Patient Information

Patient Information

Does my torn rotator cuff (shoulder tendon) need to be repaired?

Are rotator cuff tears common?

Subscapularis tendon tear (on MRI scan)

Subscapularis tendon tear (on MRI scan)


Yes, tears of the rotator cuff tendons are extremely common. Recent studies report that approximately 30% of over 60 year olds and 60% of people over the age of 70 will have a tear. As such, after the age of 60, rotator cuff tears may be considered a natural part of ageing. It is also important to note the majority of shoulders with a torn rotator cuff will not be painful.

 

 

 

 

 

 

 

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

Do I need to have surgery for my torn rotator cuff?

Most tears in patients under the age of 50-55 are traumatic in nature and require an early assessment by an Orthopaedic Surgeon.

Otherwise, it is extremely important to try a period of physiotherapy, pain-killers (including anti-inflammatory medications), modifying your activities and on occasion, steroid injections, to see if the pain from the torn tendon can be settled. Although a torn tendon does not heal itself, the pain from it can certainly be managed.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

When would you consider offering surgery to repair a torn rotator cuff?

A number of factors need to be considered:

  • the amount of pain caused by the torn tendon
  • your age and level of activity
  • the condition of the torn tendon and muscle

The amount of pain a torn tendon causes, and the response you have had to the various non-surgical means of treatment is by far the most important factor in determining whether surgery is required. It is often pain at night disturbing sleep on a regular basis that seems to make people consider surgery.

Age of the patient at time of surgery seems to be one of the most important in determining whether a repaired tendon will heal or not.

For patients under the age of 50 – 55 years
Few patients under the age of 50 – 55 will have a torn rotator cuff, and this will almost always be traumatic in nature. Surgery in these patients needs to be considered early.

For patients between the ages of 55 and 70 years
Using modern arthroscopic (key-hole surgery) techniques, most torn rotator cuffs are repairable. The arthroscope allows for better visualisation and mobilisation of the tear pattern, how to best repair it, better access to put in anchors and sutures for the repair, double-row technique to provide secure fixation of the tendon back onto bone; all without interfering with the deltoid muscle.

But just because a tear is repairable, that does not mean that it should be repaired. Not all repaired tendons will HEAL back to bone again.

The tear should not be considered in isolation. A careful assessment of the likelihood of healing needs to be made. Pre-existing medical conditions need to be taken into account. A thorough shoulder exam will determine whether it is appropriate to consider repair of the torn tendon. Additional imaging can be very valuable in determining the likelihood of functionality following a rotator cuff repair.

After the age of 70 years
In most patients over the age of 70 years, the rotator cuff muscle and tendon will often have pre-existing changes within it. Often a tear becomes painful with little further injury. Although most tears may still be repairable, unfortunately they may not heal once repaired. For this group of patients other arthroscopic (key-hole surgery) techniques may be more appropriate. Alternative treatment may result in quicker recovery time, and better outcomes.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

Is there a downside to not having surgery for my torn rotator cuff?

There is one potential downside to not having a torn rotator cuff tendon repaired. Over time a number of small partial-thickness rotator cuff tears progress to become large full-thickness tears. Some of these larger tears become painful. If you choose not to have your tear repaired, there is a possibility for the tear to become irreparable.

Despite this, I still feel that rotator cuff surgery should be done to alleviate pain in the shoulder.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

Why do some patients lose movement following a rotator cuff tendon repair?

Post operative stiffness is a possible complication following rotator cuff tendon repair. This can result in loss of movement and increasing pain in the shoulder. The commonest reason for this is because the attempted repair results in an unbalance shoulder. Hence the healing potential of rotator cuff tendon needs to be carefully assessed prior to surgery.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

Why does recovery from rotator cuff surgery take such a long time?

The aim of a rotator cuff surgery is to re-attach the tendon back onto bone. The tendon then needs time to heal back onto bone. Once the tendon heals to bone and the joint is mobile, the muscle needs to be re-strengthened. Early physiotherapy with incremented increase in rehabilitation is critical to allow for tendon healing and minimise stiffness.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

Do I need surgery for my dislocating shoulder?

Do I need surgery after my shoulder dislocation(s)?

Shoulder and Elbow Specialist
An assessment needs to be done of the likelihood of your shoulder “popping out” again.
Important factors to consider include:

  • Your age at the time of first dislocation
  • Your work and sporting requirements
  • The flexibility of your uninjured ligaments
  • Examination of your injured shoulder
  • Associated injuries to the shoulder such as bone loss (i.e. bony Bankart or Hill Sachs lesion), nerve damage, tear of the rotator cuffs, etc.

With this information, your surgeon will be able to give you an estimate of the likelihood of your shoulder continuing to dislocate.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

My shoulder has dislocated a couple of times. Do I have any alternatives, in order to avoid surgery?

Surgery to stabilise a dislocating shoulder is very much an individual’s choice. Alternatives to surgery include:

  • Modifying your activities to reduce the risk of another dislocation
  • Physiotherapy to re-educate your shoulder muscles
  • Taping (during sports) to avoid ‘at-risk’ arm positions

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

What types of operations do you do for dislocating shoulders?

By far, the commonest operation that I perform for a dislocating shoulder is an arthroscopic stabilisation of the shoulder joint (key hole surgery). For the correct indication, this operation has a very high likelihood of stabilising the shoulder, with very few complications.

Arthroscopic surgery is not appropriate for every dislocating shoulder. Depending on your age, overall flexibility, sporting needs, associated injuries to the bone, etc. it may be more appropriate to consider open surgery.

The commonest bone block operation that I perform is a Bristow-Latarjet bone graft.

Please watch the animation for more information about what a Bristow-Latarjet procedure involves.

What is a Frozen Shoulder? How is a Frozen Shoulder Treated?

What is a Frozen Shoulder?

The shoulder joint is the most mobile joint in the body. Its capsule (the tissue that surrounds the shoulder joint) has special properties that allows for this to happen. In a frozen shoulder (adhesive capsulitis), the capsule becomes tight, inflamed and scarred. This can result in severe pain and restriction of motion, which potentially can last two years.

The condition can be difficult to diagnose, especially in its early stages. Sometimes, the pain and stiffness is incorrectly attributed to a small partial tear of the rotator cuff. An accurate diagnosis early on can help with setting realistic expectations, avoiding unnecessary injections or surgery and hopefully speeding up recovery.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

So, what is the good news?

The majority of Frozen Shoulders do not have a significant injury. As such, once the capsulitis (inflammation of the capsule) settles, pain improves and motion returns. Unfortunately, the recovery can be hard to predict. A few of my patients have decided to wait a year or two, and their shoulder has completely improved.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

What is the treatment for a Frozen Shoulder?

The most important step is to accurately diagnose the condition. This is done by an accurate physical examination. On occasion, I will get an XR and MRI scan of the shoulder to exclude other conditions that can mimic a Frozen Shoulder.

The commonest way that I treat a Frozen Shoulder is by a procedure called a Hydrodilatation. This is where a Radiologist injects the shoulder joint with anaesthetic and steroid, followed by sterile saline to stretch the capsule. The procedure may cause a feeling of tightness, pressure or heaviness in the shoulder and arm. A minority of people describe the procedure as painful. The procedure should take less than 10 minutes to do. After the procedure, the shoulder may feel squelchy for a day or two. Once the anaesthetic wears off, the shoulder can be achy for a few days.

3-4 days following the procedure, your physiotherapist should re-start gentle passive stretches to help improve the range of motion. How much or how little you do, is dependent on what your shoulder feels like.

On occasion, a second hydrodilatation may be recommended, if the first does not do the trick. Thanks to the success of the majority of hydrodilatations, it is uncommon that a surgical procedure (such as a manipulation under anaesthetic or shoulder arthroscopy) is required.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

And what if the Hydrodilatation does not work?

If you have had two or three hydrodilatations and your shoulder is still very stiff, then it is an option to consider shoulder arthroscopy. Shoulder arthroscopy is key hole surgery on the shoulder – it allows for a full assessment of the shoulder, followed up by removal of all scar tissue in the shoulder joint. Following the release, the shoulder is gently manipulated under anaesthetic to regain full movement.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

What is Shoulder Arthroscopy?

What is Shoulder Arthroscopy?

During shoulder arthroscopy, a small camera (an arthroscope) is inserted into your shoulder joint and the shoulder is filled with fluid. This is also known as key-hole surgery. The camera displays images on a screen, which are then used to guide miniature instruments during the surgery. This allows inspection, diagnosis and repair of damage within the shoulder joint. New instruments and techniques mean that the procedure is becoming quicker and simpler to perform.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

Anatomy of the Shoulder Joint

The shoulder is a complex joint. It is capable of more motion than any other joint in the body. It is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula) and your collarbone (clavicle). More information can be found at orthoinfo.aaos.org

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

What is the Role of Shoulder Arthroscopy?

Shoulder arthroscopy is usually recommended if you have a painful condition of the shoulder that does not respond to nonsurgical treatment. Nonsurgical treatment includes rest, shoulder specific physiotherapy, targeted cortisone, PRP injections etc…

Inflammation is one of the body′s normal reactions to an injury or disease. The inflammation may be in the bursa (bursitis), capsule (capsulitis) or joint (synovitis). This can cause pain, swelling, stiffness and weakness. Unless the cause of the inflammation is addressed, treatment may be ineffective.

Injury, overuse and age–related wear and tear are responsible for most shoulder problems. Shoulder arthroscopy may relieve painful symptoms of many problems that damage the rotator cuff tendons, labrum, articular cartilage and other soft tissues surrounding the joint.

    Common arthroscopic procedures include:

  • Rotator cuff repair
  • Removal of bone spurs (subacromial decompression)
  • Shoulder stabilisation (for repair of torn labrum / ligament)
  • Removal of inflamed capsule or loose cartilage (for dealing with a frozen shoulder or arthritic shoulder)

Less common procedures such as nerve release, fracture repair and cyst excision can also be performed using an arthroscope.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

Do you use Nerve Blocks for Shoulder Surgery?

Shoulder arthroscopy is commonly performed using regional nerve blocks which numb your shoulder and arm. This local anaesthetic (numbing medicine) is injected in the base of your neck. This is where the nerves that control feeling in your shoulder and arm are located. In addition to its use as an anaesthetic during surgery, a nerve block will help control pain for a number of hours after the surgery is completed. The nerve block is combined with a light general anaesthetic, predominantly for your comfort.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

What is the actual procedure?

Small incisions are made around your shoulder to allow the arthroscope and instruments to be placed inside your shoulder joint. Fluid flows through the arthroscope to keep the view clear and control any bleeding.

Once the problem is clearly identified, other instruments are placed in the shoulder to allow repair or debridement. On occasion, some of the portals are extended to allow the repair.

Once the problem is clearly identified, your surgeon will insert other small instruments through separate incisions to repair it. Specialised instruments are used for tasks like shaving, cutting, grasping, suture passing and knot tying. In many cases, special devices are used to anchor stitches into bone.

Your incisions will be closed with dissolvable stitches and steri–strips. A large soft dressing is then applied. The nurses will debulk the dressings prior to your discharge. The dressing will be water–resistant, making it easier to shower.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

What does recovery involve?

Postoperative
After surgery, you will stay in the recovery room for 1 to 2 hours before being transferred to the ward. You will be discharged the following morning, after making sure that your pain is well controlled, you are eating and drinking and are able to toilet. You will need someone to drive you home and stay with you for at least the first night.

More information about recovery after shoulder operation can be found here

At Home
How quickly your shoulder recovers after surgery depends on what exactly was done and can vary quite significantly from person to person. Most patients have some pain and discomfort for at least the first week or two. If you have had more extensive surgery, the discomfort may last several weeks before subsiding.

Ice will help relieve pain and swelling. If appropriate, you will be prescribed a combination of short and long acting analgesics. These include Oxycontin or Targin, Naprosyn Slow Release (SR) and Paracetamol (Panadol). On occasion, you may be given Lyrica or Tramadol.

If a repair has been performed, you will need a sling or special immobiliser to protect your shoulder. I will discuss with you how long to use the sling.

Rehabilitation
Rehabilitation is an important part of getting maximum benefit out of surgery and returning to your usual activities. A physiotherapy based program will help you regain your shoulder motion and eventually strength. I will advise on a plan based on the surgical procedure that was performed.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

General Practitioners Information

“My Shoulder Hurts” – Rotator Cuff Tears

“My Shoulder Hurts” – Rotator Cuff Tears

Tears of the rotator cuff tendons can cause pain in the shoulder girdle. Tears are age related. For example, tears under the age of 45 years are uncommon, whereas almost 60% of over 70 year olds will have a tear. Majority of tears in older individuals are asymptomatic and do not require treatment.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

What is important in the patient’s history?

Rotator cuff tears tend to cause anterior and lateral shoulder pain. This often radiates into the upper arm (level of the deltoid insertion) and elbow. It can radiate into the forearm, but rarely into the fingers. Radiation into the fingers can be a sign of cervical nerve root impingement. Night pain can interrupt sleep, which often instigates the patient to seek treatment.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

Key points on physical examination

Often the range of movement in a shoulder with a small to medium size full thickness supraspinatus tear is preserved. Complete lack of external rotation may be a sign of adhesive capsulitis.

A painful arc (pain in the antero-superior aspect of the shoulder, in 30-90 degrees of abduction) may be present. Rotator cuff strength should also be assessed. Supraspinatus abducts the shoulder at 30 degrees, subscapularis is an internal rotator of the shoulder and infraspinatus is an external rotator.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

Imaging for rotator cuff tears

XR and US scan of the shoulder are very useful initial tests in diagnosing shoulder pain. XR can exclude fractures or arthritis as a cause of shoulder pain. Ultrasound scan is useful for showing size and location of the tear. ‘Bursal bunching’ or impingement may be reported on an ultrasound scan – its significance needs to be confirmed on physical examination.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

Treatment

The mainstay of treatment of rotator cuff tears is physiotherapy. These should target the scapula stabilisers as well as the remainder of the rotator cuff muscles. On occasion physiotherapy exacerbates the pain and is discontinued.

Sub-acromial injections can control the night pain or allow patients to do their physiotherapy exercises. If the injection makes no difference, it is useful to re-evaluate the patient to confirm the diagnosis and exclude differentials. Common differentials include AC joint arthritis (tenderness localized to the AC joint), adhesive capsulitis (lack of external rotation) and cervical nerve root impingement (radiation of pain into the fingers). Ultrasound guided injection can be used to target the area of bursitis.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

When to Refer

Young patients (under the age of 55 years) with full thickness rotator cuff tears should be referred early. In this group, the pain from a rotator cuff tear is unlikely to settle with physiotherapy alone. Otherwise, it is reasonable to persist with physiotherapy and one or two injections for 3-4 months to see if the pain will settle.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

General Practitioners Presentations

Injuries about the Shoulder and Elbow

Injuries about the Shoulder and Elbow
This is a talk that I give to local GPs about my guidelines when they should consider referral to an Orthopaedic Surgeon for fractures that they are initially managing. Please note that these are guidelines for referral to a Specialist, and not guidelines for surgery.

Injuries about the Shoulder and Elbow: Download PDF

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

Rotator Cuff Disease

My current approach to the management of patients with rotator cuff tears.

Rotator Cuff Disease: Download PDF

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.