A rotator cuff tear occurs when the tendons around the shoulder tear.
This may be the result of trauma or as a natural consequence of the ageing process. Although the tear itself won’t heal, in some cases, the pain settles over time and the other parts of the rotator cuff are able to strengthen and compensate for the tear.
The rotator cuff refers to a group of tendons and muscles in the shoulder which attach the scapula (shoulder blade) to the humeral head (upper arm bone). When activated the rotator cuff muscles provide significant tension across the joint and thereby:
- Stabilise the humeral head (ball of the shoulder joint) in the centre of the glenoid (socket of the shoulder joint). This helps to prevent dislocation to the joint.
- Allows more powerful muscles around the shoulder to provide the tension needed to move the shoulder.
- Provide movement and control into rotational positions for the shoulder.
The rotator cuff is formed from four muscles and tendons that attach your arm to the top of your shoulder blade. Injury, inactivity and ageing can cause these tendons to become compressed and tear, which can lead to severe pain and limit your shoulders range of motion. Rotator cuff repair surgery fixes the torn tendons.
Most commonly, there is shoulder pain and weakness. Individuals may suffer from referred pain radiating down the upper arm to the elbow. Weakness may result in an inability to lift the arm and affect activities of daily living such as dressing.
Pain on movements of the arm above the head, behind the back and across your body are the main aggravating activities. Lifting any significant weight with these movements will normally increase symptoms further.
A rotator cuff tear can be diagnosed by your doctor or physiotherapist by taking a history of your condition and by conducting a physical examination, alongside X-rays or scans.
The main features on examination are often pain and weakness when resisting rotational movements and movements of the arm away from the side.
An ultrasound or MRI scan may be required to assess the extent of any rotator cuff tear. This may guide future management including a possible surgical repair.
Rotator cuff tears sustained through aging or wear and tear are often managed by a period of watchful waiting to assess the degree of spontaneous recovery prior to deciding on any necessary intervention.
Exercises. A rotator cuff tear can be managed effectively by following a regular exercise routine to optimise strength and coordination of the affected shoulder joint:
5×30 second holds, 2x per day
3×10 repetitions, 3-4x per week
5×15 repetitions, 2x per day
Using painkillers when needed. Over-the-counter analgesia is available through pharmacies when needed. Paracetamol is most commonly prescribed. Anti-inflammatories, such as Ibuprofen, are also used, but as there is little or no inflammation involved in osteoarthritis these are best avoided without discussing with your GP. Side effects are even more common than with paracetamol so please ensure to take appropriate medical advice. There is a good booklet on the Arthritis Research UK website with information about the various drug options.
Corticosteroid injection therapy. These may be considered by your clinician in specific circumstances.
Surgical rotator cuff tendon repair is a minimally invasive operation, usually done by keyhole, and normally requires 6 weeks immobilisation of the operated shoulder and extensive, prolonged rehabilitation following surgery.
For patients who are willing to consider a surgical repair this decision is best discussed with your clinician as the effectiveness of this operation varies greatly according to individual characteristics:
- Patients age; outcomes after rotator cuff repairs can worsen with increasing age. Your clinician will discuss the implications of this at your consultation
- The exact location and size of the tendon tear
- Whether the tendon tear was traumatic (through an injury) or degenerative (age-related) in nature
Rotator cuff repair surgery fixes torn and damaged tendons in the shoulder to alleviate pain and improve power, strength and movement.
Rotator cuff repair surgery is suitable for people who have tears in the shoulder tendons as the result of an injury or a degenerative ageing process with or without an additional injury and where the tendon tear is not so big or so longstanding that a repair operation is unlikely to help.
After rotator cuff repair surgery, you should have considerably less pain and your shoulder will function much better, although the amount of strength that is restored depends upon the quality of the muscles and tendons before surgery.
Rotator cuff repair is usually performed arthroscopically through a number of small incisions around the shoulder.
The damaged tendons are then freed and mobilised to allow them to be repositioned back on the edge of the shoulder joint where they have detached. The area of bone to which they need to be attached is then roughened to create an environment in which healing of tendon to bone can occur. Stitches are then inserted into the tendon and secured down through the bone through drill holes or using special little harpoons. The stitches are tightened to firmly hold the tendon against the bone and hold everything in the right place while natural healing occurs.
The incisions in the skin are closed and may have stitches that need removing after one or two weeks.
Information on admission and starving instructions will be provided at your pre-operative assessment.
Shoulder and elbow surgery can result in considerable pain and discomfort after the operation. Traditional painkillers are not always effective and have side effects. We usually offer you a local anaesthetic “block” to reduce the pain and discomfort following the procedure and also allow early more comfortable physiotherapy (if required). This consists of an injection at the side of your neck onto the nerves that supply your shoulder. The injection itself is fairly painless.
The procedure is carried out before the start of your operation. You will have a small plastic tube placed in your arm (drip). Then you may have some sedation to make you feel relaxed. A small numbing injection in the skin is placed prior to the block needle (which is smaller than a blood-taking needle). Your arm will then start to feel very heavy and numb (a similar sensation to when you have been lying on it). This spreads down the outside of the arm (and spares the inside).
Surgery is then carried out under sedation (you are comfortable, relaxed and either awake or sleeping if you prefer) or occasionally under general anaesthesia (you are unconscious and unaware). If you are awake, you are welcome to watch the procedure on a TV screen, and we will explain to you what is happening. If you require any extra pain relief during the procedure, we can easily give you this through your drip. The block will reduce the overall amount of painkilling drugs that you will require during and after the operation.
After your operation
The numbness will usually last for between 8 and 24 hours (depending on anaesthetic mixture used). We will leave your arm in a sling; please protect your arm whilst it is numb.
You will initially experience some ‘pins and needles’ as the block wears off and then some pain. Please prepare for this by taking the painkillers that we provide. Start these before the block wears off and expect to need them regularly for around 48hrs.
Occasionally we may recommend that at the time of the block we also place a small tube (catheter) that is fixed in place and through which we can give you further local anaesthetic to prolong your numbness for a few days. We would recommend this in situations where your pain after the operation is likely to be severe.
Complications of Anaesthesia
Anaesthesia is fairly safe for most people. If your health is not good the risks may be increased. Commoner complications include nausea and sore throat.
Local anaesthetic nerve blocks are generally considered to be safe. There is an approximately 5% (1 in 20) chance that they will fail or not work as well as expected. They tend to cause a small pupil and droopy eyelid temporarily and you may notice a hoarse voice or slight breathlessness.
Rare complications include reactions to the local anaesthetic solutions and nerve injury (the risk of temporary nerve symptoms e.g. tingling, numbness or weakness for a limited period is around 1 in 100 blocks and the overall risk of permanent injury approximately 1 in 5,000- 10,000 injections).
Paracetamol and an anti-inflammatory drug (if suitable for you – usually ibuprofen or diclofenac) are often used in combination. Take these regularly for the first few days.
Your anaesthetist will talk to you about strong painkillers, usually codeine, tramadol, oxycodone or morphine. Take these if your pain is poorly controlled (instructions will be on the packet). Some patients experience light-headedness when taking stronger painkillers; so be careful especially at first (rest up after taking them, don’t carry hot drinks or anything sharp) and take them only to counteract severe discomfort. Nausea and constipation can also occur, so drink plenty of water and increase the fibre in your diet; occasionally laxatives may be required (available from chemists).
If you are discharged on the same day as your operation, there should be someone keeping an eye on you during the first 24 hour period. If the painkillers make you excessively drowsy, then your carer needs to rouse you and ensure you not too sensitive to them.
Emergency contact numbers will be available on your discharge information if you or your carer wishes to talk to a trained member of staff.
Rotator cuff repair surgery is usually a daycase and your arm is placed into a special shoulder immobilising sling. Exercises and physiotherapy start on the day of surgery and your physiotherapist will teach you all you need to know for the first couple of weeks of recovery after discharge.
As a general guideline, your tendons take six weeks to start to securely heal to the bone and during this time they need to be protected from significant forces being passed through them. If your shoulder repair surgery is overloaded in the early stages, the stitches can pull out of the tendon and the repair can fail. Most people need to retain the sling for six weeks but some exercises during this time are essential to stop the whole arm becoming very stiff.
After six weeks, people wean themselves out of the sling and increased exercises and movements are encouraged. Most people can return to driving a car at around eight weeks and have regained good ordinary use of the shoulder by three to four months.
Physiotherapy and exercises continue for six to nine months. The long recovery period reflects not only time spent getting over the operation but also time spent getting muscles that have done little for a prolonged period of time to start working well again.
Activities such as running and swimming can generally start between two and three months. Golf can be resumed at four to five months but more vigorous activities such as racquet sports and sailing are rarely undertaken earlier than six months.
The success rate of rotator cuff repair surgery very much depends on the initial size of the tear in the tendons and the quality of the tendons and muscles. A good assessment of this can be usually obtained preoperatively with a careful examination and the use of scans.