Rotator Cuff Repair (Shoulder)

Rotator Cuff Repair

What is the rotator cuff?

 The rotator cuff is a group of four tendons and the related muscles that stabilise the shoulder joint and allow you to raise and rotate your arm. The shoulder is a ball-and-socket joint with three main bones: the upper arm bone (humerus), the collarbone (clavicle), and the shoulder blade (scapula). These bones are held together by muscles, tendons, ligaments, and the joint capsule. The rotator cuff helps keep the ball of the arm bone seated into the socket of the shoulder blade.

Why rotator cuff repair may be needed.

Impingement – When you raise your arm to shoulder height, the space between the acromion and rotator cuff narrows. The acromion can rub against (or “impinge” on) the tendon and the bursa, causing irritation and pain.

Rotator cuff tear – When one or more of the rotator cuff tendons is torn, the tendon no longer fully attaches to the head of the humerus. Most tears occur in the supraspinatus muscle and tendon, but other parts of the rotator cuff may also be involved.

In many cases, torn tendons begin by fraying. As the damage progresses, the tendon can completely tear, sometimes with lifting a heavy object.

There are different types of tears.

  • Partial Tear. This type of tear damages the soft tissue, but does not completely sever it.
  • Full-Thickness Tear. This type of tear is also called a complete tear. It splits the soft tissue into two pieces. In many cases, tendons tear off where they attach to the head of the humerus. With a full-thickness tear, there is basically a hole in the tendon.

Non-surgical options.

Most patients suffering from impingement or a small tear can get back to good function in their shoulder by changing their activities along with a physiotherapist supervised exercise program.  You may have to modify your activities to restrict any above shoulder movements.

Simple painkillers such as paracetamol and anti-inflammatories can also help.

A steroid and local anaesthetic injection into your shoulder can sometimes help with pain but these may cause side effects if repeated too often.

When to proceed with surgery

Surgery to repair a rotator cuff is done when:

  • A rotator cuff tear is caused by a sudden injury. In these cases, it’s best to do surgery soon after the injury.
  • A complete rotator cuff tear causes severe shoulder weakness.
  • The rotator cuff has failed to improve with 3 to 6 months of conservative nonsurgical treatment alone (such as physical therapy).
  • You need full shoulder strength and function for your job or activities, or you are young.
  • You are in good enough physical condition to recover from surgery and will commit to completing a program of physical rehabilitation.

What does the operation involve?

You may need to have an ultrasound scan or MRI scan of your shoulder to assess the damage to your rotator cuff.  The results of this scan will help the surgeon decide what type of surgery is best for you.

Shoulder surgery is generally performed under a general anaesthetic and requires an overnight stay in hospital.  You may be given antibiotics during the operation to reduce the risk of infection.  A nerve block may also be administered in theatre to assist with postoperative pain relief.

Surgery to repair a torn rotator cuff tendon usually involves:

  • Removing loose fragments of tendon, bursa, and other debris from the space in the shoulder where the rotator cuff moves (debridement).
  • Making more room for the rotator cuff tendon so it is not pinched or irritated. If needed, this includes shaving bone or removing spurs from the point of the shoulder blade.
  • Sewing the torn edges of the supraspinatus tendon together and to the top of the upper arm bone (humerus).

 

Types of surgery

 This surgery can be done in two different ways:

Arthroscopy

If possible your surgeon will use the keyhole technique as this is associated with less pain, scarring and a faster return to normal activities.

The surgeon will make three or four small incisions at the front and back of your shoulder and on the side of your upper arm.  Surgical instruments will then be placed through these cuts along with a camera (scope) so they can see inside your shoulder to perform the repair.

Your surgeon will use these instruments to remove any thickened tissue, release any tight tissue and shave off some bone to enable more room for your rotator cuff to move.  This procedure is called subacromial decompression.

Your surgeon may be able to repair rotator cuff tears using the keyhole surgery as long as the tear is not too extensive.  You will have an overnight stay in hospital.

 

Open surgery

In open shoulder surgery, a surgeon makes an incision in the shoulder to open it and view the shoulder directly while repairing it. A smaller incision can be done with a mini-open procedure that allows the surgeon to reach the affected tendon by splitting the deltoid muscle. This method may reduce your chances of problems from a deltoid injury.

Open-shoulder surgery often requires a short stay in the hospital.

What To Expect After Surgery

After your rotator cuff repair surgery you will be one handed for a period of time and will need to think about how you will do certain tasks when you return home from the hospital.

Discomfort after surgery may decrease with taking pain medicines prescribed by your doctor.

The arm will be protected in a sling for a defined period of time, especially when at risk of additional injury.

Any stitches or clips are removed 10 – 14 days after the operation – usually in our offices at Bridge Road.

Physical therapy after surgery is crucial to a successful recovery. A rehabilitation program may include the following:

  • As soon as you awake from anesthesia, you may start doing exercises that flex and extend the elbow, wrist, and hand.
  • The day after surgery, if your doctor allows, passive exercises that move your arm may be done about 3 times a day (a machine or physical therapist may help the joint through its range of motion).
  • Active exercise (you move your arm yourself) and stretches, with the assistance of a physical therapist, may start 6 to 8 weeks after surgery. This depends on how bad your tear was and how complex the surgical repair was.
  • Strengthening exercises, beginning with light weights and progressing to heavier weights, can start a few months after surgery.

Risks

After rotator cuff surgery, a small percentage of patients experience complications. In addition to the risks of surgery in general, such as blood loss or problems related to anesthesia, complications of rotator cuff surgery may include:

  • Nerve injury. This typically involves the nerve that activates your shoulder muscle (deltoid).
  • Infection. Patients are given antibiotics during the procedure to lessen the risk for infection. If an infection develops, an additional surgery or prolonged antibiotic treatment may be needed.
  • Deltoid detachment. During an open repair, this shoulder muscle is detached to provide better access to the rotator cuff. It is stitched back into place at the end of the procedure. It is very important to protect this area after surgery and during rehabilitation to allow it to heal.
  • Stiffness. Early rehabilitation lessens the likelihood of permanent stiffness or loss of motion. Most of the time, stiffness will improve with more aggressive therapy and exercise.
  • Tendon re-tear. There is a chance for re-tear following all types of repairs. The larger the tear, the higher the risk of re-tear. Patients who re-tear their tendons usually do not have greater pain or decreased shoulder function. Repeat surgery is needed only if there is severe pain or loss of function.

Rehabilitation

Rehabilitation plays a vital role in getting you back to your daily activities. A physical therapy program will help you regain shoulder strength and motion.

Immobilisation

After surgery, therapy progresses in stages. At first, the repair needs to be protected while the tendon heals. To keep your arm from moving, you will most likely use a sling and avoid using your arm for the first 4 to 6 weeks. How long you require a sling depends upon the severity of your injury.

Passive Exercise

Even though your tear has been repaired, the muscles around your arm remain weak. Once your surgeon decides it is safe for you to move your arm and shoulder, a therapist will help you with passive exercises to improve range of motion in your shoulder. With passive exercise, your therapist supports your arm and moves it in different positions. In most cases, passive exercise is begun within the first 4 to 6 weeks after surgery.

Active Exercise

After 4 to 6 weeks, you will progress to doing active exercises without the help of your therapist. Moving your muscles on your own will gradually increase your strength and improve your arm control. At 8 to 12 weeks, your therapist will start you on a strengthening exercise program.

Expect a complete recovery to take several months. Most patients have a functional range of motion and adequate strength by 4 to 6 months after surgery. Although it is a slow process, your commitment to rehabilitation is key to a successful outcome.

 

This document is intended for information purposes only and should not replace advice that your relevant health professional would give you. 

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