Subacromial Decompression Surgery

Subacromial Decompression Surgery

Patient Information

Subacromial decompression surgery

This leaflet aims to help you understand and gain the maximum benefit from your operation.  It is not a substitute for professional medical care and should be used in association with treatment at the WWL NHS Trust.  Each person’s operation is individual, and you may be given specific instructions that are not contained in this leaflet.

The shoulder

The shoulder is a ball and socket joint with a ligament above it.  This forms an arch, which is called the subacromial space.  The ligament attaches to bony landmarks (the ‘acromion’ and coracoid’) on your shoulder blade.

The ball is controlled and centred in the socket by a group of deep tendons called the rotator cuff.  These tendons pass through a small space under the arch.  They are protected by a cushion called a bursa.  These tendons are involved in all shoulder movements and function.

Subacromial Pain

Poor control of the muscles around the shoulder can lead to irritation of the structures in the subacromial space.  This can cause swelling and pain. 

The poor control can be caused by: 

• weakness in the rotator cuff muscles 
• movements in positions that narrow this space such as overhead activity
• poor shoulder posture
• bony changes

The cycle of irritation and swelling can usually be helped by time, physiotherapy, and activity modification.  Sometimes cortisone injections can be used to reduce pain and inflammation and enable you to work with the physiotherapist.  In most people this resolves symptoms.  For a minority, despite physiotherapy and pain relief, surgery may be considered.

Subacromial decompression

The operation is usually a day case and performed as keyhole surgery (‘arthroscopy’) but can also be performed as an open procedure.

A subacromial decompression involves increasing the space under the arch by removing the bursa, releasing a ligament, and removing any bony spurs.  This allows the tendon to move more freely, thus breaking the cycle of irritation and swelling.

During your operation, the surgeon may identify further damage within your shoulder, which requires addressing.  This may require debridement (clean up) of tendons, tendon repair or tendon release. If a tendon release is performed, this may change the appearance of your upper arm muscle, called a “popeye sign”. This means that the muscle belly will sit lower in your arm and will have a different shape to it. 

Complications

One of the key positive changes seen in modern medicine is the concept of “shared decision making”.  Decisions regarding surgical treatment are best taken jointly between the surgeon and an informed patient.  In addition to the surgeon explaining the procedure, you must take the opportunity to ask and clarify what concerns you the most, no matter how trivial you feel your concern may be! 

All surgical procedures are associated with a degree of risk.  Your surgical team will do everything possible to minimise the risks and complications.  Below is a list of some risks and complications associated with common shoulder surgical operations, but these may differ depending on the exact type of surgery you are having.

General complications of any shoulder surgery

• Pain levels felt after surgery vary depending on the type of surgery, individual pain thresholds, nature of the problem for which surgery was done and various other factors.
• Stiffness after shoulder surgery is not uncommon and occurs as a result of pre-existing conditions, surgical scarring and prolonged post-operative protection in a sling.  It is very uncommon to see significant stiffness at 1 year after arthroscopic shoulder surgery. 
• Bleeding during or after surgery is uncommon. It is common to have oozing from the arthroscopic wound sites after surgery as the blood-stained sterile water used during surgery drains out. 
• Infection of the surgical wound is rare with arthroscopic surgery.  Early diagnosis of post-operative infection has a significantly better outcome compared to delayed diagnosis.  After your operation, you should contact the ward and your GP immediately if you get a temperature, become unwell, notice pus in your wound, or if your wound becomes red, sore or painful. 
• Unsightly scarring: most surgical scars have disappeared to a thin pale line by one year after surgery.  If you are concerned about your scar, you must discuss it with your surgeon or therapist, as there are many treatments to improve scar healing. 
• Nerve injury: the risk of nerve injury is very low but some larger operations have a higher risk. This will be discussed with you by your surgeon. 
• Vascular injury: the risk of vascular injury is very low after shoulder surgery. 
• Anaesthetic related complications such as sickness and nausea are relatively common. The risk of more serious anaesthetic related complications (such as heart, lung, and neurological problems) is very low.

Please discuss these issues with your surgical team if you would like further information. 

Alternatives to surgery 

The decision to proceed with an operation is an individual choice between every patient and their surgeon.  You will only be offered an operation if your surgeon believes that this will help improve your symptoms.  Very few operations are essential, and all have a degree of risk.  Some patients can learn to manage their symptoms with painkillers and improve function with muscle strengthening and physiotherapy. 

Frequently asked questions

Will it be painful?

Although you will only have small scars, this procedure can be painful due to the surgery performed inside your shoulder. 

The following pain control methods may be used to ensure you have as little discomfort as possible:

• a local nerve block, known as an interscalene block (see below)
• pain killers and anti-inflammatory medications, taken regularly on discharge from the hospital.

Interscalene block

You may be offered a nerve block for the surgery, known as an interscalene block.  The anaesthetist will discuss this in detail with you before the surgery.

This is an injection in the neck, to block the nerves, used to provide a heavy numbness in the shoulder and arm (in a same way that a dentist can numb a tooth), so that the shoulder surgery can be carried out with excellent pain relief.

The benefits of an interscalene block are:

• reduced risk of nausea and vomiting 
• reduced stay in hospital 
• able to eat/ drink sooner
• excellent pain control
• lighter general anaesthetic therefore speedier recovery 
• less chance of an overnight stay at the hospital

The anaesthetist, surgeon and you need to decide jointly whether you are suitable for an interscalene block.

Painkillers

You will be given painkillers (either as tablets or injections) to help reduce the discomfort whilst you are in hospital.  A one week prescription for continued pain medication will be given to you for your discharge home.  At first keep the pain under control by using medication regularly.  It is important to keep the pain to a minimum, as this will enable you to move the shoulder joint and begin the exercises you will be given by the physiotherapist.

If you require further medication after these are finished, please visit your general practitioner (GP).

Do I need to wear a sling?

A sling is for comfort only.  If you are given one following your surgery, you can take it on and off as you wish.  You do not need to wear the body strap, which can be discarded.

What position should I sleep in?

If you are lying on your back to sleep, you may find placing a thin pillow or small rolled towel under your upper arm comfortable.  If you sleep on your side, then resting your arm on a pillow in front of you can help (see below).

Do I need to do exercises?

Yes.  You will be shown exercises by the physiotherapist which you will need to continue once you go home.  They aim to prevent your shoulder getting stiff and to strengthen the muscles around your shoulder.  Do short, frequent sessions as advised, rather than one long session.

It is normal for you to feel aching, discomfort or stretching sensations when doing these exercises.  It is important to keep the pain to a minimum to enable to you to move the shoulder joint. If necessary, use painkillers and/or ice packs to reduce the pain.  Intense and lasting pain (e.g. more than 30 minutes) means you should change the exercise by doing it less forcefully or less often.

Continue to do these exercises until you get the movement back or you see the physiotherapist.  An outpatient appointment for physiotherapy will be arranged for you in approximately 2 weeks’ time.

What do I do about the wound?

Your wound will have a shower-proof dressing on when you are discharged.  You will be given extra dressings to take home with you.  You may shower or wash with the dressing in place, but do not run the shower directly over the operated shoulder or soak it in the bath. Pat the area dry, do not rub.  The stitches may need to be removed or trimmed at your GP practice or your hospital follow-up appointment.  The nursing staff will advise you when this can happen; it is usually between 10 – 14 days after your operation.  Avoid using spray deodorant, talcum powder or perfumes on or near the wound until it is fully healed.  Please discuss any queries you may have with the Nurses on the ward.

When do I return to the outpatient clinic?

This is usually arranged for approximately 3 weeks after your operation to check on your progress.  Please discuss any queries or worries you may have when you are at the clinic.  Further clinic appointments are made after this as necessary.

Are there things that I should avoid?

• There are no restrictions to movement in any direction.  Do not be frightened to start moving the arm as much as you can. You may experience some pain on movement.  Gradually, the movements will become less painful.
• Avoid heavy lifting for at least 3 weeks.  You may gradually return to these activities if your pain is under control. 
• Be aware that activities at or above shoulder height stress the area that has been operated on.  Do not do these activities unnecessarily.  Try and keep your arm out of positions that increase the pain. 

How am I likely to progress?

The discomfort from the operation will gradually lessen over time.  Time taken to improve varies between individuals.  Normally the operation is performed to relieve pain from your shoulder and this usually happens within 6 months of the surgery.  There may be improvements for up to 1 year.

When can I drive?

You cannot drive while you are wearing the sling.  After that, the law states that you should be in complete control of your car at all times. It is your responsibility to ensure this and to inform your insurance company about your surgery.

When can I return to work?

This will depend on the type of work you do and the extent of the surgery.  If you have a job involving arm movements close to your body, you may be able to return within a week.  Most people return within a month of the operation, but if you have a heavy lifting job or one with sustained overhead arm movements, you may require a longer period of rehabilitation.  Please discuss this further with the doctors or physiotherapist if you feel unsure.

When can I participate in my leisure activities? 

Your ability to start these activities will be dependent on pain, range of movement and strength that you have in your shoulder.

Nothing is forbidden, but it is best to start with short sessions involving little effort and then gradually increase the effort or time for the activity.  Sustained or powerful overhead movements (e.g.  trimming a hedge, some DIY, racket sports etc.) will put stress on the subacromial area and it may take longer to become comfortable. Discuss this with your Physiotherapist.

References and further information

www.shoulderdoc.co.uk 

Help and feedback were given from people who have had subacromial decompression surgery. 

Contact

Wrightington Inpatient Physiotherapy Team: 01257 256307 (answer machine available)

Wrightington Outpatient Physiotherapy Team: 01257 256305