Shoulder Arthroscopy

The shoulder is well suited to arthroscopy because it is a large joint with room to work in, but the approach has real limits and they are worth knowing before the conversation about options.

Handled arthroscopically as a matter of routine: labral tears including instability repairs, most rotator cuff tears, biceps tendon problems, removal of inflamed bursa and impinging bone, loose bodies, and releasing the stiff capsule in a frozen shoulder.

Still generally open, or open-assisted: shoulder replacement of any kind, tendon transfers where a cuff tear is too large and retracted to be brought back, fractures that need plating, bone-block procedures for instability with significant bone loss, and tumour work.

The distinction is mostly about what has to be moved rather than what has to be seen. Arthroscopy is excellent at visualising and repairing tissue in place. Where the operation requires repositioning bone, seating an implant, or moving a tendon a significant distance, direct access is needed.

A cuff tear that has been present for years is the common in-between case: whether it can be repaired arthroscopically depends on how far the tendon has retracted and what condition the muscle is in, which is why the plan is sometimes only finalised once the surgeon is looking at it.

An MRI shows anatomy. Arthroscopy shows behaviour, and the two do not always agree — which is why part of the operation is diagnostic even when the plan is already made.

Whether the tissue is repairable. A tear on a scan is a shape. Under the camera the surgeon can see whether the tendon edge is healthy enough to hold a stitch, how far it has pulled back, and whether it will reach its footprint on the bone without excessive tension. A repair pulled tight against resistance is a repair under strain from day one.

Whether something else is contributing. Shoulders frequently have more than one thing wrong. Biceps tendon pathology alongside a cuff tear is common, and if it is left unaddressed it can remain a pain source after an otherwise sound repair.

Where the joint is being pinched. Impingement is dynamic — it happens through movement. Taking the arm through range while watching from inside shows what is actually catching, which a static scan cannot.

The state of the cartilage. This is often the finding that changes expectations. Established cartilage wear alongside the problem being repaired means the repair addresses one source of symptoms while another remains.

Shoulder recovery is slower than patients expect and the reason is specific: a repair holds tissue against bone and biology has to knit them together. Until that happens the stitches are all that is holding it, and stitches fail under load. Every restriction below follows from that.

Stage one — protection. The arm is supported in a sling and the shoulder is moved only by someone else, or by the patient's other arm. The repair is intact but not yet biologically attached, and active use pulls exactly where healing is trying to happen. Most patients feel able to do more than they are allowed to, which is the hardest part of this stage.

Stage two — regaining motion, passively. Range is restored before strength, and deliberately so. A shoulder left completely still stiffens, and stiffness is far harder to fix afterwards than weakness. Motion in this stage is guided rather than driven by the shoulder's own muscles.

Stage three — active motion. The shoulder starts moving under its own power against gravity. This is usually when patients notice how much strength was lost, which is normal and expected rather than a sign of failure.

Stage four — strengthening. Loading begins once the repair is considered biologically secure. This stage rebuilds the rotator cuff and the muscles that control the shoulder blade, which is what determines how the shoulder feels a year later rather than a month later.

Stage five — return to demand. Overhead work, lifting and sport are added last, in that order of difficulty.

Where no repair was performed — a debridement or a decompression alone — the sequence compresses considerably, because nothing has to heal to bone.

Two shoulders having the same operation can recover very differently, and the reasons are mostly identifiable in advance.

Tear size and tendon quality. The single biggest factor. A small tear in healthy tendon behaves differently from a large one in tissue that has been degenerating for years, and where the muscle has already changed character the repair is working against biology rather than with it.

How long the shoulder was stiff beforehand. A shoulder that had lost range before surgery is more likely to stiffen after it, which is why some surgeons treat the stiffness first and operate later.

Smoking and diabetes. Both measurably affect tendon-to-bone healing. Smoking is the one most within a patient's control.

Doing too much, too early. The commonest self-inflicted setback. The shoulder feels usable well before the repair is secure, and quietly resuming normal one-handed tasks loads the repair repeatedly without it ever feeling like an injury.

Doing too little. The opposite failure, and less discussed. Protecting a shoulder past the point where motion should be reintroduced produces stiffness that then takes months to unwind.

The pattern that recovers best is a patient who respects the early restrictions precisely and then engages seriously with the progression once cleared — which is why the rehabilitation plan matters as much as the operation.