Rotator Cuff Repair

Anatomy

Your shoulder has numerous muscles and tendons controlling movement and stability of the shoulder.

Fig 1: The rotator cuff tendons

Stacks Image 1874
 
Among these are the tendons of the rotator cuff. The rotator cuff is composed of four tendons that blend together to help stabilise and move the shoulder. The rotator cuff is the collective term for a group of tendons, which includes the supraspinatus, infraspinatus, teres minor, biceps and subscapularis (Fig 1). These tendons pass under a bony-ligamentous arch.

Loss of integrity of the rotator cuff is a common cause of shoulder weakness. Those patients with large rotator cuff defects have difficulty raising the arm or rotating it out towards the side.
What causes problems with the rotator cuff?
Problems can arise within the rotator cuff when it is:
  • Irritated, bruised or frayed.
  • Weak—the bursa is swollen or the bony arch angles too far down.
  • Calcium deposits form within it.
  • Torn—either partially or completely.

Irritation, bruising or fraying of the tendons can occur with repetitive use of the arm (e.g. when carrying heavy luggage or during sports like golfing and tennis). When the tendons are inflamed but not torn then it is called tendinitis. The pain is primarily from the inflamed tendons being rubbed by the bony ligamentous arch. This can also result in a bursitis, where the bursa above the tendons also becomes irritated and swollen which causes pain. The biceps tendon can also become frayed or unstable and may require treatment at the same time.

Tearing of the rotator cuff can occur when these tendons become irritated and swollen and eventually wear out or else they can occur as a result of a major force (e.g. direct injury). Most tears have some degree of preceding wear changes. Any accidents or injuries that might occur at work, sport or a fall may precipitate a tear of these weakened tendons.

Tears of the rotator cuff tendons occur with increasing frequency as the population gets older. It is unusual for a patient younger than 40 years to have a tear whereas up to 50% of patients over the age of 75 years have a tear in one or other rotator cuff tendon. A tear of the rotator cuff does not always have to be painful.

What are the symptoms?

The most common symptoms which cause a patient to seek medical advice are:
  • pain;
  • weakness, and
  • inability to raise the arm.

How is a diagnosis made?

In determining the diagnosis it is most important to take a thorough history from the patient and also to examine them to assess their range of motion and ability to use and raise their arm. After this, one or more of the following tests may be ordered—a plain X-ray, ultrasound or MRI in order to assess the condition of the bones, tendons and ligaments.

How are these problems treated?

In patients who have an acute rupture of their rotator cuff after a fall, surgical management is generally indicated to restore function to the arm, however the majority of rotator cuff tears are degenerative in nature and occur over time. These ones rarely require surgery and are best managed with non-operative management.

Non-operative treatment includes:
  • Physiotherapy (stretches/strengthening).
  • Anti-inflammatory medication.
  • Activity modification.
  • Cortisone (steroid) injections.

If this does not help in reducing the pain or if there is poor shoulder function then surgery may be recommended. For those patients with a rotator cuff tear, a rotator cuff repair is performed. If a patient with a rotator cuff tear does not have surgery, then the tendon tear may, in some cases, increase in size. For others the shoulder may continue to function reasonably for many years.

When rotator cuff tears are relatively recent and when a significant force was required to tear the tendon, the chances of regaining shoulder strength by rotator cuff surgery are good. Conversely, when the defect is longstanding and occurred without a major injury, the quality and quantity of tissue available for repair may not be sufficient for the restoration of good shoulder function.
The goal of the surgical repair of the rotator cuff defect is to establish the connection between the torn tendon and the bone. If the tendon heals securely and durably to the bone, the force of the muscle can be effectively transmitted to the arm. This subsequently decreases pain and increases the strength of the arm.

How is the operation done?

Biceps tenodesis:
This operation involves re-anchoring the biceps in a better position to stop it slipping out of its groove or becoming irritated.
Rotator Cuff Repair:
The purpose of the surgery is to reattach the torn tendon back to the bone.

Under a general anaesthetic, the arthroscope is firstly introduced into the shoulder joint and all pathology is identified. Any surgery that can be done through the arthroscope is done at that time. With small to medium sized tears and good quality tendon the repair can be done through the arthroscope through 3 or 4 separate small incisions. (Fig 2)

Black lines are the patient’s bony anatomy landmarks. The solid red lines represent incisions for arthroscopy and arthroscopic rotator cuff repair. The dotted red line shows the mini open incision we use for larger rotator cuff tears and biceps tensodesis.
If however the tendon tear is large, I prefer to repair the tendon through a small incision 3 to 4 cm long at the side of the shoulder. This is called a mini open repair and gives excellent exposure of the tendon. The outcome and rehabilitation of an arthroscopic repair or mini open repair is no different and the result of rotator cuff surgery really depends on the quality of the tendons at the time of the repair. The rotator cuff tear is then repaired by suturing it back to the bone using stitches and bone anchors. All tears are different and a variable number of sutures and bone anchors can be used. An example is illustrated in Fig 3. The operation involves coming into hospital for one night.
Stacks Image 2009
Fig 2: Anatomy landmarks. 
Stacks Image 2011
Fig 3: sutures and bone anchors.

What happens after surgery?

Healing of the repaired tendon is slow and the loads applied to the tendon when doing normal activities are large, therefore protection of your repair is required for many months (at least six months) after the repair. Even the best surgical repair is too weak to allow the muscle to raise the arm from the side. One must wait for full healing of the tendon before actively lifting their arm unassisted.

Having said that, it is important to reduce the risk of scarring and adhesions within the shoulder and this is done by early passive motion of the arm. This means that the shoulder may be moved using the other arm for support, but the muscles of the repaired shoulder must not be used to lift the arm or rotate it against resistance for fear of disrupting the repair.

These passive, rehabilitating exercises will be taught to you at your first post-operative visit. This is usually one week after your surgery. During this time we encourage you to come out of your sling while at home so that you can begin to gradually and gently use your arm. As soon as you are comfortable, you can begin to do up shirt buttons, cut up your food, write and work on a keyboard i.e. any activities that are at desk or table level. You must not raise your arm that has been operated on at all or lift anything heavier than the weight of a full coffee cup/can of drink with this arm. Always put your sling on when you go out.

It is important to realise that the tendons that were initially torn and then repaired may be of poor quality. While a satisfactory repair can usually be performed at the time of surgery there is the possibility that the tendon repair may fail and pull apart. This may occur during the rehabilitation period or even later if an excessive load is placed onto the shoulder. If this occurs, there is a possibility that repeat surgery is required.

Occasionally the torn tendons are scarred and shortened, or there may not be enough tissue to close the defect. Under these circumstances it may be preferable to clean up the frayed edges of the tendon, and leave all or part of the defect unrepaired. It is still very likely that the shoulder will become comfortable, though strength and function may not be as good as expected. In these circumstances, the inflamed bursa will be excised which can make a big difference in pain relief.

Complications related to the surgery can occur but are quite rare. A general anaesthetic is used and there are risks related to this. Some of the risks include infection, nerve and blood vessel damage. Occasionally the shoulder may develop some transient stiffness called capsulitis. This usually resolves itself however it delays the time taken till the shoulder recovers.

Despite surgery, it is always difficult to re-establish a shoulder to 100% working condition. Although a repair can be performed, the tendon may not be of perfect quality, causing mild pain and weakness overhead in the long term. The majority of patients are generally happy after undergoing such a procedure. It is important to note that it can take up to six months to achieve the desired result.

What happens on the day of the operation?

When the staff at the Orthopaedics WA book you in for surgery, they will advise you of when you must fast (stop eating and drinking) and present at the hospital. These times may change and you will be notified by either the hospital or Orthopaedics WA a day or two before the surgery of any changes.
At the hospital, you will be seen by your anaesthetist who will ask questions about your health and talk to you about the anaesthetic he/she will give you.

Once in the operating suite, your shoulder may be shaved/hair clipped and the area “prepped” with chlorhexidine. The anaesthetic nurse will place ECG electrodes (stickers with gel on them) on your chest and a blood pressure cuff on your arm. The anaesthetic is administered through a small needle in the back of the hand/arm. This sends you to sleep quickly.
The operation to repair a rotator cuff tear takes about 60–75 minutes, however you will probably be away from the ward for about two-and-a-half hours as there is usually a short wait before the surgery and then when the operation is over you will be cared for in the recovery room for some time before returning to the ward.

In the recovery room, a nurse will be there at all times. You will have a drip in your arm, an oxygen mask on your face and your arm will be in a sling. You will remain in the recovery room until the staff are satisfied that your condition is stable and your pain is controlled. This is usually about an hour.

What happens when I get back to the ward?

When you return to the ward you will have:
  • a drip in your arm;
  • your arm in a sling, and
  • regular pain relief.

The nurses are going to check on you very regularly especially during the next four hours. They will check your pulse, blood pressure, temperature, number of breaths you are taking, and your dressing. They will also ask if you are comfortable.
There are a variety of methods of pain relief in use these days and it will be your anaesthetist who prescribes your analgesia. Regardless of the type of pain relief prescribed, it is wise to have something for pain regularly in order to avoid highs and lows in your pain management.

You will be able to drink and eat as soon as you are awake and alert. The regular checking will continue overnight so please do not be concerned and think there is something wrong.

What happens during the rest of my stay in hospital?

You will be given regular pain relieving tablets (usually Panadeine Forte, Digesic or oxycodone). It is important to have these regularly in order to keep your pain at a tolerable level to enable you to move about and exercise. The codeine in some tablets can make you constipated however it is wiser to avoid or treat the constipation rather than going without the pain relievers. This can be done by drinking at least eight glasses of water or juice per day (tea and coffee do not count), eating a high-fibre diet including fresh fruit and vegetables each day and walking around rather than confining yourself completely to bed. Mild laxatives are available should you feel you need them.

What can I expect at home?

An Orthopaedics WA nurse (Silvana is Mr Gohil’s nurse) will call you within a couple of days of coming home. While the main purpose of the call is to check that all is going well, this is also an opportunity to ask any questions and also to confirm your follow-up appointment to have your stitches taken out.

For those patients who come from the country, it may be more convenient to have your stitches removed by your local doctor.
 
See the frequently asked questions about shoulders. Also see the Related links on this page.
 

Rehabilitation Following Rotator Cuff Repair

(Modified from Rehabilitation of the Rotator Cuff: J Am Acad Orthop Surg 2006)
Mr. Satyen Gohil, Orthopaedics WA

Phase 1: Immediate postoperative period (weeks 0–6)

Avoid:
  1. Shoulder AROM
  2. Lifting of objects
  3. Shoulder motion behind back
  4. Excessive stretching or sudden movements
  5. Supporting of any weight including body weight

Keep incision clean and dry for first two weeks.
Exercises
  1. Finger, wrist, and elbow AROM
  2. Begin scapula musculature isometrics and cervical ROM
  3. Ice for pain and inflammation
  4. Begin PROM to tolerance, should be reasonably pain free
  5. May do general conditioning program, (i.e. walking, stationary bicycle, etc).
  6. Hydrotherapy/pool therapy may begin 3–4 weeks postoperative
  7. Sling/ abduction brace.

  • Continue full-time until end of week 4.
  • Between weeks 4 and 6, use for comfort only.
  • Discontinue at end of week 6.
Minimal Tension Repair
  • Sling may be removed 3-5 times per day for exercises and while resting.
  • Commence gentle passive elevation using the opposite hand to support the limb. Aim for full elevation of the arm by week 4.
  • Gentle passive external and internal rotation aiming for 50% of range by week 4 and 100% by week 6.
  • NO repetitive pendulum. Perform pendulums for washing your underarm, drying yourself etc.
  • NO abduction or extension strengthening exercises.
  • Active elbow flexion/extension strengthening exercises unless biceps surgery is performed.
Cuff Repair Under Tension (Massive Rotator Cuff tears)
  • Brace must NOT be removed at any time in the first 3 weeks.
  • Continue with full-time sling/brace until end of week 6.
  • Patient may commence gentle passive elevation of the operated limb above the level of the pillow, aiming for full arm elevation by the end of Week 6.
  • May also undertake gentle passive external rotation.
  • Active elbow flexion/ extension strengthening exercises unless biceps surgery is performed.

Phase 2: Protection and active motion (weeks 6–12)

Avoid:
  1. Lifting from the shoulder
  2. Supporting body weight with hands and arms
  3. Sudden jerking motions
  4. Excessive behind the back movements.
Exercises
  1. Begin AAROM flexion in supine position
  2. Continue PROM until approximately full
  3. Gentle scapular/glenohumeral joint mobilisation as indicated to regain full PROM
  4. Initiate prone rowing to neutral arm position
  5. Continue ice as needed
  6. Hydrotherapy OK for light AROM exercises.
Minimal Tension Repair
  • Patient may remove sling for increasing periods through the day as tolerated, and eventually discard it.
  • Continue range of motion programme for elevation, external and internal rotation, beginning with gravity eliminated and progressing to work against gravity.
  • Gentle abduction exercises only. Full abduction is not important at this stage.
Cuff Repair Under Tension
  • Sling is gradually removed for increasing periods during the day from about four weeks. Initially done with the patient supine and when the arm is comfortable at the side then patient may sit or stand.
  • Continue range of motion programme for elevation and external rotation.
  • When arm is able to be left out of sling then begin passive internal rotation.
  • At about 8 weeks introduce active assisted movement in elevation and internal/external rotation.
  • NO abduction exercises active or passive.

Phase 3: Early strengthening (weeks 10–16)

Avoid sudden lifting or pushing activities, sudden jerking motions, overhead lifting exercises.
Exercises
  1. Dynamic stabilisation exercises.
  2. Start strengthening program.
  3. ER and IR with exercise bands.
Minimal Tension Repair
  • Work towards full active range of elevation, external and internal rotation.
  • Continue terminal stretching and introduce the full cuff stretching programme including posterior and inferior stretches gradually.
  • Begin resistance strengthening.
  • Avoid repetitive overhead use of the arm.
  • Gentle active abduction but no resistance work in this arc.
Cuff Repair Under Tension
  • Work toward a full range of active elevation, external and internal rotation.
  • Continue terminal stretching and introduce the full cuff stretching programme including posterior and inferior stretches gradually.
  • Begin resistance at strengthening using Theraband (Yellow – Green – Black).
  • Avoid repetitive overhead use of the arm.
  • Gentle active abduction but no resistance work in this arc.

Phase 4: Advanced strengthening (weeks 16–22)

Exercises
  1. Continue stretching if motion is tight.
  2. Continue progression of strengthening.
  3. Advance proprioceptive, neuromuscular activities.
Light sports (golf chipping/putting, tennis ground strokes) if doing well.
 
See the frequently asked questions about shoulders. Also see the Related links on this page.