If you’re considering surgery for a rotator cuff tear, an important thing to consider is how long the recovery will take and what’s involved in the procedure.
But let’s begin with the rotator cuff itself.
What Is the Rotator Cuff?
The rotator cuff is a group of four muscles and tendons that stabilize the ball and socket shoulder joint (1). The four muscles that comprise the rotator cuff are the supraspinatus, infraspinatus, subscapularis, and teres minor.
The rotator cuff has several critical functions in the shoulder, which include:
- Holding the head of the upper arm bone firmly within the shallow socket of the shoulder blade. This stabilization is crucial for the safe and effective functioning of the shoulder.
- Facilitating shoulder movements: The rotator cuff enables a wide range of shoulder movements, including lifting, rotating, and extending the arm. Each of the four muscles contributes to different movements:
- Supraspinatus: Assists in lifting the arm.
- Infraspinatus and teres minor: Help rotate the arm outward.
- Subscapularis: Works to rotate the arm inward.
- Maintaining shoulder health: The rotator cuff muscles stabilize the shoulder joint and enable complex movements. They are essential in preventing dislocation of the shoulder and minimizing wear and tear on the joint, which can lead to arthritis or other shoulder issues.
Why Do Rotator Cuff Injuries Happen?
The rotator cuff is susceptible to injury.
The most common injuries include:
- Tendonitis: This injury occurs when the rotator cuff tendons become inflamed due to overuse or repetitive stress. Common activities leading to tendonitis include sports that require repetitive arm movements or occupational tasks involving overhead lifting.
- Impingement: This happens when the rotator cuff tendons are pinched between the bones of the shoulder. It typically occurs when the arm is lifted overhead repeatedly, causing irritation and swelling of the tendons.
- Partial tears: These are tears where only part of the tendon is torn. They can result from acute injury or the worsening of chronic wear and tear. Partial tears may not completely disrupt shoulder function but can lead to pain and weakness.
Predisposing factors for rotator cuff injuries include:
- Age: Age is a significant risk factor, with the likelihood of tears increasing dramatically as people age. Studies suggest that patients over 60 are twice as likely to develop larger and more substantial tears (2).
- Gender: Postmenopausal women have shown a higher prevalence of asymptomatic full-thickness tears (FTT), indicating hormonal or biological changes might influence tendon health (3).
- Hand dominance: some evidence suggests a greater risk of the dominant hand for developing RC tears (4).
- Contralateral shoulder risk: There is an increased risk of tears in the opposite shoulder following a tear in one shoulder, especially for those over 60, where the likelihood of bilateral tears reaches 50%.
- Smoking: Smoking significantly impacts rotator cuff health, correlating with increased tear size and frequency, which might lead to more surgical interventions (5).
- Family history: Genetic factors also play a role, with increased risks observed in relatives of individuals with rotator cuff disease, suggesting a hereditary component.
- Posture: Poor posture is a predictor of rotator cuff tears, with kyphotic-lordotic and other non-ideal postural alignments showing a higher prevalence of tears compared to those with ideal posture (6).
How Do Rotator Cuff Injuries Commonly Occur?
Rotator cuff injuries typically occur due to a combination of factors, including acute trauma and chronic degeneration. Acute injuries often result from a sudden, forceful movement such as lifting a heavy object, falling on an outstretched arm, or engaging in repetitive overhead activities like throwing or swimming. These activities can cause a sudden tear in the rotator cuff muscles or tendons.
Chronic injuries, on the other hand, develop over time due to wear and tear associated with aging, repetitive stress, or poor posture. This gradual degeneration can weaken the rotator cuff tendons, making them more susceptible to tears even with minimal trauma.
When Do Doctors Recommend Surgery As the Best Option?
Surgery for rotator cuff injuries is generally recommended based on several factors, including the severity of the tear, activity level, and response to non-surgical treatments. Surgery is required for full-thickness tears with retractions.
This is where the tendon is torn into two separate pieces. Surgical repair may also be recommended for chronic full-thickness tears that cause significant functional impairment.
In cases where conservative therapy such as physical therapy, rest, and trial of medications have failed to improve symptoms and restore function, surgery may be recommended.
Surgery except for full-thickness rotator cuff tears with retractions should never be considered unless all treatments, including regenerative injections, have been undertaken. Why? This will be explained in detail below. The short answer is that the biomechanics of the shoulder are forever changed with surgery and the underlying issues are not addressed.
What Is Rotator Cuff Surgery?
Rotator cuff surgery involves the repair of one or more of the rotator cuff tendons. The procedure can be done through a large open incision or a shoulder arthroscopy, which uses a small camera that allows visualization of the joint and rotator cuff tendons. Shoulder arthroscopy is the most common surgical technique.
Rotator cuff tendon repair involves the following steps:
- Debridement: The torn and frayed edges of the rotator cuff tendons are cleaned and debrided. The process removes the damaged tissue and prepares the tendon for reattachment.
- Anchor placement: small anchors are inserted into the bone of the humerus, where the tendon should attach. The anchors act as fixation points for the sutures.
- Suture passage: Sutures are attached to the anchors.
- Reattachment: The sutures are used to pull the tendon back to its original attachment site on the bone. The sutures are then tied down to firmly re-attach the tendon to the bone.
From 1996 to 2006, the number of shoulder arthroscopies increased by 600%, including an overall 115% increase in the number of rotator cuff repairs (7).
Is Rotator Cuff Surgery Effective?
The effectiveness of surgery in the treatment of rotator cuff tears has been questioned. Why?
A recent study demonstrated no clinically significant difference between surgery and active physiotherapy in a one-year follow-up in improving function or reducing pain caused by rotator cuff tears (8).
A meta-analysis of 57 randomized controlled trials (RCTs) found that full-thickness rotator cuff tears improved with or without surgery (9).
A recent review by the Agency for Healthcare Research and Quality looked at more than 150 published papers and concluded that there is no solid evidence that surgery was superior to conservative treatments (10).
A 2019 Cochrane Review looked at whether surgery to repair torn shoulder tendons is better than non-surgical treatments like exercises or steroid injections. The review included nine studies with a total of 1007 participants, aged 56 to 68 years. The studies compared the outcomes of people who had surgery to those who did not have surgery over one year (11).
The findings showed that surgery provided little to no significant improvement in pain, shoulder function, or quality of life compared to non-surgical treatments. The studies had some issues with how they were conducted, making the results less reliable. Overall, the review demonstrated that surgery for rotator cuff tears is no better than injections or physical therapy.
What Is the Rotator Cuff Surgery Recovery Timeline?
The rotator cuff surgery recovery timeline varies significantly and can take six months or more. A shoulder immobilizer may be required for four to six weeks for maximal healing.
There are four common phases.
- Phase 1 – Passive motion: One to six weeks, depending upon the size of the tear and strength of the repair.
- Phase 2 – Active motion: Six to 12 weeks. You start moving your shoulder with the contraction of your muscles.
- Phase 3 – Strengthening: Twelve-16 weeks. Injury, surgery, and early phases of restricted motion result in weakness that now must be restored.
- Phase 4 – Full activity: Sixteen-24 weeks. Strengthening with continued improvement in range of motion and return to play.
Different rehabilitation protocols have been evaluated. In a recent study, 64 patients were followed after rotator cuff surgery. Early, aggressive rehabilitation was compared to early, passive rehabilitation with no significant difference between the two groups at 1 year.
Unfortunately, 23.3% of the patients who underwent aggressive early rehabilitation had re-tears of the rotator cuffs (12). Immobilization vs early mobilization following surgical repair has also been evaluated with no difference in tendon healing or clinical outcome (13).
The post-surgery recovery period has been evaluated by using an 80% or better score on the Japanese Orthopedic Association shoulder scoring system.
In a recent study, 201 patients who underwent arthroscopic rotator cuff surgery were followed post-operatively. Forty percent of patients took three to six months to recover, whereas 28% took greater than six months (14). Rotator cuff surgery recovery time was shorter for younger patients without shoulder stiffness and smaller tears.
Common Challenges Surgical Patients Face
Patients who undergo rotator cuff surgery can face several significant challenges, including:
- Recovery time: Recovery from rotator cuff surgery can be lengthy, often taking several months. The patient typically needs to wear a sling for several weeks and undergo extensive physical therapy to regain strength and mobility in the shoulder.
- Pain and discomfort: Post-operative pain and discomfort are common. Narcotics and muscle relaxants are typically required.
- Limited mobility: During the initial recovery period, the patient will have limited use of their arm, which can affect daily activities and independence.
- Rehabilitation: Successful recovery often depends on a rigorous and prolonged rehabilitation program. Physical therapy can be time-consuming and demanding, requiring regular visits and diligent exercise at home.
- Risk of complications: Like any surgery, rotator cuff surgery carries risks such as infection, bleeding, blood clots, and adverse reactions to anesthesia. There is also a risk of the repaired tendon re-tearing. The rotator cuff retear rate ranges from 7.2-94% (15). The risk factors for rotator cuff retear are large initial tear size, older age, and degrees of fatty degeneration.
- Adhesive capsulitis (frozen shoulder): Some patients may develop a condition known as frozen shoulder, where the shoulder becomes stiff and painful, further complicating recovery.
- Variable outcomes: Not all patients experience significant improvements in pain and function after surgery. Some might find the surgery less beneficial than expected.
- Financial and time costs: Surgery, rehabilitation, and time off work can be financially costly and disruptive to patients’ lives.
Complications from Rotator Cuff Surgery
Rotator cuff surgery, while common, is not without potential complications that can impact patient outcomes. The major complications include:
Infections
Infection following rotator cuff surgery is a serious complication. Superficial infections may present with redness and can often be managed with antibiotics, while deep infections, characterized by pain, erythema, and drainage, typically require surgical intervention.
The risk of infection is influenced by factors such as surgical technique, patient health, and post-operative care, with deep infections having a reported incidence of up to 1.7% in open repairs and similar rates in arthroscopic repairs.
Stiffness with Restriction in Range of Motion
Restriction in range of motion is common after rotator cuff surgery and is typically managed primarily with physical therapy; resistant cases may require capsular release.
Shoulder range in motion is critical to both function and joint health. A recent study found that shoulder motion and stability were not restored by rotator cuff surgery.
Re-tears in the Tendons
Most rotator cuff surgeries are undertaken because of a tear in one or more of the rotator cuff tendons. Unfortunately, re-tears of the tendons following repair surgery are a common occurrence.
A recent retrospective review was conducted of 148 patients who underwent rotator cuff repair between May 2017 and July 2019. The results indicated a 14% retear rate, with a higher prevalence among females in their 50s (16).
Large rotator cuff tears that undergo surgical repair have re-tear at a rate of 57% in a series of 500 patients. Treatment options include additional surgery.
Non-Healing or Lack of Improvement
In patients over 60 years of age who undergo surgical rotator cuff repair, 33% will fail to heal at one year (17). Additional surgery is often required.
Adhesive Capsulitis
Adhesive capsulitis, also known as frozen shoulder, is a condition characterized by pain and a significant loss of both active and passive range of motion in the shoulder due to inflammation and fibrosis of the joint capsule.
Following rotator cuff surgery, adhesive capsulitis can occur, with reported incidence rates ranging from 2.7% and 4.9%. This complication typically develops in the short-term peri-operative period and is often managed successfully with physical therapy.
Suture Displacement
Surgical sutures can be misplaced or become torn or dislodged leading to pain, restriction in range of motion, and re-tears.
Complex Regional Pain Syndrome (CRPS)
Characterized by severe pain, hypersensitivity, edema, and dystonia, CRPS is a debilitating medication condition that typically requires an extensive multidisciplinary approach.
Are There Ways to Avoid Surgery Altogether?
Yes! Mesenchymal stem cells are found in various body tissues including bone and fat. They are the all-purpose repairers of the body and have the ability to help tendon injuries heal (18).
In 2015, we published the first research paper on the use of bone marrow-derived stem cells in the treatment of rotator cuff tears in patients with and without arthritis. Precise injections of bone marrow stem cells resulted in a reduction in pain and improvement in function in the 115 shoulders two years post-injection (19).
In a different study, patients with rotator cuff tears were randomized to undergo precise injections with bone marrow-derived stem cells and PRP or physical therapy for shoulder pain.
Bone marrow-derived stem cell injections provided improved shoulder function, reduction in pain, and healing of tears when compared to physical therapy.
The majority of rotator cuff tears occur due to a breakdown of the tendon tissue. Subjected to a series of micro-injuries, the RC tendons can degenerate like other parts of the body. An inflamed tendon can progress to a small tear, which can progress to a larger tear. Unfortunately, the rotator cuff has a poor blood supply and rarely heals itself.
One of the major reasons that surgical repairs of the rotator cuff fail is because the integrity of the rotator cuff tendon remains compromised. Debriding the tendon and placing an anchor along with sutures does nothing to repair the tendon tissue itself. Accordingly, the compromised tendon retears in a high percentage of cases.
PRP and bone marrow-derived stem cells have the potential to facilitate the healing of the damaged tendon and tears. Growth factors can increase the blood flow to the RC tendons facilitating tendon healing. In this way, PRP and bone marrow concentrate address the underlying problem.
Surgery Isn’t Always the Right Solution for Rotator Cuff Injuries
The rotator cuff is a complex set of muscles and tendons that provide stability and function to the shoulder. Injuries can occur and surgery for rotator cuff tears has become an increasingly popular treatment option.
Recovery from rotator cuff surgery is commonly divided into four phases. Healing and function vary significantly based on age, shoulder stiffness, and size of the tear. In a recent study, 28% of patients took six months or more to heal (14).
An important question is whether surgery is the best treatment option for RC tears.
Rotator cuff surgery has been demonstrated to be no more effective than physical therapy and is associated with complications including retear, pain, and restriction in motion.
Surgery does NOT address the compromised tissue but rather simply provides an improved anchor attaching the tendon to the bone. Compromised tendon tissue in many cases continues to fail, which explains the high incidence of RC re-tears after surgery.
Bone marrow-derived stem cells have been demonstrated to be effective in the treatment of rotator tears without the risks, complications, and extensive downtime associated with surgery.
See all our treatments for shoulder pain.
References
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