Shoulder Pain Management

Rehabilitation

Rehabilitation May Start Immediately After Surgery¹

After surgery, the patient will have a dressing over his/her shoulder that will need to be changed frequently over the next few days. The surgeon may have inserted a small drainage tube into the shoulder joint to help keep extra blood and fluid from building up inside the joint. The patient will receive IV antibiotics, pain medication and other medications.

At the surgeon’s discretion, the patient’s shoulder may be placed in a continuous passive motion (CPM) machine immediately after surgery. CPM helps the shoulder begin moving and alleviates joint stiffness. The machine straps to the shoulder and continuously bends and straightens the joint. This motion is thought to reduce stiffness, ease pain and keep extra scar tissue from forming inside the joint. The patient will use a shoulder sling to support the affected arm when not using the CPM machine.

Long-Term Rehabilitation May Begin the Day After Surgery¹

A physical or occupational therapist will typically see the patient the day after surgery to begin the rehabilitation program. Physical therapy will gradually improve shoulder movement. If the patient is using CPM, the physical therapist will check the alignment and settings. The therapist will practice exercises with the patient and make sure the patient is safe getting in and out of bed and moving about the room. A physical therapist may also visit the patient at home to ensure that the patient is safe getting around in the home.

Patients who live alone or who do not have a caregiver to assist them may be kept in the hospital longer, or be transferred to a rehabilitation center, in order to make sure that they can manage basic daily living activities on their own when they return home.

The recommended exercises will help improve range-of-motion and strength. Some patients may require up to three visits at home before beginning outpatient therapy.

The first few outpatient treatments will focus on controlling pain and swelling. Ice and electrical stimulation treatments may help. The physical therapist may also use massage and other types of hands-on treatments to ease muscle spasms and pain. The patient will need to continue to use the shoulder sling as prescribed.

As the rehabilitation program evolves, more challenging exercises are chosen to safely advance the shoulder’s strength and function. Finally, a select group of exercises can be used to simulate day-to-day activities, such as grooming or getting dressed. Specific exercises may also be chosen to simulate work or hobbies.

When shoulder range of motion and strength has improved enough, the patient will be able to gradually get back to normal activities. Ideally, patients should be able to do almost everything they did before surgery. However, the patient may need to avoid heavy or repeated shoulder actions.

The patient may be involved in a progressive rehabilitation program for 2 to 4 months after surgery to ensure the best results from the artificial joint. In the first 6 weeks after surgery, the patient should expect to see the therapist two to three times a week. At that time, if everything is still going as planned, the patient may be able to advance to a home program. As progress continues, the patient will only check in with their therapist every few weeks.

Potential Complications

Deep Vein Thrombosis (DVT) – DVT after reconstructive shoulder arthroplasty is not uncommon and occurs in about 13% of patients. Similar rates of DVT have been observed after hip surgery, and substantially higher rates of DVT have been observed after knee replacement.² However, reports of total complications are lower for shoulder surgery patients compared with those who undergo hip or knee replacement.³

DVT after shoulder surgery can occur in the operative upper extremity or either of the lower extremities. The acute perioperative period is the time of greatest risk, but it can occur up to 12 weeks after surgery.²

Upper extremity DVTs commonly involve the axillary vein, and may be indicated by pain and swelling in the involved limb. Lower extremity DVTs commonly involve the distal veins of the calf, but can develop proximally. Symptomatic and fatal pulmonary embolism can also occur.²

Clinicians should suspect pulmonary embolism when respiratory difficulty or a cardiac tachyarrhythmia develops in the shoulder replacement patient.²

Diabetes – Hyperglycemia can prevent wound healing by hindering collagen production, impairing leukocyte chemotaxis and phagocytosis, and causing abnormal coagulation.⁴

These problems can be minimized by good glycemic control starting several weeks before scheduled surgery.⁴

It may be helpful to admit patients with diabetes one day before surgery to ensure metabolic control and electrolyte balance before surgery.⁴

Similarly, practical postoperative steps can help minimize complications. A sliding insulin scale and "sick day" insulin rules will help account for variable post-surgery eating. Prescribing anti-nausea medications in advance of surgery and instructing the caregiver on their appropriate use may help minimize variable eating due to upset stomach.⁴

Morbid Obesity and Diabetes⁵ – These conditions have been associated with higher rates of deep infection after joint replacement. Patients with diabetes and/or BMI above 40 are more than 3 times at risk of post-operative infection compared with patients without these conditions.⁵ Therefore, patients with diabetes or who are morbidly obese should be monitored closely for signs of infection after surgery.

References