Shoulder

Rotator Cuff Repair

IThe 'Rotator cuff'

The rotator cuff is a group of muscles closely wrapped around the shoulder. These muscles help keep the joint in the correct position and control shoulder movements. They attach from the shoulder blade onto the top of the arm bone. The muscles can be torn through general wear and tear or after an accident or fall. The damage usually occurs close to where the muscle joins the bone (called the 'tendon'). If one or more of these muscles is torn, movement is no longer smoothly controlled and the shoulder becomes weak and painful. See pictures below.

 

Left shoulder, viewed from the back. Please note; in your body, there are more muscles on top of these muscles and bones!

 

About your Rotator cuff operation

The operation aims to re-attach the tendon(s) to the bone. Sometimes the tear is too big and/or the tendon is too fragile for this to be possible and only a partial repair can be achieved. The repair involves sewing the torn tendon on the bone. This is done with the help of anchors inserted into the bone. In addition, a ligament is also released, and a prominence on a bone cut away to give the repaired muscle more space in which to move. The repair can be performed entirely by a keyhole technique (arthroscopic surgery). Occasionally the tear is too big to be repaired by a keyhole surgery and it is necessary to perform open surgery. Some tears are irreparable.

 

As the strength and size of the repair can vary, we can only give you rough guidelines in this booklet. The surgeon and therapists will be able to discuss your individual surgery after the operation, please ask.

 

What are the risks?

All operations involve an element of risk. We do not wish to over-emphasise them but feel that you should be aware of them before and after your operation. The risks include:

• Complications relating to the anaesthetic such as sickness, nausea or rarely cardiac, respiratory or neurological. (Less than 1% each, i.e. less than one person out of one hundred)
  
  
• Infection. These are usually superficial wound problems. Occasionally deep infection may occur after the operation, <1%.
  
  
• Persistent pain and/or stiffness in (and around) the shoulder in 10-20% of people.
  
  
• Sometimes it is impossible to repair the muscle because it is too badly torn. The sub-acromial decompression should improve pain, but movement and strength may be no better.
  
  
• Damage to nerves and blood vessels around the shoulder.
  
  
• A need to redo the surgery. Sometimes the muscle can re-tear. This depends on the size of the tear and how well it heals.

Please discuss these issues with the doctors if you would like further information.

 

Questions that we are often asked
Will it be painful?

Although the operation is to relieve pain, it may be several weeks until you begin to feel the benefit. During the operation you may be given a nerve block. While you are asleep, an injection of local anaesthetic is given around the nerves in your shoulder. This usually means that you will not have any feeling or movement in your arm when you awake from the anaesthetic. This may last several hours. When you begin to feel the sensation returning (often a 'pins and needles' feeling), you should let your nurse know. Other pain medication will be given at this stage, before full sensation returns. It is recommended that you take pain medication regularly to begin with, to keep the pain under control. If you require further medication, please visit your General Practitioner (GP).

 

Once the sensation has returned, you may find ice packs over the area helpful. Use a packet of frozen peas, placing a piece of paper towel between your skin and the ice pack. Until it is healed, also use a plastic bag to protect the wound from getting wet. Leave on for 10 to 15 minutes and you can repeat this several times a day.

 

Do I need to wear a sling?

Your arm will be immobilised in a sling or a brace. This is to protect the repair during the early phases of healing and to make your arm more comfortable. You will be shown how to get your arm in and out of the sling or brace by the physiotherapist.

 

You will wear the sling or brace for a minimum of 6 weeks. The sling will then gradually be used less as the repair heals and the muscles regain their strength.

 

During this time you may find your armpit becomes uncomfortable. Try using a dry pad or cloth to absorb the moisture.

If you are lying on your back to sleep, you may find placing a small towel or pillow under your upper arm to be comfortable.

 

Do I need to do exercises?

Yes! To begin with you will be moving the joint only for specific exercises, which the physiotherapist will show you. You will continue with these exercises at home.

 

Outpatient physiotherapy appointments will be organised to start at an appropriate time.

 

You will need to get into the habit of doing regular daily exercises at home for several months. They will enable you to gain maximum benefit from your operation.

 

Some of the early exercises are shown at the back of this booklet.

 

What do I do about the wound and the stitches?

Keep the wound dry until it is healed. This is normally for 10 to 14days. You can shower/wash and use ice packs but protect the wound with cling film or a plastic bag.

Avoid using spray deodorants, talcum powder or perfumes near or on the scar. Normally your stitches will be removed by the nurse at your GP surgery or by a district nurse after 10 - 14 days

When do I return to the clinic?

This is usually arranged for approximately 2-6 weeks after your discharge from hospital to check how you are progressing. Please discuss any queries or worries you have at this time. Appointments are made after this as necessary.

 

Are there things that I should avoid doing?

For at least 6 weeks, do not try and use the arm for everyday activities, especially those taking your elbow away from your body. Keep it in the sling, except when you are doing your exercises. Continue with this until you are told otherwise by the consultant or physiotherapist.

 

Do not let your elbow move or stretch across the front of your body. This can happen at night when you are lying on your unoperated side. So, once you stop using the sling, place your arm on pillows in front of you. Do not lie on your operated side.

After the first 6 weeks, be guided by pain. Avoid lifting any weight for 8-12 weeks (e.g. a kettle). This is to avoid stressing the repaired muscle. Heavier lifting (e.g. digging the garden, manual work) should be avoided for 4-6 months. There may be other movements that are restricted for you. You will be told if this is the case.

 

Within these general instructions be guided by pain. It is normal for you to feel discomfort, aching and stretching sensations when you start to use your arm. Intense and lasting pain (e.g. for 30 minutes) is an indication to reduce that particular activity or exercise. In addition, avoid sudden, forceful movements involving weight.

 

How I am likely to progress?

This can be divided into three phases:

 

Phase 1. Sling or brace on, no movement except for exercises shown by the therapists (first six weeks after surgery)

You will basically be one-handed, immediately after the operation and for the first 6 weeks. This will affect your ability to do everyday activities, especially if your dominant hand (right if you are right-handed) is the side with the operation. Activities that are affected include dressing, bathing, hair care, shopping, eating and preparing meals.

 

Some guides to common problems are given later in this booklet (page 11). If you are having particular problems, an occupational therapist can suggest ways to help you. Before you are discharged from hospital, the staff will help you plan for how you will manage when you leave. In addition, we may be able to organise or suggest ways of getting help once you are discharged from hospital.

 

Phase 2. Regaining everyday movements (6-12 weeks after surgery)

This starts once you are given the go-ahead by the hospital doctors or physiotherapist. You will have outpatient physiotherapy and start exercises to gain muscle control and movement. The arm can now be used for daily activities; initially these will be possible at waist level but gradually you can return to light tasks with your arm away from your body.

 

Phase 3. Regaining strength (12 weeks after surgery)

After 12 weeks you will be able to increase your activities, using your arm away from your body and for heavier tasks. The exercises now have an emphasis on regaining strength and getting maximum movement from your shoulder. There are still some restrictions on lifting.

 

Generally do not be frightened to start moving the arm as much as you can. Gradually the movements will become less painful.

 

Guide to daily activities in the first 6-12 weeks

Some difficulties are quite common, particularly in the early stages when you are wearing the sling and when you first start to take the sling off. If necessary an occupational therapist (O.T.) can help you and specialist equipment can be borrowed from the O.T. department. Below are listed some common difficulties with guides which may help.

 

Please discuss anything you are unsure about with the staff.

 

1. Getting on and off seats.

Raising the height can help. eg. extra cushion, raised toilet seat, chair or bed blocks.

 

2. Getting in and out of the bath.

Using bath boards can help, though initially you may prefer to strip wash.

 

3. Hair care and washing yourself.

Long handled combs, brushes and sponges can help.

 

4. Dressing.

Wear loose clothing; either with front fastening or that you can slip over your head. For ease also remember to dress your operated arm first and undress your operated arm last. In addition, dressing sticks, long handled shoehorns, elastic shoelaces and a 'helping hand' may help.

5. Eating.

A non-slip mat and other simple aids can help when one handed. Use your operated arm once it is out of the sling, as you feel able.

 

6. Household tasks/cooking.

Do not use your operated arm for activities involving weight (e.g. lifting kettle, iron, saucepan) for 8-12 weeks. Light tasks can be started once your arm is out of the sling. To begin with you may find it more comfortable keeping your elbow into your side.

 

Exercises

Use painkillers and /or ice packs to reduce the pain before you exercise.

 

It is normal for you to feel aching, discomfort or stretching sensations when doing these exercises. However, if you experience intense and lasting pain (e.g. more than 30 minutes), reduce the exercises by doing them less forcefully, or less often. If this does not help, discuss the problem with the physiotherapist.

 

Certain exercises may be changed or added for your particular shoulder.

 

Do short, frequent sessions (e.g. 5-10 minutes, 4 times a day) rather than one long session.

 

Gradually increase the number of repetitions you do. Aim for the repetitions your therapist advises, the numbers stated here are rough guidelines.

 

Get into a habit of doing them! Good luck. NB: all pictures are shown for the right shoulder unless specified.

 

Phase 1 exercises (for the first 6 weeks after surgery)

Do ALL the exercises in this section unless the therapist specifically advises you not to.

 

1. Neck exercises Standing or sitting.

Turn your head to one side. Repeat 5 times. Then turn your head to the other side and repeat five times. Then tilt you head towards the other shoulder. Repeat 5 times. Then tilt your head to the other side and repeat five times.

 

2. Elbow exercise Standing or lying .
Straighten your elbow and then bend your elbow.
Repeat 5 times. (Shown for left arm.)

3. Shoulder blade exercise Sit or stand .
Shrug shoulders up and forwards. Then roll them down and back.
Repeat 10 times.

4. Shoulder exercises Lying on your back on bed or floor.

Lift your operated arm with your other arm. Keep the operated arm as RELAXED as possible. Can start with elbow bent. Repeat 5 times.

Lying on back (on bed or floor), towel under arm.

Keep elbow into your side and bent. Hold stick in your hands. Move the stick sideways, gently pushing hand on your operated arm outwards. Repeat 5 times.

Phase 2 exercises (6 weeks after surgery)

Only start these when advised to do so.

 

1. Lying on your back, elbow bent.
Help the operated arm up as before but once the arm is vertical, try and keep it there without support of the other arm. Gradually lower and raise the arm in an arc, until you can lift it from the bed. Repeat 5-10 times.

You may be later be able to progress this exercise, by doing the same action standing up. Build it up gradually and try and get your shoulder joint to move.

2. Lying on your back, elbow bent and close to side.
Hold wrist of your affected arm with your good hand. Try and move your hand on the operated arm inwards but prevent it from moving by using the other hand. Hold for 5 seconds. Repeat 5 times and gradually increase to 20 times.

2. In the same position

In the same position try and move hand outwards without allowing movement.
Hold for 5 seconds. Repeat 5 times and gradually increase to 20 times.

 

Both exercises (2 & 3) can also be done standing or sitting.

 

4. Standing facing a wall.

Elbow bent and hand resting against wall. Use paper towel between hand and wall (to make easier). Slide your hand up the wall. Initially can give support at the elbow with your other hand. Gradually stretch higher up wall. Try to make movement smooth. Repeat 5 times and gradually increase to 15-20. Progress by moving away from the wall.

5. Standing with arms behind your back

Grasp the wrist of your operated arm. Gently slide your hands up your back. Repeat 5 times. Do not force.

6. Stand or sit.

Try and set up a pulley system with the pulley or ring high above you. Pull down with your Unoperated arm to help lift the operated arm up. Repeat 10 times.

These exercises are few examples, others may be selected instead of, or in addition to these.

 

Phase 3 exercises (12 weeks after surgery)

These will concentrate on increasing the strength and mobility around your shoulder. The exercises will be selected for your individual shoulder and your lifestyle. Work hard at them as improvements in strength can increase for up to 2 years!

Who to contact if you are worried or require further information?

If your wound changes in appearance, weeps fluid or pus or you feel unwell with a high temperature, contact your GP.

 

If you have a query about exercises or movements, contact the Physiotherapy department where you are having treatment if you have already started.

 

We would like to thank the Nuffield Orthopaedic Centre, especially Professor Andrew Carr for allowing us to reproduce this information. This has then been modified to suit local patients needs taking into account varying clinical practice. Help and feedback was given from people who have had a rotator cuff repair.