Rotator Cuff Repairs
Brian E. Richardson, PT, MS, SCS, CSCS
Charles L. Cox, MD, MPH
Dr. Cox or an immediate family member is an employee of Smith & Nephew; and serves as a board member, owner, officer, or committee member of the American Orthopaedic Society for Sports Medicine. Neither Dr. Richardson nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article.
Rotator cuff disease is a common cause of pain and dysfunction, as approximately one in three individuals over the age of 65 years reports shoulder pain with some degree of disability. Approximately 5 million physician visits were due to rotator cuff–related issues from 1998 to 2004, which represents a 40% increase during this time period. Most rotator cuff repairs are performed in an outpatient setting, and although accurate numbers are not available, estimates for outpatient rotator cuff repair surgery range up to 250,000 per year. As rotator cuff disease is a condition that primarily affects individuals from middle age and beyond, the impact will only increase as the population in the United States ages.
Patients present to clinicians with a history of shoulder pain and dysfunction and a physical examination with varying degrees of limitation of motion and weakness. It is important to determine whether there was an acute injury or a more chronic evolution of symptoms. Magnetic resonance imaging, ultrasound, or CT arthrogram is frequently performed to confirm the diagnosis and quantify the size of the tear (number of tendons involved, amount of retraction, and so on) and muscle quality (muscular atrophy and fatty infiltration). Muscular atrophy generally increases with the chronicity of the tear and is associated with decreased healing rates following repair.
The indications for surgery vary from surgeon to surgeon and case to case, with wide variation across geographical areas.
Rotator cuff repair surgery continues to evolve with the advent of arthroscopic techniques and various implants. In general, the basic premise of the technique involves repairing the detached tendon(s) to the footprint of the insertion(s) on the proximal humerus. As with any tendon repair surgery, the postoperative focus relies heavily on protecting the site of repair while trying to simultaneously restore function in a protected and graduated fashion. The primary goal of surgery is to alleviate pain and to restore function. Postoperative rehabilitation plays a critically important role in the success of surgery.
The rotator cuff consists of four muscles that originate on the scapula and insert onto the proximal humerus. The site of origin and insertion determines the biomechanical function of the muscle. The subscapularis inserts onto the lesser tuberosity and assists in internal rotation (IR) of the humerus. The supraspinatus inserts onto the greater tuberosity and assists in overhead elevation of the humerus. The teres minor and infraspinatus insert more posteriorly and assist with external rotation (ER) of the humerus. The four-tendon complex assists in providing compressive forces to the glenohumeral joint and maintaining the humeral head in a centered position relative to the glenoid. Injury to the rotator cuff usually involves the tendinous attachments and ranges from partial tearing to full detachment of the tendon from the bone. Often, the tendon ends retract from the insertion point after a tear. As time passes following detachment, atrophy coupled with fatty infiltration of the muscles can occur from relative disuse.
Indications and Contraindications
It is important to recognize that there are both clinical and anatomic indications for rotator cuff repair. The primary clinical indications for rotator cuff repair surgery are shoulder pain and/or dysfunction. In the setting of chronic atraumatic rotator cuff tear, surgical treatment is usually considered after failed nonoperative treatment. In contrast, in cases of acute traumatic tears, especially larger tears in active individuals, early surgery is considered. Due to the known natural history of rotator cuff tears, clinicians more often consider earlier surgical repair for younger patients. When considering the anatomy of the rotator cuff, repair is indicated if there is a reparable tear, as not all rotator cuff tears are reparable. This may be the case in the presence of a chronic large or massive tear, especially if there is severe muscle atrophy and fatty infiltration.
Rotator cuff repair is contraindicated in the presence of severe adhesive capsulitis, glenohumeral arthritis, and chronic massive irreparable rotator cuff tear.
Rotator Cuff Repair
Traditionally, rotator cuff repairs were performed with open techniques or mini-open techniques. In the former, the anterior deltoid is detached to gain exposure; in the latter, the deltoid muscle is split after arthroscopic evaluation, preparation, and acromioplasty. Currently, most rotator cuff repairs are performed with a variety of arthroscopic techniques. Open repairs are now more typically reserved for revision surgery or procedures that augment the repair site with a soft-tissue graft. Arthroscopic techniques provide a less invasive means to evaluate and manage concomitant pathology, such as labral tears and intra-articular long-head biceps pathology. A variety of suture anchor techniques are available, including single-row, double-row, and transosseous equivalent suture bridge techniques with various suture techniques including simple, mattress, or knotless constructs. Less commonly, arthroscopic repairs are performed with transosseous sutures in the humerus (Figure 8.1).
Traditionally, acromioplasty was recommended in conjunction with rotator cuff repair. However, recent clinical trials have shown little short-term benefit in healing rates or patient-reported outcomes when comparing patients who underwent simultaneous acromioplasty at the time of rotator cuff repair versus patients in whom the acromial morphology was left alone. Similarly, there is no evidence to suggest that a careful and appropriately performed acromioplasty is detrimental to the outcome. This remains a controversial topic, and long-term outcome studies are needed.
In discussing rehabilitation following arthroscopic rotator cuff repair, one must realize that each tear and repair is different and that a specific protocol should be used as a guide for treatment that is coordinated with the individual patient’s response to treatment. Communication between the orthopaedic surgeon and rehabilitation provider is critical for the success of the rehabilitation. The surgeon should discuss with the physical therapist the surgical technique, location of the repair, severity and shape of the tear, and the tissue quality in addition to any adjunctive procedures. All of these factors are important in the success of the rehabilitation.
The guidelines outlined in this chapter describe an arthroscopic rotator cuff repair; special consideration should be made if the procedure was performed as an open repair. It should be noted that with an open repair, the deltoid is usually detached from the anterior acromion in order to improve visualization. The rehabilitation following an open repair will need to be modified in order to limit stress across the reattached deltoid. Communication with the physician is important to determine any additional precautions that need to be taken in the rehabilitation process.
Regardless of the technique utilized, the postoperative protocol hinges on protecting the repaired tendons to facilitate tendon-to-bone healing. The most common reported anatomic complication in rotator cuff surgery involves re-tearing of the tendons, and most rehabilitation protocols try to progress slowly, initially limiting active range of motion (AROM) while healing takes place. Patient-reported outcomes do not always correlate with integrity of the repaired tendons, and it is possible to achieve good results even if re-tear (partial or complete) occurs. In contrast, postoperative stiffness has a tremendous impact on the progress of recovery even though most patients eventually recover range of motion (ROM).
Authors’ Preferred Protocol
These guidelines are designed for rehabilitation after arthroscopic rotator cuff repair of small to medium cuff tears (<5 cm) with good tissue quality. Patients who have poor tissue quality, tears of multiple tendons, and larger tears (>5 cm) will need to be progressed slower. The rehabilitation program for patients who have massive rotator cuff tears should focus on regaining motion, controlling pain, and regaining periscapular strength, and should emphasize deltoid strengthening.
Phase I (0–4 Weeks)
Protect the repair
Control pain and inflammation
Allow for wound healing
Prevent the development of adhesions
No active shoulder motion for 6 weeks
Wear a sling at all times for 6 weeks
Avoid heavy lifting using the involved upper extremity (UE)
No quick sudden movements with the involved UE
Exercises (Table 8.1)
Phase II (4–6 Weeks)
Protect the repair
Control pain and inflammation
Attain full PROM