The rotator cuff muscles and disorders of them are described in the condition page - Shoulder rotator cuff tears and impingement.
Surgery for rotator cuff pathologies
Surgery is offered to those patients with very large spurs, large tears that may still be amenable to surgery repair, or those who have pursued non-operative treatment for a reasonable length of time without benefit.
Prior to any surgery it is important to consider general health and risk issues. It is important to disclose any medical problems, medications taken and allergies to medications. If there are any major concerns Dr. Mackie may request a preoperative visit to an anaesthetist or specialist physician.
Typically, patients are required not to eat or drink for about six hours before a general anaesthetic. However, some anaesthetists allow a few sips of water until two hours beforehand. For morning operations it is recommended that patients fast from midnight prior to surgery (no food or drink) although a small sip of water may be used to take normal medications. For afternoon operations it is recommended patients have nothing after an early breakfast (~ 07:00 am). Any blood thinning medications and medications for serious heart or lung conditions should be discussed prior with Dr. Mackie or the anaesthetist. Dr. Mackie will generally speak with patients prior to the anaesthetic.
Patients will receive a general anaesthetic and may have an injection of local anaesthetic between the neck and shoulder to provide postoperative pain relief. This will be discussed by the anaesthetist.
Some surgeons perform shoulder surgery via keyhole small incisions, although this generally requires 2 or 3 small cuts around the shoulder and the use of telescopes and specialist equipment for surgery. Dr. Mackie may perform shoulder surgery via such an approach but will most commonly use a more traditional single longer incision over the tip of the shoulder.
Dr. Mackie will then assess the site of impingement and remove the bony spur and enough of the acromion to allow free movement of the underlying rotator cuff tendons. If a tendon is torn with a relatively clean edge it will be repaired with stitches. A repair will entail a longer period of time in a sling and longer recovery. If the tear has been present for a long time or has a rough and weak edge then the tendon is cleared of loose edges and not stitched. The removal of a bone spur is the major factor in reducing shoulder pain, and if a tear in a tendon can be stitched it may provide an improvement in shoulder strength.
The first 24 to 48 hours following surgery can be quite painful and pain-killers are used in hospital until patients are comfortable enough to be discharged home with tablets only.
After Rotator Cuff Surgery
It will be necessary to rest after coming around from the anaesthetic. The shoulder will feel stiff and sore and painkillers will be needed to relieve the discomfort. Most patients will stay one or two nights in hospital, although very occasionally a few nights are required to get over the postoperative discomfort.
A sling is used for comfort and to minimise shoulder movements.
A general anaesthetic can temporarily affect co-ordination and reasoning skills, so patients are advised to avoid drinking alcohol, making any vital decisions or signing legal documents for24 hours afterwards.
Before discharge, a nurse will give advice about caring for stitches and bathing.
Physiotherapy is not generally required in the early postoperative period.
Once home, it may be necessary to continue taking painkillers as advised by the nursing or medical staff.
The shoulder is likely to be quite sore, so anyone who has this operation needs to be prepared to take it easy for at least a week or two.
The area will need to be kept clean and dry for about a week. Waterproof dressings may be used over the wounds when showering. Soaking the shoulder in the bath should be avoided until healing is complete. The dressings can be replaced every few days if required.
Most people are able to return to work two to three weeks after shoulder surgery if in office duties although it may be longer if their job involves bending, lifting or carrying. Dr. Mackie will provide more advice about this in each individual case. Manual labour work should not be attempted for at least 6 weeks following surgery, but may not be possible for closer to 12 weeks.
A postoperative review is usually planned at 1 – 2 weeks following surgery to review wounds, discuss the findings at surgery and to ensure no complications have occurred. From this time a few exercises are commenced and physiotherapy usually used to help with maintaining shoulder joint function and regain strength.
It usually takes 3 to 6 months to recover from surgery and final recovery may be 1 to 2 years later!
Physiotherapy after Rotator Cuff Surgery
All patients who have undergone shoulder surgery should participate in a physiotherapy program. Rotator cuff operations will not be performed on patients who have not yet trialed a physiotherapy program to try and avoid surgery.
The post-operative physiotherapy exercises are different to those used prior to surgery. Therefore it is important to plan for this. Therapy usually starts after the 2 week postoperative wound review appointment.
Most physiotherapists will have a set program for patients who have undergone a shoulder decompression and a program for patients who have also required a rotator cuff tendon repair. Any deviation from the normal program will be communicated by Dr. Mackie to the physiotherapist.
As a guide:
- A sling is worn nearly full time for the first 2 weeks after surgery.
- Gentle “pendular” exercises (rocking the shoulder back and forwards) are encouraged.
- Patients should regularly take the elbow and wrist out of the sling to encourage movement at thee joints.
- After a wound check at 2 weeks increased movement may be permitted, gently working with the therapist.
- From ~ 6 weeks following surgery patients will commence a greater range of motion.
- From ~ 8 weeks following surgery strengthening programs will commence.
- Full range of motion in the shoulder (with reasonable strength) is aimed for by ~ 12 weeks postoperative.
- The duration and frequency of visits is best determined by the physiotherapist, depending on the individual response to treatment.
Side Effects and Complications.
Shoulder subacromial decompression is a commonly performed and generally safe surgical procedure. For most people, the benefits in terms of pain relief are greater than the disadvantages. However, in order to give informed consent, anyone deciding whether or not to have this procedure needs to be aware of the possible side effects and the risk of complications.
Side effects are the unwanted but usually mild and temporary effects of an otherwise successful procedure. Examples of side effects include feeling sick as a result of the general anaesthetic, although medicines are available to help avoid this. For this operation, there is also likely to be some pain and stiffness around the joint. There will be a scar from the incision.
Complications are unexpected problems that can occur during or after the operation. Most people are not affected, but the main possible complications of any surgery are excessive bleeding, infection or an unexpected reaction to the anaesthetic. Complications may require further treatment although fewer than 1 in every 100 shoulder operations are followed by any significant complication.
If patients experience increasing pain, swelling, redness, fevers or are generally unwell it is important to be reviewed early to ensure no infection has occurred. If infection is suspected most patients will be readmitted to hospital for antibiotics and may require a repeat operation to wash out the infection.
A loss of feeling in the skin over the front of the shoulder near the incision can occur although is rarely troublesome.
Fluid can accumulate around the surgical site and can escape under pressure. If the wound then opens up it remains moist and a mild infection may secondarily develop. A very small number of patients will require return to the operating theatre in the first few weeks for cleaning of the wound and resuturing of the wound. Overall rehabilitation will be delayed by 1 – 2 weeks.
A very small number of people develop adhesive capsulitis / frozen shoulder after shoulder trauma or surgery. The shoulder may become painful for several months and marked stiffness persists for more than a year. Frozen shoulder cannot be predicted and few treatments speed up its recovery. It functionally disables the shoulder for a prolonged period.
Most structures within the shoulder are well protected but occasional cartilage, nerve or vessel damage may occur.
A small number of patients will have persistent symptoms for some time after surgery, although shoulder conditions may take 3 – 6 months to settle.
A small number of patients who have had a rotator cuff tear previously repaired may re-tear (as the scar tissue formed during repairs will never match the original tendon for strength).