Shoulder Rehab vs Surgery: Do you require surgery?

Shoulder rehab vs Surgery. What is best for your shoulder pain?

It may just be me but I feel like I am seeing a lot of post-operative shoulder surgery clients in 2019. The majority of these cases have been by-way-of atraumatic instances (ie. no mechanism of injury -> due to “wear and tear”). Please note- I do not cover the subject of traumatic shoulder injuries in my post.

 

Shoulder rehab course

I recently attended a 2 day course in Melbourne titled “Shoulder Theory and Practise”. I found this course extremely insightful and highlighted some trends as to where we are headed as rehabilitation providers regarding atraumatic shoulder injuries.

In addition, however, the course presented more questions than answers. This is seen by the trends of investment in healthcare from all levels of government. Again, we come across is the age-old debate of preventative vs. curative healthcare. I will elaborate further on this point later regarding the cost of surgery versus the cost of physiotherapy/exercise treatment.

For further reading, fellow physiotherapist, Jamie Clough, has written an excellent piece regarding shoulder injuries and rehab here.

Shoulder biomechanics

How an individual moves their shoulder is at the forefront of any rehabilitation program. This is what I, as a physiotherapist, prescribe.  Therefore, the shoulder is a very mobile joint. It moves in many planes of movement. The forces at work in a tennis serve, for example, is enormous. The interplay between the strength of the muscles as well as the control of the limbs and joints is critical.

 

Shoulder Bursa & bursitis

A typical shoulder injury that we see here at Sport & Spinal Physiotherapy is one that involves the bursa. A bursa is a fluid-filled sac that offers lubrication to the shoulder joint. It can decrease the friction between the joints. This is especially true for movements of the shoulder away from the body. An example of this is brushing your hair. When a bursa is inflamed it is known as a bursitis. A bursitis can present as extremely painful or can have little to no symptoms at all.

Shoulder Rehab vs Surgery

Surgery

Arthroscopic shoulder decompression surgery (ASDS): Typically a client will present with pain or pressure on the rotator cuff from part of the shoulder blade (scapula) as the arm is raised to the shoulder height. A shaver is used to remove the inflamed bursa. Once the bursa is removed, the rotator cuff is inspected to look for any signs of a tear. A bone spur can also be present. In this instance a burr is used to smooth off the spur(s) under the acromion. The aim of the operation is to create more space for the rotator cuff tendons to work.

Cortisone injection

We still don’t have a great deal of knowledge regarding the efficacy of cortisone treatment in the long term. Yet General Practitioner’s are continually prescribing this form of “passive” treatment, with mixed results. Cortisone is a potent anti-inflammatory medication. Cortisone does not cure the condition, rather it can offer temporary relief. In my experience, some clients swear by it’s effectiveness, others say it did nothing at all.

Study conclusions of Shoulder Rehab vs Surgery

A brilliant study stemming out of the UK (2017) highlights the cost-benefit analysis of surgery vs. conservative treatment. The study group followed up with 313 clients who had been experiencing long term, non-traumatic shoulder pain. They were split into 3 groups: 1) Decompression surgery  2) Investigative Arthroscope only (placebo) 3) No intervention. The results of this study is both simple and powerful: There was no change in pain, function or range of movement at 6 months and 12 months follow up. I find this extremely exciting!

This last point is crucial. The client should have all of the available evidence available to them. This helps to make a collective decision moving forward. This is crux of the entire physiotherapy realm! I believe this last point is crucial to where we are moving in the future.

Shoulder Rehab vs Surgery Costs

Fact – the cost of one surgery involving an ASDS is 26 times more than the cost of treating a non-traumatic shoulder injury through a strength and rehabilitation program through your physiotherapist (In England). Yet as I digressed earlier, the same outcomes at 6 months and 12 months were exactly the same. This is in terms of function, every-day use and pain levels. This is not to mention the risks of surgery as well – eg. hospital admission, increased risk of infection.

Shoulder Rehab Exercises

Exercises are critical to rehab your shoulder, and body, correctly. As I touched on earlier, the biomechanics of the shoulder are extremely complicated. Back to the example of a tennis serve, the energy transfer from the lower limbs is crucial. Specifically, 54% of the energy transfer is made up from the lower limbs and core to perform this action! That is why a comprehensive rehabilitation program here at Sport & Spinal Physiotherapy is crucial for your optimal return to play. This is irrespective of your chosen sport.

I recently treated a lady who was an ACT representative for Kendo. After discussing, role-playing and you-tubing, I had a beginner’s guide to Kendo. Kendo is a traditional Japanese Martial arts form. It involves swordsmanship. Specifically, it involves a lot of upper body strength, core control and flexibility in the lower limbs. As a result, we successfully rehabbed her foot, back and shoulder for her to participate in Nationals in Perth in mid 2019. Myself and the client were ecstatic with the outcome!

The typical home-based program we would give to a client, where someone presents with one-sided rotator-cuff related shoulder pain is as follows. NB: There typically is no event or trigger leading to symptoms and therefore classed as non-traumatic.

 

A)  Waterski stretch

B) External rotation

C) Pectoralis Stretch

Final word on shoulder rehab

In conclusion, it is not all doom and gloom out there! I have successfully rehabbed a number of people back to “functionally good.” I reluctantly use the word fix when it comes to shoulders as there are so many variables in play. I recommend an evidence-based approach towards getting your shoulder stronger.

Resources

www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32457-1/fulltext