The rotator cuff are a group of small muscles which originate on the surface of the shoulder blade and which attach to the upper part of the humerus (arm bone) just beyond the joint surface. As the muscles get close to their attachment points they become thicker tendons and become one more or less continuous sheet of tendon. This is where trouble can occur, mainly in middle age and beyond.
The rotator cuff is a common source of shoulder pain. It is prone to overuse, tendonitis and tears. Tears can occur via a sudden force or might occur without being noticed, slowly over the years as part of the aging process. It is common for a tear to be picked up incidentally on a scan without there being any history of an injury. Most of us will have a tear by the time we are 80.
The size of a tear can vary from pinhead size to a few centimetres. The symptoms can range from a minor niggle to severe pain and weakness. Symptoms don’t necessarily correlate with the size of a tear and there is much that we still don’t know about why some tears are painful and others are not. Tears don’t tend to heal themselves but it doesn’t necessarily follow that all tears need an operation.
A repair is more likely to be beneficial if the tendon is repairable and resilient enough that it won’t tear again. Patient age, the circumstances in which the tear occurred, severity of symptoms and the size of the tear are some factors that need to be considered. The decision to proceed to repair is very much a collaborative one. Sometimes, the most appropriate decision is to not operate.
Surgery and recovery
The surgery is performed under a general anaesthetic. The anaesthetist will also administer a local anaesthetic nerve block which will help with pain in the first 48 hours.
In most cases, a shoulder arthroscopy will be performed and spurs which might impinge or dig down into the tendons are removed. Depending on which approach I think will afford the best outcome, the rotator cuff tear will either be repaired arthroscopically via tiny incisions, or via one open incision. Small screws are inserted into the bony attachment points for the tendons. The screws have sutures attached and these are then passed through the tendon so that we are reattaching the tendon to the bone. Mother nature then takes over and gradually, over several months, forms lasting connections between the tendon and bone.
A sling will be required for 6 weeks, but during this time you will commence certain exercises. Stretches, exercises and physiotherapy will continue for 3 to 6 months and you will need to be cautious while the tendon heals. The shoulder will usually feel relatively free of pain by 3 months postoperatively. Further improvements in strength and function will occur over several months.