Some rotator cuff injuries may require surgery when nonsurgical treatments have not worked, but evidence suggests that nonsurgical treatments can help with most cases.
The rotator cuff is the part of the body that helps keep the top of the arm bone in the shoulder socket.
Sometimes it can tear, resulting in pain and weakness. A rotator cuff tear can also make it difficult to carry out everyday activities.
According to the American Academy of Orthopaedic Surgeons (AAOS), almost 2 million people in the United States visit a healthcare provider with issues related to their rotator cuff every year.
Nonsurgical treatment is often the preferred initial method of treating a torn rotator cuff.
However, sometimes nonsurgical treatment is not feasible or does not work. In these cases, surgery may be required.
This article looks at when rotator cuff surgery is necessary, the benefits and potential complications of surgery, what to expect during surgery, recovery times, and outlook.
What is the rotator cuff?
The rotator cuff is a term for a group of four tendons in the shoulder. They connect the muscles of the shoulder blade to the top of the arm bone.
As well as helping to keep the shoulder in its socket, the rotator cuff also allows the shoulder joint to have a wide range of movement.
If a person injures their rotator cuff, either from an acute injury such as a fall or as a result of general wear and tear, it can cause them to experience:
- difficulty sleeping on the affected shoulder
- a sense that the shoulder is unstable
- a cracking or popping sensation when moving the arm
- inability to achieve full range of motion
Someone who experiences any of the above symptoms may find it too difficult or painful to carry out their daily activities, such as securing a seatbelt, reaching things on shelves, or playing tennis.
When is surgery necessary?
The AAOS state that in around 80% of people, nonsurgical treatment may be effective in resolving rotator cuff issues, such as lack of movement, and pain. However, nonsurgical treatment may not work in approximately 20% of people.
According to one study, it is possible for the symptoms of a rotator cuff injury to spontaneously resolve.
However, the same study suggests that most cases will require surgical intervention to prevent a tear from getting larger.
In addition to when nonsurgical treatment options have not worked, a doctor may recommend surgery for the following reasons:
- if the symptoms have been ongoing for more than 6 months
- if the tear is larger than 3 centimeters
- if the tear was traumatic and due to a recent injury
- if a person has a job where they have to maneuver their shoulders or arms a lot
- if a person plays sports where they need to do the same, such as golf or lacrosse, for example
- if a person has serious loss of function in their shoulder or serious weakness
The main benefit of rotator cuff surgery is that it can eliminate the symptoms someone is experiencing when nonsurgical treatment options have not been successful: mainly shoulder pain, shoulder weakness, or both.
In the case of larger tears, surgical intervention may be the better option.
However, there are some limitations to rotator cuff surgery.
There is some evidence to suggest that surgery may not be more effective than conservative treatment, and therefore nonsurgical treatment is often initially recommended.
What to expect in surgery
Healthcare providers should ensure that anyone undergoing or considering rotator cuff surgery is well informed about the entire process.
Depending on the severity of the tear, the surgeons familiarity with different procedures, and the quality of the surrounding tissue, there are several different surgical techniques that can be used to repair a torn rotator cuff.
Regardless of technique, the operation requires some form of anesthesia. This generally includes a combination of general anesthesia, peripheral nerve blocks, as well as the injection of local anesthetic agents.
Arthroscopic rotator cuff repair
In an arthroscopic rotator cuff repair, the surgeon makes several small incisions and inserts a long thin camera called an arthroscope into the shoulder joint in order to visualize the anatomy. Instruments are also inserted through these small incisions to repair the torn tendon back down to the humerus.
Most rotator cuff surgery is currently done arthroscopically, and most people do not need to stay in the hospital overnight after this type of operation.
Open tendon repair requires a larger incision and some surgeons may recommend this operation for larger, more severe tears.
During open surgery, the surgeon may also need to detach a part of the deltoid muscle on the front of the shoulder to be able to see more clearly.
Open surgery is a good option when other issues with the shoulder need attending to at the same time.
Recovery time is longer than for arthroscopic rotator cuff repair and patients may require an overnight stay in the hospital.
After rotator cuff surgery, it is not uncommon to feel tired for a few days. Some swelling and pain around the incision site is also common.
The United Kingdoms National Health Service (NHS) stress that a person should not sleep lying on the side that has been operated on for at least 6 weeks. They are also advised not to lift any weight for up to 12 weeks.
Recovery usually involves three phases, and it can take up to a year before a person is able to do things such as play contact sports.
Phase one: 16 weeks
In the first phase of recovery, a person generally wears a sling most of the time. However, the duration of its use varies from surgeon to surgeon. Use of the operated shoulder is mostly not permitted, other than during prescribed physical therapy exercises.
Help at home may be needed for daily activities such as getting dressed and washing.
A persons physician will advise when it is appropriate for them to move onto phase two.
Phase two: 712 weeks
At this stage, most people will be attending physiotherapy sessions.
People can often resume some light activities, but they should ease into them on the advice of their surgeon, physiotherapist, or both.
Health personnel will design exercises to help regain movement and muscle control.
Phase three: 12 weeks onward
Twelve weeks after surgery, most people can increase activities that will help them regain strength in their shoulder and allow them to utilize their full range of motion.
It is always best to follow all advice from the surgeon and physiotherapist to ensure the best possible outcome.
If a person tries to push themself and move too quickly, this can be detrimental to the recovery process.
Rotator cuff surgery, like any surgery, is not without risks.
For example, any surgery requiring anesthesia carries some risks.
Common side effects associated with anesthesia generally only last for a few days and may include:
Another complication that can arise from any kind of surgery is an infection around the incision site.
Some complications specific to rotator cuff surgery can include:
- long-term shoulder pain or stiffness
- nerve damage
- damage to blood vessels
In rare cases of very large and chronic tears, the tendon may be too badly damaged and cannot be repaired at the time of surgery. Even in these uncommon instances, pain may improve post-operatively, but strength of the shoulder will not.
Occasionally, a surgically repaired rotator cuff may tear again, requiring a second operation to refix the tendon.
A 2018 study suggests that 90% of people who had arthroscopic rotator cuff repair surgery were happy with the results 6 months later.
Though health providers may recommend conservative treatment before carrying out surgery, rotator cuff repair may be the best option for those patients who have a more severe rotator cuff injury. Rotator cuff repair can significantly reduce pain and restore shoulder strength and mobility.
If rotator cuff symptoms are not improving with nonsurgical treatment, it is worth speaking to an orthopedic surgeon to discuss potential surgical options.
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