Tendonitis (ASD/ACJ)

Hopefully, if you read through this whole section, all your questions will be answered.

Your shoulder pain has come back again after a lovely 3 or 4 weeks or longer when it seemed to have been back to normal after the injection. You had been doing everything you wanted including getting a good night’s sleep but now it actually feels quite a bit worse than before which it sometimes appears to do because it tends to go from pain-free to painful very quickly when it comes back.

Time for the operation?

Yes. Time for the operation and to give you back a pain-free and fully functional shoulder on a permanent basis.

But if the injection didn’t ‘cure’ it, why will the operation?

Good question. And the answer is in the statistics and my experience. There is a very good link between doing well with the injection – even if only for a few days – and doing very well with the operation.  What I do is take the pressure off the damaged tendon so that it can run smoothly without catching and rubbing and causing pain so it can’t really come back.

What does the operation involve then?

Usually we can do the procedure as a day-case so you are in and out in half a day and can sleep in your own bed.

It is an arthroscopic or ‘key-hole’ procedure so there are only 2 or 3 small incisions about 1 cm or less long.

Let me walk you through the whole experience.

You will arrive at the hospital either bright and early (usually about 0700) if it is a morning operating list or about 1230 if it is for an afternoon list. You will be shown up to your room and the nursing staff will get you settled in and go through the admission process – checking who you are; asking quite a lot of questions; doing your blood pressure; putting a name bracelet on and answering any of your questions that they can.

The anaesthetist and I will come and talk to you. I will go through the consent form with you which details what I am going to do; what the benefits are going to be and what the complications could be.  And then I will do the most important thing of the day which is to put a big arrow on the arm we are going to operate on with an indelible marker pen. I know it looks a bit silly but believe me this is one of the most important things I do!

You will get in to the classic operating gown (tied up tight at the back!) and there will be compression stockings on your legs to minimise the chance of developing a deep vein thrombosis. (see complications)

When your turn comes you will be walked down to the operating theatre by a nurse and onto a trolley in the anaesthetic room. This is where the anaesthetic team will do their bit and put you off to sleep.

Now, shoulder surgery can be quite painful afterwards so an important element of the whole anaesthetic process is a special injection into the base of the neck/shoulder which puts your arm completely to sleep called an Inter-Scalene Block. (see Inter-Scalene Block)

Do I have to have a general anaesthetic?

Unless there is a really good medical reason then yes you do. But please don’t associate it with general anaesthetics you may have had for bigger operations or that you have had years ago. The vast majority of people wake up very quickly and without any sickness and are sitting there twiddling their thumbs and wanting to go home. The general anaesthetic (GA) makes both our lives a lot easier. We can control your blood pressure more easily which means I can do your operation more quickly and you won’t be fidgeting and moving about on the operating table making things more difficult.

And the incisions?

As I said above there will be between 2 and 4 small incisions each less than 1cm long.

Stitches? When do they come out?

Yes – one stitch in each hole. They aren’t dissolvable stitches so need to be taken out about 10 days after the surgery either back at the hospital or at your GP surgery. That will be organized before you go home.

What do you actually do?

One of the main problems causing tendonitis is a lack of space under the acromion (the bone on top of the shoulder) so that the tendon catches and rubs when you move your shoulder around. What I do is make a bigger space by shaving away some of that bone.

Is that the spur my therapist mentioned?

Yes it can be and quite a lot of patients I operate on do have a spur or a hook or an exaggerated curved shape to that part so there is naturally less space than is ideal. In some people the bone shape is normal but poor posture and the way you move the shoulder artificially narrow that space.

Before I do any operating I check that your shoulder hasn’t stiffened up – that you aren’t developing a Frozen Shoulder (see Frozen Shoulder) as sometimes happens. And if you have then I change tack and deal with that instead.

I start off looking into the main ball and socket joint (gleno-humeral joint) to check that for any arthritis; eroded or torn tendons; inflammation in the biceps tendon or damage to the labrum – all of which may need to be dealt with. In the older patient the long-head of the biceps tendon frequently gets caught up inside the shoulder when the arm goes up in the air and I do a biceps tenotomy. (see biceps tenotomy)

Then I move to where the problem is – the sub-acromial space. This is the virtual gap between the top surface of the rotator cuff tendon and the under surface of the acromion where the tendon is rubbing or ‘impinging’.

Firstly I remove the inflamed soft tissue or bursa so that I can see the bone and tendon clearly.

Once that has been done I use a powered burr to shave away bone to create that increased space.

If your Acromio-Clavicular joint is part of the problem then I go on to excise the end few millimeters of the collar-bone (see ACJ problems)

Then the stitches, dressings and sling.

You wake up quickly in the recovery area and then are wheeled back up to your room.

The physiotherapist will come and see you later to show you some basic exercises to get the arm moving and I come up and see you later to tell you how it all went.

Do I get any pictures of the operation?

Better than that – you get a CD of the whole thing! Don’t worry – it isn’t you on the operating table. It’s the inside of your shoulder showing all the nooks and crannies and everything that I do.

How long do I need the sling for?

Just till your arm comes back to life and you can move it yourself. So maybe a day or two.

I heard something about a nappy on the shoulder? What is that about?

I do use a nappy as a dressing over the top of the sticky plasters covering the stitches. It does look a bit odd but it’s the perfect shape for the shoulder and just stops any fluid or blood oozing out. It is taken off before you go home though.

Will my shoulder hurt?

It shouldn’t hurt for the first 15 to 20 hours because of the Inter-Scalene Block (the injection given to the base of your neck). We send you home with pain-killers and you should start taking those when you feel the pain starting to kick in. Don’t wait until it is genuinely painful because it is much easier to keep it under control if you don’t let it take control first.

You will need painkillers and anti-inflammatories regularly for about 2 weeks and then on an ad hoc basis afterwards.

I have seen friends in a lot of pain afterwards and some with no pain. Why?

You are right and it can be very variable afterwards with some people pretty much back to normal after a week and others still in pain after a few weeks. And I just don’t know why.

What can I do and what shouldn’t I do?

The important thing to remember is that, although it has been done through small holes, this is not a small operation. I have been shaving away bone and raw bone surfaces take 8 to 10 weeks to heal up and seal over. So it’s not like a knee key-hole procedure where the surgeon is removing cartilage and the recovery is much quicker.

So don’t rush it.

Driving a car:  if it is your right shoulder you can usually drive more quickly and with an automatic that may be after just a few days. With the left and gears it can be up to 2 weeks. But try it and see as it is very variable.

Showering: straight away really – or as soon as your arm has come back to life. Don’t worry too much about getting the stitches wet. The best thing is to put a waterproof plaster over each stitch while showering or bathing but do take those off afterwards and replace them with a breathable plaster otherwise the skin can get macerated. After 4 days you are actually water-proof anyway so don’t need to cover the stitches unless you want to but don’t soak them in a bath.

Day to day stuff: again once your arm comes back to life you should be able to dress, wash, brush your teeth and shave but it can be a struggle to do your hair for a fortnight or so.

Work: this really does depend on what you do and whether they can manage without you for a bit and the financial pressure on you. If it’s your own business and you sit behind a desk then you could be back at work the next day – if you can get there. For most office jobs a week or two is probably enough and a lot of people will work from home on a computer.

For more physical things then it can be 6 weeks before you will be much use especially if this involves repeated lifting or use at and above shoulder height. However I know a lot of self-employed peopled doing physical jobs feel they have to go back to work after 2 weeks and they do manage albeit it can be pretty tough going.

Sports: I suggest a gentle return to golf, tennis, swimming and the gym after 6 weeks.  For golf get up to the range and just hit a dozen balls with a 9 iron and a half swing; go and have a drink and go home. Much the same for tennis. Go and knock up with a few friends just playing gentle forehands and backhands.

Don’t be tempted to do too much too soon.

The most important thing is to use that initial period to work with the physiotherapist on strengthening and stabilizing the shoulder rather than being tempted to get back to doing everything you were doing before. Getting those fundamentals of posture, scapular stabilization and rotator cuff strength sorted out are absolutely vital.

And remember to build things back up slowly and gently over time. Often its what you were doing in your sport that has caused the problem so take the opportunity to revise your style, grip, stroke, swing etc to avoid it happening again.

But you have been through a lot by having the operation and the reason for doing that is to allow you to get back to doing all the things you want to do. So after 6 weeks go and try things. But do start gently and build up slowly.

Sleeping: it can take quite a while before you can sleep through the night on that shoulder but, again, it is very variable. If I have to remove your ACJ then this can be one of the last things to get back and it could be 4 months or so.

Hoovering and ironing: you won’t even be thinking about this for the first 2 weeks and when you start just do one room a day and only iron a few things. Always stop before your shoulder becomes uncomfortable.

How long before I am back to normal?

The first 2 weeks can be quite sore; by 6 weeks you should be thinking that it was worth doing and you can see the improvement week by week; it takes 3 months to hit the 80 – 90% mark at which point you are doing pretty much everything but the final little bit can take another 3 months to achieve.

But remember – you are not an invalid and you can build your activities up bit by bit after 6 weeks.