general shoulder surgeries ebook

Wellness & Lifestyles Australia

GENERAL SHOULDER SURGERIES E-BOOK

prepared by

Wellness & Lifestyles Australia

2007,2008,2009

Table of Contents Page No. IMPORTANT NOTICE ..................................................................................................... 2 INTRODUCTION .......................................................................................................... 3 SHOULDER ANATOMY ................................................................................................... 4 SUB-ACROMIAL SPACE DECOMPRESSION.............................................................................. 5

The operation .................................................................................................. 5 Rehabilitation: first 24 hours ................................................................................ 5 Rehabilitation: up to 2 weeks post operation............................................................. 8 Rehabilitation: after 2 weeks post operation............................................................ 13

LABRAL REPAIR, CAPSULAR SHRINKAGE AND CAPSULAR SHIFT SURGERIES .................................... 18 The operation ................................................................................................. 18 Advice after surgery ......................................................................................... 18 Rehabilitation: first 6 weeks ............................................................................... 19 Rehabilitation: after 6 weeks .............................................................................. 27

ARTHROSCOPY .......................................................................................................... 34 The operation ................................................................................................. 34 Indications ..................................................................................................... 34 Advice for after your operation ............................................................................ 34 Rehabilitation ................................................................................................. 35

SHOULDER MANIPULATION ............................................................................................ 42 The operation ................................................................................................. 42 Indications ..................................................................................................... 42 Advice after surgery ......................................................................................... 42 Rehabilitation: first 48 hours ............................................................................... 43 Rehabilitation: 2 weeks after surgery..................................................................... 46

SUMMARY ................................................................................................................ 54 CONTACT US ............................................................................................................ 55

MANUAL LAST MODIFIED 7/12/2010

http://www.wellnesslifestyles.com.au Ph: +61 8 8331 3000 Fax: +61 8 8331 3002

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IMPORTANT NOTICE The information provided in this document can only assist you in the most general way. This document does not replace any statutory requirements under relevant State and Territory legislation. Wellness & Lifestyles Australia (W&L) accepts no liability arising from the use of, or reliance on, the material contained in this document, which is provided on the basis that the Office of W&L is not thereby engaged in rendering professional advice. Before relying on the material, users should carefully make their own assessment as to its accuracy, currency, completeness and relevance for their purposes, and should obtain any appropriate professional advice relevant to their particular circumstances. To the extent that the material in this document includes views or recommendations of third parties, such views or recommendations do not necessarily reflect the views of the Office of W&L or indicate its commitment to a particular course of action. © Copyright Australia 2009 This work is copyright. You may download, display, print and reproduce this material in unaltered form only (retaining this notice) for your personal, non-commercial use or use within your organisation. Apart from any use as permitted under the Copyright Act 1968, all other rights are reserved.


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INTRODUCTION Welcome to the W&L series of e-books. You have chosen the edition on general shoulder surgeries and rehabilitation, including sub acromial decompression, labral repair, capsular shrinkage and capsular shift surgeries, arthroscopy and shoulder manipulation. This resource will be beneficial to Anyone who is interested in the anatomy and biomechanics of the shoulder joint Anyone who has difficulties with their shoulder from degeneration or injury and wants to know their

options for maximum recovery Anyone who is wondering what the different forms of shoulder surgery involve Anyone who is participating in a rehabilitation program after shoulder injury or surgery and wants a

comprehensive guide to their exercises Anyone who is guiding someone through a rehabilitation program and wants to deliver comprehensive

and up to date information This e-book will cover information about the anatomy of the shoulder and the ways it is commonly damaged. It will also explain the different surgeries and what to do to maximise recovery. It also will accompany you from the days leading up to surgery until you fully recover with advice, answers and exercises. The information provided is up to date and follows industry standard. W&L recommend that you continue to consult your doctor and physiotherapist so that your progress can be monitored and program tailored to your specific requirements.


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SHOULDER ANATOMY Each shoulder joint includes three main bones: scapula (the shoulder blade) humerus (the arm bone which connects to the scapula) and clavicle (the collarbone which connects the shoulder with the sternum). These joints are held in place by many muscles and ligaments.

Diagram taken from: National Institute of Arthritis and Musculoskeltal and Skin Diseases (2009), Sports Injuries, accessed 28 October 2010 on

http://www.niams.nih.gov/Health_Info/Sports_Injuries/default.asp The most obvious joint is the glenohumeral joint, where the arm attaches to the body in a shallow ball and socket joint. This shallow joint allows for large degrees of movement and relies heavily on muscles and other structures to support the joint. There is a joint capsule which surrounds the glenohumeral joint like a sock with the toes cut off. This capsule has four main muscles around it called the rotator cuff muscles. These muscles have a big role in stabilising the shoulder when the shoulder is moving and work together to hold the humerus in the joint socket. The tendons of these muscles are vulnerable to degeneration around the capsule.


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SUB-ACROMIAL SPACE DECOMPRESSION

The operation The sub-acromial space is a tunnel like structure found in your shoulder where tendons (and other tissues) pass through. This space can be reduced by a thickening of the surrounding bone from degeneration. A sub-acromial space decompression increases the space available and reduces the impingement on the tendons. This is done by arthroscopy (see arthroscopy section).

Rehabilitation: first 24 hours Elbow mobilisation – take off your sling, ensuring that your forearm is kept next to your stomach. Bend and straighten your elbow (using your other hand to help if needed) 10 times with your palm facing up and then 10 times with your palm facing down.


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Wrist mobilisation – move your wrist in circles, 10 clockwise and 10 anticlockwise 3 times a day.

Hand mobilisation – clench and open your hand 10 times hourly, this will help prevent swelling.


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Pendulum out of sling – place your good hand on a surface and lean your body forward so that your arm gently swings forward with your elbow straight. In this position draw large circles, 10 clockwise and 10 anticlockwise. Swing you arm forwards as far as you can go, slowly and controlled, and hold this position for 3 seconds before returning your arm to a relaxed position. Repeat the same exercise out to your side and also across your body.


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Rehabilitation: up to 2 weeks post operation

Posture correction – straighten your back, tuck in your chin, raise your breast bone and draw your shoulder blades downward and together. Repeat this throughout the day and while doing exercises


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Active assisted shoulder lifting – lay on your back and hold your operated elbow with your good arm. Use your good arm to help lift up your operated arm off of your chest, hold for 3 seconds and then lower it back down. Repeat 10 times. The aim is to be able to raise your arms level with your shoulders by the end of the 2 weeks. This exercise can be made harder by doing ‘overhead stick’ exercise.

Overhead stick – laying on your back, pull your shoulder blades together and downward. With a stick held between both hands, lift your arms overhead until tolerated and hold for 3 seconds before returning. Repeat 10 times.


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External rotation stick – repeat as with overhead stick, however have the upper part of the operated arm resting on the ground with the forearm perpendicular to the floor. Use the stick and your good arm to push the forearm towards your head on the floor.


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Sideward pulleys – with posture correction either sit or stand with the pulley rope in your hands (you can drape the rope over a pergola beam or something similar). Have your arms out to the side so that when you pull with your good arm, the operated arm will lift to the side. Go as far as tolerated and hold for 3 seconds before lowering. Try to use the muscles on your operated arm to assist the lift so that you rely less on the pulley rope. Repeat 10 times.

Hand behind back with pulleys – repeat as with the sideward pulley exercises except have the good arm with the pulley in front of you and the operated arm behind you. Pull with the good arm and raise the operated arm higher up the back. Alternatively, a towel can be used with the good arm pulling at the front and the operated arm lifting behind the back.


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Static shoulder exercises – these exercises involve your good arm blocking any movement of your operated arm. With your operated arm by your side and elbow bent 90°, gently try to move your operated arm forwards but resist this movement with your good arm and hold this static contraction for 5 seconds. Repeat 10 times. Repeat this exercise with your operated arm moving backwards, away from your body, squeezing into your body, rotating your forearm outwards and rotating your forearm inwards. Remember, you operated arm should not move in these exercises.


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Rehabilitation: after 2 weeks post operation Forward pulleys – with shoulder blades pulled together and down, either sit or stand with the pulley rope in your hands (you can drape the rope over a pergola beam or something similar). Pull down with your good arm to raise your operated arm as much as tolerated and hold for 3 seconds before lowering. Try to use the muscles on your operated arm to assist the lift so that you rely less on the pulley rope. Repeat 10 times. Eventually do the exercise without using a pulley and use your good arm to assist your operated arm when lowering.

Sideward pulleys – repeat as the forward pulleys exercise but bend your elbows and have your arms out to the side so that when you pull with your good arm, the operated arm will lift to the side.


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Hand behind back with pulleys – repeat as with the other pulley exercises except have the good arm with the pulley in front of you and the operated arm behind you. Pull with the good arm and raise the operated arm higher up the back. Alternatively, a towel can be used with the good arm pulling at the front and the operated arm lifting behind the back.


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Spider walking front – stand face on to a wall and place your hands of the wall with your elbows bent. Crawl your fingers up the wall until you feel discomfort. Take your hands off the wall and keep it level there for 3 seconds before placing it back on the wall on the same spot. Try to crawl up further until you are unable to replace your hand at the same level.


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Spider walking side – repeat spider walking front exercise, but this time stand side on to the wall and crawl your hand up out to your side. Make the exercise harder by standing further away from the wall and straightening your elbow more.


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4 point kneeling – kneel down on all fours and focus on keeping your shoulder blades together and down. Try to evenly distribute weight through both arms as tolerated. Gently rock backwards and forwards, transferring weight from hands to knees and back again. Go as far as you feel comfortable and repeat 10 times. Make this exercise harder by having your hands further out in front of your body.


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LABRAL REPAIR, CAPSULAR SHRINKAGE AND CAPSULAR SHIFT SURGERIES

The operation The labrum is a ring of cartilage surrounding the socket of the glenohumeral joint. Also surrounding the joint is the capsule, these two structures help to stabilise the joint. Labral repairs involve the labrum being reattached to the bone and any damaged or loose tissue being removed. This can either be done as an arthroscopy (see arthroscopy section) or with open surgery. Capsular shrinkage involves heat being applied to the shoulder which causes the capsule tissue to shrink thus increasing the stability around the joint. Capsular shift surgery involves the capsule being cut and the ends overlapped and sewn together so that the previously weaker area is now reinforced.

Advice after surgery

Depending on the doctor’s instructions, your sling will have to be worn for 6 weeks after the operation. This will involve wearing the sling for the first 2 weeks under your clothes.

Only take your arm out of the sling to do exercises and wash. Ensure that you do not move your arm more than 30° away from your body (approximately one

hand length). It is normal to experience pain after your surgery and it will usually be worse at night time. Swelling and bruising usually form and will gravitate down the arm. Take pain relief and continue to ice the shoulder to reduce swelling and discomfort. You can massage the arm (not the shoulder) to help reduce swelling. It is important to move your elbow, wrist and fingers on your operated arm so that they don’t

develop stiffness.


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Rehabilitation: first 6 weeks Posture correction – reverse your ‘hospital bed’ posture by straightening your back, tucking in your chin, raising your breast bone and drawing your shoulder blades downward and together. Repeat this throughout the day and while doing exercises


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Elbow mobilisation – take off your sling, ensuring that your forearm is kept next to your stomach. Bend and straighten your elbow (using your other hand to help if needed) 10 times with your palm facing up and then 10 times with your palm facing down.

Wrist mobilisation – move your wrist in circles, 10 clockwise and 10 anticlockwise, 3 times a day.


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Pendulum in sling – place your good hand on a surface and lean your body forward so that your arm gently swings forward in the sling. Ensure that your elbow is no more than a hand’s length away from your body. In this position, use your body to draw small circles, 10 clockwise and 10 anticlockwise.


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Check with your therapist if it is appropriate to do the following exercise: Static shoulder exercises – these exercises involve your good arm blocking any movement of your operated arm. With your operated arm by your side and elbow bent 90°, gently try to move your operated arm forwards but resist this movement with your good arm and hold this static contraction for 5 seconds. Repeat 10 times. Repeat this exercise with your operated arm moving backwards, away from your body, squeezing into your body, rotating your forearm outwards and rotating your forearm inwards. Remember, you operated arm should not move in these exercises.


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Once you become confident with the static shoulder exercises, check with your therapist first and then commence the following exercises: Pendulum out of sling – with your sling off, place your good hand on a surface and lean your body forward so that your arm gently swings forward with your elbow straight. In this position draw small circles, 10 clockwise and 10 anticlockwise. Note: If you check with your therapist, then you can add forwards and backwards swinging and side to side swinging.


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Passive shoulder lifting – lay on your back with the sling off and hold your operated elbow with your good arm. Use your good arm to lift up your operated arm off of your chest, hold for 3 seconds and then lower it back down. Repeat 10 times. Do not do any of the work with your operated arm, keep it as relaxed as possible.

Passive external rotation – have both of your arms by your side and elbows bent to 90° holding onto a ruler. Use your good arm to push your operated arm out to the side and hold for 3 seconds before returning. Repeat 10 times. Do not let your operated side do any of the work.


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Passive Abduction – holding the ruler in both hands, have your wrists rest on the front of your hips and your forearms resting on your stomach. Use your good arm to push your operated arm away from your side very slowly until you start to feel and increase in pain. Hold for 3 seconds and repeat 10 times. Do not let your operated side do any of the work.

Hand behind back – with your operated arm, reach your hand towards your buttock until you feel and increase in pain and hold for 5 seconds, repeat 10 times.


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Shrugging – shrug your shoulders up and down, then forwards and backwards, doing 10 in each direction.

Note: Remember to ice your shoulder after doing exercises for 10 minutes to reduce pain and swelling.


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Rehabilitation: after 6 weeks Spider walking front – stand face on to a wall and place your hands of the wall with your elbows bent. Crawl your fingers up the wall until you feel discomfort. Take your hands off the wall and keep it level there for 3 seconds before placing it back on the wall on the same spot. Try to crawl up further until you are unable to replace your hand at the same level.


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Ball exercises on table – stand at a table with shoulder blades down and back. Use the hand of your operated arm to hold a ball on the table. Twist the ball from 9 o’clock to 3 o’clock and back, repeat 10 times. Repeat the exercise standing side on.

Ball exercises on wall – as with the ball exercises on the table, hold onto the ball against a wall and twist from 9 to 3 o’clock. Repeat standing side on.


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Push ups against wall – place both hands against the wall at shoulder height and do 10 wall push ups. Progress the exercise by holding onto a ball against the wall, then doing push ups with only one arm and then one arm with a ball. Repeat the exercise side on with one arm.


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Once the above exercises can be performed successfully, progress to the following exercises: Reaching on all fours – kneel on all fours and pull shoulder blades together and down. Have your elbows straight and directly below your shoulders. Take your good arm off of the ground and reach forward while holding your posture still. This exercise can be made harder by doing a small push up with the operated arm, lifting the leg on your operated side OR placing a pillow under your operated hand.


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Reaching on elbows – prop yourself up on your elbows and pull shoulder blades together and down. Have your elbows directly below your shoulders. Take your good arm off of the ground and reach forward while holding your posture still. This exercise can be made harder by lifting the leg on your operated side.


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Drawing circles with a ball over edge of table – lie on a table or bed with your upper chest over the edge and your shoulder blades pulled together and back. Have an exercise ball below shoulder level and place your operated arm on the ball, carrying some of your weight. Draw small circles with the ball, 10 clockwise and 10 anticlockwise. Make this exercise harder by leaning further off the table, doing a small push up with your operated arm on the ball OR reach forward with your good arm.


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ARTHROSCOPY

The operation This operation is a relatively non-invasive surgery, involving small incisions to be made around your shoulder where an arthroscope (small camera) is inserted to look inside and repair damage around your shoulder joint.

Indications Arthroscopic procedures can be done for a variety of reasons. In general, an arthroscopy is done when there is some relatively minor damage in need of repair. These reasons include:

Injury to ligaments, tendons or cartilage (called the labrum) around the shoulder. This includes the rotator cuff repair discussed earlier.

Instability of the shoulder Degeneration from arthritis Structural deformity causing impingement of surrounding tissues Loose tissues or rough surfaces which need to be smoothed

In the cases where these injuries have a specific rehabilitation program (such as rotator cuff repair) follow that program and use this one for all other general arthroscopic procedures.

Advice for after your operation

It is normal to experience pain after your surgery and it will usually be worse at night time. Swelling and bruising usually form and will gravitate down the arm. Take pain relief and continue to ice the shoulder to reduce swelling and discomfort. You can massage the arm (not the shoulder) to help reduce swelling. Lay on your good side with your operated arm resting under pillows to reduce swelling. It is important to move your elbow, wrist and fingers on your operated arm so that they don’t

develop stiffness. The sling can be removed after 48 hours. You will not be able to drive until you are able to lift your arm in front of you to shoulder level.


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Rehabilitation Before each of the following exercises, pull your shoulder blades together and downward. Posture correction – reverse your ‘hospital bed’ posture by straightening your back, tucking in your chin, raising your breast bone and drawing your shoulder blades downward and together. Repeat this throughout the day and while doing exercises


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Elbow mobilisation – take off your sling, ensuring that your forearm is kept next to your stomach. Bend and straighten your elbow (using your other hand to help if needed) 10 times with your palm facing up and then 10 times with your palm facing down.

Wrist mobilisation – move your wrist in circles, 10 clockwise and 10 anticlockwise 3 times a day.


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Pendulum out of sling –place your good hand on a surface and lean your body forward so that your arm gently swings forward with your elbow straight. In this position draw large circles, 10 clockwise and 10 anticlockwise. Swing you arm forwards as far as you can go, slowly and controlled, and hold this position for 3 seconds before returning your arm to a relaxed position. Repeat the same exercise out to your side and also across your body.


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Shoulder mobilisation lying on your back – lie on your back with your operated arm bent at the elbow. Use your good arm to raise your operated arm in a direction over your head. Hold the stretch for 5 seconds. From this position, move your elbow out to the side and hold the stretch for 5 seconds then relax your arm by your side. Repeat 10 times.


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Shoulder rotation lying on your back – lie on your back with the hand of your good arm holding your operated shoulder. With your elbow bent so your forearm to 90°, slide your operated arm out to the side. Tilt your forearm forwards and hold the stretch for 5 seconds and then return back to the perpendicular position. Next, tilt your arm backwards and hold the stretch for 5 seconds. Repeat this 10 times.


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Static shoulder exercises – these exercises involve your good arm blocking any movement of your operated arm. With your operated arm by your side and elbow bent 90°, gently try to move your operated arm forwards but resist this movement with your good arm and hold this static contraction for 5 seconds. Repeat 10 times. Repeat this exercise with your operated arm moving backwards, away from your body, squeezing into your body, rotating your forearm outwards and rotating your forearm inwards. Remember, you operated arm should not move in these exercises.


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Sideward pulleys – with correct posture either sit or stand with the pulley rope in your hands (you can drape the rope over a pergola beam or something similar). Bend your elbows and have your arms out to the side so that when you pull with your good arm, the operated arm will lift to the side. Hold for 3 seconds before lowering. Try to use the muscles on your operated arm to assist the lift so that you rely less on the pulley rope. Repeat 10 times.



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SHOULDER MANIPULATION

The operation A shoulder manipulation under general anaesthetic involves stretching the joint beyond its normal range of motion while the muscles are relaxed. This allows for the joint capsule to be stretched. Sometimes the capsule is also cut to allow further movement.

Indications A shoulder manipulation is performed when there has been a loss of range of movement available in the shoulder joint which hasn’t responded to medication or physical therapies. It is a commonly used treatment for adhesive capsulitis, where the capsule becomes inflamed and can stick to itself thus limiting movement available at the shoulder.

Advice after surgery It is normal to experience some pain after surgery but this can be managed with pain killers and

icing your arm. Be sure to use ice packs for 10 minutes before and after you do your shoulder exercises It is important to do exercises frequently (even if it is a little bit at a time) to maintain the range

gained in your shoulder during surgery. In addition to the exercises which you can do at home, there are many treatments which your

therapist can do with you to improve your range of movement, manage pain and improve recovery.


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Rehabilitation: first 48 hours Shoulder mobilisation lying on your back – lie on your back with your operated arm bent at the elbow. Use your good arm to raise your operated arm in a direction over your head. Hold the stretch for 5 seconds. From this position, move your elbow out to the side and hold the stretch for 5 seconds then relax your arm by your side. Repeat 10 times.

Hands under head – lie on your back with your hands behind your head. Let your elbows drop to the floor and use your shoulder muscles to assist pulling your elbows back. Hold for 5 seconds and repeat 10 times or as tolerated.


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Shoulder abduction on your back – lie on your back and place your good hand over the top of your operated shoulder. Have you operated arm by your side with the elbow perpendicular to the floor. Slide your arm out to the side until you find that the movement is blocked and hold for 5 seconds. Use your good arm to help bring your operated arm back by your side. Repeat 10 times or as tolerated.


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Shoulder rotation lying on your back – lie on your back with the hand of your good arm holding your operated shoulder. With your elbow bent so your forearm to 90°, slide your operated arm out to the side. Tilt your forearm forwards and hold the stretch for 5 seconds and then return back to the perpendicular position. Next, tilt your arm backwards and hold the stretch for 5 seconds. Repeat this 10 times.


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Rehabilitation: 2 weeks after surgery Before you do your exercise, it is best to place a hot pack or have a warm shower in order to loosen the structures around your shoulder. Aim to do exercises 2 hourly and then use an icepack for 10-15 minutes after exercise to reduce swelling and soreness. Continue this for the first few days into your rehabilitation. It is important to respect pain and do as many exercises possible within pain limits. With sleeping, try to lay on your back with your arm resting above your head to keep it stretching. Posture correction – straighten your back, tuck in your chin, raise your breast bone and draw your shoulder blades downward and together. Repeat this throughout the day and while doing exercises


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Forward pulleys – with shoulder blades pulled together and down, either sit or stand with the pulley rope in your hands (you can drape the rope over a pergola beam or something similar). Pull down with your good arm to raise your operated arm as much as tolerated and hold for 3 seconds before lowering. Try to use the muscles on your operated arm to assist the lift so that you rely less on the pulley rope. Repeat 10 times. Eventually do the exercise without using a pulley and use your good arm to assist your operated arm when lowering.

Sideward pulleys – repeat as the forward pulleys exercise but bend your elbows and have your arms out to the side so that when you pull with your good arm, the operated arm will lift to the side.


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Overhead reach – hold your hands together in front of you and raise your arms overhead, holding for 5 seconds. Repeat 10 times or as tolerated.


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Spider walking front – stand face on to a wall and place your hands of the wall with your elbows bent. Crawl your fingers up the wall until you feel discomfort. Take your hands off the wall and keep it level there for 3 seconds before placing it back on the wall on the same spot. Try to crawl up further until you are unable to replace your hand at the same level.


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Doorframe stretch – place the hand of your operated arm on the corner of a doorframe or side of a cupboard. Lean or step forward to stretch your shoulder at the front and hold for 5 seconds. Return your operated arm so that it is resting by your side (you can use your good arm to help bring your operated arm down) and repeat 10 times or as tolerated.


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External rotation – stand at a doorway with your hand on the frame and your upper arm held against your body (you can use good arm to assist). Twist your body away from the operated arm until you feel a stretch. Hold for 10 seconds and repeat 10 times. Make this exercise harder by bringing you arm further up the door frame so that your upper arm comes away from your body.


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SUMMARY In summary, the shoulder is a complicated joint with many structures susceptible to injury. There are a variety of surgical options available depending on the structure damaged and the extent of the injury. Exercises will play an important role in a successful and quick recovery. It is important to not overdo exercises, instead aim to do your exercises frequently with a little bit at a time. Use ice and painkillers appropriately to manage your symptoms and avoid using your arm for heavy lifting. In all exercises, having your shoulder blades properly positioned so that they are drawn together and downward is important for moving your shoulder correctly with control. Please use this resource as a guide to your rehabilitation in consultation with your surgeon and therapist. All the best for a speedy recovery, The W&L Team


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CONTACT US Wellness & Lifestyles Australia 2/59 Fullarton Road, Kent Town SA 5067 P: +61 8 8331 3000 F: +61 8 8331 3002 E: [email protected] W: www.wellnesslifestyles.com.au www.wleducation.com.au W&L services include: Physiotherapy Aged Care Funding Instrument (ACFI) Consultancy Podiatry Speech Pathology Dietetics Diabetes Education Occupational Therapy Psychology Physiotherapy Aide Diversional Therapy Aromatherapy Natural Therapies Massage Exercise Physiology Educational Training Staff Wellness Program Locum Services Medicare Billing Aged Care Funding Instrument Documentation Online Training W&L products include: Posters E-books E-learning modules Audio/visual Hot tips/articles

general shoulder surgeries ebook

Documents

shoulder anatomy

shoulder manipulation

capsular shift surgeries

capsular shrinkage

table of contents page

labral repair

important notice

acromial space decompression