Rotator cuff surgery is used to treat chronic tendinopathy, partial tears, and full-thickness tears. It is usually recommended for patients with severe shoulder symptoms, pain, and restricted range of motion that has not responded to conservative care. In this post, we look at rotator cuff surgery in detail and its alternatives.
What Does Rotator Cuff Surgery Address?
The rotator cuff is a group of muscles and tendons in the shoulder that stabilize the shoulder and facilitate movement.
The rotator cuff is composed of four muscles:
- Supraspinatus: Responsible for lifting the shoulder overhead and away from the body (abduction) (1). It is the rotator cuff tendon that is most commonly injured (2).
- Infraspinatus: Helps with external rotation (3).
- Teres Minor: Helps with external rotation.
- Subscapularis: facilitates internal rotation.
Tendons are thick pieces of connective tissue that connect muscle to bone. They are susceptible to injury and degeneration. Rotator cuff tears are explained below.
Partial and full-thickness tears can cause severe shoulder pain. A partial tear is where there is a tear in the rotator cuff that does NOT extend across the entire tendon. A full-thickness tear is a tear of the entire tendon with complete separation such that the two ends of the tendon are no longer connected. Similar to a rubber band that has broken apart.
Rotator cuff tendons are also classified according to their location.
Rotator cuff tendons have two main sides: the articular side and the bursal side. The bursal side is the side facing away from the joint and is in contact or close to the subacromial bursa. A bursa is a fluid-filled sac that reduces friction between tendons and ligaments as they travel across bone.
Articular-sided tears are those tears that occur on the side of the tendon that is closest to the joint joint or articular surface. Bursal-sided tears are those tears that occur on the side of the tendon that is facing away from the joint.
An interstitial rotator cuff tendon tear is a tear that is located within the body of the tendon itself. Rotator cuff surgery can help reduce rotator cuff-related pain, partial and full-thickness tears, and any tendons that are impinged. Rotator cuff surgery can also release and decompress the tendon to relieve the pain.
Anatomy Of The Affected Shoulder
In addition to addressing the damaged and torn rotator cuff tendon, rotator cuff tendon surgery may also address other injuries in the shoulder that are contributing to pain and restriction in range of motion.
For example, if there are bony spurs in the acromial clavicular (AC) joint that compress or irritate the supraspinatus, the doctor can surgically remove them. If there is calcification of the coracoacromial ligament, the doctor can debride the ligament.
When the bursa is involved the doctor can remove it completely. This is called a bursectomy.
From an orthopedic surgeon’s perspective, once the abnormal or damaged structures in the shoulder are removed or repaired, the shoulder pain, range of motion, and function should be restored to normal. Unfortunately, that is not always true.
When Surgery Is Recommended
Surgery is recommended for certain candidates based on their profession, the type of injury, and the size of the injury and response to therapy. It is also advised based on the chronicity of symptoms. The criteria for the surgery are a mixture of the following factors:
The Best Candidates For Surgery
The best candidates for rotator cuff surgery are the following:
- Individuals who need to use their arm and shoulder muscles for work, such as athletes, construction workers, and pipelayers, among others.
- Those with acute injury to the rotator cuff or trauma to the shoulder.
- Individuals with large tears of more than 3 cm on MRI.
- Patients with full-thickness rotator cuff tears with retractions.
Surgery is also recommended in the following situations:
- When there is severe pain for over 6-12 months with no relief from conservative treatments or medical therapy.
- When there is shoulder weakness and range of motion limitations in the shoulder.
Types Of Rotator Cuff Surgery Procedures
There are different types of rotator cuff surgeries, chosen by the doctor based on the type and size of the tear as well as the patient’s overall health and past medical history. The different types of surgeries are listed below:
Open Tendon Repair
Open tendon repair is a type of surgery where the doctor opens up the shoulder with a single large 4-6 cm incision. It is commonly used in cases with large or complex tears as it provides the surgeon with direct access to the rotator cuff. A longer hospital stay is required since the incision site is larger and requires more extensive post-operative care to prevent infection.
Arthroscopic Tendon Repair
Arthroscopic surgery involves the use of a small camera, arthroscopy, and specialized instruments inserted through small incisions.
Arthroscopic tendon repair involves smaller incisions of about 4-7mm in size to repair the tendon. This has now become more favorable as the incision site is smaller and there are fewer postoperative complications.Arthroscopic tendon repair involves smaller incisions of about 4-7mm in size to repair the tendon. This has now become more favorable as the incision site is smaller and there are fewer postoperative complications.
This procedure combines the elements of both the arthroscopic and open techniques.
In a mini-open repair, the incision is smaller than an open tendon at 3 cm but larger than the arthroscopic repair. An arthroscope is used for subacromial decompression and tendon release. There is also less injury to the deltoid muscle with this procedure.
What To Expect After Surgery
Irrespective of the type of surgery, there are certain steps to help with pain and to restore shoulder function. They are listed below:
Medications And Pain Relief
Medications are prescribed for pain postoperatively. Common medications include:
- NSAIDs: Powerful anti-inflammatory medications such as Ibuprofen, naproxen, and diclofenac. These medications should be avoided as they have significant negative profiles and should be avoided.
- Narcotics: Also known as opioids, these medications are potent analgesics that act on the central nervous system to alleviate pain. Common examples or oral narcotics include oxycodone, hydrocodone and morphine sulfate. Significant side effects include tolerance and addiction.
Rehabilitation after rotator cuff surgery typically involves a progressive and structured program aimed at restoring shoulder function, improving strength, and promoting a full range of motion. Initially, the focus is on pain management, gentle movement exercises, and preventing stiffness.
As the healing progresses, physical therapy incorporates strengthening exercises, stretching, and gradually increasing the intensity of activities to help the patient regain optimal shoulder function. The rehabilitation process is tailored to the specific type of surgery, the extent of the rotator cuff tear, and the individual patient’s needs and goals.
Recovery Time And Outcome
The recovery time after surgery can vary from person to person based on the type of tear, the size of the tear, the type of surgical approach, and the general health of the patient. On average, it takes six months to recover from surgery.
The outcome of the surgery depends on many factors, such as if an open or arthroscopic approach was used, how many tendons were involved, and the quality of the tissue, the location of the tear.
Additionally, other factors include if the tear was L-shaped, crescent-shaped, or U-shaped, whether the mechanism of failure was due to trauma or wear and tear, whether surgery was immediate or delayed, if the person was diabetic or a smoker, and if the person has access to supervised care and rehabilitation.
Factors that can prolong recovery times and outcomes include(7):
- Open surgery
- Large size tears
- Poor quality tissue
- Degenerative changes
- Delayed surgery
- Diabetes and smokers
- Limited access to rehab
- Older age
- Large retractions
Is The Surgery Worth It?
With the exception of full-thickness tears with retractions, most rotator cuff tears do really well with conservative management and physical therapy. Before surgery, it’s important to consider some of the risks, complications, and reasons why rotator cuff surgeries aren’t always successful.
Risks Of Surgery
As with many surgeries, there are risks that you should be aware of before you decide to undergo shoulder surgery. These include:
- Bleeding: There is a risk of vascular injury during surgery which can lead to bleeding into the subacromial space. Bleeding can lead to a hematoma.
- Infection: The larger the incision, the higher the chance of an infection. Infections are also more prevalent in people with diabetes and obesity.
- Blood Clots: Shoulder surgeries can increase the risk of developing blood clots, which can have secondary effects like stroke and pulmonary embolism.
Complications Of Surgery
Shoulder surgery itself can have many complications, including those listed below:
- Nerve Injury: Rotator cuff surgery can damage the nerves that supply the shoulder. This can occur if the surgeon accidentally cuts or injures a nerve during a subacromial decompression. This can lead to muscle weakness and may affect the range of motion.
- Infection: Infection can occur post-operatively. Infection rates following open or mini-open rotator cuff repair range from 0.3-1.9%. Rates of infection following arthroscopic repair range from 0.3-0.9 (5).
- Deltoid Detachment: During the rotator cuff surgery, the deltoid is detached to access the rotator cuff and reattached after the repair has been completed. However, in some individuals, the deltoid muscle doesn’t get fully attached and separates or tears after a period. In one study the incidence was 7% of patients who underwent RC surgery (6).
- Stiffness: The shoulder may continue to be stiff even after surgery due to inflammation and prolonged healing. If the proper rehab protocol is not followed, scar tissue can replace the flexible connective tissue, leading to stiffness.
- Tendon Retear: It is entirely possible that the repaired tendon will retear. Full-thickness and larger tears have a tendency to retear especially if they are over 5 cm in size. Additionally, individuals over 66 have a higher chance of a tendon retear.
- Chronic pain: surgery does not guarantee elimination or reduction in pain. In many cases, there is no significant improvement in pain.
Failure to Heal: Despite surgical repair, there is a risk that the rotator cuff may not heal properly. This is a bad day for all and can result in persistent pain, limited shoulder function, and possible additional surgeries.
There are certain factors that can contribute to unsuccessful outcomes with rotator cuff surgery. They are listed below:
- Poor Tendon/Tissue Quality: The quality of the tendon and bone is very important. For a successful rotator cuff repair, it’s important to have good or at least adequate tissue quality. If the tendon is frayed or the bone is weak with too many spurs, the outcome may not be as successful as expected.
- Large Or Massive Tears: Large tears that are between 3-5 cm and massive tears that are over 5 cm generally have a poorer prognosis than smaller tears. These large tears are at risk of retearing after surgery.
- Patient Compliance Post-Surgery: It’s important to comply with post-surgical requirements to optimize the outcome, including wound cleaning, physical therapy, and a rehab program. Not complying with any of these can slow down recovery and lead to a poor outcome.
- Patient Age: The older the person, the higher the chance is of poor healing or retear. This is also because the wear and tear on the tissues is greater and the healing is slower in older individuals. Additionally, bone in older patients is also weaker so the attachment to the bone may not be as effective. Age is associated with reduced healing (4).
- Smoking/Nicotine: Smokers in particular are at risk of slower healing. Nicotine causes the arteries to constrict which restricts blood flow to the tissue. As a result, the delivery of oxygen and healing nutrients is delayed. Nicotine can also cause platelet aggregation and blood clots. Platelets also facilitate healing and, without them, the healing can be much slower, leading to poorer outcomes.
Alternatives To Shoulder Tear Surgery
At the Centeno Schultz Clinic (CSC), we acknowledge the limitations and risks associated with rotator cuff surgery. With the exception of full-thickness tears with retractions, many rotator cuff tears can be treated with regenerative treatment options allowing patients the opportunity to use their own tissue and forgo surgery. Treatment options include:
- Physical Therapy: Physical therapy is the best therapy for rotator cuff tears. Even people with partial-thickness tears do very well with physical therapy. At CSC, the physical therapy team focuses on aggressive rotator cuff and periscapular stabilizer strengthening programs. The team also will also include a range of motion exercises for the shoulder.
- Platelet-Rich Plasma: PRP is rich in growth factors that can increase blood flow and decrease inflammation. Blood is drawn from a patient and then super concentrated in a state-of-the-art laboratory. This allows for a customized PRP product for each patient that allows us to factor in the age and severity of injury.
- Regenexx: An advanced, proprietary procedure where bone marrow is extracted, processed, and injected into areas of injury in the rotator cuff. The bone marrow concentrate is rich in stem cells which can promote healing and clinical outcomes.
All injections are performed under ultrasound and or x-ray guidance to ensure that the PRP and or bone marrow concentrate is injected into the area of injury. Without this guidance, there is no assurance that the injected PRP or cells are delivered into the targeted tissue. This in turn can compromise function and clinical outcome.
Before You Opt For Surgery
Before you opt for rotator cuff surgery, consider the alternatives. At CSC, we offer many treatment options and use multiple therapies to help keep you pain-free. It’s not necessary to have rotator cuff surgery – not everyone needs it. Before you decide to go the surgical route, check out some of the regenerative treatments on offer at CSC.
Make an educated decision before deciding on rotator cuff surgery. Contact us now!
John Schultz, MD
John R. Schultz M.D. is a national expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate and PRP for orthopedic injuries. He is board certified in Anesthesiology and Pain Medicine and underwent fellowship training. Dr. Schultz has extensive experience with same day as well as culture expanded bone marrow concentrate and sees patients at the CSC Broomfield, Colorado Clinic, as well the Regenexx Clinic in Grand Cayman. Dr. Schultz emphasis is on the evaluation and treatment of thoracic and cervical disc, facet, nerve, and ligament injuries including the non-surgical treatment of Craniocervical instability (CCI).
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