Rotator Cuff Repair Physiotherapy Department

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Patient Information

Further Information We endeavour to provide an excellent service at all times, but should you have any concerns please, in the first instance, raise these with the Matron, Senior Nurse or Manager on duty. If they cannot resolve your concern, please contact our Patient Advice and Liaison Service (PALS) on 01932 723553 or email [email protected]. If you remain concerned, PALS can also advise upon how to make a formal complaint. Author: Paul Sealey (Clinical Specialist Physiotherapist Version: 2

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Reviewed: March 2016

Department: Physiotherapy

Next Review: March 2018

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What is the Rotator Cuff? The Rotator Cuff is a group of four muscles that come from the shoulder blade and attach onto the ball of the ball and socket joint. It is made up of the Supraspinatus, the Infraspinatus, Subscapularis and Teres Minor. Their primary action is to maintain the position of the ball within the socket throughout movement. They also contribute to individual movements.

What can cause damage to these muscles? Damage caused to the rotator cuff is primarily within the tendon. It is the tendon that connects the body of muscle to the bone, in this case the ball (humeral head). Damage can occur when the tendons are impinged between the ball (humeral head) and the top of the shoulder blade (acromion). This can cause inflammation within the tendons and potentially lead to full or partial tears. It can also irritate a fluid sack called the bursa. This is designed to stop friction between the tendons and the acromion but can become inflamed in an impingement. A full rotator cuff tear can occur following repeated bouts of impingement or from trauma. A full Page 14

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tear will manifest as severe weakness and limitation of movement in the shoulder. What are the surgical options? A full rotator cuff tear will normally be managed with repair surgery. This can be done arthroscopically or as an open surgery which will involve a larger cut. The type of surgery performed may depend on the severity and difficulty of the surgical procedure. There are a variety of anesthetic options available and your anesthetist will discuss these with you. You may also require a local anesthetic injection to help with the post-operative pain and you may be given antibiotics during the operation to prevent the risk of infection. The operation is likely to take approximately 4560 minutes. Will I always be offered surgery? Unfortunately there are occasions when the tear is unable to be repaired. This may not be clear until the surgeon has begun the procedure and is able to ascertain the extent of the damage. In this instance the surgeon is likely to still perform a subacromial decompression by where any additional bone that may be impinging on the tendon or remaining tendons is removed. You will then be referred to physiotherapy in order to utilize fully the remaining muscles around the shoulder. What happens after the surgery? Patients who have undergone the repair for a rotator cuff tear will have an abduction wedge. This is a form of sling that maintains the shoulder in an abducted (out to the side) position and thus enables an optimal position for rotator cuff healing. Depending on the size of the tear will depend on how long this will need to be Page 4

a. Potentially excessive bleeding may occur which requires a post-operative blood transfusion but this is extremely rare. 5. Damage to nerves a. There are several nerves that surround the shoulder and as a result there is a risk to these. Damage to the nerves may present with prolonged weakness and altered sensation in the arm. This may be permanent but usually resolves depending on the severity of the damage. b. It is important to note that post-operative pain, weakness and altered sensation are perfectly normal and are often the effects of the anaesthetic and therefore should resolve in a few days following surgery. When can I return to normal activities? It is important to avoid any stress on the repair and therefore you should avoid any resistance including lifting for three months. Heavy lifting should be avoided for six months. Driving should be avoided for at least six weeks but this is likely to be longer if a substantial tear is repaired and/or it is your gear changing side. It is recommendable to review your car insurance policy prior to starting back driving to ensure you are covered. Your occupation will determine how soon you will be able to return back to work and your Consultant will be able to advise you on this either pre- or post-operatively. Contact sports must be avoided for six months. Page 13

10. Stand with feet slightly apart. Hold a weight in both hands. Bend your elbows and bring them up to shoulder level. Your elbows should point slightly forwards. Repeat

times.

kg

used for. Normally 4-8 weeks. This must be used at all times, except for when exercising, including at night. Therefore patients may find it more comfortable to sleep in an upright position. You will normally spend at least the first night in hospital and will normally see a physiotherapist prior to your discharge to show you the procedure of removing and applying the wedge. For ease and safety it is advised that this should be done with assistance of one other. You must ensure that this is as passive as possible to prevent unwanted stress occurring at the newly repaired tendon. Instructions on how the wedge support should be removed and applied are below:

Possible post-operative complications Following any operative procedure there are potential risks. We aim to reduce these as much as possible through pre-operative screening and assessment and great care taken operatively. Possible complications include: 1. Complications of anaesthesia a. Your anaethetist will be able to advise further 2. Pain a. You will experience pain post-operatively which is normal and is related to the healing process. This should not be confused with ongoing damage. 3. Infection a. This is very rare due to the arthroscopic procedure but can occur at the operation site or in the shoulder. b. If you suspect this to be the case contact your local GP as you may require a course of antibiotics 4. Bleeding Page 12

Removing the wedge Step 1 Remove the strap that goes around the patient’s waist and attaches to the front of the wedge.

Step 2 Undo the wrist and upper arm velcro but DO NOT remove the straps completely from the wedge.

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8.

Lying on your back with your elbows by your side and held at right angles.

Step 3 Holding on to a stick gently move your hands away only.

Bend forwards from the waist and cradle the operated arm. Ensure the good hand is supporting the operated arm from underneath the elbow.

Step 4 Remove the black velcro strap from the front of the wedge and carefully feed the wedge out from under the arm.

Fitting the wedge Step 1 Bend forwards and cradle operated arm.

Repeat _____ times. 3 Months+ The aim is to begin to recover strength ensuring a normalised muscle pattern, particularly of the muscles that connect to your shoulder blade. 9. Stand with your hips and knees slightly bent holding 1-2 kg weights in both hands. Tighten your stomach and lower back muscles to stabilise your lower spine and lift alternately arms up and bring back down. Repeat

times.

Step 2 Position the wedge underneath the patient’s armpit and ensure the wedge is not too far forwards or back. Page 6

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4 weeks+ (depending on the size of the tear) The main aim is to recover range of motion without scapular compensation 6. Stand facing a wall. 'Walk' your fingers up the wall as high as possible. Reverse down in the same way. Repeat

Step 3 Feed the black velcro strap around the neck and through the arms and attach it firmly to the front of the wedge.

times. Step 4

7. Stand and grip one end of a stick with the arm to be exercised. Lift your arm to the side, assist by pushing with the other hand. Repeat

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times.

Carefully support the patient’s operated arm from the elbow and bring it back on the wedge as the patient straightens their back.

Step 5 Attach the upper arm and wrist straps and then reattach waist strap (2 velcro bits go at the front of the wedge first).

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Day 0 to 4-8 weeks (depending on the size of the tear) The main aim of this stage is to prevent shoulder stiffness whilst allowing the tendon to healing.

3. Stand. Bend your elbow and then straighten your elbow.

Abduction wedge to be worn day and night except for exercise time. Exercises: 1.

Repeat Stand or sit.

4. Bend and extend your wrist

Lift your arm forward assisting the movement with your other hand. Do not lift past 90°

Repeat Repeat

times.

times.

times. 5. Wrist and fingers straight.

2. Stand or sit.

Make a fist.

Lift your arm to the side, assisting the movement with your other hand.

Repeat

Repeat

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times.

times.

The following exercises are for guidance and you should liaise with your physiotherapist prior to commencing these exercises.

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