The shoulder complex is made up of three bones; the humerus, scapula and clavicle. Your shoulder is the most mobile joint in your body and is therefore dependent on strong muscles to move and stabilise it. Some of the most important muscles for this purpose are the rotator cuff muscles.
The rotator cuff is a group of muscles closely wrapped around the top of your arm (humerus). These muscles originate from your shoulder blade and their tendons form a hood covering the ball of your socket joint. These tendons can be damaged through general wear and tear, or after an accident/fall. If one or more of these muscles are damaged, movement may become difficult and the shoulder becomes weak and painful.
What Is a Rotator Cuff Tear?
A rotator cuff tear is a rip in the group of four muscles and tendons that stabilize your shoulder joint and let you lift and rotate your arms (your rotator cuff). There are two kinds of rotator cuff tears. A partial tear is when one of the muscles that form the rotator cuff is frayed or damaged. The other is a complete tear, meaning it all the way through the tendon or pulls the tendon off the bone.
It’s a common injury, especially in sports like baseball or tennis, or in jobs like painting or cleaning windows. It usually happens over time from normal wear and tear, or if you repeat the same arm motion over and over. But it also can happen suddenly if you fall on your arm or lift something heavy.
Rotator cuff tears are diagnosed by careful clinical examination. Ultrasound scan of the shoulder joint is used to screen a rotator cuff tear.
It can be confirmed on MRI (magnetic resonance imaging) scans. The type and extend of the tear , muscles involved and the condition of the muscles can be assess accurately on a high resolution (3 Tesla) Mri scan. As the rotator cuff muscles are soft tissues, they will not show on routine X-rays or CT scans.
What happens when a rotator cuff tear is not treated on time?
If a rotator cuff tear is not treated on time, the tear size can increase and the muscles undergo retraction and infiltration with fat. As the muscles of the rotator cuff are connected, a tear in one of them caused progression into the adjoining muscles. It can become irreparable as time progresses. It is like the saying “a stitch in time saves nine“.
What is a rotator cuff repair?
The operation aims to repair the damage to the torn muscles or tendons. Once you are under a general anaesthetic the torn muscles are repaired using sutures or suture anchors depending on the type of damage. Often a ligament is also released and a piece of bone may be shaved or cut away to allow more space for the repaired tendon to heal.
The operation may be done arthroscopically (key hole surgery) or rarely, through an open incision.
Advantages of Arthroscopy
There are two major benefits of arthroscopic rotator cuff surgery.
The main benefit of rotator cuff surgery in general is to eliminate pain from a partial or total rotator cuff tear. The benefit of having this surgery done arthroscopically is that it is minimally invasive and has a quick recovery time. The arthroscope allows the surgeon to make very small cuts rather than a large incision for open surgery.
Surgical Repair Options
There are a few options for repairing rotator cuff tears. Double row and single row repair options are available. Double row repair gives a strong footprint compression of the rotator compression thereby ensuring good tendon healing to bone.
After the operation
Your arm is supported in a sling straight after your operation
to protect the repair. It is essential that you wear the sling day and night for 2-6 weeks (your Physiotherapist will advise you). The amount of time will depend on the size of the rotator cuff tear. This will be explained to you after your surgery. You can remove the sling to carry out your exercises and for washing and dressing only.
It is normal to feel some pain following your operation. You will be given some painkillers and/
or anti-inflammatory medication to take in the days following the operation.
Using ice on your shoulder can be helpful in reducing pain. Wrap a bag of crushed ice, or frozen peas in a damp towel.
Protect your dressings from getting wet with a layer of cling-film, or a plastic bag, before applying the ice pack for 10-15 minutes at a time.
Posture can make a big difference to your pain after surgery. Avoid ‘hitching’ your shoulder or holding it in an elevated position. Try to avoid slumping or standing/sitting with round shoulders as this puts more stress onto your shoulder.
Getting back to normal
It is normal to feel more tired than usual for a few days after having an operation. Sleeping can be uncomfortable and it is important to try not to lie on your operated shoulder. You should wear your sling in bed for the first 3-6 weeks (your Physiotherapist will advise you) to protect your shoulder.
Using pillows to support your operated arm and maintain your posture when sleeping will help with the discomfort.
Washing and dressing
Dressings and bandages that are applied in theatre need to stay dry. Remove your sling when bathing or showering, but keep your arm close to your body. Ensure that the area is dry before dressing to prevent irritation in the armpit. It is easier to wear looser fitting clothes and dress by putting your operated arm into position in the top first.
Your wound also needs to stay clean and dry. If you have removable stitches they will be removed after 10-14 days at an outpatient clinic appointment or by your GP. If dissolvable stitches are used, they will not need to be removed.
Rehabilitation is important if you are to get the most out of your shoulder after the operation. You should be given information about your first physiotherapy appointment before you leave hospital. The amount of physiotherapy you will need will depend on your individual progress and the level of activity you wish to return to.
Returning to work
The amount of time you have off work depends on your job. If you have a manual job, or one that involves lifting or overhead activities, you will not be able to do this for 8-12 weeks. Please discuss this with your Consultant or Physiotherapist.
You should not drive until you have discussed your progress with your Consultant / Physiotherapist which will not be until at least 6 weeks following your operation. You must be able to comfortably control your vehicle and perform emergency manoeuvres.
Sports and activities
The timescale for which you can go back to any previous sport or activity will depend on your movement and strength and the particular activity you have in mind. Please discuss returning to any activity or sport with your Consultant or Physiotherapist.
With all of your exercises you should aim to repeat 10 repetitions, 3 times a day unless otherwise advised by your Physiotherapist.
1. Active hand and wrist exercises with forearm supported
It is important to keep your hand, wrist and elbow moving after shoulder surgery
- Use your non-operated hand to support the forearm on your operated side. Move your wrist up and down and side to side as far as you are comfortable
- With the same support, make a fist and then stretch your fingers as far as you can
- Slowly turn your forearm over so your palm faces up and then down
2. Passive elbow exercises
- Sit with good posture
- Use your non-operated hand to grip the forearm on your operated side
- Use the non-operated arm to slowly bend your elbow as far as you are comfortable and then straighten it as far as you are comfortable
3. Passive external rotation to neutral
- Rest your elbow on a table or the arm of a chair, keep the elbow of your operated arm into your side
- Use your non-operated hand to move your hand away from your stomach to the position shown in the photograph. Do not push any further
4. Passive flexion to 90 degrees
- Lying on your back, allow a friend or relative to move your arm towards 90 degrees by supporting around your wrist and elbow
- Only allow your arm to be moved as far as is comfortable or to 90 degrees maximum
Important things to remember following your rotator cuff repair
- Continue to wear your sling day and night as requested by your Consultant
- Do not lift your operated arm without assistance until it is allowed out of the sling
- Do not use the unoperated arm for any heavy manual work whilst in the sling
These are important to protect the repair of the tendons.