Rotator Cuff Repair
Anatomy
The Rotator Cuff is made up of the tendons of the 4 muscles of the Rotator Cuff. These tendons surround and attach onto the ball (humeral head) of the ball and socket shoulder joint.
The Rotator Cuff muscles are responsible for both motion of the shoulder and stabilising the ball in the socket joint during shoulder movements.
With a torn rotator cuff the ball is not centred in the socket and this can lead to pain, weakness and loss of motion. The most superior of these is the Supraspinatus tendon and is the most commonly torn Rotator Cuff Muscle.
Rotator Cuff Tear
Rotator Cuff Tear is the detachment of the tendon from the insertion on the ball portion of the Shoulder Joint.
This can occur from trauma / injury and can also occur as a natural part of ageing.
Once a Cuff Tear occurs it has no ability to heal.
Symptoms
Rotator Cuff tears can cause pain and weakness. Some cuff tears are painful and others are not. The reason behind why the tear is painful in some people and others not is a difficult question to answer. We believe it is due to the fact that the ball cannot be centred on the head. During shoulder motion the ball (humeral head) shears upwards – this leads to a crushing or impingement of the torn tendon on the bone of the shoulder blade above the shoulder joint.
The classic symptoms of rotator cuff tear are shoulder pain felt anterolaterally in the shoulder often with radiation into the arm. This will be made worse with use of the arm above shoulder height. Patients often have a painful arc on forward elevation of their arm, this can often be worse with descent of the arm. Patients often note clicking / crunching (crepitus) in the shoulder when they lift the arm.
Sleep is often disturbed and can be very distressing. Weakness is often noted and can range from mild to an inability to elevate the arm at all.
Treatment – Surgery or Non Operative
Some tears can be treated non – operatively with a combination of analgesics, cortisone injections and physiotherapy. If non-operative measures fail or are not suitable for your tear then surgery may be indicated.
Generally surgery is indicated if the symptoms of pain, loss of function, weakness and interference with activities of daily living continue.
In general younger, active patients with physical jobs or recreational activities that demand shoulder strength are excellent candidates for surgery.
The requirement for surgery is decided on for each individual case. The surgical success of Rotator Cuff Repair is well documented in the Orthopaedic literature with good to excellent results.
Timing of Surgery
Surgical Repair of the Rotator Cuff is best undertaken sooner rather than later.
There is a window of opportunity where Rotator Cuff Tear will be technically easier to perform. This is window highly variable.
If a tendon tear is left too long the tendon retracts and loses elasticity.
The muscle attached to the tendon undergoes fatty atrophy. This means the muscle fibres are replaced with fat. This fatty degeneration of the muscle is irreversible. This means you cannot rebuild this muscle even if the tendon is successfully attached. Once there is more muscle than fat in the muscle belly then Rotator cuff repair is not indicated
Surgery
Surgery is under a General anaesthetic and an Interscalene Block (local anaesthetic injection to the neck). A diagnostic arthroscopy is first undertaken to confirm the presence of a tear. The arthroscope enables the surgeon to look both inside and on top of the shoulder and assess any other abnormalities that may impact on the results of surgery.
The tendon tear is cleaned up and scar tissue released. The area above the tendon is usually decompressed to make sure there is adequate room for the tendon to move post surgery – often a small amount of bone is removed form the shoulder blade above the tear.
Next depending on the size, configuration and mobility of the tear it will be repaired either through a small traditional surgical incision (mini open technique) or through several small incisions (arthroscopic technique). The tendon is reattached to bone using small suture anchors embedded in the bone.
Arthroscopic (Keyhole) vs Mini Open Techniques.
Currently the literature reports that both surgical techniques are equivalent in terms of the patients end result. Neither technique enables the tendon to heal faster to its insertion on the bone.
I perform both techniques. The decision as to which technique is utilised is decided intra-operatively. If the tear reduces back to its anatomic insertion with ease then Arthroscopic Surgery is performed. If the tear configuration is more complex or difficult to reduce then I perform a Mini Open Repair.
Neither technique allows the patient to recover, rehabilitate, or return to work faster. It is important to understand that the operation performed in terms of repairing the tendon is the same whether you have a single incision or several smaller incisions.
Complications
The major complication is re-tear and the chance of this depends on the size of the tear.
Other complications are the risk of infection and shoulder stiffness.
Nerve damage is very rare. Blood clots are extremely rare following shoulder surgery.
On occasions patients may require a second operation for complications. This occurs in around 5 % of patients. It is important I review your progress regularly post operation.
Rehabilitation
Following surgery you will stay overnight or sometimes be discharged the same day. A sling must be worn for 4-6 weeks. You must wear the sling all the time even at night.
Never in the first 4-6 weeks while in the sling lift your arm upwards this contracts the muscles that will pull on the tendon that has been repaired.
This period of rest is required so the tendon attaches back to its insertion.
The tendon requires time to reattach to the area of bone it has torn from. The period of immobilisation depends on the size and quality of the tendon tear. After this rehabilitation begins.
There are 3 phases to this.
- Phase I – Regaining passive motion (gravity eliminated)
- Phase 2 – Regaining active motion (you use your muscles to move the shoulder)
- Phase 3 – Strengthening
It is important not to start strengthening (therabands) until you are cleared for phase 3. This is usually at 10 to 12 weeks post surgery. I see you at 10-12 weeks post surgery and clear you for strengthening.
Recovery Time
It takes on average 6 months to recover from Rotator cuff repair. Improvements continue in the 2 years post surgery.
Return to manual work is variable for every case. Generally speaking light duties at 3-4 months and full duties at 6-9 months.
Driving is not allowed while in a sling. After that once you are comfortable and confident you can begin to drive, it is generally 6 weeks before this occurs for most patients.
After your sling is removed and you commence physio – the next 6 weeks are the hardest in your rehabilitation. It is normal to have some pain in this period but it should decrease with time.
- At about 3 months you will feel as if your recovery is really starting to move forward.
- Between 4 and 6 months post op most patients will improve markedly.
Generally at 6 months you will be discharged. Some patients do take longer to recovery and will continue to be monitored.
The Day Of Surgery
- I see you pre-operation and check consent and mark the site we will operate on
- Later that day if your block is working and you are pain free you will be discharged if your operation was in the morning. Patients having their surgery in the afternoon stay overnight
- Clean waterproof dressings are placed prior to discharge
- Post operative wound check appointment will be organised
- You are given as required Post Operative Physiotherapy Protocol
ACC 18 / Off Work certificate ACC 41 / Physio referral
Wound Check
7-14 days post surgery the dressings will be changed and stitches removed by my practice nurse and sometimes me
- The waterproof dressings placed at discharge should last till this appointment
1st 4 - 6 weeks post Operation
- Wear your sling at all times, even sleeping. - Do not elevate / lift your arm up as this will stress the tendon and may destroy the operative repair
- You can bend your elbow and use your arm without damaging the repair - You can shower with waterproof dressings
4 - 6 weeks post operation
- Your physiotherapy can begin. - The first 6 weeks of physio is aimed at regaining motion.
- THE 1st 6 WEEKS OF PHYSIO IS THE HARDEST PART OF YOUR REHABILITATION, SOME DEGREE OF DISCOMFORT IS NORMAL - Do not start strengthening until 10-12 weeks post surgery.
1st post operative visit
- 6-8 weeks post surgery
- This is approximately 1 - 2 weeks after you have begun physiotherapy
2nd post operative visit
- 3 months post surgery - Most people have recovered by now and can be discharged
- Some patients need a few more months and another follow up visit is arranged
3rd post operative visit
- 6 months post surgery
- Discharge if recovered
- Further follow up as required
Arthroscopic & Open Techniques
Rehabilitation guidelines
Please read operation note for any alterations to guidelines
Day 1
- Cryocuff on ward +/- Interscalene block
- Rest in sling/brace – size of tear may determine type
Posture, elbow, wrist and hand exercises
Day 2
- Discharge / physio referral for 4 – 6 weeks post op analgesia
- Explanation re: importance of no active movement remain in sling ( outside clothes)
4-6 weeks (depending on state of cuff and size of tear)
- Maintain thoracic and cervical spine mobility
- Smaller tears may start pendular exercises check operation note
2 weeks
- Shoulder rehab clinic / process explained
- Stitch removal and wound check shoulder girdle posture, wrist elbow, hand check
- Remain in sling
4 – 6 weeks
- Mobilising begins / commence phase I and early phase II
- Encourage analgesia to do exercises
- Remove sling at 4- 6 weeks and wear as comfort requires
10-12 weeks
- Strengthening starts / continue with phase I and II
- Commence phase III – therabands / physio supervision as required
- Encourage activities daily living
3 – 6 months
- Continue home exercise program gradually increase strengthening return to full function
6 - 12 months
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