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Principles of Health: Occupational Therapy & Physical Therapy

Rotator Cuff Surgery

by Bonita L. Marks, Jeffrey P. Larson

Specialties and related fields: Orthopedics; Orthopedic surgery; Physical therapy

Definition: a surgical procedure that repairs a torn tendon in the shoulder

KEY TERMS

acromion: the outward end of the spine of the scapula or shoulder blade

arthroscopy: minimally invasive surgical procedure on a joint in which an examination and sometimes treatment of damage is performed using an arthroscope, an endoscope that is inserted into the joint through a small incision

deltoid muscle: the muscle forming the rounded contour of the human shoulder

humeral: relating to the humerus bone, the bone of the upper arm or forelimb, forming joints at the shoulder and the elbow

rotator cuff: a capsule with fused tendons that supports the arm at the shoulder joint and is often subject to athletic injury

shoulder impingement: a common cause of shoulder pain, often caused by the repeated activity of the shoulder; also called “swimmer’s shoulder”

tendonitis: inflammation of a tendon, often caused by overuse

INDICATIONS AND PROCEDURES

The shoulder, a ball and socket joint, is the most flexible joint in the human body. Because of its structure, a wide range of motion is permitted. The shoulder’s structure predisposes it to a high risk of injury. The shoulder is stabilized by four muscles, collectively known as the “rotator cuff”: the subscapularis, the supraspinatus, the infraspinatus, and the teres minor.

The signs and symptoms of rotator cuff injuries are the same for men and women, including point tenderness around the region of the humeral head deep within the deltoid muscle, pain, and stiffness within the shoulder region within a day of participating in activities that involve shoulder movements, and difficulty in producing overhead motions involving the upper arm. Pain often occurs at night due to sleeping positions that put excess pressure on the joint. Occasionally, a clicking noise can be heard from the joint upon movement, or the patient may experience a “sticking point” when shoulder movements are attempted. Injuries to the rotator cuff can mimic other common shoulder region problems, including bursitis (inflammation of a bursa, a soft, fluid-filled sac that helps cushion surfaces that glide over one another) and tendonitis (inflammation of a tendon). Injuries to the rotator cuff include impingement and tears.

Impingement occurs when the rotator cuff tendons are pinched because the space between the acromion (shoulder blade) process and the rotator cuff narrows. This narrowing commonly occurs with aging but can also be traumatically induced. Sports commonly stress the rotator cuff, including baseball, swimming, and tennis. Besides a traumatic injury, chronic impingement of the rotator cuff tendons can cause partial or complete tears. To evaluate the extent of shoulder dysfunction, the physician will conduct a physical examination to determine the range of motion and use diagnostic procedures such as X-rays, an arthrogram (an X-ray after a tracer dye has been injected into the shoulder), magnetic resonance imaging (MRI), and ultrasound. Nonsurgical interventions include rest, ice immediately following an injury or heat twenty-four hours afterward, painkillers, anti-inflammatory medications, and physical therapy.

Rotator cuff surgery is usually recommended when there is little improvement in shoulder function or pain reduction after noninvasive therapies. Surgery to correct rotator cuff tears is more successful if the procedure is performed within three months of injury. If the shoulder is surgically treated later, there is a complication of the torn tendons retracting from each other, increasing the difficulty of the surgery and decreasing the chances of a satisfactory outcome. Surgery can be a classic open procedure, requiring a 2- to 3-inch incision in the shoulder, or less traumatic arthroscopy, which requires only a small incision, half an inch or less, just large enough to accommodate the instruments and a video camera apparatus. Occasionally, the surgeon will use a combination of the open procedure and arthroscopy. Either general anesthesia, in which the patient is asleep, or local anesthesia, in which the region is “frozen” but the patient is awake, can be used for the procedure. Often a scalene block is also used, removing all extremity sensation that eventually returns shortly after surgery. A light sedative may also be used with local anesthesia to put the patient at ease but not asleep. Acromioplasty reduces the impingement of the rotator cuff tendons. In this procedure, a portion of the bone underneath the acromion is shaved to give the tendons more room to move and prevent them from becoming pinched. This process is often included in rotator cuff surgical repairs. The torn tendons are reattached to the humerus (upper arm bone) in rotator cuff repairs. The open surgical procedure requires a relatively large incision through the shoulder and cutting through the deltoid muscle. Any formed scar tissue is removed, and a small ridge is cut into the top of the humerus. Small holes are drilled into the bone, and the tendons are sutured to the bone using these holes as anchors. The surgeon will also correct any other problems, such as removing bone spurs, shaving down the acromion, or freeing up ligaments pressing against the tendons.

The orthopedic surgeon can perform most of these additional procedures during arthroscopic surgery. A thin tube is inserted after the small incision is made into the shoulder. This tube contains surgical instruments and a video camera to guide the repair procedure. Arthroscopic surgery is becoming more common and is preferred for small to larger tears, as it limits the amount of surgical intervention, reduces surgical risks, and quickens recovery time. If more extensive damage is discovered, the surgeon may combine the arthroscopic procedure with open surgery. However, arthroscopic tear repair has advanced tremendously, to the point that tears previously thought to be irreparable or too extensive are now being completed with arthroscopy.

IMPACT ON WOMEN

Currently, the literature provides limited consistent information on the impact of patients’ gender on recovery after rotator cuff repair. One study investigated whether gender affects pain and functional recovery after rotator cuff repair in the early postoperative period. Eighty patients (forty men and forty women) were prospectively enrolled in the study. Pain intensity and functional recovery were evaluated using a visual analog scale (VAS) pain score and range of motion on the first five postoperative days at two and six weeks and three, six, and twelve months after surgery. Perioperative medication-related adverse effects and postoperative complications were also assessed.

Results showed the mean VAS pain score was significantly higher for women than men two weeks after surgery (p = 0.035). There was no significant difference between men and women in VAS pain scores for all other periods. However, women had higher scores than men. Mean forward flexion in women was significantly lower than in men six weeks after surgery (p = 0.033). The mean degree of external rotation in women was significantly lower than in men at six weeks (p = 0.007) and three months (p = 0.017) after surgery. There was no significant difference in medication-related adverse effects or postoperative complications.

The authors of this study concluded women had more pain and slower recovery of shoulder motion than men during the first three months after rotator cuff repair. The findings can serve as pain management and rehabilitation guidelines after surgery and help explain postoperative recovery patterns to patients with scheduled rotator cuff repair.

In another study, researchers wanted to determine the differences in disability between men and women and examine the relationship between factors that represent sex (biological factors) and gender (nonbiological factors) with disability and satisfaction with surgical outcomes six months after rotator cuff surgery.

Patients with impingement syndrome or rotator cuff tear who underwent rotator cuff surgery completed several standard assessment forms, such as the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), which measures status before surgery and six months postoperatively. They also rated their satisfaction with surgery at their follow-up appointment. One hundred and seventy patients (eighty-five men and eighty-five women) entered the study. One hundred and sixty patients (94 percent) completed the six-month assessment. Women reported more disability both before and after surgery. Disability at six months was associated with a pain-limited range of motion, participation limitation, age, and strength. Satisfaction with surgery was associated with the level of reported disability, expectations for improved pain, pain-limited range of motion, and strength.

The researchers concluded that this study indicated women with rotator cuff pathology suffer from higher levels of pre- and postoperative disability, and sex and gender qualities contribute to these differences. Similar studies in the future regarding differences between men and women before and postoperative rotator cuff repair will help promote more effective and tailored care by health professionals.

USES AND COMPLICATIONS

The varying outcomes from rotator cuff surgery range from almost full recovery to no improvement. The degree of recovery depends upon the extent of damage to the rotator cuff and patient compliance with physical therapy after surgery. If the tendon has been torn for a long time, it may not be reparable.

As with all surgical procedures, the patient may react adversely to the anesthesia. This risk is greater if the person is obese or has a cardiovascular, pulmonary, or metabolic condition. Surgical incisions always have the risk of infection. Still, this risk is minimized with the arthroscopic procedure because of the small incision size and the relatively short operative time (one to two hours). In rare instances, there is also the risk of nerve damage resulting in partial paralysis or temporary numbness at the incision area.

After surgery, the recovering arm will be put in a sling with a small shock-absorbing pillow behind the elbow. The patient should take extreme care with shoulder movements in the first three months following surgery. Reaching and lifting objects above the head should be avoided during this period. Passive range of motion exercises, in which the physical therapist moves the arm, should be started as soon as possible to prevent scar tissue formation and resultant stiffness. Exercises should be done several times a day so that within two to three weeks, the range of motion (flexibility) of the repaired shoulder should be equivalent to that of the uninjured shoulder. After six weeks, more advanced exercises are recommended to strengthen the rotator cuff and the surrounding shoulder muscles. Full recovery and rehabilitation from rotator cuff surgery can take up to a year.

SIGNIFICANCE

Following rotator cuff surgery, occupational therapy plays a crucial role in rehabilitation to help patients regain strength, mobility, and function in the affected shoulder. Here’s how occupational therapy can be beneficial after rotator cuff surgery:

  • Pain management: Occupational therapists can employ various techniques to manage postoperative pain, such as applying cold therapy, providing gentle massage, or using electrical stimulation. They can also educate patients on pain-relieving strategies, including positioning techniques and assistive devices.

  • Range of motion exercises: Occupational therapists will guide patients through gentle range of motion exercises to gradually improve shoulder mobility. These exercises aim to maintain flexibility, prevent stiffness, and promote healing in the surgical area. Therapists may use manual techniques, passive or active-assisted movements, and therapeutic modalities to restore range of motion.

  • Strengthening exercises: As the healing progresses, occupational therapists will introduce strengthening exercises to rebuild the muscles around the shoulder joint. These exercises will target the rotator cuff and the surrounding shoulder and upper body muscles. Therapists will monitor the intensity and progression of the exercises to ensure proper healing and prevent reinjury.

  • Scar management: Occupational therapists can provide guidance on scar management techniques, including gentle massage, application of scar creams or gels, and the use of silicone sheets or pads. These interventions aim to minimize scar tissue formation, improve scar appearance, and prevent adhesions that can limit mobility.

  • Functional training: Occupational therapists focus on improving functional abilities and facilitating a safe return to daily activities. They will assess tasks and activities that may be challenging for the patient, such as reaching, lifting, or dressing, and develop customized treatment plans to address these functional limitations. They may introduce adaptive techniques, modify equipment, and provide strategies for proper body mechanics and joint protection.

  • Home exercise program: Occupational therapists will design a personalized home exercise program for patients to continue their rehabilitation outside therapy sessions. This program will include a range of motion exercises, strengthening exercises, and functional activities. Compliance with the home exercise program is crucial for achieving optimal outcomes and maintaining progress between therapy sessions.

Occupational therapy aims to facilitate recovery, enhance functional independence, and promote a successful return to daily activities and work. The duration and intensity of occupational therapy sessions may vary depending on individual factors, such as the extent of the injury, surgical technique, and overall progress. Regular communication and collaboration between the surgeon, occupational therapist, and patient are essential to ensure an effective and coordinated rehabilitation process.

Further Reading

1 

Bracciano, Alfred. Physical Agent Modalities: Theory and Application for the Occupational Therapist. 3rd ed., Slack Incorporated, 2022.

2 

Codsi, Michael, and Chris R. Howe. “Shoulder Conditions: Diagnosis and Treatment Guideline.” Physical Medicine and Rehabilitation Clinics of North America, vol. 26, no. 3, 2015, pp. 467-89, doi:10.1016/j.pmr.2015.04.007.

3 

Pfeiffer, Ronald P., and Brent C. Mangus. Concepts of Athletic Training. 6th ed., Jones and Bartlett, 2012.

4 

“Rotator Cuff Repair.” MedlinePlus, n.d., www.nlm.nih.gov/medlineplus/ency/article/007207.htm.

5 

“Rotator Cuff Tears.” American Academy of Orthopedic Surgeons, June 2022, orthoinfo.aaos.org/topic.cfm? topic=A00064.

6 

“Rotator Cuff Tears.” Cleveland Clinic, 28 Jan. 2021, my.clevelandclinic.org/health/diseases/8291-rotator-cuff-tears-overview.

7 

“Shoulder Joint Replacement.” OrthoInfo, Sept. 2021, orthoinfo.aaos.org/en/treatment/shoulder-joint-replacement.

8 

Simons, Stephen M., and Michael Roberts. “Patient Education: Rotator Cuff Tendinitis and Tear (Beyond the Basics).” UpToDate, May 2022, www.uptodate.com/contents/rotator-cuff-tendinitis-and-tear-beyond-the-basics.

Citation Types

Type
Format
MLA 9th
Marks, Bonita L., and Jeffrey P. Larson. "Rotator Cuff Surgery." Principles of Health: Occupational Therapy & Physical Therapy, edited by Michael A. Buratovich, Salem Press, 2023. Salem Online, online.salempress.com/articleDetails.do?articleName=POHTherapy_0166.
APA 7th
Marks, B. L., & Larson, J. P. (2023). Rotator Cuff Surgery. In M. A. Buratovich (Ed.), Principles of Health: Occupational Therapy & Physical Therapy. Salem Press. online.salempress.com.
CMOS 17th
Marks, Bonita L. and Larson, Jeffrey P. "Rotator Cuff Surgery." Edited by Michael A. Buratovich. Principles of Health: Occupational Therapy & Physical Therapy. Hackensack: Salem Press, 2023. Accessed December 14, 2025. online.salempress.com.