Rotator Cuff Tear, Surgery for

Rotator Cuff Tear, Surgery for



Indications: who needs surgery, when and why, and goals


Surgery for a rotator cuff tear is reserved for people who have continuing shoulder pain that affects activities of daily living or sports activities despite completing an appropriate rehabilitation program for at least 3 months. For younger athletes, surgery may be recommended without attempting to resolve symptoms with rehabilitation alone. This is because rotator cuff tears do not heal and usually progress to larger tears. The goal of surgery is to eliminate the shoulder pain and attempt to regain motion and strength. The thickened and chronically inflamed bursa and the curve, hook, or spur of the acromion likely cause mechanical wear to the rotator cuff and may play an important role in the development of rotator cuff tears; thus these structures are removed, and the torn rotator cuff is repaired to itself or, more commonly, it is attached back to the bone of the humeral head.



Contraindications: reasons not to operate



• Infection of the shoulder

• Inability or unwillingness of the patient to complete the postoperative program of keeping the shoulder in a sling or immobilizer or to perform the rehabilitation necessary

• When emotional or psychological problems contribute to a patient’s shoulder condition


Risks and complications of surgery



• Infection

• Bleeding

• Injury to nerves (numbness, weakness, paralysis) of the shoulder and arm

• Continued or recurrent pain

• Retear of the rotator cuff

• Detachment of the deltoid muscle (if open surgery is performed)

• Stiffness or loss of motion of the shoulder

• Inability to return to the same level of sports activity

• Weakness of the shoulder

• Fracture of the acromion (roof of the shoulder)

• Acromioclavicular (AC) joint pain

• Too much or not enough acromion removed


Technique: what is done


A variety of techniques are in use to repair rotator cuff tears. The overall goals are to remove the chronically inflamed and scarred bursa; remove the acromial curve, hook, or bone spur; to remove an arthritic AC joint (sometimes); and to repair the rotator cuff to itself or to the humeral head. These procedures may be done arthroscopically or through an open incision.


Arthroscopic techniques involve using small incisions, called portals, to look into the shoulder joint; electricity is then used to cauterize small capillaries. Electricity or a motorized shaver is used to remove the bursa and cut the coracoacromial ligament (usually). Next, a power burr is used to remove the bony curve, hook, or spur from the acromion. The rotator cuff is repaired with sutures (threads) to itself or to the bone of the humeral head with or without surgical anchors, which are inserted into the bone of the humeral head. Often the humeral head is roughened to help stimulate healing of the tendon to bone. Sometimes this surgery is performed with a small incision at the outer shoulder.


Open rotator cuff repair involves detaching the large deltoid muscle from the acromion, as well as cutting the coracoacromial ligament. Next the acromial curve, hook, or spur is removed using a saw or osteotome (chisel). A rasp is often used to smooth the cut bone edges, and the bursa is then removed with scissors. The torn edge of the rotator cuff is freshened by removing the old edge, where the rotator cuff originally attached; the bone of the humeral head is roughened, often making a trough, and the tendon is sutured in the trough. This may be done by making bony tunnels and tying the sutures over the bone below the trough or by placing surgical anchors with sutures attached into the humerus and tying the rotator cuff to the bone anchors. The deltoid muscle is then sewn back onto the acromion.


Do not eat or drink anything before surgery. Anything on the stomach, even water, makes general anesthesia more hazardous.



Postoperative course



• Management after surgery varies based on the technique used and surgeon preference.

• Keep the wound clean and dry for the first 10 to 14 days after surgery.

• Keep the shoulder in a sling, brace, or immobilizer for as long as your surgeon tells you to; this is usually for 4 to 8 weeks, if done as an open procedure or arthroscopically.

• You will be given pain medications by your physician.

• Immediately after surgery, you may be instructed to perform passive motion exercises; these move the arm without using the muscles of the operated shoulder.

• Postoperative rehabilitation and exercises are very important to regain motion and then strength.


Return to sports



• Return to sports depends on the type of sport and the position played, as well as the quality of the tendon at the time of repair.

• A minimum of 6 months is necessary after surgery before returning to sports.

• Full shoulder motion and strength are necessary before returning to sports.


When to call your doctor



• You experience pain, numbness, or coldness in your hand.

• A blue, gray, or dusky color appears in your fingernails.

• Any of the following occur after surgery: increased pain, swelling, redness, drainage, bleeding in the surgical area, or signs of infection (headache, muscle aches, dizziness, or a general ill feeling with fever).

• New, unexplained symptoms develop. Drugs used in treatment may produce side effects.

image

Figure 1


From Rockwood CA, Jr., Matsen FA, III: The shoulder, ed 2, Philadelphia, 1998, W.B. Saunders, p 812; modified from Matsen FA, III, Lippitt SB, Sidles JA, Harryman DT, II: Practical evaluation and management of the shoulder, Philadelphia, 1994, W.B. Saunders.



Range of Motion and Stretching Exercises



Phase I: zero to 6 weeks after surgery


These are some of the initial postoperative exercises you may use to start your rehabilitation program during the first phase of your rehabilitation. This phase typically lasts for approximately 6 weeks, although the duration of this phase may vary depending upon the severity of the tear, the quality of the tissue repaired, and your surgeon’s postoperative instructions. During some or all of this phase, your arm may be in a sling. How long you are in a sling is at the discretion of your surgeon. When you are allowed out of the sling, the goal of these exercises is to allow you to regain motion without putting the repair at risk. You should do these exercises until you see your physician, physical therapist, or athletic trainer again. Please remember:


• Flexible tissue is more tolerant of the stresses placed on it.

• A gentle stretching sensation should be felt.

image


Range of motion image shoulder pendulum



1. Lean forward at the waist, letting your weak arm hang freely. Support yourself by placing your opposite hand on a chair, table, or counter as shown.

2. Sway your whole body slowly, forward and back. This will cause your arm to move. Let your arm hang freely, and do not tense it up.

3. Repeat the motion above, swaying side to side and moving in circular patterns, clockwise and counterclockwise.

4. Do ____ repetitions in each direction.

5. Repeat this exercise ____ times, ____ times per day.

image


Range of motion image shoulder flexion, single arm



1. Lie on your back and grasp the bottom of a stick, handle of an umbrella, or blade of a golf club in the hand of your weak arm as shown.

2. Using the stick, raise your arm overhead as shown, until you feel a gentle stretch. Lead with your thumb in a “thumbs up” position.

3. Hold each repetition for 5 to 10 seconds.

4. Repeat this exercise ____ times, ____ times per day.

image


Range of motion image shoulder flexion, double arm



1. Lie on your back holding a stick in both hands, keeping your hands shoulder width apart.

2. Raise both hands over your head, until you feel a gentle stretch.

3. Hold each repetition for 5 to 10 seconds, and return to the starting position.

4. Repeat this exercise ____ times, ____ times per day.

image


Range of motion image shoulder flexion



1. Sit in a chair with your weak arm on a table as shown.

2. Lean forward, sliding your arm forward on the table, until you feel a gentle stretch.

3. Hold each repetition for _____ seconds, and return to the starting position.

4. Repeat this exercise ____ times, ____ times per day.

image


Range of motion image shoulder abduction, single arm



1. Lie on your back holding a stick, umbrella handle, or golf club in your hand as shown. Your hand should be in a “thumbs up” position.

2. Using the stick, slowly push your arm away from your side and as far overhead as you can without pain. Push until you feel a gentle stretch.

3. Hold each repetition for 5 to 10 seconds, and return to the starting position.

4. Repeat this exercise ____ times, ____ times per day.

image


Range of motion image shoulder external rotation



1. Lie on your back or stand with your weak arm at your side and your elbow bent to 90 degrees. Hold a stick, umbrella handle, or golf club in your hand as shown.

2. Use the stick to rotate your hand and forearm away from your body as shown. Make sure you keep your upper arm and elbow close to your side.

3. Hold each repetition for _____ seconds, and return to the starting position.

4. Repeat this exercise ____ times, ____ times per day.

image


Range of motion image shoulder pulleys


The pulleys needed for this exercise may be purchased or made out of parts from your local hardware store. They should be set up in a manner similar to that shown in the diagram. Do not do this exercise on your own until cleared by your physician, physical therapist, or athletic trainer. This exercise must be done correctly to avoid any shoulder discomfort.


1. Sit with your back or side to the pulleys, and use your healthy arm to pull up your weak arm. You should strive for a gentle stretching sensation.
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Jul 19, 2016 | Posted by in SPORT MEDICINE | Comments Off on Rotator Cuff Tear, Surgery for

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