What is rotator cuff surgery?

Indications and Procedures

The shoulder is considered to be the most flexible joint in the human body. It has a ball-and-socket structure that permits a wide range of motion, but this same structure also predisposes the shoulder to a very high risk of injury. To counter this risk, the shoulder is stabilized by a group of four muscles, collectively known as the rotator cuff: the subscapularis, the supraspinatus, the infraspinatus, and the teres minor. The signs and symptoms of rotator cuff injuries include point tenderness around the region of the humeral head deep within the deltoid muscle, pain and stiffness within the shoulder region within a day of participating in activities that involve shoulder movements, and difficulty in producing overhead motions involving the upper arm. Pain often occurs at night as a result of sleeping positions that put excess pressure on the joint. Occasionally, a clicking noise can be heard emanating from the joint upon movement or the patient may experience a “sticking point” when shoulder movements are attempted.

Injuries to the rotator cuff can mimic other common shoulder region problems, including bursitis
(inflammation of a bursa, a soft, fluid-filled sac that helps cushion surfaces that glide over one another) and tendinitis
(inflammation of a tendon). Injuries to the rotator cuff include impingement and tears. Impingement occurs when the rotator cuff tendons are pinched because of a narrowing of the space between the acromion (shoulder blade) process and the rotator cuff. This narrowing commonly occurs with aging, but it can also be traumatically induced. Sports that commonly put excess stress on the rotator cuff include baseball, swimming, and tennis. Besides a traumatic injury, chronic impingement of the rotator cuff tendons can cause partial or complete tears.

To evaluate the extent of shoulder dysfunction, the physician will conduct a physical examination to determine range of motion and use diagnostic procedures such as x-rays, an arthrogram (an x-ray after a tracer dye has been injected into the shoulder), magnetic resonance imaging (MRI), and ultrasound. Nonsurgical interventions include rest, ice immediately following an injury or heat twenty-four hours afterward, painkillers, anti-inflammatory medications, and physical therapy.

Rotator cuff surgery is usually recommended when there is little improvement in shoulder function or pain reduction after a course of noninvasive therapies. Surgery to correct rotator cuff tears is more successful if the procedure is performed within three months of the date of injury. Surgery can be a classic open procedure, requiring a 2- to 3-inch incision in the shoulder, or less traumatic arthroscopy, which requires only a small incision, half an inch or less, just large enough to accommodate the instruments and a video camera apparatus. Occasionally, the surgeon will use a combination of the open procedure and arthroscopy. Either general anesthesia, in which the patient is asleep, or local anesthesia, in which the region is “frozen” but the patient is awake, can be used for the procedure. With local anesthesia, a light sedative may also be used to put the patient at ease, but not asleep.

Acromioplasty reduces the impingement of the rotator cuff tendons. In this procedure, a portion of the bone underneath the acromion is shaved in order to give the tendons more room to move and prevent them from becoming pinched. This process is often included in rotator cuff surgical repairs. In rotator cuff repairs, the torn tendons are reattached to the humerus (upper arm bone). The open surgical procedure requires a relatively large incision through the shoulder as well as cutting through the deltoid muscle. Any scar tissue that has formed is removed, and a small ridge is cut into the top of the humerus. Small holes are drilled into the bone, and the tendons are sutured to the bone using these holes as anchors. The surgeon will also correct any other problems encountered, such as removing bone spurs, shaving down the acromion, or freeing up ligaments that may be pressing against the tendons.

During arthroscopic surgery, these extra procedures are not done. After the small incision is made into the shoulder, a thin tube is inserted. This tube contains the surgical instruments as well as a video camera that is used to guide the repair procedure. Arthroscopic surgery is becoming more common and is preferred for small tears, as it limits the amount of surgical intervention, reduces surgical risks, and quickens recovery time. If more extensive damage is discovered, then the surgeon may elect to combine the arthroscopic procedure with open surgery. However, arthroscopic tear repair has advanced tremendously, to the point that tears previously thought to be irreparable or too extensive are now being completed with arthroscopy.

Uses and Complications

The varying outcomes from rotator cuff surgery range from almost full recovery to no improvement at all. The degree of recovery is dependent upon the extent of damage to the rotator cuff as well as patient compliance with physical therapy after surgery. If the tendon has been torn for a long time, then it may not be reparable.

As with all surgical procedures, the patient may have an adverse reaction to the anesthesia. This risk is greater if the person is obese or has a cardiovascular, pulmonary, or metabolic condition. Surgical incisions always have the risk of infection, but this risk is minimized with the arthroscopic procedure because of the small incision size and the relatively short operative time (one to two hours). In rare instances, there is also the risk of nerve damage resulting in partial paralysis or temporary numbness at the incision area.

After surgery, the recovering arm will be put in a sling with a small shock-absorbing pillow placed behind the elbow. Extreme care should be taken with shoulder movements for the first three months following surgery. Reaching and lifting objects above the head should be avoided during this period. Passive range of motion exercises, in which the arm is moved by the physical therapist, should be started as soon as possible to prevent scar tissue formation and resultant stiffness. Exercises should be done several times a day so that within two to three weeks, the range of motion (flexibility) of the repaired shoulder should be equivalent to that of the uninjured shoulder. After six weeks, more advanced exercises are recommended in order to strengthen the rotator cuff as well as the surrounding shoulder muscles. Full recovery and rehabilitation from rotator cuff surgery can take up to a year.

Bibliography

Fongemie, A. E., D. D. Buss, and S. J. Rolnick. “Management of Shoulder Impingement Syndrome and Rotator Cuff Tears.” American Family Physician 57, no. 4 (1998): 667–674.

Lo, I. K., and S. S. Burkhart. “Current Concepts in Arthroscopic Rotator Cuff Repair.” American Journal of Sports Medicine 1, no. 2 (2003): 308–324.

Matsen, Frederick A., and Steven B. Lippitt. Shoulder Surgery: Principles and Procedures. Philadelphia: W. B. Saunders, 2003.

Pfeiffer, Ronald P., and Brent C. Mangus. Concepts of Athletic Training. 6th ed. Sudbury, Mass.: Jones and Bartlett, 2012.

Rockwood, Charles A., Frederick A. Matsen, and Michael Wirth. The Shoulder. 4th ed. 2 vols. St. Louis, Mo.: Saunders/Elsevier, 2009.

"Rotator Cuff Repair." Health Library, March 18, 2013.

"Rotator Cuff Repair." MedlinePlus, June 30, 2011.

Williams, G. R., and M. Kelley. “Management of Rotator Cuff and Impingement Injuries in the Athlete.” Journal of Athletic Training 35, no. 3 (2000): 300–315.

Yamaguchi, K., et al. “Transitioning to Arthroscopic Rotator Cuff Repair: The Pros and Cons.” Journal of Bone & Joint Surgery, American Volume 85, no. 1 (2003): 144–156.