Keyhole Shoulder Surgery

The shoulder is the most mobile joint in the body, which is also why it is the least inherently stable. Most of what goes wrong with it is either the tendons around it, the capsule that encloses it, or the rim of cartilage that deepens its shallow socket.

Nearly all of it can now be dealt with through keyhole surgery, and a good deal of it does not need surgery at all.

What keyhole surgery means here

A camera about the width of a pencil, and fine instruments, passed through small incisions. The joint is inflated with fluid so there is room to see and work. Compared with opening the shoulder, it means less disturbance to the tissues around the joint and a clearer view inside it.

The small incisions are the least important part. What determines your result is what was found, what was done about it, and how much rehabilitation you then do.

The five problems this covers

Rotator cuff tear. The cuff is a group of four tendons that hold the ball in the socket and lift and rotate the arm. Tears are common with age and are not all painful. A repair anchors the torn tendon back to bone. Not every tear needs one.

Frozen shoulder. The capsule around the joint thickens and contracts, and the shoulder becomes stiff as well as painful. It usually resolves on its own, but over a year or two. Treatment is aimed at shortening that and making it bearable.

Impingement. Pain as the arm is raised, from compression of the tendons and bursa under the bony arch above them. Most cases settle without surgery.

A shoulder that keeps dislocating. The socket is shallow and is deepened by a rim of cartilage, the labrum. A dislocation often tears it, and once torn the shoulder is more likely to dislocate again. A keyhole repair reattaches it.

Wear at the collarbone joint. The small joint at the tip of the shoulder, where the collarbone meets the shoulder blade, can wear out and become painful to press on and to reach across the body. It is treated in its own right, and it is sometimes mistaken for a cuff problem.

What tends not to need surgery

Being clear about this matters, because shoulder pain is frequently treated too aggressively and too early.

• Most gradual-onset rotator cuff tears, particularly where the problem is pain rather than weakness
• Most impingement, given a real trial of physiotherapy directed at how the shoulder blade moves
• Frozen shoulder in its painful phase, which usually responds better to a guided injection and time than to an operation
• First-time dislocation in an older patient, where the shoulder is much less likely to become recurrently unstable

A genuine trial means months of the right rehabilitation, not a leaflet.

What the assessment involves

• History. Whether there was a specific injury, what you cannot do, where the pain is, and whether it wakes you. Night pain is a useful pointer to the cuff.
• Examination. Movement, both what you can do and what someone else can move for you, and specific tests of each cuff tendon and of stability.
• X-ray. Bone shape, the arch above the tendons, the collarbone joint, and arthritis in the joint itself.
• Ultrasound or MRI. For the tendons and the labrum. Ultrasound is quick and good at the cuff; MRI shows more, including the labrum and the muscle quality, which bears on whether a repair will hold.

Imaging findings need to match the examination. Cuff changes are common on scans in people with no shoulder pain at all, so a scan finding on its own is not a reason to operate.

Recovery, by operation

The range is wide, and this is the part to pin down before agreeing to a date.

• Decompression or debridement. Sling briefly if at all. Ordinary use within weeks.
• Collarbone joint surgery. Comparatively quick, with a few weeks of restricted reaching across the body.
• Rotator cuff repair. A sling for around six weeks while the tendon heals to bone, then a staged programme running to four to six months. Loading it early risks the repair.
• Stabilisation repair. Similar in scale to a cuff repair, with a staged return to contact sport considerably later.
• Frozen shoulder release. The operation is the short part. Keeping the movement afterwards is the work, and it starts immediately.

Questions worth asking

1. What exactly is torn or affected, on my scan, and does it match my examination?
2. What happens if I do nothing for six months?
3. What non-surgical treatment should I have tried first, and for how long?
4. If you repair it, what is the chance it heals, given the size and the muscle quality?
5. How long in a sling, how long off work, and how long before I can drive?
6. What does the rehabilitation actually require of me, week by week?

Common questions

What is keyhole shoulder surgery?

Arthroscopy: a camera the width of a pencil and fine instruments passed through small incisions rather than opening the joint. Most shoulder problems that need surgery are now dealt with this way. It is done under anaesthetic as a day case or an overnight stay in most instances, and the small incisions matter less to your recovery than what was done inside and how much rehabilitation follows.

Does a rotator cuff tear always need surgery?

No, and that is an important thing to establish early. Many tears, particularly those that come on gradually with age rather than from an injury, are managed without surgery and settle with physiotherapy and time. Repair is considered more readily for a tear that follows a specific injury, for a tear that is enlarging, for significant weakness rather than pain alone, and in younger and more active patients. The size, the position and the quality of the muscle all bear on whether a repair is likely to hold.

How long does a frozen shoulder take to get better?

Longer than anybody wants. It is a self-limiting condition in most people, meaning it does resolve, but it typically runs through a painful phase, a stiff phase and a thawing phase over a year to two years. Treatment is aimed at shortening that and making it tolerable: a guided injection often helps the painful phase considerably, and physiotherapy matters more in the stiff phase. Surgery, either a release or a manipulation under anaesthetic, is for shoulders that stay stuck.

What is shoulder impingement?

Pain as the arm is lifted, classically in an arc partway up, from the tendons and the bursa being compressed under the bony arch above them. Most cases improve with physiotherapy aimed at how the shoulder blade moves, and with an injection where the pain is limiting that. Surgery to make more room under the arch is considered when a genuine trial of that has not worked, and the evidence for it is more contested than it once was, so it is worth asking why it is being proposed for you.

My shoulder keeps dislocating. What can be done?

After the first dislocation the rim of cartilage around the socket, the labrum, is often torn, and once that has happened the shoulder is more likely to go again. A keyhole repair reattaches it, which is called a Bankart repair. The younger you were at the first dislocation and the more times it has happened, the stronger the case for repairing it. Where a good deal of bone has been lost from the socket, a bony reconstruction rather than a soft-tissue repair may be needed, which is a different and larger operation.

How long is the recovery?

It depends entirely on what was done, and the range is wide. A decompression or a simple debridement may allow ordinary use within weeks. A rotator cuff repair usually involves a sling for around six weeks and a rehabilitation programme running to four to six months, because the repair has to heal to bone before it is loaded. A stabilisation repair is similar in scale. Ask for the timeline for your specific operation before you agree to a date, and plan work and travel around it.

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