Rotator Cuff Tears and Rotator Cuff Surgery:

The Shoulder & Rotator Cuff Tears: 

How does the shoulder work?

The shoulder is made up of a ball and socket joint. The shoulder socket is relatively small, and the ball part of the joint is relatively large. In this way the shoulder is like a big golf ball on a small golf tee. The rotator cuff surrounds the ball and socket joint and keeps the ball centered on the socket. The rotator cuff also helps move the arm upward, outward, and behind the back. Other larger muscles around the shoulder also help move the arm and give power and strength, but the smaller rotator cuff stabilizes the ball and socket joint and give fine control of the arm.

Above: The image on the left is the bone structure that makes up the shoulder. The image on the right shows the muscles and tendons that surround the shoulder ball and socket joint.

* The images above are courtesy of the AAOS (American Academy of Orthopedic Surgeons)

What is the rotator cuff?

The rotator cuff is a group of 4 muscles and 4 tendons. These tendons help control shoulder function and help to lift the arm and rotate the hand away from the body and behind the back. When one or more of these tendons tear it can cause pain, but it can also cause loss of function of the shoulder. After a rotator cuff tear, the shoulder may lose strength and/or motion. Patients may also feel that they have lost the ability to move the arm in certain ways.

* The images above are courtesy of the AAOS (American Academy of Orthopedic Surgeons)

What are some of the symptoms of a rotator cuff tear?

• Nighttime shoulder pain

• Shoulder weakness

• Pain when using the shoulder

• Loss of shoulder motion

• Pain with reaching or lifting

• Clicking in the shoulder

Individuals with a rotator cuff tear often note shoulder pain with use of the shoulder. In some cases, the pain may be worse with overhead lifting, lifting away from the body, and when lifting heavy objects. Shoulder pain at nighttime is very common after a rotator cuff tear. Shoulder pain is often located over the side of the shoulder, but it can be in the front, back, or radiate up the neck or down the arm. In larger tears, some individuals may experience shoulder weakness.

Why does the rotator cuff tear?

Rotator cuff tears can broadly be divided into two types of tears: chronic tears and acute tears.

Chronic rotator cuff tears: The most common type of rotator cuff tear is a chronic tear. Chronic tears occur over time and are related to wear and tear and aging. As individuals become older, chronic rotator cuff tears become more and more common. About 40% of individuals over age 70 will have some form of a rotator cuff tear. Most people with these tears aren’t even aware of them as many cause either mild symptoms or no symptoms at all. The first-line treatment for these types of tears is generally non-surgical, consisting of medications, physical therapy, and steroid injections. If symptoms persist for 6-12 months or longer, surgery can be considered.

Acute or traumatic rotator cuff tears: These tears are less common. They occur after a trauma, most commonly after a fall or after lifting something heavy. Often people will immediately know they injured something in their shoulder. Although some acute or traumatic tears are treated without surgery, many of these tears are larger and are treated with surgery. Multiple studies have shown that when these tears are fixed sooner (within 3 months of the injury), healing rates of the tendon repair is higher which is better for long-term shoulder health and function. However, the treatment of each traumatic rotator cuff tear is individualized, based on a patient’s age, tear type on MRI, activity level, medical health, goals, and personal preferences. Non-surgical treatment can always be considered as a second-line option.

Treatment of Rotator Cuff Tears:

How do we treat rotator cuff tears?

Rotator cuff tears can be treated either without surgery or with surgery. Not everyone with a rotator cuff tear requires surgery. Chronic rotator cuff tears (see previous page) are almost always initially treated without surgery. However, many acute or traumatic tears (see previous page) are treated with surgery. Non-surgical treatment often consists of medications, physical therapy, and steroid injections. Occasionally PRP (platelet rich plasma) injections are used. It’s important to note that rotator cuff tears do not heal without surgery. However, many individuals can have good pain relief and improvement in strength and range of motion with non-surgical treatment. For individuals with specific types of tears and those that do not improve with the above treatment, surgery is considered.

What type of rotator cuff tears are treated without surgery?

In general, rotator cuff tears that are chronic (see previous page) are treated initially without surgery. Signs of a chronic rotator cuff tear are shoulder pain that occurred without an injury and may become slowly worse over time. These are common in individuals over age 60. The preferred initial treatment of chronic rotator cuff tears is often non-surgical, which often includes time, physical therapy, pill medications, steroid injections, and occasionally PRP (platelet rich plasma) injections. Many individuals with chronic rotator cuff tears can improve with non-surgical management.

What type of rotator cuff tears are treated with surgery?

Non-surgical treatment can always be considered for a rotator cuff tear, regardless of tear type. However, there are some tears that do better in the long run with surgery. Rotator cuff tears that are chronic (see previous page for a discussion of chronic rotator cuff tears), but not improving with non-surgical treatment may be considered for surgery. Surgery is often the preferred treatment of acute (see previous page) or traumatic tears, especially those that are larger in patients healthy enough for surgery. Rotator cuff tears do not heal without surgery. Therefore, a tear that is large and left unrepaired can have a permanent impact on long-term shoulder pain and function. In time, a fully torn rotator cuff tendon may become only partly fixable or even unfixable. Over time, torn rotator cuff tendons can retract, and the muscle attached to them can atrophy, or shrink away, until it is no longer functioning. The treatment of each traumatic rotator cuff tear is individualized, based on a patient’s age, tear type on MRI, activity level, medical health, goals, and personal preferences. Non-surgical treatment is always considered, regardless of tear type.

How soon after a rotator cuff tear should it be fixed with surgery?

Some literature has shown higher healing rates after surgery for acute/traumatic rotator cuff tears in the first 3 months. There is limited data to support higher healing rates in the first 3 weeks after injury. However, there is generally good agreement that surgery should be done within 3 months of injury, or as soon as is convenient. Over time, the rotator cuff tendons can retract, and muscles can shorten and retract. This can cause the repaired tendons to be under more tension after surgery, which can reduce healing rates after surgery. However, some tears can still be fixed months or occasionally years later.

What happens if a rotator cuff tear is not fixed with surgery?

A rotator cuff tendon tear will not heal without surgery. For some smaller tears, this may not be a major issue. Some persistent smaller rotator cuff tendon tears can lead to ongoing shoulder discomfort, weakness, and reduced shoulder endurance. However, a larger tear that does not heal can lead to significant loss of shoulder range of motion, substantial weakness, and pain. An untreated larger tendon tear can cause a significant reduction in shoulder function, which can be permanent.

How Does Surgery Work for Rotator Cuff Tears?

How is the rotator cuff tendon(s) repaired during surgery?

The majority of rotator cuff tears are fixed arthroscopically, or by a minimally invasive technique. This typically involves several incisions around the shoulder that are about 1/2 inch (1 cm) in length. The total number of incisions can vary based on tear type and size. A small camera and small instruments are used to repair the rotator cuff tendons back down to bone, using a minimally invasive technique. A device called an anchor is used to attach sutures to bone, which is used to repair the tendon to the bone. For individuals that have a mini-open biceps procedure, they may also have a smaller incision on the front part of the arm, typically around 1.5-2” in length.

What happens on the day of surgery?

Surgery is typically done in an outpatient surgery center. Patients come in 1-2 hours prior to surgery. Typically, an anesthesiologist will administer a nerve block prior to surgery. A nerve block involves an injection by the neck which then numbs up the shoulder and entire arm. The block typically gives good pain relief for 12-18 hours after surgery. Surgery is then done under a general anesthesia, where the patient is fully asleep. Patients then recover after surgery for 1-2 hours and are then discharged home. After the nerve block wears off in 12-18 hours after surgery, patients use ice and pill medications to help reduce shoulder discomfort.

When kind of pain medications do I use after surgery?

The regional anesthetic nerve block (the injection by the neck before surgery) will typically last for 12-18 hours and give good pain control during that time. However, after the nerve block wears off the shoulder can be very uncomfortable after rotator cuff repair surgery. This discomfort is typically the worse for the first 2-3 days. After that, the discomfort will slowly decrease over the next several days or next 1-2 weeks. During the first 2-3 days a multi-modal approach to pain control is essential.

Recovery After Rotator Cuff Repair and Frequently Asked Questions:

Do I need a sling after surgery?

Typically, a sling is used at all times for the first 6 weeks after a rotator cuff repair surgery, with two exceptions. 1) The sling is removed while showering and while doing home exercises. While showering, the shoulder muscles remain relaxed, and the arm can just hang at the side. The shoulder should not be actively moved or used, and the hand should not be used for showering, washing hair, etc. Moving the shoulder can significantly damage the tendon repair. 2) The second occasion where the sling is removed is to work on elbow, wrist, and hand range of motion exercises, which begin right after surgery and is done 3 times per day. The tendon repair will be at highest risk of re-tearing during the first 3 months after surgery. A sling will help protect the shoulder during the first 6 weeks, and specific restrictions on shoulder use (no lifting with the shoulder) will help protect the shoulder from week 6-12.

How do I shower after surgery?

The dressing remains on for 3-5 days after surgery and then can be removed. The discharge instructions you receive after surgery will list whether your dressing can be removed on day 3 or day 5 after surgery. After dressing removal, you may remove the sling, let the arm hang by the side, and shower directly over your incisions. After showering, pat the incisions dry, cover them with Band-Aids, and put your sling back on. The sling is used typically for the first 6 weeks after surgery, both day and night. You should wear the sling while sleeping to protect the shoulder.

How do I sleep after surgery?

Sling use is recommended at nighttime for the first 6 weeks after surgery. You may sleep however is comfortable. Although you may sleep on a flat bed, many patients are more comfortable for the first 2-6 weeks after surgery sleeping in a somewhat reclined position. Some patients find it more comfortable to sleep in a recliner or with something called a “wedge pillow.” These can be purchased locally or online (for example, Amazon has a wide selection).

When can I return to work after surgery?

The timing to return to work depends on the type of work you do and your work environment. A sling must be worn while at work to protect the shoulder. Patients that do mostly desk or computer type work can return to work as soon as their pain is controlled, they are off narcotic pain medications, and they feel comfortable going back to work – this is often 1-2 weeks after surgery. However, some patients prefer to take more time off (4-6 weeks). Some patients that do heavy manual labor may not be able to return to work until 5-6 months or more after surgery. The timing of return to work is individualized for patients that have more physical work; you should discuss this with Dr. Harold.

When can I drive after surgery?

In general, you should not drive for 4-6 weeks following surgery. The arm on the surgery side should not be used for driving, as this requires active motion. Active motion of the shoulder starts 6 weeks after surgery. Additionally, a sling should be worn for 4-6 weeks after surgery, and you should not drive a vehicle while wearing a sling.

What is recovery like and when am I fully recovered after surgery?

Recovery comes in stages after surgery. The first challenge after surgery is pain control, as rotator cuff repair surgery can be uncomfortable after surgery. This discomfort tends to be the worse in the first 2-3 days after surgery. After that, pain typically steadily reduces over days and weeks. Most patients are off prescription pain medications by 1-2 weeks after surgery.

It is important to understand that tendon to bone healing of the rotator cuff after surgery is a biologic process that occurs very slowly and cannot be accelerated. The tendon will only heal as fast as the body is able to do so. The process cannot be rushed or sped up.

The first 6 weeks represents the first phase of healing and is a critical time for rotator cuff healing (full healing takes about 5 months). Therefore, during this time only minimal shoulder rehabilitation and home therapy is done. Once PT starts typically 6 weeks after surgery, the second phase of recovery starts where you are working to regain motion. Strengthening of the shoulder starts in the third phase of recovery, either 12 or 16 weeks after surgery, depending on the size of your rotator cuff tear.

The tendon repair will be at highest risk of re-tearing during the first 3 months after surgery. A sling will help protect the shoulder during the first 6 weeks, and specific restrictions on shoulder use (no lifting with the shoulder) will help protect the shoulder from week 6-12.

Restrictions on the use of the shoulder are lifted 5 months after surgery. At this point, the shoulder is considered fully healed. There are no formal restrictions at this point, but activity level should slowly increase without abrupt changes in activity level. However, we know from many studies over the past several decades that patients often take a full year until their shoulder reaches its full potential for strength, mobility, and coordination.

When can I return to athletics such as golf, tennis, pickle ball, cycling, etc. after surgery?

Return to activities depends on the injury, the surgery, the activity, and each individual’s progress with physical therapy and overall recover. Typically, patients can begin to return to most athletics around 5 months after surgery. Full return to sports that are more demanding on the shoulders may be 6-8 months after surgery (golf, tennis, pickle ball, etc.), while other very intense athletics (rugby, water skiing, martial arts, etc.) can be 8-12 months after surgery.

How is the rotator cuff fixed with surgery and how does surgery work?

Surgery is typically performed arthroscopically, or with a shoulder scope, using a minimally invasive technique. Most patients will have multiple incisions around the shoulder that are about 1/2 inch (1 cm) in length. The rotator cuff tendons are repaired using small diameter instruments that are similar to the size of a pen or pencil. Suture anchors go into the bone and strong sutures are used to repair the tendons back down to bone. It is important to note that although the anchors and sutures are very strong, the tendon must heal back down to bone for a good outcome and for the tendon repair to remain strong over many years. The tendon repair will be at highest risk of re-tearing during the first 3 months after surgery.

Rotator cuff tendon healing after surgery – how the process works:

It’s important to understand that during rotator cuff repair surgery, the tendons are repaired down to the bone. However, the body must then heal the tendon to the bone to make the repair permanent. Tendon to bone healing occurs very slowly and cannot be sped up any faster than the body’s own natural healing process. Success after rotator cuff repair is dependent on a healed tendon, so it is of critical importance that the healing tendons be protected. Special physical therapy protocols have been designed to achieve a balance between regaining shoulder range of motion, while allowing for appropriate tendon healing to occur.

What kind of outcome should I expect after surgery?

In general, most patients have no discomfort or minimal discomfort, good motion, and good strength after they are fully recovered. Typically, most people can return to the same activities they participated in prior to surgery. Full rotator cuff healing is generally considered 5 months after surgery. Physical therapy typically stops 5-6 months after surgery. Some patients are in physical therapy for 8-12 months. However, most individuals will continue to improve for an entire year after surgery. Studies of large numbers of patients show that motion and strength will continue to increase for 12 months after surgery.