Rotator cuff repair surgery

Rotator cuff repair surgery reattaches tendons which have torn off the ball of the shoulder at the top of the arm bone. There are many techniques and variations. 

This operation is needed if the tear is the result of an injury or if the pain and weakness in the area isn’t improved with injections and physiotherapy. During the procedure, injured tendons and muscles are repaired. This may include replacing damaged parts of the tendon with a graft tendon from another part of the body. Bone spurs, if present, will be removed.  

The repair is done to relieve pain and improve shoulder strength. A period of physiotherapy is required in addition to the surgery.

What is the rotator cuff?

The shoulder joint itself is formed between the humeral head, which is the ball shape at the top of the upper arm bone, and the socket on the flat shoulder blade.

The rotator cuff is the name given to the group of four shoulder muscles and the tendons that surround the shoulder joint. Tendons are strong bands of tissue that connect muscles to bones.

In the shoulder joint, the muscles are attached to the shoulder blade and become the tendons attached to the top of the arm bone (humerus); these keep the humeral head and the glenoid stable so that the ball is centred in the socket. When you move your arm, the rotator cuff muscles contract. This stops the head of the humerus from sliding out of the socket, keeping it in place while allowing for a full range of motion and controlling those movements.

Rotator cuff tears can be categorised in various ways.

It's possible to have a partial or full tear:

• Partial tear: This is where the tendon has been damaged but it's not a complete tear. This means that the tendon is still attached to the bone, but it’s weakened by the damage.
• Full tear: The tendon has torn completely and is completely detached (torn away) from the bone. This is known as a full-thickness complete tear.

It’s possible to tear some or all of the tendons:

• Small tear: A single tendon
• Large tear: Two or more tendons or more than 2cm
• Massive tear: Three tendons or more than 5cm

It’s possible to tear quickly or slowly:

• Degenerate tears occur over months or years as part of ageing
• Acute traumatic tears occur after a fall, crash or wrench

It’s also possible to have new and old tears:

• Acute tears are younger than six months old and can usually be repaired
• Chronic tears are older than six months and may be irreparable as the muscle shortens irreversibly.

The type of tear you have will often dictate the type of surgery your consultant recommends.

Choosing rotator cuff surgery is a complex decision made by you and your specialist. If your pain does not improve with non-surgical methods, your doctor may offer surgery as an option for a torn rotator cuff.

Also, if you are very active and use your arms for overhead work or sports, you might need a rotator cuff operation to ensure that your shoulder can support these activities that affect the area.

Other factors that make surgery the right treatment option include:

• Your symptoms have lasted six to 12 months
• Your tear was caused by a recent, sudden accident
• You have weakness and loss of function in your shoulder
• You have a large tear that's more than 3cm in size

To confirm that a rotator cuff operation will be the most effective way to treat your symptoms, your consultant will carry out a full medical assessment. They'll also ask about any activities that make the pain worse. Your consultant will assess your shoulder's range of movement, strength and stability during a physical examination.

They may recommend imaging tests such as an X-ray and an MRI scan. These can confirm the level of damage to the joint. A specialist musculoskeletal radiologist will report on the results, providing your consultant with the full picture before discussing your treatment options with you.

What happens during torn shoulder cuff surgery?

A rotator cuff repair involves freeing up the detached tendon and securing it back where it belongs. It then heals back to the bone over about three months. Attaching the tendon is commonly done with ‘suture anchors’, often made of dissolvable material, to hold the tendon down onto the bone. Other methods can involve permanent sutures through tunnels in the bone.

There are two types of rotator cuff operation: arthroscopic or open. What kind you have will depend on how advanced the tear is. It's likely that, whichever type of surgery you have, it will be performed under general anaesthetic, although regional anaesthetic is possible.

Arthroscopic rotator cuff repair surgery

Most rotator cuff repair operations are carried out arthroscopically. This is a minimally invasive procedure that's a form of keyhole surgery. Surgeons make small cuts around your shoulder so that they can then pass equipment that includes a small surgical camera (arthroscope) into the shoulder.

The camera projects images of the inside of your shoulder onto a monitor and your surgeon uses these images to locate the damaged part of your rotator cuff. They use specialised equipment to reattach the tendon to the upper arm bone. 

Open rotator cuff repair surgery

In some cases, open surgery is required. This will be recommended if you have a large tear in your rotator cuff. 

The surgeon makes an incision through the deltoid muscle to gain access to the torn tendon. Sometimes this muscle is partially detached. 

Reattaching the torn tendon is just the same as the keyhole operation. Stitches or staples are used to close the skin incision.

Other variations

For partial tears a ‘trans-tendon’ repair can be carried out to reinforce the damaged part, or the tear can be completed and repaired as a normal full-thickness tear.

A thin degenerate tendon can be thickened by adding a patch of material to the repair.

Sometimes massive irreparable tears are best treated by shoulder replacement.

You should be able to go home the same day. The incision made during your operation will be covered post-surgery with a dressing. After leaving hospital, you'll be advised on ways to reduce the risk of any infection.

Any stitches or clips are usually removed after one to two weeks. We'll invite you to a clinic for a follow-up assessment around six weeks after your operation. It can take up to a year to get back enough strength in your shoulder to return to normal activities.

Regular exercise should help you to return to normal activities as soon as possible. Before you start exercising, ask your healthcare team or your consultant for advice. It's important to be aware that you may not get back the same strength that you had before you damaged your shoulder.

Rehabilitation

Functional recovery from rotator cuff repair is quite a long process with distinct phases.

First three months

The tendon takes three months to heal back to the bone. During this time you should not try to use the repair, as it is not strong enough. You need physiotherapy to help you protect the repair. The physio will also help you recovery the range of movement in your shoulder in a safe manner.

Second three months

Once the tendon is healed you can start to rebuild the muscles that have not been able to exercise for many weeks. Strength can be regained. It is important to relearn the muscle patterns with physio supervision, to avoid the complications of poor co-ordination.

Third three months

By now you should have a fairly ‘normal’ shoulder, and you can start to train for your chosen work and leisure activities

Up to and over a year

Data shows that shoulders continue to improve a little even this long after rotator cuff repair repair surgery