Rotator Cuff Repair

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What’s the problem?

Your shoulder is a ball and socket joint. In order to move effectively, a number of muscles called the rotator cuff attach to the “ball” of the shoulder and help it to raise your arm, as well as rotate it. These muscles can be torn, either through general wear and tear, or traumatically such as after a car accident. Once this happens, it may be painful to move your shoulder (particularly overhead) or you may have weakness of your arms.

How can you treat it?

Not all rotator cuff tears require surgery. Treatment of these includes pain relief, physiotherapy or injections into the shoulder. However some tears are large enough or symptomatic enough that surgery is recommended.

The Operation

An arthroscopic rotator cuff repair is keyhole surgery. A camera is inserted into your shoulder and the rotator cuff inspected. The tear in the tendon of the rotator cuff can then be performed using a combination of bone anchors and sutures/stitches and knots. In total you will have 3-4 incisions of 1cm length surrounding the shoulder.

The Other Parts of the Operation

In addition to a torn rotator cuff, there are often other parts of the shoulder that may be painful, and these can be addressed at the same time arthroscopically. They include:

• Tearing or inflammation of the biceps tendon (the long head). This can be either released (tenotomy) or re-routed (tenodesis) to remove pain with shoulder movement
• Under the acromion is a bursa which can be inflamed. This can be surgically removed (a subacromial decompression). Part of the bone on the under surface of the acromion can also be removed if it is rubbing or impinging on the rotator cuff muscle beneath it (acromioplasty)
• The ACJ (acromioclavicular joint) can be arthritic and painful. It can be removed at the same time as a rotator cuff repair

The Anaesthetic

You will be asleep for the duration of the operation (ie a general anaesthetic). The anaesthetist will talk to you about a nerve block before the operation, which helps with pain relief and generally lasts 24-48 hours. This is normally done while you are sedated/half asleep just prior to the operation.

What are the Risks of this Operation?

• Ongoing pain and slow recovery:
  Levels of pain felt after surgery vary, depending on the patient and type of tear. However, most patients will have significant improvement in the pain they feel in their shoulder in the long term. Pain during the night is particularly common early after a rotator cuff tear. Rehabilitation can be lengthy and arduous, and you should expect to feel significant progress in both pain and function only from 3 months post operatively.
• Stiffness:
  This can occur as a combination of pre-existing stiffness, surgical scarring and immobilisation in a sling to protect the rotator cuff tear. Although a physiotherapy program will be instituted afterwards, some stiffness can occur. It is very uncommon to see significant stiffness of the shoulder in the long term.
• Infection:
  If it occurs, it will usually only be a superficial wound infection to the top most layer of the skin. It is very rare after arthroscopic surgery (less than 0.2%)
• Nerve Injury:
  Very uncommon in repairs of mild/moderate tears. However, occurs in <0.5% when larger tears requiring extensive mobilisation are repaired
• Re-Tearing of the Cuff:
  Clinically significant “re-tears” of the cuff are rare and >95% of patients remain satisfied after their surgery. However, 15-20% of tears either do not fully heal, or re-tear. Even if this is the case, your symptoms may not be significant and it does not mean you will require further surgery
• Cuff Tear Arthropathy:
  In a minority of cases (~5%), untreated rotator cuff tearing can result in a severe form of arthritis. Repair of the rotator cuff should help prevent this development

Benefits

Most patients are able to achieve a pain free shoulder with functional range of motion. You should be able to freely reach the top of your head and toilet behind your back. Higher level activities like sports are usually able to be returned to.

What can I expect?

You will wake up with your arm in a sling after your surgery. If you have had a nerve block, you shouldn’t feel any pain till the next day. The nurses will provide you pain relief and the next morning a physio will see you to go through some exercises you can do to help rehabilitate your rotator cuff.

These exercises will change over the next few months but you should try to do them regularly to maximise your rehabilitation.

Most patients stay overnight in hospital after surgery, before going home. A number of allied health staff (physios, occupational therapists) will make sure you have adequate support at home before discharge. An appointment will be made for you for a wound check at 2 weeks, and another appointment with Mr Lau at 6 weeks.

What should I avoid doing?

Although your rotator cuff tendons have been repaired, it still takes time for the repair to heal fully. In particular, in the first two weeks, it is very important to keep your arm in the sling most of the time (you can come out for hygiene reasons) to allow the tendon the best chance to heal back to bone.

Other than this, your physiotherapist will arrange a specific programme of rehabilitation, including exercises, restrictions and progression based on how well you are performing.

Return to…?

• Work
  Depends what you do. Desk based work can be done from 2 weeks post operatively, if you can do these tasks single handedly. Otherwise generally 6-8 weeks before you can use both hands freely whilst seated.
  For manual work, it depends on what kind of lifting/pushing you do, but generally not before 3 months
• Drive
  In Australia, you can’t drive unless you are in full control of both your arms. Therefore, whilst you’re in a sling, you cannot drive. Generally 6 weeks post operatively.
• Sports/Hobbies (may vary depending on the size/nature of your rotator cuff tear):
• Gentle swimming: after 12 weeks
• Gardening (light tasks only): 8-12 weeks
• Bowls: after 3-6 months
• Golf, tennis, badminton, squash: after 3-6 months

Concerns or questions?

If you have any concerns post operatively, or you would like further information, please contact Mr Lau through the VBJS on 03 5752 5020 or via email at admin@vbjs.com.au

If you need urgent medical help, call 000 or go to your nearest emergency department.

Rehabilitation protocols

• Rotator Cuff Repair (small/medium)
• Rotator Cuff Repair (large/massive)

These notes have been prepared by Mr Simon Lau. They are general overviews and information aimed for use by his patients. They reflect Mr Lau’s views, opinions and recommendations. They do not constitute medical advice. The contents are provided for information and education purposes only. Please seek Mr Lau’s specific advice with any questions regarding medical conditions and treatment.