While prompt surgery is usually recommended for acute cuff tears in generally healthy shoulders, exercises may be helpful in maintaining the flexibility and strength of joints with long-standing cuff tears. In most cases, these exercises can be done in the patient's home with little equipment. Shoulder exercises are best performed gently several times a day on an ongoing basis. The exercises are not dangerous if they are performed gently so that they do not risk enlarging the cuff tear.
Sometimes physical therapists suggest other types of therapy. Patients should learn the possible risks of these approaches as well as their costs and anticipated effectiveness.
When combined with a good rehabilitation effort, rotator cuff surgery allows people to regain much of the lost comfort and function in shoulders with cuff disease. In experienced hands, this procedure can address the restricting scar tissue and roughness that frequently accompany cuff disease. If the quantity and quality of the tissue is good, surgery can help repair the tendon back to the bone from which it has been torn. This is most likely to succeed soon after a cuff tear in otherwise healthy shoulders of non-smokers who have not had multiple cortisone injections.
Rotator cuff surgery can improve the mechanics of the shoulder, but cannot make the joint as good as it was before the cuff tear. In many cases, the tendons and muscles around the shoulder have been weakened from prolonged disuse before the surgery. The tissue may be insufficient for a strong repair. In such cases the mechanics of the shoulder may be improved by carefully smoothing out the cuff area and moving the shoulder immediately after surgery so that new scars are not formed.
If the cuff is repaired, it takes months before the tendon is strongly healed to the bone. During this time, strengthening exercises must be avoided so that healing is not impaired. After the healing, it may take months of gentle exercises before the shoulder achieves maximal improvement.
The effectiveness of the procedure depends on the health and motivation of the patient, the condition of the shoulder, and the expertise of the surgeon. When performed by an experienced surgeon, rotator cuff surgery usually leads to improved shoulder comfort and function. The greatest improvements are in the ability of the patient to sleep, perform activities of daily living, and engage in non-contact recreational activities.
What will happen if a torn rotator cuff is not treated with surgery? Will I lose the use of my arm? Will the tear get larger over time? These are common concerns patients have, and the answers are not always clear. In one study, 40 percent of patients with a rotator cuff tear showed enlargement of the tear over a five-year period; however, 20 percent of those patients had no symptoms. Therefore, less than half of patients with a rotator cuff tear will have tear enlargement, but 80 percent of patients whose tear enlarges will develop symptoms. This data is based on a small group of patients; it is important to realize that once symptoms develop, progression may have already progressed and enlarged.
Non-surgical treatment typically involves:
- Strengthening Exercises
- Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
- Activity modification (avoidance of activities that cause symptoms)
Non-operative management of a rotator cuff tear can provide relief in approximately 50 percent of patients.
These studies show that about half (50 percent) of patients have decreased pain and improved motion, and are satisfied with the outcome of nonsurgical treatment. Surgeons may recommend nonsurgical treatment for patients who are most bothered by pain, rather than weakness, because strength did not tend to improve without surgery. There are a few predictors of poor outcome from nonsurgical treatment:
Long duration of symptoms (more than 6-12 months)
Large tears (more than 3 centimeters)
Nonsurgical treatment has both advantages and disadvantages.
Patient avoids surgery and its inherent risks:
- Permanent stiffness
- Anesthesia complications
Patient has no "down time"
Strength does not improve
Tears may increase in size over time
Patient may need to decrease activity level
Surgical management is indicated for a rotator cuff tear that does not respond to non-operative management and is associated with weakness, loss of function and limited motion. Because there is no evidence of better results in early versus delayed repairs, many surgeons consider a trial of non-operative management to be appropriate. Tears that are associated with profound weakness, are caused by acute trauma, and/or are very large (greater than 3cm) on initial evaluation may also be considered for early operative repair. Operative treatment of a torn rotator is designed to repair the tendon back to the humeral head (ball of joint) from where it is torn. This can be accomplished in a number of ways. Each of the methods available has its own pros and cons; all have the same goal--getting the tendon to heal to the bone. The choice of surgical technique depends upon several factors including the surgeon's experience and familiarity with a particular procedure, the size of the tear, patient anatomy, quality of the tendon tissue and bone, and the patient's needs. Regardless of the repair method used, studies show similar levels of pain relief, strength improvement, and patient satisfaction.
Hope that helps