Rotator Cuff Tears

Treatment
Surgery
FAQs

The Rotator Cuff (see shoulder anatomy)

The rotator cuff is a group of four muscles and their tendons that attach around the top of the arm bone (humerus) forming a ‘hood’. The rotator cuff holds the ball in the socket providing stability and mobility. By keeping the ball in the socket, it allows the outer muscle (deltoid) to move the shoulder joint in a co-ordinated way.

Above the rotator cuff is a shelf of bone (acromion) which is an extension of the shoulder blade (scapula). This acromion forms a joint (acromioclavicular joint) with the end of the collarbone (clavicle).

Between the rotator cuff and the acromion there is a bursa or cushion of fluid, which allows for smooth movement when the rotator cuff moves against the acromion as the arm is lifted up.

Soft tissue thickening or bony prominences (spurs) under the acromion and acromioclavicular joint can result in irritation of the rotator cuff as it moves under and against the acromion.

Rotator Cuff Inflammation

Narrowing of the space above the rotator cuff can result in mechanical wear and tear. This can lead to inflammation of the rotator cuff and thickening resulting in pain as it moves against the shelf of bone (acromion) when the arm is lifted up. This process is called

ROTATOR CUFF IMPINGEMENT

Rotator Cuff Tears

Arthroscopic view of a rotator cuff tear

In the initial stages of rotator cuff irritation, inflammation of the rotator cuff occurs (TENDONITIS). With continued mechanical wear and normal ageing process of the tendons, erosion of the tendon can occur leading to tears of the tendons. Most tears occur as a degenerative process and only a small percentage of tears are due to an injury. In degenerative tears which occur over a long period of time, the patient’s shoulder may adapt to this and this may not necessarily result in pain. The incidence of tears in the normal aging population is high; i.e this averages 25% in people of 60 years, 40% at 70 years and between 50% -80% at 80 years (this is in people without pain).


MRI scan of a rotator cuff tear

These tears can affect only part of the thickness of the tendon (PARTIAL THICKNESS TEARS) or can extend right through the tendon (FULL THICKNESS TEARS). With time or an injury these tears can extend to affect a larger area of the tendons.








Rotator cuff tear arthritis

In a proportion of people with longstanding tears of the rotator cuff, mechanical wear and tear of the ball and socket joint can occur.

This process is known as ROTATOR CUFF TEAR ARTHRITIS.

How is the diagnosis made?

This is made from the history and examination. Pain is the most common presenting complaint and is usually sited over the shoulder joint itself and can radiate down the arm, into the neck or into the shoulder blade. Some patients only feel the pain over the midpart of the arm with no pain felt in the shoulder itself. Pain is related to movements of the shoulder and in particular movements with the arm overhead, behind the back, when stretching out or when lifting anything heavy.

Most patient feel the pain at night, which disturbs their sleep and can be very distressing. Patients may feel that the arm is weak.

X-ray showing spur of bone on the acromion

The examination is aimed at reproducing the pain and testing the strength of the rotator cuff muscles. X-rays are taken to look at the bony configuration of the shoulder joint, acromion and acromioclavicular joint. The rotator cuff can be viewed with the use of Ultrasound, which can help to diagnose the presence or absence of a rotator cuff tear. Occasionally MRI is used to aid in the diagnosis but in most cases is not necessary.

TREATMENT

NON-OPERATIVE

Initially rest, avoidance of movements that cause pain, anti-inflammatories and physiotherapy are prescribed.

PHYSIOTHERAPY

Physio is aimed at stretching exercises to loosen up the capsule or lining of the joint. Strengthening of the rotator cuff muscles and the muscles that stabilise and move the scapula (shoulder blade).

STRETCHING

This is done in the following ways:

Standing or sitting. Take the hand of you affected arm across your body towards the opposite shoulder. Give gentle assistance with your other arm.

Repeat 10 to 30 times and do 2 to 3 times a day.





STRENGTHENING OF THE ROTATOR CUFF MUSCLES

The function of the rotator cuff muscles is to stabilize and mobilise the shoulder. They keep the ball (humeral head) in the socket. If there is any weakness of the rotator cuff muscles then the humeral head may move slightly abnormally resulting in rotator cuff impingement.

Strengthening of the rotator cuff muscles will help prevent or resolve impingement. This is done by strengthening the muscles that turn the arm outwards (external rotation) and the muscles that turn the arm inwards (internal rotation)

STRENGTHENING OF EXTERNAL ROTATION

Shown for left arm.

Sitting or standing with your elbow bent. Keep your elbow INTO your side.

Hold one end of elastic band – other end fixed. Start with your hand in front of your stomach and pull hand outwards until it is in front of you.

CONTROL the movement on return and do NOT try and pull out too far.

Repeat 30 times

STRENGTHENING OF INTERNAL ROTATION

Shown for left arm.

Stand with arm close to your body and elbow bent.

Hold rubber elastic band – other end of band fixed.

Pull your hand towards your stomach.

Keep the elbow in. Control the movement on return.

Repeat 30 times.

Strengthening exercises may also be done with dumb-bells.

STRENGTHENING WITH DUMB-BELLS:

Repeat 30 times







STRENGTHENING OF SCAPULAR MUSCLES

The scapula function is often altered in impingement with resultant winging of the scapula and altered scapulothoracic rhythm.

Strengthening of the muscles that control scapula movement is important and can be done as follows:

SCAPULA SHRUG

With your feet 3 feet apart and keeping the elbows straight, adjust the rope so the weight is just resting on the ground. Now shrug your shoulders so the weight is lifted off the ground.



WALL PRESS-UPS
With your feet 2 feet apart and hands on the wall in front, bend your elbows till your face almost touches the wall.
Start with doing 10 repetitions and then moving to do 30 repetitions. You should do all these exercises 2 to 3 times per day.




KNEE PRESS-UPS

Start with doing 10 repetitions and then moving to do 30 repetitions. You should do all these exercises 2 to 3 times per day.







CHAIR PRESS-UPS

Start with doing 10 repetitions and then moving to do 30 repetitions. You should do all these exercises 2 to 3 times per day.

If this treatment is unsuccessful, then local anaesthetic and cortisone injections are given.A maximum of 3 of these injections in one course (i.e.: 3 to 4 weeks apart).

These conservative measures will resolve the condition in up to 50- 70% of cases.


SURGERY

Bone anchor and sutures

This is indicated when the condition has been present for over 6 months and has not responded to conservative methods of treatment. It is indicated early when there is an acute tear i.e. tear occurring after an injury.

This is done with arthroscopy or key hole surgery. Usually 4 or 5 keyholes are made and each closed with a single suture or stitch. Surgery involves shaving of bone from the undersurface of the acromion (acromioplasty) to increase the ‘space’ between the tendons and acromion. The end of the collarbone (clavicle) may need to be removed if it has been identified as a source of pain.



The tendons are repaired using anchors in the bone and sutures passed through the tendon. These hold the tendon against the bone till the tendon heals to the bone.

Following a rotator cuff repair, the tendon requires to heal to the bone. Complete healing of the tendon may take up to 6 months but it is sufficiently adherent at 6 weeks to allow active movements of the arm. Thus in the first 6 weeks, patients must keep their arm in and sling and not lift their arms from their side.

REHABILITATION

It is advisable to see a physiotherapist initially to adive and instruct you on the exercises.

Prior to doing exercises, take a pain killer and use ice packs.

It is normal for you to feel aching, discomfort or stretching sensations when doing these exercises. However, you must not hurt yourself and if you experience intense pain then you should reduce or even stop the exercises.

Do short, frequent sessions (e.g. 5 – 10 minutes, 4 times a day) rather than one long session.

The rehabilitation goes through 3 stages:

STAGE 1 – first 6 weeks

As you have to wear the sling for 6 weeks, you may experience spasms in the muscles of the neck, shoulder blade and upper arm. Massage during this period may be very helpful to alleviate these spasms. Just taking your arm out of the sling and straightening the elbow often helps the spasm in the upper arm muscles.

It is advisable to do exercises to keep your neck, shoulder blades, elbows and hands mobile.

NECK EXERCISES

Tilt your head towards one shoulder.
Repeat 5 times.

Then tilt your head to the other side and repeat 5 times.



Turn your head to one side.
Repeat 5 times.

Then turn your head to the other side and repeat 5 times.




SHOULDER BLADE EXERCISES

Sit or stand.

Shrug shoulders up and forwards.

Then roll them down and back.

Repeat 10 times.

Sit or stand.
Shrug shoulders up and forwards.
Then roll them down and back.
Repeat 10 times.





ELBOW EXERCISES

Standing or lying.
Straighten your elbow and then bend your elbow.
Repeat 5 times.

Only passive movements will be done for the first 6 weeks. These passive movements will be shown to you by the physiotherapist

STAGE 2 – from 6 weeks

You may now remove the sling permanently and use the arm as much as possible. Your arm will be stiff and you must start the following exercises to regain the movement.

Lying on your back on a bed or the floor. (Shown for left arm.)
Lift your operated arm with your other arm.
Keep the operated arm as RELAXED as possible.
Can start with elbow bent.
Repeat 5 times.





Lying on back (on bed or floor), towel under arm.
Keep elbow into your side and bent.
Hold stick in your hands.
Move the stick sideways, gently pushing the hand on your operated arm outwards.
Repeat 5 times.



Standing with arms behind your back.
Grasp the wrist of your operated arm.
Gently slide your hands up your back.
Repeat 5 times.
Do not force




Standing facing a wall.
Walk hand up the wall, try and keep shoulder down.
Then take hand away from the wall and try and keep it there.
Hold this for 5 seconds.
Try this with your hand at different heights.
Repeat 5 times (each position)


STAND OR SIT.

Try and set up a pulley system with the pulley or ring high above you.
A simple pulley can be made by using the strap from your sling or a towel draped over a door.
Pull down with your UNoperated arm to help lift the operated arm up.
Repeat 10 times.

STAGE 3 – From 12 weeks

Now is the time to start strengthening exercises as below.

Show for the left arm.

Sitting or standing with your elbow bent.
Keep your elbow INTO your side.
Hold one end of elastic band – other end fixed.
Start with your hand in front of your stomach and pull hand outwards until it is in front of you.
CONTROL the movement on return and do NOT try and pull out too far.

Shown for the left arm

Stand with arm close to your body and elbow bent.
Hold rubber elastic band – other end of band fixed. Pull your hand towards your stomach.
Keep the elbow in.
Control the movement on return.
Repeat 30 times.


PRESS-UPS










Start by doing these against a wall.

Keep your back straight.

Progress to doing from your knees and then doing a full press-up.
Keep your elbows under your body rather than out to the sides.
Repeat 10 to 20 times.


GUIDE TO DAILY ACTIVITIES IN THE FIRST 6-12 WEEKS

*** YOU WILL NEED SOMEONE TO HELP YOU IN THE INITIAL PERIOD ***

Some difficulties are quite common, particularly in the early stages when you are wearing the sling and when you first start to take the sling off.

If necessary an occupational therapist (O.T.) can help you and specialist equipment can be borrowed from the OT.

Below are listed some common difficulties with guides which may help.
Please discuss anything you are unsure about with the staff 1.

GETTING ON AND OFF SEATS.

  1. Raising the height can help e.g. extra cushion, raised toilet seat, chair or bed blocks.
  2. Getting in and out of the bath. Using bath boards can help, though initially you may prefer to strip wash. It will be much easier to shower.
  3. Hair care and washing yourself. Long handled combs, brushes and sponges can help.
  4. Dressing. Wear loose clothing, either with front fastening or that you can slip over your head. For ease also remember to dress your operated arm first and undress your operated arm last. In addition, dressing sticks, long handled shoe horns, elastic shoe laces and a `helping hand’ may help.
  5. Eating. A non slip mat and other simple aids can help when one handed. Use your operated arm once it is out of the sling as you feel able.
  6. Household tasks/cooking. Do not use your operated arm for activities involving weight (e.g. lifting kettle, iron, saucepan) for 8 – 12 weeks. Light tasks can be started once your arm is out of the sling. To begin with you may find it more comfortable keeping your elbow into your side. The devices mentioned above may be obtained from an occupational therapist.

FREQUENTLY ASKED QUESTIONS

Will it be painful?

Although the operation is to relieve pain, it may be several weeks until you begin to feel the benefit. The local anesthetic block will last for between 8 and 24 hours. After this you will be given pain-killers (either as tablets or injections) for the pain. You will be given pain killers to take home with you on your discharge. Even though this is done with arthroscopy (key hole surgery) it is still an operation inside and may be very painful.

A rotator cuff repair can be the most painful shoulder operation; even more painful than a shoulder replacement!

You may find ice packs over the area helpful. Use a packet of frozen peas, placing a piece of paper towel between your skin and the ice pack. Leave on for 10 to 15 minutes and you can repeat this several times a day.

Often patients experience much spasm and pain in biceps muscle and this can be alleviated by simply straightening the elbow.


Do I need to wear a sling?

Your arm will be immobilised in a sling. This is to protect the repair during the early phases of healing and to make your arm more comfortable. You will be shown how to get your arm in and out of the sling by the physiotherapist. You will wear the sling for 6 weeks. You may find your armpit becomes uncomfortable whilst you are wearing the sling for long periods of time. Try using a dry pad or cloth to absorb the moisture. If you are lying on your back to sleep, you may find placing a small towel or pillow under your upper arm will be comfortable.


Do I need to do exercises?

Yes!
To begin with you will be moving the joint only for specific exercises which the physiotherapist will show you. You will continue with these exercises at home for 6 weeks. The physiotherapist will organise to see you as an outpatient or refer you to a physiotherapist near your home.


What do I do about the wound and the stitches?

On the day after the operation, waterproof dressings will be applied to the wounds and you will be able to wash and shower with these on. These waterproof dressings are left on till your follow-up appointment. Occassionally then may need to be changed before follow-up.

Avoid using spray deodorants, talcum powder or perfumes near or on the scar.

The stitches will be removed at your first postoperative visit (8-14 days).

A follow-up appointment with the surgeon will be made for you before you are discharged.


When will I be reviewed by the surgeon?

You will see the surgeon 8 to 14 days after the operation. Further reviews will be at 6 weeks, 3 months then 6 months post-operation. If you have any problems prior to review please do not hesitate to contact the rooms.


Are there things that I should avoid doing?

First 6 weeks:
Do not try and use the arm for everyday activities, ESPECIALLY those taking your elbow away from your body. Keep it in the sling, except when you are doing your exercises. Continue with this until you are told otherwise by the surgeon and physiotherapist. Do not let your elbow move or stretch across the front of your body. This can happen at night when you are lying on your unoperated side. Once you stop using the sling, place your arm on pillows in front of you.

6 weeks and after:
Do not lie on your operated side. After this time be guided by pain.
Avoid lifting any weight for 8 – 12 weeks (e.g. a kettle). This is to avoid stressing the repaired tendons.

Heavier lifting (e.g. digging the garden, manual work) should be avoided for 4 – 6 months

There may be other movements that are restricted for you. You will be told if this is the case. Within these general instructions be guided by pain. It is normal for you to feel discomfort, aching and stretching sensations when you start to use your arm. Do not hurt yourself, and if you experience intense pain the reduce or stop the exercise. In addition avoid sudden, forceful movements involving weight.


How am I likely to progress?

This can be divided into three phases:

PHASE 1. Sling on, no movement except for exercises

You will basically be one-handed, immediately after the operation and for the first 6 weeks. This will affect your ability to do everyday activities, especially if your dominant hand (right if you are right-handed) is the side that has been operated on. Activities that are affected include dressing, bathing, hair care, shopping, eating and preparing meals. If you are having particular problems, an occupational therapist can suggest ways to help you. Before you are discharged from hospital, the physiotherapist will help you plan for how you will manage when you leave. In addition, we may be able to organise or suggest ways of getting help once you are discharged from hospital. Night pain, sleeping on the side and getting your hand up your back take the longest to improve.

PHASE 2. Regaining everyday movements

This starts once you are given the go-ahead by the surgeon and physiotherapist (6 weeks after your operation). You will have outpatient physiotherapy and start exercises to gain muscle control and movement. The arm can now be used for daily activities; initially these will be possible at waist level but gradually you can return to light tasks with your arm away from your body.

PHASE 3. Regaining strength

After 12 weeks you will be able to increase your activities, using your arm away from your body and for heavier tasks. The exercises now have an emphasis on regaining strength and getting maximum movement from your shoulder. There are still some restrictions on lifting.

You are likely to see the most progress in the first 6 months. At times it can feel like a lot of hard work for little in return. Set small, achievable goals and try and keep a positive attitude. You may continue to see improvement in the use of your arm and shoulder for 1 to 2 years following the operation.


When can I return to work?

You may be off work for between 2 -l2 weeks, depending on the type of job you have. If your job involves lifting, overhead activities or manual work you are advised not to do these for 4 to 6 months. Please discuss any queries with the physiotherapist or surgeon.


When can I drive?

This is likely to be 2 – 3 weeks after you have stopped wearing the sling (i.e. between 8 to 9 weeks after your operation).

Check you can manage all the controls and it is advisable to start with short journeys. The seat-belt may be uncomfortable initially but your shoulder will not be harmed by it. In addition, check your insurance policy. You may need to inform the insurance company of your operation.


When can I participate in leisure activities?

Your ability to start these will be dependent on the pain, range of movement and strength that you have in your shoulder following the operation. Please discuss activities you may be interested in with your physiotherapist or surgeon.

Start with short sessions, involving little effort and gradually increase. Patients vary greatly in their speed of recovery and time to return to sport and leisure activities.

General examples:
Gentle swimming – after 6 – 8 weeks
Gardening (light tasks e.g. weeding) – after 12 weeks
Bowls, Golf – after 16 weeks (4 months)
Tennis, Squash, Badminton – after 4 to 6 months.