Wellness & Lifestyles Australia

SHOULDER RECONSTRUCTION E-BOOK

prepared by

Wellness & Lifestyles Australia

2007,2008,2009

Table of Contents Page No. IMPORTANT NOTICE ..................................................................................................... 2 INTRODUCTION .......................................................................................................... 3 SHOULDER ANATOMY ................................................................................................... 4 SHOULDER RECONSTRUCTION ......................................................................................... 5

The operation .................................................................................................. 5 Indications ...................................................................................................... 5 Advice after surgery .......................................................................................... 5 Rehabilitation: first 6 weeks................................................................................. 6 Rehabilitation: after 6 weeks .............................................................................. 14

SUMMARY ................................................................................................................ 29 CONTACT US ............................................................................................................ 30

MANUAL LAST MODIFIED 22/11/2010

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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 shoulder reconstruction and rehabilitation. 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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SHOULDER RECONSTRUCTION

The operation This surgery involves replacing the joint surfaces of the glenohumeral joint (see shoulder anatomy section). Depending on the case, sometimes only one joint surface needs replacing, sometimes both or sometimes the joint is reversed so that the ball at the end of the humerus is now a flat socket and the glenoid of the scapular is now round and fits into the socket. The operation can also involve smoothing over other rough surfaces around the shoulder or repairing the capsule, depending on what other damage is involved with the shoulder. An incision is made to reach the shoulder joint and the shoulder is dislocated forward to expose the joint surfaces. The damaged surfaces are removed and special implants made of metal and plastic are inserted as a replacement. Any other tissue damage is then repaired and the wound is closed up, usually with a wound drain left in to allow excess fluid to escape in the few days after surgery.

Indications Common indications include

Shoulder pain and loss of function from damage to the shoulder joint surfaces Shoulder joint degeneration from different forms of arthritis

Advice after surgery

Depending on the doctors 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 dont

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

Pendulum in sling place your good hand on a flat 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 hands 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 lie 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. The aim will be to raise your arm so that it is perpendicular to the ground (90).

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 After having your arm in a sling for 6 weeks, it is normal for some of your muscles to have shortened so a large focus of rehabilitation will be to regain this range along with strength in these muscles. It will be important for you to not overdo your exercises, so listen to your body and back off with your exercises if your shoulder aches while resting. Use ice and painkillers to keep the pain and swelling down. Be sure to have good posture while you do all of your exercises, with your shoulder blades pulled together and downwards. The following exercises are a progression of the range of movement exercises: Diagonal stick lying on your back, pull your shoulder blades together and downward. With a stick held between both hands, lift your arms overhead and out towards the side until tolerated and hold for 3 seconds before returning. Repeat 10 times.

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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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Spider walking side stand side on to a wall (with your operated arm closest to the wall) and place your hand of the wall at chest level. Crawl your fingers up the wall until you feel discomfort. Take your hand 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. Make the exercise harder by standing further away from the wall and straightening your elbow more.

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Horizontal flexion with your operated arm up in front of you, use your good arm to pull your elbow across your body and hold the stretch for 10 seconds. Repeat 10 times. Make this exercise harder by raising your operated arm higher.

Hand behind back lying down while laying on your back, position the hand of your operated arm up as far as you can behind your back. Bend the knee on the opposite side and role your body towards your operated side. Hold the stretch for 10 seconds and repeat 10 times.

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External rotation stick repeat as with diagonal 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.

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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The following exercises are designed to improve the range of movement available in your shoulder: 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.

Arm circles on back lie on your back with an empty hands or a light weight and raise your arm straight directly over your head. Gently do 10 circles clockwise and then 10 anticlockwise.

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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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Forward 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). 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.

Hand behind back with pulleys repeat as with the forward pulley exercise 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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The following exercises are designed to help you strengthen and control you shoulder: 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 oclock to 3 oclock 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 oclock. 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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External rotation in side lie lie on your good side with the elbow of your operated arm bent to 90. Slowly lift your forearm with your upper arm against your side and slowly lower again. Repeat 10 times.

Resisted flexion lying on your back, hold a Theraband in both hands and place your good hand by your hip. Pull with your operated arm diagonally upwards and return to your opposite hip with control. Repeat 10 times. Make the exercise harder by shortening the Theraband length between your hands.

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Bilateral external rotation in sitting, hold Theraband in both hands, squeeze your shoulder blades together and have your upper arms in by your sides. Turn your forearms away from each other and hold for 5 seconds before bringing your arms back slowly. Repeat 10 times.

Shrugging with arms out 45 from your side shrug you shoulders up and hold for 5 seconds, repeat 10 times. Make this exercise harder by having weights in your hands.

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The following exercises are a progression of the strengthening and stabilising 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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SUMMARY In summary, the shoulder is a complicated joint which can be susceptible to degeneration. Shoulder reconstruction is a viable treatment after conservative therapies have been tried. 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: contact@wellnesslifestyles.com.au 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