JOINT HORIZONS Mount Stuart Hospital
St Vincent's Road Torquay
Devon
TQ1 4UP
T: 01803 326688
F: 01803 322006
Impingement Syndrome & Arthroscopic shoulder decompression
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One of the commonest cause for shoulder pain in middle age is impingement syndrome. It occurs as a result of the pinching of the tendons and the surrounding structures at the an area called subacromial space. This may become narrow and tight due to bony over growth at shoulder blades arch bone (the acromion) and/or loss of resilience in a ligament. As a result of this the tendon becomes swollen only to be pinched again further. Typically pain is felt around the shoulder and may radiate down the arm.
The Painful Arc
When one suffers from impingement syndrome, pain occurs during certain arm position and may disappear in other position. It may often start after a minor trauma but more often than not there is no preceding insult. Typically one may feel the pain when the arm is lifted forwards beyond 30 degrees and may completely disappear when the arm is lifted beyond say 120 degrees, hence called painful arc syndrome.
Treatment
Majority of such problems respond well to simple measures. It may include rest, activity modification, avoiding over head activities in addition to a course of anti-inflammatory tablets. A well directed physiotherapy session may also give immense pain relief. In some instances, one may advise injection of cortisone and local anaesthetic into this tight space (subacromial space) to settle the inflammation.
Surgical Solution
The shoulder really needs to earn its operation. It would be unlikely that surgery will be offered as the first choice treatment. However, if the quality of life is significantly reduced, then surgery is offered. The aim of the operation is to create more space for the tendon to glide, so that it is not pinched during arm movements. This is achieved by shaving the prominent bone and releasing the taut ligament thus enlarging the space (subacromial space). This procedure is therefore termed subacromial decompression. It is usually done with the aid of arthroscope (key-hole surgery).
The Day of Operation
Please confirm the side of operation with the surgeon and clear any doubts in your mind. The limb to be operated will be marked with an indelible ink pen. Your will be asked to change to theatre gown. Remove all jewels especially rings, bracelets, body piercing etc. Also please remove any nail varnishes. You will be taken to the theatre on a trolley. Drips will be attached, monitors connected and an area in the limb may be shaved if needed, to apply a special diathermy plate.
The operation is usually performed under general anaesthetic and may be supplemented with a nerve block at neck. Once anaesthetised, you will be transferred into the operating theatre. You will be well looked after in the theatre. Sometimes you may have to be turned on your side to perform the operation. You will be safely held in place with appropriate supports and pressure points cushioned. Your head and neck will be well supported. Traction may be applied to the arm to aid manoeuvring the instruments inside the shoulder.
The shoulder joint is visualised by introducing the telescope via a small stab incision of less than a cm long in the back of the shoulder. Sterile saline is pumped in to the shoulder under pressure to distend this small joint. A small metal probe may be introduced to assess the internal structures through a further stab incision made in the front of the shoulder. Then the space above the tendon is entered and the tendon visualised from the top. The ligament is then released and the prominent bone shaved. This is done by introducing special instruments via an additional stab incision. This space is then washed thoroughly with sterile saline. The surgeon may seek your permission at the time of consenting to proceed to attend to any other problems which may be encountered during the operation – like repair of torn tendon or removal of outer end of collar bone.
The wound is closed with sutures and water resistant dressing is applied. This is covered with a further layer of padding held with adhesive dressing. The arm is then placed in a sling
Common Questions
Arm & Wound Care
Your will shown how to apply the sling and clear instructions will be given regarding its use. The main bulky dressing will be removed in 4 to 6 hours. You will leave the hospital with a shower resistant dressing which should be left undisturbed until checked by the practice nurse in about 2 weeks unless there is a problem. The sling has easily adjustable Velcro straps and you will be shown how to look after this. After a week one may discard the sling during the day.
Sleeping
In the first 1 week we recommend that you sleep with your sling on. Lie down flat with pillow or cushion supporting the elbow to keep the arm in the front of the body or lie on the non-operated side. Some may prefer to sleep on a recliner.
Daily activities
You will not be able to use the arm comfortably for dressing, eating, lifting or for holding objects steady at least for the first week or two. This may limit your independence and please make sure that you are safe and have someone to look after you. Discuss any special needs with physiotherapist, nurse or occupational therapist before discharge.
Driving
You may take up to 6 weeks before you are safe to drive. However, you are the best judge to decide. Check on a stationary vehicle you can reach controls easily and safely. Attempt the manoeuvres you would do when you took the driving test to make sure that you can control the car safely. Also you need to inform the insurance company of the operation and adhere to any stipulation laid by them.
Work
Return to work will depend on the type of job. Starting a simple desk job not entailing lifting may be possible within 2 weeks; but remember you need to get there to work and you will not be able to drive. Heavy manual work may need further 8 to 12 weeks of rehabilitation before rejoining.
Leisure activities
The period of rest would depend on the level of activity. Whereas it may be possible to commence cycling , jogging and gentle swimming after 4 weeks, using the arm for racquet sports may need 3 months of rehabilitation. We recommend not taking part in contact sports for at least 3 months in order to maximize the success rate of the operation. Please discuss any specific needs with the physiotherapist or the consultation.
Physiotherapy
0-3 weeks (Protective Phase)
Rest the arm in the sling for majority of the time during the 1st week for comfort.
- Elbow straightening exercises – Loosen the sling and rest the elbow on arm rest and slowly let the elbow straighten and bend fully.
- Pendulum exercises – Stand up and lean forwards and support yourself with the good arm on say a table. Keep your thumb pointing inwards. Slowly and very gently swing the arm forwards and backwards like a pendulum. You can also swing the arm side to side, crossing the front of the body. In addition, commence gentle circular movements, 10 rounds clockwise then 10 anticlockwise. With more practice, increase the size of the circle formed.
- Commence assisted forward lifting as soon as able usually within days after the operation with pain being the limiting factor.
- All the exercises should be done with slow and deliberate movements and never rushed. The movements should be more of a Tai-Chi type rather than that of Karate! Perform 10 sets of each 3 to 4 times a day.
3-6 weeks (Strengthening phase)
Continue with the above set of exercises. In addition one can start weaning off the sling completely.
- Pulley exercises can be commenced now for regaining elevation of the shoulder. Use of sticks and towels will all aid in improvement of the movement.
- One may start isotonic exercises with Theraband at the discretion of Physiotherapist. Further strengthening exercises like push-ups etc can be commenced under the guidance of the physiotherapist. The rehabilitation programme will be modified if you have the surgery done to address problems at the joint between collar bone and shoulder blade. One may be asked to hold back the elevation movement in this situation.
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