Rotator cuff
Rotator cuff repair surgery
How a torn rotator cuff is repaired through keyhole surgery, what the anchors and sutures do, and the six months of recovery.
Read the transcript
Introduction
This is Dr Kalman Piper's guide to rotator cuff repair: how the operation is done and what the recovery involves.
Treatment options
The first treatment option is always non-operative, meaning without surgery. That's cortisone injections and physiotherapy. It can settle the pain down, but it won't fix the tear. For older, less active people, that's often a good option. For younger, active people, a tear that's left alone tends to stay weak, the pain is more likely to come back, and there's a risk of arthritis in the shoulder down the track. That's when Dr Piper recommends surgery to fix the tendon.
Keyhole surgery
The operation is called an arthroscopic rotator cuff repair. Arthroscopic means keyhole. It's done through two or three small incisions, and you usually stay in hospital overnight.
Preparing the footprint
First, the surgeon roughens up the footprint with a gentle scrape. That gets it bleeding and creates a healing response, so the bone behaves as if the tear is fresh.
Suture anchors
Then the surgeon puts a series of suture anchors into the bone. They look like plastic, but they're made of a high-tech material that dissolves over time and turns back into bone. Each one carries a big, strong suture.
Tying the tendon down
The sutures are passed through the torn tendon and used to tie the tendon back down onto the bone. The ends of the sutures aren't cut. They're fed into a second row of anchors in the side of the bone, which presses the tendon flat onto the footprint. Seen from above, each knot sends one suture limb to each of the second-row anchors, so the sutures cross over the top of the tendon and oppose more tendon onto the bony footprint. That's the rotator cuff repair.
Why the repair needs protecting
Unfortunately that repair isn't very strong. Imagine a torn, ratty tendon end with a few stitches through it, and a big, strong muscle at the other end that can normally lift ten or twenty kilos with the arm out straight. If you do too much too soon, the tendon strips straight out of the repair, so the repair has to be protected with restrictions after surgery, to reduce the risk of it tearing again.
Slow healing
So the job of rehab is to protect the repair while your body heals the tendon back to the bone. That healing process is slow, because tendon has almost no blood supply. The tendon slowly grows lots of little fibres back into the bone to reattach itself. Imagine a tree trying to grow its roots into a rock. Overall it takes about six months for the tendon to fully heal to the bone and for the bond to get back to full strength.
The rehab timeline
After the operation you wear a sling for six weeks. Then you start physio, which usually runs for three to four months. Initially you might see the physio once or twice a week, but towards the end of the program, you might be seeing them every two or three weeks and do the exercises yourself, at home. The repair is most at risk in the first three months, so early physio is range of motion only, and the restrictions are strict. By three months, the tendon has healed to the bone sufficiently that the lifting limit can go up and your physio can start a graduated strengthening program. Most people are back to normal use at six months.
The restrictions
For those six months there are three restrictions. No heavy lifting: two kilos when you first come out of the sling until month three, and five kilos from three months to six months post surgery. No repetitive shoulder movements, like digging, sweeping or vacuuming. And no overhead work. The main rule is simple. If it makes the shoulder sore, don't do it.
Biceps tenodesis
Two other steps are often done at the same time as the rotator cuff repair. The first is a biceps tenodesis. The biceps muscle has two tendons at the shoulder called the long and short heads. The short head has a straight line of pull from the shoulder down to the elbow. The other, the long head, is a thin tendon that does a ninety-degree turn as it exits the shoulder, right next to where the cuff tears. It often gets inflamed and causes pain down the front of the arm. In a tenodesis, it's stitched into the repair and the inflamed portion is removed. That doesn't change the strength of the biceps at the elbow. It just moves where the long head attaches, and stops that pain.
Acromioplasty
The other step performed with a rotator cuff repair is an acromioplasty. The acromion is the part of the scapula or shoulder blade that sits over the top of the shoulder like a roof, and forms the point of the shoulder. Some people have a flat undersurface. Some have a curve, and some have a small hook or spur that catches when you lift the arm up. That catching sensation is called impingement. A few millimetres are shaved off the undersurface of the acromion to give the shoulder more room to move.
AC joint resection
If your AC joint is inflamed and causing pain, an AC joint resection can be performed at the same time as the rotator cuff repair. The AC joint is where the collarbone or clavicle meets the acromion, right on top of the shoulder, about where a bra strap or bag strap sits. The resection removes the very end of the collarbone so the two bones stop rubbing.
Close
This short video describes the surgery and the rehabilitation required. Every surgery carries risks which will be discussed with you before your surgery. There's also information on the risks of surgery at kaliper.com.au. If you have questions about your own shoulder, Dr Piper can go through them with you at your consultation.