Rotator Cuff Repair

Rotator cuff tears are among the most common causes of shoulder pain, especially in people over the age of 50. These injuries can result in pain, weakness, limited movement, and, in some cases, ongoing disability. If conservative treatments such as physical therapy and injections do not bring relief, surgical repair may be considered.

What is the Rotator Cuff?

The rotator cuff is a group of four muscles and their tendons that stabilize the shoulder joint and enable arm movement. These include:

• Supraspinatus
• Infraspinatus
• Subscapularis
• Teres minor

These tendons blend into a single sheet as they insert into the humeral head, and play a critical role in stabilizing the shoulder and allowing overhead and rotational arm movements.

How Do Tears Occur?

Rotator cuff tears can be:

• Traumatic, from sudden injuries like falls
• Degenerative, resulting from wear-and-tear over time

Most degenerative tears begin in the supraspinatus tendon, often deep-sided, and can progressively extend to adjacent tendons. While some people with tears remain pain-free, others develop significant symptoms like pain, weakness, and loss of function. Tear progression is more likely in individuals over 60, smokers, or those with poor tendon vascularity or fatty degeneration.

When Is Surgery Considered?

Surgical repair is typically considered when:

• Conservative treatments fail after several months
• There is a full-thickness tear
• The tear is repairable, with minimal muscle degeneration
• Patients are under 65 and otherwise healthy

In certain cases, partial repair or even palliative procedures like debridement may be considered when full repair is not feasible.

What Does Surgery Involve?

Rotator cuff repair can be performed using:

• Arthroscopic surgery (minimally invasive)
• Mini-open or open surgery (small incision or larger exposure)

During the procedure:

1. The tendon is released and mobilized.
2. The bone surface is prepared to enhance healing (decortication).
3. Sutures and anchors are used to reattach the tendon to bone.
4. The arm is immobilized in a sling and followed by structured physical therapy.

The goal is to ensure tendon-to-bone healing under minimal tension. When this is not possible, partial repairs aim to rebalance the shoulder for pain relief and improved motion.

Does Surgery Improve Outcomes?

In patients with full-thickness rotator cuff tears:

• Pain improvement at 1 year: Surgery reduced pain by 0.9 points on a 10-point scale compared to exercises alone.
• Function improvement: Surgery improved functional scores by 6 points out of 100—modest and below the threshold often considered clinically meaningful.
• Quality of life: No significant difference was observed.
• Success perception: 7% more people rated their outcome as successful after surgery, but this difference was not statistically significant.
• Adverse events: Extremely rare; no serious events reported.

When Is Surgery Most Likely to Help?

• The patient is younger than 65
• The tear is recent and not massive
• There is minimal muscle fatty degeneration (Goutallier grade < 2)
• The acromiohumeral distance is greater than 6-7 mm
• The patient does not smoke and has good health overall

Surgical repair is less likely to succeed when:

• The tendon is retracted and stiff
• The muscle has significant atrophy or fatty degeneration
• There is a static elevation of the humeral head
• The patient has diabetes or autoimmune conditions like rheumatoid arthritis

What if a Full Repair is Not Possible?

In some patients with large or irreparable tears:

• Partial repair can still help restore shoulder balance and reduce pain.
• Debridement, biceps tenotomy, or muscle advancement may be used to improve symptoms without full repair.
• These methods aim to stabilize the joint and preserve function, especially when full healing is unlikely.

Is Arthroscopic Surgery Better Than Open Surgery?

Comparative studies show:

• Similar healing rates and functional outcomes
• Arthroscopy offers less surgical trauma and faster early recovery
• Open surgery may be preferred for very large tears

Ultimately, surgeon experience plays a larger role than the specific technique.

Recovery and Rehabilitation

Post-surgery:

• A sling is worn for 3–6 weeks
• Passive motion starts early to prevent stiffness
• Gradual strengthening begins after healing progresses
• Full recovery may take 4–6 months or longer, depending on the tear size and patient compliance

Bottom Line: Should You Have Surgery?

Surgery for rotator cuff tears can relieve pain and improve function, especially in younger, healthier patients with acute or repairable tears. However, for many with degenerative or small tears, non-surgical treatment is equally effective—at least in the first year.

 

Do you have more questions?

Q. What is the rotator cuff?

A. The rotator cuff is a group of four muscles and their tendons—supraspinatus, infraspinatus, subscapularis, and teres minor—that stabilize the shoulder joint and enable arm movement.

Q. How do rotator cuff tears occur?

A. Rotator cuff tears can be traumatic, resulting from sudden injuries like falls, or degenerative, developing over time due to wear and tear.

Q. What are common symptoms of a rotator cuff tear?

A. Common symptoms include shoulder pain, weakness, limited movement, and, in some cases, ongoing disability.

Q. When is surgical repair of the rotator cuff considered?

A. Surgical repair is typically considered when conservative treatments fail after several months, there is a full-thickness tear, the tear is repairable with minimal muscle degeneration, and the patient is under 65 and otherwise healthy.

Q. What does rotator cuff repair surgery involve?

A. The surgery can be performed arthroscopically, mini-open, or open. It involves releasing and mobilizing the tendon, preparing the bone surface, reattaching the tendon to bone using sutures and anchors, and immobilizing the arm in a sling followed by structured physical therapy.

Q. What is the goal of rotator cuff repair surgery?

A. The goal is to ensure tendon-to-bone healing under minimal tension. When this is not possible, partial repairs aim to rebalance the shoulder for pain relief and improved motion.

Q. Does surgery improve outcomes for rotator cuff tears?

A. In patients with full-thickness rotator cuff tears, surgery reduced pain by 0.9 points on a 10-point scale and improved functional scores by 6 points out of 100 compared to exercises alone. However, these improvements are modest and may not be clinically significant.

Q. What factors increase the likelihood of successful rotator cuff surgery?

A. Factors include being younger than 65, having a recent and not massive tear, minimal muscle fatty degeneration (Goutallier grade < 2), an acromiohumeral distance greater than 6-7 mm, not smoking, and being in good overall health.

Q. What factors decrease the likelihood of successful rotator cuff surgery?

A. Factors include the tendon being retracted and stiff, significant muscle fatty degeneration, a small acromiohumeral distance, smoking, and poor overall health.

Q. What are the risks associated with rotator cuff repair surgery?

A. Adverse events are extremely rare; no serious events have been reported.

Q. What is the typical recovery process after rotator cuff repair surgery?

A. The arm is immobilized in a sling, followed by structured physical therapy to restore movement and strength. The specific rehabilitation protocol depends on the individual case.

Q. Can partial repairs be beneficial when full repair isn’t feasible?

A. Yes, partial repairs aim to rebalance the shoulder for pain relief and improved motion when full repair is not possible.

Q. What is the role of physical therapy after rotator cuff repair?

A. Physical therapy is crucial for restoring shoulder movement and strength following surgery.

Q. Are there alternatives to surgery for rotator cuff tears?

A. Yes, conservative treatments such as physical therapy and injections are often tried before considering surgical repair.

Q. What is the acromiohumeral distance, and why is it important?

A. The acromiohumeral distance is the space between the acromion and the humeral head. A distance greater than 6-7 mm is associated with better surgical outcomes.

Q. What is the Goutallier grade?

A. The Goutallier grade assesses muscle fatty degeneration. A grade less than 2 indicates minimal degeneration, which is favorable for surgical repair.

Q. Does smoking affect rotator cuff healing?

A. Yes, smoking is associated with poorer tendon vascularity and healing, decreasing the likelihood of successful surgical outcomes.

Q. Can rotator cuff tears progress over time?

A. Yes, degenerative tears can progressively extend to adjacent tendons, especially in individuals over 60, smokers, or those with poor tendon vascularity or fatty degeneration.

Q. Is it possible to have a rotator cuff tear without symptoms?

A. Yes, some people with tears remain pain-free and may not experience significant symptoms.

Q. What is decortication in rotator cuff repair surgery?

A. Decortication involves preparing the bone surface to enhance healing by promoting tendon-to-bone attachment.