Full Thickness Rotator Cuff Tear Repair Protocol
Desiderato Merriwether
The following article provides in-depth information about surgical treatment for rotator cuff injuries and is a continuation of the article "Rotator Cuff Tears." For a good introduction to the topic of rotator cuff injuries, please refer to Rotator Cuff Tears .
Surgery to repair a torn rotator cuff most often involves re-attaching the tendon to the head of the humerus (upper arm bone). A partial tear, however, may need only a trimming or smoothing procedure called a debridement. A complete tear is repaired by stitching the tendon back to its original site on the humerus.
Your doctor may offer surgery as an option for a torn rotator cuff if your pain does not improve with nonsurgical methods. Continued pain is the main indication for surgery. If you are very active and use your arms for overhead work or sports, your doctor may also suggest surgery.
Front (left) and side (right) views of the tendons that form the rotator cuff. The blue arrows indicate a full-thickness tear in the supraspinatus tendon, the most common location for rotator cuff tears.
There are a few options for repairing rotator cuff tears. Advances in surgical techniques for rotator cuff repair include less invasive procedures. While each of the methods available has its own advantages and disadvantages, all have the same goal: getting the tendon to heal back to bone.
Most surgical repairs can be done on an outpatient basis and do not require you to stay overnight in the hospital. Your orthopaedic surgeon will discuss with you the best procedure to meet your individual health needs.
A traditional open surgical incision (several centimeters long) is often required if the tear is large or complex. The surgeon makes the incision over the shoulder and detaches or splits part one of the shoulder muscles (deltoid) to better see and gain access to the torn tendon.
During arthroscopy, your surgeon inserts a small camera, called an arthroscope, into your shoulder joint. The camera displays a live video feed on a monitor, and your surgeon uses these images to guide miniature surgical instruments.
This technique typically uses arthroscopy to assess and treat damage to other structures within the joint. Bone spurs, for example, are often removed arthroscopically. This avoids the need to detach the deltoid muscle.
Once the arthroscopic portion of the procedure is completed, the surgeon repairs the rotator cuff through the mini-open incision. During the tendon repair, the surgeon views the shoulder structures directly, rather than through the video monitor.
Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.
Be aware that although opioids help relieve pain after surgery, they are narcotics and can be addictive. Opioid dependency and overdose have become critical public health issues. It is important to use opioids only as directed by your doctor and to stop taking them as soon as your pain begins to improve. Talk to your doctor if your pain has not begun to improve within a few weeks after your surgery.
Immobilization. After surgery, therapy progresses in stages. At first, the repair needs to be protected while the tendon heals. To keep your arm from moving, you will most likely use a sling and avoid using your arm for the first 4 to 6 weeks. How long you require a sling depends on the severity of your injury.
Passive exercise. Even though your tear has been repaired, the muscles around your arm remain weak. Once your surgeon decides it is safe for you to move your arm and shoulder, a therapist will help you with passive exercises to improve range of motion in your shoulder. With passive exercise, your therapist supports your arm and moves it in different positions. In most cases, passive exercise is begun within the first 4 to 6 weeks after surgery.
Active exercise. After 4 to 6 weeks, you will progress to doing active exercises without the help of your therapist. Moving your muscles on your own will gradually increase your strength and improve your arm control. At 8 to 12 weeks, your therapist will start you on a strengthening exercise program.
Expect a complete recovery to take several months. Most patients have a functional range of motion and adequate strength by 4 to 6 months after surgery. Although it is a slow process, your commitment to rehabilitation is key to a successful outcome.
Each surgical repair technique (open, mini-open, and arthroscopic) has similar results in terms of pain relief, improvement in strength and function, and patient satisfaction. Surgeon expertise is more important in achieving satisfactory results than the choice of technique.
After rotator cuff surgery, a small percentage of patients experience complications. In addition to the risks of surgery in general, such as blood loss or problems related to anesthesia, complications of rotator cuff surgery may include:
To assist doctors in the management of rotator cuff tears, the American Academy of Orthopaedic Surgeons has conducted research to provide some useful guidelines. These are recommendations only and may not apply to every case. For more information: Plain Language Summary - Clinical Practice Guideline - Management of Rotator Cuff Injuries - AAOS
Appropriate post-operative rehab can be asimportant to the success of your surgery as the operation itself. We workwith a variety of therapy providers throughout the Louisville area, westernKentucky and Southern Indiana. In many cases, your therapy location mayalready have a copy of our specific physical therapy protocols. If youwould like a personal copy, or your therapist needs a protocol, please seebelow for a downloadable procedure specific rehabilitation protocol.
This protocol is intended as a general guideline for the therapist in directing the post-operative rehabilitation course following a reverse shoulder replacement. The timing of recovery and ultimate outcome following reverse shoulder replacement is variable, often depending to some extent on the integrity of remaining rotator cuff musculature and deltoid strength. Modifications to the protocol may be needed to accommodate patients who recover either more quickly or more slowly than this protocol.
This protocol is intended as a general guideline for the therapist in directing the post-operative rehabilitation course of patients undergoing a total shoulder replacement. Modifications and alterations may be necessary depending on each patient's recovery.
This protocol is designed to assist the therapist in directing the post-operative recovery of patients following an arthroscopic rotator cuff repair. This protocol is a general outline of the anticipated progress for the majority of repairs. In cases of anticipated post-operative stiffness or PASTA repairs, this protocol may be accelerated. Alternatively, in massive, retracted multi-tendon repairs, it may be delayed with strengthening after 14-16 weeks in some cases. In subscapularis repairs, passive external rotation should advanced slowly, as should internal rotation against resistance.
Please note this protocol is intended solely for use in patients receivingan isolated bovine collagen graft for treatment of a partial thicknessrotator cuff tear. For patients in whom the graft is used as an adjuvantto a revision rotator cuff repair of a full thickness defect please followthe rotator cuff repair protocol above.
This protocol is a general outline to assist in directing the post-operative rehabilitation of patients undergoing a SLAP repair. Full return to prior level of play occurs in only 80-90% of athletes. Adherence to a structured program is critical to improving chances at return to play.
This protocol is designed to assist the therapist in directing the post-operative recovery of patients following an arthroscopic anterior labral (Bankhart) repair. This protocol is a general outline of the anticipated progress for the majority of repairs. Patients may progress more slowly than anticipated in cases of concomitant posterior labral or SLAP repairs, age greater than 40 yrs, or in cases significant tightening of the anterior capsule. Restoration of external rotation, especially in the abducted position, should be pursued slowly, as outlined below. Patients may experience a 10-15 loss of ER compared to the contralateral side in some instances.
The rotator cuff is a set of a four small muscles in the shoulder that allow the upper arm to rotate. When a rotator cuff is torn, the tendon part of the muscle tears away from the bone of the upper arm. A rotator cuff tear can result from an injury such as a fall or heavy lifting, or from normal wear-and-tear and repetitive activities over many years. Some minor tears may be treated without surgery. Many, however, require surgical intervention to heal properly.
Patients at Hospital for Special Surgery have this procedure done under a nerve block (regional anesthesia) and partial sedation rather than under general anesthesia. This minimizes the amount of pain and anesthesia medications that are given, thereby reducing nausea and vomiting. These improvements in minimally invasive techniques and anesthesia allow most of our patients to go home only a few hours after their procedure.
First, an arthroscopy of the glenohumeral joint (the ball-and-socket portion of the shoulder joint) is performed to identify and treat other associated problems, such as a biceps tendon injury, loose bodies or a torn labrum. (The shoulder labrum is a rim of cartilage that surrounds the glenoid, the cup portion of the shoulder joint.) A partial rotator cuff tear (a tear through less than 50% of the thickness of the rotator cuff tendon) can be trimmed with a shaver at this time.
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