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Rotator Cuff Tear

Rotator Cuff Tear - Do You Need Surgery?

Last updated on:
13/05/2013

Contributing Author: Guy Slowik FRCS

If a rotator cuff tendon has torn completely, it usually will not heal completely without surgery. Whether a doctor actually recommends surgery, however, will depend on several factors, including:

  • The extent of the injury
  • If the pain has not responded to simple conservative treatments
  • The person's age and general health
  • How much the symptoms affect overall function of the shoullder
  • And most importantly to what extent the persons day to day activities are affected

Usually surgery is recommended in the following circumstances:

  • The rotator cuff was torn as the result of an acute injury, accident, dislocation, or fracture .
  • The torn rotator cuff results from chronic degeneration (wear and tear) and does not respond to medication, physical therapy, and other nonsurgical treatments.
  • Ongoing pain or weakness in the injured shoulder interferes with a person's ability to perform necessary tasks.

Age itself does not determine whether someone is a good candidate for surgical repair of a torn rotator cuff. But if someone is elderly, and the injury affects his or her non-dominant arm, doctors are more likely to recommend non-surgical treatment. As many as half of all patients with a full rotator cuff tear regain enough strength and flexibility to avoid surgery.

Some rotator cuff tears (very large tears - "massive tears" - are very difficult to repair, or cannot be repaired. This may be the case with longstanding very large tears. The torn tissues are so degenerate they cannot hold the sutures, or the gap may be too large to bring the torn edges close together, or the tendon may have retracted (pulled back) too far from the bone making it impossible to re-attach it to the bone.

What Are The Risks Of Rotator Cuff Surgery?

Every operation involves some element of risk. But most people do well and are pleased with the results of rotator cuff surgery (over 80% do well).

Complications are rare and include:

  • A very small number of surgical patients react adversely to anesthesia. For such patients the risk would be the same for any surgical procedure (patients who are obese, or who have heart disease, high blood pressure, or diabetes are at a higher risk;  rarely allergic reactions to anesthetic agents may occur.
  • Infections can occur as a result of any operation. The risk of infection for rotator cuff surgery  is relatively low especially if done by keyhole surgery.
  • There is  an extremely small risk of injury to a major nerve that cross near the shoulder that may result in partial paralysis or loss of feeling. Some people experience numbness in the vicinity of the shoulder incision, but this usually is temporary.

Not everyone with a rotator cuff tear needs surgery. Many do not. Surgery is never urgent. Surgery need not be done immediately following an injury. So early treatment is usually conservative  to see how the patient will do on conservative treatment. For some patients this is very successful and so surgery will not be required.

Nonsurgical Treatments

Nonsurgical treatments of rotator cuff injuries include:

  • Rest. The first step in treating any rotator cuff problem is to rest the injured joint until the pain and swelling subside.
  • Ice. In the first 24 hours after an injury, ice can help reduce pain and swelling.
  • Heat. After 24 hours have passed, a heating pad or hot compress can help an injured rotator cuff to heal.
  • NSAIDS (non-steroidal anti-inflammatory drugs). NSAIDS such as aspirin and ibuprofen can reduce both pain and swelling. Be careful to take NSAIDS as instructed, since they sometimes can produce stomach upset and gastrointestinal problems.
  • Physical therapy/exercise. Many rotator cuff problems can be successfully treated with gentle exercises designed to stretch and strengthen the shoulder muscles. Usually, it's best to begin physical therapy as soon after an injury as is possible. Avoid lifting heavy weights overhead, and avoid activities such as throwing a baseball that put a significant amount of stress on the tendons.
  • Steroids. Steroids such as cortisone may be used to reduce inflammation. Steroids can be taken orally, but for rotator cuff problems they are usually injected directly into the area around the tendon. Steroid injection should be used carefully and multiple injections should be avoided.

Surgery

Surgical repair of a completely torn or partially torn rotator cuff  may be performed as "open" surgery, requiring a two- to three-inch incision in the shoulder, but now more commonly, depending on the experience of the surgeon it is done by keyhole surgery (arthroscopic surgery) in which a video camera and surgical instruments are inserted through a few small incision about the size of a buttonhole (2 to 4 small incisions - the width of a pencil). Some surgeons prefer to sometimes use a combination of arthroscopic and open surgical techniques.

Rotator cuff surgery can be performed under general anesthesia (with the patient asleep) or regional anesthesia (with the patient awake.)

 

Preparing For Surgery

Before a patient undergoes surgery, physicians routinely perform a variety of tests to make sure he or she is  fit for surgery. These usually include blood tests, chest x-rays, an EKG (electrocardiogram), and urinalysis.

In addition, physicians may take x-rays of the damaged shoulder and perform other tests, including an MRI, or less commonly, an arthrogram, to assess the extent of the injury.

Patients are usually admitted to the hospital on the day of their scheduled operation. Sometimes people with particular health problems, such as diabetes, heart disease or lung disease, are admitted a day early.

The anesthesiologist visits the patient before surgery to discuss the type of anesthetic that will be used.

  • Rotator cuff surgery is usually  performed under general anesthesia, with the patient asleep during the procedure.
  • Frequently, a regional (or local) anesthetic is used to block the nerves leading to the arm. In that case, the patient is conscious but cannot feel pain. Usually a sedative is also used, putting the patient in a conscious but dreamy state.
  • The choice of anesthetic is based on the type of surgery that is planned, as well as the patient's health and personal preferences.

 

You should not eat or drink anything after midnight on the day before the procedure. This includes water. A completely empty stomach reduces the risks associated with anesthesia.

Also, you should make sure that both the surgeon and anesthesiologist know in advance about all medications you are taking - even aspirin. Both physicians should also be told about any allergies you might have.

 

 
 
 
 
 

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From Andrew Maynard - Chair of the University of Michigan Department of Environmental Health Sciences, with help from David Faulkner - 2013 Master of Public Health graduate.