What is it?

The shoulder joint is a ball and socket joint. The round top of your arm bone (the ‘ball’) fits into the groove of your shoulder blade (the ‘socket’). It is dependent on muscles, the joint capsule and a rim of cartilage (called the labrum) to stabilize it during movement. A dislocated shoulder is when the entire ball is out of the socket

The unstable shoulder joint can be repaired using arthroscopic surgery. The purpose of the surgery is to repair torn/stretched capsule and the labrum so that they are better able to hold the shoulder joint in place.

The success rate of this surgery is very high. The vast majority of patients are able to return to work and sport without further dislocations.

Risks of surgery

The main risks associated with this surgery:

  • Infection
  • Excessive stiffness or loss of motion
  • Damage to the nerve that activates your shoulder muscle
  • Failure of surgery i.e. Re-dislocation

Nerve Block for Shoulder Surgery

Patients will often have a nerve block under sedation when having a shoulder arthroscopy and decompression/rotator cuff repair. Once the block is placed (which takes about 10 minutes), more medication will be given resulting in general anaesthesia. You will be asleep for the surgery.

What is it?

  • The type of block is called an interscalene Brachial Plexus block.
  • The effect of the nerve block is to make your shoulder/arm numb
  • Your arm will be numb and immobile for 8-16 hours following the surgery

Does it work?

  • Interscalene blocks have a success rate of about 95%
  • It is a safe procedure and complications are rare

How is it done?

  • Local anaesthetic is injected around the nerves to block the sensation from the body i.e. arm/shoulder
  • An ultrasound is used to see the nerves

What happens after?

  • You may experience tingling in the arm as the block wears off
  • Normal muscle strength and sensation should return within 24 hours
  • Take regular Paracetamol for 5 days after surgery i.e. 1000mg four times per day
  • If further analgesics are required, take an anti-inflammatory tablet eg Nurofen or the prescribed pain tablet

Possible Complications

  • Areas of numbness, weakness and tingling in the arm (1 in 2500)
  • Prolonged permanent nerve damage (1 in 6666)
  • Local anaesthetic spreading into the blood stream and causing illness (1 in 1000)

Should any of these symptoms persist contact Dr Sim’s rooms or after hours emergency.

SHOULDER STABILIZATION

Instructions for AFTER the surgery

Bandaging

  • All wounds are closed with “dissolving “ stitches and covered with waterproof dressing.
  • Leave bulky dressing undisturbed for 48 hours.
  • Remove bulky dressing after 48 hours.
  • Leave waterproof dressing on till review by Dr Sim in two weeks.
  • You may shower and get waterproof dressing wet.

Sling

  • Sling with abduction pillow ON at all times (including sleeping)
  • Remove for daily shower/hygiene and exercise

Physiotherapy

  • You will need to book physiotherapy, this should commence 2-3 days after surgery.

Exercises

  • Do hand and wrist exercises as much as possible whilst in sling
  • Refer to Shoulder Stabilization Rehabilitation Protocol handout

What to expect

  • Swelling. This may track all the way down your arm to your fingers due to gravity.
  • Clear / Blood Stained discharge from wound. THIS IS NORMAL for the first few days.
  • Pain. You will receive a prescription for pain medication on discharge. Pain relief medication works best if taken REGULARY.

Unexpected Symptoms/Signs

  • Excessive persistent pain
  • Pus discharge from wound
  • Fever

Should any of these symptoms persist contact Dr Sim’s rooms or after hours emergency.

Arthroscopic Anterior Shoulder Stabilization Rehab Protocol

Stage 1

Passive Range of Motion (PROM)

(Movement to the joint by a physio, with no effort from the patient)

WEEKS 0-6

Goals

  • Decrease pain and swelling
  • Ensure wound is healing
  • Protect the surgical repair
  • Prevent stiffness

Precautions

  • In the first 6 weeks you MUST remain in a sling (including sleeping). It is often more comfortable to sleep in a recliner or on several pillows.
  • In the first 6 weeks avoid lifting and carrying

Exercise Suggestions

  • Your first physio appointment should be within 3 days after your surgery.

Muscle Activation

General:

  • Posture awareness/exercises
  • Ball/thera-putty squeezes

Scapula (with sling one):

  • Elevation (bring the shoulder blades up) / depression (move the shoulder blades down)
  • Retraction (move the shoulder blades towards the spine) / protraction (move the shoulder blades forward – away from the spine)

Elbow & Wrist:

  • Active and passive – flexion,extension, pronation (rotate the hand so the palm faces down), supination (rotate the hand so the palm faces up) – (avoid elbow flexion if biceps repair or tenodesis)

Neck:

  • General range of motion (ROM) if needed

Shoulder:

  • Passive motion in supine position (lying on your back) through a combination range.
  • 0-2 weeks: Pendulum exercises (see below)
  • 2-4 weeks: Therapist guided supine passive range of motion in therapy sessions
  • 4-6 weeks: Patient passive ROM

DO NOT PROGRESS TO STAGE 2 UNTIL ALL GOALS ARE MET

 

Stage 2

Active Assisted (AAROM) –> Active Range of Motion (AOM)

(Movement to the joint with partial assistance by a physio à movement to the joint provided entirely by the patient)

WEEKS 6-12

Goals

Ensure adequate mobility

  • Active-assisted ROM with progression to active ROM exercises to progressively restore motion
  • Considerably decrease resting pain
  • Initiation of functional activities of daily living

Precautions

  • The sling is no longer necessary
  • You may now use your arm. Avoid having the arm forcefully pulled behind you
  • Continue to avoid heavy lifting or manual labour
  • Do not lift objects overhead with the weight of the object going behind the head. In other words, keep objects in front of you where you can see them.
  • Start driving when you can turn the steering wheel WITHOUT any pain in the shoulder.

PROM and AAROM

  • Must be supervised/instructed by physio
  • Use cane/stick (PROM) progressions: supine – 45o, semi-reclined – sitting/standing – pulleys (=AAROM)
  • e.g. cane/stick exercises, pulleys

AROM

  • Be guided by physio e.g. wall slides

Scapula:

  • Continue with protraction, retraction, elevation, depression
  • Therapist guided advanced exercises for scapula

Cardiovascular

  • Stationary bicycle
  • Treadmill
  • Stairmaster
  • Elliptical trainer (no arms), walking

DO NOT PROGRESS TO STRENGTHENING UNTIL FULL, PAIN FREE ACTIVE RANGE OF MOTION ACHIEVED

Stage 3

Strengthening

MONTHS 3-4 ½

Goals

  • Non-painful normal range of motion
  • Progression of functional activities/heavier activities of daily living below shoulder height
  • Address specific deficits of the affected upper extremity

Precautions

  • Avoid overhead loads with affected arm (especially in the ‘throwing’ position)
  • Avoid activities that cause pain

Exercise Suggestions

AROM

  • MUST continue with AROM exercises to MAINTAIN movement

Muscle Strength and Endurance

  • Progression is endurance THEN strength. Exercises should have HIGH REPETITIONS (3 sets x 30 reps) before adding resistance.

Closely monitor shoulder/postural mechanics and pain throughout all exercises.

Rotator Cuff:

  • Be guided by physio – e.g. resistance bands/tubes

Scapula:

  • Be guided by physio – e.g. Swiss ball stabilization exercises

Cardiovascular

  • Continue with stationary bicycle
  • Treadmill
  • Stairmaster
  • Elliptical trainer (no arms)
  • Walking

Stage 4

Advanced Strengthening & Preparation to Return to Sport

4 ½ MONTHS +

Goals

  • Full pain free AROM
  • Continue to improve muscular strength, stability and endurance with emphasis on external rotation strength
  • Functional activities of daily living above shoulder height
  • Advanced strengthening program

Precautions

  • It is unacceptable to experience pain with activities/exercise. This indicates the load/stresses placed on the arm are too much.
  • In the first 6 weeks avoid lifting and carrying

Exercise Suggestions

Muscle Strength and Endurance

It is important to start with a weight that you can do 30 reps x 3 sets, the GRADUALLY increase the weight with the final aim of 12 reps x 3 sets.

General:

  • Biceps/Triceps
  • Chest press
  • Shoulder press (military press)
  • Reverse flys

Rotator Cuff:

  • Be guided by physio

Scapula:

  • Be guided by physio

Cardiovascular Fitness

  • Train specific to demand of sport (aerobic, anaerobic)

Stage 5

Return to Sport

> 6 MONTHS

  • Return to competitive sport once all goals achieved

AND

  • Physio and Surgeon have declared you fit to do so