Chronic Shoulder Pain

The Shoulder

The shoulder is a ball and socket joint with a ligament above it. This forms an arch, which is called the subacromial space. The ligament attaches to bony prominences (the ‘acromion’ and coracoid’) on your shoulder blade.

The ball is controlled and centred in the socket by a group of deep tendons called the rotator cuff. These tendons pass through a small space under the arch. They are protected by a cushion called a bursa. These tendons are involved in all shoulder movements and function.

One of the key positive changes seen in modern medicine is the concept of “shared decision making”. Decisions regarding surgical treatment are best taken jointly between the surgeon and an informed patient. In addition to the surgeon explaining the procedure, you must take the opportunity to ask and clarify what concerns you the most, no matter how trivial you feel your concern may be!

All surgical procedures are associated with a degree of risk. Your surgical team will do everything possible to minimize the risks and complications. Below is a list of some risks and complications associated with common shoulder surgical operations, but these may differ depending on the exact type of surgery you are having.

The decision to proceed with an operation is an individual choice between every patient and their Surgeon. You will only be offered an operation if your Surgeon believes that this will help improve your symptoms. Very few operations are essential and all have a degree of risk. Some patients can learn to manage their symptoms with painkillers and improve function with muscle strengthening and physiotherapy.

If the subacromial space narrows, the bursa or tendons can become inflamed and painful. This condition is known as a subacromial impingement.

The narrowing can be caused by:

  • weakness in the rotator cuff muscles from wear and tear
  • movements in positions that narrow this space such as overhead activity
  • poor shoulder posture
  • bony changes

These can cause a vicious cycle of irritation, pain and muscle weakness.

The cycle of rubbing and swelling can usually be helped by time, rest, physiotherapy and activity modification. Sometimes cortisone injections can be used to reduce pain and inflammation. However, if your symptoms persist surgery can be considered.

The operation is usually performed as keyhole surgery (‘arthroscopy’) but can also be performed as an open procedure.

A subacromial decompression involves increasing the space under the arch by removing the bursa, releasing a ligament and excising any bony spurs. This allows the tendon to move more freely, thus breaking the cycle of rubbing and swelling.

During your operation, the Surgeon may identify further damage within your shoulder, which requires addressing. This may require debridement (clean up), tendon repair or tendon release. If a tendon release is performed this may change the appearance of your arm muscle, called a “popeye sign”.

  • Pain levels felt after surgery vary depending on the type of surgery, individual pain thresholds, nature of the problem for which surgery was done and various other factors.
  • Stiffness after shoulder surgery is not uncommon and occurs as a result of pre- existing pathology, surgical scarring and prolonged post-operative protection in a sling. It is very uncommon to see significant stiffness at 1 year after arthroscopic shoulder
  • Bleeding during or after surgery (less than 1%). It is common to have oozing from the arthroscopic wound ports after surgery as the blood-stained sterile water used during surgery drains
  • Infection of the surgical wound is rare with arthroscopic surgery. Early diagnosis of post-operative infection has a significantly better outcome compared to delayed diagnosis. After your operation, you should contact the ward and your GP immediately if you get a temperature, become unwell, notice pus in your wound, or if your wound becomes red, sore or
  • Unsightly scarring of the skin (less than 1%). Most surgical scars have disappeared to a thin pale line by one year after surgery. If you are concerned about your scar you must discuss it with your surgeon or therapist as there are many treatments to improve scar
  • Nerve injury is rare (less than 0.5%) with most shoulder operations, but some larger operations have a higher risk and this will be discussed with you by your surgeon.
  • Vascular injury is very rare (less than 0.5%) after shoulder
  • Anaesthetic related complications such as sickness and nausea are relatively common. Heart, lung and neurological problems are much rarer at less than 1 person in 1,000.

Please discuss these issues with your surgical team if you would like further information.

Frequently Asked Questions

Yes. At first, you will only be moving the joint for specific exercises that the Physiotherapist will show you. You will be referred for continued physiotherapy as an outpatient.

Your wound will have a shower-proof dressing on when you are discharged. You will be given extra dressings to take home with you. You may shower or wash with the dressing in place, but do not run the shower directly over the operated shoulder, or soak it in the bath. Pat the area dry, do not rub. The stitches/clips will need to be removed at your GP practice or your hospital follow up appointment. The nursing staff will advise you when this can happen; it is usually between 10–14 days after your operation. Avoid using spray deodorant, talcum powder or perfumes on or near the wound until it is fully healed. Please discuss any queries you may have with the nurses on the ward.

You may be offered a nerve block for the surgery, known as an interscalene block. The Anaesthetist will discuss this in detail with you before the surgery.

An interscalene block is a nerve block in the neck used to provide a heavy numbness in the shoulder and arm (in the same way that a dentist can numb a tooth) so that the shoulder surgery can be carried out with excellent pain relief.

The benefits of an interscalene block are:

  • Reduced risk of nausea and vomiting and sedation
  • Earlier to leave hospital
  • Early intake of food and drink
  • Excellent pain control
  • Lighter general anaesthetic with speedier recovery from the anaesthetic
  • Less chance of an overnight stay at the hospital

The Anesthetist, Surgeon and you need to decide jointly whether you are suitable for an inter scalene block.

You will be given painkillers (either as tablets or injections) to help reduce the discomfort whilst you are in hospital. A one week prescription for continued pain medication will be given to you for your discharge home. Keep the pain under control by using medication regularly at first. It is important to keep the pain to a minimum, as this will enable you to move the shoulder joint and begin the exercises you will be given by the Physiotherapist.

If you require further medication after these are finished, please visit your General Practitioner (GP).

Yes, your arm will be immobilised in a sling for a period of time. The time and type of sling will vary according to the procedure (see below for the 2 types of sling we may use). This is to protect the surgery during the early phases of healing and to make your arm more comfortable. A Nurse or Physiotherapist will show you how take the sling on and off safely.

If you are lying on your back to sleep, you may find placing a thin pillow or rolled towel under your elbow helpful.

This is usually arranged for approximately 3 weeks after you are discharged from hospital, to check on your progress. Please discuss any queries or worries you may have when you are at the clinic. Appointments are made after this as necessary

For the first 3 weeks you should avoid using your operated arm.

This can be divided into 3 stages.

  1. Sling on, no movement of shoulder except for exercises

You will basically be one handed immediately after the operation. This will affect your ability to do everyday activities, especially if your dominant hand is the side of the operation.

Activities that are affected include dressing, shopping, eating, preparing meals and looking after small children. You will probably need someone else to help you. You may also find it easier to wear loose shirts and tops with front openings.

  1. Regaining everyday movements

When advised, you can gradually wean off using the sling and you will start outpatient physiotherapy. You will be encouraged to use your arm in front of you, but do not take it out to the side and twist it backwards. Exercises will help you regain muscle strength and control in your shoulder as the movement returns. The arm can now be used for daily activities.

Gradually, you can return to light tasks with your arm away from your body. It may take 6-8 weeks after your operation before you can use your arm above your shoulder height.

  1. Regaining strength with movement

Under guidance, you will be able to increase your activities, using your arm away from your body and for heavier tasks. You can start doing more vigorous activities, but contact sports are restricted for at least 4-6 months. This is dependent on the procedure and should be discussed with your surgical team. You should regain the movement and strength in your shoulder within 6-8 months. Research has shown that after 2-5 years about 90 out of 100 people have a stable shoulder with few limitations. Vigorous sports or those involving overhead throwing may require adaptation for some people, although many return to their previous levels of activity.

You cannot drive while you are wearing the sling. After that, the law states that you should be in complete control of your car at all times. It is your responsibility to ensure this and to inform your insurance company about your surgery.

You may be off work between 2-12 weeks, depending on the type of job you have, which arm has been operated on and if you need to drive. If you are involved in lifting, overhead activities or manual work you will not be able to do these for 8-12 weeks. Please discuss any queries with the surgical team

Some difficulties are quite common, particularly in the early stages when you are wearing the sling and when you first start to take the sling off. If necessary, an Occupational Therapist can help advise you. Below are listed some common difficulties with guides which may help.   If you have any caring responsibilities for others you may need to make specific arrangements to organise extra help. Discuss your needs with your GP or hospital staff prior to your surgery.

Getting on and off seats – raising the height can help e.g. extra cushion.

Hair care and washing yourself – long handled brushes and sponges can help.

Dressing – wear loose clothing with front fastening or which you can slip over your head. For ease, also remember to dress your operated arm first and undress your operated arm last.

Eating – a non-slip mat can help when one handed. Use your operated arm once it is out of the sling as you feel able.

Household tasks/cooking – light tasks can be started once your arm is out of the sling. To begin with you may find it more comfortable keeping your elbow into your side.

Your ability to start these will be dependent on the type of stabilizing surgery and on the range of movement and strength that you have in your shoulder following the operation. Your surgical team will advise you on exact timescales for your individual procedure. Start with short sessions involving little effort and gradually increase. General examples are:

Cycling (road non-competitive)                                         8-12 weeks

Swimming (breast stroke)                                                   6-8 weeks

Swimming (freestyle)                                                           12-16 weeks

Golf                                                                                         12-16 weeks

Racquet sports using operated arm                                  12-16 weeks

Contact sports                                                                      4-6 months

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