Rotator Cuff Repair. A guide for patients Gateshead Upper Limb Unit Mr Andreas Hinsche Mr John Harrison Mr Jagannath Chakravarthy Page 1 of 8 What is the Rotator cuff? Your shoulder is a ball and socket joint and is the most mobile joint in the body. It depends on strong muscles and ligaments to move and stabilise it. The most important muscles for this are the rotator cuff muscles. The rotator cuff is a group of 4 muscles that work together to move the shoulder. They originate from your shoulder blade and their tendons form a hood covering the ball of your shoulder joint. The 4 tendons come together to hold the end of the upper arm in the shoulder socket. What is a rotator cuff tear? The four tendons mentioned about attach to the side of the ball of your shoulder joint. Occasionally one can develop a rent in the tendon at the attachment point. This may be to just one, or to a combination of the tendons. How does one develop a tear? This is a fairly common condition and can be caused by Injury (trauma) which could happen when lifting or catching a heavy object Fall on an outstretched hand A gradual weakening of the tendons of the shoulder. In the middle age /elderly population the tear is a result of wear and tear to the tendons. This leaves the tendon vulnerable to a tear with minimal trauma Overuse, especially after a period of inactivity Poor blood supply to an area of the cuff (which occurs with increasing age) What are the symptoms? If associated with an injury, a patient would present with sudden inability to raise or rotate the arm after the incident. One would be able to lift the arm up with the help of the other arm but not on its own. Pain is typically seen when the tear has occurred gradually or if one has been present for a long time. Pain is worse on movement and in bed whilst sleeping on the affected side. Pain is typically felt over the side of the arm and radiates to the elbow. Occasionally one may feel pins and needles in the hand the cause of which is not known. Stiffness can happen in long standing cuff tears and is usually means that full movement would not be achieved after treatment Page 2 of 8 Will I need any tests? Typically you would have had an x-ray in A&E or in your orthopaedic clinic After a thorough examination your surgeon will usually request an ultrasound scan. This may occasionally be done by your surgeon in clinic. If not, you will be sent an appointment for this test. This test uses similar equipment to those used for scanning pregnant ladies. It is entirely safe. If your surgeon is concerned about the quality of your tendons or is suspecting an additional diagnosis, and MRI scan may be requested. This is a magnetic scan and is safe. What are the treatment options? Once torn the rotator cuff does not heal on its own. Tears tend to get larger with time. Some tears are irrepairable Pain killers are commonly advised Physiotherapy is useful and helps the intact tendons compensate for the torn one. It also builds muscle strength which aids on recovery. Steroid Injections are offered to patients in who pain in the main symptom. Often adequate pain relief is sufficient to maintain a good function. Injection treatment may be advised because the patient is not fit for surgery or if the tear is considered irreparable. The pain relief one gets varies from patient patient and is usually temporary Surgery is usually recommended to improve function. This is more so in patients who suffer a tear after an injury and in those where the above measures have failed. Depending on the type of tear and surgeon preference, this may be done through key hole surgery or a small open incision. The surgery involves stitching the tendon back to the arm bone. On an x-ray you might see a metal ‘anchor’ to which the stitches are attached. You might need additional procedures during the same sitting which will be discussed by your surgeon. Picture showing torn tendon and surgical repair with sutures and anchors Page 3 of 8 Picture showing repaired tendon Are there any complications with this operation? The risk of complications may vary from patient to patient. This is because this type of surgery is specific to individual patients. Your consultant or physiotherapist will discuss any individual risks or complications with you. Generally the most common problems with this type of surgery are: Shoulder stiffness You may not get full pain relief Failure of the repair. This is more likely if you fail to adhere to the physiotherapy guidelines. How long will I be in hospital? The majority of patients are admitted to hospital on the day of their surgery. However it may be necessary to admit you the day prior to surgery. The anaesthetist will make this decision and inform you. You should be able to go home on the day of surgery but you may need a short stay in hospital. Advice will be given on the day, once the operation is completed. What happens before the operation? Before you are admitted you may need to have a pre-operative assessment. This is an assessment of your health to make sure you are fully prepared for your admission, treatment and discharge. Before the date of your admission please, read very closely, the instructions given to you. If you are undergoing a general anaesthetic you will be given specific instructions about when to stop eating and drinking, please follow these carefully as Page 4 of 8 otherwise this may pose an anaesthetic risk and we may have to cancel your surgery. You should bath or shower before coming to hospital. The surgeon and anaesthetist will visit you and answer any questions that you may have. You will be asked to sign a consent form. A cuff will be put on your arm, some leads placed on your chest, and a clip attached to your finger. This will allow the anaesthetist to check your heart rate, blood pressure and oxygen levels during the operation. A needle will be put into the back of your hand to give you the drugs to send you to sleep. Occasionally you might just receive an injection into the side of your neck to numb your shoulder and you will remain awake during the procedure if this is the case. What happens after the operation? After your operation you will then be taken to the recovery area where you will be closely monitored by a recovery nurse until you are awake and comfortable. Once your initial recovery period is over you may be transferred to the ward. You will normally be able to have a drink shortly after the procedure and eat as soon as you feel hungry. You can usually get out of bed an hour or so after you wake up and you should wait for the nurses to help you as you may feel a little dizzy at first. It is likely to be a bit painful where the operation has been carried out, but if you move carefully, the pain is not usually severe. The nurses will monitor your pain and give you painkillers, if necessary. It is quite normal for a small amount of blood to soak through the dressing and this can easily be changed. Recovery after surgery The following leaflet gives you advice as to when you may be able to do things, however your progression depends on the size of your tear and you should always be guided by your physiotherapist/surgeon as to when you can start to do things. It is very important that you follow the advice given to you as failure to do so could result in your repair failing. If the tendon repair fails you may need a further operation. You may see a physiotherapist on the ward after surgery and they will advise you on very gentle exercises to maintain movement at your elbow, wrist and hand. You will NOT be given any exercises for your shoulder at this stage. An appointment will be made for you to be reviewed by a member of the upper limb team in follow up clinic after your operation. You will also be monitored by a physiotherapist on discharge from hospital. If you have not been given your physiotherapy appointment within 2 weeks of your operation, please contact us, tel. 4452320 (see numbers at back of booklet). When do the stitches come out? The stitches will be removed at your GP surgery, usually 10-14 days after your operation. Keep the wound dry until it is well healed. Page 5 of 8 Pain Some degree of pain and discomfort is common after surgery. You will be given appropriate painkillers on discharge from hospital. If you feel you are unable to manage your pain please discuss this with your GP, Surgeon or Physiotherapist. Wearing a sling On return from theatre your shoulder will be in a sling to protect the tendon during the healing period. The sling will need to be worn for approximately 4-6 weeks, however, your physiotherapist will guide you on this. You must not remove your sling except for washing, dressing and exercises. The sling must be worn at all times, including in bed. You will be shown how to remove the sling safely. Sleeping Your sling must be worn in bed. Sleeping can be uncomfortable if you try and lie on the affected arm. We would recommend that you lie on your back or on the opposite side. Use ordinary pillows to give yourself comfort and support. You should not lie on your operated shoulder for the first 6 weeks. Lying on your side: Lying on your back:: One pillow folded under your neck gives enough support for most people. A pillow folded in half supports the sling and your arm in front. You may also require a pillow along your back to help prevent you rolling onto your shoulder in the night. Tie a pillow tightly in the middle or use a folded pillow to support your neck. Fold another pillow to go under the elbow of your operated arm. Page 6 of 8 Washing You can remove your sling to wash, however it is very important that no movement takes place at your shoulder. The easiest way to do this is to allow your arm to hang down by your side and lean your body away. Daily Activities For the first 6 weeks all activities of daily living e.g. eating, dressing, cooking etc must be done using your un-operated arm. Physiotherapy Rehabilitation is important if you are to get the most out of your shoulder after the operation. The first stage is to let your shoulder heal by resting it in the sling for the recommended period of time as advised by your physiotherapist. During this time you can move your elbow, wrist and hand to make sure they do not get stiff and swollen. Exercises In general for the first 4-6 weeks you will perform only elbow, wrist and hand exercises. Please check with your physiotherapist before starting. 1. Keep your arm in the sling and move your hand up and down at the wrist. 2. Keep your arm in the sling and turn your hand to face the ceiling and then the ground. 3. Keep your arm in the sling and shrug shoulders up and down. 4. Carefully removing your sling, bend and straighten your elbow, you must keep your upper arm close to your side i.e. not moving your shoulder. Repeat exercises four times a day, you will be instructed how many repetitions of each exercise to do by your physiotherapist. Continue these exercises until otherwise instructed by your physiotherapist. Your physiotherapist will tell you when you can do more with your shoulder. Functional activities (these are minimum times and could be longer.) Driving Swimming Golf Lifting Return to work 6 Weeks Breaststroke: 2-3 months Freestyle: 3 months 3 Months 3 Months (Then guided by the strength of the individual patient) Sedentary job: 3 weeks Manual job: usually 3 months (guided by surgeon) If you are at all worried by your shoulder please contact us, see telephone numbers at the back of this booklet. Page 7 of 8 Telephone numbers During the hours of 8am -8pm contact the Day Surgery Unit, North East NHS Surgery Centre, Queen Elizabeth Hospital During the hours of 8pm -8am contact Level 1, North East NHS Surgery Centre, Queen Elizabeth Hospital During the hours of 0800 -1630 contact the Physiotherapy Department (please ask for a member of the upper limb team) Main switchboard 0191 4453009 0191 4453005 0191 4452320 0191 4820000 Data Protection Any personal information is kept confidential. There may be occasions where your information needs to be shared with other care professionals to ensure you receive the best care possible. In order to assist us improve the services available your information may be used for clinical audit, research, teaching and anonymised for National NHS Reviews. Further information is available in the leaflet Disclosure of Confidential Information IL137, via Gateshead Health NHS Foundation Trust website or the PALS Service. Useful Organisations  www.shoulderdoc.co.uk Please go to the patient information link on the website www.patient.co.uk  Patients Association PO Box 935 Harrow Middlesex HA1 3YJ Tel Helpline: 0845 608 4455 www.patients-association.com Provides a helpline, information and advisory service. It also campaigns for a better health care service for patients Information Leaflet: Version: Title: First Published: Last Reviewed: Review Date: Author: NoIL257 2 Rotator Cuff Repair July 2006 October 2012 October 2014 Gateshead Upper Limb Team This leaflet can be made available in other languages and formats upon request Page 8 of 8