Shoulder Impingement Syndrome and Acromioclavicular Pain: arthroscopic surgery

You have been diagnosed with a shoulder impingement, which causes shoulder pain. This leaflet will explain what a shoulder impingement is, the signs and symptoms, and how it can be diagnosed. Although the exact method of treatment will differ from patient to patient, the most common treatments used by East Kent Hospitals and their likely outcomes are also covered here. It will also give you information about what you need to do through the process.

If after reading this leaflet you still have questions or concerns, please speak to your surgeon or anaesthetist at your next appointment.

Contents page

• What is a shoulder subacromial impingement?

• What are the signs / symptoms?

• What treatments are available?

• If I have surgery, what will happen during my procedure?

• Procedures you might need or may be carried out during your operation

• How can I prepare for my surgery?

• What happens on the day of my surgery?

• What kind of anaesthetic will I need?

• What are the complications and risks?

• How long will I stay in hospital?

• Will I be in pain after my surgery?

• What painkillers will I be sent home with?

• How do I care for my wound(s) at home?

• How long will my wound(s) take to heal?

• What if my wound bleeds at home?

• Can I have a bath or shower?

• Why am I wearing a sling after my surgery?

• What is the best position to sleep in?

• When can I drive again? When can I return to work?

• When can I start my normal daily activities?

• How soon will I recover after my surgery?

• Will I have a follow-up appointment?

• What if I have any questions or concerns?

• Exercises and physiotherapy advice

• Contact details

What is shoulder subacromial impingement?

The shoulder joint is a very mobile joint, which allows it to be used for a wide range of movements.

The subacromial area lies between the top of the arm bone (humerus) and a bony prominence on top of the shoulder called the acromion, which is part of the shoulder blade. The rotator cuff is a set of muscles and tendons that surround the shoulder joint to provide stability and function.

In some cases, some extra bone can grow underneath the acromion, this is called a “bone spur”. When that bone spur is large enough, it can start rubbing on the rotator cuff muscles beneath it, causing pain. This is called subacromial impingement because it happens underneath the acromion.

With certain movements and positions the soft tissues in your shoulder (rotator cuff muscles and tendons) can become pinched and inflamed. The pain that you have been feeling is caused by this pinching and is typically felt on movements such as reaching and putting your arm into a jacket sleeve. This is known as impingement. Moreover, the regular rubbing of the bone spur against the soft tissues can make these become thinner and weaker (like a piece of fabric being constantly rubbed with something hard and rough, like a rock).

What are the signs / symptoms?

• Pain, usually felt in the outer arm/shoulder.

• It may feel like something in your shoulder is ‘catching’ when you move your arm in certain directions.

• Stiffness / reduced range of movement in your shoulder, especially movements that involve reaching to the small of your back.

• Your arm may feel weak as the muscles / tendons cannot work properly due to pain.

What treatments are available?

Treatment of a shoulder impingement is usually non-surgical (we use physiotherapy, pain management, and steroid injections), and most patients find that their pain settles down with these simple measures. However, if conservative treatments do not work, surgery is an option. All the options available to you will be discussed with your surgeon at your clinic appointment.

If I have surgery, what will happen during my procedure?

Please note that the Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW) trial shows little difference in the results between having this operation as compared with having a simple arthroscopy (placebo). However, surgery provided a better improvement of symptoms than no treatment. The procedure is used for patients who have failed non-operative management as per guidelines from the British Elbow and Shoulder Society. Do not hesitate to discuss this with your surgeon before your operation, if you need to. For more information, please read this Lancet article.

Your surgeon may also need to do a repair or carry out further surgery if they find other problems or further damage. If the issue can be solved during your surgery they will do it there and then, as long as that is what has been agreed with you when you gave consent before your surgery.

It is important to keep in mind that your surgeon might not know if you need further surgery or a repair until your operation has begun. Which repair you have will be discussed with you after your procedure, during your first follow-up appointment.

The following are procedures you might need or may be carried out during your operation

• Examination under anaesthetic (EUA)

  Your shoulder will be examined under anaesthetic (EUA). If it is found to be stiff with restricted movement due to a frozen shoulder, manipulation under anaesthetic (MUA) for release of the tight soft tissue may be needed.

  *This will involve different aftercare advice to the Arthroscopic Subacromial Decompression. You will not be allowed to use your arm or drive for six to eight weeks after this procedure.

• Acromio-clavicular (AC) joint excision

  The Acromio-Clavicular Joint is a small joint formed between the top of the shoulder blade (acromion) and the collarbone (clavicle) (between your shoulder and your neck). This joint can cause pain at the top of the shoulder, especially while doing movements high above the level of the shoulder. Moving your arm across your chest at shoulder level, to reach past your opposite shoulder can cause sharp pain or feel like something is catching in the joint.

  This is due to a tear in the soft tissue or arthritis arising from wear and tear. In these cases, resection of the AC joint with removal of a few millimeters of bone from each side of this joint is performed, which should reduce the pain because of removing the surfaces that are rubbing against each other and gives the joint more space to move.

How can I prepare for my surgery?

You will have a preassessment appointment before your surgery, to check if you are ready and fit for surgery. You will also be swabbed for MRSA and Covid-19, if necessary.

Before surgery it helps if you try to get as fit as possible to avoid anaesthetic risk and/or failure of the surgery. It is important that you lose weight if you are above your ideal weight.

• Smoking advice

  It is important to stop smoking at least 30 days before your surgery. Studies have shown that wound healing is significantly delayed by smoking/nicotine, and the infection rate is much higher. Smoking also harms how your tendon heals following a repair, so smoking after your operation is also not advised.

  If you need support to stop smoking, please contact One You Kent on 0300 123 1220, or email.

• How does eating a healthy diet help my recovery?

  Recovering from surgery can take a long time and it is normal to get frustrated and anxious. But remember that while you are recovering, there are some things you can do to help your wound to heal. We suggest limiting the amount of alcohol you drink, stopping smoking, eating a healthy diet, drinking plenty of fluids (especially water), and staying active. If you need any extra support, do not hesitate to get in touch with us on the contact numbers listed at the end of this leaflet.

  Some painkillers (especially those containing Codeine) can cause constipation. To avoid this, please follow a healthy well-balanced diet rich in fruit, vegetables (including green leafy vegetables), nuts, seeds, wholegrains, and legumes, which contain the necessary fibre, and drink plenty of water. More information is available on the NHS 5 A Day: what counts? web site.

While you wait for your surgery date, you can start preparing for your operation. Research shows that fitter patients, who are able to improve their health and activity levels before surgery, recover more quickly. Taking an active role in planning and preparing for your operation will help you:

• feel in control

• leave hospital sooner, and

• get back to normal more quickly.

To help with this, you may be contacted by a member of the One You Kent (OYK) team. OYK work in the community, and help patients improve their general health. This includes help and advice on:

• Stopping smoking

• Losing weight

• Getting more exercise

More information can be found on the following web sites.

• One You Kent (Kent Community Health)

• Fitter Better Sooner Toolkit (Royal College of Anaesthetists)

What happens on the day of my surgery?

• Please arrange for someone to pick you up from the hospital after your surgery, as you will not be able to drive yourself. Please make sure to arrange this before your surgery.

• To avoid complications with your anaesthetic, you should not eat anything for six hours before your surgery, or drink anything for two hours. You will be given further instructions during your preassessment.

• On the day of your surgery, you can take your usual medication as advised during your preassessment. If possible, do not take non-steroidal anti-inflammatory medication, such as ibuprofen and naproxen, for at least 10 days before your surgery, as they can affect how your wound heals. Please bring any medications that you are taking into the hospital with you.

• If possible, please wear loose-fitting clothes, as after surgery you will be wearing a sling.

• Bring your appointment letter with you, so you know which department to come to when you arrive at the hospital.

• At arrival, you will be asked to put a hospital gown on, and maybe a pair of compression stockings.

• You will see the anaesthetic and surgical team before your surgery to go through the consent form and discuss any questions you may still have. Remember you can withdraw your consent for treatment at any time.

• You may be tested for Covid-19. All appropriate precautions will be taken during your admission to minimise the risk of contracting the illness as per Healthcare England Guidelines.

What kind of anaesthetic will I need?

This procedure is usually performed under general anaesthetic (you will be asleep for the procedure). However, you may be offered the option of “awake anaesthesia” during your surgery to avoid putting a tube into your windpipe. This may be discussed and decided with you and the anaesthetist on the day of your surgery. Should you be suitable for this type of anaesthesia, it is important to understand and be assured that you will be kept comfortable, and you will not feel any pain during your procedure. Patients describe their experience after this type of “awake anaesthetic” as if waking up from a usual night’s sleep, as it is often supplemented with some light sedation. If you need any more information, please speak to your anaesthetist before your procedure.

In addition, a local anaesthetic or nerve block is used during your operation. As a result, your shoulder and arm may feel numb for a few hours after your operation. It is important to take your pain medications during this time, to allow a gentle and easier control of pain when the nerve block wears off and your shoulder is likely to be sore and uncomfortable.

What are the complications and risks?

As with all surgery, there are a few risks and complications. These are rare and will be discussed with you before your surgery.

Anaesthetic risks will be discussed with your anaesthetist on the day of your surgery.

• Wound infection: we do everything we can to avoid this but an infection might still happen. If your wound becomes increasingly red or swollen after your surgery, please contact your GP or speak to your surgical team as soon as possible.

• Bleeding: if this happens during your surgery, we will do our best to stop it as soon as possible. However, some oozing could still happen after your surgery. For more information, see the What if my wound bleeds at home? section below.

• Soft tissue (nerve / tendon / blood vessel) injury could happen during surgery. We will try our best to avoid any damage.

• Stiffness / loss of movement that may cause frozen shoulder (your shoulder is painful and stiff for up to several months beyond the usual period expected for the stiffness to recover from a simple procedure). This could be avoided or improved if you take adequate pain relief and do the exercises listed at the end of this leaflet as your pain permits.

• Continued pain and Chronic Regional Pain Syndrome (CRPS). CRPS is a condition where a person has persistent, severe, and debilitating pain. Although most cases of CRPS are triggered by an injury, the resulting pain is much more severe and long-lasting than normal.

• Deep vein thrombosis (DVT) and / or pulmonary embolism (PE). These are blood clots which form in the blood stream and can be serious conditions. Compression stockings and other measures might be taken by the hospital to avoid them.

• Fracture of the acromion or humerus. We will do everything we can to stop this from happening. If it does happen your surgeon will deal with it either during your surgery or at a later date, whichever is appropriate for you.

• Failure of surgery or a need to redo the surgery. If your surgeon is unable to complete your surgery successfully or the repair fails, other options or further treatment can be discussed after your surgery.

If you have any questions or concerns about these complications, please speak to your surgeon either during your clinic appointment or before your surgery.

How long will I stay in hospital?

This procedure is usually carried out as a day operation, so you should be able to go home the same day.

You will be taken to the ward until its safe for you to be discharged home. You will be seen by your surgeon, your nurse practitioner (surgical care practitioner), and / or your physiotherapist before you go home. They will show you what exercises to do and give you further advice to guide you through your recovery.

If you need to stay in hospital overnight, this will usually be explained to you during your preassessment appointment. If you have to stay overnight, make sure you bring with you items you may need, such as hygiene items (toothpaste and toothbrush), a dressing gown, slippers, and your usual medication. Also, we suggest you bring a book or magazine, in case there is a delay.

Will I be in pain after my surgery?

This type of surgery may be uncomfortable, and you will need appropriate pain relief afterwards. If your anaesthetist has given you a nerve block, your shoulder and arm may feel numb and weak. You may not feel any pain immediately after your surgery, as the block may take 12 to 24 hours to wear off completely.

However, it is very important that you take your pain relief as advised and as early as you can before the nerve block wears off; this will help you to keep on top of your discomfort. It is advisable to take your painkillers regularly for the first few days. If possible, avoid non-steroidal anti-inflammatory medication, such as ibuprofen and naproxen, for at least 10 days before your surgery and six weeks following surgery. This is because anti-inflammatory medication could slow down the healing process.

You will be given painkillers when you leave the hospital, to take at home; these should last for at least two weeks. This will be discussed with you before you leave hospital.

Take pain relief regularly to try and keep your level of discomfort at a bearable level at all times. This allows the inflammation (redness, swelling, and heat) and pain to settle. Do not wait until your shoulder is very painful to take the pain relief, as it is then more difficult to control.

What painkillers will I be sent home with?

• Surgical patients might be given some of the following painkillers, depending on their age, body weight, and individual circumstances, unless told otherwise by their doctor.

• Take each painkiller as advised on your prescription.

  • Tablet paracetamol, 1g every four to six hours (no more than 4g per day).

  • Codeine Phosphate, 30 to 60mg every six to eight hours.

  • Tablet Tramadol, 50 to 100mg every eight hours.

  • Oramorph, 10 to 20mg every hour, as needed.

  • Anti-inflammatories may be prescribed; but you should try and take as few as possible immediately after your surgery.

  Please note that Codeine, Oramorph, and Tramadol should not be taken together; you should only take one of the three at any one given time.

Ice packs or bags of frozen peas may also help reduce your pain. Wrap the pack / bag with a cloth and place it on your shoulder for up to 15 minutes. Do not eat these peas once they have defrosted.

If your pain continues and is not controlled with the medication you have been advised to take, then please contact your GP. You may also contact the East Kent Upper Limb Team if you need further help.

If you notice your wound area is becoming more painful, red, hot, and / or discharging pus (thick yellow discharge), you may be developing an infection. Contact your GP or surgical team for advice as soon as possible.

How do I care for my wound(s) at home?

As you had a keyhole surgery, there will be few (around three) keyhole incisions (cuts) around your shoulder, including one or two at the back.

It is important to keep your wound and dressing dry and in place until your wound is well healed, and have your stitches removed at your two week follow-up appointment with your GP practice nurse or at the hospital, with your surgeon or your nurse practitioner (surgical care practitioner). You will be told where your follow-up appointment is going to be before you leave the hospital.

If the dressing gets wet or bloodstained, you can change them yourself by carefully placing a dressing from a pharmacy. If you are unable or have difficulties doing this yourself, you can ask a relative or a friend to change it for you, or you can make an appointment with your GP practice nurse to do it for you.

If you are being seen by your GP practice nurse for a wound check 10 to 14 days after your surgery, please make sure the nurse reads the following. These instructions are for healthy looking surgical wounds only.

• *Colourful stitches are non-absorbable and need to be completely removed to avoid them getting buried under the patient’s skin.

• *White / clear stitches are absorbable. If any suture knots have been made outside the patient’s skin, please remove these to avoid suture abscesses. Thank you.

*The appearance and material of the sutures can be different from Trust to Trust, but these are the most common.

If a wound does not seem to be healing appropriately, please leave the stitches/knots in place and make another appointment to remove them in few days.

How long will my wound(s) take to heal?

Wounds usually take between 10 to 14 days to heal.

The area around your wounds may have some numbness, which is usually temporary. You may feel occasional sharp pains or ‘twinges’, as well as itching near the scar as it settles.

What if my wound bleeds at home?

Occasionally there can be minor bleeding or clear fluid ooze in the first day or two after your surgery. If your dressings get wet or bloodstained, you can change them yourself by carefully placing a dressing from a pharmacy over your wound. If you are unable to this yourself, you can ask a relative or a friend to help or you can get an appointment with your GP practice nurse to do it for you. This bleeding or oozing should be controlled by pressing firmly but gently on your wound for 15 minutes.

If you are worried about the bleeding, you can contact the hospital on the number given to you (during normal working hours) or go to a walk-in centre or Emergency Department (after hours).

Can I have a bath or shower?

You should have a ‘dry wash’ or a shallow bath instead of a shower. This keeps your arm in the correct position and prevents your dressing(s) and sling from becoming wet.

While your wound is still healing:

• do not use soaps, lotions, creams, or powders on your wounds, to avoid any infection getting in to your wound(s); and

• keep your wound(s) dry at all times.

It is very important to remember to keep your armpit on your operated side clean and dry. Lean forward so you can reach your armpit, as separating it from the body sideways may be difficult or painful and is not allowed for the first four to six weeks.

Why am I wearing a sling after my surgery?

You will return from surgery wearing a sling; this is usually used for the first couple of days following your surgery. The sling is only there to keep your arm comfortable. It may be taken off as much as you wish and discarded as soon as possible. If your shoulder feels sore, some people find it helpful to continue to wear the sling at night for a little longer. We encourage you to use your arm.

If you had a repair during your surgery, you might need to use a sling for four to six weeks following your operation. The sling protects your repair while it heals. If this is the case, you will be given further instructions about how to wear your sling.

What is the best position to sleep in?

To begin with sleeping will be difficult. Take regular painkillers and try to support your shoulder with pillows, by placing them behind it. If you lie on your back, a pillow under your arm and elbow may make you feel more comfortable. You may also find it easy to lay on your non-operated side. You can lie on your operated side as soon as you feel comfortable and confident to do so.

When can I drive again?

You will not be able to drive for at least a few days after your surgery. Your surgeon will tell you when you can drive again.

The advice from the DVLA is that you should not drive until you are physically capable of controlling a motor vehicle and can perform an emergency manoeuvre safely and confidently. This will take longer if any structures needed to be repaired during your surgery.

Please arrange for someone to collect you from hospital and take you home after your surgery.

When can I return to work?

This will depend on your job. If you have an office job or light duties you may return to work as soon as you feel able to; usually after one week. If your job involves heavy lifting or using your arm above shoulder height, you may need to stay off work longer. This may be even longer if you needed to have further surgery during your procedure. Please discuss this with your surgeon before your procedure, they will advise you on the amount of time you will need to be away from work; you can ask for a sick note before you leave the hospital.

When can I start my normal daily activities?

A physiotherapist will see you in hospital to give you advice about using your arm and exercises. Outpatient physiotherapy will be arranged when you are discharged.

You should avoid continued, repetitive overhead activities for three months.

With swimming, you may begin breaststroke as soon as you are comfortable but you should wait three months before doing the front crawl.

You can start practising golf at six weeks.

For advice on DIY and racquet sports you should speak with your physiotherapist.

How soon will I recover after my surgery?

This varies from one patient to another. However, experience shows us that by three weeks after surgery, movement below shoulder height becomes more comfortable. By this stage you should have almost full range of movement, although there will probably be discomfort when moving your arm above your head.

Three months after your surgery your symptoms should be approximately 80% better and you will continue to improve for up to a year following your procedure.

Will I have a follow-up appointment?

Before you leave hospital, an appointment will be made for you to have a follow-up appointment at the Upper Limb Unit. At this appointment you will be seen by a physiotherapist, surgical care practitioner, or surgeon who will check your progress, make sure you are moving your arm, and give you further exercises, as appropriate.

This appointment will usually be three to four weeks after your surgery. You will be monitored by a physiotherapist throughout your rehabilitation.

What if I have any questions or concerns?

If you have any questions or concerns, please contact your surgical care practitioner, surgeon, or physiotherapist. Their contact details are listed at the end of this leaflet.

If you notice your wound area is becoming more painful, red, hot, and / or discharging pus (thick yellow discharge) you may be developing an infection. Contact your GP or your surgical team for advice as soon as possible.

Exercises you can do after surgery, before your first physiotherapy appointment

Before starting the following exercises, please take painkillers and use ice, if needed. It is normal to experience some pain and discomfort when you perform any exercises. If you experience prolonged pain or discomfort when moving, then do the exercises less forcefully or less often. If this does not help, speak to your physiotherapist.

On the next page you will see how to perform these exercises, but if you have any questions, please contact the physiotherapy department (see the contact details at the end of this leaflet). These exercises are a guide. Specific instructions will be given to you in your post-operative notes.

It is best if you do a few short sessions (two to four times a day, for five to 10 minutes each time) rather than one long session. Gradually increase the number of repetitions you do.

Following your first appointment with your physiotherapist, you will receive more exercises and, depending on your progress, your physiotherapist will give you personalised advice.

Physiotherapy guidelines while you are still in the hospital

• An outpatient physiotherapy referral will be arranged by a member of the inpatient physiotherapy team.

• You will be shown how to put on and care for your sling.

• Advice on managing your pain and using ice will be given.

• You will be shown the following exercises on the ward:

  • elbow, wrist, and hand exercises

  • shoulder girdle and posture exercises

  • shoulder range of movement exercises.

Physiotherapy guidelines once you leave the hospital

• Outpatient physiotherapy will start within two weeks of leaving, unless you are told otherwise.

• You can do early exercises two to four times a day.

Hand exercises

• Open and close your fist 20 times.

Wrist exercises

• Move your wrist up and down 20 times.

Forearm exercises

• Turn your palm up and down 20 times.

Elbow exercises

• Bend and straighten your elbow 20 times. This can be completed with help from your other arm.

Shoulder girdle and posture

• Try not to slouch after your surgery.

• Try pulling your shoulder blades back and down 20 times.

Pendular exercises

• Lean forwards, supporting yourself with your other arm.

• Swing your operated arm forwards and backwards gently, like a pendulum.

• Do this 20 times.

Shoulder exercises (1)

• Lay down and lift your operated arm up, with help from your other arm.

• Do this 10 times.

• When you are able, do this exercise sitting up.

Shoulder exercises (2)

• Stand up and gently reach round your back. Use your other arm to help. Hold for 10 seconds.

• Do this three times.

Shoulder exercises (3)

• Hold a stick or rolling pin.

• Gently rotate your operated arm out to the side with the help of your other arm.

• Do this 10 times.

Shoulder exercises (4)

• Walk your fingers up the wall. You may need to use your other hand to help.

• Do this 10 times.

Isometric static contractions (1)

• Gently rotate the operated side out to the side, resisting with your other hand.

• Hold for 10 seconds.

• Do this three times.

Isometric static contractions (2)

• Gently push your operated arm out to the side, resisting with your other hand.

• Hold for 10 seconds.

• Do this three times.

Isometric static contractions (3)

• Gently push your operated arm forwards, resisting with your other hand.

• Hold for 10 seconds.

• Do this three times.

Contact details

Consultants and their secretaries

• The teams listed below work at Kent and Canterbury Hospital as well.

Physiotherapists

Surgical Preassessment Units

Fracture Clinics