What Is A Frozen Shoulder After Rotator Cuff Repair Surgery

Oft Asked Questions

Why am I withal having symptoms afterwards rotator cuff surgery?

The most common causes of pain later rotator cuff surgery are (one) that the shoulder is still recovering from the surgery itself and (2) the shoulder has gotten stiff due to lack of movement. Information technology is well known that rotator cuff surgery is a major operation where the rotator cuff tendons (Figure 1) are sewn dorsum to the upper arm os (humerus) (Figures ii and three).

The other major reason patients have pain later rotator cuff surgery is due to stiffness of that shoulder. It is mutual later rotator cuff surgery to take some stiffness due to the fact that the performance caused the arm to be held without movement for some fourth dimension. It is important later on the surgery to protect the rotator gage repair for several weeks while it heals, and during this time information technology is very common for the shoulder to get stiff to a bottom or greater degree. Your md and physical therapist tin can keep an eye on this for you and allow y'all know if your stiffness is the expected amount or too excessive. Ofttimes times the stiffness tin be treated, and the pain resolves.

It takes the repaired rotator gage tendons about half dozen weeks to heal initially to the bone, three months to form a relatively potent attachment to the os, and most 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 nearly nine months earlier the shoulder feels completely normal. This observation is supported by a report showing that in patients who accept had rotator cuff surgery, strength in the shoulder muscles is not fully recovered until nine months after the surgery. As a consequence, it is normal to expect some continued symptoms of pain or soreness after rotator cuff surgery for several months.

How do I treat the stiffness?

Yous 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 intendance. We tell our patients that ice is helpful for the hurting, along with pain medicine of some sort, such as acetaminophen (e.m. Tylenol), anti-inflammatory medications (east.g. aspirin, ibuprofen, naproxen, etc.), pain relievers (not-narcotic or narcotic) and even prednisone by oral fissure (e.g. cortisone dose packs). You should take these medications only at the direction of your doctor. We normally recommend that during the first three months the accent in physical therapy and with your home plan should be on regaining motion in your fingers, wrist, elbow and shoulder. We tell patients they have the remainder of their lives to get strong, merely during the first iv months after rotator cuff surgery, the major goal should exist largely to regain motion in the shoulder. Stiffness in the shoulder tin exist the crusade of pain months after the surgical repair, so it is important that stiffness be addressed even months or years after the surgery.

How much therapy should I accept afterward surgery?

Your surgeon can answer this since they are the ones who know how much piece of work had to exist 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 permit a little more motion before than usual afterwards the surgery.

Diagram showing permitted degrees of shoulder movement. Described under the heading How much therapy should I have after surgery?

It is possible to take too much therapy, and that is usually experienced every bit lots of pain after the therapy session or hurting for days after the therapy session. It is important that the physical therapist has a dialogue with you to brand sure that the exercises are washed at a proper pace for your particular surgery. We typically recommend concrete therapy just twice a week. However, we recommend that patients stretch on their ain the other days when they exercise 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, information technology is typically non 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 lot do not do the exercises over 60 degrees of elevation of the shoulder (Figure 4). This is because the rotator gage begins to have increased stress above this level, and it can worsen the pain if the shoulder is irritated already. We recommend that yous water ice the shoulder after any exercise program to keep the pain under control.

What if I experience a tear or pull in therapy?

Information technology 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 pocket-size twinges are usually nix to worry most. It is not actually known what causes them, merely it is believed that it may exist scar tissue being stretched or the shoulder joint moving around commonly in the socket. Information technology would be rare for the therapy to actually crusade a repaired tendon to tear, as will exist discussed later.

How do I know if the tendon repair has torn again?

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 exist expected. We practise not recommend a magnetic resonance scan or other studies when these setbacks occur for several reasons. The first reason is that magnetic resonance imaging later a surgical repair of the rotator cuff does not have the same accurateness in determining whether tendons are torn. If an MRI is performed, we recommend that information technology exist performed with dye in the affected shoulder (arthrogram) with a needle under x-ray or CAT browse guidance by a radiologist. This examination is called an arthrogram-MRI and may exist positive if the tendon has not had plenty fourth dimension to heal or if parts of the tendon have not healed to bone. As a result, inside three months after a rotator cuff repair, it is common for the dye to leak through the tendon since it has non completely healed. Afterwards this catamenia of time, the degree of tear in the tendons can be adamant all-time with this study.

What do I do if my tendon has non healed?

The reality of rotator cuff surgery is that while well-nigh tendons heal dorsum to the bone subsequently surgery, not all repaired tendons heal completely, and some do not heal at all. In that location are many reasons for this lack of healing with surgery. The first is that the rotator gage tendons are big tendons which may have as well 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 every bit 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. How to determine the size of the rotator gage tendon tear will be discussed beneath.

The second reason that the tendons may not have healed with surgery is that these tendons begin to wearable out in virtually humans beginning around the age of xxx, and the amount of habiliment and tear varies from person to person for reasons we practice not empathize. This wear of the tendons occurs in some people but not in others. By the age of 50, many people have some wear of their rotator gage tendons.

When rotator cuff tendons tear prior to any surgery, in that location are two ways they can tear. The first is that in that location is an injury that pulls the tendon off the os. When this happens, in that location is nevertheless 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 identify was because information technology already had some violent due to wear and tear over the years. This clothing and tear over time is the second fashion the tendon tin can tear. This type of tear is best described as a tear that occurs in a way coordinating to "wearing a pigsty in the seat of i'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 gage tear is that they can occur and not cause any problems until the tear gets large. These "wearable a hole in your pants" tears tin be any size from the size of a pinhole to "massive" tears where there is lilliputian tendon left. In these tears, the edge of the tendon at the hole is thin, and it is difficult to sew information technology back together. If one tries to repair a hole in the tendon that is the size of one fingernail or smaller, it is easier to repair than a larger pigsty. In big holes caused past this type of damage (attritional or "wear a hole in your pants" type of tear), the rotator cuff tissue around the edges is not equally sturdy, and one is asking the tissue to fill up a pigsty where at that place is really no tendon. For this reason, the major factor in determining whether a rotator cuff tear tin heal is how large the hole was to being with prior to the surgery. The larger the rotator cuff tear before surgery then the higher the failure rate of surgery.

How do you describe the size of tendon tears?

The outset way to describe tears of the rotator gage tendons is whether tears are office of the mode through (called "fractional thickness") or all the way through the tendon (called "full thickness". The tears of the rotator gage tendons tin can exist partial thickness (similar sawing through a rope part of the way) (Figure five) or they can progress to tears all the way through the tendon (like sawing all the way through a rope) (Figure 2). One time a tear is all the way through the tendon (chosen "full thickness"), the adjacent effect to consider is the size of the hole in the tendon. Equally the tendons tear more than, they tin be of any size (depth and width).

The normal anatomy of the shoulder and rotator gage tendons are demonstrated in Figure 6. Full thickness tears of the rotator cuff are described as small, medium, large or massive (Figures 7, viii, 9 and 10). Since virtually rotator gage tendons are about as broad as 3 of your fingers, a modest tear would be ane the size of your fingernail or smaller (less than one centimeter of tendon torn) (Figure 7). A moderate size full thickness tear through the tendon would be one that is the size of three fingernails (about ane centimeter in one management and three centimeters in another). Normally tears of this size mean the whole tendon width is pulled off of the bone (Figure 8). A large tear is one that would mean the tendon is torn from the knuckle to your fingertip; this is chosen a big or massive tear (Figures 9 and x). It is also possible to tear more one tendon completely. The size of the tear is very important as it determines the chances that the tendon will heal with surgery.

What are the chances a tear volition heal with surgery?

At that place accept been many studies that tell the states gauge odds of tendons healing with surgery depend upon the size of the tendon [ane, three, seven, 13]. It has been demonstrated that modest full thickness tears the size of a fingernail (one centimeter) (Figure 7) heal in a majority of cases, but approximately five% will not heal for the reasons mentioned in the discussion above. For full thickness tears that are moderate size (one to three centimeters), the re-tear rate is around xx% (Figure 8). For large tears (iii by 5 centimeters), the re-tear rate is approximately 27% (Effigy 9). For massive tears (where ane tendon is largely or completely gone or more than 1 tendon is torn), the re-tear rate is anywhere from fifty to xc% [eight, 14] (Figure 10). The reason for this high failure rate with big to massive tears is because in that location is a hole too large to exist filled past stretching the remaining tendon, and the edges of the tendon will non hold the stitches used in the repair of the tendons.

So what do I practice if a rotator cuff tear fails?

Usually a tendon repair fails considering it was going to fail and not because of a bad surgery or bad therapy. The reality is that rotator cuff surgery is non perfect, and not all tendons will heal completely with surgery. Once a tendon has failed an attempted surgical repair, the odds are that it volition be difficult to repair once more and to get it to heal. In some cases, the tear may be pocket-size enough after a failed repair to be successfully repaired, but the exact risk of failure with farther surgery is related to how large the tear is at that fourth dimension. The larger the tear, the less likely information technology can exist successfully repaired a second time. In well-nigh cases a 2nd endeavour at repairing the tendon is not going to be successful unless the tear is small-scale.

If the tendon has re-torn and cannot exist repaired with further surgery, there is still hope for the function of the shoulder; the shoulder is not doomed and all is not lost. There are 2 myths about rotator cuff tears. 1 myth nearly rotator gage tears is that the shoulder is doomed if the tendon is non repaired. The reality is that some people can have good range of motion and role with torn rotator cuff tendons. The degree of symptoms after a failed rotator cuff repair depends upon many factors. The typical symptoms of shoulders with un-repaired tendon tears are weakness with lifting to a higher place shoulder level or away from the torso. The symptoms tin can often exist controlled by watching one'southward activities, maintaining a good range of motility of the shoulder, and being careful virtually how much lifting one does with the shoulder. Basically one can do whatever action he/she chooses every bit long as it does not injure. We recommend that the patient lets their symptoms exist their guide to action level.

The 2d myth about have a rotator cuff tear that is too large to repair is that the shoulder is doomed to become arthritis or to gradually lose function. There is no fashion to predict what rate the shoulder will have any issues or if it will have whatsoever issues at all. In that location is only one study which has suggested that the shoulder with no rotator cuff tendons may develop arthritis over time [x]. This written report was not conclusive, so it is currently believed that being active does non atomic number 82 to degeneration of the shoulder when there are irreparable tears. We encourage people with torn rotator cuff tendons that cannot be repaired to be as active as possible within the limits of their pain and weakness.

What about patching up the hole?

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 nigh of those attempts have failed as they do not regenerate or heal the pigsty in the rotator gage tendons. Things that take been used unsuccessfully to patch the pigsty in the past include a person's own tissue (called "autografts" and include iliotibial ring and biceps tendon), a cadaver or human donor tissue (called "allografts" and include iliotibial band and posterior tibialis tendons from the leg), tissue from animals (called "xenografts" and include sterilized pig-gut mucosa) and more recently patches made from culture cells (human skin cells, fibroblast scaffolds). In well-nigh instances these take no restored function and strength to the shoulder, and they should be considered experimental at this time. We exercise non recommend them in most instances, especially in tendon tears that have had previous surgery that has failed. Some physicians recommend these patches in tears that are very large, just 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.

What about tendon transfers?

A tendon transfer is an operation where the tendon of another musculus 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 [2, 9, eleven]. The beginning is a large muscle in the back of the shoulder called the "latissimus dorsi muscle." While this is a large muscle, the tendon is really very sparse and not very big. While this operation was one time advocated for patients with large rotator cuff tears with pain, the results were non as good as initially reported. This operation is helpful for only a minority of patients and has lost favor amidst shoulder surgeons [12].

A 2d muscle and tendon transfer that was described in one case was the apply of the deltoid muscle and tendon as a buffer or spacer for the space where the rotator cuff tendons were located. This functioning was largely a failure and is no longer recommended.

What about shoulder replacement?

Shoulder replacements for patients with rotator cuff tears tin can be successful just patient eligibility continues to change and evolve. 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 move alone, and we tell patients that the replacements are indicated mainly for reducing hurting in the shoulder. However, as there are increasing improvements in shoulder replacements, this may change and should exist discussed with your doctor.

There are several kinds of shoulder replacements available for patients with arthritis and painful rotator cuff tears. Each type has its advantages and disadvantages depending on the age of the patient, the activity level of the person, and the amount of harm to the shoulder. In some instances it might be best to supervene upon 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 mostly very good for pain relief and do result in some improvements of motion. The pluses and minuses of these procedures should be discussed with your doctor.

References

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