Rotator Cuff Disease

Background

Rotator cuff problems are usually caused by the tearing or the stretching and inflammation of the rotator cuff tendons of the shoulder. They can occur with a single accident, multiple small incidents, or repetitive use of the shoulder. The usual symptoms are of pain, particularly at night time, and when attempting to raise the arm as well as weakness of the shoulder. Arthritis of the shoulder can develop with long term disease. Treatment initially can include rest, physiotherapy and injections but often requires surgery especially in younger people or those with very large tears.

Anatomy

The shoulder joint consists of a ball and socket, held together with loose ligaments and surrounded by a cloak of tendons called the rotator cuff. There are 4 of these, and they work to keep the ball centred in the socket and help to move the arm in certain directions. Above the rotator cuff tendons is a fluid sac call the bursa which lies between these tendons and the arch of bone forming the point of the shoulder (the acromion). Making up part of this arch is a ligament called the CA ligament.

Structural damage

Rotator cuff tearing is usually the result of the tendons of the rotator cuff pulling away from the bone which they are attached to. Of the four tendons making up the rotator cuff the one at the very top called the supraspinatus is the one most frequently torn. Larger tears can involve 2, 3 or all 4 tendons of the rotator cuff. Associated with this tearing is usually an element of inflammation of the bursal sack above the tendons called bursitis and there may be a bone spur present. The thin biceps tendon which passes in front of the shoulder may also be frayed or damaged in conjunction with rotator cuff injuries.

Symptoms

Pain from rotator cuff disease is usually felt over the top and front of the shoulder and may travel down the arm towards the elbow usually on the outside. Some pain may be felt up around the base of the neck and over the shoulder blade at the back. This is usually to secondary to overuse of muscles nearby. It may be very difficult to lie on the affected shoulder at night time. Weakness may be noticed with progressive difficulty in lifting the arm itself above the level of the shoulder and especially with lifting any objects.

The severity of pain does not usually correlate with the size of the tear. Merely inflamed tendons or those with a small “partial thickness” tear may be more painful than those completely torn.

Initial symptoms of pain and decreased use of the arm can settle down by themselves, often flaring up again with excessive use of the arm or with repeated minor trauma. A fluctuating course of improving and worsening symptoms is frequent.

Consequences

• Pain in the shoulder tends to worsen with time.
• Interference with normal daily duties and work – manual labour may not be possible.
• The tears often increase in size with time and with this is a progression of increasing pain and further weakness of the arm.
• With long standing tears which are large particularly those with a weak shoulder arthritis can ultimately develop. At this point the rotator cuff tears are not able to be repaired surgically and treatment is along the lines of an arthritic shoulder. This may include joint replacement.

Treatment

Rotator cuff tears especially small tears of a single tendon in a person of advanced age can be managed initially without surgery. This treatment includes:

• Avoiding persistent overhead duties or heavy lifting or any other specific aggravating activity.
• Physiotherapy designed to maintain flexibility and improve the strength of the remaining good rotator cuff tendons and also to maintain good posture.
• Analgesic and anti-inflammatory tablets.
• Injections of local anaesthetic with cortisone. These injections help to settle inflammation however do not alter the underlying structure of the tendons. Excessive use of cortisone is recognized to weaken tendons and should be discouraged.

Large tears of the rotator cuff which involve one or more of the tendons particularly in a younger person are best treated with surgery in the first instance. Surgery is also appropriate for the smaller tears discussed above when symptoms do not resolve with the measures outlined.

The surgery

Fig. 1 Rotator cuff tear

The surgery is performed mostly via a keyhole (arthroscopic) technique and occasionally as a combination of keyhole technique with a small incision.

Initially 3 or 4 incisions (1cm each) are made around the shoulder through which the camera (arthroscope) and arthroscopic instruments are inserted.

Fig. 2 Rotator cuff repair

It is often necessary to initially shave the bone of the acromion to remove a spur and create more room for the tendons to move, as well as to remove scar tissue and a thickened C/A ligament if present. Once this is accomplished the rotator cuff tendons are repaired to the bone using small plastic or titanium tacks within the bone connected to stitches which are passed through the tendons (Figs 1 and 2). The inflamed bursa covering the rotator cuff is also removing during this procedure.

The keyhole technique has some advantages compared with traditional methods of ‘open’ surgery using larger incisions:

• Less pain
• Shorter hospital stay (day case or overnight only)
• Faster rehabilitation
• Less stiffness (restriction of movement) following the surgery
• Better ability to identify and treat other areas of damage

For larger tears or when work needs to be done to the small biceps tendon as well an open incision (approx 4 cm.) is made over the front of the shoulder. This is later closed with a dissolving stitch.

What to expect after the surgery

You will wake up in the recovery area of the operating suite with a bulky dressing over the shoulder and a sling applied.

Pain will be present however not extreme. By evening it should be well controlled with tablets given on the ward. Occasionally a small dose of a strong pain killer given via injection is needed.

The shoulder will be swollen for approximately 24 hours due to collection of sterile fluid used during the operation to enable vision inside the joint.

Discharge from hospital is usual the following morning. The bulky dressing is taken down and the small waterproof dressings replaced if soiled. These should be left in place until the time of the post-operative review, and the date of this will be given to you at the time the surgery is booked. You may shower but try not to directly soak the dressings. The wounds should be kept dry until the stitches are removed.

A physiotherapist will see you prior to discharge and instruct on simple exercises to do and how to manage the sling. In general terms the sling should be used constantly for the first 6 weeks in order to allow the rotator cuff tendons to heal. It can be taken off for showering and for periods of time to do prescribed exercises and when resting quietly at home.

You will receive a short (usually 5 day) supply of pain killing tablets to use at your discretion. Reaction to the tablets may occur and can include a rash, nausea, stomach pain, dizziness and light-headedness. Stop them and see your local doctor for alternatives if needed.

The small wounds usually heal well with only a faint scar ultimately visible.

In the short term, the size of the muscle surrounding the shoulder will decrease due to lack of use. This will return following rehabilitation and is expected to take many months.

Rehabilitation

The goal of the rehabilitation period which can take up to 6 months is to initially rest the shoulder allowing the tendons to heal, then to gradually build up flexibility and movement, and thereafter develop strength.

Initial instructions for home movement exercises, some within the sling and some out of the sling, will be given by a physiotherapist prior to leaving hospital on the following day. It is important to stick to these guidelines within the first 6 weeks following the surgery so as to maintain some movement and flexibility in the shoulder to prevent it from seizing up while the tendons heal. These are gentle movements designed to discourage active use of the muscles and tendons of the rotator cuff.

From the review at the 6 week point following surgery the sling will be discarded and physiotherapy accelerated. Light stretch bandage or weight work will be introduced to gradually strengthen the rotator cuff when close to full movement has first been achieved. This will usually be between the 2nd and 3rd month following the surgery.

The strengthening programme will progress with gradually increasing loads to restore the shoulder to full or near full strength by the 6-9 month period following the surgery. Some improvement is often seen up to 1 year following surgery.

Although the procedure is often performed through an arthroscopic or keyhole technique keeping pain levels down the actual healing time for the tendons is no different than if the surgery were performed through a more traditional larger incision. Some discomfort in the shoulder is expected particularly if full movement hasn’t been regained up to 3 months following the surgery. Night pain may persist until this time also.

Driving is not permitted while the sling is in use. Work that involves supervisory or office based duties is possible from 2 weeks following the surgery pending comfort. Heavier physical duties will not be permitted until at least 3 months following the surgery when some light duties may be possible in people who have had small tears repaired. In most cases heavy labouring work will not be possible until 6 months. Timing of return to sporting activities can be discussed and individualized and in general will follow the same time frames as for physical labour with contact sports not encouraged until 6-9 months following surgery.

Complications

Complications are rare from this type of surgery. The procedure generally takes between one and two hours to perform and there is minimal blood loss. Some of the more common or important potential complications or consequences are outlined below.

1. Some complications which are related more directly to the shoulder:

• Bleeding under the skin related to the arthroscopy entry holes leading to local bruising. This bruising may run down the arm and across to the chest area. It is common, goes away in a couple of weeks, and does not require treatment.
• Infection may occur and may be indicated by an increase in pain, fever, nausea and generally feeling unwell. The surgical wounds may be surrounded by reddening of the skin and may discharge fluid, blood or pus. There may be a foul odour. Infection around the small wounds only will settle without consequence after treatment to the area such as removing the stitch, local dressings and possibly antibiotic tablets. Infection deep within the shoulder is very rare however more serious when it occurs, and may require surgical washout of the shoulder along with prolonged courses of antibiotics. This type of infection may lead to permanent damage to the rotator cuff or the cartilage within the shoulder joint.
• Stiffness (restricted movement) may occur despite appropriate rehabilitation with exercise and physiotherapy. It is uncommon. On occasions a brief procedure under anaesthetic may be required to free up the shoulder.
• Failure of the procedure will result in persistent pain and weakness of the shoulder. This may happen due to re-tearing of the rotator cuff tendon, or persistent inflammation. Re-tearing of the tendon usually occurs following another injury to the shoulder but may occur simply due to failure of the tendon to heal to bone due to its poor quality. Surgery is not always necessary for recurrence of symptoms, or re-tearing of the rotator cuff.
• Nerve injury resulting in weakness of the muscles around the shoulder or of the arm or hand, and / or loss of feeling in the skin in the same areas, has been reported following this type of surgery. It may result from stretching of the nerves during grasping and positioning of the arm during the surgery, or direct damage to the nerve from the arthroscope or arthroscopic instruments used. Nerve injury is usually temporary but rarely may be permanent. Permanent nerve injury may require grafting or other corrective surgery.
• Injury to the major blood vessels passing by the shoulder is possible however extremely rare. If this happens, surgery to reconstruct the artery or vein could be needed. Permanent loss of muscle function in the arm or hand may occur.

2. Some complications of a more general nature:

• The surgery is carried out under general anaesthetic which is extremely safe, however on very rare instances a problem relating to the airway, lungs or heart and circulation may occur.
• An intravenous line is always required, and often an additional line into a small artery near the wrist to monitor blood pressure. Its use may result in pain or bruising at the point of entry, and rarely an infection or thrombosis of the vein or artery.
• Blood clots in the veins of the calf and / or leg (Deep Venous Thrombosis) may occur despite the surgery not involving these areas. It is very rare but when large can pose the threat of movement of the clots within the veins to the lungs (Pulmonary Embolus) and this can be serious or even fatal.
• Your anaesthetist will discuss the use of an injection above the shoulder near the neck (Nerve Block) to help ‘deaden’ the shoulder and arm for approximately 24 hours to help control pain. There are complications reported relating to this including bruising and nerve damage. My anaesthetist will be happy to provide further details relating to nerve blocks or other issues regarding the anaesthetic on request. You will be given contact details for the anaesthetist at the time of surgery booking.
• Infection within the body at a place other than the shoulder can occur, e.g. pneumonia, urinary or blood infection. This is more likely in elderly people or those who smoke cigarettes.
• Allergy to the antibiotic which is routinely used immediately prior to the surgery can occur. This most often causes a rash. Very rarely when serious an allergy can cause obstruction to the airway or reduced blood pressure.

In case of problems:

1. Pain control – contact local GP initially if you have run out of the tablets given to you at discharge, or you are experiencing side-effects.
2. Signs of infection (persistent increase in pain, wound discharge beyond 2 days following surgery, foul odour, fevers) – contact Mr. Dallalana via the rooms or through the hospital where you had your surgery if out of business hours. A GP may be contacted for review at the same time.
3. Tingling in the arm or hand or calf pain – contact Mr. Dallalana via the rooms or GP. Contact the hospital where you had your operation if out of hours.
4. Numbness or persistent coolness in the hand or fingers – attend the nearest emergency department.
5. Shortness of breath, severe lack of energy or sudden high fevers with chills or shakes – attend nearest emergency department.

Non-urgent matters should be listed for discussion at the next review with Mr. Dallalana or alternatively queries can be directed via email or by calling the rooms.

Certificates can be obtained at review or by your GP at other times.

• Please contact Mr Dallalana's rooms if you require further information.