The shoulder joint is so complex that it requires a complex management strategy if surgery is needed to help get the best outcomes.
The shoulder joint is a ball and socket joint like the hip joint and since they have different functions, the shoulder joint needs to have a laxity that the hip joint doesn’t want.
The hip joint needs to be as stable as possible to carry our weight and allow enough range of movement to keep us upwardly mobile. The top of the thigh bone sits in a deeper cavity in the hip and is protected by a strong capsule with lots of support so the thigh bone stays in place when we walk, jump, run, and sit. At the hip joint we do need to put the leg in different positions, swinging forwards, backwards, sideways and able to crossover the legs. But we don’t want the leg to go beyond a certain limit and the hip joint needs to be kept safe and so is designed with an ability to restrict large inappropriate movements.
The shoulder joint on the other hand requires amazing flexibility because it is this joint that allows us to get our hand to all the places, we need to put it. Think about where our hands need to reach and what they need to be able to do. The whole structure from shoulder, to elbow and to the hand that can swivel in so many directions, is quite incredible. And this is why the setup of the joint allows swimmers to do all the stokes from butterfly to back stroke, and for gymnasts to do all the movements required from strong poses to dynamic powerful thrusts. And it allows us to put our hand around behind us to scratch our back or manage personal hygiene, to brush our hair and put heavy items in shelves above our head.
If we have a problem with our shoulder joint it has a huge impact on what we can do on a daily basis. If we are unable to activate the shoulder it affects exactly where we can use our hand and this may mean we restrict our activities. If the other shoulder is not affected, we may try to do everything with the other hand but eventually it becomes clear that something needs to be done about the lack of two functional hands.
When we have a shoulder problem, especially if it is painful as well as restricted, all we think about is how we can fix our shoulder and most people seldom think about the big picture of “where do I need to get my hand”. At the end of the day, we must have resolution at shoulder level to return to normal daily use of our hand. Without that purpose in mind, we may continue to live with day-to-day challenges because we can’t get our hand in position to do the most basic tasks.
When surgery is required in the shoulder, it may be because one or more of the rotator muscles have been damaged. These four muscles act as stabilisers of the shoulder joint and keep the arm bone in the very shallow socket while the bigger powerful muscles, the deltoids, the pecs or chest muscles, and the lats or long back muscles, pull the arm around into positions to enable the hand to get where it needs to. Working well, this activity at shoulder level is a symphony of movement and wonderful to observe.
Surgery may be recommended for many reasons including removal of bone that has expanded, growing out to impede the flow of movement, affecting tendons, ligaments and other bony structures. Everything on the shoulder is delicately balanced and there are many surgical procedures now to address multiple dysfunctions.
Recovery from surgery is complex because it is so important to allow the healing to happen without challenging it by using the arm and hand. Depending on exactly what has been operated on, rehabilitation exercises may need to wait as long as 6 weeks and for that whole time the joint might have to be kept very stable in one position. The longer the healing time and the longer the delay in being allowed to move the joint, the more important it is to have a plan of action and to use both exercise and soft tissue manipulation to help with getting the body back into normal functionality.
In relation to exercise, the protocol to follow is well developed now. Once you have had the surgery the physiotherapist that the surgeon uses will see you in hospital to advise you about what you need to do. They may have a machine that pumps icy water through a pad that is securely positioned over the shoulder joint to help with pain management.
Once out of hospital the recovery continues and the arm is restricted by a sling that will help stabilise the joint and protect the surgeon’s work. Following the recommendations carefully at this stage is critical to keep the surgical work intact. Real rehabilitation can only commence once out of the sling and this may be anything up to six weeks later.
In relation to exercise, for best results, guidance should be provided by an allied health professional proficient and experienced in shoulder rehabilitation, whom is also very knowledgeable about surgical procedures of the shoulder, and the do’s and don’ts.
Some people will choose the physiotherapy pathway however I recommend Exercise Physiology as very effective post-surgery management, especially if they are involved with your exercise prescription prior to having surgery. If your exercise physiologist has the knowledge in regards to effective shoulder rehabilitation they will see your recovery in the context of whole-body integrity rather than site-specific joint rehab. When you consider the need to have total use of that hand again, you will be happy to have someone who can understand just what they need to expose you to, as well as expose you to all the usual shoulder rehab protocol.
Soft tissue rehabilitation, or Clinical Massage, can be a neglected aspect of post-surgical shoulder rehab. When you consider the huge responsibility that all the muscles, tendons, ligaments and joint capsule play in a healthy shoulder joint it seems common sense to provide hands-on work that will help get the surgical site and surrounding tissues pliable and supplied with a good blood flow as it heals. Since this is very specialised work it is important to source a highly qualified Massage Therapist whom is both experienced in working with post-surgical rehab as well as currency in the latest treatment protocol.
If choosing a physiotherapist to do the soft-tissue hands-on work, it is important to check if they specialise in massage. There are many good physiotherapists whom provide exercises for rehab purposes however massage is not always a significant part of their work, and for shoulder massage, experience can only be gained by hours and hours of working in this particular field.
Shoulder surgery can take many forms and some will be major and require diligent recovery efforts. Combining exercises, which provide progressive improvements, with effective massage therapy provides the best results.
Trying to exercise the recovering shoulder if there are soft tissue obstacles makes the exercise more difficult and more painful.
And just using massage without exercises to re-instate the full spectrum of movements required for best use of the hands is not advisable.
Exercise plus Massage is the prescription for best shoulder surgery recovery.
Victoria Gill
09/06/2021
My shoulder surgery was the result of a fall in the Kimberleys. Three rotator cuff muscles were affected, supraspinatus and subscapularis requiring re-attachment and the infraspinatus surgical repair of a large tear. Six weeks of immobility in my shoulder followed by a comprehensive recovery using both exercise protocol and soft tissue recovery.