Rotator Cuff Tear & Surgery

Anatomy of the Rotator Cuff

A group of 4 rotator cuff muscles in the shoulder joint make up the rotator cuff. These include the supraspinatus, infraspinatus, teres minor, and subscapularis. These muscles originate in the scapula and attach to the head of the humerus through tendons. The rotator cuff forms a sleeve around the humeral head and glenoid cavity, providing stability to the shoulder joint while enabling a wide range of movements.

What are Rotator Cuff Tears?

Rotator cuff injuries may occur due to pressure on the rotator cuff from part of the shoulder blade (scapula). It may occur due to repeated use of the arm for overhead activities or while playing sports. A forceful injury such as trauma can cause one or more of these tendons to tear, a condition called rotator cuff tear. Rotator cuff tears are one of the most common causes of shoulder pain in middle-aged adults and older individuals.

Causes of Rotator Cuff Tears

Rotator cuff tears may result from pressure on the rotator cuff from part of the shoulder blade (scapula) as the arm is lifted. A rotator cuff tear may occur with repeated use of the arm for overhead activities, while playing sports or during motor accidents. This may result in a full or partial rotator cuff tear.

The common causes for a rotator cuff tear include:

A blow or injury to your shoulder
Sudden excessive loading of the shoulder joint such as while lifting an object
Sports such as baseball and tennis which can lead to overuse or a torn tendon
Excessive overhead activities such as carpenters and painters
Bone spurs on the acromion
Tendon degeneration due to aging

What are the Common Symptoms of Rotator Cuff Tears?

The most common symptom of a tear, often requiring rotator cuff repair, is pain that is usually over the outer and front portion of the shoulder. It is typically worse when your shoulder is moved in certain positions. Other symptoms include:

A dull pain deep in the shoulder emanating from the damaged rotator cuff tendon
A tearing sensation or popping sound in your shoulder
Muscle weakness, particularly when lifting the arm affected by the damaged rotator cuff tendon
Pain in the night that stops you from sleeping on the affected side

What are Massive Rotator Cuff Tears?

A tear in the rotator cuff can cause pain and disability. It can occur from degeneration of the rotator cuff due to overuse or from a sudden injury. Massive rotator cuff tears involve tears in two complete tendons of the rotator cuff. A tear of more than 5 cm is described as massive. A massive tear may be associated with degeneration and retraction of the tendon and can be difficult for rotator cuff repair if any treatment is delayed.

Complications of Massive, Retracted Rotator Cuff Tears

Massive rotator cuff tears may be associated with:

Fatty infiltration of muscle (accumulation of fats) causing loss of elasticity
Humeral head subluxation (partial dislocation)
Impingement of tissues
Formation of bone spurs
Osteoarthritis

What is Rotator Cuff Surgery?

Rotator cuff surgery is a surgical procedure to repair an injured or torn rotator cuff. The surgery may be performed as an open procedure or as an arthroscopic rotator cuff repair, depending on the severity of the tear, which can be a massive or partial tear.

When Do I Need Rotator Cuff Repair Surgery?

Your doctor may recommend a rotator cuff repair surgery in the following scenarios:

Your symptoms have lasted for 6 to 12 months
You have a significant loss of function and weakness in your shoulder
You are an athlete and wish to return to sports soon
Your rotator cuff tear is larger than 3 centimetres
Non-surgical treatments have failed to alleviate symptoms

What are the Preoperative Preparations Involved with Rotator Cuff Repair Surgery?

In general, preoperative preparation for rotator cuff muscle surgery may include:

A thorough history and physical examination
Routine blood work and imaging
Refraining from certain medications like blood thinners, aspirin, or NSAIDs
Informing your doctor of any allergies to medications, anaesthesia, or latex
Refraining from solids or liquids at least 8 hours prior to surgery
Arranging for someone to drive you home following surgery
Signing a consent form after the risks and benefits of the surgery have been explained

How is the Rotator Cuff Surgery Performed?

Rotator cuff repair can be accomplished either arthroscopically or with a traditional open surgical approach, alleviating rotator cuff problems.

Arthroscopic Rotator Cuff Repair

Rotator cuff surgery is usually performed as arthroscopic shoulder surgery. This is a minimally invasive surgery performed through tiny incisions, about 1 cm each, with an arthroscope – a small fibre-optic viewing instrument made up of a tiny lens, light source, and video camera. The surgery is performed under general or regional anaesthesia and involves the following steps:

2 to 3 incisions are made on the skin near the shoulder joint.
An arthroscope is inserted through one of the incisions.
The camera attached to the arthroscope displays the image of the shoulder joint on a monitor, allowing your surgeon to determine the amount of damage and type of injury present. Miniature surgical instruments are inserted through the other incisions to remove the damaged part of the tendon and injured surrounding tissue.
The damaged ends of the torn rotator cuff tendon or tendons are sewn together. A suture anchor may be used to reattach a completely torn rotator cuff tendon to the upper arm bone.
The incision is closed and covered with a bandage.

Open Rotator Cuff Repair

A traditional open surgery is warranted if the rotator cuff tear is large or complex. The surgery is done under regional or general anaesthesia. A large incision is made over the affected shoulder joint and the underlying muscles are separated to expose the torn rotator cuff tendons. The extent of rotator cuff damage and type of injury is assessed, and suitable correction is carried out accordingly. The incision is closed and covered with a bandage.

How Long Does the Surgery Take?

An arthroscopic rotator cuff surgery may take around 1 to 1.5 hours, whereas an open surgery may take around 1.5 to 2 hours. Surgery time may vary slightly based on the complexity of your injury and the procedures required on the shoulder joint.

How Many Days of Hospital Stay Do I Need After Surgery?

For an arthroscopic rotator cuff surgery, you may need an overnight stay in the hospital and then discharged on the following day, whereas an open surgery may require at least 2 to 3 days of hospital stay.

What Does Recovery Involve after Rotator Cuff Injury Surgery?

After the surgery, pain medications and antibiotics are prescribed to control shoulder pain and prevent infection. You may also apply ice packs on the shoulder to help reduce swelling and pain. Your arm will usually be secured in a sling/immobilizer for 4 to 6 weeks to facilitate healing and protect the repair of the torn tendon. The rehabilitation program includes physical therapy, which is started soon after the rotator cuff injury surgery and is very important to strengthen and provide mobility to the shoulder. You should avoid strenuous activities and lifting heavy weights for a time specified by your doctor or physical therapist. Instructions on surgical site care and bathing will be provided to keep the wound clean and dry. You should be able to perform gentle daily activities in a couple of weeks after surgery. You can expect to return to the office/work in 2 weeks, return to driving after 2 months, and fully recover by 3 to 6 months.

What are the Benefits of Rotator Cuff Surgery?

The benefits of arthroscopic repair compared to open repair, include the following:

Smaller incisions
Minimal soft tissue trauma
Less pain
Lower infection rate
Less scarring
Earlier mobilization
Shorter hospital stay

What are the Risks and Complications of Rotator Cuff Surgery?

Rotator cuff surgery is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as the following:

Infection
Bleeding
Inflammation
Damage to nerves or blood vessels
Blood clots or deep vein thrombosis (DVT)
Shoulder stiffness
Allergic or anaesthetic reactions