Rotator cuff tears represent one of the most common reasons for shoulder pain. The rotator cuff is a group of muscles and tendons very important for the function of the shoulder joint. Do you know why the name “cuff” is used? This is because the tendons of these four muscles blend together as they attach to the arm bone (humerus). The subscapularis comes from the undersurface of the shoulder blade and attaches to a flat surface in the front of the humerus, called the lesser tuberosity. The supraspinatus, infraspinatus and teres minor come from the back and side of the shoulder blade, attaching to a larger platform of bone, the greater tuberosity. The biceps tendon in the front of the arm has two tendon ends towards the shoulder; one of them (the tendon of the long head of the biceps) lies in parallel to the upper portion of the subscapularis tendon and the front portion of the supraspinatus tendon, in the so-called interval region.
Although the rotator cuff can get injured at the muscle-tendon junction, most commonly a rotator cuff tear involves tendon fiber detachment off of bone. These tears may be the result of an injury (you can read our post on acute rotator cuff tears) or wear and degeneration (read our post on chronic rotator cuff tears). When these tears are painful and interfere with shoulder function, repair of the tendon tear to bone is considered. At the present time, many of these tears can be repaired using arthroscopic surgery: a small camera is inserted through a small skin cut and the repair is performed by introducing instruments through additional small skin cuts. Today we will discuss what people should expect if they are facing arthroscopic rotator cuff repair surgery.
How do I know if my rotator cuff is torn?
Individuals with rotator cuff tears often feel a combination of pain and weakness. Over time, their shoulder may become stiff as well. Most people feel a dull, deep ache on the side of the shoulder. It is especially painful when trying to reach up or out, or with sudden motion of the shoulder. Pain is particularly bothersome at night. Weakness varies: individuals with smaller tears may have near normal strength, whereas very large tears, involving most of the cuff, may make it impossible to raise the arm. Not uncommonly, individuals with a torn rotator cuff realize that it is easier to raise the affected arm with the assistance of their other hand, or by keeping the elbow bent. Bringing the arm down from an upward position becomes particularly painful. Medical attention should definitely be sought soon when an individual suddenly looses the ability to raise the arm after a shoulder injury; however, most cuff tears develop slowly over time.
Shoulder specialists evaluate patients suspected of having a cuff tear by assessing motion and strength. There are a few ways to test for shoulder strength that are particularly useful. In the subscapularis bear hug test, the patient is requested to place the flat palm of the hand on the opposite shoulder with the elbow up, and the doctor tries to lift the arm off the shoulder. In the supraspinatus empty can test, the patient is asked to extend their arms forward, with the thumb pointing down, as the doctor tries to push the arm down. Testing the strength of the patient’s ability to push out with their arm at their side will test the integrity of the infraspinatus and teres minor.
Plain radiographs may hint to the presence of a torn rotator cuff if the head of the humerus is higher than it should. However, the diagnosis is confirmed almost always with so called advanced imaging studies (magnetic resonance, ultrasound, or computed tomography). We prefer magnetic resonance: it shows the structure and length of all tendons in detail, and allows us to determine how much the muscles and tendons have shortened, as well as the quality of the muscles themselves. Based on your exam and images, your shoulder specialist will determine if your tear can be repaired or not. Yes, believe it or not, some times the amount of tendon damage is so bad that the tendons cannot be repaired! But if your tear is fixable, you may be offered an arthroscopic rotator cuff repair.
How is arthroscopic cuff repair performed?
This surgical procedure is almost always performed under general anesthesia. Some times, your anesthesiologist will recommend an injection of a local anesthetic in your neck area, into the bundle of nerves that supply sensation to the arm, the brachial plexus. Blocking the brachial plexus temporarily with local anesthesia decreases or completely eliminates shoulder pain for a number of hours after surgery.
The bed where you will lay in the operating room is articulated, which will allow the surgeon to position you on your side or in a sitting up position for easy access to the shoulder. A mechanical device is often used to hold the arm in different positions. The shoulder is isolated from the rest of the body with drapes to avoid infection.
A camera is introduced into the shoulder using a metal sleeve -called a cannula- through a small skin cut. Additional small skin cuts are used as needed to introduce additional instruments. Once the scar tissue and the so-called bursa are removed, the bony surface that will receive the tendon end is prepared by cleaning all scar tissue and lightly brushing the bone with a burr. Bone preparation facilitates tendon to bone healing.
Anchors are the most common devices used for cuff tendon reattachment to bone. These anchors come loaded with sutures or tapes. They are screwed or tapped into the bone to gain strong purchase. Therefore, the sutures or tapes are secured to bone and can be weaved through the tendons, and are either tied or secured to additional anchors. The tendon edge is thus compressed to the bone and hopefully healing occurs. Remember how the biceps tendon lies in the interval region? In some individuals with cuff tearing, the long head of the biceps is either partially torn or very loose and unstable. In these circumstances, the long head of the biceps is addressed as well by releasing it, lengthening it, or fixing the biceps tendon in a new spot (this part of the procedure is called biceps tenodesis).
What is the recovery like?
After surgery, your repair needs to be protected using an immobilizer or sling. Depending on the severity of the tear, the strength of the repair, and other factors, your shoulder specialist will tailor the recovery program to you. Most of the time, the shoulder needs to be immobilized day and night for six weeks. During the first six weeks, the elbow, wrist and hand should be exercised to decrease swelling and other symptoms. However, motion of the shoulder itself is not recommended typically during this first month and a half.
When shoulder therapy starts, exercises are introduced progressively. Passive motion is followed by active assisted motion and strengthening. Initially, your shoulder will be moved gently by someone else (a family member, friend, or physical therapist). Eventually, you will start to move the shoulder yourself actively or with the assistance of your other arm by using a cane, wand, umbrella or broom. Strengthening is last, and starts with active contraction of the muscles in the resting position (isometric exercises), followed by use of elastic bands.
As you can imagine, it takes weeks, and weeks, and weeks,… to recover from this surgery. It can be very frustrating! Most individuals need some form of physical therapy for six months after surgery, and most people do not feel their best for at least a year (or longer)after surgery. But in the end, if the cuff tendons heal, most individuals are very, very satisfied.
Any possible complications?
We would all love to think that surgery never has complications…, but unfortunately they some times happen. Some of the complications that occur after cuff repair can be expected (due to problems with anesthesia, infection at the site of surgery, a nerve or vessel injury) but the main two issues shoulder specialists worry about are stiffness and poor tendon healing.
Stiffness occurs when excessive scar tissue is laid down in the shoulder region as a reaction to surgery. Some stiffness at the beginning of the recovery phase is actually good, since healing does require scar tissue formation to some extent. However, a small number of individuals form so much scar tissue that motion is permanently limited. If this happens, but the tendon tear is healed, motion can usually be restored with the same treatment alternatives used for frozen shoulder (read our post on adhesive capsulitis for more information).
Poor tendon healing can be really devastating: imagine going through surgery, physical therapy and the recovery time simply to end up in the same spot as before surgery; no fun! Unfortunately, these darn tendons do not always heal, even if the repair is done perfectly. There are some risk factors that increase the chances of incomplete tendon healing. The main ones include older age, very large tear size, muscle atrophy and fatty infiltration, short tendon length, poor bone quality (osteoporosis or cysts), smoking, poorly controlled diabetes (high blood sugar), multiple injections with steroids, and active use of the shoulder too soon after surgery.
Can I do anything to have a better chance to heal well?
Yes, you can do a lot! First of all, if you suspect you have sustained an acute rotator cuff tear, see a shoulder specialist as soon as possible. Secondly, if you have a chronic tear, and get the sense that the way your pain and weakness are evolving, one day you will have surgery, do not delay the surgery unnecessarily: the longer you wait, the more your tendon can retract, and the more your muscle will atrophy, degenerate, and be replaced by fat. Third, if you are planning to undergo surgery, and smoke and/or have diabetes, do not smoke, and keep your diabetes well controlled (if you have diabetes, you know the key words: low hemoglobin A1C, low glucose levels). Finally, if you undergo rotator cuff repair surgery, follow the instructions of your shoulder specialist “to a T”: no one wants to have surgery twice!