These are some examples of exercises to stretch your shoulder. Do exercises regularly 1–2 times a day. You may find them easier to do after a hot shower or bath. Using a hot water bottle is another alternative.

It is normal for you to feel aching or stretching sensations when doing these exercises. However severe and lasting pain (e.g. more than 30 minutes) is not recommended. Reduce the exercises by doing them less often or less forcefully. If the pain is still severe discontinue the exercises and see the physiotherapist or doctor.

Please note: Raising your arm forwards often improves first. Getting your hand behind your low back appears to be the last movement to return. Do not do these movements if they are painful rather than stiff.

1. Pendulum 

• Lean forwards with support (shown for left shoulder)
• Let arm hang down
• Swing arm forwards and back side to side around in circles (both ways) Repeat 5–10 times each movement

2. Twisting outwards Sitting holding a stick (rolling pin, umbrella)
• Keep elbow into your side throughout
• Push with unaffected arm so hand of problem side
is moving away from the mid-line
(can be done lying down)
• Do not let your body twist round to compensate
• Repeat 5–10 times

3. Arm overhead Lying on your back (shown for left shoulder)
• Support problem arm with other hand at wrist
and lift it up overhead
• Do not let your back arch
• Can start with elbows bent
• Repeat 5–10 times

4. Twisting outwards/arm overhead Lying on your back, knees bent and feet flat

• Place hands behind neck or head, elbows up to ceiling
• Let elbows fall outwards
• Repeat 5–10 times

5. Kneeling on all fours Keep your hands still

• Gently sit back towards your heels
• To progress take your knees further
• away from your hand Repeat 5–10 times

6. Sit or stand

• Try and set up a pulley system with the pulley or ring high above you.
• Pull down with your better arm to help lift the stiff arm up
• Repeat 10 times NB. Normally it is best to have the fixed pulley point behind you.

7. Stretching the back of the shoulder (shown for left shoulder)

• Take hand of your problem shoulder across body towards opposite shoulder
• Give gentle stretch by pulling with your uninvolved arm at the elbow
• Sometimes you can feel more stretch if you lie on your back to do the movement
• Repeat 5 times, holding for 20 seconds

8. Hand behind back Standing with arms by side

•    
• Grasp wrist of problem arm and gently stretch hand towards your opposite buttock
• slide your arm up your back
• Can progress and use a towel
• Repeat 5 times
  Remember this is often the last movement to return – do not force if
  painful, rather than stiff

Reference

Patient Information Leaflets Nuffield Orthopaedic Centre NHS Trust

These are some examples of exercises which may help with your shoulder impingement problem. The exercises should not be painful. They may feel hard work, stretchy or aching. Often a physiotherapist will guide you with exercises specific for your shoulder.  However, in general terms, if you try the exercise on both arms and it feels much more difficult, hard work, stretchy on the problem shoulder, it would be worth you trying that particular exercise. You do not need to do all the exercises listed below! Continue with the exercises which feel different on the problematic shoulder, aiming to try and get rid of the difference between the two arms. Do the exercises regularly 1–2 times a day.

Do not continue with them if the pain worsens. Reduce them by doing them less often or less forcefully. If the pain is still worse, see the physiotherapist or doctor.

Shoulder blade exercises

1. Sitting or standing

• Keep your arms relaxed.
• ‘Square’ your shoulder blades back.
• Hold it for 10 seconds, repeat 10 times.
• Do not let your back arch, breathe!
• If one shoulder is lower, ‘square’ it by lifting that one, UP and back.
• Lying face down, with head in front on a towel or turned towards shoulder.

.

2. Keep arm relaxed by side

• Lift shoulder straight up in air. Try and keep a gap approximately 5 cms between front of shoulder and bed.
• Hold the shoulder up for 30 seconds but arm relaxed by side. Repeat 4 times.
• Progress – by lifting the arm up and down (elbow straight), but keeping the shoulder blade up all the time.
• Aim to do this for 30 seconds.
• Repeat 4 times.

.

Standing close to and facing a wall/door
3. Arms up overhead in a V shape

• Little fingers against the wall, thumbs pointing back behind shoulders.
• Rest your arms against the wall.
• Shrug your shoulder blades up, letting the hands slide upwards.
• Repeat 10 times.
• Progress by pulling shoulder blades together whilst they are shrugged up.

.

Stretching exercises
4. Overhead stretch lying on your back

• Knees bent up and feet flat on floor/bed.
•  Stretch your problem shoulder arm up overhead,using your other arm. Aim to try and get the upper arm towards the floor/bed.
• Repeat 3–5 times, holding for 20 seconds.

.

Stand or sit.
5. Cross body stretch. Take arm across your body

• Giving a gentle stretch with your other hand at the elbow. Try and keep your shoulder down.
• The stretch should be felt at the back of the shoulder and upper arm.
• Repeat 3–5 times, holding for 20 seconds.
• Do not do if it is painful in the front of the shoulder
• Sometimes you can feel more stretch if you lie on your back to do the movement.

Reference

Patient Information Leaflets Nuffield Orthopaedic Centre NHS Trust

The aim of this information sheet is to give you some understanding of the problem you may have with your shoulder. It has been divided into sections, describing your shoulder, what we know about frozen shoulder and your treatment options.

About your shoulder
The shoulder is designed to have a large amount of movement so that we can use our hands/arms in a wide variety of positions. Some movement occurs between the shoulder blade and chest wall. However most shoulder movements are at the ball and socket joint. The ball at the top of the arm bone (‘humerus’) fits into the shallow socket (‘glenoid’) which is part of your shoulder blade (‘scapula’). There is a loose bag or capsule which surrounds the joint. This is supported by ligaments and muscles.

What is ‘frozen shoulder’?
Typically the joint is stiff and initially painful, often starting without an apparent cause.  The loose bag (capsule) around the shoulder joint becomes inflamed. The bag then appears to tighten or shrink. This tightening combined with the pain restricts the movement.

How common is it?
It is most common in people between the ages of 40 and 70 years and has been estimated to affect at least one person in 50 every year. A staggering one million people in the UK will have frozen shoulder in a year. About 10% of people may develop frozen shoulder in the other shoulder within 5–7 years of the first one. However it tends to resolve more quickly than the first. Although it is widespread, it is a difficult condition to treat. We hope that this information sheet will help to explain what we know about it so far.

Why does it occur?
A primary frozen shoulder is when the exact cause is not known. It is more common in people with diabetes and with a thyroid gland problem. About 15% of patients link it to a minor injury to the shoulder.

A secondary frozen shoulder can develop if the shoulder area is kept still for some time, for example, after a stroke or heart attack. It can also occur after major injury or surgery to the shoulder.

Some experts think the inflammation starts with a problem in the shoulder itself, others feel it is related to factors away from the shoulder (e.g. stiff neck, certain diseases). Research is continuing to try and answer some of these questions.

What tests may be done?
The main way we diagnose the problem with your shoulder is from what you tell us and from our examination. Sometimes an X ray will be done to check there are no bone changes in your shoulder joint.

What is likely to happen?
There are 3 main phases

1) Painful phase (which can last from 2 to 9 months)

The pain often starts gradually and builds up. It may be felt on the outside of the upper arm and can extend down to the elbow and even into the forearm. It can be present at rest and is worse on movements of the arm.

Sleep is often affected, as lying on it is painful or impossible. During this time movements of the shoulder begin to be reduced.

2) Stiff phase (which can last from 4 to 12 months)

The ball and socket joint becomes increasingly stiff, particularly on twisting movements such as trying to put your hand behind your back or head. These movements remain tight even when you try to move the shoulder with your other hand or someone tries to move the shoulder for you.

It is the ball and socket joint which is stiff. The shoulder blade is still free to move around the chest wall, and you may become more aware of this movement.

3) Recovery phase (which can last from 5 to 26 months)

The pain and stiffness starts to resolve during this phase, and you can begin to use your arm in a more normal way.

The total duration of the process is from 12 to 42 months, on average lasting 30 months.

It is important to realise that although the pain and stiffness can be very severe, usually the problem does resolve. It will not bother you for ever!

A review of people who had frozen shoulder approximately 7 years earlier shows that only 11% still had mild interference with everyday activities.  However, 60% continued to have some stiffness in the shoulder joint when it was measured. So ultimately, it should have little effect on your daily life, although the joint may remain stiffer when tested.

What are your treatment options?
During the painful phase the emphasis is on pain-relief. Therefore painkilling tablets and anti-inflammatory tablets may be prescribed.

You can also try using heat, such as a hot water bottle, or cold (ice packs).

Injections into the joint may also be offered if the pain continues.

Physiotherapy at this stage is directed at pain- relief (heat, cold and other pain relieving modalities such as electrotherapy). Forcing the joint to move can make it more painful and is best not pursued. You can try using a TENS machine (transcutaneous nerve stimulation) which some people find helpful or try alternative therapies such as acupuncture.

Once stiffness is more of a problem than pain, physiotherapy is indicated.

You will be shown specific exercises to try and get the ball and socket moving. In addition, the therapist may move the joint for you, trying to regain the normal glides and rolling of the joint. These are known as joint mobilisations. Muscle based movement techniques may also be used.

If movement is not changing with these measures, physiotherapy will be discontinued, although it is appropriate to continue with the suggested exercises to try and maintain the movement that you have.

Hopefully, as the recovery phase starts you will find that the movement gradually increases. This, again, can be a useful time to have physiotherapy to help maximise the movement.

Surgery
If you have significant pain and stiffness the doctors may offer you a ‘Manipulation under Anaesthetic ’(MUA) plus arthroscopy operation. There is a separate information leaflet on this. It involves a distension procedure which tries to stretch the loose bag (which is now tight) around the shoulder joint. The tight capsule may be released or removed. In addition the joint is stretched in certain directions to try and free the joint up.

This operation is not done routinely for frozen shoulder, only for those which are very slow to resolve.

Reference

Patient Information Leaflets Nuffield Orthopaedic Centre NHS Trust

The aim of this information sheet is to give you some understanding of the problem you may have with your shoulder. It has been divided into sections, describing the shoulder, types of instability and your treatment options.

The Shoulder
The shoulder joint is a ball and socket joint. Most shoulder movements occur where the ball at the top of your arm bone fits into the shallow socket which is part of the shoulder blade.

The joint is designed to give a large amount of movement. This also means that it has a tendency to be too loose. There are various structures which help to keep the joint in position. The most important ones are:

• Ligaments, which hold the bones together
• A rim of cartilage, which deepens the socket
• Muscles, which keep the shoulder blade and ball in the correct position when moving or using the arm.
  

Shoulder Instability
When the ball is not moving normally on the socket (or vice versa) you may feel the ball slipping, catching or coming out of joint. This can be associated with pain and a sense of a ‘dead arm’ and you become apprehensive of moving your arm in certain positions.

There is a wide range of shoulder instability, from the joint slipping (subluxation) to a complete dissociation of the joint surfaces (dislocation). With a dislocation, you may not be able to put it back in joint yourself. A dislocation is more likely to damage the structure of the shoulder.

The instability does not normally progress, so don’t think it is all going to get worse! However, you can get both dislocation and subluxations in the same shoulder. For example: you dislocate your shoulder with a fall and require help at the hospital to relocate it. Then you find the joint is
slipping on throwing or swimming.

Types of shoulder instability There are different types of shoulder instability, which affect the treatment that you will be offered.

1. Traumatic instability
The main distinguishing feature is whether your shoulder was forced out of joint through contact with something e.g. the ground, another person. This is known as traumatic instability. You can injure other structures around the shoulder when this happens, such as nerves and muscles, especially if you are older. Usually the ball is forced forwards and downwards. Commonly the ligament in the front of your shoulder is over-stretched and can pull part of the rim of cartilage off the socket. If the cartilage is detached in this way it is called a ‘Bankhart lesion’. It is sometimes detectable with an MRI (Magnetic Resonance Image) scan but may only be visible when the surgeon looks in your shoulder joint at surgery. Sometimes you can have a dent in the back of the ball which is formed as the ball is forced out of the socket. This is known as a ‘Hill-Sachs lesion’. Unfortunately having had this injury once, it tends to recur, usually when your arm is out to the side and twisted backwards. This is because there is often damage to the structure of your shoulder.

From research, we know that the younger you are when you have the first dislocation, the more likely it is to recur. At present it is not clear whether the way you are treated immediately after the injury (i.e. put in a sling, given exercises, physiotherapy), makes a difference to the joint dislocating
again in the future.  For very few people the ball may be forced out backwards (posterior
dislocation). This tends to occur if your arm is in front and across your
body on impact.

2. Atraumatic Instability
For some people the shoulder is not involved in a specific accident/event but the joint gradually feels unstable. This may develop with specific, repetitive movements of the arm (e.g. throwing, swimming). Sometimes people have ‘loose-joints’ and these can become a problem and start dislocating or slipping on everyday activities. This is known as atraumatic instability. The ball may be sliding forwards (‘anterior’), backwards (‘posterior’) or downwards (‘inferior’). Sometimes it may slide in more than one direction and occur in both shoulders. A few people can make the muscles pull the ball out of the socket, without moving the arm at all. This is known as ‘voluntary’ dislocation. Often it starts as a party trick but then the joint slips out when you don’t want it to. Do not do this movement! It trains the muscles incorrectly and reminds your brain of an incorrect movement. You will probably always have the ability to do this, our advice however is not to!

What tests may be done?
The main way we find out about shoulder instability is through what you tell us and by examining your shoulder. However, sometimes an X-ray will be done and very occasionally an MRI scan will be ordered, to see if there is any damage to the rim of cartilage and bone.

What are your treatment options?
Treatment options are often dependent on the type of instabillty group you are in.

Traumatic instability
If the joint is stiff or the muscles weak when tested, you may be sent for a trial of physiotherapy. However if the movement is good and muscles are working well, but the joint is dislocating or slipping regularly and stopping you doing what you want to do, the doctors may offer you an operation.  This is called an Anterior Stabilisation Operation. You will be given further details on this operation if this option is given to you. Mainly this operation is carried out through a keyhole and the labrum is reattached to the front of the shoulder joint.

Atraumatic instability
You will be probably sent for a course of physiotherapy.

Surgery is not recommended unless an extended, appropriate course of physiotherapy has been given and has been unsuccessful. Surgery is not always a helpful option and can make some people in this category worse, so it is important that you work hard at the physiotherapy. It is unfair to say physiotherapy has been unsuccessful if you have not done your exercises! In the unlikely case that you are offered surgery, options will be discussed with you. The joint can be stabilised with an ‘open’ stabilisation operation – where the joint is opened and capsule tightened.

You are less likely to be offered surgery if you can voluntarily dislocate your shoulder as the research tends to show poor results in this group of patients. If you show signs of having both traumatic and atraumatic instability, your treatment options will be discussed with you. Physiotherapy may be suggested in the first instance.

What is physiotherapy about?
The broad aims of physiotherapy are to: Retrain movement – this is probably the most important aspect of treatment. The emphasis is on getting the optimal movement of the shoulder blade (socket) and arm bone (ball). Sometimes you develop unusual movement patterns which need to be corrected. Strengthen muscles – this is often not like weight-lifting type training!

Initially the aim is to regain control of your muscles around the shoulder blade and the deep muscles around the ball and socket joint. Muscles that are weak or get tired easily need to be strengthened.  Retrain ‘position sense’ – the unstable shoulder can have a reduction in the ability to know where your arm/ shoulder is in space. Certain types of exercises may help retrain this.

Return to sport or activity – once the control, muscle endurance and strength have improved you will be slowly guided back into positions or activities where the shoulder was feeling unstable.

How long do I need to do the exercises?
You need to do the exercises at least 3 times a week to give them any chance of working. Ideally, try and get into the habit of doing them every day, then it does not matter so much if you miss an occassional day.

In addition, you need to continue with the exercises over a minimum of 12 weeks. If your muscles are weak it will take this length of time for them to respond to the exercise programme. It is important to realise that the response to physiotherapy takes time. You may not see any changes for 6 weeks, even though you are doing your exercises regularly. If you have been doing your exercises and there is no response at all after 12 weeks, then it is probable that physiotherapy is not going to help.

Summary
The shoulder is the commonest joint in the body to dislocate or sublux. The most usual cause is trauma but some people are born with loose joints.

Dislocations and subluxations caused by trauma often give ongoing problems and 50% of people will need an operation to stabilise the joint. The operation has a high success rate.

For people who develop instability without trauma, the best treatment is physiotherapy. Surgery can be used in severe cases but the success rates are much lower than with traumatic dislocations.

Reference

Patient Information Leaflets Nuffield Orthopaedic Centre NHS Trust

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 Trusteserved.

The aim of this information sheet is to give you some understanding of the problems you may have with your elbow. It has been divided into sections, describing your elbow, what we know about tennis elbow and your treatment options.

About your elbow
The elbow consists of the upper arm bone and two bones in the forearm. It works in two parts. One part acts as a hinge enabling you to bend and straighten the elbow. The second part provides rotation of your forearm, for example to put your palm up towards the ceiling to receive change in a shop.

The joint is surrounded by muscles which move the elbow. Muscles which move your wrist and fingers also attach around the elbow. In addition there are nerves which pass close by the joint (e.g. hitting your elbow can produce pain and pins and needles in the forearm and/or fingers).

What is tennis elbow?
It is characterised by pain on the outside of the elbow and is a problem with tendons around the elbow. Tendons attach muscles to bone so using and stretching the muscles will have an effect on the tendon.

One or more tendons which attach around the elbow and move the wrist and forearm become inflamed. If the inflammation process continues the tendons can then show changes of wear and tear, with the tendon tissue becoming thickened or swollen. One muscle (called extensor carpi radialis brevis) is commonly involved, although it works in conjunction with several others so can be difficult to isolate and test specifically.

Gripping, writing and/or twisting movements requiring muscular effort often make the pain worse. The discomfort can be felt into the forearm (i.e. along the length of the muscles).

This test, shown for the right elbow, is often painful, and can be worse when the elbow is straight. Resistance to middle finger extension is another commonly positive test.

A similar pain can be felt on the inside of the elbow. This is sometimes called medial tennis elbow or ‘golfer’s elbow’ where it affects different tendons.

How common is it?
It can occur at any age, but you do not have to play tennis to get it. It may happen as a result of a sporting injury, but most commonly it occurs for no apparent reason. It is most frequently found in middle age (between the ages of 40–50). Repetitive wrist and hand movements in work or sports are often a feature. It is found in equal numbers of men and women.

What are the symptoms?
Varying degrees of pain on the outside of the elbow, from a mild discomfort when the elbow and wrist are used, to severe pain interfering with sleep and when the arm is still. Gripping and twisting movements are often painful and may be worse still against resistance or weight. Repeated movements such as doing DIY, or computer mouse work often aggravate the symptoms.

The outside of your elbow may be very tender to touch and you may notice some pain travelling down the forearm.

Symptoms of neck, shoulder or upper arm or hand pain should be reported to the doctor. In addition tell them if you feel any pins and needles or tingling in the arm or hand as these may indicate that the pain is coming from your neck or wrist, via the nerves in your arm.

Why does it occur?
The exact cause of lateral epicondylitis is not known. However it is thought to be an overuse problem. This relates both to how long and how hard the muscles are worked.

What tests may be done?
The main way we diagnose tennis elbow is through what you tell us and by examining your elbow. Sometimes an X ray will be taken although this only shows bones, and does not show muscle inflammation or wear and tear.

What are your treatment options?
We appreciate that as you are attending the Nuffield Orthopaedic Centre you have probably had the problem for a long time or that it is particularly severe. However treatment is usually non-operative, with only a very small proportion requiring surgery. For most people the pain will go, although it may take up to a year.

Non-operative treatment
There are various things that you can do that may change your pain. If you have not already tried these measures it is worth doing so now.

The aims of the treatment are

• to reduce the stress on the tendon(s) so that your body can try and heal the area.
• to break the pain cycle. How to reduce the stress on the tendon

Change things!

• If possible, stop the particular activity that causes pain or find a different way of doing it. For example, you may find that you tend to use your wrist and hand rather than your elbow and shoulder. Try to avoid this and use the larger joints in the arm to ‘spread the load’.
• If you are involved in a sport/profession using repetitive movements, seek expert advice on your technique. A physiotherapist may be able to give you advice on your movement patterns as well as appropriate stretching and progressive strengthening exercises.
• Be aware of the amount of force that you use to grip things. Look at your knuckles, are they white, showing you are gripping hard? Try and use the minimum amount of force to maintain contact.
• Altering the grip size on objects you use may also have some beneficial effect. Often enlarging the grip is helpful, possibly reducing the weight of rackets/tools etc. is useful.
• Using a splint or brace may be helpful. There are many available. It is better to try the counter-force braces for the elbow (see examples) rather than splints that stop the wrist moving. The wrist splints are best used only if the pain is very severe.

The counter-force splints aim to decrease the tension on the tendon, by using pressure from the brace on a different part of the muscle.  Place the brace just below (i.e. towards the wrist) the painful area. Wear it when you are using you arm and take it off at night/resting. Experiment with the brace in different places – if it is going to work it normally makes an immediate difference.

How to influence/break the pain cycle
All the ideas mentioned above will, hopefully, influence the pain. Specific treatments may also help.

• Try using a wet ice cube and massage it over the tender area for up to 10 minutes.
• Try using anti-inflammatory cream on the area (from chemist without a prescription, but check you have no allergies or conditions that are influenced by these drugs).
• Pain medication (i.e. tablets).
• Physiotherapy – this may include treatments to relieve pain such as transcutaneous nerve stimulation, ultrasound and laser. The effects are not proven, but rarely cause worsening symptoms. Thorough assessment of your arm, advice and exercises are probably more important aspects of treatment.
• Injection – this is given around the area (rather than into the tendon). It is usually local anaesthetic and steroid. Although it can be a painful procedure, injection can have a good effect. Doctors will generally not want to give more than 3–5 injections in a year, and if your symptoms keep returning, other treatment methods would be suggested.

Surgical treatment
This is rarely done, but as you are attending the hospital for help, you may have a resistant or ‘stubborn’ tennis elbow. You may be offered surgery if you have had the problem for over a year, have pain when your arm is resting, and your everyday life is influenced in a significant way by your problem (i.e. unable to work etc.).

The operation is done as a day case. You may have a general anaesthetic, or regional anaesthetic where just your arm is ‘put to sleep’, you are still awake. The surgeon cuts the skin to find the damaged tendon tissue which is taken out. The healthy tendon tissue left should heal during the next 6– 12 weeks. During this time activities to reduce the stress on the tendon (as explained earlier) can be followed. Gradually re-start your activities. You may be sent for physiotherapy following surgery. The results of this operation can be quite mixed with approximately 30% still having problems on aggressive activities.

Reference

Patient Information Leaflets Nuffield Orthopaedic Centre NHS Trust