Rotator Cuff Surgery And What To Expect After SurgeryWednesday, January 23, 2013 - 16:00
To read whether one needs or should have surgery for a rotator cuff tear go to Rotator Cuff Tear - Do You Need Surgery?
Surgery for rotator cuff tear is usually performed under general anesthesia, where the patient is asleep. Sometimes a regional (or local) anesthetic is used to block the nerves leading to the arm. In that case, the patient is conscious but cannot feel pain. Usually a sedative is also given, putting the patient in a conscious but dreamy state.
Rotator cuff surgery usually takes one to two hours, sometimes less.
The repair of the rotator cuff is done either by an ‘open repair’ (through a skin incision to expose the rotator cuff) or by keyhole surgery (better termed arthroscopic surgery). The trend today is toward keyhole surgery. More and more cuff repairs are being done this way. Sometimes, if the tear is not amenable to repair by keyhole surgery then an open repair will be done (for example if the surgeon feels the tear is to big to be dealt with arthroscopically).
If performed arthroscopically (keyhole surgery):
Arthroscopic surgery is a technique for performing an operation using pen-shaped instruments with a miniature video camera attached to the end. It is "keyhole" surgery.
The surgeon makes a number of small incision in the shoulder about the size of a buttonhole.
The video camera and specialized surgical instruments are inserted into the shoulder through these small incisions.
The surgeon performs the operation while watching on a video screen.
Because arthroscopic surgery requires only limited surgical access, the incision is much smaller than is necessary for open surgery, resulting in fewer risks. The patient's recovery time is also shorter.
However, because repairing a torn rotator cuff can sometimes be a complicated procedure, especially with very large tears, it is often performed as an open procedure or the arthroscopy is combined with an open procedure. Most rotator cuff tears can be repaired by arthroscopic surgery.
To read in detail about arthroscopic surgery of the shoulder go to Arthroscopy Of The Shoulder.
If performed by open repair:
This surgery involves several key steps:
In order to gain access to the injured rotator cuff, the surgeon makes a two- to three-inch incision in the shoulder, then cuts through the deltoid muscle.
The surgeon removes any scar tissue that has built up on the damaged tendon (or tendons).
The surgeon carves a small trough at the top of the upper arm, then drills small holes through the bone.
Finally, the surgeon re-attaches the tendon to the bone, with the sutures or special ‘anchor’ sutures going through the tiny holes in the upper arm. (Sometimes a surgeon will use permanent anchors to attach the tendon to bone.) The edges of a partial tear may simply be re-approximated and held with sutures.
During surgery (whether arthroscopic or open), the surgeon may also shave a small portion of bone from the underside of the acromion, thus thinning the acromion bone and giving the rotator cuff tendons more room to move and preventing them from being pinched (as described on the previous page). For similar reason the nearby ligament may also be divided (cut). The surgeon also removes any bone spurs (that may have developed from degenerative arthritis affecting the nearby acromio-clavicular joint) and may clear any inflammation affecting the nearby swollen or irritated bursa.
The part of the procedure where the bone is thinned is called an acromioplasty or a subacromial decompression
This same surgery (but without the repair of the rotator cuff) may be offered to relieve symptoms of a chronic tendinitis that does not respond to nonsurgical treatment, or for symptoms of impingement, even without a tear of the rotator cuff.
Following the surgery, the patient's arm is placed in a sling. Patients usually go home the same day (but may remain in hospital a day or two following open surgery). With time, healing occurs, as scar tissue connects the tendon to bone. Because tendons receive such poor blood supply, healing is a slow process.
What To Expect After Surgery
Returning to normal life after rotator cuff surgery is a gradual process. Walking is encouraged immediately. Lifting must be avoided during the first 3 months, (heavier lifting longer than that), and overhead lifting of heavy loads using the operated arm may need to be avoided perhaps forever.
The majority of people who have had rotator cuff surgery, though, can perform most everyday tasks with relatively little discomfort within about three months of having surgery.
The arm will remain in a sling for up to 12 weeks (depending on what was found and done at surgery). The physical therapist will teach you various exercises – see below. You will not be allowed to raise your arm above shoulder level during the first 3 months after surgery (earlier for some, again dependent on what was found and done at surgery). If you do the surgical repair is likely to break down. While in the sling you must move your elbow regularly to avoid it becoming stiff.
During the first twelve weeks after surgery, it's important to follow two basic principles:
Perform physical therapy exercises regularly. Moving the surgically repaired arm as shown to you by the physical therapist is crucial to prevent scarring and stiffness.
Strictly control activity when not exercising. Be extremely careful not to lift the surgically repaired arm away from the body. Don't use it to push or pull anything.
The arm should always be kept in the sling when you are standing or walking. When sitting or lying awake in bed, you can release the sling without removing it. The sling should be worn at night until satisfactory control of the arm is regained. Remove the sling only to exercise or take a shower.
The injured arm should be used only for exercise. It's okay to use the hand for writing, eating, or drinking, as long as the arm is moved only at the elbow and wrist. Under no circumstances should the injured arm be used to reach for or lift something. It should not be lifted above the head or moved away from the body.
You should not keep the shoulder stiff (i.e. not move it at all) as otherwise it could get stiff from early scarring inside the joint. Stiffness may cause discomfort and limit the ability of the shoulder to function. Ice should be applied to the shoulder after exercising.
Once the sutures are removed, you can shower without covering the incision. The arm should be supported while taking a shower.
Don't drive for at least six weeks after surgery, usually for 12 weeks, or until the sling is discontinued. Driving with one arm is unsafe, and the surgically repaired arm shouldn't be moved away from the body. It's also easy to re-injure the shoulder in an accident or an emergency stop.
Call your physician immediately if you notice that the wound is red or warm, or if you develop a fever. Also call if you notice fluid draining from the wound, or if the pain is intolerable.
The pain and discomfort that led to rotator cuff surgery should improve gradually' noticeably by three to four weeks after surgery, but allow up to 12 weeks.
Your surgeon will have prescribed anti-inflammatories and pain killers which you may need to take for the first few weeks following surgery.
Physical Therapy (physiotherapy; rehabilitation)
Physical therapy plays an extremely important role in the recovery process. Physical therapy is crucial to recovering the flexibility and strength of the injured shoulder after surgery.
A physical therapist teaches the patient exercises designed to help regain flexibility and strength in the injured shoulder.
You need to take physical therapy seriously. Appropriate exercises will continue to improve strength and flexibility in the surgically repaired shoulder.
Most patients begin physical therapy before leaving the hospital. The physical therapist is an educator. The therapist's role is to teach the patient appropriate exercises that can be done safely at home to speed the recovery process. The therapist will work with the patient in the clinic while doing the exercises, making sure they are being done safely, properly and obtaining maximum benefit from each exercise.
Because physical therapy can be difficult and physically demanding, therapists usually like to meet with members of the patient's family in the hospital so they can learn to help the patient with physical therapy at home.
The early exercises during the first few weeks after surgery are called passive exercises, where someone else (the physical therapist, a family member, or your good arm) moves the injured arm.
After that you begin doing active exercises when you begin to move the shoulder without assistance.
Please continue reading about the types of shoulder exercises that are needed after a rotator cuff repair
When To Return To Work?
Whether and when you return to work will depend mostly on your occupation.
Some people who have had rotator cuff surgery and work at desk jobs can return to their old jobs within a week or two.
Others may need to wait 3 to 6 months depending on the type of job and the demands of the job (lifting, heavier lifting)
Others have to find a new line of work as a result of having rotator cuff surgery. People who work in a job that involves heavy overhead lifting will be encouraged to find another type of work. People who need to climb or use heavy tools may also need to consider another job.
When To Play Sports Again?
Because many sports put pressure on the shoulder and rotator cuff, it is extremely important not to play sports before the shoulder has adequately healed. The timing for return to each sport depends on:
The nature of the sport
The extent of the original injury
How well the repaired tendons have healed
The individual's progress in physical therapy
Walking (with the surgically repaired arm in a sling) is a healthful exercise that can be started immediately after surgery.
Other activities require a longer wait:
Swimmers and runners should wait at least three months before returning to action. Swimmers should ask their doctors whether the surgically repaired shoulder is strong enough to do the crawl. It may need 6 months to a year depending on what was found at surgery.
Bowling and throwing requires at least a four- to six-month recovery period. Golfers should also wait four to six months before resuming play. When they return, they should start slowly, with putting and chipping. As the surgically repaired shoulder grows stronger, they can hit soft iron shots. Driving off the tee should be the last thing to attempt. Again, some patients may be told by their doctor to wait between 6 months to a year before returning.
Sports that place a great deal of strain on the shoulder, such as tennis, baseball, softball, and racquetball, require at least a six-months (sometimes up to a year) recovery period.
Falling likewise puts enormous strain on the surgically repaired rotator cuff. Individuals who have had rotator cuff surgery should wait at least a year before participating in sports like football, hockey, downhill skiing, and wrestling.
Lifting heavy weights also requires at least a yearlong recovery period. Following repair of a full thickness tear a patient may be advised to avoid overhead heavy lifting forever.
Every case of course is unique and so the doctor and physical therapist will advise accordingly. Do Listen.
Talk to your surgeon or physical therapist before attempting any sport after rotator cuff surgery.