Observations on Post-op Rotator Cuff Repair
Rotator cuff tears hurt. They limit your overhead activities, weaken your strength, and wake you up from sleep. The repair is worse, at least for a while. Here are my observations from years of patient care and personal experience.
The rotator cuff is made up of four tendons that coalesce as a cuff on top of the humerus (upper arm bone). They elevate, rotate, and guide the arm through a complex range of motions. When working together they permit a baseball pitcher to hurl a 100 mph fastball—without throwing his arm to the batter along with the ball.
When the rotator cuff is torn, however, nothing works properly. Fortunately, outpatient arthroscopic repair techniques have evolved to make rotator cuff repair extremely common—though not as foolproof as one might expect. The failure rate of cuff repairs is approximately 30% and over 40% when all four tendons are torn. Part of the failure rate is because tearing the tissue in the first place requires either extreme force or blood supply limitations that have led to tendon degeneration in the tissue.
In either case, repair involves heavy sutures laced across the tendon, sealing it to the top of a bloodied, surgeon-prepared humerus. Seventy percent of the time this works well, returning the athlete to full sports. But after a year—when the squashed tendons fail to heal, the bone gives way, or the sutures fail—the rotator cuff repair often frustrates the best intentions of both surgeon and patient. This tissue compromise is likely to be (at least partially) solved by the introduction of growth factors at the time of surgery; these induce new vessel and cell migration into the repaired tissue. Repair success rates will go up as tissue healing is accelerated.
Another glaring problem is the post-operative rehabilitation. The cuff, once sewn to the bone, requires at least six weeks healing to allow unrestricted motion and three months to gain meaningful strength.
As far as strategy goes, the shoulder surgeon community is torn. Some believe that patients should be locked up in an abduction sling for six weeks without physical therapy, active arm motion, or strengthening. Others are committed to early motion of the repaired shoulder and hands-on therapy. Since the failure rate of cuff surgery is so high, the conservative, “lock ‘em up” surgeons blame the therapists and early motion advocates for ruining their results. The early motion advocates, on the other hand, say that the days of locking up joints and hoping for normal healing ended in the 1980s—when ACL surgeons promoted accelerated rehabilitation and saw improved results. The fundamental problem is this: While the biology of healing always favors early motion for improved blood supply and collagen formation, the near strangulation the rotator cuff with the heavy sutures and bands attaching it to the bone inhibit the blood supply to the point where early motion may add more risk than reward.
Locking your shoulder up in an abduction splint, without physical therapy, is a nightmare. The affected arm hangs in the sling, pulling the neck to the injured side. This shortens the neck and shoulder muscles, leading to stiffness and more pain. The elbow stiffens and the hand swells. Dangling it a few times a day does little to improve the situation. The abduction splint (which you are told to wear 24/7) slides around on the body, making it necessary to adjust it throughout the day and night. Icing with ice packs feels good—but the packs last only a few minutes and fall off the body as soon as you stand up. Sleeping through the night is a dream that patients can only hope will come true, someday soon. Rolling over onto the operated arm, either consciously or subconsciously, wakes you up. Many suggest sleeping in a Lay-Z-Boy recliner—but try turning on your side in one. Want to sleep in an airplane seat every night for six weeks? One solution may be to rent a hospital bed, in which the sleeping position can be optimized during first couple of months of healing.
The pain drugs are also problematic. Narcotics make you nauseated and constipated. Sleeping pills make you groggy the next day and do not overcome the rolling-over pain. The anti-inflammatories irritate the stomach—and the data says they interfere with collagen healing. Tylenol (acetaminophen) works the best, but you can only take so much before risking liver failure. Injections of hyaluronic acid, combined with PRP and growth factors, are potent anti-inflammatories without the downside of cortisone. It may be that sequential injections during the first couple of months will both reduce the agony and accelerate healing.
The solutions to these issues are obvious, but not so easy. Icing with compression pump machines (such as Game Ready) is better than using ice packs alone but the attachments need to be improved to stay in place. The abduction sling needs to be more like a backpack, so that the neck and torso are not as twisted—but the straps must be designed so that they do not lean on either the surgical wounds or the abduction pad. Moreover, you cannot sleep with a backpack on.
Massage and physical therapy can be started immediately to relax the muscles, address the swelling, and passively move the arm—but the therapists must be expertly trained so as not to stress the rotator cuff repair. This relies on a close collaboration between the surgeon, therapist, and patient. Real-time imaging is required, to show exactly which positions and motions negatively affect any given type of cuff repair. If you can get yourself to a therapist, the relief of pain and stiffness afforded by hands-on soft tissue and massage therapy in the first week following surgery is a godsend.
What else? Exercise programs that focus on core strengthening, posture, balance, and lower extremity muscle building, while protecting the arm, should start as soon as possible. Exercise recruits natural testosterone and helps build an athletic, positive mindset. The stationary Peloton bike is a go-to cardiovascular exercise, while the best floor exercises are abdominal crunches on an exercise ball. Try this while listening to a 15-minute meditation, a 15-minute coaching app, or rocking music.
The journey from tearing your rotator cuff to surgery and through rehabilitation is tough. It takes an entire team to help you travel this road successfully. Pull the team together and you will be forever grateful.