Rotator Cuff Tear

What Is The Rotator Cuff? What is a Rotator Cuff Tear?

The term “rotator cuff” refers to a group of  4 muscles in the shoulder that attach to the upper aspect of the humerus bone in the upper arm. The muscles connect to the bone by tendons, which are tough stringy tissues. The tendons of the 4 rotator cuff muscles combine to form the rotator cuff tendon.

The 4 tendons are named the supraspinatus, infraspinatus, subscapularis and teres minor tendons.They function to raise and rotate the arm

A tear of the rotator cuff can occur to any one of these 4 tendons. Most commonly it is the supraspinatus tendon that tears. When the tendorn tears it is tearing off its attachment to the bone. The muscle may also be involved.

The rotator cuff converges into a tendon that inserts onto the bone

Tears of the rotator cuff are probably the commonest of shoulder problems.

A healthy shoulder is the most versatile joint in the human body. It has a wider range of motion, able to more freely, and in more directions, than any other joint. The shoulder’s versatility enables us to retrieve soup cans from the cupboard, to hammer nails, swing golf clubs, roll bowling balls, and perform thousands of other activities.

The shoulder’s flexibility is due to its unique structure. Like the hip, the shoulder is a “ball-and-socket” joint – a “ball” at the top of the upper arm bone (the humerus) fits neatly into a “socket” formed by the shoulder blade (scapula).

But unlike the hip joint, where the ball sits in a deep, well-protected socket, the shoulder socket is very shallow. So the soft tissues surrounding the shoulder are most important in maintaining the stability of the shoulder. The rotator cuff tendons help to stabilize the shoulder joint and turn the arm outward and inward.

The rotator cuff tendons are particularly susceptible to wear and tear over time, and hence susceptible to injury, due to the way the rotator cuff tendons pass across the shoulder to the upper arm (see below).

Most rotator cuff problems therefore develop over time. Over a period of years, the rotator cuff can become increasingly damaged as part of its normal function (“chronic degeneration”), and may become susceptible to tearing, either partially or completely.

Why does the rotator cuff tear?

Ordinarily, the rotator cuff tendons move freely in the space between the top of the upper arm and a part of the shoulder blade known as the acromion, which overhangs the rotator cuff. The space is an arch (formed by the acromion bone, the coracoid bone and the ligament connecting these bones, the coracoacromial ligament). But in some people, this space may be inadequate to allow the normal smooth gliding movements of the rotator cuff as it moves the arm. This may be simply due to the different shape of the acromion (more slopy than normal and so lessening the space ), or due to degenerative changes that may affect the acromio-clavicular joint, which sits just above the rotator cuff; bony spurs may develop (as part of the degenerative changes) and irritate the underlying rotator cuff. Or there could be anatomical anomalies (for example an accessory bone called the os acromiale).

So when the arm is raised the rotator cuff is “pinched” between the two bones, and with time increasing damage occurs to the tendons (‘repetitive trauma to the tendon as it is squashed in the narrow space (the arch). This may result in inflammation of the tendons (“tendonitis”) and with time degenerative changes develop in the rotator cuff tendons. This makes these tendons vulnerable to tearing if one injures the shoulder (for example in a fall), and sometimes even if no injury occurs.

This is the reason that tears of the rotator cuff are more commonly seen as we get older (ie the commonest cause of a rotator cuff tear is degeneration of the cuff as we age). Trauma (from a fall, injury or sport injury) are much less common causes of a tear.

3 stages of degeneration of the tendon are recognized.

  • Stage I –  the tendon is swollen and bruised. This is the common finding in under 25 year olds.
  • Stage II – the tendon is inflamed (tendonitis) with the presence of scar tissue (‘fibrosis’).  This is the common finding in 25- to 40-year-olds.
  • Stage III – the tendon is torn, either a partial or full-thickness tear. This is common in those over 40 years old.

The early shoulder symptoms that develop from the friction occurring to the rotator cuff (and ultimately what could develop later into a tear of the rotator cuff), are known as the condition called  impingement (the rotator cuff impinges against the bony prominences as the arm is elevated).

 

Shoulder impingement

Rotator cuff tears can also occur suddenly, usually after a forceful movement of the shoulder; for example from a heavy fall onto an outstretched hand, or from a sudden forceful overhead throwing movement, or when lifting a heavy object above the head.  But usually if the rotator cuff does tear following a sudden injury of this type it is often found that the person was susceptible to a tear occurring even though they may never have suffered shoulder symptoms before (the same mechanism of injury in another person may not have resulted in a tear of the rotator cuff).

Rotator cuff tears may also occur as part of another injury to the shoulder for example if the shoulder dislocates, or the clavicle (collarbone) fractures, or the long head of biceps tendon tears. 

Types of Rotator Cuff Tear:

There are various types of tears of the rotator cuff: 

  • If the tear extends through the full thickness of the tendon then it is called a “full thickness tear”.
  • If the tear does not penetrate the full thickness of the tendon then it is called a “partial thickness tear”.
  • If the affected tendon becomes detached from its attachment site to the bone then it is a “detached tear”
  • If the tear of the cuff is huge then it is referred to as a ‘massive’ tear.

These differences are important as the treatment and type of surgery offered differs for the different types of tear.

Any type of tear of the rotator cuff can cause pain in the shoulder. The pain may be minimal (or there may be no pain) or severe. The severity of the pain does not always correlate with how bad the tear is. Movement of the shoulder may be very restricted, particularly trying to lift the arm above the level of the shoulder. The arm may feel weak.

Tears that develop over a long period of time, essentially due to the degenerative changes that increasingly affect the tendon, are called chronic tears.

Repeatedly performing a strenuous task with the shoulder such as throwing a baseball, or repetitive overhead heavy lifting can contribute to the degeneration of the rotator cuff in susceptible people (said to cause ‘repetitive microtrauma to the cuff’)

What Is Rotator Cuff Tendinitis?

The term tendinitis refers to an inflammation of the rotator cuff that generally occurs as a result of impingement or overuse. Tendinitis bothers some people for a time and then seems to disappear. Their symptoms vary greatly, depending on several factors, the most important of which is how they use the affected shoulder or shoulders.

Some the tendonitis develops as a result of calcium deposits occuring in the tendon (we don’t really know why). This can  be very painful (or may not be painful at all). It is called a calcific tendonitis. 

What Is Shoulder Bursitis?

bursa (plural bursae) is a soft, fluid-filled sac that helps to cushion and lubricate joints. In the shoulder, there are bursae located between the rotator cuff and the overlying bone (acromion) or beneath the deltoid muscle. When a bursa becomes irritated or inflamed, it causes bursitis. Pain and swelling of the joint often accompany bursitis. Not uncommonly, a bursitis may develop when the rotator cuff is inflamed (tendonitis) or torn.

 

Facts about rotator cuff injury

  • About 6 million people in the U.S. seek medical care each year for shoulder problems.
  • Shoulder problems account for about 1.5 million visits to orthopedic surgeons each year in the U.S.
  • Rotator cuff tear is a common problem for people over age 40.

 


What Are The Symptoms Of A Rotator Cuff Tear?

The most common symptoms of a rotator cuff tear are pain and weakness of the shoulder. The pain may be constant, or felt only when reaching or attempting to raise the arm overhead or lift something above shoulder level. Sometimes, particularly with a complete tear of the rotator cuff, one may hardly be able to lift the arm  from one’s side.

People with rotator cuff tears often experience pain at night because sleeping in certain positions puts pressure on the shoulder. In some people, the injured shoulder makes popping or clicking sounds when moved. For others, the shoulder seems to stick momentarily.

How severe the pain is for a rotator cuff tear does not always correlate with how bad the tear is (see previous page). For some people the pain may be just minimal while for others the pain may be severe. Some people experience no pain at all. Thus, some people with just a small tear or a partial thickness tear of the rotator cuff may experience marked pain while others with a large tear or full thickness tear may experience little pain. Commonly though a large tear is more painful. But not uncommonly a partial thickness tear may be more painful than a full thickness tear.

Q: Are there any early warning signs of a rotator cuff tear?

A: Many people experience weakness, pain, swelling, and/or stiffness in the shoulder long before the rotator cuff actually tears. That’s because, while some rotator cuff tears happen suddenly as a result of a fall or injury, most develop gradually, as a result of wear-and-tear on the rotator cuff.

If these early warning signs are heeded, specific steps can be taken to attempt to resolve the symptoms without surgery. That’s why it’s important to see a doctor if you suffer pain in the shoulder or are unable to properly use the shoulder.

How are Rotator Cuff Tears Diagnosed?

Physicians use a variety of tests to diagnose and evaluate the severity of a rotator cuff tear. These include:

Physical examination
X-ray
Magnetic resonance imaging (MRI)
Ultrasound

Physical Examination:

The doctor will (and should) do the following:

Inspect the shoulder for tenderness, muscle wasting, swelling and the general contour of the shoulder.
Assess range of motion of the shoulder and at what height the pain commences
Look for signs of weakness, instability, and pain during specific movements. Some of these simple tests are designed to figure out whether the rotator cuff is being pinched between the upper arm bone and the acromion (impingement).
Assess the strength of resisted movements of the shoulder and if these type of movements are painful
Possibly inject an anesthetic, or painkiller, into the injured shoulder in an attempt to localize the problem (is the pain coming from the rotator cuff or possibly from another area of the shoulder). The degree of pain relief or change in movement after the injection may help determine the nature of the problem.

X-ray:
Because x-rays do not show soft tissue such as tendons, they cannot show whether or not the rotator cuff is torn. X-rays are used to rule out other causes of shoulder pain, particularly arthritis (osteo or degenerative arthritis) of the nearby acromio-clavicular joint which may be a contributory cause to the shoulder pain or even a contributory cause to the tear of the rotator cuff. Degenerative arthritis affecting the acromio-clavicular joint can result in formation of bone spurs which can irritate the underlying rotator cuff.

The x-ray can also show whether the space between the humerus (arm bone) and the acromion has narrowed, which would suggest that the rotator cuff is not functioning normally (maintaining downward pressure on the humerus). X-rays can also reveal the presence of calcium deposits, bone spurs, or previous fractures. In longstanding severe rotator cuff tears the x-ray may show advanced degenerative changes of the main shoulder joint with the head of the humerus  ‘riding high’ (because of the loss of the normal depressor function of the rotator cuff).

 
Magnetic Resonance Imaging (MRI)
:
Magnetic resonance imaging (MRI) scan is one of the most powerful diagnostic tools available to doctors. An MRI scan uses magnetic waves and computers to create detailed images of the interior of the shoulder. An MRI can reveal even small, partial tears of the rotator cuff. An MRI is painless and has, for the most part, replaced the arthrogram for the diagnosis of rotator cuff tears.

For more information about MRI, go to MRI.

Sometimes the physician may opt to inject dye into the shoulder joint before doing the MRI scan. This is called an MRI arthrogram. One will get better pictures and learn a lot more about the shoulder joint (if there is a tear the dye will be seen leaking through the tear). An MRI arthrogram is commonly used to determine if there is a tear of the labrum (another soft tissue in the shoulder related to the stability of the shoulder joint) rather than to investigate rotator cuff tears.

Ultrasound:
Ultrasound tests use sound waves to examine the inside of the shoulder. This is now commonly used to diagnose a tear of the rotator cuff. It is not as sensitive or as reliable as an MRI scan.

An ultrasound scanner emits harmless waves; the returning echoes are recorded by a computer which produces an image of the part of the body scanned.

For more information about ultrasound, go to Ultrasound.

 

 
 
 

Treatment for Rotator Cuff Tear – Do You Need Surgery?

If a rotator cuff tendon has torn completely, it usually will not heal completely without surgery. Whether a doctor actually recommends surgery, however, will depend on several factors, including:

  • The extent of the injury
  • If the pain has not responded to simple conservative treatments
  • The person’s age and general health
  • How much the symptoms affect overall function of the shoullder
  • And most importantly to what extent the persons day to day activities are affected

Usually surgery is recommended in the following circumstances:

  • The rotator cuff was torn as the result of an acute injury, accident, dislocation, or fracture .
  • The torn rotator cuff results from chronic degeneration (wear and tear) and does not respond to medication, physical therapy, and other nonsurgical treatments.
  • Ongoing pain or weakness in the injured shoulder interferes with a person’s ability to perform necessary tasks.

Age itself does not determine whether someone is a good candidate for surgical repair of a torn rotator cuff. But if someone is elderly, and the injury affects his or her non-dominant arm, doctors are more likely to recommend non-surgical treatment. As many as half of all patients with a full rotator cuff tear regain enough strength and flexibility to avoid surgery.

Very large tears – “massive tears” – may be very difficult to repair, or sometimes cannot be repaired, particularly with longstanding very large tears. The torn tissues are so degenerate they cannot hold the sutures, or the gap may be too large to bring the torn edges close together, or the tendon may have retracted (pulled back) too far from the bone making it impossible to re-attach it to the bone.

Nonsurgical Treatments:

Nonsurgical treatments of rotator cuff injuries include:

  • Rest. The first step in treating any rotator cuff problem is to rest the injured joint until the pain and swelling subside.
  • Ice. In the first 24 hours after an injury, ice can help reduce pain and swelling.
  • Heat. After 24 hours have passed, a heating pad or hot compress can help an injured rotator cuff to heal.
  • NSAIDS (non-steroidal anti-inflammatory drugs). NSAIDS such as aspirin and ibuprofen can reduce both pain and swelling. Be careful to take NSAIDS as instructed, since they sometimes can produce stomach upset and gastrointestinal problems.
  • Physical therapy/exercise. Many rotator cuff problems can be successfully treated with gentle exercises designed to stretch and strengthen the shoulder muscles. Usually, it’s best to begin physical therapy as soon after an injury as is possible. Avoid lifting heavy weights overhead, and avoid activities such as throwing a baseball that put a significant amount of stress on the tendons.
  • Steroids. Steroids such as cortisone may be used to reduce inflammation. Steroids can be taken orally, but for rotator cuff problems they are usually injected directly into the area around the tendon. Steroid injection should be used carefully and multiple injections should be avoided.

What Are The Risks Of Rotator Cuff Surgery?

Every operation involves some element of risk. But most people do well and are pleased with the results of rotator cuff surgery (over 80% do well).

Complications are rare and include:

  • A very small number of surgical patients react adversely to anesthesia. For such patients the risk would be the same for any surgical procedure (patients who are obese, or who have heart disease, high blood pressure, or diabetes are at a higher risk;  rarely allergic reactions to anesthetic agents may occur.
  • Infections can occur as a result of any operation. The risk of infection for rotator cuff surgery  is relatively low especially if done by keyhole surgery.
  • There is  an extremely small risk of injury to a major nerve that cross near the shoulder that may result in partial paralysis or loss of feeling. Some people experience numbness in the vicinity of the shoulder incision, but this usually is temporary.

Not everyone with a rotator cuff tear needs surgery. Many do not. Surgery is never urgent.    Surgery need not be done immediately following an injury. So early treatment is usually conservative  to see how the patient will do on conservative treatment. For some patients this is very successful and so surgery will not be required.

Surgery for Rotator Cuff Tears

Surgical repair of a completely torn or partially torn rotator cuff  may be performed as “open” surgery, requiring a two- to three-inch incision in the shoulder, but now more commonly, depending on the experience of the surgeon it is done by keyhole surgery (arthroscopic surgery) in which a video camera and surgical instruments are inserted through a few small incision about the size of a buttonhole (2 to 4 small incisions – the width of a pencil). Some surgeons prefer to sometimes use a combination of arthroscopic and open surgical techniques.

Rotator cuff surgery can be performed under general anesthesia (with the patient asleep) or regional anesthesia (with the patient awake.)

Preparing For Surgery

Before undergoing surgery, a variety of routine tests are performed to make sure one is fit for surgery. These usually include blood tests, chest x-rays, an EKG (electrocardiogram), and urinalysis.

Patients are usually admitted to the hospital on the day of their scheduled operation. Sometimes people with particular health problems, such as diabetes, heart disease or lung disease, are admitted a day early.

The anesthesiologist visits the patient before surgery to discuss the type of anesthetic that will be used.

  • Rotator cuff surgery is usually  performed under general anesthesia, with the patient asleep during the procedure.
  • Frequently, 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 used, putting the patient in a conscious but dreamy state.
  • The choice of anesthetic is based on the type of surgery that is planned, as well as the patient’s health and personal preferences.

You should not eat or drink anything after midnight on the day before the procedure. This includes water. A completely empty stomach reduces the risks associated with anesthesia.

Also, you should make sure that both the surgeon and anesthesiologist know in advance about all medications you are taking – even aspirin. Both physicians should also be told about any allergies you might have.

 

 
 
 

Surgery for Rotator Cuff Tears and What To Expect After Surgery

Do I Need Surgery?

If a rotator cuff tendon has torn completely, it usually will not heal completely without surgery. Whether a doctor actually recommends surgery, however, will depend on several factors, including:

  • The extent of the injury
  • If the pain has not responded to simple conservative treatments
  • The person’s age and general health
  • How much the symptoms affect overall function of the shoullder
  • And most importantly to what extent the persons day to day activities are affected

Not everyone with a rotator cuff tear needs surgery. Many do not. Surgery is never urgent.      Surgery need not be done immediately following an injury. So early treatment is usually conservative  to see how the patient will do on conservative treatment. For some patients this is very successful and so surgery will not be required.

Usually surgery is recommended in the following circumstances:

  • The rotator cuff was torn as the result of an acute injury, accident, dislocation, or fracture .
  • The torn rotator cuff results from chronic degeneration (wear and tear) and does not respond to medication, physical therapy, and other nonsurgical treatments.
  • Ongoing pain or weakness in the injured shoulder interferes with a person’s ability to perform necessary tasks.

Age itself does not determine whether someone is a good candidate for surgical repair of a torn rotator cuff. But if someone is elderly, and the injury affects his or her non-dominant arm, doctors are more likely to recommend non-surgical treatment. As many as half of all patients with a full rotator cuff tear regain enough strength and flexibility to avoid surgery.

Very large tears – “massive tears” – may be very difficult to repair, or sometimes cannot be repaired, particularly with longstanding very large tears. The torn tissues are so degenerate they cannot hold the sutures, or the gap may be too large to bring the torn edges close together, or the tendon may have retracted (pulled back) too far from the bone making it impossible to re-attach it to the bone.

Nonsurgical Treatments:

Nonsurgical treatments of rotator cuff injuries include:

  • Rest. The first step in treating any rotator cuff problem is to rest the injured joint until the pain and swelling subside.
  • Ice. In the first 24 hours after an injury, ice can help reduce pain and swelling.
  • Heat. After 24 hours have passed, a heating pad or hot compress can help an injured rotator cuff to heal.
  • NSAIDS (non-steroidal anti-inflammatory drugs). NSAIDS such as aspirin and ibuprofen can reduce both pain and swelling. Be careful to take NSAIDS as instructed, since they sometimes can produce stomach upset and gastrointestinal problems.
  • Physical therapy/exercise. Many rotator cuff problems can be successfully treated with gentle exercises designed to stretch and strengthen the shoulder muscles. Usually, it’s best to begin physical therapy as soon after an injury as is possible. Avoid lifting heavy weights overhead, and avoid activities such as throwing a baseball that put a significant amount of stress on the tendons.
  • Steroids. Steroids such as cortisone may be used to reduce inflammation. Steroids can be taken orally, but for rotator cuff problems they are usually injected directly into the area around the tendon. Steroid injection should be used carefully and multiple injections should be avoided.

What Are The Risks Of Rotator Cuff Surgery?

Every operation involves some element of risk. But most people do well and are pleased with the results of rotator cuff surgery (over 80% do well).

Complications directly related to the surgery are rare but include:

  • A very small number of surgical patients react adversely to anesthesia. For such patients the risk would be the same for any surgical procedure (patients who are obese, or who have heart disease, high blood pressure, or diabetes are at a higher risk;  rarely allergic reactions to anesthetic agents may occur.
  • Infections can occur as a result of any operation. The risk of infection for rotator cuff surgery  is relatively low especially if done by keyhole surgery. 
  • Post operative shoulder stiffness – this is dealt with by physical therapy should it occur.
  • There is  an extremely small risk of injury to nerves that cross near the shoulder (suprascapular nerve, axillary nerve) that may result in loss of feeling around the shoulder or shoulder weakness. Some people experience numbness in the vicinity of the shoulder incision, but this usually is temporary.
  • Recurrent tear of the rotator cuff – if the cuff is completely torn and difficult to repair, it may tear again. Newer methods of repair have been developed in an attempt to prevent this.

Surgery for Rotator Cuff Tears

Surgical repair of a completely torn or partially torn rotator cuff  may be performed as “open” surgery, requiring a two- to three-inch incision in the shoulder, but now more commonly, it is done by keyhole surgery (arthroscopic surgery) in which a video camera and surgical instruments are inserted through a few small incision about the size of a buttonhole (2 to 4 small incisions – the width of a pencil). 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 successfully be dealt with arthroscopically).

Rotator cuff surgery can be performed under general anesthesia (with the patient asleep) or regional anesthesia (with the patient awake.)

Preparing For Surgery

Before undergoing surgery, a variety of routine tests are performed to make sure one is fit for surgery. These usually include blood tests, chest x-rays, an EKG (electrocardiogram), and urinalysis.

Patients are usually admitted to the hospital on the day of their scheduled operation. Sometimes people with particular health problems, such as diabetes, heart disease or lung disease, are admitted a day early.

The anesthesiologist visits the patient before surgery to discuss the type of anesthetic that will be used.

  • Rotator cuff surgery is usually  performed under general anesthesia, with the patient asleep during the procedure.
  • Frequently, 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 used, putting the patient in a conscious but dreamy state.
  • The choice of anesthetic is based on the type of surgery that is planned, as well as the patient’s health and personal preferences.

You should not eat or drink anything after midnight on the day before the procedure. This includes water. A completely empty stomach reduces the risks associated with anesthesia.

Also, you should make sure that both the surgeon and anesthesiologist know in advance about all medications you are taking – even aspirin. Both physicians should also be told about any allergies you might have.

Rotator cuff surgery usually takes one to two hours, sometimes less.

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, either debriding the torn tendon or re-attaching the tendon to the bone held by special anchor sutures.

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 (“subacromial decompression” or “acromioplasty”), thus thinning the acromion bone and giving the rotator cuff tendons more room to move and preventing them from being pinched.  . 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.

This same surgery (subacromial decompression)  may be offered to relieve symptoms of a chronic tendinitis (when the tendon is not torn but inflamed) 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 may 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. You will not be told not 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 may possibly 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.

Pain Relief

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

Exercises For The Rotator Cuff

and

What To Expect After Shoulder Arthroscopy

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.

 
 
 

Complications of Rotator Cuff Surgery

Most individuals recover well and are extremely pleased with the results following rotatar cuff surgery. But complications can occur.

In addition to the risks associated with any major surgical procedure (for example, complications associated with anaesthesia, deep vein thrombosis and infection), there are a number of complications that are unique to rotator cuff surgery. They include:

  • Stiffness of the shoulder
  • Re-injury of the rotator cuff
  • Failed rotator cuff repairs

Stiffness

Shoulder stiffness is a major complication of rotator cuff surgery. Sometimes post-operative stiffness is caused by problems that existed before surgery. Sometimes it relates to the surgery itself. More often, it results from  failure to move the arm adequately after the operation.

If the affected arm isn’t moved sufficiently in the weeks after surgery, excess scar tissue can build up. That’s why it’s so important to begin physical therapy soon after surgery (in line with instruction from the surgeon and physical therapist) and to continue performing the exercises regularly.

If aggressive rehabilitation does not alleviate stiffness, a second operation may be necessary. Sometimes a surgeon can increase flexibility by moving the joint under anesthesia. In other cases, the surgeon must operate to remove the scar tissue that is limiting the shoulder’s flexibility. Removing scar tissue also reduces pain related to stiffness.

Re-Injury Of The Rotator Cuff

Some individuals try to do too much too soon after having rotator cuff surgery. Overzealousness can result in re-tearing the surgically repaired tendons. The rotator cuff can also tear a second time because of an inherent weakness in the tendon or bone.

Failed Rotator Cuff Repairs

If the rotator cuff tears a second time, a second operation may be necessary. Repairing a torn rotator cuff a second time is much more difficult. Half of all rotator cuffs that tear a second time cannot be repaired again. In that case, a surgeon might trim the torn edges of the damaged tendon, remove scar tissue, and remove any bone spurs that remain.

Recent research suggests, however, that even individuals who tear a rotator cuff a second time after surgery are better off than they were before the operation. In one study, most patients were stronger, had more flexibility, and reported feeling less pain after the second injury than before the initial surgery. The second tears were usually smaller than the one that first led to surgery.

Some individuals who have had rotator cuff surgery that has failed will be considered for a shoulder joint replacement. This will not be the usual shoulder joint replacement but what is called a ‘reverse joint replacement’. It is a technically more difficult procedure and should only be done by a shoulder surgeon who has experience with this operation if it is to succeed. For a normal shoulder replacement to work the rotator cuff needs to be functioning reasonably normally. The reverse shoulder replacement allows the shoulder to function without the normal action of the rotator cuff (relying on the deltoid muscle).

 

 

Exercises After Surgery For a Rotator Cuff Tear

Here are  commonly recommend exercises after rotator cuff surgery.

Your physical therapist generally would have shown you and taught you specific exercise.

Physical therapy exercises should be performed at least three and preferably five times every day. Each exercise should be repeated 10 to 15 times, with the number of repetitions gradually being increased. Positions should be held for a three to five seconds.

The initial goal of physical therapy is to restore the full range of motion to the surgically repaired shoulder.

There are two types of physical therapy exercises:

  • In passive exercises, the arm that was operated on is moved by the physical therapist, a family member, or the patient’s healthy arm. They are designed to restore flexibility (range of motion) to the injured shoulder. Passive exercises are performed during the early weeks of recovery.

  • During active exercises, a person moves the injured arm and shoulder without outside assistance. These exercises are done after muscles and tendons have had time to heal.

Physical therapy can be very difficult. Though some pain and stiffness are to be expected, tell your physical therapist and/or physician if you experience marked pain.

It may take up to  9 to 12 months to fully recover from the surgery (i.e. for the shoulder to have recovered to optimal situation expected after the surgery)

 

Beginning Exercises

 

  • Forward elevation of the arm. This exercise is performed while lying on the back. It’s designed to move the surgically repaired arm through its full range of motion.

Begin with the injured arm laying at your side and your elbow straight.

  • The physical therapist slowly lifts the injured arm, moving it through a 180-degree arc, until it is alongside your head. You should use your uninjured arm to lift the arm on which you had surgery. In this way you can perform your exercises without the need for assistance.

  • Don’t use the muscles of the surgically repaired arm to perform this exercise. Also, don’t arch your back. Keep the elbow straight.

  • External rotation. Lie on your back with the elbow of your surgically repaired arm resting by your side on a small pillow or folded towel. Hold the injured arm so that the elbow is bent at a 90-degree angle and the hand is pointed towards the sky. Grasp a dowel or stick in both hands and use your good arm to push the injured arm outward, away from your body. Stop when you feel the arm stretching.

  • Elbow flexion and extension. Sit in a chair with your surgically repaired arm out of the sling. Keeping your elbow against your side, slowly flex and extend your injured arm so that you are moving the elbow joint through its full range of motion. This is an active exercise; use the muscles of the injured arm to do it.

  • Grip exercises. While sitting, squeeze a rubber ball. For this exercise, keep the surgically repaired arm in a sling. Keep the elbow at your side. This exercise helps to maintain strength in your muscles. It also helps to reduce swelling.

 

Advanced Exercises

 

Starting around six to eight weeks after surgery, physical therapists usually recommend several new exercises. These include active range of motion exercises, in which the muscles of the surgically repaired arm are used to move the shoulder through its entire range of motion.

Some exercises simply stretch the shoulder. Strengthening exercises begin later and involve stretching rubber bands or lifting light weights TO STRENGTHEN the rotator cuff and shoulder muscles.

Perform these exercises five times a day, repeating each one 10 to 15 times. Your physical therapist will give you goals and instruct you on how to increase the number of repetitions or the amount of weight you lift.

As with the beginning exercises, although you may experience some discomfort and pain, you should tell your doctor and physical therapist if you feel sharp or severe pain.

  • Internal rotation. Bend your surgically repaired arm behind your back and place your thumb against the base of your spine. Slide this thumb slowly up your backbone and down again.

If necessary, hold one end of a towel with the hand that is behind your back and the other end above your head with your good arm. Use the uninjured arm to lift the injured arm.

  • Cross-body adduction. Hold your surgically repaired arm in front of you at shoulder level with the elbow straight. Move this arm across your body, towards the uninjured shoulder. To stretch the injured shoulder more, use your healthy arm to pull the injured arm across your body.

 

Strengthening Exercises

 

  • External rotation. Attach one end of a piece of long rubber tube to the knob of a closed door. (Your physical therapist will give you the tubing or tell you where to buy it.)

    • Stand perpendicular to the door, with your healthy arm nearer to it.

    • Hold the elbow of your injured arm at your side and bend at a 90-degree angle.

    • Grab the free end of the rubber tube in the hand of your surgically repaired arm and pull the tube outward, away from your body.

    • Hold the rubber tube so that it’s taut enough to provide resistance.

  • Internal rotation. Attach the rubber tube to the doorknob, as in the external rotation exercise described above.

    • Once again stand perpendicular to the door, but turn around so that your injured arm is closer to the door.

    • Hold the elbow of your injured arm at your side and bend at a 90-degree angle.

    • Grab the free end of the rubber tube in the hand of your surgically repaired arm and pull the tube inward, towards your body.

    • Hold the rubber tube so that it’s taut enough to provide resistance.

  • Pressing. Lay on your back with your surgically repaired arm to your side, at shoulder height and aimed away from your body. Hold a light weight in your hand. Keeping your injured arm straight, slowly lift the weight until your arm is pointed towards the sky.

 
 
 

Rotator Cuff Tear – Glossary

Here are definitions of medical terms related to rotator cuff injury.

Acromion: A portion of the shoulder blade (scapula) that overhangs the rotator cuff and humerus (upper arm bone).

Acromioplasty: An operation in which the surgeon removes bone spurs and other abnormalities and widens the space between the rotator cuff and the acromion, or shoulder blade. Also called impingement surgery or subacromial decompression.

Arthroscopy: A technique in which the surgeon makes a small incision, then inserts a thin tube that contains a miniature video camera and surgical instruments. Doctors can sometimes perform arthroscopic, rather than open, surgery to repair rotator cuff problems.

Ball-and-socket joint: A joint in which the ball-like end of one bone fits into a cavity, or socket, of another. Human beings have two types of ball-and-socket joints – the hip and the shoulder. Because of their structure, ball-and-socket joints are more flexible than other joints, most of which act like hinges, moving back and forth in one plane.

Bone spurs: Abnormal bone growths.

Bursa: (Plural bursae) A soft, fluid-filled sac that helps to cushion and lubricate soft tissue surfaces that glide over one another. In the shoulder, bursae are located between the rotator cuff and the acromion.

Bursitis: Chronic irritation or inflammation of a bursa (plural bursae), a soft, fluid-filled sac that helps to cushion and lubricate soft tissue surfaces. In the shoulder, bursae are located between the rotator cuff and the acromion.

Cartilage: Smooth, elastic tissue that acts as a cushion between bones.

Humerus: The upper arm bone. The four tendons of the rotator cuff connect muscles of the shoulder to the humerus.

Impingement: A defect of the shoulder in which the space between the acromion and rotator cuff narrows and pinches the rotator cuff tendons. Impingement is the most common cause of rotator cuff problems, including rotator cuff tears.

Impingement surgery: An operation in which the surgeon removes bone spurs and other abnormalities and widens the space between the rotator cuff and the acromion, or shoulder blade. Also known as acromioplasty or subacromial decompression.

Ligaments: Strong, flexible, bands that connect bones to each other.

Passive exercise: An exercise in which a joint is moved without using the muscles that ordinarily control the joint. Passive exercise is an important part of rehabilitation from rotator cuff surgery because it helps to prevent the buildup of scar tissue.

Range of motion: The full spectrum of a joint’s possible movements. The shoulder joint has a greater range of motion than any other joint in the human body.

Rotator cuff: A collective term for the four tendons that connect muscles of the shoulder blade to the upper arm bone (humerus).

Scapula: The shoulder blade. A hollow cavity at the end of the scapula forms the “socket” of the shoulder joint. A part of the scapula known as the acromion overhangs the rotator cuff.

Subacromial decompression: An operation in which the surgeon removes bone spurs and other abnormalities and widens the space between the rotator cuff and the acromion, or shoulder blade. Also known as acromioplasty or impingement surgery.

Tendinitis: Chronic swelling or inflammation of tendons due to overuse or irritation; a common problem affecting the shoulder.

Tendon: A stringy tissue that connects muscle to bone. Four tendons collectively form the rotator cuff.

 

Rotator Cuff Tear: Additional Sources Of Information

Here are some reliable sources that can provide more information on rotator cuff injury.

The american Orthopaedic Society for Sports Medicine (AOSSM) 
http://www.sportsmed.org

American Academy of Orthopaedic Surgeons 
Phone: 847/823-7186 or
Phone: 800/346-AAOS
http://www.aaos.org.

The University of Washington has excellent information about the shoulder, including video clips and a self-assessment test for shoulder injuries, available on its Web site: 
http://www.orthop.washington.edu/shoulder/shoulder.htm

American Family Physician – “Management of Shoulder Impingement Syndrome and Rotator Cuff Tears,” February 15, 1998. 
http://www.aafp.org/afp/980215ap/fongemie.html

“Four Exercises to Strengthen the Muscles of Your Rotator,” 
http://familydoctor.org/handouts/265.html

 

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