Arthroscopic Subacromial Decompression

Subacromial pain is a common symptom. It is most often felt as pain over the top and side of the shoulder. It can affect all people though it is more common in people over 40yrs old. It is commonly made worse by lifting your hand over-head, to perform simple activities such as combing your hair, or putting things on high shelves. The site of pain can vary and in some people it can radiate into the neck or down to the elbow. Subacromial pain at night is common and some people can have difficulty sleeping on the affected side.

The cause of subacromial pain is not fully understood. Most health professionals believe that there are multiple causes. In some patients there is a mechanical cause where the rotator cuff muscles of the shoulder pinch against the undersurface of a bone above the shoulder joint called the acromion. This is usually because of a bony spur on the undersurface of the acromion. This repeated pinching causes inflammation and pain. In others the pain is because of degeneration in the rotator cuff muscles around the shoulder.

Subacromial pain is diagnosed by taking a detailed history of your symptoms, including when it started, whether there was any preceding event, where the pain is and what makes it worse. A thorough clinical examination is then performed, which involves finding out what movements reproduce your pain. You will also have an X-ray to confirm the shape of your bones and to ensure there are not any other diseases such as osteoarthritis. In the majority of patients the diagnosis will then be confirmed with an injection into the subacromial space. This is used for diagnosis and for treatment. You will be examined after the injection to reassess your movements. Some patients will need further imaging such as an ultra-sound or MRI to examine the rotator cuff muscles, not all patients will need to have this performed though.

First line treatment for subacromial pain is physiotherapy to improve the control of your shoulder and the strength of the shoulder muscles. If this is unsuccessful or if the disease is severe, an injection into the subacromial space to improve the inflammation will be performed followed by physiotherapy. If you still have significant symptoms after first-line treatment, your surgeon may offer you an operation. Your chance of success is improved if your injection provides you with some pain relief, even if this is only for a few hours.

Firstly, your shoulder will be assessed whilst you are under anaesthetic to check your range of movement and the stability of your shoulder. Through key-hole incisions your shoulder will be assessed and the operation performed. Your inflamed tissue will be removed and if necessary the under surface of your bone shaved smooth to create more space for your shoulder to move with less pain. During the operation it may be necessary to remove the end of your collar bone if this is painful or causing impingement, this can usually be performed through key-holes. It may also be necessary to repair a torn rotator cuff muscle if one is identified. The different surgical procedures will be thoroughly discussed with you as they may change your post-operative rehabilitation

Surgery is a successful method of treating patients with subacromial impingement. Surgery will only be performed if you have not improved from first line treatments described above.

Some of the possible complications of arthroscopic subacromial decompressions are listed below: Infection: Infection can complicate any surgery. It may be possible to treat this with antibiotics alone, but further surgery may be required, the chance of this happening is about 1%. Stiffness: Post-operative stiffness can occur. It is important that you work with the physiotherapist to try and avoid this. Reoccurrence: Unfortunately a small proportion of patients’ symptoms return requiring a second procedure. This is less likely with modern techniques. Nerve and blood vessel injury: There is a very small risk of damage to nerves or blood vessels around the shoulder. Cardiovascular problems such as heart attack and stroke, and also blood clot formation, can very occasionally be caused by anaesthesia and surgery. If there are any reasons why you would have an increased risk of these occurring, your anaesthetist will discuss this with you, and take steps to minimise the risks.

Arthroscopic subacromial decompression surgery can usually be undertaken as a day case. You may need to stay overnight if you are not operated on until late in the day, or if you have other medical illnesses that need monitoring after your operation.

You will be assessed by a physiotherapist on the ward. They will ensure you are able to undertake your post-operative exercises to maximize the benefit of the operation. You should continue these exercises as directed until you are assessed again by an outpatient physiotherapist within two weeks of your discharge. Please keep the wounds dry to decrease the chance of infection. The wounds will be reviewed at your two week post-op out-patient clinic visit. The sutures will also be removed. Range of movement will also be assessed at this visit to ensure you have not developed any post-operative stiffness. If you feel unwell or concerned after the operation, you should seek medical attention via your GP. If you have not had any form of repair to your rotator cuff muscles you may move your arm freely as comfort allows. No restrictions will be placed on you concerning range of movement or lifting. You can sleep on the operated shoulder when it is comfortable to do so. Driving – You can return to driving once you are able to fully control of your vehicle. Work – When you can return to work depends on your job. If you have a desk-based job you can usually go back to work after about two weeks although some people need longer. If you have a manual job you are likely to need a longer recovery period to avoid aggravating your pain with heavy activities. You may need about six weeks off work before you return to full duties. You may be able to return earlier if your employer supports a phased return. Sports – This depends on how quickly you recover your flexibility and muscle strength and the type of sport you wish to return to, you will need to return gradually and your physiotherapist can guide you on how to do this. When your wounds are healed and dry you can return to swimming breast stroke if this feels comfortable.