Shoulder Replacement

This information booklet is to help you after your operation and to gain the maximum benefit from your shoulder replacement. It is not a substitute for professional medical care.

The shoulder
The shoulder joint is a ball and socket joint. Most shoulder movement occurs where the ball at the top of your arm bone (‘humerus’) fits into the socket (‘glenoid’) which is part of the shoulder blade (‘scapula’).

Why the joint needs replacement
The most common reasons for replacing the shoulder joint are for arthritis, either osteo-arthritis (wear and tear) or rheumatoid arthritis. It may also be necessary following a fracture or bad accident. With arthritis the joint becomes painful and difficult to move. Sometimes the deep layer of muscles (the ‘rotator cuff’) which control shoulder movements can also be worn or damaged.

About the shoulder replacement
The operation replaces the damaged joint surfaces. It consists of a metal replacement for the ball component and a plastic cup for the socket. Often only the ball of the joint is replaced leaving the socket alone, this is called ‘Hemiarthroplasty’. Surface replacement of the shoulder joint involves shaving the head of the arm bone and capping it with a metal shell as shown in the figure on right. The main reason for doing the operation is to reduce the pain in your shoulder. Ultimately you may also have more movement in your shoulder. This depends on how stiff the joint was efore the operation and if the muscles around the shoulder are damaged and able to work normally. If the muscles are badly damaged, then only the ball part of the joint is replaced. When you have the operation, the doctors will be able to see if there is significant damage to the muscles. From this information we can give you a realistic idea of what movements to expect.

 

What are the risks?
All operations involve an element of risk. We do not wish to over- emphasise the risks, but feel that you should be aware of them.
They include:
a) complications relating to the anaesthetic such as sickness, nausea or rarely cardiac, respiratory or neurological. (Less than 1% each, i.e. less than one person out of one hundred)
b) infection – this is usually a superficial wound problem. Occasionally deep infection may occur after the operation.(less than 1%)
c) unwanted stiffness and/or pain in (and around) the shoulder. (Up to 20%)
d) damage to the nerves and blood vessels around the shoulder.(less than 1%)
e) a need to redo the surgery. (5–10% at 10 years)
Note: Dislocation is very rare. As with all joint replacements, the components can loosen. This is not normally a problem until several years after the operation.
Please discuss these issues with the doctors if you would like further information.

Questions that we are often asked
Will it be painful?
Although the operation is to relieve pain, it may be several weeks until you begin to feel the benefit. You will be given pain-killers (either as tablets or injections) to help reduce the discomfort whilst you are in hospital. A prescription for continued pain medication will be given to you for your discharge home. Please visit your General Practitioner (GP) if you require further medication after that.
You will probably have some bruising around the shoulder/upper arm and the arm may be swollen. This will gradually disappear over a period of a few weeks. You may find ice packs over the area helpful. Use a packet of frozen peas, placing a piece of wet paper towel between your skin and the ice pack. Until it is healed, also use a plastic bag to protect the wound from getting wet. Leave on for 10–15 minutes and you can repeat this several times a day.

Do I need to wear a sling?
The sling is for comfort and to protect the shoulder after the operation. You can take it on and off as you wish and you do not need to have your arm strapped to your body. The therapists and nurses will show you how to take the sling on and off. You will gradually wear the sling less over 4–6 weeks. You may find it helpful to wear the sling at night (with or without the body strap),  particularly if you tend to lie on your side. Alternatively, you can use pillows in front of you to rest your arm on. If you are lying on your back to sleep you may find placing a thin pillow or folded towel under your upper arm will be comfortable.

Do I need to do exercises?
Yes! You will be shown exercises by the physiotherapist. You will start exercises to move the shoulder on the first day after the operation. You will then need to continue with exercises when you go home and outpatient physiotherapy appointments will be organised for you. You will need to get into the habit of doing regular daily exercises at home for several months. They will enable you to gain maximum benefit from your operation. The exercises aim to stop your shoulder getting stiff and strengthen muscles. They will be changed as you progress and made specific to your shoulder and your lifestyle. Some early exercises are shown at the back of this booklet.

What do I do about the wound?
Keep the wound dry until it is healed. This is normally for 10–14 days. You can shower or wash and use ice packs but protect the wound with cling film or a plastic bag. Avoid using deodorant, talcum powder or perfumes near or on the scar. Normally your stitches or clips will be removed by the nurse at your GP surgery after 10 days. You will need to make an appointment at the surgery to have this done.

When do I return to the specialist clinic for the follow up?
This is usually arranged for approximately six weeks after you are discharged from hospital, to check on your progress. Please discuss any queries or worries you may have when you are at the clinic. Appointments are made after this as necessary.

Are there things that I should avoid?
For the first 6 weeks
1. Avoid taking your arm out to the side and twisting it backwards. For example; when putting on a shirt or coat, put your operated arm in its sleeve first. Try not to reach up and behind you (e.g. seat belt in car). It is normally too painful/difficult to do!  Do not force these movements for 3 months.
2. Avoid leaning with all your body weight on your arm with your hand behind you. For example leaning heavily on your arm to get out of a chair. The occupational therapist will show you ways of avoiding these movements and can give you aids and appliances if necessary. See ‘guide to daily activities’ on page 14 of this booklet. Generally do not be frightened to start moving the arm as much as you can.  Gradually the movements will become less painful.

How I am likely to progress?
This can be divided into four phases:

Phase 1. Immediately after the operation until you are discharged You will start to move the shoulder with the help of the physiotherapist, but to begin with you will be quite one-handed. If your dominant hand (right hand if you are right-handed) is the side with the operation, your daily activities will be affected and you will need some help. Activities that are affected include dressing, bathing, hair care, shopping and preparing meals. Before you are discharged from hospital, the staff will help you plan for how you will manage when you leave. Please discuss any worries with them. We may be able to organise or suggest ways of getting help for when you are home.

Phase 2. After you have been discharged and for up to 6 weeks after the
operation
The pain in your shoulder will gradually begin to reduce and you will become more confident. Wean yourself out of the sling slowly over this time, using it only when you feel necessary. Do not be frightened to try and use your arm at waist level for light tasks. You will be seeing a physiotherapist and doing regular exercises at home to get the joint moving and to start
regaining muscle control. If you feel unsure about what you can or cannot do, please discuss this with the physiotherapist. Lifting your arm in front of you may still be difficult at this stage.

Phase 3. Between 6 and 12 weeks
The pain should be lessening. The exercises are now designed to improve the movement available and get the muscles to work, taking your arm up in the air or away from your body when you are sitting or standing. Overall, you will have an increasing ability to use your arm for daily tasks (see driving, work and leisure sections later).

Phase 4. After 12 weeks
You can progress to more vigorous stretches if this is necessary for the activities that you want to do. If the muscles are weak because before the operation the shoulder pain stopped you being able to use them, you should find that you will regain the strength in them with regular exercise. Strength can continue to improve for many months, even up to a year or more. However,  unfortunately sometimes the muscles are badly damaged and then you may find it is difficult to regain movement even though you are trying very hard. Even if the muscles will not work properly, the pain in the shoulder joint should still be much less than before your operation and often you can find small ‘trick’ movements that enable you to do what you want to do.  Most improvement will be felt in the first 6 months, but strength and movement can continue to improve for 18 months to 2 years.

When can I return to work?
You will probably be off work approximately 8-10 weeks, depending on the type of job you have. If you are involved in lifting, overhead activities or manual work you are advised not to do these for 3 to 6 months. Please discuss any queries with the therapists or hospital doctor.

When can I drive?
It is normally about 6–8 weeks before you can do this safely. You may find it is more difficult if your left arm has been operated on because of using the gear stick/ handbrake. Check you can manage all the controls and it is advisable to start with short journeys. The seat belt may be uncomfortable initially but your shoulder will not be harmed by it. In addition, check your insurance policy. You may need to inform the insurance company of your operation. When can I participate in my leisure activities?

Your ability to start these activities will be dependent on pain, range of movement and the strength that you have in your shoulder following the operation. Please discuss activities in which you may be interested with the therapists or hospital doctor. Start with short sessions, involving little effort and gradually increase.

General examples:
• Swimming – after 6 weeks
• Gardening (light tasks e.g. weeding) – after 6–8 weeks (NB. Heavier tasks e.g. digging – do not do!)
• Bowls – after 3–6 months
• Golf, tennis, badminton or squash – after 4–6 months

Guide to daily activities in the first 4–6 weeks

Some difficulties are quite common, particularly in the early stages.
1. Getting on and off seats. Raising the height can help. e.g. extra cushion, raised toilet seat, chair or bed blocks.
2. Getting in and out of the bath. Using bath boards may help. (Initially you may prefer to strip wash.)
3. Hair care and washing yourself. Long handled combs, brushes and sponges can help to stop you twisting your arm out to the side.
4. Dressing. Wearing loose clothing, either with front fastening or which you can slip over your head. For ease also remember to dress your operated arm first and undress your operated arm last. In addition dressing sticks, long handled shoe horns, elastic shoe laces, sock aids and a ‘helping hand’ can help.
5. Eating. Use your operated arm as soon as you feel able for cutting up food and holding a cup. Non slip mats and other simple aids can help.
6. Household tasks/cooking. Do light tasks as soon as you feel able e.g. lift kettle with small amount of water, light dusting, ironing, rolling pastry.  Various gadgets can help you with other tasks.

Exercises – General points
1. Use pain-killers and/or ice packs to reduce the pain before you exercise.
2. It is normal for you to feel aching, discomfort or stretching sensations when doing these exercises. However, if you experience intense and lasting pain (e.g. more than 30 minutes), it is an indication to change the exercise by doing it less forcefully, or less often. If this does not help, discuss the problem with the physiotherapist. Certain exercises may be changed or added for your particular shoulder.
3. Do short, frequent sessions (eg. 5–10 minutes, 4 times a day) rather than one long session.
4. Gradually increase the number of repetitions that you do. Aim for the repetitions your therapist advises, the numbers stated here are rough guide-lines. After 3–4 weeks you can increase the length of time exercising. Get into a habit of doing them! Good luck. NB. Exercises shown for right shoulder, unless specified.

Phase 1 exercises
From operation day to 10–14 days after *shown for left arm
1.Lean forwards.

• Let your arm hang freely.
• Start with small movements.
• Swing your arm iii) forwards and backwards iii) side to side iii) in circles
• Repeat 5 times each movement.

2. Sit or stand.
• Shrug shoulders up and forwards. Then roll them down and back
• Repeat 10 times.

3. Lying on back, folded towel under arm.
Keep elbow to side. Hold stick in hands.
• Move stick sideways, gently pushing hand on your operated arm outwards. Do not over-stretch.
• Repeat 5 times.

4. *shown for left shoulder Lying on your back.
• Support your operated arm with the other arm and lift up overhead.
• Start with your elbows bent, then with arms straight.
• Repeat 10 times.

5. Sit or stand.
• Try and set up a pulley system with the pulley or ring high above you. Pull down with your un-operated arm to help lift the operated arm up.
• Repeat 10 times.
NB. Normally it is best to have the pulley point behind you.

Phase 2 exercises
From 10–14 days to 6 weeks after your operation

6. Lying on your back, elbow bent.
• Help your operated arm up as before, but once it is vertical try and keep it there without the support of the other arm.
• Gradually lower and raise your arm in an arc, until you can lift it from the bed.
• Once this is easy, progress to exercise number (13) standing.
• Repeat 10 times.

7. Standing with arms behind your back.
• Grasp the wrist of your operated arm and gently stretch hand towards opposite buttock. Then slide your hands up your back.
• Repeat 5 times.

8. *shown for the left shoulder Standing or sitting.
• Take hand of your operated arm across body towards opposite shoulder. Give gentle assistance from your other arm.
• Repeat 5 times.

9.Standing with your operated arm against a wall.
• Bend your elbow. Push your HAND into the wall. Hold for 10 seconds.
• Repeat 5 times.
• Gradually increase to 3!10 repetitions.

10. Stand with back against wall.
• Keep arm close to side, elbow bent. Push the elbow back into the wall. Hold for 10 seconds.
• Repeat 5 times.
• Gradually increase to 3!10 repetitions.

11. Stand sideways with operated arm against wall.
• Keep arm close to side, elbow bent.
• Push elbow into wall.
• Hold for 10 seconds.
• Repeat 5 times.
• Gradually increase to 3!10 repetitions.

12. Stand facing a wall.
• Keep arm close to side and elbow bent to 90°. Push your fist into the wall (use a towel if this is uncomfortable for your hand).
• Hold for 10 seconds. • Repeat 5 times.
• Gradually increase to 3X10 repetitions.

13. Standing facing a wall.
• Elbow bent and hand resting against wall.
• Use paper towel between hand and wall (to make easier).
• Slide your hand up the wall.
• Initially can give support at the elbow with your other hand.
• Gradually stretch higher up the wall.
• Try to make movement smooth.
• Repeat 5 times and gradually increase to 15–20.
• Progress by moving away from the wall. Start this exercise 3 weeks after operation

14. Sitting or standing with your elbow bent.
• Keep elbow INTO your side. Start with your hand in front of your stomach
and pull hand outwards until it is in front of you. Control the movement on return and do NOT try and pull out too far.
• Repeat 5 times.
• Aim to gradually increase to 3!10 repetitions. Start this exercise 4 weeks after your operation

15. Sitting or standing with your elbow bent.
• Stand with arm close to side and elbow bent. Push the palm of your hand into other hand (or do this against wall, or in door frame).
• Hold 10 seconds
• Repeat 5 times.
• Aim to gradually increase
to 3X10 repetitions.

16. Stand with arm close to body and elbow bent.
• Hold rubber exercise band. Pull your hand towards your stomach. Keep the elbow   in. Control he movement on return.
• Repeat 5 times.
• Aim to gradually increase to 3X10 repetitions.

17. Stand with hands clasped in front of you.
• Lift arms up in air. Separate your arms sideways, bend your elbows and lower them down.
• Progress this by i) reversing the movement (start by taking elbows out to the side). ii) keeping the  arms straight.
• Repeat 5 times.

18. Lying on back.
• Try and take both hands behind neck with your elbows pointing up to the ceiling.
• Then progress to allow elbows to gently move apart.
• Repeat 3–4 times.

Phase 3 continued and Phase 4
There is great variation in what people can achieve during rehabilitation, therefore it is not possible to give all potential exercises. The physiotherapist will design an ongoing exercise programme for you which is specific to your shoulder and your needs.  Keep the exercises going until you feel there is no more improvement. This may continue for a year to 18 months… so think positive, keep at it and enjoy them!

Reference
Patient Information Leaflets Nuffield Orthopaedic Centre NHS Trust
http://www.noc.nhs.uk/shoulderandelbow/information/patient-information.aspx