Shoulder Conditions & Treatment
- Frozen Shoulder / Adhesive Capsulitis
- Instability and Labral Tear
- Rotator Cuff Repairs
- Double-Row Arthroscopic Rotator Cuff Repair (VIDEO)
- Day of Surgery for Rotator Cuff Repair Surgery
- Diagnosis of Rotator Cuff Tear
- Going Home after Shoulder Surgery
- Risk of Rotator Cuff Surgery
- Surgical Technique for Rotator Cuff Tears
- Arthroscopic Superior Capsular Reconstruction
- The 3 Phases of Tendon Healing
- The Recovery from Surgery
- Rehabilitation Following Rotator Cuff Repairs: Risk of Retear
Frozen Shoulder / Adhesive Capsulitis
In this brochure I wish to answer the following the following questions regarding a frozen shoulder.
- What is it?
- Why me?
- How do you know what I have?
- How does it affect me?
- What can be done to treat my shoulder pain?
What is it?
In order to proper understand this somewhat confusing condition I will first start by discussing a working definition of the condition of frozen shoulder based on the American shoulder and elbow surgeon’s society. A frozen shoulder is condition of unknown cause which is characterised by significant stiffness both active and passive of the shoulder joint in the absence of any known underlying shoulder condition. A frozen shoulder however is an often over used and applied to any person with a stiff and painful shoulder and the term frozen shoulder can often be a “waste can” diagnosis. A true frozen shoulder can be divided into a primary and secondary frozen shoulder. The primary frozen shoulder or true frozen shoulder is as defined above with painful and stiff shoulder joint in the “absence of known intrinsic shoulder” in other words with no significant history of injury or investigations which can explain the pain and stiffness. A secondary frozen shoulder is shoulder pain and stiffness from any other causes such as shoulder injury for example a fracture.
The shoulder joint is a ball and socket joint not very dissimilar from the hip joint but having a striking difference in being far more mobile. It has little bony constraint to movement and it is the surrounding cartilage, ligaments and capsule which provides shoulder stability but still allow an enormous range of motion.
The capsule containing the ligaments is usually very loose.
In a frozen shoulder the capsule initially becomes very inflamed which causes a deep ache in the shoulder joint radiating down the arm.
After the development of inflammation the surrounding capsule and ligaments shrink which restricts shoulder motion causing gradual and increasingly severe stiffness.
The cause of the inflammation is unknown. The body perceives the shoulder as being injured and therefore triggers an inflammatory response in order to try to heal it. As the inflammatory cascade occurs, healing tissues including white cells and platelets and subsequently fibroblasts migrate towards the shoulder joint. These migrating tissues attempt to heal the shoulder joint which is perceived by the body as being damaged, this creates a domino effect as more and more inflammatory factors are produced and ongoing inflammation and healing occurs. Like the falling dominos it does not matter what triggers the initial domino falling but subsequent dominoes continue to fall unrelated to the initial insult. Eventually the domino’s run out.
The cells responsible for healing are called fibroblasts. typically tissue damage simulates migrations and growth of these fibroblasts and these cells are responsible for the production of scar tissue. Cytokines are the chemicals which trigger fibroblasts activity; they bond to the fibroblast and stimulate scar formation. Special fibroblasts called myofibroblasts are responsible for shrinking scar tissue. So when the fibroblasts accumulate in the shoulder joint, scar tissue is laid down and the myofibroblasts shrink that scar tissue. This inflammatory process occurs largely in the lining tissues of the shoulder joint and the capsule with their surrounding ligaments.
As a consequence of this the lying tissues of the joint (the synovium) and capsule with the shoulder ligaments which are normally extremely thin and elastic becomes thickened, hard and inelastic.
The cause of this condition remains poorly understood despite many attempts to explore the cause. The clinical features of frozen shoulder warrant describing. Incidence The condition of frozen shoulder is very common. 2% of the general population develop a frozen shoulder, while diabetics have a risk of over 10%. Insulin dependent diabetics have a 40% chance of developing a frozen shoulder. Women are more commonly affected than man, by a ratio of female to male 3 to 2. The most striking clinical feature of frozen shoulder is its predilection for people in their 50’s. Frozen shoulders can occur in people in mid to late 40’s to mid to early 60’s but far commonly are in their 50’s. Women are slightly younger than man on average when they develop this condition with the average age of women developing frozen shoulder is 52 years old and men 55 years old.
Also there appears to be a significant genetic increase risk. Once you have developed a frozen shoulder on one side you are at increased risk at developing it in the other side. 15% of people develop a frozen shoulder on both sides. rarely it can occur simultaneously(both at the same time) but more typically affects the other shoulder within the 5 years after the first shoulder. Surprisingly recurrence in the same shoulder is extremely unusual.
How do you know this is what I have?
As we said in the definition above, in the primary frozen shoulder there is no known underlying disorder. As x-rays, ultrasounds and even MRI are good at picking up damaged tissues, these investigations are therefore often unfruitful. There is an old expression “if it looks like a duck and quacks like a duck and walks like a duck, it must be a duck”. So we therefore rely on typical clinical features to suggest the diagnosis of a frozen shoulder. If however features are not typical, such as these occurring in both shoulders or in an unusually young (less than 45 years old) or unusually old patient (greater than 65 years old), then further investigations are warranted. Blood tests to exclude thyroid disease, raised cholesterol or blood sugars may be of some benefit but will not help confirm the diagnosis. We therefore do not rely exclusively on investigations to confirm the diagnosis. Nevertheless they are of benefit in excluding other conditions such as an underlying arthritis. The only investigation which can really assist in making the diagnosis is an Arthrogram in which dye is injected into the shoulder joint. In a normal shoulder joint as we mentioned earlier the surrounding capsule is extremely thin and elastic and one can see on the MRI Arthrogram distension of the capsule. In the presence of a frozen shoulder no distension occurs, confirming a tight capsule which is diagnostic of a frozen shoulder.
How does it affect me?
Typically the condition starts with often a very mild subtle onset of shoulder pain which becomes increasingly severe over the weeks. Usually after some time of increasing pain some stiffness in the shoulder joint is noted, typically by 6 months after the onset of symptoms the pain is at its worst and movement is also deteriorated to its lowest level. This worsening phase is often described as the freezing phase of a frozen shoulder, at approximately 6 months the condition stabilizes with little change in the pain or movement. This is often referred to as the frozen phase of a frozen shoulder.
Over the subsequent 4-6 weeks typically pain gradually starts to settle and some weeks or months after that range of motion also starts to improve. We call this the thawing phase of a frozen shoulder. Gradually symptoms of pain and stiffness resolve. It is described as been like a locomotive, gradually building up speed, reaching its maximum speed and then gradually slowing down. This is very typical of a frozen shoulder where we do not see wild fluctuations in pain and stiffness as we do in other conditions. In one study by Reeves he shows the typical symptoms occur anywhere between 1-3½ years with an average of 30 months of symptoms over the next 2½ years. In another study by Hand, looking at the long term outcome of frozen shoulders at 4½ following the onset of symptoms they noticed that 60% of people had essentially regained a normal or near normal shoulder joint with minimal or no pain or stiffness. Nevertheless even at 4½ 40% of patients still had some degree of ongoing symptoms.
On the whole these were usually quite mild but 5% of patients still had severe pain and stiffness, interestingly they noted that these 5% of patients are usually those with most severe symptoms at clinical onset and these patients had the worst long term outcome.
We described the natural history of the condition as what would occur if there was no intervention.
The natural history of frozen shoulder is extremely variable, some people have only short periods of pain and stiffness, some have a very long period, some have mild to moderate pain and stiffness, and some have extremely severe pain and stiffness.
What can be done to treat my shoulder pain?
Once we understand the natural history of this condition we can determine what can be done about it. For many patients who symptoms are tolerable, a wait and see approach is quite reasonable. Typically if symptoms are tolerable at the 6 months following onset, no intervention will be required.
Instability and Labral Tear
The shoulder is the most mobile joint in the human body. Its mobility is almost unique in the animal kingdom. It is a ball-and-socket joint like the hip joint. The difference is that in the shoulder joint the boney socket is very shallow to allow for greater movement.
This therefore compromises its stability. Relying more heavily on the cartilage and ligaments than bone for stability, the shoulder joint is at much greater risk of injury which results in loss of stability.
What is instability?
If ball dose not remain well centered in in its socket, we call that “instability”.
- When the ball is in the joint we call it located, or enlocated.
- If it comes out of its socket completely, even for a second, we call that a dislocation.
- If the joint does not come completely out, we call it a subluxation.
What causes instability?
To answer this we have to appreciate what keeps the ball in the socket. The ball is relatively large with respect to the socket. The analogy is like a golf ball sitting on a tee. The bony socket is extremely shallow and is deepened by cartilage called the labrum. The ligaments which includes the capsule attach the ball to the socket via the labrum.
When a first time dislocation occurs, the labrum gets torn off, called a Bankart lesion, and the ligaments may get stretched.
Once this has occurred, when the should is reduced to its normal postion, the labrum rarely relocates completely. A persistent Bankart lesion occurs. Recurrence is more likely if the cartilage around the shoulder joint has been torn (Bankart Lesion) or the ligaments have been stretched or torn.
The injury usually occurs when the arm is forced out of postion (dislocates), for example, following a fall. These injuries can also occur as a result
of repetitive trauma, such as in the throwing athlete or swimmers where possible subluxations or repeated stretching of the capsule occurs.
The torn labrum usually occurs at the front (anterior) of the socket, but can occur at the back (posterior) or the top (superior) of the socket (or all three).
How is Shoulder Instability Diagnosed?
The diagnosis of this condition is largely based on the history provided.
X-rays taken at the time of a dislocation make a definite diagnosis.
The degree of shoulder looseness or laxity of the shoulder joint can also be assessed by specific tests during the examination. However the shoulder may be normal at clinical evaluation as the muscles play an important role in the stability of the shoulder and it is sometimes difficult to test the ligaments alone if you are awake and reflexly tightening these muscles.
Repeat X-rays performed some time after the initial dislocation are sometimes done to see if any damage to the bones of the joint have occurred, such as a bony bankart or a Hill-Sacks lesion. Bony injuries are best shown up on a CT scan. Occasionally done to further evaluate the bones. An MRI (magnetic resonance imaging scan) with or without a dye(arthrogram) image the torn cartilage.
How is Shoulder Instability Initially Treated?
After a shoulder has dislocated, an exercise program is done in conjunction with a physiotherapist as soon as the shoulder is comfortable enough. The goal of therapy is to restore shoulder motion and increase the strength of the muscles around shoulder. Strong muscles, especially those of the rotator cuff, may help to protect and prevent the shoulder from re-dislocating or subluxing. Once full function of the shoulder has returned, you may gradually return to your pre-injury activities.
The risk of ongoing instability can be very high and largely depends on:
Your age. if you are under the age of 20 at initial dislocation the chance of recurrent dislocation is extremely high, especially in people who go back to high risk sports. By the age of 40 years old the chances are quite small. However as you grow older the chance of associated injures such as rotator cuff tendon tears or fracture increase.
How traumatic the dislocation was. A fracture or a large tear to the cartilage or ligaments occurred, recurrent instability is more common.
Activates you return to. If you play a high risk sport you are more likely to re-dislocate.
When would I need an Operation?
Despite a course of physiotherapy in which full shoulder motion and strength are restored, the shoulder may still feel loose or unstable. Treatment options then consist of activity modification and surgery.
Activity modification is primarily an option for people who experience instability only with certain activities such as playing basketball, contact or overhead racquet sports. In these people, avoidance of the activity may reduce their episodes of subluxation or dislocation.
Surgical treatment is considered in people
- not willing to give up the activities or sports which provoke their episodes,
- in people in whom instability occurs during routine daily activities (dressing, sleeping, etc) or work.
- after an initial dislocation in “high risk” individuals not willing to take the risk of suffering another dislocation.
Technique of Reconstruction
It is usually, but not always possible to stabilize the shoulder by arthroscopic techniques.
The surgery includes examination of the shoulder under anaesthesia to fully assess the extent and direction of the instability while the muscles surrounding the shoulder are completely relaxed.
An arthroscope is used to inspect the inside of the shoulder joint in order to evaluate the joint and its cartilage. The arthroscope allows direct assessment of the condition of the labrum and rotator cuff tendons.
The operation tightens the ligaments that are loose and repair the torn cartilage (labrum). In this type of operation the ligaments and labrum are fixed back into their original position. The ligaments are reattached by reshening up the edge of the bony socket and using sutures through the labrum and ligaments to hold them in the appropriate place for healing. The sutures are often anchored to bone with a special anchors.
Most, not all, of these anchors are now made of plastics such as PEEK. Metal anchors may also be used. These anchors are inserted into the bone and hold the sutures that are used to reattach or tighten the ligaments. these anchors stay in the bone permanently
To correct severe instability, especially when the episodes of dislocations have caused significant damage to the bones of the joint as well as cartilage and ligaments (Large bony Bankart lesion), open surgery is sometimes necessary.
In this situation an incision is made over the shoulder and the tendon of subscapularis is divided to gain access to the joint. The capsule, ligaments and labrum are repaired., A bone graft is often required to replace the damaged bones. Some local bone can be removed and fixed (grafted) to the glenoid called the Latarjet or Bristow procedures.
Rehabilitation after Surgery
Why do rotator cuffs tear?
The cause of rotator tears are complex. While tears were first thought to be caused by “impingement”, that is catching of the tendon on the bone, impingement is now thought to be a consequence rather than a cause of cuff tears.
Sudden tearing of a normal tendon occurs rarely. Usually the tear occurs slowly in a tendon that is weakened. Many factors contribute to this. Aging with resultant poor healing and reduce circulation in the tendon is a significant factor. There also appears to be inherited factors. Mechanical forces on the rotator cuff (such as repeated lifting) contribute to its failure.
The combination of these factors results in partial tendon tears which ultimately progress to full thickness rotator cuff tears.
A partial rotator cuff tears even on a microscopic level cause a vicious circle as each tendon fibre tears; it is subsequently under loaded throughout the length of the tendon causing degenerative changes. Subsequent the tendon elsewhere is overloaded also causing degenerative changes to the tendon. Like a fraying rope, as each strand tears, the remaining strands take up more of the weight till they all tear and a full thickness tear develops.
Over time, the full thickness tear increases in size and the tendon and muscle shortens and retracts away from its attachment. As the tears size increases, so does the retraction. The muscle then wastes away. This is an irreversible process. This is why it is important not to neglect rotator cuff tears.
In this video, Dr Haber explains how a double-row arthroscopic rotator cuff repair is performed. He details the principles of the repair with clips of animations as well as arthroscopic video.
Day of Surgery for Rotator Cuff Repair Surgery
The hospital should give you complete instructions before your procedure.
FOLLOW THESE INSTRUCTIONS CAREFULLY!
If you have any questions, call the hospital. Arrive early. Hospital operating rooms are on a tight schedule, so please arrive at your scheduled time.
Do not eat or drink as instructed
The reason for this is primarily due to the anesthesia that can cause nausea and vomiting if the stomach is not empty.
Bring any hospital documents and current medications. Come to the hospital with your information and any documents we have given to you.
Also, have your current medications, in their original containers, with you.
PLEASE BRING ALL X-RAYS, ULTRASOUNDS and MRI’s.
Diagnosis of Rotator Cuff Tears
The physical examination
This can be the most important part of the assessment and can be suggestive of a rotator cuff tear. If I can demonstrate selective restrictive movement and weakness of your shoulder, there is a high likelihood of a tear in the tendons. It is also helpful excluding a frozen shoulder.
These may give clues that there is a rotator cuff tear. It does not image the tendons at all. X-rays may demonstrate the presence of spur formation (which if large is suggestive of a tear) and help exclude arthritis.
In experienced hands, Ultrasonography (US) can non-invasively reveal tears of the rotator cuff. They also can measure accurately the size of the tear. US has the advantages of speed and safety. The disadvantage is that its accuracy is very dependent on the experience of the operator. Due to the variable experience of outside ”operators”, we often repeat the ultrasound in our clinic to confirm the findings and take our own measurements. While US in experienced hands is as accurate, and in some cases more accurate than MRI in diagnosing RC tear, it is not very good at looking at the bones or cartilage.
In some cases, injection of a local anaesthetic into the bursa under ultrasound guidance can be used to make sure that the pain is in fact coming from the shoulder, and not radiating from the neck (The impingement test).
Magnetic Resonance Imaging (MRI)
An MRI scanner is a large machine that uses magnetic waves and a computer to provide a 2 dimensional picture. The MRI Scan can be used to look at the rotator cuff tendons as well as the bones and cartilages. Rarely contrast injection (arthrogram) may be used.
Going home after shoulder surgery
Exactly what will happen in your case will vary depending on where and when you surgery takes place. However, the general schedule of your day will be somewhat consistent.
Going home after shoulder surgery
You usually go home the morning after your surgery. Your follow-up appointment will be arranged prior to discharge.
Day Surgery Patients
You will remain in the recovery ward for approximately 2 to 4 hours. When you are fully awake you may go home.
When you leave the hospital you will have 2 types of dressing:
- A large bulky white dressing (combine dressing). Once the combine dressing is removed you may shower but try and keep the waterproof dressing as dry as possible.
- Small waterproof dressings which, if possible remain intact for 5 days. If the waterproof dressings do get wet or are soiled, you may remove them and put clean dressing on remembering not to touch the inside of the waterproof dressing.
After 5 days post operation you may take all of the dressing down.
You will have steri-strips which will probably come off on their own or with the waterproof dressings. If they are still on they will be taken out on your first visit to Dr Haber’s Surgery.
If there are stitches they may catch on your clothing. You can just put a band aid over the stitches.
The sling is only removed when you need to shower and remains on until your first post-operative visit with Dr Haber.
You may leave the wound intact but if you wish to shower after this period it is advised you change your dressing to a light dry dressing.
This may be changed each time the wound gets wet at showering. Leave the waterproof dressing on for 5 days, unless they it is wet underneath the dressing.
Some swelling and discomfort around your incision is normal.
Call Dr Haber’s Surgery (or if after hours, the hospital at which your surgery was performed) immediately if you notice any of the following:
- You notice signs of infection such as fever, chills, drainage from the incision, redness and/or swelling of the incision.
- Excessive swelling, fever, chills, bleeding or discoloration, drainage from the incision;
- Bleeding that does not stop after 15 minutes of direct pressure;
- Your incision opens.
After discharge from hospital the sling is only removed when you need to shower. To shower just take your arm out of the sling, bend over, let the arm hang and wash under your arm. Always remember to support your arm and not to actively lift your arm away from your body.
The sling must otherwise remain on until your post-operative visit with Dr Haber.
At this appointment you will be advised to commence passive exercises and will be given information on rehabilitation and physiotherapy. Don’t start any exercises before we advise you
The anesthetist will give you a prescription for medication to control pain. It may be filled at the hospital’s pharmacy or at your local pharmacy depending on when and where your surgery is performed.
Take the prescribed medication as ordered when you need it. The pain should improve slowly within a few days.
You may receive a note on discharge explaining the medications the anesthetist has recommended for you, based on his preoperative consultation.
Sleeping as upright as possible (possibly in a recliner) seems to help.
If you are taking any regular medications, please resume them after your surgery. This includes blood thinners such as aspirin and Warfarin unless specified otherwise.
We will give you a follow-up appointment prior to you discharge. Typically this will be 8-10 days after surgery. Please call us if you are unable to attend.
Risks of Rotator Cuff Surgery
Modern techniques do minimize risks, but cannot eliminate them completely. The most significant risks of rotator cuff surgery include, but are not limited to, the following:
Irreparable the rotator cuff tendon. Unfortunately, longstanding tears may not be able to be repaired despite out best attempts. The inability to obtain or maintain a durable repaired tendon may cause ongoing pain and the need for revision surgery may occur.
Stiffness of the joint. With arthroscopic, the risk of severe longstanding stiffness is rare but still occurs in 1/20. Stiffness is usually temporary but may take 6–12 months to resolve. Occasionally further surgery may be required to release tight scar tissues.
Infection. With arthroscopic, as opposed to open surgery, the incidence is around 1/1000. Antibiotics at the time of surgery are frequently used to help prevent infection. If infection occurs this may require antibiotics and occasionally further surgery.
Re-tear of the repaired rotator cuff. Especially large, chronic tears have very poor healing rates. Further surgery may be required to re-repair the tendons if they fail to heal, especially in an injury occurs during the healing phase. Failure of the hardware may occur if the tendons do not heal and there may be a need for additional surgery to remove these.
There are also risks associated with anesthesia but these are extremely rare.
The general risks of a procedure include:
- Small areas of the lungs may collapse
- Clots in the legs with pain and swelling. Rarely part of this clot may break off.
- A heart attack or a stroke.
- However death from these complications is extremely rare.
Surgical Technique for Rotator Cuff Tears
The tendons of the rotator cuff can be repaired either as an “open” technique or an arthroscopic technique, often referred to as “key-hole” surgery.
My preference is for arthroscopic techniques for all repairs, small or large.
With this technique, the entire procedure is performed through 2-3 small nicks in your skin of 6mm to 8mm, referred to as portals.
The portal in the back of the shoulder is used to visualize the shoulder joint, the rotator cuff tear and the subacromial bursa, using an instrument known as an arthroscope. It which contains a fiber-optic tube attached to a miniaturized video camera and the inside of the shoulder is visible to the surgeon on a computer screen.
Two side (lateral) portals are used to insert stitches and “anchors” to pair the torn rotator cuff tendons.
The arthroscopic repair can be performed by two different techniques, single and double row repairs. The attachment site of the supraspinatus tendon is very broad (shaded area). To reproduce this large area of contact between tendon and bone (the footprint), I believe it is preferable where possible to fix the tendon at both sides, the inside (medial) and the outside (lateral). It is likened to fixing a load such as a container onto a semitrailer. You fix one side of the load, and then ratchet down the other side. In some circumstances it is not possible to achieve a double row repair, such as very large and retracted tears. Small tears which are only partially detached don’t need a medial row.
The patient is placed on their side and is supported by a bean bag to stabilize their body. The anesthetist will frequently make sure you are comfortable in this position before being anesthetized (put to sleep).
The patient is placed on their side and is supported by a bean bag to stabilize their body. The anaesthetist will frequently make sure you are comfortable in this position before being anaesthetized (put to sleep).
An examination and possible manipulation under anaesthetic is performed to eliminate any stiffness in the shoulder prior to the procedure.
Inserting stitches into the tendon
With the use of specialized instruments we are able to pass sutures through the tendon via an incision less than a centimetre long. The stitches are inserted using an instrument which contains a suture cartridge. The jaw at the end of this instrument closes on the torn end of the tendon by pulling the silver handle holding the tendon gently in place. The instrument passes a needle thru the tendon and pulls the suture through, much like a sewing machine. Once the suture is passed through the tendon, the sutures are retrieved out of the portal.
Fixing the Stitches to the Bone Using Anchors
The suture can then be attached to an anchor. A tiny drill hole (<3mm) is placed in the bone. The anchor with its attached suture is placed in the bone and locked into position. With the anchors in place, the sutures can be tightened. When adequate compression of the tendon onto the bone has been achieved the suture can be locked in position.
Arthroscopic Superior Capsular Reconstruction
The management of people with potentially irreparable rotator cuff tears remains a difficult problem. There are several options if a rotator cuff tear is deemed irreparable or a rotator cuff repair procedure has failed.
Recently the procedure of Arthroscopic Superior Capsular Reconstruction (SCR) has been described.
The superior capsule is the upper part of the lining of your shoulder joint. It has been shown to assist the rotator cuff in helping centre the humeral head on the glenoid socket.
When the rotator cuff is irreparable, reconstructing the superior capsule has been shown to be a helpful strategy. The procedure was developed by Dr Teruhisa Mihata in Japan, who initially presented a series of these procedures performed in 2007 to 2009. The technique has been significantly improved since then.
This new surgical technique works by placing a graft where the superior capsule once was. This may limit superior humeral migration. The procedure itself is an arthroscopic day surgery procedure. A dermal allograft is used as a graft. This is fixed in position using stitches and “anchors” very similar to a rotator cuff repair technique.
The rehabilitation following this procedure follows the lines of a very conservative rotator cuff repair rehabilitation protocol.
The 3 Phases of Tendon Healing
The inflammatory phase
This phase occurs during the first 7 days. Even a small amount of bleeding occurs after the surgery. Platelets help form a clot and a fragile bond, which helps limit the bleeding. Messenger chemicals attract inflammatory cell such as white blood cells.
The proliferative (new cell formation) phase
The inflammatory phase gradually transforms into the proliferative phase, which occurs 2 to 3 weeks after surgery. New cells replace the inflammatory cells to produce scar tissue (collagen) and new blood vessels which replace the original clot. This scar tissue is the scaffold of the more permanent repair tissue. During the following week, this repair tissue grows stronger during the transition to the maturation phase
The maturation and remodeling phase
This begins around week 3 after surgery as tissue production slowly tapers and scar tissue (collagen) matures. Immature scar tissues are replaced by mature tissues. The collagen is continually remodeled until permanent repair tissue is formed.
Tendon healing takes at least 12 to 16 weeks, but may indeed take up to 26 weeks to reach its final strength.
Aggressive early movements following surgery, which overly stresses the repair and exceeds the mechanical strength of the repair construct, must be avoided
The recovery from surgery
There are two important principles in the rehabilitation.
1. Protecting the repair
2. Preventing stiffness
Protecting the repair
The rotator cuff is repaired using stitches and plastic or metallic “anchors” which fix the torn tendon back on the bone. Initially, the success of the operation is dependent on the ” hardware”. Over the subsequent twelve weeks the tendon will knit onto the bone. Protection of the repair during this early phase of healing is therefore extremely important. Protect the repair by being careful not to use your shoulder actively, that is, do not lift your arm away from your side under its own power. Unless we tell you otherwise, you may use your hand for typing or writing as long as your arm is supported. The nursing staff may instruct you on how to change clothes and wash. You may rest with your arm supported on pillows for periods out of the sling to let your skin breath. However, raising the arm actively, even a small amount places demands on your repair and should be avoided. We will tell you how long these restrictions need to be in effect. During this time you should leave your sling on and you should not drive!
While your shoulder is healing, gentle passive motion is helpful in preventing stiffness. Passive motion means that the shoulder is moved, but not under its own power. Your operated shoulder is moved by your other hand while the muscles of the operated shoulder are completely relaxed.
Remain in the sling until your first visit unless showering.
At the first visit we will show you how to do some gentle stretches finger walks)
You may perform finger and wrist exercises such as squeezing a ball several times a day.
You can move your shoulder passively by standing up and bending over at the waist, allowing the operated arm to dangle down in a relaxed way (see diagram). Your good, non-operated arm can lift the operated arm which is relaxing, allowing the good arm to take all the weight.
Dos and Don’ts
Do wear the sling as specified, usually full time for 4-6 weeks
Do use your hand and forearm for eating, writing etc.
Do perform finger, wrist, and elbow movements and hand strengthening
Don’t actively lift your arm for at least the first 6 weeks
Don’t leave your sling off unless performing exercises or showering for the first 6 weeks unless specified.
Don’t lift any weights above shoulder height for at least 3 to 6 months unless specified.
With your forearm resting on a table you may use your fingers to “walk” your arm
The rehabilitation need to be significantly varied based on a number of factors which may delay tendon healing. These include
- large longstanding tears with significant tendon retraction
- degenerative changes in the tendon,
- cigarette smoking,
- Other diseases and medications.
A conservative rehabilitation and compliance with the rehabilitation is critical in the healing, especially in the first 12 weeks. It is always a balancing act between stiffness and damage to the repair.
A number of studies have shown “aggressive” early range of motion exercises do not decrease the risk but are associated with increased risk of damage to the repair.
Therefore there is little to be gained trying to quickly restore range of motion, placing the tendon at risk of retear.
The rehabilitation phases with typical time periods in brackets are:
- Phase 1: Immediate postoperative period, minimal motion
- Phase 2: Protection and passive motion
- Phase 3: Protection and active motion
- Phase 4: Early strengthening
- Phase 5: Advanced strengthening
(weeks 24- 52)
Physiotherapists are experts in applying the appropriate rehabilitation programs. They monitor exercises to make sure you are doing them correctly. They develop new exercises and modify existing ones for maximum benefit.
Careful exercise to strengthen and rehabilitate the rotator cuff muscles is an important aspect of treatment. But they must not be performed until specified as per above protocols. These programs are often initially developed with the help of a physiotherapist and then continued at home as a home exercise program. They consist of stretching and mobilization exercises followed by a specific strengthening program. Formal Physiotherapy commences about 6 weeks after surgery.
Return to Activities
For the first 6 weeks after surgery you will remain in a sling most of the time. Physical activities/duties with the operated arm are not possible during this period apart from short periods for stretching exercises and washing. Driving is also not recommended
At 6 weeks after surgery, you may commence very light active use of your arm, that is, without any resistance. You remain unfit for any manual duties using the operated arm. You may start to drive an automatic car at this stage if you have achieved an adequate comfortable range of motion.
You are therefore fit for essentially clerical duties only.
At 12 weeks following surgery, resisted active use of the arm will be permitted. You may commence light duties using the operated arm. You will however have significant restrictions using the arm above shoulder level and away from the body. At that stage, the shoulder remains very weak.
At 24 weeks following rotator cuff repair surgery, strong tendon to bone healing should have occurred and some significant improvement in your strength will have returned. It is hoped a more aggressive return to pre-injury activities/duties can be pursued. Nevertheless at this stage some restrictions may still apply.
Full recovery from surgery may take 12 months and it may be this period of time before you can return to pre-surgery activities/duties.