We never operate on a scan, we operate on a problem that bothers you. A worrying X-ray in someone who has no pain anywhere justifies no operation at all, and I regularly see patients who are relieved to learn they need nothing done.
Three situations lead to shoulder surgery. The first, and the most common, is pain that persists after several months of well conducted medical treatment, with painkillers, physiotherapy and sometimes an injection. The second is a loss of function: an arm that no longer lifts, strength that is missing for work or for daily life. The third is a lesion that will get worse if nothing is done, a recent tendon tear in an active patient, a shoulder that dislocates again and again, a displaced fracture.
Time matters more than people think where tendons are concerned. A torn tendon never heals back on its own, and the muscle it belongs to gradually turns to fat. That degeneration cannot be reversed, and it is what closes the door on a repair if you wait years. This is why I would rather see a painful shoulder early, even if the decision is to do nothing for now.
There is no single shoulder operation, there are around ten of them, and they differ both in how major they are and in what recovery looks like.
A rotator cuff repair reattaches a torn tendon to the bone, by arthroscopy. It is the most frequent procedure in shoulder surgery.
A shoulder replacement, anatomic or reverse, replaces the worn joint. It is the treatment for advanced arthritis and for certain complex fractures.
Treating a calcific deposit removes the crystals lodged inside the tendon that cause attacks of severe pain.
A Latarjet bone block or a Bankart repair stabilises a shoulder that dislocates repeatedly, by rebuilding the bony stop or by repairing the labrum.
Releasing a frozen shoulder frees a contracted joint capsule, when the shoulder stays blocked despite physiotherapy.
Fixing a fracture holds the bone fragments together with plates, screws or a nail, when the bone cannot heal in the right position without surgery.
To these are added the steps often combined with the above: treating the long head of the biceps tendon, an acromioplasty that gives the tendon more room under the acromion, or removing the acromioclavicular joint when it is worn.
Less time than patients imagine. Most shoulder operations take between forty-five minutes and an hour and a half of actual operating time.
Fitting a shoulder replacement takes forty-five minutes to an hour. An arthroscopic rotator cuff repair usually takes under an hour, longer if the tear is extensive or if several procedures are combined. Treating a calcific deposit is shorter still.
The time spent in theatre is always longer than the operating time, because it includes positioning, the regional block and waking up in recovery. Warn your family that a three hour absence does not mean three hours of surgery.
I fit around one hundred and fifty shoulder replacements a year, and it is that repetition that explains how consistent the timings and the recoveries are.
Arthroscopy means operating inside the joint through small incisions of less than a centimetre, through which a camera and the instruments pass. The image is shown on a screen, magnified, and reveals damage that no scan can show.
The benefit is not only cosmetic. By not opening the muscles, keyhole shoulder surgery reduces pain after the operation, the risk of infection and stiffness.
Not every operation is done by arthroscopy. Rotator cuff repair, treating a calcific deposit, stabilising a dislocating shoulder and releasing a frozen shoulder all suit it perfectly. A shoulder replacement, on the other hand, is fitted through a conventional approach, a vertical incision of about eight centimetres at the front of the shoulder, in a natural interval between the deltoid and the pectoralis major.
With this approach, I detach no muscle. It is a technical difference with a very concrete consequence for you: after a shoulder replacement there is no sling and no immobilisation, and you can drive again immediately.
Shoulder surgery is carried out under a general anaesthetic, almost always combined with a regional anaesthetic, called a nerve block, which numbs the shoulder and the arm.
This combination has a simple purpose: that you feel nothing during the operation and as little as possible in the hours that follow. It is this block that explains why many patients feel almost no pain on the day itself.
It is normal for the arm to stay numb and heavy for several hours after you wake up, sometimes until the next morning. This is not a complication, it is the block wearing off. The trick is to start the painkillers before feeling comes back completely, rather than waiting until it hurts.
The anaesthetic consultation is compulsory and takes place a few days before the operation. That is the moment to mention your medication, in particular anticoagulants and antiplatelet drugs.
Most shoulder operations are now done as a day case, meaning you come in during the morning and go home the same evening. That is true of arthroscopy, and it is possible for a shoulder replacement, which otherwise needs a single night in hospital.
Day case surgery is not a matter of saving money, it is a matter of comfort and recovery: you sleep better at home, you move sooner, and the risk of infection goes down.
It does assume a few conditions: not living too far away, not being alone for the first night, and having no medication or condition that requires monitoring. We decide together in consultation, with the anaesthetist.
Preparing for shoulder surgery counts as much as the operation itself, and it comes down to a few points.
Stop smoking. Tobacco starves the tendon of its blood supply and clearly reduces the chances of healing after a repair. It is the one risk factor you can act on.
Get your teeth seen to and report any current infection, including a urine or skin infection. An infection elsewhere in the body can settle on a shoulder replacement.
Get your home ready before you leave for theatre: loose clothes that open at the front, everyday items brought down to hand height, ice packs in the freezer, a comfortable armchair for the first few nights.
Organise what comes next: physiotherapy sessions are booked before the operation, not after. Hunting for a practice with room once you are discharged costs precious weeks.
And arrange for someone to be around for the first few days if you live alone. It is not the pain that gets in the way most, it is the tasks that need two hands.
No surgery is without risk, and I would rather name the risks than keep quiet about them.
Infection affects about one per cent of cases in my series and remains the most feared complication. It is prevented by a strict protocol and it is why the wound is watched closely.
Stiffness after the operation is more frequent after a tendon repair than after a shoulder replacement, and is treated with physiotherapy.
Failure of the tendon to heal, or a re-tear, is the risk specific to rotator cuff surgery. It depends on the size of the tear, the state of the muscle, your age and smoking.
Temporary nerve irritation, a haematoma and, for replacements, dislocation of the implant complete the list. Across my first time shoulder replacements, the dislocation rate is zero.
I go through these risks one by one with you in consultation, before we set a date. An operation is a decision made by two people.
Recovery depends entirely on which operation you had, and the gap is sometimes wide. After a shoulder replacement fitted without detaching the muscles, there is no immobilisation, the arm is used from the next day and you can drive again immediately. After a rotator cuff repair, the tendon has to be protected while it heals onto the bone, which takes about three months.
All the detail, day by day and week by week, is set out on the page after shoulder surgery.
Most operations take between forty-five minutes and an hour and a half. Fitting a shoulder replacement takes forty-five minutes to an hour, an arthroscopic rotator cuff repair usually under an hour. The time spent in theatre is longer, as it includes positioning, the anaesthetic and waking up in recovery.
When pain persists after several months of medical treatment and physiotherapy, when loss of strength gets in the way of daily life or work, or when the damage will get worse if nothing is done. We never operate on a scan, we operate on a problem that bothers you.
Most of the time, yes. Arthroscopy is done as a day case, and it is possible for a shoulder replacement, which otherwise needs a single night in hospital. You need to live not too far away, not be alone for the first night and have no medication that requires monitoring.
A general anaesthetic combined with a nerve block that numbs the shoulder and the arm. It is this block that explains why many patients feel almost nothing on the day itself. The arm stays numb for several hours after you wake up, sometimes until the next day.
It is keyhole shoulder surgery, carried out through small incisions of less than a centimetre, with a camera and instruments. By not opening the muscles, it reduces pain, the risk of infection and stiffness. Rotator cuff repair, calcific deposits and stabilising a dislocating shoulder all suit it.
Stop smoking, get your teeth seen to and report any current infection. Get your home ready with clothes that open at the front and useful items at hand height. And above all, book your physiotherapy sessions BEFORE the operation, not after.
Infection, about one per cent of cases, stiffness after the operation, failure of the tendon to heal after a rotator cuff repair, temporary nerve irritation and a haematoma. Across first time shoulder replacements, the dislocation rate is zero.
Rotator cuff repair, an anatomic or reverse shoulder replacement, treating a calcific deposit, a Latarjet bone block or a Bankart repair for an unstable shoulder, releasing a frozen shoulder and fixing a fracture. To these are added combined steps such as treating the long head of biceps or an acromioplasty.
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