Physiotherapy in Toronto for Shoulder Conditions

What To Do When Your Rotator Cuff Surgery Fails

Rotator cuff tears are a common cause of shoulder pain, stiffness, weakness, and loss of motion and function. Treatment starts with conservative (nonoperative) care in physiotherapy and/or with steroid injections. But in some cases, conservative care fails to reduce the painful symptoms or restore normal motion. That's when surgery may be needed.

The rotator cuff is a group of four muscles with their tendons that surround the shoulder joint giving it both strength and stability. Without an intact rotator cuff, the shoulder can dislocate or may be so weak the person can no longer lift the arm up overhead or reach out to the side. Surgery to repair the damage is usually successful.

But what happens if conservative care fails and surgery fails? What are your options then? Dr. Ryan T. Bicknell, an orthopedic surgeon from Queen's University in Ontario, Canada presents seven different treatment approaches for the failed rotator cuff repair. These patients continue to have pain, stiffness, weakness, and loss of function despite having surgery to repair the damaged tendons.

Just as before, conservative care is the first line of treatment. It is still possible that a program of strengthening exercises combined with postural changes can bring about the changes patients are looking for. But if a three-month trial of physiotherapy and home program doesn't solve the problem, then the patient is probably looking at a second surgery.

The surgeon will evaluate each patient in order to determine the most appropriate next step. It could be something as simple as a re-repair. The surgeon goes back in and resutures the torn tendon, stitiching the tear closed. This option isn't usually possible because of poor tendon integrity, too many torn tendons, or too much fat replacing collagen (tendon) tissue.

Sometimes it's just a matter of going in and cleaning up frayed edges of tendon. This procedure is called debridement. At the same time, the surgeon may address lesions of the long head of the biceps tendon. Damage to the biceps (muscle that bends the elbow) is often associated with massive rotator cuff tears and may be responsible for chronic shoulder pain and dysfunction. The surgical procedure for biceps repair is called a biceps tenotomy or tenodesis.

The real key to determining what to do next depends on what is causing the persistent shoulder pain and symptoms. For example, without a normal healthy rotator cuff doing its job, the head of the humerus starts to move up putting pressure on the suprascapular nerve. Relieving tension on the nerve may reduce painful symptoms.

Some patients have massive tears that just can't be repaired. In such cases, the age of the patient may dictate the treatment. In younger patients, the surgeon can take another tendon nearby and transfer it to do the work of the torn rotator cuff. In older adults, a hemiarthroplasty or reverse shoulder arthroplasty are better choices.

Both of these procedures are a type of shoulder replacement. The hemiarthroplasty just replaces one side of the shoulder (usually the round head and attached neck of the humerus, the upper arm bone).

A reverse shoulder arthroplasty is a total shoulder joint replacement with a twist. Instead of the round head at the top of the humerus, the surgeon inserts a socket-shaped implant. The round portion fits where the natural socket used to be. This type of replacement surgery works well when the rotator cuff is so severely damaged it no longer functions to stabilize the joint.

Results using these different approaches to the failed rotator cuff surgery are varied. Reports from studies indicate problems with continued pain, inability to raise the arm, and disapointed or dissatisfied patients. Overall, the results are better than without surgery but they aren't close enough to "normal" to satisfy the customer. The type of motion that is lost (lifting the arm overhead and externally rotating the shoulder) results in significant problems with function.

The author concludes that in treating massive rotator cuff tears, all efforts should be made to attain good results with conservative care first and then rotator cuff repair. If the first surgery fails to do the job, a second procedure may be needed. Revision surgeries are often less than successful with high rates of complications. Patients should be warned of possible problems and prepared for the fact that the surgery may not be as successful as they would like.

Reference: Ryan T. Bicknell, MD, MSc, FRCSC. Failed Rotator Cuff Surgery: What Can We Do? In Current Orthopaedic Practice. September/October 2010. Vol. 21. No. 5. Pp. 448-452.