Physio after acromioplasty

History
Shoulder pain, cortizone injections worked briefly, course of physiotherapy which included tens, microwave and laser made it worse, so finally opted for surgery.
Had the surgery a week ago and went back to see surgeon today. He removed all the dressings, told me that the stitches would disolve and that as they had to cut through muscle to perform the surgery I was to continue with the sling for a further 2 weeks to take the weight of my arm from the shoulder. He asked when I wanted to start physio - being nearly 2 hours away from the clinic, I said today.
Physio consisted of being attached to a TENS machine for 30 minutes which left me in pain (I was fairly comfortable until then) and then some exercises which were excruciatingly painful.
My biggest concern is the TENS - am I the only person that ends up in more pain after using it?
The clinic gave me a regimen of exercises to do at home - is it too soon to start these if they hurt so much?

All advice gratefully received

Regards

Wendy

I am due to have the same surgery in 2 weeks time; I have read loads and frightened myself to death I think, today I found myself in google books reviewing the procedure.
Personally I have been in immense pain since January and been left with traditional treatments until just recently, my major concern is that I still do not have full motion of the shoulder before the procedure, and read that this is a major setback.

I actually use the tens machine at home for addition pain relief on top of diclo and tramadol, but have read clinical papers that its benefits post surgery are not confirmed as of yet. Its like accupuncture, in the past it has worked in pain relief this time, the pain beats it.

I see that you had laser treatment, what was this, I have read about laser treatment and not yet found anyone here in the Netherlands who can help me with this.

Lesley

Have a look over some information over the physiotherapy after acromioplasty. Impingement syndromes of the shoulder are man-aged by a variety of surgical methods known as sub acromial decompression procedures or anterior acromioplasty. An arthroscopic subacromial decompression involves removal of a portion of the anterior acromion (arthroscopic acromioplasty) and debridement of the undersurface of the acromion through several portal sites. The inferior aspect of the remaining portion of the acromion is often beveled to provide adequate gliding space for the inflamed tendons. In an arthroscopic approach, the deltoid is left intact. An open procedure involves an arthrotomy through an anterolateral incision at the lateral border of the acromion. The anterior and lateral origins of the deltoid are detached from the acromion and later repaired before closure. In open and arthroscopic approaches, the coracoacromial ligament is released. In both approaches sometimes the distal clavicle is also resected.

Postoperative Management

The position and duration of immobilization of the shoulder and initiation and progression of exercise vary with the surgical approach. Rehabilitation after arthroscopic acromoplasty is quite rapid, primarily because the deltoid is left intact. Since the arthroscopic approach is used far more frequently for surgical management of primary impingement syndrome than an open acromoplasty, the postoperative guidelines and the progression of exercises outlined in this section are appropriate after arthroscopic sub-acromial decompression. If arthroscopic decompression is combined with a mini-open (arthroscopically assisted) repair of the rotator cuff, many of the same exercises are appropriate but in a slower progression. With an open acromioplasty, which is frequently used in combination with a traditional open rotator cuff repair, as noted previously, the deltoid must be detached and then repaired. Accordingly, the progression of exercises.

Regardless of the type of procedure selected, close communication among the patient, therapist, and surgeon is necessary throughout all phases of post-operative rehabilitation. Effective patient education is the basis of early self-management by the patient and positive functional outcomes.

Immobilization

The shoulder is usually positioned in adduction and internal rotation, and the forearm is supported in a sling with the elbow flexed to 90 degrees. The sling is removed for exercise the day after surgery but otherwise is worn for several days for com-fort.

Exercise: Maximum Protection Phase

The goals and interventions for exercise in this phase of rehabilitation, which usually extends from 1 to 2 weeks postoperatively, are consistent with the guidelines for no operative management of acute impingement. Emphasis is placed on immediate but pain-free assisted movement. Use of modalities and prescribed anti-inflammatory medication is indicated to control inflammation and pain.

Control pain.

• Cervical spine active ROM and shoulder relaxation exercises

Prevent or correct postural malalignment.
• Active exercises of the scapula with emphasis on retraction
• Posture awareness training, placing emphasis on an erect trunk (avoiding excessive thoracic kyphosis) during exercises and ADL

Prevent loss of mobility of all joints and muscles in the involved upper extremity.

CPM from 0 to 90 degrees of shoulder flexion initiated in the recovery room or the day after surgery, predicated on the philosophy of the surgeon. It is used for only 48 hours postoperatively
For patients undergoing inpatient surgery.
Active ROM of the elbow, wrist, and hand through full ranges.
Active-assistive shoulder ROM begun on the first postoperative day, emphasizing shoulder flexion, scaption, abduction, and horizontal abduction and adduction within pain-free ranges. Start in the supine position to provide additional stability to the scapula against the thorax using therapist-assisted, short-arc motion, progressing to full-arc ROM; then transition to self-assisted ROM with the uninvolved hand and finally with a wand.
Progress to assisted elevation of the arm in the seated position.
Active-assistive external and internal rotation with a wand, first in supine and later while seated. Keep the elbow flexed to 90 degrees and the arm slightly flexed and abducted during assisted rotation.
Gear-shift exercises in sitting.
Pendulum exercises for pain control and mobility.
Assisted shoulder extension in a standing position with a wand held behind the back.
Assisted scaption above the level of the shoulder with a rope-pulley system through a pain-free range.
Transition to active-free (unassisted) ROM of the shoulder by 10 days to 2 weeks postoperatively.

Prevent atrophy and improve strength, stability, and endurance of the shoulder girdle musculature.

Pain-free, low-intensity, multiple-angle isometrics of GH musculature against minimal resistance. Begin isometrics a few days to a week postoperatively.
Lightly resist with the uninvolved upper extremity. Focus on increasing repetitions more than resistance.
Alternating isometric and rhythmic stabilization exercises for scapulothoracic muscles with the involved arm supported by the therapist. Target the serratus anterior and trapezius muscles.

Exercise: Moderate Protection/Controlled Motion Phase

Rehabilitation proceeds very rapidly after arthroscopic subacromial decompression. Controlled active motion is emphasized while moderate protection of the shoulder is maintained by only performing pain free movements. This phase of rehabilitation usually begins by 2 weeks postoperatively. Criteria to advance to this phase include pain-free active elevation of the arm well above the level of the shoulder and at least Fair (3/5) muscle testing grade of shoulder musculature. The priori-ties during this phase are to restore full ROM, strengthen key muscle groups, and begin to use the involved arm for light functional activities.


Restore and maintain full, pain-free passive mobility of the shoulder.

• Joint mobilization, emphasizing posterior and caudal glides of the humerus and scapulothoracic mobility.
• Gentle stretching of range-limiting muscles that could restrict sufficient upward rotation of the scapula and rotation of the humerus necessary for full elevation of the arm overhead, specifically the levator scapulae, rhomboids, middle trapezius, latissimus dorsi, and pectoralis major and mi-nor. Remember, shortening of these muscles con-tributes to impingement of soft tissues during overhead movements of the arm.
• Self-stretching (cross-chest stretch) of the posterior deltoid and posterior capsule of the GH joint, which is usually tight in stage II and stage III impingement.
A tight posterior capsule causes excessive anterior translation and superior migration of the head of the humerus in the globoid, which, in turn, causes impingement of soft tissues during overhead reach.
• Active shoulder motions, incorporating the gained ROM into exercises and functional movement patterns during ADL.

Continue to improve strength, stability, en-durance and control of scapulothoracic and GH muscles.

• Stabilization exercises against greater resistance and in weight-bearing postures. Use a Body-blade in various positions of the shoulder.
• Upper extremity ergometry. Initiate in a standing position rather than while seated to avoid an impingement arc.
• Dynamic exercises of isolated shoulder muscles against low levels of resistance (1–5 lb) and gradually increasing repetitions. Use manual or mechanical resistance. Once again, begin shoulder elevation in the supine position to stabilize the scapula against the thorax; progress to sitting.
Target the upward rotators of the scapulothoracic joint (serratus anterior, the upper and lower
Trapezius) and the rotator cuff muscles, as well as the latissimus dorsi, teres major, and biceps brachii, which act as humeral head depressors and, therefore, oppose superior translation during active elevation of the arm. Initially perform resisted motions of the humerus below the level of the shoulder; later progress to overhead exercises if motions remain pain-free.
Note: If winging of the scapula occurs with progressive resistance or weight bearing, provide manual support or decrease the imposed loads. Emphasize isolated strengthening or the serratus anterior and trapezius muscles.
Use the involved arm for light functional activities.

Exercise: Minimum Protection/Return to Function Phase

The final phase of rehabilitation usually begins by 6 weeks postoperatively at which time soft tissues are reasonably well healed and require minimum protection. Criteria to progress to this phase is full, pain-free, active ROM of the shoulder, 70 to 75% strength shoulder musculature compared with the sound shoulder, and a negative impingement test. Criteria to return to full activity, which usually occurs by 8 to 12 weeks postoperatively, depends primarily on desired functional outcomes and the potential demands and stresses that will be placed on the shoulder. A patient wishing to return to competitive sports will require a more demanding progression of advanced exercises than a sedentary individual. Include the following goals, exercises, and activities in the final phase of rehabilitation.
Progress exercises to include advanced activities, such as more rapid motions and directional changes.
Isokinetic exercises.
Kinesthetic/proprioceptive training, using rapid, alternating resistance with rhythmic stabilization.
Plyometric training.
Simulate functional activities in drills and then gradually return to actual work or sports-related functional activities. Refer to detailed, sports-specific protocols in the literature to return to such sports as golf, volleyball, throwing sports, and tennis. Modify functional activities, if necessary, to prevent recurrence of impingement.

Note: Exercises for the final phase of no operative rehabilitation of impingement syndrome, cuff tears, and instabilities discussed earlier in this chapter are also appropriate in the final stage of postoperative rehabilitation.

Outcomes

There appears to be no significant difference in the long-term results (pain-free ROM and return to de-sired functional activities) after either open or arthroscopic surgery for primary impingement syndrome with or without associated rotator cuff disease. Based on the results of numerous outcome studies of open and arthroscopic procedures, between 85 and 95% of patients report good to excel-lent results 1 to 2.5 years postoperatively. In general, patients reporting the least satisfaction with their function after surgery are those involved in high-demand athletic activities, involving overhead throwing and those with work-related injury receiving workers’ compensation. Follow-up studies have documented several advantages of an arthroscopic over comparable open surgical management of impingement syndrome. They are: less postoperative pain; earlier restoration of full ROM and strength; earlier return to work, often as early as 1 week postoperatively; less cost (shorter hospital stay or outpatient surgery); and a more favorable cosmetic
Result.

Hi Lesley,

I am now 9 weeks after the surgery - I have followed the exercises given to me - mostly stretching and I have totally managed without a TENS machine. I scoured the internet and found lots of different exercises - at the beginning I have a lot of difficulty in raising my arm above waist level, however, the same exercise in the water or lying on my back on the bed/floor was possible. I have slogged away at the exercises three times a day plus swimming (breast stroke) at least twice a day and after nine weeks I have full mobility in my shoulder.
Prior to the operation, I could not move my arm behind me at all - immediately after the operation, I could do this movement, however, any upper movement was impossible.
I take voltoral (an anti-inflammatory) at night as I also have oesto-arthritis but do not need any painkillers apart from this. My shoulder gets a little stiff occasionally, however, I do a few stretching excercises and it is ok.
Try some of the stretching excercises now to see if it helps - my favourite is hanging forward with your arm hanging down in front like a pendulem and swing your body back and forth to get the movement in your shoulder. This puts no pressure on anything but the weight of your arm should gently stretch the tendons.
Whatever else you do, make sure you keep your shoulder mobile after the operation - I have heard of many who do not and lose all mobility due to adhesions formed during surgery.
Good luck
Wendy
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