Bone surgery

What is subacromial shoulder surgery?

Recent research published in the Lancet in November 2017*, testing the effectiveness of subacromial shoulder surgery compared to placebo surgery or no treatment, has brought into question whether subacromial shoulder surgery is an effective treatment. If you are considering subacromial shoulder surgery this site provides information and patient experiences on this type of surgery.

A shoulder is a ball and socket joint. The joint is surrounded by a deep layer of tendons called the rotator cuff. When the arm is lifted up to the side or in front of the body, these rotator cuff tendons pass underneath the bony roof of the shoulder. These tendons can rub on this bony roof and sometimes a bony spur develops. This rubbing results in pain felt over the shoulder and the side of the upper arm. The tendon can become thickened, painful and worn, and may even tear. This rubbing of the tendon can settle with time, rest, physiotherapy and a cortisone injection. If the symptoms persist, though, day case surgery called arthroscopic subacromial decompression (ASD) may be needed. Subacromial shoulder surgery is carried out by an orthopaedic shoulder surgeon (a doctor who specialises in bone surgery of the shoulder). The surgery usually takes no more than half an hour. Once the anaesthetic has taken effect, the surgeon will usually make two small keyhole cuts in the skin around the shoulder. He or she will look inside the shoulder joint with a small keyhole camera and insert specially designed keyhole surgical instruments through the small cuts and shave off a bony spur from the roof of the shoulder (acromion). The surgeon may also decide to repair any damaged tendons at the same time which then makes the operation and the recovery longer. This may mean that the surgeon has to change from keyhole surgery to an open operation and will make a small open cut over the top of the shoulder. At the end of the operation, the surgeon will remove the surgical instruments and close the cuts with sticky dressings or stitches.

A doctor explains what subacromial shoulder surgery is?

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Well, it has a big, long name. It’s called arthroscopic subacromial decompression or ASD for short. But that’s basically keyhole surgery of the shoulder, usually performed through two keyholes, one for the little camera, one for the little instruments.

And what the surgeon, and what we’re really trying to do at that point is to shave a spur or little prominence of bone from the roof of the shoulder, which has been catching on some tendons in your shoulder and causing the pain that you get when you lift your arm up.

As with every operation, there are some risks associated with subacromial decompression but these are very rare. The chance of infection is small, with most surgeons quoting an infection risk of 1 in 200 or 1 in 300 people (Professor Jonathan Rees 2015). There is a higher chance (5%) of getting a stiffness problem called frozen shoulder, which can take several months to resolve*. The risks to nerves are extremely rare with this type of surgery.**

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.

It usually takes between two and six months to make a full recovery from subacromial decompression but it can take longer. How long it takes to recover depends on a number of things, including how healthy a person is before the operation and how well they keep up with the physiotherapy [exercises] after the operation.

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.

See our resources for more information.

*Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial, Prof David J Beard, DPhil; Prof Jonathan L Rees, FRCS; Jonathan A Cook, PhD; Ines Rombach, MSc ; Cushla Cooper, MSc ; Naomi Merritt, BSc ; et al. Published: November 20, 2017 DOI:https://doi.org/10.1016/S0140-6736(17)32457-1
**Yeranosian MG, Arshi A, Terrell RD, Wang JC, McAllister DR, Petrigliano FA. Incidence of acute postoperative infections requiring reoperation after arthroscopic shoulder surgery. American Journal of Sports Medicine. 2014 Feb;42(2):437-41

Last reviewed November 2018.
Last updated November 2018.

• *Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial, Prof David J Beard, DPhil; Prof Jonathan L Rees, FRCS; Jonathan A Cook, PhD; Ines Rombach, MSc ; Cushla Cooper, MSc ; Naomi Merritt, BSc ; et al. Published: November 20, 2017 DOI:https://doi.org/10.1016/S0140-6736(17)32457-1