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Bone surgery

Wanting more information about shoulder surgery

Most people we interviewed were very happy with the information they’d been given by health professionals before and at the pre-operative assessment, particularly about the operation (see ‘Sources of information on shoulder surgery’). They also praised the information on the Technology Enhanced Patient Information (TEPI) videos about the surgery, pre-operative assessment, what happens on the day of the operation, and recovery. Many people said they had all the information they needed, though a few looked at websites such as YouTube to watch videos of the actual surgery. Information that participants would have liked from health professionals but felt was missing from leaflets or the TEPI videos focussed on:

•    the risks of surgery
•    managing at home and exercising
•    recovery time
•    the follow-up appointment

Risks of surgery

A few people had had problems after surgery and wished they’d been warned more about these. Jenny developed a nerve problem and said the possibility of having this hadn’t been mentioned before surgery. She felt she’d been told about the advantages of surgery but not the risks. Patricia was very disappointed because she was still having lots of shoulder pain after surgery and limited arm movement. She felt the surgery had made no difference and was waiting to see a consultant to find out why she still had pain and limited movement. Patricia was interviewed about 8 weeks after surgery. Many patients still have problems at this early stage and doctors suggest that, with physiotherapy and more time, the shoulder is likely to improve.
 
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Patricia would have liked to know before surgery that the operation might not work and about the type of operation she’d be having and why.

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Age at interview: 69
Sex: Female
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Patricia: They [consultants] didn’t actually tell me that I wouldn’t get the full use of my arm. I anticipated that was going to happen and it hasn’t. I mean it’s no difference at all, if indeed it’s not worse. 

And in terms of information, what else would you have wanted, would have liked to have had at that time? 

Patricia: Well, I suppose the fact that things may not have worked as well because I really and truly did not expect that I would be in this pain or, and not able to move my arm or hand any further than, nothing’s changed. Nothing’s changed......I was hoping it was going to be more or less back to normal but it isn’t. I mean to me it’s just been a perfect waste of time, that’s the truth...... They just did a decompression operation and that was explained to us after. 

Did they explain why? Why did they do that? 

Patricia: I don’t think they did explain why, did they? 

Husband: Yeah, they did. 

Patricia: I mean why say that I needed one operation and then not do it and I wonder if that’s why I’m not feeling any different at all. 

Do you remember, do you remember the reasons? 

Husband: Yeah. So well that I’ve written it down [looking at paperwork]. The registrar came to see my wife after the operation, and I was sitting with her, explained what they found during the operation. They found that the MRI scan had misled them, the findings, because the tendon muscle, whatever it is, was still attached to my wife’s rotator cuff, had not been torn away but it had holes in it and they had to decide whether there was a facility where they could remove the whole part of the tendon and reconnect it to the rotator cuff. In the event they decided there wasn’t enough of the tendon in order to do that. So they left it attached although it has holes in it. 

Patricia: They decided to leave it attached. The long head of biceps tendon was removed in the operation to decrease the likelihood of pain and a chromial decompression was then carried out and the spur of bone was removed...

Husband: And we, we were then puzzled that if the rotator cup tendon was still attached, what was stopping my wife raising her arm. 

Patricia: Because I still can’t do that. 

Husband: We’ve never had a response about that. 

Patricia: I still can’t do it. I mean, [raising arm] that is as far as I can go and that is painful and I don’t think it’s been any different. Now if I hold my arm and go up, but that, I can’t hold it up there because it’s so painful here and you can hear it click when I bring my arm down. So it’s not perfect. I mean I don’t expect it to be perfect but I expected it to be better than it is. 
Subacromial shoulder surgery is relatively straightforward. Patients are usually fully mobile within an hour or two and able to go home the same day, with some simple painkillers to take during recovery. Full recovery, however, can take many weeks or months and physiotherapy exercises are an important part of getting the best results. Complications are quite rare and include infection, stiffness / frozen shoulder, no improvement, and recurrence of pain.
 

A doctor talks about the risks of subacromial shoulder surgery.

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Well, I think with keyhole surgery, the risks are generally a lot lower than with other types of surgery. Because it’s normally done as a day case, so you’re in and out of hospital quickly. It’s keyhole, so the wounds generally tend to heal a lot more speedily as well. But no operation comes without any risks, so there’s still a small risk of infection. It is small. Most surgeons and most hospitals would probably quote about a 1 in 300 chance of getting a problem with the wound or possibly a more serious infection deeper in the shoulder. 

About 1 in 100 people can get some stiffness that develops in the shoulder after keyhole surgery. And that’s classically called a frozen shoulder. It’s not a dangerous problem, because it does get better. But it’s a real nuisance, because it can last for several months before it gets better. And you definitely wouldn’t thank your surgeon or your team until you got better from that. So that’s a bit of a frustrating one. It’s about 1 in 100 people. I personally think that actually one of the main risks is that you might not get better from that operation. You know, it doesn’t come with 100 per cent guarantee, but most surgeons and most teams will quote a success rate of about 90 to 95 percent. 

So that, you know, and while there are many people who will focus on that, that does mean some people will still have some ongoing pain and may not get the result that they were looking for. And perhaps over about ten years we’ll probably see a few people coming back with the same sort of problem. It’s more common with every decade of life. So the younger you are when you get it, you might get it again. The older you are when you get it, the less likely.

And if someone does have a frozen shoulder, how is that treated?

Well, actually it does just get better on its own. So probably the most common treatment in the UK is to do little with it except make the right diagnosis, reassure your patients. But it is a really painful condition in some people. So sometimes it does need an injection into the joint, of some anti-inflammatory Cortisone and some local anaesthetic. But generally speaking it’s one that gets better on its own. I suppose ironically a few people do come back and ask for a keyhole operation to free up their frozen shoulder. Which has a little irony, because it was the keyhole operation that maybe caused it in the first place.
Beverley had had shoulder surgery before and wondered if she’d get calcium build up again. She wanted to find out more about this at the follow-up appointment. Mary had two ‘episodes’ after surgery, where she had very bad pain triggered by certain movements, and wondered if her shoulder would completely recover with time.

Managing at home and exercising

A few people would have liked to know more about managing when back at home. Alan would have liked advice on getting in and out of the bath. Jenny, who lives alone, had a lot of pain after the operation and found it hard to shower, wash her hair, and garden. She would have liked more information on managing in the early stages of recovery.
 

Doing everything with one arm was hard in the first few days. This included going to the toilet, getting out of the bath and reaching things in high places.

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Age at interview: 63
Sex: Male
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The only thing was the after bits, like when I said about, you know, only having one hand, one arm, and doing something without thinking about it. Maybe they could talk more about that perhaps, like going to the loo, you know that’s like a problem if it’s your proper arm. You know, if it’s not, then it’s fine, but if it’s that one. 

Or I can remember being at home going to get something out of a cupboard and thinking I can’t reach the cupboard, and realised my arm was in the way. I couldn’t feel it. So maybe that possibly for those couple of three first days. Because you know I jumped in, because I can remember them saying you shouldn’t be on your own for the first day after the op, which was okay. But the second day I thought, “Oh, I’ll be fine.” You know, that’s when I got in the bath and I was on my own and I thought, “Oh God, how do I get out?” So, it might be worth a bit more information about that side of it. I think the rest of its fine. 
Mary’s only question when she was recovering was about when to have the stitches removed:
 
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The discharge letter, leaflet and TEPI video gave different information about when to get stitches removed. Mary should have had them removed earlier.

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Age at interview: 45
Sex: Female
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One other thing that I just thought of, when you, on your discharge notes you get given a note that sort of says about having the stitches taken out. And I, of course I, this was done just before Easter. I needed to, I would be needing to have them taken out round the Easter weekend. And so I can remember checking the thing and one, the discharge letter said one thing. The NOC [Nuffield Orthopaedic Centre, an NHS hospital] leaflet said another and then the TEPI website said another. So I thought, ‘Well is it, I think one said seven days. Another said ten days and another said fourteen days.’ That may not be quite correct but it was something like that.

So I tried to ring the number that I’d been given to ring and, being Easter week, there was nobody about and so we went with the, what the GP had said. And then of course when I got in there at fourteen or whatever it was, because of the bank holiday, we’d left it until afterwards and sort of, they sort of said, ‘Well you really should have come [laughs], you should have come in earlier.” So that was just feedback really to try and put all the paperwork to say the same thing [laughs].
Exercising was a key factor in recovery, discussed by many participants. Most were pleased to have a TEPI video they could watch at home to guide them, refresh their memory, and help them do the exercises correctly. Sue said the TEPI videos were ‘absolutely brilliant’ but she would have liked a set of exercises that people could do later into their recovery.
 

The TEPI exercises are good for the early stages of recovery. Five weeks after surgery Sue would have liked to know about exercises to do after 6 weeks.

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Age at interview: 48
Sex: Female
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So you don’t think nothing should be added or taken away?

No, no, absolutely brilliant. The only thing you could do is possibly put a third set of exercises but for later use, not in that first bit, because obviously you can't do, you wouldn’t be able to do it when you first come out of surgery. But maybe sort of like now, I’m a month, five weeks probably after surgery now, it would be quite good to have something that I could extend it, further strengthen you know, just a few more physio bits which I’m sure the consultant will give me when I go in. And maybe that’s the reason they don’t put it on there because they don’t want to overdo things.
Ken also would have liked more challenging exercises on the TEPI video and looked on YouTube and other websites to find these:
 

Ken would like the TEPI exercises to be tailored for use by different age groups and fitness levels. He found them easy and had done them all by the first week.

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Age at interview: 46
Sex: Male
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All the exercise they asked me to do on the thing [TEPI videos and booklet], I probably done it all in less than a week and I’d done everything, that’s more than they ask for already. 

And I could do a lot more and I would recover a lot quicker than majority, as I say, of the older people. So that’s what I say, I think there should be some terminology where you can ask people and say, you know, or some kind of table of some kind, that’s you know, or a graph for example, this is the age, you know, or whatever you come, which group category you come under and you might be able to do that. You don’t have to but it says you might be able to. 

I would like to see if it says something like, for example, okay if you’re 18-25 and very fit you probably can do something like 40, 30 or 40 seconds rather than 10 seconds, it depends on how you, or something like it depends on your age right, you know, or how fit you are. 

You can do from ten seconds if you are able to or 50 seconds or a minute if you are really fit, and if you want to and are determined to get back or something like that. So at least let people know how, you know, because a lot of people just follow the doctor, you know, everything ten seconds that’s it. I do ten seconds, but if the doctor tells you like say which type that you might fit into or which category you might fit into.

Okay, no that’s very good, that’s very good information. So I mean just to give the same information but to cater for different groups?

Different groups, yeah.

Of the population.

That’s right, yes.
David said he didn’t know that patients are advised to rest after keyhole surgery, which he assumed was minor surgery. Although he’d been given lots of information, he hadn’t read through it. He watched the videos 4 or 5 times before surgery and showed them to his wife and sons. He went back to work 2 days after the operation and wished he’d been told more about recovery time, the importance of exercising, and that he’d read through the leaflets:
 

David didn’t realise that keyhole surgery takes time to recover from. Going back to work too soon slowed his recovery down.

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Age at interview: 50
Sex: Male
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In my mind, one of the things that they didn’t get through to me was, with it being key hole surgery I thought I’d be fine to go back to work after a few days and I wasn’t. And I should have taken more time off and I’ve got a physical job. So the physio did say that I should have taken longer, you know, a week, maybe two weeks easy and I didn’t.

So how long did you take off?

Two days. Obviously I was taking it easy but I was doing too much and I, she said that that will prolong the recovery because obviously the bone where they’ve ground it from was inflamed, and it’s got nerves and everything else so it's probably taken me longer to recover than I should have done. 

And that’s something that, maybe it was explained to me and I decided in my mind not to listen, or maybe it wasn’t clear enough the amount of time and the recuperation that I should have had after I came out of hospital.

So, you know, I’m not, as I say portion the blame, it’s probably me in my nature, the way I am, if I can work I’ll work, you know. But I think it’s taken longer and it still aches.
David didn’t do the exercises because he was active at work 2 days after surgery. Nicola also didn’t do the exercises recommended by the physio because she ‘just got up and got on with it’. She felt that she was ‘doing exercises anyway, every day all day. I lift my arms up to make the beds, to do the sheets and, sometimes when I lift up to the cupboard, it hurts. But I’d keep doing it. So I’m gradually doing things, so I think I’m exercising.’

Recovery time

Many people we spoke to wanted to know how long they’d take to recover, often saying that it was taking longer than they’d been told by doctors or longer than they’d expected. Taking time off work had been an important consideration in deciding to have the operation and when to have it, so knowing about recovery time was crucial.
 

A doctors talks about recovering from subacromial shoulder surgery.

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Most surgeons and most teams would probably say to their patients that 90 to 95 per cent of people will improve with this operation. But they can improve over a 6 to 9 month period. So for some people it can be quite slow improvement and for others it’s quite rapid improvement. 

But generally speaking you’ll go home, you’ll be in a sling. But you don’t need to stay in the sling. Once the nerve block has worn off and the arm has come back to life, you can start moving the shoulder pretty much as you want. And for some patients, they find they’re able to move it very quickly, within a few days. For others it might take up to a week. 

Most people are off driving for 7 to 10 days. You need to be out of the sling and have a reasonable range of movement back in your shoulder to be able to drive. I think most people on average take about 2 weeks off an office job after this sort of surgery. Manual work, it’s often 6 weeks before you really feel able and comfortable to go back to do your job. Many people have to go back sooner than that. You probably can’t really damage what the surgeon has done. But you can make your shoulder sore and that can eventually slow things down. 

So how much movement can people expect? So in the first few days they...

Within the first few days they’ll need to take some painkillers. And if you take some painkillers, you expect your shoulder to get to the point where perhaps you’re getting your arm up to your face, you’re able to eat and drink again normally. But it might be 2 weeks before you’re getting to the stage where you can get your arm above shoulder height. And for many patients, that could even be 6 weeks before they’re able to achieve that. So it does really vary. But I think the important thing to remember is you can’t really damage or do any harm to the shoulder. So if it’s feeling okay, you can just get on and move it.
It usually takes between two and six months to make a full recovery from subacromial decompression surgery but it can take longer. How long it takes depends on a number of things, including how healthy a person is before the operation and how well they keep up with the exercises after the operation. Returning to work depends on the type of work a person does. Most people return within 4 weeks. 

This video explains more about recovery and returning to work 



Rosemary expected to recover in 6 weeks and felt that recovery was taking longer than she’d expected. Had she known this could happen, she might not have agreed to have the operation. Jasmine also wondered how long recovery would take. She was recovering well and wanted to see a physio about more advanced exercises so she could improve further. Jenny thought she’d be back to work after 3 weeks but felt upset that the pain was still affecting her everyday life. Having surgery was having a financial and emotional impact as she was still not well enough go to back work:
 

Jenny has had problems since having surgery. She expected to go to work soon after the operation and is finding it hard to live on statutory sick pay.

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Age at interview: 64
Sex: Female
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Has it [surgery] created difficulties, financial or?

Oh yeah, yeah. This is it because I’m only getting SSP [statutory sick pay] now, you know, and that’s nothing. So I’ve got to go to the council and council tax and rent and all this sort of thing because I haven’t got the money there to pay it. And you [upset] shouldn’t be put in this situation. It shouldn’t happen, you know. It’s not my fault that I’m ill and why should I struggle with finances because I have to go round and ask, you know, for help [upset].

Okay, what would you like to happen?

It’s just a silly situation that the firm only pays you for so long and then you have to go on supplementary benefit and it’s peanuts, you know. It really is peanuts and you can’t live on it [upset].

Yeah, yeah. Any, and how is your, your, is your job secure? Will it be waiting for you?

Yeah, yes. Well they keep saying, “When am I coming back? you know, especially the people I support, you know, “Why’s Jenny not back yet? You know, because of course they can’t understand why, they just know that, you know, I’m not there to support them as I usually do.

Okay, so you need, it is affecting you also emotionally, I can see. 

It is, yeah.

Sort of, kind of, yeah it is the shoulder but it’s the whole kind of, 

Yeah, this is it. I expected at the end of three weeks to go back to work and everything would be hunky dory and it hasn’t been like that.

Because you are in pain?

Yeah.

Dealing with your nerves, kind of issue that doesn’t allow it. Okay, you were told that it might, it might be related to, it might be a side effect or a complication of....

It might, but they don’t know. This is the, nobody can pinpoint anything at the moment until I get this appointment through from the hospital and I don’t know when that will be. She is chasing it up - my doctor. But until somebody can pinpoint what the problem is so that we can do something about it, we’re just sitting here not being able to do anything. It’s just so frustrating. You know, it’s not what I expected.
Taking time off to recover had to come second to earning a living for Nicola, a single mum. She would have liked to take more time off to recover properly but had had to go back to work:
 

Nicola could only have sick pay for 2 weeks. Advice on managing financially would have been helpful.

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Age at interview: 46
Sex: Female
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You went back to work, how many weeks after surgery?

Two weeks. 

Two, three weeks?

Two.

Two, okay. Why did you have to go back?

Because I was only covered through, sick pay would only cover me for two weeks and I actually did lose because I’d already had a couple of days, sick days off already, and I actually lost three days as well in them two weeks. So, my income, because I’m a single parent, my income got messed up and I lost money, which was like for my house, like rent, and it did interfere that side of it and I am struggling a bit trying to get myself back, you know, which is hard. Which was a bit of a downfall.

Okay, so there was a financial implication to this?

Yeah, definitely.

And how are you coping with work because usually people take four weeks off or something like that?

Not good. I wish I wasn’t there. I wish I could recuperate a bit more, you know, and have some time to rest it a bit more and, but it’s just. [Children enter room] They’re all coming now [laughs]. 

Hi.

Yeah, I wish I could have more time off of work and I wish I could have healed it a bit more but my circumstances didn’t allow that and isn’t gonna allow it. 

Okay, anything that the doctors can do in, in that regard?

No, I don’t think so. I don’t know. That I don’t know. 

So you haven’t contacted I don’t know, I mean Citizen Advice Bureau, or Patient Advisory Services or found out about it?

I didn’t, I didn’t know that I could. I didn’t know anything about that side of it. But maybe that would not have been a bad idea to maybe get some advice on situations like mine, when you’re a single parent and you work and you’ve little children. Don’t [laughs].

That’s okay. That’s okay, he’s fine.

That would have been, that would have been a help for this side now because, as I say, it’s really been, like financially I am struggling now because I have debts. 
Recovering from shoulder surgery was taking Rosemary longer than from the hip replacement operation she’d had 2 years earlier. Nine weeks after surgery she still felt very bruised and had another follow-up appointment lined up with the physio. Ken felt he had full arm movement but still had pain more than 2½ months after surgery when he did things that required a bit more strength, including playing badminton.
 

Rosemary thought she’d recover in 6 weeks. Nine weeks after surgery, her arm muscle feels bruised. The physio strapped her shoulder up and wants to see her again.

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Age at interview: 62
Sex: Female
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I’ve struggled with the pain. It just wasn’t as good as it was the first week and I’m going to have to admit that my shoulder operation, because I’d had my hip replaced two years previously, and it has taken me longer to get over my shoulder operation than it did my hip.
 
And to this day I, because I bruised badly after my shoulder operation, my chest, I was black across my chest and up my neck had all gone black and my arm had all gone black. But even now my arm, the muscle feels very bruised still and I’m what, about nine, ten weeks down the line.

Okay, did they explain sort of side effects or how long this was going to take? Did they say anything about the recovery time following the surgery?

Well they did warn you, you know, it would take time but I never expected it to take as long as this. I mean I, you know, I was expecting six weeks but I’m not sure how many weeks I am now.

Did they say six weeks that you will recover?

I think they sort of indicated it could take up to six weeks and that’s what I was expecting. But I must admit it’s, even now to do the indicators and that, it still hurts the arm to lift it up to do the indicators on the car. But I know the muscle is still very bruised and I went for a check-up, my six week check-up, I went back and saw the nurse, well the physiotherapist, and she said my shoulder was very dropped on the one side, so she strapped it up with elastoplast. She strapped it all up to help get it, because she admitted it was very, very low down position to what it should be. So she strapped it all up and I have an appointment to go back and see her in two months from when I saw her.
The follow-up appointment.

Most people knew little or nothing about what the follow-up appointment would involve and who they’d be seen by. Mary realised at follow-up that she’d done one of the exercises wrong and felt that an appointment with a physio sooner would have been helpful. She saw the physio at her follow-up appointment, around 6 weeks after surgery but, like many people we interviewed, hadn’t known what the appointment would involve (see ‘The follow-up appointment for shoulder surgery’).
 
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Mary was doing an exercise wrong even though she’d read the booklet and watched the videos. An appointment 3 or 4 weeks after surgery would have been better.

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Age at interview: 45
Sex: Female
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I went back for my follow up appointment with oh, what’s her name, [physiotherapist’s name] and that would have been at about six weeks. And I, you’re just going to a clinic, you don’t know who you’re going to see but that’s actually, I did actually see [physiotherapist’s name] herself. And she went through various exercises and was pleased at the strength of it and how it was moving. 

There was just, I was explaining to her how it was becoming more painful again. It was more an achy pain, it was more a sort of, I was getting frustrated in the few weeks where you’re not doing very much, it hadn’t hurt at all. But as soon as I started doing more activity, back to the sort of things that I would like to be able to do, it was becoming un, it was uncomfortable.

And so we ran through the exercises that I had been given and found that one of them was the one where you lie on your front. You’re lifting your arms behind you but I wasn’t doing that one as it should be done. So I found that slightly frustrating because I’d got both the written document things that I’d come out of the hospital with, also the TEPI website which gives you very clear instructions. But I just wish I’d been able to see the physio sooner. I wish the follow up had been at maybe four weeks, three or four weeks rather than at six, nearly seven weeks. Because I just feel in that time, if I’d got that exercise corrected earlier then it would have made a bit, a lot more, do you know what I mean? You just, if that’s the one area that really needs strengthening, then if I hadn’t been doing it properly, then it’s not going to have done what it should do. So that was a little bit frustrating.
 

A doctor explains what happens at follow-up and who to contact if there are shoulder problems after that.

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This [follow-up] will vary throughout the country. Certainly in our own region, our own centre, most patients after this type of shoulder operation will come back to Outpatients at 6 weeks. And at 6 weeks they’ll either see one of the surgical team or perhaps more importantly they’ll see the physiotherapist. Because after surgery, it’s usually down to the rehabilitation and the physiotherapy. So they may not see their surgeon again. If they see the physio and they’re doing well and they’re happy with their exercises, they may not see the surgeon. If they’re not doing as well, the surgeon is usually called in to say hello and to have a look at them as well. 

And generally speaking most patients aren’t discharged from hospital care until they’ve got the result that they want. So it’s not usually an issue of struggling to get back in contact. That line of contact should be open until they’re better. But otherwise obviously their GP is a great source of information and can usually get back in contact with the hospital team if needed.

And when they attend the follow-up appointment, what happens at the appointment? Some people wondered if they’d have x-rays. What usually happens?

So after this particular type of operation, where a little bit of bone has been trimmed from the shoulder, nothing has been put in, so x-rays aren’t usually required. It’s all about ensuring that the pain is improving, the range of movement is improving. So it’s really about physiotherapy and exercises. And that’s what is looked at and that’s what is checked. And the physios may then modify or change the rehabilitation or the exercises that need to be done by that patient. 

Many patients ask about physiotherapy after this operation. And actually again that will vary throughout the country. Many patients won’t see a physiotherapist during those first 6 weeks. And that’s because most people after this operation can just get on with their own exercises, their own rehabilitation. And they get checked at the 6-week mark with the physiotherapist. Those that are doing well can probably just carry on as they are. Those that are struggling a little are usually picked up by the physios at that point and may need some more concerted input.

So patients can do gentle exercise, or if they feel able to move on to something a bit more challenging, that’s okay?

Again I think the important thing to remember after this operation is you can pretty much let your shoulder tell you. If your shoulder is feeling comfortable, you can increase the level of activity and do more and more things without worrying about harming your shoulder. If it gets sore, it probably means you did a bit too much and you just need to cut down things a little, and then try again a week or two later. 
Last reviewed August 2018.

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