Introduction

The rotator cuff tear is an extremely common pathology. Studies have shown that almost 20% of the general population suffers from a transfixing rupture after the age of 60. Many remain asymptomatic (see symptoms below), i.e. they suffer little or no pain. In the event of a rupture, tendon surgery is not systematic. It depends on several factors, such as age, profession and location of the rupture, but especially the pain.

The rotator cuff

The rotator cuff is made up of 5 tendons: the supraspinatus, the infraspinatus, the teres minor, the upper part of the subscapularis and the lower part of the subscapularis.

They keep the head of the humerus in front of the glenoid and thus enable the arm to be raised (see video). In the event of lesions (partial or transfixing rupture), bursitis (inflammation) of the shoulder can set in and cause pain.

Rotator cuff tear

Symptoms

The shoulder presents diffuse pain, more frequently at night. It is rarely acute shoulder pain, but rather chronic pain. Most of the time, a non surgical rotator cuff tear allows free movement, but the shoulder remains painful at night. A torn tendon can also, but not always, lead to a loss of strength.

Transfixing rupture of the cuff

In the vast majority of cases, the rotator cuff tear is transfixing, which means that the tendon is completely detached from the bone (see photo 1) and this specifically affects the supraspinatus. The lesion then spreads forwards (subscapularis) or backwards (infraspinatus).

The rupture of the supraspinatus is not always transfixing; we then speak of partial rotator cuff tear (photo 2), which means that the tendon of the supraspinatus is not totally detached from the bone. Partial ruptures of the cuff can hurt as much as transfixing ruptures, since the pain is mainly related to shoulder bursitis.

Rotator cuff surgery

Surgical Technique

The shoulder surgeon introduces a camera (we talk about shoulder arthroscopy) to perfectly visualise all the tendons and the ruptures. Then he performs an acromioplasty: he shaves a very small part of the bone. The shoulder tendons are then reinserted onto the bone using anchors. In the video, you can watch live rotator cuff surgery.

Surgery flow

The rotator cuff repair is performed by an orthopaedic shoulder surgeon. The surgery takes place on an outpatient basis: you will arrive in the morning on an empty stomach, and in most cases, you will not undergo general anaesthetic. The rotator cuff can be repaired under locoregional anaesthesia (only the nerves close to your shoulder are put to sleep). Hypnosis approach is also possible.

The shoulder surgery lasts about half an hour; then you can rest for a few hours in a suitable lounge with a snack. You will receive a booklet with all the information. Your medication for shoulder pain should still be taken even if there is no pain, to prevent the pain re-emerging when the nerves are no longer asleep.

Rehabilitation exercises

Cuff tendon repair - Phase 1

Cuff tendon repair - Phase 2

Cuff tendon repair - Phase 3

Rehabilitation: rotator cuff repair

These dates are only indicative.
All rehabilitation evolves at its own pace.

Week 1 to 3

● An abduction cushion must be worn day and night (with the exception of dressing, washing, eating, physiotherapy sessions and self-rehabilitation exercises)

● Rehabilitation with a physiotherapist 3 times a week

● Self-rehabilitation exercises to be done 5 times a day (1 minute per exercise)

● No more than 30 minutes' walking

Week 4 to 6

● An abduction cushion must be worn day and night, then progressively removed in the 4th week (1 hour in the morning/1 hour in the afternoon, then increased very gradually)

● Self-rehabilitation exercises to be done 5 times a day (1 minute per exercise)

● Rehabilitation with a physiotherapist 3 times a week

● No prolonged or excessive walking

Week 7 to 12

● No more abduction cushion

● Minimum use of the arm (= simple activities of daily living: washing/dressing/eating)

● Picking up light objects

● Nothing heavy, nothing repetitive, no cleaning, no dishes

● Resume driving around 1 and a half months

● Rehabilitation with a physiotherapist 3 times a week

● Self-rehabilitation, start exercises 4–6 weeks, 5–8 weeks, 6–10 weeks, 7–12 weeks

● Maximum 45 minutes' walking

From 3 to 6 months

● Resume housework gradually, cycling/exercise bike, swimming, walking

● Rehabilitation with the physiotherapist twice then once a week

● All self-rehabilitation exercises

From 6 months

● Physical activities, carrying loads, DIY, gardening

Frequently Asked Questions

When will I be able to: take a shower, return to work, drive again, etc.?

● Shower: From the following day, subject to the use of waterproof dressings.

● Work: If your work is sedentary, your work stoppage will be at least 3 months, if your work requires physical effort it will be at least 6 months.

● Drive my car: From 1 and a half months.

● Play sports: From 6 months.

● DIY: From 6 months.

● Gardening : From 6 months.

● Housework: From 3 months.

What will happen to the anchor attached to the bone and the wires?

They will always stay in place.

Is it normal to be in pain?

Logically, the surgery does not cause any pain. Moreover, rehabilitation and self-rehabilitation must be carried out at an intensity below the pain threshold.

In case of excessive pain, reluctant to medecine, you will need to review with your physiotherapist and especially with yourself if you have scrupulously followed the instructions. There are usually common reasons for these pains.

Is balneotherapy essential?

No, it's not necessary at all. It is true that if your physiotherapist has a balneotherapy the gain of mobility will be facilitated. Besides, in case of delay in the recovery of amplitudes at the different assessments, we will offer you a balneotherapy treatment alternating with the usual treatment of your physiotherapist.

Can you have a recurrent cuff rupture?

Yes, the failure rate varies from 5% to 30%. The factors of poor prognosis are tobacco consumption, significant tendon retraction, damage to several tendons, and poor-quality muscles.

Nutritional advice

According to Dr D Bligny

Shoulder tendons are living, metabolically active tissues that require adequate nutritional intake to allow them to function properly. In order to allow good healing and restoration of joint function, particular attention must be paid to the quality of the diet. It will notably help to limit inflammatory phenomena and pain.

Thus, poorly adapted rehabilitation can contribute to poor nutrition of the tendons by promoting the destruction of the small channels that allow nutrients to pass into the synovial sheath. In order to allow good healing and restoration of joint function, particular attention must be paid to the quality of the healing process. It will notably help to limit inflammatory phenomena, pain, and to avoid necrosis and stiffness.

Here are some simple recommendations for taking care of your shoulder:

Many inflammation proteins, the eicosanoids, are produced from dietary fat. This is the case of those found mainly in sunflower or corn oils and margarines. Other fats, the omega-3s, on the other hand, have anti-inflammatory and protective effects on cartilage and tendons. This is the case of the majority of fatty acids in rapeseed, walnut, soybean and linseed oils, and the fats provided by walnuts, linseed and fatty fish. Change oil and eat fish. Vegetables should provide the largest share of daily calories vegetables, raw vegetables (cooked and raw tomatoes), tubers, herbs, pulses and legumes, fresh fruit and dried fruit. They provide the minerals and vitamins that are essential for joints (vitamins A, C, Zinc, magnesium, lycopene). They have a powerful antioxidant effect that limits inflammation.

Favour pasta, rice and wholemeal or semi-wholemeal bread: they are richer in fibre, with a lower glycaemic index, and contribute to antioxidant and anti-inflammatory defences.

Eat 2 (and no more than 3) dairy products per day, and favour waters rich in calcium and magnesium.