Frequently Asked Questions
Why am I still having symptoms after rotator cuff surgery?
The most common causes of pain after rotator cuff surgery are from continued recovery after the surgery itself as well as the possibility that the shoulder has gotten stiff due to lack of movement. It is well known that rotator cuff surgery is a major operation where the rotator cuff tendons are sewn back to the upper arm bone (humerus).
It is common after rotator cuff surgery to have some stiffness due to the fact that the operation requires the arm to be held without motion for some time. It is important after the surgery to protect the rotator cuff repair for several weeks while it heals, and during this time it is very common for the shoulder to stiffen. Your doctor and physical therapist can keep an eye on this for you and let you know if your stiffness is the expected amount or too excessive. Often times the stiffness can be treated, and the pain resolves.
It takes the repaired rotator cuff tendons about six weeks to heal initially to the bone, three months to form a relatively strong attachment to the bone, and about six to nine months before the tendon is completely healed to the bone. Most patients who have had rotator cuff surgery will tell you that it takes about nine months before the shoulder feels completely normal. As a result, it is normal to expect some continued symptoms of pain or soreness after rotator cuff surgery for several months.
You should always follow the directions of your surgeon after surgery, since some tears need more time to heal than other tears. The best thing is to listen to your doctor as well as the physical therapist involved in your care. Ice is often helpful for the pain, along with pain medicine of some sort, such as acetaminophen (e.g. Tylenol), anti-inflammatory medications (e.g. aspirin, ibuprofen, naproxen, etc.), pain relievers (non-narcotic or narcotic) and even prednisone by mouth (e.g. cortisone dose packs). You should take these medications only at the direction of your doctor. It is typically recommend that during the first three months the emphasis in physical therapy and with your home program should be on regaining motion in your fingers, wrist, elbow and shoulder. We tell patients they have the rest of their lives to get strong, but during the first four months after rotator cuff surgery, the major goal should be largely to regain motion in the shoulder. Stiffness in the shoulder can be the cause of pain months after the surgical repair, so it is important that stiffness be addressed even months or years after the surgery.
Your surgeon can answer this since they are the ones who know how much work had to be done to repair the tendons. The doctors can prescribe therapy based on the work done during the operation. If more than one tendon had to be repaired or if the tendon tear is a big tear, the surgeon may recommend that the therapy progress slower to allow more time for healing; on the other hand, if the tear is small, they may allow a little more motion earlier than usual after the surgery.
It is possible to have too much therapy, and that is usually experienced as lots of pain after the therapy session or pain for days after the therapy session. It is important that the physical therapist has a dialogue with you to make sure that the exercises are done at a proper pace for your particular surgery. Typically physical therapy is recommended to be only twice a week. However, we recommend that patients stretch on their own the other days when they do not see the therapist. Sometimes physical therapy with the therapist three times a week is indicated, and this should be discussed with your physician and physical therapist. Similarly, it is typically not necessary to stretch more than once or at most twice a day with a home program. Lastly, if strengthening exercises are causing you pain, we recommend that you do not do the exercises over 60 degrees of elevation of the shoulder. This is because the rotator cuff begins to have increased stress above this level, and it can worsen the pain if the shoulder is irritated already. We recommend that you ice the shoulder after any exercise program to keep the pain under control.
It is not uncommon to have a small “twinge” or “pull” in physical therapy, which typically does not mean that the rotator cuff repair has failed. Normally these small twinges are usually nothing to worry about. It is not really known what causes them, but it is believed that it may be scar tissue being stretched or the shoulder joint moving around normally in the socket. It would be rare for the therapy to actually cause a repaired tendon to tear, as will be discussed later.
It is not easy to tell if the rotator cuff tendon repair has failed or not. The symptoms of pain or loss of strength are common after rotator cuff surgery while the tendons are healing, and minor setback are to be expected. We do not recommend a magnetic resonance scan or other studies when these setbacks occur for several reasons. First, magnetic resonance imaging after a surgical repair of the rotator cuff does not have the same accuracy in determining whether tendons are torn. If an MRI is performed, it is recommended that it be performed with dye in the affected shoulder (arthrogram) with a needle under x-ray or CAT scan guidance by a radiologist. This test is called an arthrogram-MRI and may be positive if the tendon has not had enough time to heal or if parts of the tendon have not healed to bone. As a result, within three months after a rotator cuff repair, it is common for the dye to leak through the tendon since it has not completely healed. After this period of time, the degree of tear in the tendons can be determined best with this study.
The reality of rotator cuff surgery is that while most tendons heal back to the bone after surgery, not all repaired tendons heal completely, and some do not heal at all. There are many reasons for this lack of healing with surgery. The first is that the rotator cuff tendons are large tendons which may have too extensive damage to heal. The rotator cuff tendons are big, and there are four of them. Each rotator cuff tendon is as thick as your little finger and as wide as two to three fingers. The chance that the tendons will heal with surgery is directly related to how large the tear in the tendons was before surgery.
Secondly, tendons begin to wear out in most starting around the age of 30, and the amount of wear and tear varies from person to person for reasons we do not understand. This wear of the tendons only occurs in some. By the age of 50, many have some wear of their rotator cuff tendons.
When rotator cuff tendons tear prior to any surgery, there are two ways they can tear. The first being an injury that causes the tendon to pull from the bone. When this happens, there is still some tendon left to repair with very little tendon missing. However, in many cases when the tendon tears with minimal trauma, the reason the tendon tore in the first place was because there was already some tearing due to wear over time. This wear is the second way the tendon can tear. This type of tear is best described as a tear that occurs in a way analogous to “wearing a hole in the seat of one’s pants”; the tendon just gets thinner and thinner over time until there is a hole there (called an “attritional tear”). This type of rotator cuff tendon tear typically happens without the person being aware that it is happening.
The thing that is strange about this type of rotator cuff tear is that they can occur and not cause any problems until the tear gets large. These “wear a hole in your pants” tears can be any size from the size of a pinhole to great tears where there is very little tendon left. In these tears, the edge of the tendon at the hole is thin, and is difficult to sew it back together. Typically, repairs in smaller holes, around the size of a finger, prove much easier than larger holes. In large holes caused by this type of damage (attritional or “wear a hole in your pants” type of tear), the rotator cuff tissue around the edges is not as sturdy, resulting in trying to fill a hole where there is really no tendon. For this reason, the major factor in determining whether a rotator cuff tear can heal is how large the hole was prior to surgery. The larger the rotator cuff tear before surgery then the higher the failure rate of surgery.
The first manner in which to describe tears of the rotator cuff tendons is whether tears are part or all of the way through the tendon. The tears of the rotator cuff tendons can be partial thickness or they can progress to tears all the way through. Once a tear is all the way through the tendon (called “full thickness”), the next problem to consider is the size of the hole in the tendon. As the tendons tear more, they can be any size (depth and width).
Full thickness tears of the rotator cuff are described as small, medium, large or massive. Since the majority of rotator cuff tendons are about as wide as three fingers, a small tear would be one the size of your fingernail or smaller (less than one centimeter). A moderate size full thickness tear through the tendon would be one that is the size of three fingernails (about one centimeter in one direction and three centimeters in another). Usually tears of this size mean the whole tendon width is pulled off of the bone. A large tear would mean the tendon is torn about the size of the distance from the knuckle to your fingertip; this is called a large or massive tear. It is also possible to tear more than one tendon completely. The size of the tear is very important as it determines the chances that the tendon will heal with surgery.
What happens if a rotator cuff tear fails?
Typically a tendon repair fails because it was already going to fail and not because of a bad surgery or therapy. The baseline is that rotator cuff surgery is not perfect, and not all tendons may heal entirely with surgery. Once a tendon has failed in an attempted surgical repair, the odds are that it will be difficult to repair again and to heal. In some cases, the tear may be small enough after a failed repair to be successfully repaired a second time, but the exact risk of failure with further surgery is related to how large the tear is at that time. The larger the tear, the less likely it can be repaired a second time. In most cases a second attempt at repairing the tendon is not going to be successful unless the tear is small.
For decades there have been many attempts at finding some tissue or something manufactured to put in the hole of the torn rotator cuff tendon to help it heal. Unfortunately most have failed as they do not regenerate or heal the hole in the rotator cuff tendons. Some physicians recommend various patching options for tears that are very large, but the failure rate is exceedingly high. There is currently no known or proven advantage to using patches in the repair of torn rotator cuff tendons.
A tendon transfer is an operation where the tendon of another muscle around the shoulder is moved to replace the rotator cuff tendon. There are a couple of tendon transfers that have been described for this purpose. One is a large muscle in the back of the shoulder called the latissimus dorsi muscle. While this is a large muscle, the tendon is actually very thin and not very big. This operation was once advocated for patients with large rotator cuff tears with pain, however the results were not as good as initially reported. This operation is helpful for only a minority of patients and has lost favor among shoulder surgeons.
A second muscle and tendon transfer was the use of the deltoid muscle and tendon as a buffer or spacer for the space where the rotator cuff tendons were located. This operation was largely a failure and is no longer recommended.
Shoulder replacements for patients with rotator cuff tears can be successful but patient eligibility continues to change. Typically shoulder replacements are reserved for patients with torn rotator cuffs who also have arthritis of the shoulder joint. The replacements are not often used for patients who have just loss of motion alone, and the replacements are indicated mainly for reducing pain in the shoulder. However, as there are increasing improvements in shoulder replacements, this may change and should be discussed with your doctor.
There are several kinds of shoulder replacements available for patients with arthritis and painful rotator cuff tears. Each has advantages and disadvantages depending on the age of the patient, the activity level of the person, and the amount of damage to the shoulder. In some instances it may be best to replace the shoulder with a more conventional shoulder replacement. A relatively new prosthesis called the reverse prosthesis has had some promise in patients with arthritis and torn rotator cuff tendons that are not repairable. These operations are generally very good for pain relief and do result in some improvements of motion.