Things to consider before opting for shoulder surgery

With a special clinical interest in shoulder surgery, Mr Toby Baring performs approximately 350 operative procedures each year.

Here, Mr Baring outlines the different types and causes of shoulder pain and when you can treat your shoulder without surgery. He also explains the signs that suggest that you might need surgery to relieve your shoulder pain.

What are the causes of shoulder pain?

There are several causes of shoulder pain, including:

• Poor posture
• Regularly putting pressure on your shoulder such as carrying a heavy bag
• Injury such as a broken arm or collarbone
• Frozen shoulder
• Disorders of the rotator cuff
• Shoulder instability
• Acromioclavicular joint disorders
• Joint disorders such as osteoarthritis

The shoulder is a complex joint, with a system of muscles and tendons (that secure the muscles to the bones), ligaments, bones and cartilage. They can all be susceptible to damage or wear and tear, which leads to shoulder pain.

The muscles and tendons that surround the shoulder are collectively known as the rotator cuff. The rotator cuff allows the shoulder to move up, down, side to side, backwards and forwards while keeping it stable.

The muscles and tendons of the rotator cuff can swell and become inflamed as a result of a shoulder injury or overuse, causing pain and discomfort. The tendons can tear leading to more severe pain.

As well as the rotator cuff, like any joint, the shoulder also contains cartilage, a flexible, fibrous substance that keeps the joints lubricated. It also stops the bones of each joint rubbing against each other.

As we age, or as a result of overuse, the cartilage can become worn, another common cause of shoulder pain.

The shoulder, like the hip is a ball and socket joint. This means the top of the upper arm bone has a rounded head that fits inside a rounded socket within the collarbone. Shoulder instability occurs when the ball joint of the arm doesn’t fit into the socket properly, and can lead to full shoulder dislocations.

Furthermore, another shoulder joint, called the acromioclavicular joint, sits on the top of the shoulder, and can be at risk of stretched or torn ligaments that hold the muscles together.

Which shoulder conditions can be treated without surgery?

Most shoulder conditions will improve over time without surgery — only a small proportion of people with shoulder pain require surgery.

How to treat a shoulder injury without surgery

Your doctor may suggest you try a corticosteroid injection. These are particularly useful in the non-surgical treatment of a frozen shoulder.

Corticosteroid injections are administered by an expert and help to reduce inflammation, swelling, pain and restricted movement. They can cause damage to the shoulder joint if administered too frequently, so they’re generally only used after other treatments have failed, and only then up to two or three times a year.

Physiotherapy can also be useful, and your doctor can refer you if they think you’ll benefit from certain exercises that can be taught by a physiotherapist. Physiotherapy works by stretching out tight tissue, improving posture and strengthening weak muscles.

Signs that you might need shoulder surgery

Sometimes, it’s necessary to treat shoulder pain with surgery. Your specialist will discuss your options with you, but if non-surgical treatments haven’t worked to relieve your pain and restore your freedom of movement, then it could be a sign that you require shoulder surgery.

As a general rule, if any of the following apply to you, your surgeon will discuss surgery with you:

• A frozen shoulder that hasn’t improved despite six months or more of treatment
• A rotator cuff disorder that hasn’t improved despite three to six months of treatment (depending on the severity of your pain and rotator cuff problem)
• A complete tear of your rotator cuff
• An acromioclavicular joint disorder that hasn’t improved despite three months of treatment
• Shoulder instability and frequent shoulder dislocations and you’re young — 30 years old or younger
• Your shoulder pain is causing considerable pain that is preventing you from carrying out your job
• You’re an athlete who needs to be physically fit as soon as possible

What does shoulder surgery involve?

Shoulder surgery differs, depending on the reason for your shoulder pain.

If you’re having surgery for a frozen shoulder, you may have either manipulation surgery or arthroscopic capsular release.

Manipulation surgery involves your surgeon moving your shoulder and stretching the muscles and tendons while you’re under a general anaesthetic.

Arthroscopic capsular release is carried out as keyhole surgery again under general anaesthetic. Your surgeon will use long, thin instruments to free your shoulder muscles from scar tissue.

Both are usually followed by a series of physiotherapy visits.

Surgery for rotator cuff tears involves the repair of damaged tendons and possibly removing a small shaving of bone from the top of the shoulder joint. It can be carried out as open shoulder or keyhole surgery depending on various factors, and will be followed up with physiotherapy.

Shoulder instability and regular dislocations can be treated surgically by the surgical reattachment or tightening of the shoulder ligaments or by tightening the whole shoulder joint with surgical stitches.

This kind of surgery can be carried out as open shoulder or keyhole surgery and is a fairly major procedure. You will have to wear a sling for several weeks after to stop your shoulder joint from moving while it recovers.

Shoulder surgery recovery tips

The most important thing to do after any surgery, is to listen to your surgeon’s advice. With regard to shoulder surgery specifically, your surgeon will tell you whether you need to keep your arm and shoulder completely still, and for how long, or if you should begin gentle movements within a few days.

You may also be given a sling to wear to support your arm during the day. An extra pillow under your arm can help to keep your shoulder stable when you’re asleep and prevent you from rolling onto your surgery side. Sleeping upright, propped up on pillows may also help.

You may benefit from pain relief medications and ice packs to reduce pain and swelling, but check with your medical team.

Make sure you organise enough time off work and your normal duties in order to recover. You may need from one week to several months off work, depending on your surgery, and up to a year avoiding impact sports.

It’s also important to remember to ask for help when you need it. You’re likely to be only able to use one arm for some time, and you’ll struggle with everyday tasks. You will need to avoid moving your arm above your head or behind your back, so make sure you have someone with you to help.

More information

• If you’re suffering with shoulder pain, speak to your GP about a possible referral to a specialist.
• If you don’t have a GP, you can make an appointment with one of our same day private GPs.
• Our Physiotherapy Department is fully equipped and staffed by experts on hand to help you back to full shoulder mobility and function.
• Our Orthopaedic Surgery Department is a world famous centre of excellence for all orthopaedic surgeries including shoulder surgery. To enquire about shoulder surgery, contact us to make an appointment to see one of our experts.