Rotator Cuff Tear

The rotator cuff can be acutely injured and torn by trauma (such as from falling onto the shoulder) or by chronic inflammation, age related degeneration and overuse.

A torn tendon can lead to a painful weak shoulder that makes it difficult to lift your shoulder out from your side.

Cuff tears can be either partial thickness or full thickness.

Opinion on the management of rotator cuff tears can vary between surgeons and is influenced by their training, their interpretation of the available literature and the techniques and resource available to them. I believe that if a tendon is torn and has been symptomatic then it should be repaired. A complete rotator cuff tear will not heal. Complete ruptures require surgery to return your shoulder to optimal function.

If left untreated partial thickness articular sided tears can progress to full thickness tears. When a full thickness tear is present the rotator cuff muscle gradually atrophies and becomes infiltrated with fat. These changes are irreversible, however repair of the torn tendon can prevent further progression and atrophy of the rotator cuff muscle.

Once clinical examination suggests the presence of a rotator cuff tear, my practice is to request an MRI scan. This provides information on the size of tear and quality of remaining muscle. It helps formulate a treatment plan and aides in decision to operate. If the muscle is too atrophied and infiltrated with fat then there may be no benefit to be gained from reconstructive surgery.

Post operatively your repair needs protected in a sling. Experimental evidence has shown that it can take up to 12 weeks for the new bone-tendon interface to mature and attain maximum strength.

Fatty Atrophy

Rotator Cuff Repair (Arthroscopic)

A rotator cuff repair involves mobilizing the retracted torn tendon, pulling it back to its anatomical insertion and securing it to bone via sutures and bone anchors. I perform this procedure arthroscopically because this method allows me to treat more complex tears safely.

The first stage in rotator cuff repair is subacromial decompression. Two to three additional 5mm incisions are usually.

Next the cuff is mobilized and the tear characteristics and pattern identified. The footprint (broad insertion area) of the torn tendon is roughened and microfractured to promote increased vascularity at the insertion site and improve bone – tendon interface healing. Bone anchors with sutures are inserted into the bone and finally the tendon is sutured back in place.

Occasionally the rotator cuff has been torn for so long that it is retracted too far and cannot be pulled back to its insertion point even with extensive mobilization. In these circumstances it is sometimes possible to advance a neighbouring tendon forwards or perform other salvage procedures arthroscopically to achieve improvement in function of the shoulder.

Post-operative Care

Immediately following your surgery:

- you will have an absorbent dressing covering you shoulder for 24 hours to absorb the arthroscopic fluid that was pumped through your shoulder during the procedure.
- you will have an icepack to help reduce post op inflammation. I recommend it is applied for 30-45 minutes and then removed for 2 hours before being re-applied. This has been shown to be effective for up to 72 hours post surgery.
- your arm will be supported in an Abduction Brace. This is both for pain relief and to protect the repair site. It is necessary to wear this sling for 4-6 weeks depending on the quality of the underlying tendon and bone-tendon interface.
- Physiotherapy can commence when the post-operative pain begins to settle. It is important to be guided by your therapist and not to overdo your exercises.

Post-operative physiotherapy program.

I use two different rehabilitation programs, depending on quality of the torn tendon and security of the repair.

Accelerated Rehabilitation

Standard Rehabilitation

Following discharge from hospital you will have regular outpatient review until your symptoms are significantly resolved.

Outcome

Successful tendon repair not only requires a high quality technical repair, but relies upon the patient’s own healing response, to heal the tendon to bone.
Outcome can be variable because it is dependent on patient age, size and chronicity of the tear, and muscle degeneration and atrophy.
Patients with good quality bone and tendon that can be brought easily to the insertion area can expect a success rate of 85% - 90%. In patients who have poor quality irreparable tissue, the majority still experience an improvement in their symptoms if they are carefully selected for surgery.

Timetable for Recovery

Accelerated Rehabilitation Program
Weeks 1 -3 Pendular exercises
Weeks 3 - 6 Gentle Isometrics
Week 6 + Begin Active movements and RD strengthening

Return to Function
Driving 6 /52
Golf 3/ 12

All milestones are delayed by 2 weeks in patients who are on standard (non accelerated ) rehabilitation program.

Complications of Surgery

Complications are rare but can include:

Post operative stiffness – usually temporary and responds well to steroid injection
Infection – very rare in keyhole surgery.
Nerve irritability.