Rotator cuff repair

Physiotherapy

Below you will find some important information about your rotator cuff surgery and subsequent recovery. The instructions and exercises provided in this booklet are given as a guideline only. Each patient is treated as an individual and the care you receive may vary slightly.

If you are in any doubt or have any questions about the information provided please ask a member of the shoulder team.

Why is the rotator cuff important?

The shoulder is the most mobile joint in the human body; therefore, it relies on strong muscles to control it. The shoulder joint is formed between the ball shape at the end of the upper arm bone (humeral head) and a nearly flat surface of the shoulder blade that forms the socket (glenoid).

The rotator cuff is a group of four muscles that originate from the shoulder blade and attach on to the top of the upper arm. Their main role is to help keep the ball and socket shoulder joint stable, but they also help you to lift and rotate your arm.

These tendons can become torn in two ways; either following an injury or through general wear and tear which can result in weakening of the tendon over time. As you get older your muscles and tendons can get thinner and moving your arm into certain positions such as reaching up can cause pain.

What is rotator cuff repair surgery?

The surgery is usually carried out as a keyhole procedure (arthroscopy) resulting in usually 2 to 4 small scars on the back, side and front of your shoulder.

The surgeon will examine your shoulder joint with a small ‘telescope’ and camera to identify any tears in your rotator cuff muscles or tendons. If there is a tear and it can be repaired, your surgeon will repair the torn muscles or tendons and secure them into place. They will also smooth out the bone on the underside of the acromion and remove any inflamed or scarred tissue if needed.

If during the surgery your biceps tendon looks inflamed or worn, your surgeon may perform a procedure called a biceps tenotomy. This means releasing the biceps tendon from where it attaches in the shoulder joint. This could result in an altered appearance of the bicep muscle (‘Popeye sign’, like Popeye the sailor), but this very rarely causes any problems or concerns.

Occasionally there may be a technical reason why the surgeon cannot perform the procedure arthroscopically and an open procedure will be used. This will result in a bigger scar along the front or side of your shoulder.

The size of the tear and strength of the repair can vary between individuals. As a result this booklet is designed to provide a guideline of what to expect following your rotator cuff surgery. The surgeon and your physiotherapist will be able to provide you with more individual information.

What are the potential risks?

Although rare, all operations have some potential risks or complications and it is important that you are aware of them:

• Minor side effects such as sickness and nausea, sore throat and discomfort are relatively common, and you may need medication to help control such symptoms.
• More serious complications such as allergies, chest infections, dental damage and nerve damage are rare.
• Complications affecting the heart, lung, kidney or brain function are even rarer.

What happens on the day of your surgery?

On the morning of your surgery you will be assessed by a member of the surgical team and an anaesthetist to confirm that you are ready for surgery. They will also answer any questions that you may have about your surgery. You will also be required to sign a form giving your consent to proceed with the operation if you have not done so already.

Rotator cuff surgery is often performed under a general anaesthetic. An injection of local anaesthetic around the nerves in the neck that supply the arm called an ‘interscalene nerve block’ may be used in shoulder surgery. This is usually performed by the anaesthetist with the guidance of an ultrasound machine to identify the correct nerves and minimise risk. This nerve block is often used, as it provides a good form of pain relief for the first 24 hours after the operation.

If you have had a nerve block your arm will feel numb and heavy but this should resolve within 24 hours.

Following your surgery, you will be taken to recovery before being transferred to the Day Surgery Unit. Your arm will be placed in a sling and there will be a dressing over your surgical sites. Once you have recovered sufficiently from your anaesthetic you will be seen by a physiotherapist who will give you advice about wearing your sling and teach you some exercises, which you can begin once your nerve block as worn off.

The majority of people can go home on the same day of their surgery but occasionally it may be necessary to stay overnight.

What happens after your surgery?

You will be expected to perform your exercises at home, as advised by your physiotherapist and continue with taking regular pain relief tablets. You will normally have to visit your GP Practice ten days following your surgery to have your wound checked and if stitches have been used, they will be removed.

You will be referred for outpatient physiotherapy to continue with your rehabilitation and this will normally start one to two weeks following your surgery. If you have any questions or concerns before this time please do not hesitate to contact a member of the shoulder team. Gaining the best outcome following your surgery takes time and rehabilitation.

You are likely to see most of the improvement in the first three to six months following your surgery, but sometimes a more gradual improvement can continue for between one and two years.

You will have a review appointment in a post-operative shoulder clinic between four and six weeks after your surgery. This appointment will be with a member of the consultant’s team or an advanced physiotherapy practitioner.

Pain control

It is normal to have some pain and discomfort in your shoulder following your rotator cuff surgery. It is recommended you take regular pain relief as advised by the hospital team to help keep this under control which will help with your recovery. If you feel that you require any further medication then please visit your General Practitioner (GP).

Once your sensation has returned around your shoulder you can use ice to help with managing your pain. To apply ice, wrap an ice pack or bag of frozen peas in a damp towel and place in a plastic bag or wrap in cling film (this will keep your dressing dry) and place the ice on your shoulder for 10 to 15 minutes, 3 to 5 times a day. It is important to never apply ice directly to your skin.

Be aware of the position of your shoulders if you are getting pain. If you feel tense, try taking a deep breath in, and then, when you breathe out letting your shoulders relax. Being aware of your breathing may also help to reduce tension, as it is easy to hold your breath or forget to breathe correctly when you are in pain.

Wearing your sling

You will normally have to wear your sling for between four and six weeks depending on the nature of your repair. This will not only help to protect the repair but may also help with pain relief. It is important to remove your sling to perform your exercises and when washing and dressing. You can use your hand for very light tasks, for example, reading or using a computer whilst your arm is supported in the sling, if your pain allows.

Before you go home, a physiotherapist will show you how to take your sling on and off and how to look after your arm when using the sling.

Sleeping

Initially you may find it more comfortable to sleep in a more upright position supported by pillows.

Placing a pillow underneath your arm may support the arm when lying down (diagram 1).

Do not sleep on your operated side for the first six weeks andafter this be guided by how comfortable your arm feels. Initially you will need to wear your sling when sleeping to support your shoulder.

Washing and dressing

You can usually wear your sling over indoor clothing but underneath bulky outdoor clothing. You might find it easier to wear loose fitting clothing that buttons down the front. When washing and dressing try to keep your operated arm as still and relaxed as possible. Try to keep your sling as clean and dry as possible (you should ask for a replacement sling if yours becomes dirty or uncomfortable).

Remove your sling by sitting with your arm supported on a pillow. Undo the velcro fastenings at the elbow and the wrist and gently slide the sling out. First, thread your sleeve onto your operated arm and take the item of clothing up to the shoulder as far as possible. Next, place your non-operated arm into the other sleeve bringing the garment up and around your shoulders and fasten the clothing.

Replace the sling by gently sliding it under your forearm and securing the velcro fastening (you may need to lean forward and support your arm on the table to help with this). For undressing perform the routine in reverse.

It is important to wash your elbow creases and underneath your arm pit to prevent any soreness whilst in the sling. To do this sit at a table with your arm supported on a pillow. This will allow you to comfortably wash under your arm.

Domestic tasks

It may be useful to prepare meals in advance prior to your surgery or have meals that require little preparation e.g. pre chopped vegetables. You should avoid heavy household tasks for at least twelve weeks after your surgery, but you can begin gentle daily activities once you come out of your sling. Your physiotherapist will be able to guide you further with regards to returning to these activities.

Driving

You will be unable to drive whilst you are in your sling. Return to driving is normally 6 to 8 weeks following your surgery. Your physiotherapist will help guide you on when you have sufficient movement and a good level of pain control to be able to drive. You need to make sure that you have full control of the vehicle and are able perform an emergency manoeuvre if needed. It is a good idea to start with a short journey and build up slowly.

It is advised to contact your insurance company to inform them about your operation.

Work

You will normally be off work for between four and twelve weeks depending on the type of work that you do. It is advised not to perform any heavy lifting, overhead or manual work for four to six months following your surgery. If you have any queries regarding this, please discuss with your consultant or physiotherapist.

Physiotherapy

Physiotherapy will form an important part of your recovery following your rotator cuff surgery. When you come out of your sling the aim is to regain movement in your shoulder and start using your arm for light daily activities. Once you have regained good movement and control of your shoulder you will then begin working on increasing the strength and endurance of the muscles surrounding your shoulder. This will then progress to more specific rehabilitation depending on your individual goals.

The physiotherapist on the ward will teach you some exercises that you can begin once your nerve block has worn off. Initially following your surgery, the aim is to protect the surgical repair of the tendons by not placing too much demand on the shoulder and rotator cuff muscles. All the exercises you perform for your shoulder should be supported and relatively pain free. It is important to start moving your shoulder as advised by your physiotherapist to prevent the shoulder from becoming stiff. It is important not to force or stretch your shoulder initially.

The exercises may vary slightly depending on the nature of the repair and any specific instructions that have been given by your consultant. Try to keep active after your surgery, taking regular walks can help with your recovery.

Neck exercises

It is important to keep your neck moving as it can become stiff when wearing the sling. Move your neck in all directions, look up, look down, and turn to the right and to the left.

Elbow, wrist and hand exercises

Make an effort to keep your wrist and fingers moving every couple of hours whilst you are wearing your sling, to prevent stiffness and to maintain your circulation. Move your wrist up and down and draw circles. Try to keep your fingers moving by opening and closing your hand regularly.

To prevent any stiffness in your elbow it is important to perform a few exercises when you remove your sling.

With your elbow bent and tucked into your side turn your palm up to the ceiling and down towards the floor. Bend your elbow bringing your hand towards your shoulder and then straighten your elbow as far as you can, you can support the forearm with your non operated arm initially if this is more comfortable.

Postural exercises and shoulder slump

In sitting, slump down into your seat rounding your shoulders, then sit up tall squeezing your shoulder blades together. Then shrug your shoulders up towards your ears and roll your shoulders back down.

Supported flexion

Place your hands flat on a table top or work surface. Place a towel underneath your hands and gently slide the arms forward on the table using the non-operated arm to assist. Slide the arms away from the body as far as comfortable before bringing the arms back in towards your body. This exercise can be performed in sitting or standing.

Walk away

Stand in front of a table with your palms placed flat onto a table. Slowly walk your feet away from the table as far as you feel comfortable. You do not need to force or stretch this movement. Stay in this position for 5 seconds before walking your feet back to the starting position.

Outward rotation

You can perform this exercise if advised to do so by your physiotherapist. They will advise you how far you are able to perform this movement. It is normal for this movement to feel stiff following your surgery. It is important not to force or stretch this movement in the first four weeks.

You can perform this exercise sitting or standing. Holding a walking stick (or something similar) in both hands, gently move your operated arm out to the side and then back
to your starting position. Keep your elbows tucked into your side during this exercise.

Patient experience

South Tees Hospitals NHS Foundation Trust would like your feedback. If you wish to share your experience about your care and treatment or on behalf of a patient, please contact The Patient Experience Department who will advise you on how best to do this.

This service is based at The James Cook University Hospital but also covers the Friarage Hospital in Northallerton, our community hospitals and community health services.

To ensure we meet your communication needs please inform the Patient Experience Department of any special requirements, for example; braille or large print.

T: 01642 835964
E: [email protected]

The James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW.
Telephone: 01642 850850

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