I need shoulder surgery. What should I consider and are there alternatives?
Many surgeries have been developed to repair the muscles, connective tissues, or damaged joints that can arise from traumatic or overuse injuries to the shoulder. These are often extremely common injuries that may be helped with physiotherapy or for more chronic conditions may require medical intervention. Although not an exhaustive list, here are some of the most common significant shoulder problems with possible treatment pathways and estimated recovery times.
Rotator Cuff Repairs
The rotator cuff is a group of tendons and muscles in the shoulder that helps you lift and rotate your arm and also keeps the shoulder joint in place. Sometimes these rotator cuff tendons tear or get pinched by the bones surrounding them.
An injury can occur from a sudden fall on the arm, lifting something heavy, or wear and tear over time. You are more likely to cause damage if you have a job where you repeatedly move the arm in a certain way over and over such as a painter, carpenter or athlete.
Other causes of damage to the rotator cuff include slouching or chronically pushing the head forward. As you age, the rotator cuff can be irritated or pinched by calcium deposits in the shoulder area or bone spurs due to arthritis. These rotator cuff injuries can vary and be inflamed from overuse or partially or fully torn.
Home care such as rest and icing, painkillers, and physio should always be considered first when dealing with the rotator cuff but surgery could be the answer if the pain doesn’t go away or improve after six to twelve months. Surgery is also considered if all strength has been lost from the shoulder area and it’s painful to move, if the arms cannot be raised or lift, and if there is a clicking or popping sound. Also if there is an actual tear in the rotator cuff tendon and the patient relies on shoulder strength and activity for either their employment or to participate in sports.
The surgery is designed first and foremost to relieve pain, and then restore function to the shoulder. If surgery is delayed the issue can become more serious and lead to problems such as frozen shoulder or arthritis.
Common types of rotator cuff surgery are- Arthroscopic repair – after making 1/2 cut in the skin, the surgeon will insert a tiny camera called an arthroscope and specialised instruments into the shoulder. This allows the surgeon to see which parts of the rotator cuff is damaged and how to repair them. The surgeon will use the instruments to reattach the tendon to the bone.
Once the tendon is in the right place, the surgeon will attach it with sutures. Often surgeons will use small rivers called suture anchors. These rivets may be made of metal or a material that eventually dissolved. The rivets do not need to be removed. The sutures attach to the rivets, reattaching the tendons to the bone from where it was torn.
Open tendon repair -historically, this was the first technique used to repair the rotator cuff and has been the most traditional form of surgery. If the tear is large and complex, this is the method the surgeon will choose. A large incision is made in the shoulder, then the shoulder muscle is detached so the surgeon has direct access to the tendon. The incision could be 2.5 to 4 inches long for an open repair or 1.5 to 2 inches for a mini open repair. Direct access is needed should the tendon or shoulder need replacing. Both of these surgeries are done under general anaesthesia or a regional block which allows the patient to be awake while the arm and shoulder stay numb.
Open surgery, mini open surgery, or an arthroscopy might be necessary if the surgeon wants to remove calcium deposits or a bone spur. A bone spur is a bony growth that can press on nearby ligaments, nerves or tendons causing severe pain. Bone spurs often develop as people age.
Rotator cuff surgery is major surgery and there are risks involved such as infection, nerve damage and excessive bleeding. In rare occasions, patients may also have an allergic reaction to the anaesthetic or suffer from breathing problems. Patients who smoke, who are over 65, who have larger tears or have shoulders which are already weak will need a longer time period to heal.
The shoulder will still be painful post surgery and in recovery, and will be extremely stiff due to the lack of movement. After surgery it is normal to keep the arm in a sling for 4-6 weeks and wear a shoulder immobiliser strap wrapped around the chest. This protects the shoulder by holding it in its place.
It takes the repaired rotator cuff tendons about 6 weeks to heal to the bone, 3 months to form a relatively strong attachment to the bone, and 6-9 months before the tendon is completely healed to the bone. Most patients will take 9 months before the shoulder feels normal and there will continue to be pain and soreness for several months.
The chances of surgery reducing and eliminating shoulder pain is very good, however surgery may not restore the shoulders full strength. Time and physiotherapy will regain function but there may still be some weakness,stiffness and chronic pain. It will take a few months before sport can be played and other activities that require shoulder strength and a full range of motion can be performed.
Another complication can also arise that not all tendons heal back to the bone after surgery, some do not heal completely and some do not heal at all. Large tendons can have far too much extensive damage to heal.
Once a tendon has failed an attempted surgical repair, the odds are that it will be difficult to repair again and to get it to heal. In some cases, the tear may be small enough after failed surgery to be repaired again, but the larger it is the more unlikely it will be successful. In most cases a second attempt at repairing a tendon will not be successful.
The operation can fail not due to bad surgery or bad aftercare and therapy but that the reality is that the surgery is not perfect and not all tendons will and can heal with surgery.