by Mr Devinder Garewal
19 July, 2018
Having shoulder surgery may be a daunting prospect. Certainly, questions about the aneasthesia, post-operative pain and the journey of rehabilitation after your operation to get your shoulder back to normal, can be of considerable amount of concern.
Before embarking on shoulder surgery, your orthopaedic surgeon will discuss your perioperative journey including postoperative recovery instructions, and depending on the type of shoulder surgery, there are some general guidelines you can follow on what to expect and your recovery time.
You’ll need to fast 6 hours before your operationPreparing for rotator cuff surgery begins with eating and hydrating well in the days up to the operation. You will need to fast for at least 6 hours before your operation to ensure that you have a safe anaesthetic.
Having an anaesthetic on a full stomach can cause issues with bringing up those contents and filling up your lungs (aspiration) so we won’t put you to sleep unless its completely safe and your stomach is empty of food and liquids.
6 hours is enough time for this to happen with food. 2 hours after clear fluids is also safe.
Take your usual medications unless advised otherwise by your doctorOn the day of your operation, you should take your usual medications with small sips of water unless you are advised not to take particular medication by your doctor.
Medications that thin the blood in particular are stopped prior to your operation to reduce bleeding whilst you are having your surgery. All medications are checked to ensure they can continue to be taken around the time of your operation.
Wear a stretchy, loose fitting topWearing appropriately clothing on the day of rotator cuff surgery also makes the day of the operation flow seamlessly – stretchy, loose fitting tops or shirts are easy to take off before the operation and once the operation is completed, they are easy to drape over your shoulder and over the top of your sling. Avoid wearing anything that is tight or difficult to put on.
Don’t wear hair or face products, deodorant or makeupRefrain from wearing makeup, hair or face products and jewelry on the day of surgery. Makeup, face products or perfumes/liquids/deodorants can affect monitoring you during the operation and also pose an infection concern. For men, do not shave the hair around your shoulder as this can also cause infection issues.
Arrange for help from a family member or friendHaving a support person in a family member or friend to give you a ride to the surgery centre and back home is vital. You cannot drive home post shoulder surgery. This is due to the fact that your arm will be in a sling and after a general anaesthetic it is not safe to drive until all its effects have worn off.
They also offer support at a time that you might feel anxious. It also might be helpful for them to offer support the evening of the operation and even overnight to help with meals, showering and keeping you comfortable in that immediate phase.
Having someone at home can be critical to help you with daily tasks. This might be helpful for the first few days and having someone to assist you will help avoid any shoulder pain and also help you to adhere to post-operative rehabilitation restrictions and guidelines.
Gaining as much information as possible about your anaesthesia and perioperative care is important. Aneasthetists will give you detailed information about the process before embarking on shoulder surgery.
Most shoulder surgery is performed with you completely asleep using a general anaesthetic. You will get a drip (IV cannula) placed into the back of your hand so that medication can be given to make you sleepy, as well as medication thru a face mask.
You will also get another drip placed into your artery to monitor your blood pressure while you are sleeping.
Limiting your pain during the process of shoulder surgery and during your rehabilitation is our aim.
Nerve block for pain will last 12-24 hoursBefore you go to sleep, the anaesthetist will perform a nerve block for shoulder surgery. This block will numb the nerves that supply the shoulder and the rest of the arm so that you will not feel anything when you wake up. This is performed using an ultrasound machine to locate the nerves just before the shoulder and using it as guidance, introduce local anaesthetic carefully via a small needle next to these nerves.
This means that the anaesthetic doctor doesn’t need to give you pain medications while you are sleeping which means waking up fresher and without the common side effects of these medications including nausea, vomiting or drowsiness.
This nerve block usually lasts between 12-24 hours. The feeling to your shoulder and arm will return, as will some shoulder pain. However, we can be pre-emptive and on the front foot in addressing this pain by taking tablets before the block wears off.
This means that the pain can be well controlled and you can be comfortable throughout the entire process. We usually advise taking oral tablets for pain relief for the first few weeks after surgery to keep you comfortable and allow you do start doing your exercises and rehabilitation work.
Once the operation is completed, the anaesthetic specialist will wake you up. They do this by reducing the medications that keep you asleep and giving you medications to wake you up.
At first you will feel groggy and still sleepy but this should wear off over the first hour whilst you are in the recovery room. The nurses here will monitor you until you are awake and comfortable.
By using the nerve block, you should have no feeling in your shoulder or arm. You should be comfortable immediately when you wake up.
Once you feel less groggy and are breathing normally, you will be moved into a post-operative recovery area where you can sit in a chair. By now you should be feeling mentally clear and awake and staff will provide you with some food and water.
During this stage, the surgeon will talk you about the operation and your recovery, and a shoulder physiotherapy specialist will also discuss your rehabilitation with you as well as exercises to start immediately to begin your recovery. Once these are completed, you are safe to be discharged and can return home to rest.
Pain medication can help with painTaking a combination of different pain medications will keep you comfortable in the early phase after shoulder surgery. We prefer you to take lower doses of a few different pain medications than maximum doses of a few types.
These different pain tablets work on different pathways to attack and alleviate pain. By reducing their doses, it means less chance of having their side effects. Common side effects include nausea, vomiting, drowsiness or a stomach upset.
Most of these medications are required for the first 5 to 7 days. As your pain subsides you can start to reduce the doses of each of the medications, before tapering the actual pain tablets themselves.
Most of the opioids can be ceased within the first week or two. We suggest keeping up with simple pain relief (like paracetamol) and an anti-inflammatory until at least the 6-week mark. Whilst on pain relief, we also suggest taking medications to help soften your stools as these medications can cause constipation. Keeping up your fluid intake is also helpful.
Taking pain relief is also vital for you to embark on shoulder rehabilitation and exercises. It allows you to be comfortable while attending to your exercises and decreases the inflammation after these exercises have occurred. It will ensure that you recover quicker.
Use a cold pack for inflammationUsing ice compression is also useful after surgery. It reduces pain by decreasing the inflammation. We suggest using a bag of peas wrapped in a light cloth or a specific cold pack from a pharmacy that can be placed directly onto your shoulder for 15-20 minute periods every few hours for the first 3 to 5 days.
Once this phase has passed, using a heat device such as a heat pack can also be soothing.
Getting prepared for surgery with clothing, equipment for your home, food and toiletries are essential to help you after shoulder surgery.
Loose fitting clothes that you can easily put on or even wear over your sling might be best in the early phase and appropriate during the warmer months.
Otherwise, tops that have easy to use buttons or a zip might work well instead of ones that you to pull over your head. Tops that don’t require you to put your arm above shoulder level are best.
Finding easy to apply bras are also useful. Front closing bras are often easier to use in the early post operative phase than the traditional back closing ones. Otherwise applying the bra at the front and twisting it to the back might a useful strategy.
Finding some shoes that are easier to put on with one hand might help after surgery. Tying shoe laces up with one hand can be quite the challenge! Either use slip on shoes or ones with Velcro in the early phase after surgery.
Getting some food prepared before surgery makes meal times much easier after surgery. Certainly, things like soups, frozen meals and a few bags of frozen fruits and vegetables can help you in a pinch.
High fibre foods might also be useful to combat constipation which can occur after surgery and with the use of pain medications. Drinking plenty of water after surgery is another good practice.
Find some extra pillows around your house or purchase one or two. You might find it more comfortable if you prop your operated arm up with a pillow while you are sitting on your couch or lying in bed.
Be prepared to wear a sling for 4 Weeks after shoulder surgery.After most surgery, especially if structures within your shoulder are repaired, the arm needs to be rested for this period.
Coping with daily activities with you arm in a sling needs to be planned and thought out prior to embarking on surgery. Depending on if the shoulder operated on is your dominant or non-dominant side you might need to reconsider basic daily tasks to compensate.
You might need help to shower, get dressed and alter the way you eat and drink. Driving is not advised during this time.
Even though you need some rest during this period in your sling, you are able to remove the sling to do some basic activities and your exercise. Most things that are below the level of your shoulder can be performed as long as they don’t cause pain.
You will commence shoulder rehabilitation exercises immediately after your surgery and can remove your sling 3 or 4 times per day to do so. We also encourage you to move and exercise your elbow, wrist and hand to prevent any stiffness from occurring.
Depending on how much you move when you sleep, you might find it more comfortable to remove the sling at night and rest the arm on a pillow. If you move about whilst sleeping, it’s recommended to keep the arm in a sling to prevent any uncontrolled movement.
You won’t be able to drive for 6 weeks.Not being able to drive a car after surgery for a period of 6 weeks is an inconvenience. We certainly rely on cars to perform most daily activities.
Immediately after shoulder surgery, driving is not appropriate. Without the use of both upper limbs controlling a car, especially in a case of an emergency, is not possible or safe. Even if you drive an automatic car, you need both arms to control the vehicle.
With adequate rehabilitation and shoulder exercises, most people can move and control their arms enough to attempt driving from about 6 weeks.
We suggest short drives when the roads aren’t busy to begin with to ensure that your shoulder feels up to it, before increasing the duration of your driving and dealing with busy traffic.
Given the restrictions to your range of movement after shoulder surgery, especially if you have had to have torn rotator cuff tendons reattached, you will quickly realise that this advice is sensible and it is indeed motivation to attend to rehabilitation exercises so you have enough range of movement, strength and endurance to start to drive at 6 weeks.
On the other hand, if you have a minor shoulder procedure like a subacromial decompression or bursectomy, you may be able to return to driving at an earlier stage.
In these cases, you only require your sling for 5-7 days and may find it comfortable enough to commence driving from 3-4 weeks. It is best to discuss this with your shoulder surgeon as it is often a case by case basis.
Driving before these recommended guidelines is not advisable and is also against the law, and will result in voiding your car insurance.
Find your best position to sleep after shoulder surgeryFinding a comfortable way to sleep after shoulder surgery can be challenging. Lying directly on the operated shoulder will not be comfortable initially. Sleeping on your opposite side is recommended.
Sleeping in a more upright position with the use of pillows to prop yourself up may work. Alternatively, resting in a wide arm chair or a recliner might be more comfortable and allow you to sleep.
As the symptoms subside in the first few weeks you might again try lying flatter to sleep.
Using pillows behind your back might help prevent you from rolling back onto your operated shoulder. Wedge shaped pillows can also work well in preventing your turn whilst deep asleep.
Another tip is to use something under the mattress to tilt the mattress slightly that it makes it difficult for you to turn over.
Depending on your bed habits and which side you normally sleep on, you might want to swap sides with your partner if that helps your sleep on your un-operated side.
Putting your bed and mattress up against a wall might also help you stop turning towards the wall-side.
Keeping your operated arm in a sling will also help you protect the shoulder and prevent unnecessary movement.
Using some pillows under the shoulder to elevate it, which also helps swelling, will also stop you from turning directly onto it.
Shoulder rehab will help with a faster recoveryRehabilitation is essential for you to attain maximal results after shoulder surgery. Convention used to mandate 6 weeks in a sling to protect the repair before moving your shoulder, but this results in stiffness and a slow recovery process.
By fixing structures securely in your shoulder, we know that the repair is stable and strong enough to start moving and beginning rehabilitation from the moment your shoulder surgery is over.
This will hopefully prevent stiffness or frozen shoulder and will allow you to return to function much quicker.
Shoulder rehabilitation exercises are best addressed even before your operation. Maximising your range of movement and shoulder strength before the operation means that you’re that much further ahead in your rehabilitation once the operation is over.
During this time, your physiotherapist will also teach you the initial post operative exercises so you can practice these before the operation. It means a much easier transition in that early phase after your operation.
We recommend using a sling for the first 4 weeks. During this early phase, you can come out of your sling 3 or 4 times a day to perform your exercises. The initial exercises are called passive assisted exercises.
That means using your other arm to move the operated shoulder. It keeps you from getting stiff whilst preventing you from activating your rotator cuff muscles whilst the healing is occurring.
In your second phase of rehabilitation (between 4-8 weeks), the physiotherapist will instruct you on more exercises that improve range of movement and teach you exercises relating to posture and scapular (shoulder blade) control.
Once you have a good range of movement and enough time has passed for your rotator cuff tendon to heal to bone (about 10-12 weeks) we can start strength re-training. This is done in a gradual manner to avoid stressing your repair.
It can take up to 12 months to achieve full enduranceIn our experience, it takes up to 12 months to achieve your final result after rotator cuff surgery. Indeed, maximal strength and endurance is achieved between the 6 to 12-month mark.
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