Rotator Cup, Rotor Cuff, Rotary Cuff – we’ve heard it called many things – but just what is your ‘Rotator Cuff’?
Many people with shoulder pain present to a physiotherapist, or doctor, and get diagnosed with a rotator cuff injury. These people can be left confused, because they don’t fully understand what exactly that is, or why it matters. All they know, is their shoulder hurts, and they want it to stop.
The first step to rehab is understanding your injury, and understanding why or how you hurt.
What is a Rotator Cuff?
Is it a muscle? A ligament? A tendon? A bone?
The rotator cuff is a couple of those things. It is a collection of muscles. Four muscles to be exact. Muscles turn into tendons, and tendons attach muscles to bones. Therefore, muscles allow us to move our bones.
The short answer: the rotator cuff is 4 muscles and their associated tendons.
Here’s a picture:
In the picture, the red parts are the muscle bellies, the white parts are the tendons. These 4 muscles start on your shoulder blade (scapula) and attach to your upper arm (humerus). The left part of the picture shows what it would look like from the front (looking through and past your torso/rib cage). On this side of the shoulder blade, we have 1 of the 4 rotator cuff muscles: the subscapularis muscle. The right part of the picture shows what it would look like from the back, with the supraspinatus muscle on the top, and two muscles, the infraspinatus and teres minor, coming from the big body of the shoulder blade.
Individually (and simplified), these muscles do the following movements:
- Supraspinatus: arm abduction (lifting your arm up to the side)
- Infraspinatus and Teres Minor: external rotation (turning your arm outwards)
- Subscapularis: internal rotation (turning your arm inwards)
However, like most things in our body, it’s not that simple. The rotator cuffs’ main job is to keep the humeral head (ball on the end of your upper arm), centred in the glenoid cavity (the shoulder socket) (see below).
As you can see, the glenoid cavity (shoulder socket) is pretty shallow, so the rotator cuff works quite hard in certain positions – for example, when working overhead or when reaching. (The cavity is this shallow to allow our shoulders to be super mobile – and don’t worry, there are other things that help – but that’s a different blog post!).
How do you hurt your rotator cuff?
You can injure your rotator cuff in many ways, but here are some of the more common ways:
- Repetitive use (using your shoulder a lot tires out the rotator cuff and it gets painful)
- Overreaching (or lots of reaching)
- Overhead work (working with your arms above your head, especially for a long time)
- Trauma or falling (like a body-check in hockey, or falling on your arm)
- Combining these things – like repetitive overhead reaching, can be very strenuous on your rotator cuff
A Word on Injury ‘Names’
When you injure a muscle, it’s called a strain (you sprain a ligament). So therefore, a muscle injury to 1 (or more) of your 4 rotator cuff muscles is called a rotator cuff strain. If a strain worsens, or it is a big strain, it can become a partial tear, and progress further to a full tear. A complete tear is when the muscle detaches from the bone.
Note: These things can sound scary, but not all of these require surgery, and it is important to get a proper assessment to determine the appropriate plan of action!
The above names are sometimes used for rotator cuff injuries, but more commonly, people will be told they have rotator cuff tendinitis.
But what is that? It simply means that the tendon(s) of the rotator cuff are inflamed (the ending ‘-itis’ means ‘inflammation’). Remember, the tendon is what attaches the rotator cuff muscle to the bone (see above pictures).
How do I know if I even need rotator cuff surgery?
Typically, to qualify for a surgical rotator cuff repair, the following statements are true:
- You have significant shoulder pain that is greatly limiting your ability to complete your activities of daily living (i.e. get dressed, sleep, work)
- You have imaging results (i.e. an MRI) that show rotator cuff damage (and this damage is ‘fixable’ with surgery)
- You have tried to reduce your pain and improve your function through virtually every other conservative option, including a significant bout of physical therapy
Do I have to do pre-operative physiotherapy?
In short, yes, you should. It helps in the following ways:
- Helps you understand what to expect with surgery and postoperatively (just like this blog post should!)
- Helps strengthen muscles to their maximum potential (not just rotator cuff muscles, but also neck, back, and other arm/shoulder muscles)
- Improves your range of motion to help limit stiffness in all associated joints
- In some cases, physiotherapy eliminates the need for surgery in the first place!
What else should I do before rotator cuff surgery?
- Understand what you’re getting yourself into (read on!)
- QUIT smoking (smoking can increase rotator cuff retear rates by up to 25%!)
- Eat well, and take steps to improve your overall health
- Organize assistance for after surgery (you’ll have trouble bathing, dressing, and cooking with just 1 arm!)
- Assistance may be needed for a couple of months – for example, you will not be allowed to drive for at least 6 weeks post-op.
How is rotator cuff surgery performed?
Every surgeon has their individual preferences, however, most surgeons do arthroscopic rotator cuff repairs.
Arthroscopic means that the surgeon will use a tiny camera called an arthroscope. The arthroscope is inserted into your shoulder via a fairly small incision.
The tools required to fix your rotator cuff are inserted through additional small incisions.
Therefore, you’ll likely only have a few small incisions around your shoulder!
To repair the rotator cuff muscle/tendons, the surgeon will use ‘sutures’ and ‘suture anchors’ (or ‘anchors’ for short).
The sutures and anchors will help to hold tears together or help to attach a torn tendon securely to the bone.
These sutures and anchors are not removed. They are safe to stay in your shoulder for life.
Before we get into the next part of this blog post, it is important to note that everything in this blog post is for information purposes only.
This blog post is not intended to be strict medical advice. As previously mentioned, everyone is an individual, and therefore, individual variances do occur.
It is important to consult your physiotherapist, surgeon, and/or doctor for the most applicable advice for you.
What does the typical rehabilitation process look like?
Commonly, postoperative care looks something like this:
- You will wear a sling for at least 6 weeks. Morning and night. Wear it. It can come off to do physiotherapy exercises as instructed by your physiotherapist. Otherwise, it’s on. Seriously. Wear your sling. You don’t want to undo everything the surgeon just did.
- Under the supervision of a skilled physiotherapist, you will start rehab around weeks 2-4 post-op.
- Passive range of motion exercises for the shoulder (meaning the therapist moves your arm for you) usually start around week 4 post-op.
- You will learn to start moving your arm on your own around week 6 post-op (after the sling comes off!). Again, you will normally have to wait until week 6 post-op to move your arm on your own.
- Strengthening of your rotator cuff muscles must happen slowly, safely, and progressively, under the supervision of a physiotherapist. Usually, this starts (slowly), around weeks 8-10 post-op.
- All additional strengthening (i.e. for overhead work, sports, etc) is introduced only when deemed safe by the surgeon/physiotherapist, and will usually start no earlier than week 12 post-op.
How long does it take to heal after a rotator cuff repair surgery?
In uncomplicated cases,
- Surgical healing of your rotator cuff will take at least 8-12 weeks after surgery.
- Surgical healing does not mean full function. It means the surgical sites and sutures are likely physiologically healed.
- Full function will most likely take at least 9-12 months of rehabilitation. Progressive, safe, and necessary functional strength training exercises will take months to appropriately complete. It is normal for it to take a year for your shoulder to feel “normal”.
That last point carries some weight to it, and for many reasons!
Due to the lengthy recovery associated with a rotator cuff repair surgery, here are some things to consider:
- You may be off work a long time, depending on your job (for example: if you have to lift heavy stuff overhead a lot, that will take time to re-learn!)
- Physiotherapy appointments will be necessary for a long time. Yes, the frequency of appointments will decrease over time, but it will be important to stick with your physiotherapy appointments for months.
- If you have private insurance coverage, that’s great! But keep in mind, depending on how much you have, it is not uncommon to use all of it, and then some.
- If you don’t have private insurance coverage, rehabilitation costs will be expensive.
- Couple this with being off work, and finances can be a significant added stress that many people do not consider!
- Be aware of the financial considerations associated with surgery.
What exercises are safe to do right away after a rotator cuff surgery?
Although you should not move or exercise your shoulder/rotator cuff muscles immediately after surgery (see above), there are a few things you can work on right away. See a physiotherapist and get started on exercises for:
- Your neck (for example: side to side stretches, rotation movements)
- Your shoulder blade (for example: shoulder blade clocks, shoulder squeezes)
- Your elbow (for example: gentle bend and straighten (with your elbow against your side))
- Your wrist and hand (for example: ball squeezes, wrist rotations)
- Your posture
Your physiotherapist can also work on many of these body parts for you.
This should help to reduce any postoperative complications in your other joints, all while decreasing your pain!
How much function and how little pain can I expect at the end of my rehabilitation?
Alas, the loaded question.
Again, everyone is an individual, everyone heals differently, and therefore final pain and function is highly individualized.
Here are some things we consider:
1. Number of anchorsApproximately, anchors and range of motion are inversely related. This means that the more anchors needed to repair the damage, the less range of motion you can expect. If you have 3-4 anchors, it’s common to only get approximately 120 degrees of shoulder elevation by the end of rehab (but it hopefully won’t hurt!). If you have 1 anchor, you should get full range of motion in all planes, and it should be pain-free.
2. How much pain did you have before surgery, and how long did you have that pain?Again, these can be related. If you were in absolute agony for 3 years before surgery, there will be a lot of additional things to consider when trying to reduce pain post-operatively. Pain has biopsychosocial components. See this awesome blog post on pain for more information: Why Is My Pain So Stubborn? If you tore your rotator cuff from a one-off accident, got assessed quickly, started pre-operative physiotherapy, and received surgery fairly quickly, there should be fewer things limiting your overall recovery.
3. What are your goals?If your goal is to lift 50 pounds overhead repetitively, your rehab will probably take longer than if your goal is to get yourself dressed and cook your own meals. Therefore, depending on your goals, your perception of your overall function will also change. That being said, set appropriate, attainable goals with your physiotherapist and work towards these goals!
What are the potential complications associated with rotator cuff surgery?
All steps will be taken to limit complications postoperatively, however, it’s important to understand the possibilities.
- Infection. It’s important to follow the hospital’s instructions on keeping your incisions clean, and free of debris. Change your bandages as instructed, and take good care of your wounds. Keep an eye out for:
- Ill-smelling, discolored discharge coming from your wounds.
- If you’re running a fever, have a significant increase in pain, swelling, or redness around the shoulder.
- Retearing. You may retear your surgically repaired rotator cuff. The rates of retear vary a lot depending on the research paper you read. In short, listen to your surgeon’s restrictions (i.e. wear your sling), follow the rehab protocol, and don’t rush your recovery.