Rotator Cuff Tears
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; ac 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.
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Rotator Cuff Inflammation and Tears
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.
Diagnosis
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.
The examination is aimed at reproducing the pain and testing the strength of the rotator cuff muscles.
Investigations
X-rays are taken to look at the bony configuration of the shoulder joint, acromion and acromioclavicular joint. A spur of bone may be present. 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 & Post-Surgery Exercises
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
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.
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.
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.
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.
- Raising the height can help e.g. extra cushion, raised toilet seat, chair or bed blocks.
- 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.
- Hair care and washing yourself. Long handled combs, brushes and sponges can help.
- 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.
- 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.
- 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 done to relieve pain, it may several weeks until you begin to feel the benefit. The local anaesthetic block will last for between 8 and 24 hours. After this you will be given pain-killers. You will be given pain killers to take home with you on your discharge (or a script as some medical aids do not pay for ‘take home’ medication). Although the operation is done with arthroscopy (key hole surgery), it is still an operation inside and may be very painful.
An ice packs over the shoulder is often helpful. Leave this on for 10 to 15 minutes and repeat several times a day.
Much spasm and pain maybe felt over the biceps muscle and this can be alleviated by taking off the sling and simply straightening the elbow.
Different people recover at different rates so never compare yourself to someone who has had a similar operation.
Complete recover may take up to 6 months with some patients taking up to a year. Most patients will feel improvement by 6 week and complete recover by 3 months.
Yes! You will be shown exercises by the physiotherapist in the hospital the day after the operation and you will need to continue with the exercises once you go home. They aim to stop your shoulder getting stiff and to strengthen the muscles around your shoulder.
The physiotherapist will arrange an appointment to see you as an outpatient or will refer you back to your own physio or one near your home.
Waterproof dressing will be applied to the small wounds on the day after the operation and you will be able to wash and shower with these on.
Avoid using spray deodorant, talcum powder or perfumes near or on the wounds until they are well healed (usually by 10 days).
When will I be reviewed by the surgeon?
You will see the surgeon 10 to 14 days after the operation and your dressings will then be removed. The wounds will be healed by that time and your stitches will be removed.
Are there things that I should avoid?
Generally there are no restrictions to movement in any direction.
You will be encouraged to use your arm normally below shoulder height.
Gradually the movements will become less painful.Avoid heavy lifting for 3 week.
Be aware that activities at or above shoulder height stress the area that has been operated on. Do not do these activities for 3 weeks. Try and keep your arm out of positions which increase the pain.
Patients progress at different rates. The discomfort from the operation will gradually lessen over the first few weeks. You should be able to move your arm comfortably below shoulder height by 2 – 4 weeks and above shoulder height by 6 weeks.
The things that take the longest to improve are night pain, being able to sleep on that side and getting your hand up your back (i.e. to fasten your bra).
Complete relief pain may take up to 6 months (80% of people have complete relief by 6 months according to research). However, there may be improvements for up to 1 year.
This will depend on the type of work you do. If you have a job involving arm movements close to your body you may be able to return within a week (i.e. using a computer). Most people return within 2 weeks of the operation but if you have a heavy lifting job or one with sustained overhead arm movements you may require a longer period off work. Please discuss this further with the surgeon or physiotherapist if you feel unsure.
When can I participate in my leisure activities?
Your ability to start these activities will be dependent on pain, range of movement and strength. Nothing is forbidden, but it is best to start with short sessions involving little effort and then gradually increase the effort or time for the activity. However, be aware that sustained or powerful overhead movements (e.g. trimming a hedge, some DIY, racket sports etc.) will put stress on the subacromial area and may take longer to become comfortable. You may be unable to do these for 4 months post operation.
You can drive as soon as you feel able. This is normally within 2 weeks. Check you can manage all the controls and it is advisable to start with short journeys.
Surgery procedure
Shoulder Arthroscopy
Most surgical procedures of the shoulder are now performed with arthroscopy. This involves the inserting of a telescope (fibre optic) through a thin tube in small incisions around the shoulder. The incisions are between 0,5 to 1,0 cm in size and between 2 and 6 incisions are used depending what operation is done. A single stitch or suture is used to close the incisions after the operation.
This is less invasive but the operation inside is the same as those done with an open operation and thus recovery may still take months depending on the procedure performed.
ARTHROSCOPIC PUMP
To facilitate the arthroscopic (keyhole) surgery, fluid is pumped into the shoulder. This opens the spaces in the shoulder and prevents bleeding. During the procedure some fluid leaks into the tissues around the shoulder which can become very swollen. This fluid is absorbed over the following few hours and patients may find that they pass more urine during this period as this fluid is excreted. Some of this fluid which is blood stained leaks out the small incisions and an absorbent dressing (nappy) is strapped to the shoulder. This is left on overnight and is replaced with small waterproof dressings the next morning so that the patient can shower normally.
This bloody fluid tracks down between the skin layer and muscle and patients may develop quite marked bruising down their arm and over their chest/breast during the week following the operation. This bruising will disappear over 2 -3 weeks.
ANAESTHESIA
This is done with a general anaesthetic and a regional block. It can be done with a block alone but the patient is placed into a seated position on the operating table which can be uncomfortable and thus a general anaesthetic is preferred. The block is done with local anaesthetic injected into the side of the neck where the nerves to the arm are passing. This provides excellent pain relief during the operation thus less anaesthetic drugs are required, patients thus wake up quite refreshed afterwards. The block provides excellent relieve of pain after the operation and lasts for between 8 and 24 hours. The arm may be completely dead and the patient may not even be able to move their fingers initially. Care must be taken not to put anything hot on the arm as this will not be felt and a burn may occur. In approximately 1% of cases there may be a persisting area of numbness in the arm, forearm or hand which usually disappears within 3 months. Occasionally neuralgia (nerve pain) may occur after the block and may require medication till it settles of its own accord.
HOSPITAL STAY
Patients come in on the day of the operation and may be discharged a few hours after the operation or may stay overnight depending on the operation performed and how they are feeling.
MEDICATION
An anti-inflammatory and a pain killer are prescribed. The anti-inflammatory is taken for a week and the pain killer if and when necessary. Most patients take the pain killer for an average of 5 days after the operation. Some patients however don’t take any medication whereas other patients may need pain killers for up to 6 weeks. This is dependent on the individual and the operation performed. More pain is usually felt following a rotator cuff repair. Patients often struggle to sleep initially and a sleeping tablet may be required.
SLEEP
Patients often have difficulty sleeping and besides taking sleeping tablets, sleeping propped up with pillows or sleeping in a chair will be easier. A recliner (lazy boy chair) will often be the best option.
Anaesthesia
The anaesthetist will see you in the ward prior to the operation or in the reception room in theatre. If you have medical problems; eg: heart condition, previous cardiac surgery, chest disease (eg: emphysema), you will be referred to a physician for an assessment and may see the anaesthetist a few days prior to the operation. A premed is sometimes given prior to theatre which will make you a little drowsy and relaxed. In theatre you will sit on the theatre table and make yourself comfortable prior to the induction of anaesthesia. A drip will be inserted into your arm through which the anaesthetic drugs are administered. Gases will be given by a mask and once you are asleep a tube will be inserted into your throat, this is why you may have a sore throat for a short time after the operation.
The anesthetic is a general anaesthetic with a regional block. It can be done with a block alone but you are placed into a seated position on the operating table which can be uncomfortable and thus a general anaesthetic is preferred. The block is done with local anaesthetic injected into the side of the neck where the nerves to the arm are passing (essentially an epidural of the arm). This provides excellent pain relief during the operation thus less anaesthetic drugs are required; you tend to wake up quickly and are quite refreshed afterwards. The block provides excellent relieve of pain after the operation and lasts for between 8 and 24 hours. The arm may be completely dead and you may not even be able to move your fingers initially. Care must be taken not to put anything hot on the arm as this will not be felt and a burn may occur. In approximately 1% of cases there may be a persisting area of numbness in the arm, forearm or hand after the block has worn off. This numbness will usually disappear within 3 months. Occasionally neuralgia (nerve pain) may occur after the block and may require medication till it settles of its own accord. Although extremely rare, permanent nerve damage has been reported.
You tend to wake up very quickly after the operation and may eat soon afterwards. The drip will be taken down when you are back in the ward. The block provides excellent pain relief for between 8 and 24 hours but pain killers and anti-inflammatories are started before the block wears off so that they are already working when the pain starts. Patients vary in the amount of pain killers that they need; some don’t need to take any whereas others may need to take them for up to 6 weeks.
