The essence of dealing with rotator cuff tears is that they only need to be fixed if they are causing a functional problem. Otherwise the pain you are getting is from the tendonitis element of the condition and not from the hole in the tendon.
How do you fix the tendon back?
I do what is called a mini-open repair. That means that I do the first half of the surgery as a key-hole procedure – that includes the decompression, the ACJ excision if required and a Biceps Tenotomy if required. This also allows me to accurately assess the size of the tendon tear and the quality of the tendon and to decide if it is fixable or not.
The actual reattachment of the tendon back to the bone is done through a 6 – 8 cm incision on the outside of the shoulder.
I divide the deltoid muscle so I can see the hole in the tendon and the bone that it was attached to. Then I roughen up that area on the bone– called the footprint – so the bone is fresh and bleeding because that gives the best environment for the tendon to bond back on to it. The tendon is released from any scarring around it and pulled back over the footprint. I use things called ‘suture anchors’ to do the reattachment. These are metal or plastic screws with sutures attached to them which I drill into the bone and then pass the sutures through the tendon and tie knots in the sutures pulling the tendon back down onto the bone. It usually requires between 2 and 5 anchors depending on the size of the tear.
Then I close the wounds and put your arm in a sling. The sling might be the normal type with your arm by your side. However if there was quite a bit of tension on the repair then I may well put you in a brace sling with your arm at 45 degrees away from your body. I am afraid that is a real pain to manage but it is very important.
How long do I have to be in the sling?
Usually 6 weeks. Tendon has a poor blood supply (which explains why it can erode through in the first place) so it needs a good long period without any tension on it to really bond back to the bone.
Can I move my arm?
What I let you do depends on the size of your tear and how happy I am with the repair.
So, if it’s a smallish tear with good quality, elasticy tissue that I could easily pull over the footprint without much tension, then we will get you doing passive range of motion exercises straight away. That’s where you use your good arm to move the bad one. After only 4 weeks we let you start doing active exercises – firing up the muscles in your bad arm and starting to move it under it’s own steam.
And if it’s a big tear?
That is a different story! The first thing is that you will be in a shoulder brace with your arm held away from your body at about 45 degrees – this is to keep any tension or pull off the repair while it heals. And the second thing is that you will be in that for 6 weeks before we get you out and start moving the shoulder.
That sounds like a nightmare!
It is not easy – it really isn’t. Make no bones about it because I am being truly realistic here about what you are letting yourself in for if you need to have a massive cuff tear repaired. The brace gets in the way, it is awkward to manage and can be sweaty and uncomfortable.
You aren’t really selling this operation to me!
Too many people are told that fixing a cuff tear is not a big deal and that they will be back to normal in a couple of months. That is just not the case. With a big tear it is a big operation and big recovery time.
But remember that you presented with a shoulder that really was not much good. You couldn’t lift it up, it was no real use to you and it was painful. Those are the elements we are planning to get rid off but it is going to take you between 6 months and a year to achieve that. So you are going to go through a lot but you should gain a lot – a useful and pain-free shoulder.
How long do you think the recovery time is? Be honest.
For a medium sized chronic tear or any size of acute tear then you should be pretty much back to normal by 6 months.
For a larger chronic tear that can take a year.
Let’s take the acute tear as an example: hopefully you will just need the ordinary sling and will be in that day and night for 4 weeks but coming out regularly to do passive exercises.
Between weeks 4 and 6 you can start active exercises and start to wean yourself out of the sling so that by the end of week 6 you won’t need it any more.
At that point you should have reasonable to full passive movement but active movement will be lagging a long way behind.
By 3 months though you should have full passive movement and a pretty good functional active range.
You should have been driving a car after 8 weeks and starting to do some gentle exercises about then as well: maybe some swimming, gentle running and perhaps hitting a few golf-balls with a half-swing .
After 3 months you start building up strength, stamina and resistance in the shoulder muscles and do more physical activities: weights in the gym (guided by your physio!!); playing some tennis and playing 9 holes of golf for example.
At the 6 month mark I would expect you to be 80 to 90% back to normal and happy that you had the operation and that you can see just how well you have done and that normality is not too far away.
And what is the timescale for the massive chronic tear? Double that?
Yes – just about. It is long and it is slow but it is worth it.
What happens if you can’t fix my tendon?
Remember the basic ethos here – I will only fix your tendon if it is a functional problem to you. There are a lot of massive tears that don’t need to be fixed even if they could be because functional weakness or lack of movement is not the issue. And even if there is weakness using the arm over head height, a lot of my older patients are happy to adapt around that if I can do something to get rid of their pain: steroid injections, a decompression or a biceps tenotomy.
However there are a group of patients who have what we call ‘massive irreparable cuff tears’ and have an associated loss of function that makes that arm pretty useless. These are the poor souls who can’t lift their hand to their face or head and are really struggling to manage.
What can you do for them?
Well we know the tendon can’t be repaired because the hole is too big, the tendon has retracted back too far and the muscle has wasted away. Often times too the humeral head is no longer sitting centrally on the glenoid so the joint has become eccentric and that can’t be sorted out with a cuff repair.
In this situation I offer a Reverse Geometry Shoulder Replacement and if you go to the section on Cuff Tear Arthropathy you can find out all about that.
The rotator cuff tendons wear through as we get older –that is just what happens so many people will have a tear without even knowing about it. The corollary of that is just because you someone finds a tear it may well NOT be the cause of your pain and therefore does not need to be repaired.
I will only put you through a cuff repair if you have a functional problem directly related to it.
