Rotator Cuff Tears and Repair

What is it?

The rotator cuff is a group of tendons of 4 muscles that move and stabilise the shoulder. The integrity of the cuff is vital to normal function; any injury may result in pain and/or weakness and restriction of function.

Shoulder anatomy

The rotator cuff is found under the acromion (roof of the shoulder), and may be damaged by a bony spur that protrudes from the undersurface of the acromion (sub-acromial impingement). Alternatively, the tendon tissue itself may undergo degenerative change with age, which results in increased vulnerability to injury either through mild injury or overuse

Thus, a tear of the rotator cuff can occur through trauma (e.g. shoulder dislocation), attrition (sub-acromial impingement) or the natural ageing process of the tendon. They are more common in patients over 40 yrs of age.

Tears can be partial or complete. Complete tears result in tendon retraction away from where the tendon should attach on the humeral head and therefore, complete rotator cuff tears don’t heal spontaneously. Partial tears may become less symptomatic with physiotherapy and analgesia, but also may not heal or even become complete tears if the cause is not removed (i.e. bony spur). It should be noted that initial attrition related injury starts with inflammation (tendonitis) of the tendon, which through continued injury, progresses to a tear.

Massive rotator cuff tears are those that have retracted more than 5cm (seen on a Ultrasound or MRI scan) and are more common in the older person (>60yrs); frequently, they occur in the setting of a degenerative tendon and atrophied muscle. They are difficult to repair; if a repair is possible, a high failure rate is recognised and thus alternatives exist (see below).

Who should have rotator cuff repair?

The most important fact is that tears that do not cause pain or disability do not need surgical treatment.

Rotator cuff tears are intially treated with analgesia, typically anti-inflammatories if tolerated and physiotherapy. Ocassionally a cortisone injection may be considered.

Surgery is considered if non-operative treatment fails; it aims to relieve pain and improve function. Sustained physiotherapy post-operatively, is paramount to the success of rotator cuff repair.

As aforementioned, some tears (massive) may be irreparable. Options for treatment of massive tears include:

  • Deltoid strenthening and compensation – the deltoid muscle is conditioned to take over the function of the rotator cuff.
  • Arthroscopic sub-acromial decompression and debridement of tendon +/- biceps tenotomy – this is very effective in relieving pain and can be combined with deltoid conditioning to provide good results
  • If the massive tear is associated with arthritis of the joint then a special joint replacement called a reverse shoulder replacement may be considered.

Will I need any tests/scans?

It is likely that X-rays and an Ultrasound scan will be requested for potential rotator cuff tears. MRI maybe requested if any concomitant intra-articular pathology is suspected. Please see the section Surgery FAQs to see if you will need any other tests e.g. blood tests before your surgery.

How is it done?

Rotator cuff repair can be done using shoulder arthroscopy. The procedure is carried out under general and/or regional anaesthesia.

It aims to reattach the torn tendon to its bony origin located on the humeral head. It is achieved using bone anchors (usually biodegradeable devices which can be fixed into the bone with very strong sutures attached). Multiple anchors may be required depending on the size of the tear.

Three to five portals (incisions <1cm) are made around the shoulder to facilitate the repair.

Concomitant pathology (e.g. bony spurs, bursitis etc) can be treated simultaneously.

At the end of the operation, steri-strips or one stitch is used to close each portal. Waterproof dressings and then a bulky dressing pad are applied to absorb the natural ooze from the joint. The arm is always placed into a polysling for comfort and to immobilise the shoulder to allow tissues to heal.

Can I go home the same day?

More often than not, as with most arthroscopic surgery, this is a day case procedure. Occasionally an overnight stay is advised depending on post-operative comfort levels, medical co-morbidity and time of day of the surgery.

What about after the operation?

You will see a physiotherapist before discharge to be instructed on simple exercises to carry out in the short term. This usually involves simple pendulum exercises out of the polysling and light stretches, often with assistance (e.g. your other arm or your physiotherapist) and you will be instructed on axillary hygeine. You should aim to exercise the shoulder 3-4 times a day; although the shoulder will be sore to start, there should be no lasting pain or pain that is not alleviated by the analgesia prescribed to take home. Sleeping with a pillow under the shoulder is recommended. It will be painful to sleep on the side of the operated arm for several weeks.

Restrictions of movement: for 6 weeks Mr Patel recommends no combined abduction and external rotation and restriction of forward flexion to shoulder height. This is dependent on age of the patient and size of the tear.

You will be prescribed analgesia to take home and Mr Patel strongly advocates its use to keep pain to a minimum; it should be noted that pain is more difficult to control if allowed to establish itself. Mr Patel recommends the regular application of ice as an adjunct to relieve pain and swelling in the acute post-operative period.

You will see Mr Patel two weeks after surgery for a wound check (and stitch removal) and a physiotherapy program will ensue thereafter which is paramount to the success of the operation. You are likely to have been seeing a physiotherapist before the operation and Mr Patel will liaise with him/her in detail to advise on the post-operative exercise program. For this procedure, Mr Patel recommends return to work (sedentary) when you feel able; for manual work this may be 3-6 months. Driving can resume after 6-8 weeks, as can swimming breastroke. Return to freestyle swimming, overhead athletic activity and contact sport is recommended at 3-4 months but is often guided by the strength of the individual.

What are the potential complications?

All surgery carries a risk. Specific risks to arthroscopic rotator cuff repair are:

Infection – this can be either superficial (portals) or within the joint. You will be given antibiotics to reduce this risk.

Stiffness – It is very important that some mobility of the shoulder is maintained after surgery. The physiotherapist will advise on simple exercises that can be carried out at home. Mr Patel also recommends that you take regular analgesia and use ice (see Surgery FAQs) to help minimise post-operative discomfort and facilitate early movements.

Bleeding – this may require a return to the operating room for removal of blood clots and to stop the bleeding.

Neurological – patients often describe a patch of numbness or a heavy feeling around the shoulder in the early post-operative phase. This is commonly swelling related and resolves as swelling reduces and full shoulder mobility is recovered.

Non-union – despite a good repair, the tendon tissue may not heal to the bone successfully. This usually manifests as peristent pain, continued poor function and commonly a re-tear of the tendon. This risk is greater with increasing age and poor quality tendon.

Device failure – rarely, the bone anchors used for repair can migrate (move out of position). They will need to be retrieved if this happens as if they are not flush with the bone surface or left to float around the joint, they can cause damage and inflammation in the sub-acromial space.

Recurrence – re-tear can and does occur. Good compliance with post-operative rehabilitation will reduce your risk greatly. Contact sports and increasing age carry a higher risk for re-tear.