Delmarva Orthopaedic Clinic

The Shoulders

The Shoulder Joint
A joint is a junction where two or more bones meet. The shoulder joint is considered one of the most complex joints in the body, with three bones meeting there - the scapula (shoulder blade socket), clavicle (collar bone) and humerus (upper arm bone). The shoulder joint is unique in that the ball of the upper arm bone is two times larger than the socket of the shoulder blade. This creates a very mobile joint, but demands an extensive array of ligaments and muscles to keep the joint together. The muscles and ligaments together allow the free and easy movement found in the healthy shoulder. The muscles around the shoulder include the powerful and large deltoid muscle which forms the bulk of the shoulder muscle mass; four smaller and deep muscles that comprise the rotator cuff; and multiple large muscles of the back and neck that help to stabilize the shoulder joint.

When Joint Problems Arise
The most frequent source of debilitating pain and joint destruction is arthritis. It is estimated that 36 million people in the United States have some form of arthritis. That's one in seven people. Of the more than 100 types of arthritis, the following three are the most common sources of joint damage:

Osteoarthritis, sometimes called degenerative arthritis, is a disease which involves the breakdown of the tissue (cartilage) that normally allows the joint to move smoothly. When the gliding surface of the cartilage is gone, the bones grind against each other, creating popping sounds, pain and loss of normal shoulder movement. This condition occurs primarily in people over 50. Osteoarthritis commonly affects the hip, knee and shoulder.
Rheumatoid arthritis is considered a systemic disease because it can attack any or all joints of the body. It affects women more often than men, and can strike both young and old. Rheumatoid arthritis causes the body's immune system to produce a chemical that attacks and destroys the protective cartilage that covers the joint surface.
Trauma-related arthritis results when the joint is injured, either by fracture, dislocation or damage to the ligaments surrounding the joint causing instability or damage to the joint surfaces.

Your Shoulder Evaluation
An orthopaedic surgeon specializes in problems affecting bones and joints. Your shoulder evaluation will begin with a detailed questionnaire. Your medical history is very important in determining whether surgery is necessary. It helps the surgeon understand your pain and the progression of your shoulder problem.

After your history is taken, a physical exam is performed. The range of motion of your shoulder is measured and your muscle strength is evaluated. A small amount of fluid may be taken from your shoulder joint to check for infection.

X-rays are then taken of your shoulder joint. You should also bring any x-rays that may have been taken of your shoulder in the past. These x-rays will help your surgeon plan the surgery and identify the correct size shoulder prosthesis, if necessary.

After your initial orthopaedic evaluation, the surgeon will discuss all possible alternatives to surgery. If the x-rays show severe joint damage and no other means of treatment has provided relief, total shoulder replacement may be recommended.

Progress
Depending on your progress, you will gain independence about one week after surgery. You will continue strengthening yourself in preparation of your return home. It is important for you to adhere to precautions and proper positioning techniques throughout your rehabilitation. Your stitches will be removed seven to ten days after surgery. It is not uncommon to still experience pain at the surgical site. Your recovery period may last three to six months.

Preparing to Go Home
Just before your discharge, you will receive instructions for your at-home recovery, including how and when to wear your shoulder sling, changing your bandage and bathing and showering. The surgical team will also give you directions and the necessary equipment to continue your rehabilitation program at home, any prescriptions for medication and a date for your return appointment.

At Home
Until you see your surgeon for your follow-up visit, you must take certain activity precautions. Look for any changes around your incision. Contact your surgeon if you develop any of the following:

Drainage and/or foul odor from the incision.
Fever (100.4 degrees F or 38 degrees C) for two days.
Increased swelling, tenderness, redness and/or pain.

Take time to adjust to your home environment - it is okay to take it easy. You may need help with your daily activities, so it is a good idea to have family and friends prepare to help you. It is normal to feel frustrated, but these frustrations will soon pass.

Resuming Activities

Walk as much as you like, but do not tire yourself.
With the help of family or friends, you will need to do the exercises you learned in the hospital four to six times daily. These exercises will gradually increase the movement in your joint, so it is important to do them as scheduled. Do not skip your stretching exercises.
As necessary, rest in bed. Be sure to rest on your back.
For bathing, sit in a bathtub and wash. Wash your armpit with warm water and dry the area thoroughly. Five or six days after surgery, your surgeon may allow you to take a shower. To do this, you should remove the bandage, but leave the sutures in place. After the shower, apply a clean bandage. Use only roll-on or stick deodorants. Avoid spray deodorants because they may irritate your incision.
Your surgeon will tell you when you can begin driving a car.
You may return to work when authorized by your surgeon. You are encouraged to return to your normal eating and sleeping patterns as soon as possible, and to be as active as possible in order to control your weight and muscle tone. But remember to increase your activity level or exercises only as your surgeon has directed. Increasing activity too quickly may cause injury and damage to the healing tissue.

Avoid activities that could cause stress on your shoulder, especially those that may result in a collision or fall such as contact sports or skiing. During your follow-up visits, your surgeon will discuss your progress with you.

Contact Your Family Doctor If:
You develop colds, fever, sore throat, pulmonary problems, cardiovascular problems or other general physical difficulties that cause you concern.

Contact Your Surgeon If:
You develop an increase in shoulder pain, drainage, swelling, elevated temperature or have questions about your rehabilitation program.

Medication/Pain Control
It is normal for you to have some discomfort, but it will be unusual for you to use pain medication more than five to seven days after surgery. You will receive a prescription for pain medication before you leave the hospital. If a refill is needed, please call your surgeon's nurse at least five days before you run out of pills. Remember to call your surgeon if you have an increase in discomfort or pain.

Special Instructions
You may be seen six weeks, five months and twelve months after your surgery. You may also see your surgeon once a year after the first year, even if you are not having any problems.

Note for the Future:
You should always tell your dentist or physician that you have an artificial joint. If you are having dental work performed, please notify your dentist or physician so that they can give you antibiotics for the day before and day of your dental care. Antibiotics must be used before and after any medical or dental procedure. This precaution must be taken for the rest of your life.

Any infection must be promptly treated with proper antibiotics because infection can spread from one area to another through the blood stream. Every effort must be made to prevent infection in your artificial joint. Your surgeon can give you instructions on the use of special antibiotics. If you have any questions about the use of antibiotics, call your surgeon.

Shoulder Rehabilitation Program
The postoperative rehabilitation program is divided into two phases:

Phase I
The shoulder stretching exercises are done first so that you can regain as much shoulder motion as possible.

Phase II
Strengthening exercises are used to regain strength of all the muscles around your shoulder. These exercises are done only after you have completed Phase I.

Regardless of your age, it is necessary to first regain shoulder motion with the following special stretching exercises before you begin strengthening the muscles around your shoulder. Your surgical team will give you detailed instructions on which stretching exercises to do and how often you should do them. You will begin strengthening exercises only after you have obtained as much motion as possible. Ordinarily, the strengthening program begins six to 12 weeks following your operation.

Do not begin strengthening exercises until your surgical team has provided the necessary supplies and instructions on which exercises to perform and how often to perform them.

Your Questions Answered

Question: How long will I be in the hospital?
Answer: Shoulder replacement surgery generally involves three to five days in the hospital, but can be longer if you live alone or experience any problems.

Question: When will I be able to move my shoulder?
Answer: You will be instructed in the active use of your arm for the gentle activities of daily living on the first postoperative day.

Question: What do I wear?
Answer: You should be able to wear regular clothes after surgery, i.e. a loose fitting, buttoned shirt and comfortable trousers/skirt. Women may find a bra uncomfortable in the early days. You will be instructed to wear your sling for a week or two after your surgery when you are out in public. It usually is not necessary to wear the sling when you are in your home.

Question: Will I need to do anything special when I go home?
Answer: You will need to perform the special rehabilitation exercise program as directed by your surgeon.

Question: When can I return to work?
Answer: This depends on your job. On average, you may return in one to two weeks for light work and 12 to 16 weeks for heavier work. A more accurate assessment of the time you will need to take off work will be given by your surgeon.

Question: When can I drive?
Answer: Driving is usually permitted after one to two weeks if the car has power steering. If not, it will take approximately four to six weeks until you'll be ready to drive. Your surgeon will advise you in special situations.

Question: Will I have a scar?
Answer: Yes, there will be a scar, however, the formation of scars varies from patient to patient.

Disclaimer: This material does not constitute medical advice. It is intended for informational purposes only. NO ONE ASSOCIATED WITH DELMARVA ORTHOPAEDIC CLINIC WILL ANSWER MEDICAL QUESTIONS VIA EMAIL. Please schedule an appointment with one of our physicians for specific treatment recommendations.


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