Rotator Cuff Repair

What Causes a Rotator Cuff Injury?

Younger patients who play throwing and overhead racket sports such as baseball, tennis and badminton, may be at risk of rotator cuff injury. Usually, a small partial thickness tear may occur in the supraspinatus tendon which can progress with time to become a full thickness tear. Other causes of rotator cuff injury are a fall onto an outstretched arm. In older patients, rotator cuff tears can occur without a sudden injury.

There are two main causes of rotator cuff tears: injury and degeneration.

Acute Tear

Acute tears are caused by accidents. Traumatic injuries which often cause a broken collarbone, a dislocated shoulder, or a wrist fracture can also cause damage to the rotator cuff. Acute tears are typically caused by a fall onto an outstretched arm or the improper lifting of heavy objects.

Degenerative Tears

Degenerative tears are caused by the wearing down of tendons as one ages. In older patients, rotator cuff tears can sometimes occur without a traumatic injury; and usually in their dominant arm.

Degenerative tears can be caused by different factors, such as:

• Repetitive Stress – Repeatedly performing the same shoulder motions can stress the muscles and tendons of the rotator cuff. Rotator cuff tears arising from repetitive stress are common among people with jobs that require them to repeat the same shoulder and arm motions, such as painters.

  Younger patients who play throwing and overhead racket sports such as baseball, tennis and badminton, are also at a higher risk of rotator cuff injury.

• Insufficient Blood Supply – Good blood supply allows the muscles and tendons to repair themselves. However, as people age, the blood supply in the rotator cuff decreases, thereby increasing the risk of tears.

What are the Different Types of Rotator Cuff Injuries?

Rotator cuff injuries can be categorised into the following:

• General Wear and Tear – This refers to tears that may occur to older adults, or to people who perform repetitive overhead movements, such as athletes and labourers.

• Tendonitis – Tendons in the rotator cuff can become inflamed due to overuse or overload. This condition is common among athletes who participate in swimming and tennis.

• Bursitis – The bursa are small, fluid-filled sacs that protect the rotator cuff. They can become irritated by repetitive movements, overuse, or injury.

• Tendon Strain or Tear – The tendons are fibrous connective tissues that attach muscle to the bone. A strain or tear in the tendons of the rotator cuff can be caused by a sudden injury or overuse.

• Shoulder Impingement – This occurs when a tendon in the shoulder rubs against, or catches on, nearby tissues and bones. This results in pain in the shoulder, especially when lifting the arm.

How Will I Know I Have a Rotator Cuff Tear?

You will have a painful shoulder and weakness of movement. Typically pain is on the outside of the shoulder, worse on raising the arm and at nighttime. There may be weakness in lifting the arm, or rotating your arm away from the body with the elbow bent.

Your orthopaedic doctor should examine you carefully and may request an Xray and MRI scan of your shoulder.

Do I Need Rotator Cuff Repair Surgery?

I usually recommend a trial of non-operative management which may involve painkillers, physiotherapy and a steroid injection to the shoulder. Those who do not improve may benefit from surgery.

One important exception is a sudden full thickness tear following injury, of a previously normal shoulder, with inability to lift the shoulder. In this instance surgery is recommended, as delay may worsen the problem.

What are Non-Surgical Treatments for Rotator Cuff Injuries?

If the rotator cuff injury is mild to moderate, the orthopaedic doctor may recommend non-surgical options like:

• Rest and Physiotherapy – Orthopaedic specialists recommend resting to lessen the pain and swelling caused by a rotator cuff injury. Additionally, physiotherapy can help improve strength and functionality of the shoulder.

• Nonsteroidal Anti-Inflammatory Medicines – Doctors may prescribe nonsteroidal anti-inflammatory drugs which reduces pain and swelling.

• Steroid Injections – In some cases, the patient may be given steroid or corticosteroid injections directly into the shoulder joint. These have anti-inflammatory properties and can usually relieve pain effectively.

What are the Different Types of Rotator Cuff Surgery?

If non-surgical methods are unable to address the rotator cuff injury and symptoms get worse as time passes, patients may be advised to undergo rotator cuff surgery. Surgeons may perform different types of rotator cuff surgery, such as:

• Traditional Open Repair – Open rotator cuff repair involves a larger incision on the shoulder to gain full and direct access to the rotator cuff before treating the damaged parts. Surgeons usually use this approach in cases of severe tears.

• Arthroscopic Repair – An arthroscopic repair is minimally invasive and is used for patients with small- to medium-sized tears. Here, the surgeon creates small incisions around the shoulder before inserting an arthroscope (a specialised instrument attached to a light and camera), allowing him or her to get a clear view of the internal structures while performing the surgery.

• Mini-Open Repair – This uses smaller incisions than traditional open surgery, and the surgeon will not have to detach the deltoid muscle; which means that the surgery is less risky and allows for a faster recovery. The surgery is initially performed arthroscopically with the option to make an open incision thereafter, if needed.

What Happens During Rotator Cuff Surgery?

You will be asleep during the operation, and I make several small keyhole incisions around your shoulder. I look at your shoulder using a camera (arthroscope). Using the small incisions, I place small screws (anchors) into the bone. Small ropes (sutures) are attached to the anchors, and are used to tie the torn rotator cuff into a secure and stable position. Surgery takes around an hour and your will wake up with your arm in a special sling (abduction brace).

What is the Recovery Period Like?

Most people go home the following day, although some are well enough to go home the same day. The exercise program you are prescribed depends upon the severity of injury and quality of tissue. Most wear the abduction brace for around six weeks. Initially you will begin with passive exercises, and progress onto active motion exercises. Finally you will move onto light resistance and strengthening of your rotator cuff.

Immediate use of the elbow, wrist, and hand when sitting may be allowed for simple daily activities, such as holding a phone, whilst eating, and showering. You MUST keep the elbow on the side of the affected shoulder against your side at all times when the abduction brace is not in place.

At three months, most patients are allowed to use the shoulder for light activities above shoulder height. At six months, more vigorous activities are permitted. An extended period of time may be needed to regain strength and stamina in the affected shoulder.

Return to work is depends on your job, and can range from one week for office workers, to six months for jobs involving heavy overhead lifting or strenuous overhead sports. Following a supervised program of physiotherapy is extremely important to achieve a good result.