Your shoulder has numerous muscles and tendons controlling movement and stability of the shoulder.
Among these are the tendons of the rotator cuff. The rotator cuff is composed of four tendons that blend together to help stabilize and move the shoulder.
The rotator cuff is the collective term for a group of tendons, which includes the supraspinatus, infraspinatus, teres minor, biceps and subscapularis. (Fig. 1) These tendons pass under a bony-ligamentous arch.
Problems can arise within the rotator cuff when it is:
• Irritated, bruised or frayed
• Weak, the bursa is swollen or the bony arch angles too far down
• Calcium deposits form within it
• Torn either partially or completely
Irritation, bruising or fraying of the tendons can occur with repetitive use of the arm e.g. When carrying heavy luggage or during sports like golfing and tennis. When the tendons are inflamed but not torn then it is called tendinitis. The pain is primarily from the inflamed tendons being rubbed by the bony ligamentous arch. This can also result in a bursitis, where the bursa above the tendons also becomes irritated and swollen which causes pain. The biceps tendon can also become frayed or unstable and may require treatment at the same time.
Tearing of the rotator cuff can occur when these tendons become irritated and swollen and eventually wear out or else they can occur as a result of a major force eg, direct injury. Most tears have some degree of preceding wear changes. Any accidents or injuries that might occur at work, sport or a fall may precipitate a tear of these weakened tendons.
Tears of the rotator cuff tendons occur with increasing frequency as the population gets older. It is unusual for a patient younger than 40 years to have a tear whereas up to 50% of patients over the age of 75 years have a tear in one or other rotator cuff tendon. A tear of the rotator cuff does not always have to be painful.
The most common symptoms which cause a patient to seek medical advice are:
• weakness and
• inability to raise the arm
In determining the diagnosis it is most important to take a thorough history from the patient and also to examine them to assess their range of motion and ability to use and raise their arm. After this, one or more of the following tests may be ordered – a plain x-ray, ultrasound or MRI in order to assess the condition of the bones, tendons and ligaments.
In patients who have an acute rupture of their rotator cuff after a fall, surgical management is generally indicated to restore function to the arm, however the majority of rotator cuff tears are degenerative in nature and occur over time. These ones rarely require surgery and are best managed with non-operative management.
• Physiotherapy (stretches/strengthening)
• Anti-inflammatory medication
• Activity modification
• Cortisone (steroid) injections
If this does not help in reducing the pain or if there is poor shoulder function then surgery maybe recommended. For those patients with a rotator cuff tear, a rotator cuff repair is performed.
The purpose of the surgery is to reattach the torn tendon back to the bone.
Under a general anaesthetic, the arthroscope is firstly introduced into the shoulder joint and all pathology is identified. Any surgery that can be done through the arthroscope is done at that time. With small to medium sized tears and good quality tendon the repair can be done through the arthroscope through 3 or 4 separate small incisions. (Fig. 2)
This operation involves re-anchoring the biceps in a better position to stop it slipping out of its groove or becoming irritated.
Black lines are the patient’s bony anatomy landmarks. The solid red lines represent incisions for arthroscopy and arthroscopic rotator cuff repair. The dotted red line shows the mini open incision I use for larger rotator cuff tears and biceps tenodesis.
If however the tendon tear is large, I prefer to repair the tendon through a small incision 3 to 4 cm long at the side of the shoulder.
This is called a mini open repair and gives excellent exposure of the tendon. The outcome and rehabilitation of an arthroscopic repair or mini open repair are no different and the result of rotator cuff surgery really depends on the quality of the tendons at the time of the repair. The rotator cuff tear is then repaired by suturing it back to the bone using stitches and bone anchors.
All tears are different and a variable number of sutures and bone anchors can be used. An example is illustrated in Fig. 3. The operation involves coming into hospital for 1 night.
You will be placed in a sling for 6 weeks to protect the repaired tendon. A physiotherapist will show you circular or pendular exercises, which you need to do for 6 weeks to prevent stiffness. Healing of the tendon is slow and it can take between 6 to 12 months to gain full recovery.
You MUST NOT raise your arm that has been operated on at all or lift anything heavier than the weight of a full coffee cup / can of drink with this arm for the first 6 weeks. Always put your sling on when you go out.
Complications related to the surgery can occur but are quite rare. A general anaesthetic is used and there are risks related to this. Some of the risks include infection, nerve and blood vessel damage. Occasionally the shoulder may develop some transient stiffness called capsulitis. This usually resolves itself however it delays the time taken till the shoulder recovers.
When the staff at the room’s book you in for surgery, they will advise you of when you must fast (stop eating and drinking) and present at the hospital. These times may change and you will be notified by either the hospital or the rooms a day or two before the surgery of any changes.
At the hospital, you will be seen by your anaesthetist who will ask questions about your health and talk to you about the anaesthetic he/she will give you.
When you return to the ward you will have:
• a drip in your arm
• your arm in a sling
• regular pain relief
You will be able to drink and eat as soon as you are awake and alert. Your vital signs (blood pressure, pulse, temperature) will be checked overnight.
You will be given regular pain-relieving tablets. It is important to have these regularly in order to keep your pain at a tolerable level to enable you to move about and exercise.
A physiotherapist will show you exercises to be done for the first 6 weeks and how to put on and take off your sling. You will be able to go home mid-morning the day after surgery.
I will see you 2 to 3 weeks after surgery to remove your dressings and check your wounds. I use dissolvable stitches, so I will not need to remove any stitches.
Please get in touch with us by completing the form here or alternatively you can contact us by fax or phone at the numbers below. We will endeavour to get back to you as soon as possible.