Treatment of Rotator Cuff injuries
What is the rotator cuff?
The shoulder is a remarkable joint and the most mobile joint in the body. Because of this, the shoulder is vulnerable to injury.
The rotator cuff consists of four muscles that connects the scapula (shoulder blade) to the humerus (upper arm). These muscles attach around the head of the humerus. These muscles stabilise the shoulder joint and allow you to lift your arm and reach above your head.
There are 2 main reasons for rotator cuff tears. The most common reason is ageing or degeneration in the tendons which is more common in people over 40. The second reason is an acute injury from falling on the shoulder or grabbing onto something – like a jerk injury.
As far as degeneration (wear and tear) of the tendons is concerned, they can either be small or partial. Over time a partial tear can increase in size. If the tendons rupture completely, a person is normally not able to move or elevate their arm at all, and this is called a pseudo (false) paralysis.
Full-thickness rotator cuff tears are unlikely to heal, as the tendon normally has quite bad blood supply. Movement of the arm and contraction of the muscle pulls the tendon away from the bone.
How is a tear diagnosed?
In addition to a history and physical examination, you might need to have further tests done to confirm the rotator cuff injury / tear.
These tests include:
- X-ray of the shoulder.
- Ultrasound of the shoulder.
- Magnetic resonance imaging (MRI).
Treatment of rotator cuff injury / tears:
Treatment options for rotator cuff injuries may include the following:
- Rest / immobilisation for a period in a sling.
- Pain medication which is normally a combination of Paracetamol and anti-inflammatories.
- Physiotherapy to strengthen the rotator cuff and shoulder muscles.
- Ultrasound guided cortisone injection.
- Surgery.
Surgical treatment of rotator cuff tears:
It is important to remember that not all rotator cuff tears need to have surgery. Surgery is normally reserved for the following:
- Partial rotator cuff tears that are not improving with non-operative treatment.
- Increasing size or increasing pain, with a partial rotator cuff tear.
- A complete tear with loss of movement of the arm.
Successful repair of a rotator cuff depends on:
- The age of the patient and as a rule, the older you are, the less likely it is that surgical repair will be successful, especially if you are over 70.
- The quality of the torn tendon/s that are remaining and the number of tendons torn. The more tendons that are torn, the less likely it is that surgery will be successful.
- The length of time since the tendon has been torn. With a long-standing tear, the muscle atrophies and the muscle get replaced by fat.
- The capacity of the patient to heal. This is worse in patients with diabetes and smokers.
Rotator cuff surgery can be performed arthroscopically (preferred method) as well as mini open / open techniques. The surgery is performed through several small cuts where a camera is inserted into the shoulder, in combination with other tools and suture anchors to repair the rotator cuff tendons.
General risks of surgery:
- Surgery to repair the rotator cuff is done using general anaesthesia when a patient is put to sleep. Unexpected death from an anaesthetic is very rare.
- Antibiotics are routinely used during surgery to prevent infection – some patients may have an allergic reaction or anaphylaxis.
- Wound infection.
- Bleeding in the wound with haematoma (big collection of blood) formation.
- Pain / numbness around the incision.
- Allergies to antiseptic solutions used to clean the surgical site.
- Allergies to sutures and / or dressings.
- Deep vein thrombosis – there is always a risk of DVT with surgery.
- Nausea and vomiting after surgery.
Specific Risks of Surgical Repair of the Rotator Cuff:
- The patient will be asked to wash the shoulder daily for 3 days before the surgery with a shampoo (Benzoyl peroxide) to prevent an infection by an organism (Cutibacterium Acnes) living in hair follicles which can cause a low-grade infection with shoulder surgery – this might cause an allergy.
- The patient is normally positioned in the ‘beach chair’ position for the surgery. This means that you will in a seated position. Because this can lead to low blood pressure, the anesthetist will insert and arterial line into the opposite arm to monitor your blood pressure very carefully.
- The anaesthetist will discuss a nerve block that is administered to help with pain control, which will be done after you go to sleep. The nerve block normally last about 12 hours – during this time your arm will feel very heavy and numb.
- During arthroscopic surgery, a pump is used to control bleeding in the shoulder. This results in swelling of the shoulder that can be quite significant. This normally settles overnight after the surgery.
- Injury to the nerves around the shoulder.
- Sometimes it may not be possible to repair all the tendons as these tendons might be too contracted or shortened.
- After surgery, the patient is placed in an abduction shoulder brace – this is a sling with a pillow, on which the arm rests, to prevent any tension on the repair. The brace will be worn for 6 weeks.
- Because the shoulder is immobilized for a period of 6 weeks, stiffness is common after surgery. It will take a long time for the movement to return. Sometimes persistent stiffness might need further surgery.
- The surgery might not work and there might be ongoing weakness with elevation of the arm and overhead activities.
- Ongoing pain and discomfort.
Recovery after Surgery
You will wake up in the recovery room and you will have a shoulder brace on the operated arm. The nurses in the recovery room will monitor your recovery by checking your vital signs (pulse, blood pressure etc), pain- and consciousness levels, before you are discharged to the ward. When you get home, you will need to continue using the shoulder brace all the time, including when you go to sleep. Oftentimes it is easier to sleep in a recliner after the surgery.
You will be discharged home with strong pain medication. Try to only use the stronger pain medication, when the more regular pain medication like Paracetamol is not effective.
It is important to keep the surgical area clean and dry and to keep the wound dressings intact. The dressings on you shoulder should be waterproof. Please change any wet dressings.
When you shower, use an empty 2 litre milk bottle or a small plastic ball in the axilla to keep your arm away from your body. This is to make sure that no tension is put on the repaired tendons.
You will be supplied with a follow-up date for removal of sutures and a wound review.
A physiotherapist will see you in hospital and will supply you with some initial exercises. These are very gentle exercises that you will do for the first 6 weeks. It is important for you to book an appointment with the physiotherapist of your choice, to continue with your rehabilitation after 6 weeks.
Every person’s recovery is as unique as they are. Aftercare and rehabilitation are extremely important for a successful outcome. It is very important not to use the arm for any active movement in the first 6 weeks after surgery. Recovery is a slow and gradual process and maximum recovery is only after 12 -15 months. It is common to have discomfort and stiffness for a fairly extended time after rotator cuff surgery.
Please contact the surgery immediately if you have any of the following:
- Any redness, swelling, bleeding or drainage from your incision site.
- Any fever or chills.
- Any increase in pain around the incision site.
- Any tingling or numbness in the arm.
Please find some useful links with regards to additional information on surgery:
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