What is the Rotator Cuff?
The rotator cuff is a group of four tendons and their related muscles (Supraspinatus, Infraspinatus, Teres Minor, and Subscapularis) that surround the shoulder joint. These are relatively small muscles that help stabilize the shoulder joint. They also help with motion and rotation of the shoulder.
Is a Rotator Cuff Tear Common?
Pain and weakness due to a rotator cuff tear is one of the most common causes of shoulder pain. A rotator cuff tear can be the result of a fall or traumatic injury; however, most tears develop more gradually. Rotator cuff tears are seen more frequently in patients over age 40.
Can a Rotator Cuff Tear Heal without Surgery?
No, however, not all rotator cuff tears require surgery. Many patients with small tears who are not having pain or weakness may do well without surgery. We may recommend arthroscopic rotator cuff repair if you are having pain with overhead use of your arm, difficulty with sleep because of your shoulder, and weakness in the arm. Other available options including no treatment, physical therapy, and pain medication may be appropriate in some circumstances.
Can the Rotator Cuff Tear become worse over time?
Yes, rotator cuff tears may enlarge over time resulting in atrophy (shrinking) of the rotator cuff muscles and gradual loss of strength and motion. Typically this happens very slowly over a period of years. Patients who have torn the rotator cuff due to a sudden injury or trauma are at a greater risk for having this process occur more quickly. For these acute tears we recommend early surgical repair to preserve as much strength and function as possible.
Can the Rotator Cuff Tear always be repaired?
In the vast majority of cases the rotator cuff tear can be repaired. A very small number of patients have such advanced atrophy of the rotator cuff muscles that a repair is not possible. In these cases we may recommend other procedures to help provide pain relief and increased function.
As part of the aging process or due to a gradual loss of muscle tissue after a rotator cuff tear the muscle can waste away. The “use it or lose it” theory says that because the rotator cuff is torn the muscle is not able to have any use or stress to keep it healthy. Sometimes a “pinched nerve” can cause muscle wasting as well. We typically recommend an MRI before proceeding with surgical repair especially in chronic tears to better advise you about the chances for successful repair. Also, the amount of atrophy can help us advise you on the amount of strength return you can expect after repair.
What are the advantages of arthroscopic repair?
Arthroscopic repair allows us to evaluate and treat the entire shoulder joint and rotator cuff without damaging normal muscles and tissues.
As the surgery is performed through several small stab incisions (<1″) a large incision is not required. This results in minimal scarring and a much lower risk of infection and stiffness. Patients typically report much faster functional recovery and satisfaction. As nearly 50% of patients with rotator cuff tears also have other treatable pathology (scar tissue, frozen shoulder, biceps fraying) these are easily addressed at the time of arthroscopic repair letting patients start their rehabilitation with more confidence.
How is arthroscopic repair performed?
Arthroscopic repair is designed to restore normal tension in the rotator cuff muscles in order to restore function. Small absorbable anchors are placed in a way to oppose the natural pull of the rotator cuff muscle.Sutures are precisely placed in the rotator cuff tendon to restore the anatomy and neutralize the pull or shear of the rotator cuff muscles.This limits the stress on the tendon allowing it to heal back to the bone. For more detail please refer to our technique for Arthroscopic Rotator Cuff Repair.
How successful is arthroscopic rotator cuff repair?
Arthroscopic rotator cuff repair almost always results in excellent pain relief. The level of strength return as we outlined earlier is more variable and dependent on the quality of the rotator cuff muscles and tendons.
No surgical procedure is successful in all cases, however, we utilize the most advanced and reliable procedures available and will do everything possible to provide you with the best outcome. We have performed over 1000 arthroscopic repairs and find our technique is successful in 94-98% of cases. View our published results here, here, here and here.
What are the most common risks and reasons for failure in your experience?
In our experience the most common reasons for failure are an accident or inadvertent use of the arm during the healing period (about 5%) and stiffness (1-3%). It is very important to not use your arm or move it without help for the first six weeks after surgery. It is also very important to not tighten the muscles in your shoulder and hold it splinted at your side all the time. The primary goal is to relieve all tension in your shoulder and arm and allow it to simply hang at your side. Wearing the sling for the first six weeks is also very important. It helps support the weight of your arm allowing the rotator cuff repair to heal without tension or stress. Please review your preoperative program as this will help you understand what to expect and greatly improve your chances for success.
Patients who have a “pinched nerve” along with the rotator cuff tear are also at a higher risk for pain and stiffness after shoulder surgery. If you have had a history of neck pain, carpal tunnel, or numbness and tingling in your shoulder, arm or hand please let us know before surgery. We find that addressing these before proceeding with shoulder surgery results in improved outcomes. We may ask you to have a special nerve test (EMG/NCV) and x-rays to help us confirm the diagnosis during your evaluation. We also specialize in treating patients with previously Failed Rotator Cuff Repair.
When can I return to work?
We recommend taking at least one week off from work. If your work involves sedentary work with no pushing, pulling, lifting or twisting you may return to work within one week.
You may drive a car with automatic transmission after one week, but this may be difficult. Practice before surgery to see if this is something you can do without using your operative arm at all. You may be safer making arrangements for a ride for the first 4-6 weeks after surgery.
Be careful to let your harm hang free in the sling and not move it without help. You will also want to allow some time every hour or two to perform your postoperative stretching program. No lifting, pushing, pulling, or twisting is allowed with your arm for six weeks following surgery. During this time only the postoperative stretching program and complete relaxation of your shoulder is recommended.
If your work involves lifting, pushing, pulling, or other strenuous activity even with your other (non-operative) arm, we recommend making arrangements for sedentary or modified duty with restrictions including no use of your operated arm and less than 1# lifting with your non-operative arm for six weeks.
Return to full unrestricted work typically takes 12-16 weeks from the date of surgery.
What about rehabilitation?
Understanding and following your rehabilitation program is crucial to your recovery. As the rotator cuff is unique in that it lies between two bones, tension and guarding after surgery can reduce this space pinching the rotator cuff causing pain and stiffness. The main goal of rehabilitation especially during the first six weeks is to increase this space for the rotator cuff by relaxing your arm and shoulder.
This allows the rotator cuff to heal without tension or stress. The postoperative stretching program is designed to maintain your range-of-motion without creating tension or stress on the repair. It is important to perform the stretches at least 5-8 times daily for a few minutes at a time. We find that this not only helps the shoulder feel better, it also maintains your range-of-motion.
Why is it important for me to not use my arm muscles during the first six weeks?
As these pictures show, the deltoid (large triangular muscle surrounding the shoulder) supports 3.5 times your body weight when it works to support just the weight of your arm. This reduces the space for the rotator cuff and can increase pain and stiffness after surgery. Relaxing these muscles, letting your shoulder hang freely and making sure all movements of your affected arm are done with the help of someone else, your other arm, or gravity are the best ways to help yourself recover faster.
It is the best thing you can do to speed up your recovery!