechanics of the shoulder by providing a smooth surface, which is often less painful. It cannot however, make the joint as good as it was prior to the arthritis. The effectiveness of your surgery depends on your level of motivation, the condition of the shoulder, your age, your surgeon and your Physiotherapist.

The aim of a surface replacement is primarily pain reduction; however, other benefits may include improved stability and function. These are however, very much dependent on your rehabilitation with your Physiotherapist, and the quality of the deep muscles around your shoulder.

The procedure

This is usually performed under a general anaesthetic, with a small incision being made on the front of your shoulder. The surface replacement is a small metal cup like device that is attached onto the top your arm bone (humeral ball). For the majority of patients the socket (Glenoid) part of your shoulder does not have to be replaced, but can be refashioned to create a smooth surface.

During the procedure some of the muscles around the shoulder are released to enable the surgeon to get into the joint. These muscles are reattached towards the end of the procedure.

Your recovery

When you awake from your surgery, your arm will have been placed in a sling by the surgeon. It is usual for patients to continue wearing the sling for up to 4 weeks. It is fine to use your hand and elbow out of the sling during the day, with your arm close to your body. However when in the sling, you will probably need help with activities such as dressing, or washing your hair. It is usual for the sling to remain on at night for 4 weeks.

Pain control

During your stay your post-operative pain will be controlled by prescription medication on the ward. On leaving the ward you will be given a 5 - day prescription, after this time you may be able to downgrade to over the counter analgesics, or you may need to visit your GP to continue with the prescription drugs. Ice can be used at home as a useful adjunct or alternative.

The recovery process: physiotherapy and milestones

Your recovery

A surface replacement is a big undertaking with regards to the rehabilitation. You will need to see your physiotherapist once or twice a week during this initial stages (depending on how well your shoulder moves) and to prevent stiffness. Following this, your physiotherapy sessions will become less frequent as you continue your exercises independently and move through the subsequent stages of rehabilitation, namely the return to functional activities and finally to hobbies and interests. This can often take up to 9 months.

Recovery milestones

  • Sling up to 4 weeks
  • Return to driving 4-6 weeks
  • Regain passive range of movement. This can take up to 6 weeks, although it is unlikely full movement will be achieved
  • Regain active range of movement. This can take up to 12 weeks, although it is unlikely full movement will be achieved
  • Lifting: avoid heavy lifting for 4 months

To contact us

Call the Physiotherapy team on 0118 955 3413

Use the enquiry button below and complete the form

E-mail dunedinphysio@spirehealthcare.com