Information for Patients about Shoulder

Clinical Professor Allan Wang FRACS PhD FAOrthA Shoulder and Upper Limb Surgeon www.allanwangorthopaedics.com.au

MURDOCH SUBIACO Murdoch Orthopaedic Clinic St John of God Subiaco Clinic St John of God Murdoch Clinic Suite 302, 25 McCourt St Suite 10, 100 Murdoch Drive Subiaco WA 6008 Murdoch WA 6150

Telephone: 08 6332 6390 Page | 2 Information for Patients about Shoulder Surgery

Introdution

e hae ut this information boolet together to eduate our atients about their shoulder ondition treatment otions and ostsurgial are

Please ee this boolet for future referene It is not a detailed soure of information and you may also ish to refer to our ebsite www.allanwangorthopaedics.com.au for animated ideos of surgial roedures If you reuire further information or hae onerns regarding your treatment lease ontat the offie to disuss ith r ang or his staff

ontents Pages 1. Shoulder natomy

2. Shoulder Imingement and otator Cuff endon isorders

3. Shoulder oint Instability and abrum ears 7

4. Post eratie Instrutions

a. romiolasty eision

b. otator uff eair anart abrum eair

roen Shoulder dhesie asulitis

otal Shoulder oint elaement Page | 3 Shoulder Anatomy

one and ont o the houlder

mortant ule rou o the Shoulder Page | 4 Shoulder mnement and otator u endon order hat mnement Syndrome he moement o the houlder ont deendent on the urroundn mule and tendon the rotator u omle he rotator u omre o our tendon Suranatu tendon the mot reuently damaed tendon eaue hen the arm eleated the tendon an ru mne aant the underurae o the aromon one at the to o the houlder (Fig 1)

he uaromal ura hh urround the rotator u tendon an alo eome ollen and nlamed urt ure endont leaton o the arm an aue the ura to mne aant the aromon a ell (Fig 2)

mnement more lely the aromon one ha a donard ure or ha a ur Sur rom an arthrt aromolaular A ont may alo ontrute to ymtom

hat aue mnement Syndrome otator u tendon damae and urt an reult rom a udden traumat nury uh a a all or heay ltn ure ura elln and mnement eenerate endon damae may alo our loly rom reette atty and oerue or a art o the an roe endon damae are rom tendon rayn to artal tear to ull thne tear and multle tendon tear an our (Fig 3)

Symtom rom mnement Syndrome ou ll note an eeally reahn oerhead and at nht lyn on the nured houlder eane and lo o houlder moement may our hee ymtom are alled the mnement Syndrome

ure otator u tear Page | 5

hat treatment aalale

n mld ae your houlder ymtom ll mroe th ret antnlammatory talet ome hyotheray and one or to ortone neton hen ymtom are hron or are more eere your dotor ll order houlder ray and an ultraound or an there a one ur on the aromon urery oten neeary to remoe the one ur aromolaty to reent onon tendon mnement and urther tendon damae there a tear n the rotator u tendon urery uually reured a the tendon annot heal y tel and the tendon tear may enlare n uture arer or multle tendon tear ll reure more etene urery and oaonally the tendon damae may not e ully rearale hat haen at Surery

At urery an arthrooy erormed thru mall eyhole Long Head of non he all and oet ont neted A rayed or Bicep Tendon torn rotator u tendon tear an e onrmed Fig 4 damae to other truture dented e e tendon and lenod larum they may need ural attenton a ell otator u Bicepstendon tear

Labrum A artal tear or uluaton o the lon head o e tendon ute a ommon arthroo ndn and maye ure ontrutn to an h e tendon damae treated y releae tenotomy or ural rear tenode Aromon enotomy may lead to a hane n the e mule contour in the upper arm (“popeye muscle”). However as the e ormed y to tendon the other hal o e omenate ell ater tenotomy enode Imnement an oton n youner and more ate atent thouh early reoery ll e loer than tenotomy

endon ear Aromolaty A on ure he arthrooe then laed n the uaromal ae Acromioplast Aromolaty he thened lament and nlamed ura are derded y (Fig 5) Any ur on the underde o the aromon are haed aay and the aromon lattened aromolaty (Fig 6) h allo learane or the underlyn rotator u learane tendon to lde moothly thout mnement the A ont arthrt the end o the lale and t one ur are alo haed A eon

endon Tear a mall tendon tear noted – a derdement and trmmn o the tear oten uent ure Page | 6

otator u epair urery enon Tear

a larer or ull thicness tenon tear is note surical repair is perorme with sutures an small resorale anchors passe into the one. (Fig 7)

Humerus

iure

maller rotator cu tears are repaire arthroscopically with minimal sin scarrin. (Fig 8)

iure

arer rotator cu tears reuire a sin incision on the sie o the arm. are an lonstanin tenon tears may not e ully repairale or may not heal well ater surery. etearin o the cu tenon may occur. ccasionally urther surery is reuire. ore recent surical avances inclue usin a collaen patch to reinorce the rotator cu repair or aition o rowth actors (platelet rich plasma) which may improve tenon healin. Page | 7 Page | 7 Shouullddeerr JJooiinntt IInnssttaabbiilliittyy a anndd L Laabbrruumm T Teeaarsrs Anatomy

The shoulder is a ball and socket joint held Bicep tendon Bicep tendon Coracoid together by tendons, capsular ligaments and a Coracoid fibrous which deepens the socket called the labrum.

What is Shoulder Instability?

Wrenching or jarring injuries can cause the shoulder joint to dislocate, sublux (partially dislocate) or feel unstable with painful clicking or a loose sensation. Treatment includes wearing a shoulder brace, followed by physiotherapy and modifying sports or work activities. Further investigations including x rays and MRI scans will show the extent of damage to bone and soft igiugurer e1 1 oromrmala Sl hSohuoludledre r nantaotmomy y tissue structures.

aannaarrtt T Teeaarr

II thethe shouldershoulder has has dislocated dislocated a acommon common type type o o damage damage is isan an anterioranterior labrum labrum tear tear with with separation separation rom rom the the glenoid glenoid socet socet anartanart tear tear I I physio physio isn’t isn’t helping helping or or you you wish wish to to remain remain very very active,active, your your shoulder shoulder is is at at ris ris or or recurrent recurrent dislocation dislocation ananarat rt LabrumLabrum lalabbrruumm r reeppaairi r su surgrgeeryr y maymay bebe necessarynecessary This This is iseyhole eyhole GlenoidGlenoid arthroscopicarthroscopic surgery surgery igure 2

The TTII labrumlabrum isis repairedrepaired toto thethe edgeedge oo thethe socet socet glenoid glenoid with with bone bone anchors anchors and the capsularcapsular ligamentsligaments areare tightenedtightened with with sutures sutures The The posterior posterior labrum labrum can can also also tear, tear, causing posteriorposterior shouldershoulder painpain andand clicingclicing STSTII anart anart arthroscopic arthroscopic repair repair or or debridement cleanclean upup maymay be be reuired reuired

ith severe oror multiplemultiple dislocations,dislocations, bonebone damagedamage occurs occurs The The edge edge o o the the glenoid glenoid bone bone socet maymay ractureracture oror erode,erode, oror thethe humeralhumeral head head may may be be damaged damaged ill ill Sach Sach lesion lesion which which puts the shouldershoulder ointoint atat greater greater riss riss or or re re inury inury Page | 8

SL Tear

nother common type o damage is the SI labrum tear or SL tear Superior Labrum tear rom nterior to osterior SL tears can be traumatic or degenerative The biceps tendon attaches to the superior labrum and SLAP tears usually don’t heal well without surgery. SLAP tears can be debrided or can also be repaired arthroscopically with suture anchors nother surgical treatment or SL tears is detachment o the biceps tendon rom the superior labrum thereby reducing the stress on the SL inury The bicep tendon can then be repaired outside the shoulder oint with suture anchors tenodesis or let to reattach spontaneously urther down the arm tenotomy

Biceps tendon

Superior Labrum

igure anart Tear igure rthroscopic anart igure SL Tear repair with suture anchors ultidirectional Instability Some patients will have generalied looseness o their oints ingers, neecaps, anles etc and may develop pain, a loose sensation and lac o conidence in using their shoulder The instability may be in one or more directions hysiotherapy and taping oten restore stability or these patients ccasionally surgical tightening o oint laity is reuired pen Surgery ter severe or multiple dislocations, other oint damage can occur otator cu tendons may tear and may also reuire surgical repair Joint suraces are scued and subected to abnormal shear orces and chondral damage and can develop one damage or ractures may need screw iation In the presence o bone damage, multiple dislocation, previous ailed surgery with scarred and poor uality labrum and capsule tissue, oint hyperlaity and young patients playing contact sport, arthroscopic anart repair may not be appropriate one grat surgery rom the pelvis or transerring o the bony igure Lataet epair coracoid to reconstruct the anterior glenoid damage may be reuired Lataet procedure

This is an open surgical procedure, not eyhole surgery Two screws usually i the coracoid to reinorce the glenoid (Fig 6) Page | 9

Ater Surgery

A sling is worn ull time or our to si wees. Physio is then reuired or months to recoer moement. Progress continues or months and igorous wor actiity and sports are restricted during this time to reduce the ris o the repair breaing down.

omplications ater shoulder instability and stabilisation surgery are ery uncommon. hey do include

 ecurrent dislocation instability  nection  Stiness o the shoulder oint  eelopment o arthritis due to the preious dislocations.  mplant loosening or breaage.  one non union screw problems ater the lataet procedure.

he inal leel o unctional recoery depends on the degree o bony and sot tissue damage to the shoulder oint. Page | 10 Post peratie nstructions Acromioplasty ± AC Joint Excision

A prescription or pain tablets will be proided by the hospital on discharge. enerally tae Paracetamol regularly to mg tablets three times a day with meals and this will reduce the need or stronger medication. ou can tae Antiinlammatory medication eg elebre aprosyn obic oltaran etc as well. or breathrough pain eg. ater eercise or at bedtime tae ycodone tradename ndone or ynorm to mg tablets once or at most twice a day. his is a narcotic prescription. ycodone should be taen sparingly. t may mae you lightheaded and nauseous and should not be combined with alcohol or sleeping pills.

PAS 1. ear the sling or days ater surgery. hen the sling has been remoed please be ery protectie o your operated shoulder. Any actiity or eercise that S potentially AS your shoulder at this early stage ater surgery. 2. In general, don’t lift or push greater than 1.0kg with the operated arm for the first 2- wees. 3. Aoid sudden moement. 4. Aoid the ris o reinury. t is a good idea to wear the sling as protection in busy shopping centres or or support when out on long wals. 5. Please eep your hospital dressings on. 6. enerally it is best to remain o wor and driing a motor ehicle until you are reiewed by r ang one to two wees ater surgery.

PS PA SS a. he aim o these eercises is to recoer oerhead moement o the operated arm with the assistance o the good arm. se your good arm to control moement o the operated arm. b. o the ollowing eercises to discomort neer pain. arm up irst eg hot shower do the eercises SLL and smoothly. o two eercise sessions per day each session need be only minutes. ool down with a cold pac aterwards. c. our physiotherapist may also attend to your nec and upper bac. aintain good posture. Sueee your shoulder blades together. uc your chin in. d. t is normal to hae some pain or wees ater acromioplasty. Sleeping on your aected shoulder or heay or impact actiity should be aoided or months. PagePagePagePagePage || 1111 | | 11| 1111

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eepeepeepeepeep thethe the elowtheelowthe elow elowelow yy y thethe yy the sidethesidethe side side sideandand and andusingandusing using usingusing sesese se thesethe the oppositetheoppositethe opposite oppositeopposite leftleft left leftleft armarm arm arm toarmto gentlytogently toto gently gentlygently thethethe oppositetheoppositethe opposite oppositeopposite leftleft left leftleft arm,arm, arm, arm,arm, gentlygently gently gentlygently pushpush push pushpush pullpullpull pull thepullthe the operatedtheoperatedthe operated operatedoperated rightright right rightright armarm arm arm posteriorarmposterior posterior posteriorposteriorlyly lyly ly thethethe operatedtheoperatedthe operated operatedoperated rightright right rightright armarm arm arm armoutwards,outwards, outwards, outwards,outwards, thenthenthenthenthen eleateeleate eleate eleateeleate thethe the right therightthe right rightright handhand hand handhand higherhigher higher higherhigher upup up upup hold,hold,hold,hold,hold, andand and and thenandthen then thenthen pullpull pull pullthepullthe the armthearmthe arm arm inwardsarminwards inwards inwardsinwards youryouryouryouryour ack.ack. ack. ack.ack. Page | 12

PagePage || 1212 Pst Operatie nstrctins Page | 12 PPsstt OOppeerraattiiee nnssttrrccttiinnss tatr Pfsf t eOppaier rati ea nnasrttr Lacbtrimn se pair ttaattrr ffff eeppaaiirr aannaarrtt LLaabbrrmm eeppaaiirr tatr ff epair anart Labrm epair . will stay in hspital erniht.

. ntibitics.. are willwill prided staystay inin hspitalhspital t minimie erniht.erniht. the ris f infectin. . will stay in hspital erniht. .. ntibiticsntibitics areare pridedprided tt minimieminimie thethe risris ff infectin.infectin. 3. will wear cmpressin stcins t help preent deep ein thrmbsis. . ntibitics are prided t minimie the ris f infectin. 4. pres3c3.r.ipti nwillwill f wearrwear pain cmpressincmpressin tablets will stcinsbestcins prided tt helphelp by thepreentpreent hspital deepdeep n einein dischare. thrmbsis.thrmbsis. Generally tae 3. will wear cmpressin stcins t help preent deep ein thrmbsis. Paraceta4m4..l pprelarlyrreessccrriippttiin n f ftrr ppaa iminn ttaabblleettss willtabletswill bebe pridedprided three times byby thethe a hspitaldayhspital with nn meals dischare.dischare. and this GenerallyGenerally will redce taetae the need4PP .fraarra ap ccstrnerreeettasacmmripltl irelarlyrelarly nmedicatin. fr pa i n tttab lre mmts willbreathrh be tablets tabletsprided threethree painby thetimestimes e. hspital after aa dayday eercisewithnwith dischare. mealsmeals r and andat Generally bedtime thisthis willwill redceredcetae tae OycdPthentheaer a tradename needcneedetam frfrl relarly strnerstrner Endne medicatin. medicatin. t r Oynrmm rr tablets breathrhbreathrh t three m times painpain tablets e.ae. day afterafter nce with eerciseeercise mealsr at mst and rr atat this bedtimetwicebedtime will aredce day. taetae his is a thenarcticOOyy needccddn nfrprescriptin.ee tradenametradename strner medicatin. EndneEndneOycdne rr r OynrmOynrm shld breathrh be tt taen m mpain sparinly. e. tabletstablets after ncence eerciset may rr atmaeat r mstmst at bedtimey twicetwice aa day.taeday. lihtheadedOhishisyc and isisd aa nnarctic narcticnasese tradename prescriptin.prescriptin. and Endne shld OycdneOycdne r nt Oynrm be cmbined shldshld t bebe mwith taentaen alchltablets sparinly.sparinly. nce r sleepin tt r maymay at mstmaemae pills. twice yy a day. hislihtheadedlihtheaded is a narctic andand nasesprescriptin.nases andand Oycdne shldshld ntnt beshldbe cmbinedcmbined be taen withwith sparinly. alchlalchl rtr may sleepinsleepin mae pills.pills. y lihtheaded and nases and shld nt be cmbined with alchl r sleepin pills. ce pacs will help redce pain and redce swellin and brisin. haematma cllectin f ccee ppaaccss willwill helphelp redceredce painpain andand redceredce swellinswellin andand brisin.brisin. haematmahaematma cllectincllectin ff bld maybldcblde pfrmac maymays willdwn frmfrm help yr dwn dwnredce arm yryr pain especially armarm and especiallyespecially redce if y swellin ifif are yy n areare and bld nn brisin. bldbld thinners. thinners.thinners. haematma his hishis haematma haematmahaematma cllectin will willwill f resle erbldresleresle time. may erer frm time.time. dwn yr arm especially if y are n bld thinners. his haematma will resle er time.

. f a slin.. f fhas aa ss llibeeninn hashas applied beenbeen appliedapplied please pleaseplease eep eepeepthis nthisthis day nn daydayand and andniht nihtniht t tt preent preenttensinpreent. f a s l itensinntensinand has stress beenandand stressappliednstress the nn pleasesrical thethe sricalsrical eep repair. this repair.repair. n Learn day LearnLearn and hw nihthwhw t ttt apply thepreentapplyapply slin thethe tensinwhile slinslin y whilewhileand are stress yy in areare hspital.n in inthe hspital.hspital. srical he slinhe herepair. slin slinshld shldLearnshld rest hw restrest n ntn the sideapply thethef sideyrside the f fslinhip yryr whilent hiphip restin y ntnt are restinrestin n in hspital.the nn frntthethe hefrntfrnt f slin yrff shldyryr chest. chest. chest.rest t n tt shld spprttheshldshld side spprtspprt thef yrweiht thethe hip weiht weiht fnt yr restin ff arm.yryr n arm. arm.r the rrshldersfrnt shldersshlders f yr shld shldshldchest. be bebet n the sameshldnn thethe leel. samespprtsame (F leel.ileel.g 1the) ((F Fweihtiigg 11)) f yr arm. r shlders shld be nhehe the slinslin same cancan leel. bebe (remedremedFig 1) nlynly frfr washinwashin dressindressin andand entleentle he slineercises.eercises. can be remed shldshld nlyntnt sleepsleepfr washin nn thethe affectedaffected dressin side.side. and nitiallynitially entle yy eercises.he slin shld can bent remed sleep n nly the fr affected washin side. dressin nitially and yentle eercises.maymay bebe mre mre shld cmfrtablecmfrtable nt sleep sleepinsleepin n the inin affectedaa reclinerrecliner side. chairchair nitially rr slihtlyslihtly y may be maysittinsittinmre be p p cmfrtablemre ratherrather cmfrtable thanthan sleepin fllyflly flat. flat.sleepin in a inrecliner a recliner chair chair r rslihtly slihtly sittin psittin rather p thanrather flly than flat. flly flat. 66.. hehe slinslin willwill bebe reiredreired frfr weeswees afterafter srery.srery. canntcannt 6. he slin6driedrie. he will aa slinmtrmtr be reiredwill ehicleehicle be reired drindrinfr frthisthis wees time.time. wees after after srery. srery. cannt cannt drie a mtrdrie a ehicle mtr ehicledrin drin this time. this time. 77.. GentleGentle eerciseseercises willwill decreasedecrease stiffnessstiffness ff thethe shldershlder andand therther 7intsints. Gentle inin the theeercises pperpper will limb.limb. decrease yryr stiffness eerciseseercises f the slwlyslwly shlder andand andentlyently ther t t 7. Gentlethethe eercises pint pint ff discmfrtwilldiscmfrt decrease neerneer stiffness pain.pain. f the shlder and ther ints in ints the pperin the limb.pper limb. yr yreercises eercises slwly slwly and and ently ently t t the pinttheefreefre f pint discmfrt eercisineercisin f discmfrt neer warmwarm neerpain. pp pain.withwith a a warmwarm shwershwer rr htht pac. pac. iirree fterfter eercisineercisin applyapply aa cldcld pac.pac. yryr eerciseseercises frfr 33 mintesmintes ire efre eercisin warm p with a warm shwer r ht pac. ire efre eercisinftertwicetwice eercisin daily.daily. warm apply p a cldwith pac. a warm yr shwer eercises r fr ht 3 pac.mintes fter eercisintwice daily. apply a cld pac. yr eercises fr 3 mintes twice daily. PagePagePage | 13 | 13 | 13 Page | 13 nitniaitl inSahilt Siahl lSdheldr eErld eEerrce iErsceeisr eicnsis cienlscd linedc led e nitial Shlder Eercises inclde

. “.Cr“aC.drlae“dC tlrheae dt hAleer mtAhr eam nA dar mnRdo a cRnkod tc hRke ot hcBkea tbBhyae”b BPy”ae bnPyde”un Pldueumnlud Emuxl euErmxcei srEecxi:eserc:ise: . “Cradle the Arm and Rock the Baby” Pendulum Exercise: StandStand Standand and bend and bend frwardbend frward frward at atthe theat waist. thewaist. waist.ld ld theld the perated theperated perated arm arm at arm atthe theat elbw theelbw elbwwith with yrwith yr yr ppsiteppsiteStandppsite hand.and hand. bend hand. Lift Lift thefrward Liftthe perated theperated atperated the arm armwaist. t arm t f ld tthef the fslin.the theslin. perated slin.se se yr se yr arm ppsite yr ppsite at ppsite the hand elbwhand t hand tspprt with spprt t spprtyr thetheppsite weiht theweiht weiht fhand. fthe thef Liftperated the peratedthe perated perated arm arm at arm atthe ttheat elbw. thefelbw. the elbw. slin. O seO let Oyr letthe ppsiteletthe arm thearm hanarm handhan rhan t rswin spprt swinr swin nspprted.nspprted.thenspprted. weiht f the perated arm at the elbw. O let the arm han r swin nspprted. SlwlySlwlySlwly me me meyr yr perated yr perated perated arm arm side arm side t side tside side t then side then frward then frward frward and and bac and bac thenbac then circle then circle clcwisecircle clcwise clcwise andandSlwly anticlcwiseand anticlcwise meanticlcwise yr fie peratedfie times fie times timesarmeach. each. side each.(F i g(tFsi g 2side(s F &i 2g s&then 3 ) 2 3Only&) frwardOnly 3) meOnly me and meas bacasfar far asas then farasis iscmfrtable.ascircle cmfrtable.is cmfrtable.clcwise hishisand willhis willanticlcwise help willhelp preent help preent preent stiffnessfie stiffness timesstiffness in thein each. the inperated theperated (F iperatedgs shlder. 2 & shlder. 3 )shlder. Only me as far as is cmfrtable. his will help preent stiffness in the perated shlder.

ee affectede affected affected MoveMove affectedMove affected affected armarme frwardarm frward affected frward armarmMove sidewaysarm sideways affected sideways andandarm bac andbac frward bac arm sideways and bac

FiguFirgeu F2rie g u2r e 2 FiguFirgeu F3rie g u3r e 3 Figure 2 Figure 3 . “.Op“Oe.np“ eO tnhp ee t hn Ge a tth Geea” t e G E”ax t Eex”rtn e Earxln ta Relor nt Raotl tioa Rntoi:ot anhet:i ohen :perated he perated perated arm arm has arm has the hasthe Elbw theElbw Elbwfleed fleed fleedat at90˚ 90˚at and 90˚ and and psitinedpsitined. “psitinedOpe nby t hbythee Gbythe aside. te the”side. E x side.tsin e rnsina l sin Rtheo tthea tppsite io thenppsite: heppsite handperated hand handleft left arm leftently hasently entlyther tra Elbwtte a rttheet athe t efleedperated theperated peratedat 90˚arm arm and arm twardstwardspsitinedtwards t tthe by the tside the theside st side.side st t st tthesin the tpint thepintthe fpint ppsite fdiscmfrt discmfrtf discmfrt hand nt ntleft pain. ntpain. ently(pain.Fi g(F 4ig ) ( F4 rldi)g t a4ldt)e theldthe the stretch perated thestretch stretch then thenarm then pllplltwards thepll the perated theperated t perated the arm sidearm inwards arm inwardsst inwards t aain. the aain. pintaain. epeat epeat f epeat discmfrtfie fie times. fie times. times. nt pain. (Fig 4) ld the stretch then pll the perated arm inwards aain. epeat fie times.

te thee hete perated he perated perated shlder shlder shlder mements mements mements are are pa arespsais espi abyess ibysine sinby sin thethe ppsitet theppsitee he ppsite arm.perated arm. ctiearm. ctie shlder ctiemements mements mements mements f thef the fperated are theperated p peratedass ishldere shlderby shldersin n ntheits itsnwn ppsite wnits accrd wn accrd arm. accrd shld shld ctie shld be bemementsaided aidedbe aided as asthesef thesetheas thesecan perated can damae candamae damaeshlder the the the sricalsricaln sricalits repair.wn repair. accrdrepair. he he same shldhe same samemst be mst aided applymst apply apply drinas drinthese drin shwerin canshwerin shwerindamae and and the and dressin.dressin.sricaldressin. repair. he same mst apply drin shwerin and dressin.

3. 3Gently. Gently3. Gently and and slwly and slwly slwlybend bend andbend and straihten and straihten straihten yr yr elbw yr elbw elbwfie fie fie 3. Gently and slwly bend and straihten yr elbw fie times.times.times. OperatedOperatedOperated arm arm arm times. Operated arm

4. 4Gently. Gently4. Gently clench clench clench yr yr hand yr hand thand tmae mae t amae fist a fist and a fistand stretch and stretch stretch yr yr yr finers4. finersGentlyfiners t tclench straiht tstraiht yrstraiht fie fiehand times. fie times. t times. inermae iner inera swellin fist swellin and swellin andstretch and stiffness and stiffness yr stiffness is cmmnisfiners cmmnis cmmn t and andstraiht tinlin and tinlin tinlinfie frm times.frm sbclinicalfrm sbclinicaliner sbclinical swellin carpal carpal carpal andcbital cbital stiffness cbital tnneltnnelis cmmntnnel syndrme syndrme syndrme and may tinlin may ccr. may ccr. frm ccr. his hissbclinical sally his sally sally resles reslescarpal resles when cbitalwhen thewhen the the swellinswellintnnelswellin es syndrme es dwn. es dwn. dwn. may ccr. his sally resles when theFiguFirgeu F4rie g u4r e 4 swellin es dwn. Figure 4 Page | 14

5. ake sure your posture is ood and aoid slouchin o some neck stretches and chin tucks

6. n the irst day or to ater surery – perormin some eneral exercises ill aid recoery hese include couh and deep breathin to keep your chest healthy and reuent short alks to preent deep ein thrombosis and pulmonary embolus ou can discard your hite compression stockins hen you are mobile

Rehabilitation Proram At eeks ater urery hen the slin has been remoed and the shoulder is comortable more actie rehabilitation exercises can bein he olloin are uidelines and you ill be superised by your physiotherapist or exercise physioloist

Actie Assisted Exercises

Oerhead pulley tick Exercises later

a. he aim o these exercises is to recoer oerhead moement o the operated arm ith the assistance o the ood arm ia the pulley or stick se your ood arm to control moement o the operated arm Page | 15 b. c.

In general, don’t lift or push greater than 1.0kg with the operated arm.

PagePagePage | 16 | 16 | 16

1. 1. 1. pidpeirdp eidrli merl imsl itmhse t sh etha ell allall

sese ourse our ourfingers fingers fingers to slowlto toslowl slowl lim lim lim the the operated the operated operated arm arm sidewasarm sidewas sidewas up upa up walla walla adutionwall adution adution. leating. .leating leating our our ourarm arm atiatesarm atiates atiates our our our shouldershouldershoulder musles. musles. musles. lowl lowl lowl desend desend desend the the wallthe wall wallusing using using similar similar similar fingerfingerfinger ation. ation. ation. Initiall Initiall Initiall stand stand stand lose lose lose to tothe tothe wallthe wall walland and onland onl onl eleateeleateeleate our our ouroperated operated operated arm arm toarm theto tothe point the point point of disomfort.of ofdisomfort. disomfort.

. . . herhaehraaenrdanadnd

ourour ourphsiotherapist phsiotherapist phsiotherapist will will start will start startou ou on ou onlight on light elastilight elasti elasti ands ands ands red, red, red,ellow ellow ellow and and later and later laterprogress progress progress to strongerto tostronger stronger ands ands ands green green green and and add and add eerises add eerises eerises as omfortas asomfort omfort allows. allows. allows. he he aoe he aoe aoe two two two eeriseseeriseseerises are are good are good good to startto tostart startwith. with. with.

 oidoidoid sidewas sidewas sidewas rm rm aisesrm aises aises with with weightswith weights weights or orelasti orelasti elasti ands ands ands. dution. dution. dution moements moements moements

tudiestudiestudies show show show most most most patients patients patients reoer reoer reoer good good good funtio funtio funtion forn for ndail for dail dailatiitie atiitie atiities s fours four monthsfour months months after after after surger.surger.surger. oweer oweer oweer funtional funtional funtional improements improements improements and and strength and strength strength will will slowl will slowl slowl improe improe improe for for up for upto up 1to to 1 1 months.months.months. ehailitation ehailitation ehailitation times times t imeswill will ar will ar dependingar depending depending on onthe on the etent the etent etent of ourof ofour oursurger. surger. surger. It is It est isIt estis toest to to startstart startslowl slowl slowl and and gentl and gentl gentl with with ourwith our ourrehaili rehaili rehailitationtationtation eerises, eerises, eerises, rather rather rather than than triskhan risk an risk anearl an earl earlmis mishap mishap orhap orre orre re inurinurinur to ourto toour ourshoulder shoulder shoulder whi whi hwhi mah mah affetma affet affet our our ourfinal final outome.final outome. outome. Page | 17 Frozen Shoulder“Adhesive Capsulitis”

hat is it he shoulder oint is a all and soet oint held in plae the surroundin usles and tendons and enlosed the oint apsule he oint apsule an eoe inlaed or several reasons inludin inor traua surer edial onditions inludin diaetes or olloin a stroe

Sptos hen the apsule is inlaed apsulitis ou ill notie pain elt over the ront and side o our shoulder and don the ar he pain a e severe and distur our sleep ver several onths the inlaation settles and the pain lessens ut the apsule thiens and ontrats ausin shoulder stiness adhesive apsulitis he stiness a stop ou reahin overhead or ettin our hand ehind our a t a put ore strain on the ase o the ne ausin ne pain Frozen shoulder a persist ro several onths to one or to ears ut in ost ases the ondition ill resolve on its on aord

o is it treated hen the pain is severe usuall tests inludin ras and sans are done to elude other auses or shoulder pain hese auses inlude arthritis aroial one spurs and tendon tears or reerred pain ro our ne oever i these tests are noral treatent oprises o pain ediation phsiotherap assae and entle hoe eerises and hdrotherap he ar ater helps to rela tiht usles and uoan aids assist in reover o otion Attention to posture is iportant as a slouh ill oten ause seondar ne pain ne or to ortisone inetions under radiolo uidane into the shoulder oint apsule is helpul to redue the inlaation

the pain is settlin ut the stiness is severe a anipulation under eneral anaestheti an e perored to readon the ontrated apsule Also an arthrosopi surial release o the oint ontrature is oasionall reuired and an iprove shoulder oveents uite uil

Contracted band of capsule Release of contracture

Tendon PagePagePagePage |Page 18 | 18 | | 18 18 | 18

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nn an anoral anoral noral shoulder shoulder shoulder oint oint oint artilae artilae artilae overs overs overs the the the head head head o o o the huerus one and soet lenoid o the sapular thethethe huerus huerus huerus one one one and and and soet soet soet lenoid lenoid lenoid o o theo the the sapular sapular sapular one he artilae allos sooth and painless lidin oneoneone he he he artilae artilae artilae allos allos allos sooth sooth sooth and and and painless painless painless lidin lidin lidin o the oint surae on shoulder oveent n shoulder oo theo the the oint oint oint surae surae surae on on onshou shou shoulderlderlder oveent oveent oveent n n shouldern shoulder shoulder Worn arthritis the artilae laer ears throuh and the WornWornWorn arthritisarthritisarthritis the the the artilae artilae artilae laer laer laer ears ears ears throuh throuh throuh and and and the the the Cartilage CartilageCartilageCartilage eposedeposedeposed one one one suraes suraes suraes rate rate rate ausin ausin ausin oint oint oint pain pain pain and and and stinessstinessstiness F i FgiF g1i g)1 n)1 )n additionn addition addition the the the usles usles usles and and and tendons tendons tendons Bone Spur surroundin the shoulder oint rotator u develop BoneBoneBone Spur Spur Spur surroundinsurroundinsurroundin the the the shoulder shoulder shoulder oint oint oint rotator rotator rotator u u u develop develop develop earearear and and and tear tear tear d aaed daaedaaeaae and and and this this this also also also aets aets aets shoulder shoulder shoulder oveentoveentoveent and and and strenth strenth strenth

Fiure FiFuiFriueru er e

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AnotherAnotherAnother common common common type type type of of shoulderof shoulder shoulder replacement replacement replacement is isthe is the the “reverse “reverse “reverse TSR”, where the socket is placed on the huerus and the head TSR”,TSR”,TSR”, where where where the the the socket socket socket is isplaced is placed placed on on onthe the the huerus huerus huerus and and and the the the head head head either etal or polethlene is plaed on the lenoid Fig 3 eithereithereither etal etal etal or or polethleneor polethlene polethlene is isplaed is plaed plaed on on onthe the the lenoid lenoid lenoid F i FgiF g3i g3 3 A AeverseA everse everse S S S is isdesined is desined desined or or orarthritis arthritis arthritis it it ithith hrotatorh rotator rotator u u u tendon tendon tendon daaedaaedaae or or endor end end stae stae stae rotator rotator rotator u u u disruption disruption disruption ith ith ith loss loss llossoss o o ativeo ative ative shouldershouldershoulder oveent oveent oveent

Fiure everse S FiFuiFriueru er e ev eeveresvers resS e S S Page | 20

hen is a TSR reuired The main reason to undero TSR is severe chronic shoulder pain from arthritis ther treatments such as physiotherapy, pain medication, inections, or arthroscopic keyhole surery may have een unsuccessful in manain symptoms atients underoin TSR have shoulder pain severe enouh to interfere with daily activity, disturin sleep, and reuirin reular pain medication ost patients underoin TSR will also have stiffness and weakness in shoulder movement This may interfere with overhead reachin or ehind the ack activity A TSR will usually improve shoulder movement and strenth owever movement of the artificial oint will not e normal, especially if there is etensive rotator cuff tendon damae as well A third and uncommon reason for shoulder replacement is a severe fracture dislocation of the humeral head The ony damae is too severe to fi with surical plates or pins A shoulder replacement for fracture dislocation of the shoulder produces a comfortale shoulder ut movements are usually uite limited

hat happens in hospital re admission is performed efore surery lood tests, and urine tests are taken Any sites of infection such as skin rashes, dental sepsis need to e dealt with efore surery sually you are admitted the day of surery The anaesthetist may contact you eforehand to discuss eneral anaesthetic and nerve locks to help keep you comfortale after surery ollowin surery, you will remain in hospital for three to four days urin this time, the surical drain and intravenous line are removed, and you will e dischared with a prescription of pain medication

ow lon is the recovery iure A slin is reuired to immoilise the shoulder for four to si weeks (Fig 4) o shoulder eercises are permitted for two weeks owever in the slin, you should sueee a soft all or clench your fist several times a day to prevent finer stiffness ou should o for freuent short walks for eneral wellein and to prevent thromosis in your les After your postsurical review with r an, very entle passive movement eercises are allowed PagePagePagePage Page|Page 21 | 21 | | 2121 | |21 21

hysiotherapyhysiotherapyhysiotherapyhysiotherapyhysiotherapyhysiotherapy eercises eercises eerciseseercises eercises eercises and and andandhydrotherapy hydrotherapy and hydrotherapyandhydrotherapy hydrotherapy hydrotherapy can can caneincan ein can eineincan when ein whenein whenwhen the when thewhen theslinthe slin the slin slinthe is slinisremoved slin isisremoved removedremoved is is removed removed Shoulder Shoulder ShoulderShoulder Shoulder Shoulder comfort,comfort,comfort,comfort,comfort,comfort, rane rane ranerane of rane raneofmotion of ofmotion motion motionof of motion andmotion and andandstrenth strenth and strenthandstrenth strenth strenth radually radually raduallyradually radually radually improve improve improveimprove improve improvefor for many forfor many formanymany for months many monthsmany monthsmonths months months owever owever oweverowever owever owever a TSRa aTSRa TSRTSR a aTSR TSR doesdoesdoesdoes not doesnotdoes notrecovernot recover not recoverrecovernot recover normalrecover normal normalnormal normal shoulder normal shoulder shouldershoulder shoulder shoulder function function functionfunction function function ven ven venven lon ven lon ven lonlon term, term,lon lon term,term, some term, someterm, somesome patients some patientssome patientspatients patients patientswith with withwith a TSRawith with aTSRa TSRTSRmay a may aTSR mayTSRmay may may havehavehavehave some havesomehave somesome discomfort, some discomfort,some discomfort,discomfort, discomfort, discomfort, stiffness, stiffness, stiffness,stiffness, stiffness, stiffness, they they theythey may theymay they maymay not notmay maynotslnot eepsl not eepsleepslnot eepcomfortaly sl comfortalysleep comfortalyeepcomfortaly comfortaly comfortaly on on the onon the theonaffectedthe on affected the affected affectedthe affected affectedshoulder, shoulder, shoulder,shoulder, shoulder, shoulder, and and andand and and wouldwouldwouldwould needwould wouldneed needneed to need to limitneed toto limit limit limitto heavy to limitheavy limit heavyheavy ardenin heavy heavyardenin ardeninardenin ardenin ardenin and and andandsportin sportin and sportinandsportin sportin sportinactivity activity activityactivity activity activity

osot sooTtso sTttot o TaoTstoltos a SttTla h aToSlol oh tSSuatohhalud oolS leuShudrlholed dRouree eulRrrdp l eRdeRlpaerec lprRpae lRcelamaepccmpeleanlmmeactecnee emtnnmt atese n ainctsaa ti scs i icace as riescirie cesc rericscseiei sesrsecer sicss i eses s PagePage | 16 | 16

1. 1. pidpeird erli mlims thse t hea ll all

sese our our fingers fingers to slowlto slowl lim lim the the operated operated arm arm sidewas sidewas up upa walla wall adution adution. leating. leating our our arm arm atiates atiates our our shouldershoulder musles. musles. lowl lowl desend desend the the wall wall using using similar similar fingerfinger ation. ation. Initiall Initiall stand stand lose lose to tothe the wall wall and and onl onl eleateeleate our our operated operated arm arm to theto the point point of disomfort.of disomfort.

1.1“.P11“r..aP““yr1PaP a.1ryran“.a ayPd“y nrP aaLdrninya fdL tdya”i fLnaLti”indffttd ”L” iLftif”t” 2.2“.S22“p..Si“d“p2SSeip.2dpr“i. eidCSd“relpS eiCrmiprd l CiCbdmellsireimb mrCts hbClb ietsmlshi mtWetbhh bseWae s tl Wl hWa”tehlala” eWlll l”W”alal”ll” orwarorwarorwarorwardorwar elevation,orward delevation,d elevation,elevation,d delevation, elevation, count count countcount count seconds count seconds secondsseconds seconds upseconds up upup up up SidewaysSidewaysSidewaysSidewaysSidewaysSideways elevation elevation elevationelevation elevation elevation aduction aduction aductionaduction aduction aduction

oldoldoldold seconds,old old seconds, seconds,seconds, seconds, seconds,and and andand seconds and seconds and secondsseconds seconds downseconds down downdown down down sese seyourse yourse youryour sefiners finersyour your finersfiners tofiners finers toclim to toclim clim climto theto climthe clim arm thethe arm the armarmslowly the slowly arm slowlyarmslowly slowly slowly

upwardsupwardsupwardsupwardsupwards upwardsin inaduction ininaduction aductionaduction in in aduction aduction then then thenthen slowly slowlythen then slowlyslowly descend slowly descendslowly descenddescend descend descend . . herhaeraandand

3.3“.H3our3“i..tH“cour“i3HhtH.3c hiphsiotherapistith“.tickcHh“h ehphsiotherapistHihkt”hiceitikhkc”eeh””ihkiek”e” will will start start ou ou on onlight light elasti elasti4.4“ ands.R44“o.. Randsw““o4RRiwn.4oo “g.wired,wnR”“igRoi nnred,”owggw” i”ellowning ”ellowg” and and later later progress progress TheraandTheraandtoTheraandTheraand strongerto TheraandstrongerTheraand Strenthenin Strenthenin ands StrentheninStrenthenin ands Strenthenin Strenthenin green green and and add add eerises eerises as omfortasTheraand omfortTheraandTheraandTheraandTheraand allows.Theraand Strentheninallows. Strenthenin StrentheninStrenthenin he Strenthenin heStrenthenin aoe aoe two two eeriseseerises are are good good to startto start with. with.

 oidoid sidewas sidewas rm rm aises aises with with weights weights or orelasti elasti ands ands. dution. dution moements moements

tudiestudies show show most most patients patients reoer reoer good good funtio funtion forn for dail dail atiitie atiities s four four months months after after surger.surger. oweer oweer funtional funtional improements improements and and strength strength will will slowl slowl improe improe for for up upto 1to 1 months.months. ehailitation ehailitation times times will will ar ar depending depending on onthe the etent etent of ourof our surger. surger. It is It est is est to to startstart slowl slowl and and gentl gentl with with our our rehaili rehailitationtation eerises, eerises, rather rather than than risk risk an anearl earl mis mishaphap or orre re inurinur to ourto our shoulder shoulder whi whih mah ma affet affet our our final final outome. outome. Page | 22

nctional improements and strength will slowly improe for p to 12 months. Rehabilitation imes will ary depending on the etent of yor srgery. t is best to start slowly and gently with yor rehabilitation eercises rather than risk an early mishap or reinry to yor sholder which may affect yor final otcome.

What are the possible complications of SR

SR is maor srgery and sally performed in older patients with seere sholder disability. Complications are rare bt can occasionally occr. hese inclde

1. nfection

his occrs in approimately one percent of cases despite rotine antibiotic prophylais. here is a higher risk in patients with diabetes or skin rashes. ost infections are minor and can be treated if detected early with antibiotics and a srgical wash ot. ery rarely infections can be serios with antibiotic resistant bacteria and the SR components may need remoal and replacement at a later date when the infection has settled. en more rarely the infection may still not settle and more radical srgery sch as a sholder fsion may be reired.

nfection may occr many years after srgery and it is important that any ftre episodes of skin infection dental sepsis or other infections are promptly treated with antibiotics to preent the spread of infection to yor SR.

2. hromboembolism

his is ncommon compared to hip and knee replacement. eertheless blood clots can form in the legs deep enos thrombosis and can trael to the lngs embols after sholder srgery. o will be fitted with compression stockings before srgery and post operatiely will receie anticoaglant inections ntil yo are flly mobile. hese anticoaglant inections may case bleeding problems sch as wond ooe and brising down the arm or swelling hematoma bt will preent thromboembolism.

3. amage to bone neres or blood essels

SR srgery is performed close to arteries and neres. amage to these strctres is possible bt this is ery rare. one ality is sally weakened in chronic arthritis. Rarely the bone may fractre when implanting the prosthesis. Page | 23

4. Prosthesis Complications

SR is not as strdy as total hip and total knee replacements. he socket component is small and may loosen in bone or dislodge after an inry sch as a fall. er many years the plastic bearing srface may wear ot. lso the oint replacement may dislocate where the hmeral head separates from the socket. his may occr following a specific inry sch as a fall or progressiely oer years as the rotator cff tendons srronding the SR breakdown.

f prosthesis complications occr frther srgery may be reired. he implants may need adstment in position or replacement. ost sholder replacements last ten years or more before reision srgery is reired. onger more actie patients are more likely to reire reision srgery than sedentary patients.

. eneral edical Complications

n older patients medical conditions eg. preeisting cardiac respiratory or asclar disease may be eacerbated by anaesthesia or srgery. r Wang may refer yo to the appropriate specialist to optimise yor general medical condition prior to yor SR srgery.