Rotator cuff tear

You have been diagnosed with a rotator cuff tear. This leaflet will explain what a rotator cuff tear is, the signs and symptoms, and how it can be diagnosed. Although the exact method of treatment will differ from patient to patient, the most common treatments used by East Kent Hospitals and their likely outcomes are also covered here. It will also provide you with information about what you need to do through the process.

If after reading this leaflet you still have questions or concerns, please speak to your surgeon or anaesthetist at your next appointment.

Contents page

• What is a rotator cuff tear?

• What are the signs / symptoms?

• How can I help myself?

• What treatments are available?

• What are the non-surgical treatments?

• If I have surgery, what will happen during the procedure?

• How successful is the surgery for rotator cuff tears?

• How can I prepare for my surgery?

• What happens on the day of my surgery?

• What kind of anaesthetic will I need?

• What are the complications and risks?

• How long will I stay in hospital?

• Will I be in pain after my surgery?

• What painkillers will I be sent home with?

• How do I care for my wound(s) at home?

• How long will my wound(s) take to heal?

• What if my wound bleeds at home?

• Can I have a bath or shower?

• Why am I wearing a sling (with or without a wedge) after my surgery?

• What is the best position to sleep in?

• When can I drive again?

• When can I return to work?

• When can I start my normal daily activities?

• Will I have a follow-up appointment?

• What if I have any questions or concerns?

• How soon will I recover after my surgery?

• Exercises and physiotherapy advice

What is a rotator cuff tear?

Rotator cuff tears are among the most common causes of shoulder pain and disability.

The “rotator cuff” is made up of four muscles and their tendons, which connect the shoulder blade to the humerus (upper arm bone), forming the shoulder joint. One of the key roles of these muscles is to stabilise and hold the shoulder joint in place when we use our arms. The strength of these tendons allows the arm to be lifted and rotated (move in a circle around the joint).

The shoulder joint is a very mobile joint, which allows it to be used for a wide range of movements. As such, if the stability of this joint is compromised, the rotator cuff muscles will need to work harder. As we age it is normal for the rotator cuff tendon to wear, which helps to explain why rotator cuff tears (partial or complete) are more common later in life (over the age of 40 years).

A complete rotator cuff tear is a full thickness rupture (tear) of the rotator cuff tissue (muscles and tendons). A partial rotator cuff tear is an incomplete rupture of the tissues.

1. 
   The “rotator cuff” muscles and their tendons, connecting the shoulder blade to the humerus (upper arm bone), forming the shoulder joint.
2. 
   A rotator cuff tear

What are the signs / symptoms?

• Pain, usually felt in the shoulder area.

• It may feel like something in your shoulder is ‘catching’ when you move your arm in certain directions.

• Difficulty sleeping on the affected side, due to pain.

• Weakness in the affected shoulder, although this depends on the size of the tear. When your arm is raised above your head you may not be able to lower it down to your side in a smooth and pain free manner. Generally, the larger the tear, the more weakness it causes. Sometimes popping / clicking can be felt over your shoulder, this may be painful.

• Sometimes you may also experience neck pain with your shoulder pain.

Some people experience painful symptoms with rotator cuff tears, but many people will have a tear with no symptoms or disability. A rotator cuff tear is often linked with previous shoulder problems. Occasionally individuals who have never had any previous shoulder problems, may develop a tear due to a fall or injury.

How can I help myself?

• In the acute (early) stage, you can place a bag of frozen peas wrapped in a damp tea towel over your shoulder for 10 minutes at a time; this may help to reduce the pain and inflammation (redness, heat, and swelling). Do not use these peas for eating once they have defrosted.

• You may find it more comfortable to lift your arm away from your side, with your palm up rather than with your palm down. You may also find it helpful when lifting or lowering your arm, to support your affected arm with your unaffected arm.

• Try to avoid repetitive overhead activities (such as tennis or manual labour over your head) until your pain settles.

• Try to improve your posture (how you sit); hold your back straight and your shoulders back.

• If your symptoms are aggravated by a sport you may benefit from advice from a coach / instructor regarding your techniques.

• Do not let your shoulder stiffen; make sure that twice a day you move your arm through the full available range, or as pain allows. You can do this by lying on your back and lifting your arm above your head using your unaffected arm.

What treatments are available?

Treatment of a rotator cuff tear can be non-surgical (we use medication, platelet rich plasma or steroid injections, occupational therapy or physiotherapy) or surgical. Surgery can be done by keyhole or open methods. Which treatment we use for your tear will depend on the size of your tear and your general health and fitness.

What are the non-surgical treatments?

Many patients with rotator cuff tears manage well with non-surgical treatments, after 12 weeks of exercise therapy.

Recent studies have shown that exercise therapy (occupational or physiotherapy) has good results for patients with rotator cuff tears from wear and tear. It helps them regain the use of their shoulder, and should be the first treatment tried by most patients.

As recovery and rehabilitation depends very much on the individual patient, returning to work or normal everyday activities should be discussed with your surgeon or physiotherapist, who will help decide what is appropriate for you.

If I have surgery, what will happen during the procedure?

Sometimes, the tear is too large to repair. If this is the case, either partial repair of the tear or a debridement (clean out) of the soft tissue is performed to relieve your pain.

It is important to keep in mind that your surgeon will decide the type of repair you will have during your operation. This will be discussed with you after your procedure, during your first follow-up appointment.

During your operation, your surgeon might shave away any bony spurs to increase the space and allow your tendons to move freely. If they find further damage in your shoulder, they may also do a repair or carry out further surgery if the issue can be solved there and then; as long as that is what has been agreed with you when you gave consent for surgery. This further treatment may involve a debridement (clean up) of unhealthy soft tissue, a tendon repair, or a tendon release.

How successful is the surgery for rotator cuff tears?

The results of your surgery will depend upon the size of your tear, your age, and the cause of your tear (was it due to an accident or wear and tear). We will try to restore as much as possible of your shoulder function and improve your pain.

If you are experiencing pain, surgery should help you with it. However, it might not to be as successful if your main problem is increased weakness in your shoulder. If what you need is to restore the strength after an injury, you should discuss non-medical treatments with your surgeon.

Rehabilitation after surgery can be slow and you should expect a full recovery to take up to 12 months.

How can I prepare for my surgery?

You will have a preassessment appointment before your surgery, to check if you are ready and fit for surgery. You will also be swabbed for MRSA and Covid-19, if necessary.

Before surgery it helps if you try to get as fit as possible to avoid anaesthetic risk and / or failure of the surgery. It is important that you lose weight if you are above your ideal weight.

• Smoking advice

  It is important to stop smoking at least 30 days before your surgery. Studies have shown that wound healing is significantly delayed by smoking / nicotine, and the infection rate is much higher. Smoking also harms how your tendon heals following a repair, so smoking after your operation is also not advised.

  If you need support to stop smoking, please contact One You Kent on 0300 123 1220, or email.

• How does eating a healthy diet help my recovery?

  Recovering from surgery can take a long time and it is normal to get frustrated and anxious. But remember that while you are recovering, there are some things you can do to help your wound to heal. We suggest limiting the amount of alcohol you drink, stopping smoking, eating a healthy diet, drinking plenty of fluids (especially water), and staying active. If you need any extra support, do not hesitate to get in touch with us on the contact numbers listed at the end of this leaflet.

  Some painkillers (especially those containing Codeine) can cause constipation. To avoid this, please follow a healthy well-balanced diet rich in fruit, vegetables (including green leafy vegetables), nuts, seeds, wholegrains, and legumes, which contain the necessary fibre, and drink plenty of water. More information is available on the NHS 5 A Day: what counts? web site.

While you wait for your surgery date, you can start preparing for your operation. Research shows that fitter patients, who are able to improve their health and activity levels before surgery, recover more quickly. Taking an active role in planning and preparing for your operation will help you:

• feel in control

• leave hospital sooner, and

• get back to normal more quickly.

To help with this, you may be contacted by a member of the One You Kent (OYK) team. OYK work in the community, and help patients improve their general health. This includes help and advice on:

• Stopping smoking

• Losing weight

• Getting more exercise

More information can be found on the following web sites.

• One You Kent (Kent Community Health)

• Fitter Better Sooner Toolkit (Royal College of Anaesthetists)

What happens on the day of my surgery?

• Please arrange for someone to pick you up from the hospital after your surgery, as you will not be able to drive yourself. Please make sure to arrange this before your surgery.

• To avoid complications with your anaesthetic, you should not eat anything for six hours before your surgery, or drink anything for two hours. You will be given further instructions during your preassessment.

• On the day of your surgery, you can take your usual medication as advised during your preassessment. If possible, do not take non-steroidal anti-inflammatory medication, such as ibuprofen and naproxen, for at least 10 days before your surgery, as they can affect how your wound heals. Please bring any medications that you are taking into the hospital with you.

• If possible, please wear loose-fitting clothes, as after surgery you will be wearing a sling.

• Bring your appointment letter with you, so you know which department to come to when you arrive at the hospital.

• At arrival, you will be asked to put a hospital gown on, and maybe a pair of compression stockings.

• You will see the anaesthetic and surgical team before your surgery to go through the consent form and discuss any questions you may still have. Remember you can withdraw your consent for treatment at any time.

• You may be tested for Covid-19. All appropriate precautions will be taken during your admission to minimise the risk of contracting the illness as per Healthcare England Guidelines.

What kind of anaesthetic will I need?

This procedure is usually performed under general anaesthetic (you will be asleep for the procedure). However, you may be offered the option of “awake anaesthesia” during your surgery to avoid putting a tube into your windpipe. This may be discussed and decided with you and the anaesthetist on the day of your surgery. Should you be suitable for this type of anaesthesia, it is important to understand and be assured that you will be kept comfortable, and you will not feel any pain during your procedure. Patients describe their experience after this type of “awake anaesthetic” as if waking up from a usual night’s sleep, as it is often supplemented with some light sedation. If you need any more information, please speak to your anaesthetist before your procedure.

In addition, a local anaesthetic or nerve block is used during your operation. As a result, your shoulder and arm may feel numb for a few hours after your operation. It is important to take your pain medications during this time, to allow a gentle and easier control of pain when the nerve block wears off and your shoulder is likely to be sore and uncomfortable.

What are the complications and risks?

As with all surgery, there are a few risks and complications with rotator cuff repair. These are rare and will be discussed with you before your surgery.

Anaesthetic risks will be discussed with your anaesthetist on the day of your surgery.

• General risks for surgical procedures

  Risks of any surgical procedure are low but do happen and may include the following.

  • Bleeding: this could happen during your surgery; we will do our best to stop it as soon as possible. However, some oozing could still happen after your surgery. For more information, see the What if my wound bleeds at home? section below.

  • Wound infection: we do everything we can to avoid this but an infection might still happen. If your wound becomes increasingly red or swollen after your surgery, please contact your GP or speak to your surgical team.

  • Deep vein thrombosis (DVT) and / or pulmonary embolism (PE). These are blood clots which form in the blood stream and can be serious conditions. Compression stockings and other measures might be taken by the hospital to avoid them.

  • Soft tissue (nerve / tendon / blood vessel) injury could happen during surgery. Your surgeon will try to deal with it during your operation and it will be discussed with you after your surgery.

• Specific risks to rotator cuff repairs

  • Local swelling (swelling around the rotator cuff). This could happen after your surgery due to “upsetting” the soft tissues around your shoulder during surgery. It should improve as you recover from your surgery.

  • Continued muscle weakness. Please discuss this with your physiotherapist.

  • Numbness / tingling in your arm. If you notice this after your surgery, please speak to your surgeon or physiotherapist during your follow-up appointment. It is normal to have some numbness around the surgery area for few months, but it should improve as you recover.

  • Fracture of the acromion or distal clavicle (parts of the shoulder). We will do our best to stop this from happening.

  • Continued pain and Chronic Regional Pain Syndrome (CRPS). This is a condition where a person has persistent, severe, and debilitating pain. Although most cases of CRPS are triggered by an injury, the resulting pain is much more severe and long-lasting than normal.

Even though rotator cuff repair is successful, in some cases the complications listed above may lead to you needing further surgery.

• Failure of healing of the repaired tendons and re-tear of the rotator cuff. If your surgeon s unable to complete your surgery successfully or the repair fails, other options or further treatment can be discussed after your surgery.

• Stiffness / loss of movement that may cause frozen shoulder (your shoulder is painful and stiff for up to several months beyond the usual period expected for the stiffness to recover from a simple procedure). This could be avoided or improved if you take adequate pain relief and do the exercises listed at the end of this leaflet as your pain permits.

• If a biceps tendon release is performed this may change the appearance of your arm muscle known as “popeye sign”, which will appear as a bulge between your shoulder and your elbow.

If you have any questions or concerns about these complications, please speak to your doctor either during your preassessment appointment or before your surgery.

How long will I stay in hospital?

This procedure is usually carried out as a day operation, so you should be able to go home the same day.

After your operation, you will be taken to the ward until it is safe for you to be discharged home. You will be seen by your surgeon, your nurse practitioner (surgical care practitioner), and / or your physiotherapist before you go home. They will show you exercises to do and give further advice to guide you through your recovery.

If you need to stay in hospital overnight, this will usually be explained to you during your preassessment appointment. If you have to stay overnight, make sure you bring with you items you may need, such as hygiene items (toothpaste and toothbrush), a dressing gown, slippers, and your usual medication. Also, we suggest you bring a book or magazine, in case there is a delay.

Will I be in pain after my surgery?

Rotator cuff repair surgery will cause quite a bit of pain and discomfort, and you will need to take appropriate pain relief in the period following your surgery. If your anaesthetist has given you a nerve block, your shoulder and arm may feel numb and weak after your surgery. You may not feel any pain immediately after your surgery, as the block may take 12 to 24 hours to wear off completely.

However, it is very important that you take your pain relief as advised and as early as you can before the nerve block wears off; this will help you to keep on top of your discomfort. It is advisable to take your painkillers regularly for the first few days. If possible, avoid non-steroidal anti-inflammatory medication, such as ibuprofen and naproxen, for at least 10 days before your surgery and six weeks following surgery. This is because anti-inflammatory medication could slow down the healing process.

Before you leave the hospital you will be given painkillers to take at home; these should last for at least two weeks. This will be discussed with you before you leave hospital.

Take pain relief regularly to try and keep your level of discomfort at a bearable level at all times. This allows the inflammation (redness, swelling, and heat) and pain to settle. Do not wait until your shoulder is very painful to take the pain relief, as it is then more difficult to control.

What painkillers will I be sent home with?

• Surgical patients might be given some of the following painkillers, depending on their age, body weight, and individual circumstances, unless told otherwise by their doctor.

• Take each painkiller as advised on your prescription.

  • Tablet paracetamol, 1g every four to six hours (no more than 4g per day).

  • Codeine Phosphate, 30 to 60mg every six to eight hours.

  • Tablet Tramadol, 50 to 100mg every eight hours.

  • Oramorph, 10 to 20mg every hour, as needed.

  • Anti-inflammatories may be prescribed; but you should try and take as few as possible immediately after your surgery.

  Please note that Codeine, Oramorph, and Tramadol should not be taken together; you should only take one of the three at any one time.

Ice packs or bags of frozen peas may also help reduce your pain. Wrap the pack / bag with a cloth and place it on your shoulder for up to 15 minutes. Do not use these peas for eating once they have defrosted.

If your pain continues and is not controlled with the medication you have been advised to take, then please contact your GP. You may also contact the East Kent Upper Limb Team if you need further help.

If you notice your wound area is becoming more painful, red, hot, and / or discharging pus (thick yellow discharge), you may be developing an infection. Contact your GP or your surgical team for advice as soon as possible.

How do I care for my wound(s) at home?

• If you had an open surgical repair there will be one long incision at the top of your shoulder.

• If you had a repair through keyhole surgery, there will be few (three to five) keyhole incisions around your shoulder, including one or two at the back.

It is important to keep your wound and dressing dry and in place until your wound is well healed, and have your stitches removed at your two week follow-up appointment with your GP practice nurse or at the hospital, with your surgeon or your nurse practitioner (surgical care practitioner). You will be told where your follow-up appointment is going to be before you leave the hospital.

If the dressing gets wet or bloodstained, you can change them yourself by carefully placing a dressing from a pharmacy. If you are unable or have difficulties doing this yourself, you can ask a relative or a friend to change it for you, or you can make an appointment with your GP practice nurse to do it for you.

If you are being seen by your GP practice nurse for a wound check 10 to 14 days after your surgery, please make sure the nurse reads the following. These instructions are for healthy looking surgical wounds only.

• *Colourful stitches are non-absorbable and need to be completely removed to avoid them getting buried under the patient’s skin.

• *White / clear stitches are absorbable. If any suture knots have been made outside the patient’s skin, please remove these to avoid suture abscesses. Thank you.

*The appearance and material of the sutures can be different from Trust to Trust, but these are the most common.

If a wound does not seem to be healing appropriately, please leave the stitches / knots in place and make another appointment to remove them in few days.

How long will my wound(s) take to heal?

Wounds usually take between 10 to 14 days to heal.

The area around your wounds may have some numbness, which is usually temporary. You may feel occasional sharp pains or ‘twinges’, as well as itching near your scar as it settles.

What if my wound bleeds at home?

There may be minor bleeding or clear fluid oozing from your wound in the first day or two following surgery. If your dressing gets wet or bloodstained, you may need to replace it. You can change this yourself by carefully placing a dressing from a pharmacy. If you are unable to or have difficulties doing this yourself, you can ask a relative or a friend to change for you, or you can arrange an appointment with your GP practice nurse to do it for you. You should be able to control this bleeding or oozing by pressing firmly but gently on your wound for 15 minutes.

If you are worried about the bleeding, you can contact the hospital on the number given to you (during normal working hours) or attend a walk-in centre or Emergency Department (after hours).

Can I have a bath or shower?

You should have a ‘dry wash’ or a shallow bath instead of a shower. This keeps your arm in the correct position and prevents your dressing and sling from becoming wet.

While your wound is still healing:

• do not use soaps, lotions, creams, or powders on your wounds, to avoid any infection getting into your wound(s); and

• keep your wound(s) dry at all times.

You can go back to normal cleaning routine once your wound is completely healed.

It is very important to remember to keep your armpit on your operated side clean and dry. Lean forward so you can reach your armpit, as separating it from the body sideways may be difficult or painful and is not allowed for the first four to six weeks.

Why am I wearing a sling (with or without a wedge) after my surgery?

You will return from surgery wearing a sling. This is usually used for the first four to six weeks following your operation. The sling protects your tendon repair while it heals.

To start with the sling must be worn at all times, including in bed. After three to six weeks you can remove the sling for exercises, washing, and dressing only. While wearing the sling, you may find that your armpit becomes uncomfortable. If you lean forward you will be able to reach your armpit and use a dry pad or cloth to absorb any moisture.

As you begin to heal you will be able to slowly stop using your sling. Your physiotherapist will advise you about this. To start with you can remove your sling when sitting watching TV or reading, and just rest your arm by your side or on cushions.

Follow the instructions on how to use your sling that were given to you by your physiotherapist.

What is the best position to sleep in?

To begin with sleeping will be difficult. Take regular painkillers and try to support your shoulder with pillows, by placing them behind it. If you lie on your back, a pillow under your arm and elbow may make you feel more comfortable. You may also find it easy to lay on your non-operated side.

It will take at least three months before you can lay on your operated shoulder.

When can I drive again?

You will not be able to drive for at least eight weeks following your surgery. Your surgeon will tell you when you can drive again. The advice from the DVLA is that you should not drive until you are physically capable of controlling a motor vehicle and can perform an emergency manoeuvre safely and confidently.

Please arrange for someone to collect you from hospital and take you home after your surgery.

When can I return to work?

This will depend upon the size of your tear and your job. Your surgeon will advise you on the amount of time you will need to be away from work; you can ask for a sick note before you leave the hospital. If you have a manual job or one that involves overhead activities, you will not be able to do this until at least three months after your surgery.

When can I start my normal daily activities?

This will depend upon the size of the tear. Your physiotherapist and surgeon will advise you when it is safe to resume your leisure activities. Simple activities that do not involve your upper arm can start after about three months, but sports that need you to use your upper arm or contact sports can take more than six months.

Your physiotherapist can tailor your treatment depending on your personal objectives.

Will I have a follow-up appointment?

An appointment will be made for you to see a physiotherapist after your discharge from hospital. This appointment will usually be three to four weeks after your surgery. You will be monitored by a physiotherapist throughout your rehabilitation.

Please remember that your rehabilitation will take time; a cuff repair is very successful but is not a quick fix procedure.

What if I have any questions or concerns?

If you have any questions or concerns, please contact your surgical care practitioner, surgeon, or physiotherapist. Their contact details are listed on the last page of this leaflet.

If you notice your wound area is becoming more painful, red, hot, and / or discharging pus (thick yellow discharge) you may be developing an infection. Contact your GP or your surgical care team for advice as soon as possible.

Please remember that your rehabilitation will take time; a cuff repair is very successful but is not a quick fix procedure.

How soon will I recover after my surgery?

As not all cuff tears are the same and the strength of the repair varies, this leaflet will only give you general rehabilitation advice. The team that looks after you will provide you with personalised rehabilitation advice after your surgery.

There are three phases of recovery

• Phase 1 starts immediately after surgery and will last from three to six weeks, depending on your surgery. During this time, you will only be able to use one hand. This will affect your ability to do most daily activities using your operated arm, including dressing, bathing, hair care, shopping, eating, and preparing meals. During this period, you will be using your sling most of the time and you will perform limited exercises.

• Phase 2: during this phase, with the help of physiotherapy, you will start doing everyday movements. This period lasts another three to six weeks. You will start to use your arm at waist level and gradually start tasks with your arm away from your body, such as sidewise and forwards from your body. This will be explained by the team.

• Phase 3: after 12 weeks you will start doing more activities. At this stage your physiotherapy will move to strengthening exercises and continue to improve your range of movement.

Most of the progress happens within the first six months but you may continue to see improvement for up to two years after your surgery.

Physiotherapy exercises

Before you see a physiotherapist for the first time, there are few exercises that are safe for you to do. These will help avoid stiffness in your hand and elbow, and reduce stress at your neck and scapula (shoulder blade).

On the next page you will see how to perform these exercises, but if you have any questions, please contact the physiotherapy department (see the contact details at the end of this leaflet).

Following your first appointment with your physiotherapist, you will receive more exercises and depending on your progress your physiotherapist will give you personalised advice.

Exercises you can do after surgery, before your first physiotherapy appointment

Before starting the following exercises, please take painkillers and use ice, if needed. It is normal to experience some pain and discomfort when you perform any exercises. If you experience prolonged pain or discomfort when moving, then do the exercises less forcefully or less often. If this does not help, speak to your physiotherapist.

It is best if you do a few short sessions (two to four times a day, for five to 10 minutes each time) rather than one long session. Gradually increase the number of repetitions you do.

Hand exercise

• Open and close your fist 20 times.

Wrist exercise

• Move your wrist up and down 20 times.

Forearm exercise

• Turn your palm up and down 20 times.

Elbow exercise

• Bend and straighten your elbow 20 times.

• This can be completed with help from your other arm.

Shoulder girdle and posture

• Try not to slouch after your surgery.

• Try pulling your shoulder blades back and down 20 times.

Pendular exercises

• Lean forwards, supporting yourself with your other arm.

• Swing your operated arm forwards and backwards gently, similar to a pendulum.

• Do this 20 times.

You will be shown further exercises at your outpatient physiotherapy appointment or your clinic appointment. If you have any questions, please contact the physiotherapists listed at the end of this leaflet.

Contact details

Consultants and their secretaries

• The teams listed below work at Kent and Canterbury Hospital as well.

Physiotherapists

Surgical Preassessment Units

Fracture Clinics