The operation is performed for rotator cuff tears that are causing pain or disability. The procedure involves an arthroscopy for confirmation of the diagnosis. The insertion site on the greater tuberosity is freshened and the cuff is approximated to the insertion site using suture anchors. Adjunctive procedures such as a subacromial decompression, biceps tenotomy or tenodesis may be carried out at the same time. As the procedure is performed arthroscopically, there is minimal disturbance of the deltoid.

Background

Tendon healing takes approximately 6-12 weeks. Any undue strain on the repair site during the early phase of healing (first 6 weeks) may jeopardise the repair and lead to a retear. Active use of the torn part of the cuff and overhead stretching are therefore avoided during this phase. Stiffness associated with immobilisation (which is common after open cuff repairs) does not seem to occur after arthroscopic repairs provided that early passive external rotation is carried out.

Provided that the repair is intact at 6 weeks, it will progressively consolidate. However a strong bond may not form between tendon and bone until about 12 weeks after repair; therefore to avoid the risk of retear resisted exercises should be deferred for 12 weeks.

 Arthroscopic repair of small to medium rotator cuff tears

 0-6 weeks:    Arm is placed in a Donjoy ultrasling after surgery. This is worn most of the time but may be removed for short periods to shower, dress, eat. May also be removed for short periods if sitting in a chair with arm supported on an armrest. Instruct patient on technique to remove and wear Donjoy ultra sling. 

Commence hand, wrist and elbow exercises immediately. Commence supine passive external rotation to 30° and passive flexion to 90° using table slides as tolerated.

AVOID active elevation / external rotation as well as internal rotation stretching during this phase unless instructed otherwise.

7-12 weeks:   Discard Donjoy ultrasling gradually.  Commence passive overhead stretching with a rope and pulley and supine overhead stretches using the other arm.  Continue passive external rotation. 

Commence assisted active elevation in flexion initially and subsequently in abduction. Encourage periscapular muscle exercises.

AVOID internal rotation stretching and strengthening exercises.

After 12 weeks: Continue with stretches if full PROM has not been achieved. Commence strengthening of the rotator cuff, deltoid, biceps and scapular stabilisers. Progress activities as strength allows. Unrestricted activities including recreational sports (e.g. tennis, golf) should be deferred for 6 months.

Variations: The regime described above may be modified if the tear involved the subscapularis. In these patients passive external rotation should be restricted to the limit specified at surgery (or to 0° if not specified).

For partial thickness tears the regime may be accelerated by 2 weeks ie active-assisted movements may be started at 4 weeks.

 

Arthroscopic repair of large or massive rotator cuff tears

0-6 weeks:  Arm is placed in a Donjoy ultrasling after surgery. This is worn most of the time but may be removed for short periods to shower, dress, eat. May also be removed for short periods if sitting in a chair with arm supported on an armrest. Instruct patient on technique to remove and wear Donjoy ultra sling. 

Commence hand, wrist and elbow exercises immediately. Commence supine passive external rotation to 30°.

After 4 weeks commence passive flexion to 90° using table slides as tolerated.

AVOID elevation / active external rotation as well as internal rotation stretching during this phase unless instructed otherwise.

7-12 weeks:  Discard Donjoy ultrasling gradually.  Commence table slides, passive overhead stretching with a rope and pulley and supine overhead stretches using the other arm.  Continue passive external rotation. AVOID internal rotation stretching and strengthening exercises. 

Commence active/assisted elevation as tolerated.

After 12 weeks:  Continue with stretches if full PROM has not been achieved. Commence strengthening of the rotator cuff, deltoid, biceps and scapular stabilisers. 

For massive tears, delay strengthening for 15 weeks. Progress activities as strength allows.

Return to full activity may take upto 12 months.


Biceps tenodesis

A biceps tenodesis may be performed in isolation or in conjunction with a rotator cuff repair. Elbow flexion and extension may be commenced immediately but any strengthening or loading of the biceps should be deferred for 12 weeks.

 

Adapted and modified from: Burkhart S.- “The Cowboy’s Companion: A trail guide for the Arthroscopic Shoulder Surgeon” Wolters Kluwer/ Lippincott 2012.