What is it?
The shoulder can be divided into 2 main areas. The main shoulder joint itself (gleno-humeral joint) and the sub-acromial space.
The sub-acromial space is a small tunnel lined above by bone (the acromium) and below by the gleno-humeral joint. Through this tunnel runs important tendons (the rotator cuff), whose action is to help lift and rotate the arm.
This tunnel can become smaller due to a number of factors (arthritis, trauma, inflammation) thus causing impingement of the rotator cuff tendons running through it. This is sub-acromial impingement.
A simple way of thinking about it is like a train (the rotator cuff) running through a tunnel (sub-acromial space). If the tunnel is too narrow, then the train will have problems.
Initially the tendons will become inflamed, and if the impingement continues the tendons may tear.
Symptoms include pain in the shoulder and arm, especially when doing any overhead activities (e.g reaching for items from a high shelf), stiffness and weakness.
What can be done?
As with all treatments in Orthopaedics , simple measures will be started first and more complex measures later if required (the Therapeutic ladder).
1. Rest. Stop activities which aggravate the symptoms
2. PainKillers. Simple paracetamol or anti-inflammatories
3. Physiotherapy. This can help with maintaining range of movement, and settle inflammation.
4. Injections. A mixture of local anaesthetic and steroid can be injected into the subacromial space. This helps by initial pain relief (local anaesthetic) and subsequent anti-inflammation (steroid). Injections can be painful for a day or two, and there is always a small risk of infection and ongoing pain. Beneficial affect can be unpredictable, with long or short lived pain relief. I do not like to perform more than 2 injections in a treatment cycle (1 year period).
A general anaesthetic is used and time in hospital is either a day case or one overnight stay. Surgery can be carried out either as an open procedure or as a key-hole (arthroscopic) procedure.
1. Open Surgery.
A 5cms incision is made at the top/front of the shoulder in line with an imaginary bra strap. The subacromial space is found after passing between the deltoid muscle. Once there the underside of the roof (acromium) is removed in order to open up the space. Inflammed tissue is removed and the rotator cuff is inspected. If a tear is found, this will be repaired.
2. Arthroscopic Surgery.
2- 3 small (1cms) incisions are made at the front, side and back of the shoulder and a small camera and instruments are passed into the shoulder (gleno-humeral joint) and sub-acromial space. The underside of the acromium and inflamed tissue is removed with a high speed burr and shaver. The rotator cuff is inspected with the camera. If a tear is seen, then a small 3cms incision is used on the side of the shoulder to allow a reapir to be performed.
What happens after your operation?
– You will have a large padded dressing over the shoulder which is removed 3 days after the operation.
– You will have a sling to hold the arm close to your chest.
– I will advise you post surgery what was found and what the rehabilitation plan is. You will be seen by a physiotherapist who will give you a planned programme on what to do with the arm and shoulder over the following few weeks.
– If a simple decompression was carried out, then rehabilitation will be relatively quick
– If a rotator cuff repair has been carried out as well, then your rehab will be more prolonged
– Do not drive or return to sporting activities until you have been reviewed by the doctor.
Nerve damage – Nerves running in the region can be bruised or damaged during the surgery and form a painful spot in the scar (neuroma) or numbness.
Infection – Any operation can be followed by infection and this would be treated with antibiotics.
Scar – You will have scar(s) around the shoulder. They will be somewhat firm to touch and tender for 6-8 weeks. This can be helped by massaging the area firmly with the moisturizing cream.
Stiffness – Your arm will be stiff for a period of time. It is imperative you carry out the physiotherapy which has been shown to you
Muscle weakness – rarely the muscles around the shoulder do not function well after surgery. The deltoid muscle at the front of the shoulder can very rarely fail to heal properly and cause weakness.
Function -The symptoms and your function will recover slowly and it will probably be six months before you will get your final result.