Rotator Cuff Repair

What is the Rotator Cuff?

Your shoulder is the most mobile joint in your body and is therefore dependant on strong muscles to allow movement and provide stability.

The most important of these muscles are your rotator cuff muscles. These are four muscles which originate from your shoulder blade (scapula) and combine together to form a hood covering the ball of your shoulder joint.

These four rotator cuff muscles are individually called Supraspinatus, Infraspinatus, Teres Minor and Subscapularis.

The tendons of these muscles can become damaged in two ways; either due to an accident such as a fall onto your arm; or due to weakening over time.

What happens during a Rotator cuff repair?

During a rotator cuff repair, your surgeon will examine your shoulder to find any tears in the muscles or tendons and then fasten them back into place again. The aim is to reattach the tendons to the bone with the help of anchors. The bone on the underside of the acromion may also be smoothed out. The acromion is the arch of bone at the end of your shoulder blade, which acts as a bony roof over the rotator cuff.

Sometimes the tear is too big and /or the tendon is too fragile for the repair to be possible and only a partial repair can be achieved. Some tears cannot be repaired.

As the size of the tear can vary , only an estimated guideline of what can be done can be discussed. Your surgeon and physiotherapist will be able to discuss your individual surgery after he operation.

How is the operation carried out?

The operation is carried out under a general anaesthetic, usually as a day case. This means you will go home on the day of your operation. Some patients who have other medical conditions may require an overnight stay in hospital.

It may be done as either open surgery or by keyhole (arthroscopic) surgery.

The open procedure involves an incision along the front of you shoulder and will leave a scar about 4 - 7cm in length. This is usually along the bra or vest strap line, or over the top of your shoulder.

An arthroscopy is an operation using a specially designed small telescope linked to a TV camera which allows your surgeon to look inside your shoulder joint. This allows the surgeon to examine the shoulder joint and then use very small instruments to repair any tears.

Arthroscopic surgery will leave you with 2 to 4 small scars on the back, side and front of your shoulder.

What are the benefits of having a rotator cuff repair?

A rotator cuff repair may be offered to you if the tear in your muscle/tendon is causing pain in your shoulder. You may also be finding it difficult to move your arm and be struggling with lack of strength.

It is normal to feel discomfort following the operation but a rotator cuff repair can relieve a lot of the pain previously experienced. Following rehabilitation after the surgery you should also begin to see improved movement of your shoulder, and eventually an increase in strength.

It can take up to three months for the repair to the muscles and tendons to heal, and you may still be seeing improvements in your shoulder up to 18 months after your surgery.

Are there any complications of having a rotator cuff repair?

As with most types of surgery there are risks involved and complications can occur unrelated to the rotator cuff repair.

These include:

• Anaesthetic risks, such as nausea, sickness or rarely cardiac, respiratory or neurological (less than 1%)
• Chest infections
• Blood clots in the legs (deep vein thrombosis)
• Blood clots in the lungs (pulmonary embolus)

Some other complications, which can occur specifically following a rotator cuff repair, are:

• Infection
• Re-tearing of the rotator cuff
• Ongoing pain and stiffness in the shoulder (in around 10-20% of people).
• Unable to repair the muscle.

These risks are very small but if any occur, further treatment or an operation may be necessary.

• Infection can be a serious complication. Some infections show up immediately whilst you are still in hospital, others are not apparent until you have gone home. If you are at particular risk your surgeon may recommend that you take antibiotics. These are usually superficial would problems. Occasionally, deep infection may occur after the operation (less than 1%).
• Re-tearing of the cuff is possible following surgery before the rotator cuff has fully healed. This is why it is important to wear your sling as directed. This could result in a need to re-do the surgery. Your therapist will instruct you carefully about exercises to minimise this risk.
• On going pain and stiffness of your shoulder is possible especially if you do not continue with your individual home exercise plan. To minimise this risk you will be given exercises by the therapists before you leave hospital. If your shoulder is particularly stiff the physiotherapists may need to see you before surgery to help you gently stretch your shoulder.
• Unable to repair the muscle. Sometimes it is impossible to repair the muscle because it is too badly torn. The subacromial decompression should improve pain, but movement and strength may not change.

Please discuss these issues with the doctors if you require any further information.

What happens if I agree to have a rotator cuff repair?

If you and your surgeon agree that a rotator cuff repair is necessary, you will be asked to attend a Pre-Assessment Clinic a few weeks before your surgery to ensure you are fit for the operation and to record some baseline information. This will include your current functional ability and the range of movement of your shoulder.

We must seek your consent for any procedure or treatment beforehand. Staff will explain the risks, benefits and alternatives where relevant before they ask for your consent. If you are unsure about any aspect of the procedure or treatment proposed, please do not hesitate to ask for more information.

During your clinic appointment, the pre-operative assessment nurse will discuss your stay in hospital and organise any other necessary tests. These may include a blood test, urine test, an ECG (heart tracing) and x-rays.

A physiotherapist may also see you, and you will be examined by your consultant or a senior member of his/her team.

If you feel that you may need extra support or help at home following your operation, please mention it at this clinic appointment.

Another purpose of this clinic is for you to ask any questions about the forthcoming surgery.

When will I know the date of my operation?

You may be given a provisional date at Pre-Assessment Clinic and this will be confirmed by letter.

How long will I be in hospital for?

This operation is generally carried out as a day case procedure unless you have any other medical conditions which may require you to stay over night.

If you are having your operation as day surgery, you will need to have someone to collect you from the hospital and stay with you overnight to check that you are okay.

After your rotator cuff repair - Will I have any stitches?

Your shoulder wounds will have dressings on them and if you have had stitches they can be removed at your GP's surgery, usually 10 days after the operation.

An arthroscopic wound does not usually need stitches, only small sticking plasters over the wounds.

It is normal for your shoulder to appear swollen after surgery and you may also find that your shoulder leaks a watery blood stained fluid, this usually settles after 24 - 48 hours.

Keep all wounds dry until well healed. Avoid using spray deodorants, talcum powder, or perfumes near the scar.

Will I have to wear a sling?

Your arm will be supported in a sling straight after your operation. This is to protect the repair to your muscle. You must wear the sling all the time for the next six weeks. The surgeons or therapists will advise you as to when it is safe to stop wearing the sling.

What clothes should I wear with the sling?

Most people find it difficult to manage ordinary clothes immediately after surgery, due to limitation of shoulder movements; therefore you are advised to wear a loose fitting button through shirt or blouse, and comfortable trousers/skirt. A bra may be uncomfortable in the early days so it would be advisable to bring an underslip or loose fitting underwear in hospital.

How will I sleep?

You must sleep in your sling until directed not to by your surgeon or therapist. Sleeping can be a little uncomfortable. We recommend that you lie on your back or the opposite side, as you prefer.

Ordinary pillows can be used to give you comfort and support. (Feather pillows are easier to mould than foam ones). We do not recommend trying to sleep in a sitting position.

If lying on your side, a pillow tucked along your back helps to prevent you rolling onto your operated shoulder in the night. If sleeping on your back, tie a pillow tightly in the middle to support your neck.

Will I have to come for physiotherapy?

Physiotherapy is very important following a rotator cuff repair if you are to get the most out of your shoulder following your operation. A physiotherapist on the ward will show you some elbow, wrist and hand exercises o do whilst you are in a sling.

You will also be given an appointment to attend your nearest outpatient physiotherapy department four weeks after your discharge from the ward in order to progress your exercises.

Whilst waiting for your physiotherapy appointment, it is important to keep your elbow and hand moving, and also to make sure your neck muscles don't stiffen up.

Try the following exercises.

• Take your arm out of your sling and gently bend and straighten your elbow to prevent your elbow getting stiff.
• With your arm in your sling, gently practise shrugging your shoulders up and down.
• With your arm in your sling, stretch your neck from side to side to gently stretch the muscles muscles down the side of your neck. In your sling, practise making a fist and then straightening your fingers out to make sure your hand doesn’t stiffen.

Your physiotherapist or surgeon will advise you when to remove the sling. Following this there will be a gradual emphasis on increasing your shoulder movement further. Depending on your progress, you may also be referred to our occupational therapists for additional rehabilitation.

How often will I have to come to physiotherapy?

Four weeks after your operation you should expect to have physiotherapy once a week. As you improve this may reduce to once a fortnight.

Is that the end of my treatment?

You will be seen in orthopaedic clinic at six weeks following your operation. This may be your surgeon's specialist physiotherapist or occupational therapist to check that your rehabilitation is going to plan. Your surgeon may see you at about 3 months after your operation.

How am I likely to progress?

Phase 1:

Sling on, no movement except for exercises show by the therapists (immediately, post operatively until six weeks after surgery).

You will basically be one handed during this time. This will affect your ability to do every day activities, especially if your dominant hand (right if you are right-handed) is the side with the operation.

If you are having particular problems, an occupational therapist can suggest ways to help you.

Phase 2:

Regaining everyday movements (6 to 12 weeks after surgery). This starts once your surgeon and physiotherapist advise you that you can remove your sling. Your physiotherapist will progress your exercises at your physiotherapy out-patient appointment.

Phase 3:

Regaining strength (12 weeks after surgery) You will be able to increase your activities (for guidance, speak to your physiotherapist).

Guide to daily activities - first four to six weeks

1. Some difficulties are common. The occupational therapist will help you be as independent as possible during your rehabilitation.
2. Getting on and off seats Raising the height can help, e.g. extra cushion, raised toilet seat, chair or bed blocks.
3. Getting in and out of bath Using bath boards may help (initially you may prefer to strip wash). Hair care and washing yourself Long handled combs, brushes and sponges can help.
4. Dressing Wear loose clothing. Dress operated arm first and undress your operated arm last.
5. Eating Use your operated hand as soon as possible for cutting food and using a cup. Non-slip mats are simple aids can help.

Returning to work:

• Light work (no lifting) - 6 weeks onwards
• Medium work (light lifting below shoulder level) - 12 weeks onwards
• Heavy work (above the shoulder level) 3 - 6 months

If you feel that your work or leisure activities come into the heavy category, please discuss this with the physiotherapists and occupational therapists, so that they can plan the best rehabilitation for you.