Reading
Berkshire
Harley Street
London
Rotator Cuff tear
What?
The rotator cuff are a group of four muscles that control your shoulder movements. Each muscle is attached to your humeral head (Ball of the shoulder joint) via a tendon.
The most common tendon to be torn is the 'Supraspinatus' which sits on the top of your shoulder joint working to enable you lift your arm.
Why?
Your rotator cuff can be torn after a fall or an injury ' Acute tear' or more progressively from wear and tear 'Chronic tear'. Furthermore, tears can be full thickness or partial thickness. Generally it is full thickness tears that we worry about.
Symptoms caused by a rotator cuff tear are generally around the shoulder and arm. You may you have weakness with lifting your arm, pain on sleeping on the affected shoulder, pain and weakness with lifting objects.
Pain and weakness is caused by a mixture of inflammation and inability of your other shoulder muscles to compensate for the torn muscle tendon.
Who?
Rotator cuff tears are very common in the general population. 20-25% of the population can have a rotator cuff tear on a scan, many of whom have no symptoms. The incidence of tears increases rapidly with advancing age.
Generally patients fall into two groups; those with Acute tears after an injury and those with chronic tears from 'wear and tear'. The vast majority of patients with an Acute full thickness tear will require surgical repair and should consult a Shoulder specialist reasonably soon.
Patients with a chronic tear generally have progressive symptoms over a longtime. The first line of treatment is usually a Cortisone/ Steroid injection followed by physiotherapy. If after 3- 4 months or so your symptoms have not resolved and are affecting your quality of life then it would be reasonable to have a discussion with a shoulder specialist about rotator cuff repair surgery.
How?
DIAGNOSIS:
The diagnosis of a rotator cuff is made by taking a history ' asking you a set of questions' and examining your shoulder.
Generally the key symptoms is pain in your shoulder which goes down the side of your arm and the key test is weakness trying to lift something with your arm in front of you with your thumb pointing down 'Empty can test'.
To confirm the condition of your rotator cuff you will either be referred for an Ultrasound scan or an MRI scan. This will confirm if you have a partial or full thickness tear, the size of the tear (Small, medium, large, massive) and how many of the cuff tendons are torn.
SURGICAL TREATMENT:
Rotator cuff repair can be performed either open (Incision) or arthroscopic 'keyhole' using a camera to repair the tendon back to its insertion 'footprint' on humeral head. My preference arthroscopic surgery as this reduced post -operative pain and wound complications.
Suture anchors are used which essentially are made of a bio- compatible plastic material to secure the tendon.
In a small number of patients the rotator cuff tear is very extensive and requires additional Augmentation using special dermal 'skin' graft. This will be discussed with you in detail before surgery if it will be required.
IF YOU HAVE BEEN TOLD YOU HAVE AN IRREPARABLE ROTATOR CUFF TEAR AND WHAT FURTHER INFORMATION PLEASE CLICK THE LINK.
Me?
TREATMENT OPTIONS:
The decision to undergo an arthroscopic rotator cuff repair is yours and my duty as your surgeon is to help guide you. My general guidance to patients is surgical repair for traumatic/ acute full thickness rotator cuff tears. The ideal time frame for surgery is within 3 or 4 months from injury if not sooner.
Chronic (wear and tear) rotator cuff tears only require surgical repair once you have failed to improve with non- operative treatment measures which include at least one cortisone/ steroid injection, physiotherapy and pain killers.
Many patients with chronic rotator cuff tears can have a shoulder that functions completely pain free, especially if their physical demands are low.
If you are diagnosed with a rotator cuff tear and do not have surgery the estimated risk of the tear increasing in size is about 25% in the future. Generally you will have worsening of symptoms indicating your tear has progressed. This would be an indication to see your doctor.
The outcomes of rotator cuff repair surgery are good even if you have a small re-tear in the future. 90% of patients improve by 6 months, however, success rates do vary and depend on a number of interplaying factors.
Factors that affect overall outcomes generally surgical include technique, tendon tissue quality, bone quality, size and retraction of tear. Smoking, uncontrolled diabetes, advanced age are negative factors for healing.
Good quality Physiotherapy after surgery is also key to getting a good result. I believe it is key to offer patients' an individualised post-operative rehab programme from the length of time to wear a sling to time to return to recreational activity. Therefore, I work closely with your physiotherapist and keep track of your progress with exercises.
Rotator cuff surgery is performed whilst you under a general anaesthetic which will be performed a Consultant anesthetist. You will also be offered a intrascalene nerve block to help with pain. In some circumstances the surgery can be performed whilst you are awake under a nerve block.
General anaesthesia is very safe but still carries a small risk (<1%) of Heart Attack, Stroke, Deep Vein Thrombosis, Pulmonary embolism. It is important to have all details of your medications and past medical history so you can be optimised for surgery and these risks can be assessed individually.
It is important that you understand the risk of surgery which are outlines below:
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Infection (<1%)
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Nerve & Vessel damage (<1%)
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Persistent pain
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Re-tear/ Failure
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Stiffness/ Frozen shoulder (5%)
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Need for revision surgery
How long do I wear a polysling after my operation?
The length of time of shoulder immobilisation varies between 3 to 6 weeks. Factors taken into consideration are; size of tear, degree of retraction, tendon quality, bone quality, age, smoking status, diabetes. Your discharge letter will have clear instructions. Generally, you will be in a sling for 3 weeks day and night for a small size tear, 4 weeks for a medium to large size tear, 6 weeks for a massive tear/ augmentation/ SCR.
Is it normal for my shoulder to be swollen & wound to leak fluid?
You will notice that after surgery that your shoulder has a bulky padded dressing. This is designed to absorb excess fluid from the arthroscopy (Saline is pumped into your shoulder to allow visualisation) for 24 hours and then can be taken off. Your shoulder will appear swollen which is very normal and this will reduce over a few days. Leaking fluid from your key hole wounds will be blood tinged but not frank blood.
Can I take my sling off for showering/ changing clothes?
You may take your sling for axillary hygiene and showering. However, for the first 7 days you must keep your dressings/ wounds dry. You should keep your arm as close to your body as possible when changing your clothes.
When Can I start driving?
It is illegal to drive while wearing a sling. You may start to drive once the sling has been discarded but not until you can safely control the vehicle. This is normally between 6 and 12 weeks after the operation. It is advisable to start with short journeys.
When can I go back to work?
This will depend on the type of work you do and the extent of the surgery. If you have a non-manual job and do not need to drive you may be able to return within 2 weeks. If you have a heavy lifting job or one with sustained overhead arm movement you may require 3 or more months off.
How am I likely to progress?
It is important to recognise that improvement is slow and that this is not a quick fix operation. By 3 to 6 months after the operation, most people have noticed an improvement in their symptoms and are pleased with their progress. Everything continues to improve slowly for up to 18 months although by 9 to 12 months after the operation your shoulder should feel almost back to normal.
When can I resume heavy lifting/ recreational activities?
Generally around the 3 month mark once your physiotherapist and surgeon are satisfied with your recovery (Strength & range of motion).
Help?
Useful external
patient info links:
Post-operative Rotator Cuff repair physio guidelines (RBH).
Rotator cuff repair surgical video (Arthrex education)
Irreparable
Cuff Tears
It is not uncommon that a rotator cuff tear can progress over time and become chronically scarred and retracted resulting in a irreparable tendon. Treatment is complex and must be tailored to the individual patient. There are 3 options to manage irreparable rotator cuff tears surgically after failure of non-operative management:
Arthroscopic Superior Capsular reconstruction (SCR)
This procedure in essence reconstructs the absent/irreparable using a human dermal (Skin) graft. SCR was invented in Japan and has been adopted globally. There are specific requirements for this surgery to be successful and my recommendation is to seek advice from a specialist who has been trained in this procedure.
Further patient info link (Arthrex education Superior capsular reconstruction video)
Arthroscopic debridement/sub-acromial decompression plus biceps tenotomy.
This procedure essentially is key hole surgery to clear the inflamed/ scarred tissue in the region where the tendon was and create more space so that the humeral head (Ball of shoulder joint) does not rub against the bone above (Acromion) to reduce pain. If your biceps is damaged this may also be contributing to pain and the treatment for this is to release it (Tenotomy).
Current UK evidence does not support use of an inflatable balloon device. Further link: (Subacromial balloon spacer for irreparable rotator cuff tears of the shoulder (START:REACTS):)
Reverse shoulder replacement
If you cannot raise your arm at all due to a massive irreparable rotator this is know as 'Pseudo-paralysis'.
The only reliable surgical option to treat this situation is a Reverse shoulder replacement. For further information on what a Reverse shoulder replacement is please click the link.