Rotator Cuff Tear

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.

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.

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.