Rotator Cuff Repair Surgery

What is the rotator cuff and what does it do?   

To help explain what the rotator cuff is, it is useful to understand some basics of what your shoulder looks like on the inside (its anatomy).

Most people are aware that their shoulder is a ball and socket joint and interestingly, so is your hip, however, they are actually quite different because their jobs are different. Your hip is primarily built for stability and strength i.e. taking your weight, running, kicking and jumping and as such, the ball is a bit smaller than the socket to allow it to fit in snugly and very securely. As a result of the shape, you get lots of strength and stability from the hip, but not quite as much movement.

picture of woman from behins with her arms up flexing muscles

Your shoulder’s main job is movement and therefore its shape is different to your hip. The ball is actually quite a bit bigger than the socket and the socket itself is quite small and shallow. The best way to think about this is that your shoulder is like a golf ball sitting on a golf tee. The shape of the shoulder means that it can give you lots of movement but it can’t rely solely on the bony shape to make it work properly. As such, the shoulder has some really important soft tissues (muscles, ligaments and tendons etc.) that not only help it do its job but help it stay strong and move properly.

 

You haven’t exactly said what the rotator cuff is though!

You’re right.

The rotator cuff is part of the soft tissues that we’ve mentioned that help the shoulder work properly. They are a group of 4 muscles and their tendons wrap around the top of the ball (of the ball and socket joint). They help to provide movement, strength and stability to the shoulder.

 

How does it become a problem?

Like with most aches and pains in most parts of the body, there are a number of things that make things sore. This could include trauma (a fall or a sports injury), repetitive movements and doing more or less activity than you’re used to.

 

So, why does it cause shoulder pain?

Muscles and tendons are a normal part of your anatomy (including your rotator cuff). A tendon’s main job is to connect muscle to bone so that when your muscle contracts (works), it passes the force (or energy) to the tendon and then to the bone which creates movement.

Tendons are incredibly strong and robust things. This means they are designed to work and sometimes work hard, and they normally do this without any issues. Just like any other body part, they can be trained to work harder if you need them to (i.e. by lifting weights or doing your job) but equally, they can become less efficient at doing their job if you don’t use them.

Tendon irritation can be caused by many things but in a lot of cases, it is normally caused by one of the following three things:

1. Doing more than you are used to

2. Doing something new or different that you are not used to

3. Doing either of the two things above but having a period (sometimes a long time) of doing less before

OK, so what happens to the tendon?

If you think of your tendons as being really good at doing their job (passing the energy from the muscle to bone to create movement), it means they can put up with a lot of work when they need to. If you find yourself doing more than you are used to, doing something you are not used to doing or more importantly, having a period of doing less activity before, then you can push your tendon’s ability to cope. Most of the time you notice very little, maybe a bit of an ache here and there, but sometimes your tendons can react and say “I’m struggling”.

If this happens, you will normally notice some discomfort and may find that moving can be uncomfortable. Think of this as your tendon being an ‘unhappy worker’ and as now struggling to do its normal day job and complaining about the work it has to do. Most of the time the soreness will settle with time, but sometimes it can last a bit longer, maybe into weeks or months.

What are the common symptoms of shoulder pain?

As described above, shoulder pain will generally be felt around the shoulder and/or upper arm region. In a lot of cases, moving the arm can make the pain worse, but equally, it can be sore when resting or after activity. Some people find helping the sore arm move (by using the other arm) seems to feel a little easier.

People with shoulder pain will often feel that they might not be as strong, as lifting weight makes their shoulder sore and the arm gets tired more quickly i.e. you cannot do the things you want to do for as long before your discomfort starts.

Night pain is common with most soft tissue irritations of the shoulder.

Dice with letters on spelling 'Comfort/ Discomfort'.

But I’ve been told that my tendon is torn. Does this all apply to me?

Using the word torn in any walk of life can conjure up scary images of things not being attached or hanging limply and not being able to do their job. Often, when we think of things that are torn we find ourselves thinking of a piece of paper ripped in half, or a rope all frayed and broken, however rotator cuff tears are not like this at all.

Firstly, it’s useful to know that if you’ve been told you have a rotator cuff tear (which normally needs an ultrasound to diagnose it), often they are considered a normal sign of aging. In a large study of people (664), Minagawa (2013) found that 147 people had rotator cuff tears but only 35% had any pain. In other words, two thirds of people who had a rotator cuff tear DID NOT HAVE ANY PAIN!

The rotator cuff’s tendons are actually a bit more like a broad flat blanket, therefore a tear is a bit like having a hole in the blanket. The blanket might look a bit different on a scan, but it can still work and still keep you covered and warm. Having a rotator cuff tear does not mean that surgery is inevitable and that nothing else can help. Rehabilitation can be as effective at helping people with rotator cuff tear as surgery, but with no side effects and at a fraction of the cost (Kukkonen et al. 2014).

Surely if the scan says the tendon is torn, nothing can be done can it?

It would be lovely if things were that simple, wouldn’t it? Unfortunately, the human body is more complicated than that. There are a number of clinical studies (experiments with people with and without shoulder pain) that suggest healthcare professionals should put more emphasis on what patients say and do, rather than what a scan result says. An interesting study in 2003 showed that people can have large rotator cuff tears that end up causing them no problems and don’t get worse over time (Connor, 2003). Another large study found only a weak link between what the shoulder looked like on a scan and how bad it was for the person themselves (Moon, 2014).

What this all means is that you are not simply just a scan result and your shoulder is unlikely to be either. Your shoulder might show some things on a scan that might or might not be linked to your shoulder pain and therefore, your shoulder may well have the potential to get better without having to resort to surgery.

Using the description of a rotator cuff tear as a hole in a blanket, rehabilitation is aimed at treating and improving the blanket, not the hole.

Surely there must be some rotator cuff tears that can’t be helped with physio?

Yes, of course there are. Everyone is different and so are shoulder issues. There are some unfortunate people who have an issue that won’t respond to rehabilitation, but this self-help page has been written to help you understand that a lot of people can help their shoulders and can avoid having surgery. If you are willing to try and help your shoulder, then you are much more likely to see if it has the potential to get better with a bit of time, effort and perseverance.

But will I make my shoulder worse by exercising?

Your shoulder is built for movement; it is strong and robust. Using your shoulder normally (which includes exercise) will not damage your shoulder or make the tear worse. In fact, it has the potential to have the opposite effect and actually help to make it better.

Doing nothing and simply waiting for your surgery is an option, but it worth considering that by doing something (exercising, using your shoulder etc.), you are probably giving it the best chance to improve or at the very least, a better chance of the surgery being more successful.

Close up of some iron chains

OK, I’m willing to try doing something to help but what can I do to help myself?

Firstly, you should know that it is possible to feel better. Sometimes, these issues can be really quite sore and can get in the way of things that you would normally take for granted, making you feel that you’ll never get better. However, most cases of shoulder pain will get better by themselves over time. If it hasn’t settled by itself then physiotherapy can help.

Understanding the issue is often the best place to start. Reading the information above can help you better understand that shoulder pain does not normally mean damage or that it is a dangerous problem, and that it can get better.

Secondly, there are two important things that can help you on your recovery journey:

1. Calm the problem down

2. Build yourself back up again

What does ‘calm the problem down’ mean?

If you think back to the idea that your irritated tendon is an unhappy worker, then if you keep asking your tendon to do the same job, in the same way that it always has, then the tendon will keep being sore. In other words, when something is sore, think of it like your tendons saying “I can’t do that as easily as I used to right now”. Making some changes to the things that are sore may help calm the issue down to then allow you to move on with your recovery. Think of it as putting the tendon on lighter or amended duties whilst it’s sore.

We have written a whole page on ‘calming things down’; you can find it here along with some homework to try to help your shoulder’s recovery: Load Management

 

Can you give some examples of what you mean?

Sure, but remember everyone is different and you will have to do some thinking yourself around how your shoulder is affecting you, and some of the changes you might need to make.

 

Things that are sore

Why is it sore?

Possible solution

 

Dressing

 

Sore tendons will find certain positions uncomfortable

Try putting your sore arm in sleeves first or asking for help if you can

 

Lifting

 

Sore tendons will tire more quickly and will find hard work more challenging

Reduce how much you are lifting, use the other hand, ask for help or lift with a bent shoulder

 

Sleeping

 

Sore tendons can grumble after a day’s work

 

Use pillows behind or under the arm to support it, review what you’re asking your shoulder to do during the day

 

Reaching

 

 

Sore tendons find hard work and certain positions more challenging

 

Try reaching with a bent arm, or the other arm. Move items to an easier-to-reach position.

 

So, should I just rest it and do nothing?

No, this is not what we are trying to say.

Firstly, it is impossible to completely rest your shoulder as you still have everyday tasks to complete like brushing your teeth, making a cup of tea and working etc.

Secondly, completely resting your shoulder may temporarily ease the symptoms, but it will not address the underlying cause. If you simply rest and make no other changes (such as looking at the things that make your shoulder sore and completing the exercises set out below), then you are unlikely to progress as well or as quickly as you might like.

How long will it take to get better?

Shoulders issues can take a long time to settle. It is worth knowing that it can sometimes take a matter of months to ease a shoulder problem, rather than weeks or days.

You are likely to have time where you feel that you are getting nowhere or your progress has just hit a bit of a roadblock, but with most shoulder issues, being patient, persevering with the exercise/advice laid out here on this page and being kind to yourself are key to improving things.

OK, so how long should I work on the ‘calming things down’ side of things that you recommended?

This is a little tricky to be specific about and it is probably best to think about what your shoulder is saying. If you have been really good at adjusting, modifying and looking at the things that make your shoulder sore, then you should notice some changes within a few short weeks.

 

What do I do once it starts to feel a bit better?

Firstly, well done! Often ‘calming it down’ is the hardest part of your recovery.

Now that your shoulder feels somewhat calmer, the temptation might be to start going back to your normal activities in the same way you did before your shoulder issue. Sometimes this can be ok, but equally, sometimes you might find that your shoulder is not quite ready to return to normal just yet and may get irritated again. It might be best to think that your shoulder needs to get fit and strong again in order to get back to doing normal things in normal ways.

As we’ve said before, if you've considered your sore shoulder as an unhappy worker and you’ve adjusted and modified things (putting it on ‘lighter duties’) to help calm it down, now you’ve got to start a gradual or phased return to work (or normal). Jumping in at the deep end and going back to normal might result in your shoulder becoming grumpy and sore again.

As well as the advice above, it is now time to consider ‘building it up’ again.

So, how do I build it up?

It is very important to understand that it might take some time and your shoulder will be more likely to cope better if you do things in a gradual way, as the temptation will be to rush in, especially if it’s less sore than before.

No one is the same just like no shoulder problem is the same as the next, therefore there are no ‘formulas' that will be right for everyone. However, we have provided (below) some exercise ideas that, if followed, can be effective in helping you move forwards with your shoulder complaint.

Before I start, I’d like to know what the exercises are trying to do.

Excellent point; it’s often useful to know what you’re aiming to do before you start.

Firstly, the exercises are aiming to introduce a little bit of work into the tendons around the shoulder (the rest of the blanket if we use the ‘hole in a blanket idea’) by asking the muscles to do some work.

As you move through the exercises (as your shoulder allows), you will notice that the amount of work/effort and the amount of movement increases.

Lastly, one of the most important things about all of these exercises, is they are trying to help you regain some trust in your shoulder. If your shoulder has been sore for some time, it is only normal to be a little cautious when you start to move back into doing things that caused you pain before. This is why the exercises are best done gradually and shouldn’t be rushed too much.

 

What should I expect with these exercises? Will they be painful?

This is a very important question.

If your shoulder has been sore for some time, it would be a bit unrealistic to expect that it will be pain-free when doing these exercises. However, it is important that you don’t do too much to then upset the problem all over again.

A good marker for how hard to work is that you should feel some discomfort (not too much though), but it should settle within 24 hours. If you are still obviously sore the following day, you may have done too much/pushed too hard, therefore next time you do the exercises, reduce the effort a bit.

 

Will this get better with just adjusting the things that are sore, and exercises?

Excitingly, there is considerable scientific research (experiments with people who have/have not got shoulder pain) that suggests that rehabilitation (exercise, lifestyle changes, education etc.) can really help.

Rehabilitation for shoulder pain can be:

• As effective as surgery for soft tissue irritations, even up to 5 years later (Ketola 2013)

• Significantly reduce the need for surgery - up to 80% (Holmgren et al. 2012)

Is there anything I should look out for with my shoulder?

With shoulder pain, most cases are likely to be due to some kind of muscle or bone irritation. However, it is worth being aware of the following symptoms that are considered less common:

  • Redness, swelling and heat around the shoulder/arm, especially with a fever or feeling generally unwell
  • Significant pain that is not helped with pain relief or exercises (with or without a family history of cancer)
  • Ongoing shoulder pain following a trauma
  • Being unable to move the shoulder at all (unless with help from the other arm)
  • Being under 18 years old with shoulder pain with/without a history of trauma
  • A noticeable loss of muscle bulk (size) around the upper arm/ shoulder region
  • Considerable swelling of the whole arm (especially if pressing it leaves a finger mark)
  • Difficulty breathing

If you have any concerns about any of the symptoms listed above, you should speak with your GP or physio.

Apart from these exercises, is there anything else I can be doing to help myself?

Yes there is - here are just a couple of the most important things.

 

Shoulder pain can be challenging to live with sometimes. Pain levels can often be high and shoulder issues will often force you to have to do things differently i.e. work differently, not lift the grandchildren, ask for help etc. Pain of any sort can be worrying and the longer it goes on for, it can take your thoughts to some interesting places. However, as mentioned before, most shoulder problems are not from anything ‘nasty’. It is important to know this as what you think and how you feel about your shoulder can influence the chances of you getting better from it or not (Chester et al, 2018). We have intentionally written this information to give you the right advice and guidance to see your way through to a better place with your shoulder.

Some people will choose to manage their shoulder pain with pain relief, whilst some may choose to avoid medication. Applying something warm or cold to your shoulder may also be useful in helping with some of the pain (do remember to wrap your frozen peas in a towel before applying them to your skin to avoid cold burns/don’t go too hot with your hot water bottle).

General exercise, including strengthening exercise (working against something like a weight, gravity or exercise bands) is considered one of the key treatments for most aches and pains, even if it doesn’t specifically involve your shoulder.

Exercise comes in many shapes and forms and there is no ‘best’ exercise. Often it is best to think of the most effective exercise as the one you enjoy and will actually do. Current recommendations on exercise and how often we should be looking to do it can be found here: Understanding Exercise

Weight loss is recommended as something that is important for the management of most muscle and bone issues. Losing weight is difficult and we understand that.

Often people will think that simply putting more weight through their joints is the reason why they get problems and being closer to their ideal body weight will simply stop their symptoms. Unfortunately, it isn’t that easy. It is worth knowing that fat cells are very active cells and one thing they do is produce chemicals that can affect pain sensitivity (Tashani et al, 2017).

By looking at diet, exercise, sensible goal setting and establishing a good support network, a weight loss journey is more likely to succeed and the benefits to your shoulder are more likely to be influenced by the journey you take to lose weight, rather than being lighter.

If you would like some support to help you with your weight loss journey, please contact our partners at One Life Suffolk or Active Norfolk.

Getting the best out of your diet is important to support your training programme. There are lots of different opinions as to what is best, but generally it is agreed that if you want to build muscle, you should look to increase the protein in your diet. 1.5 grams of protein to every kilogram of your body weight is often suggested as a good starting point. More advice about diet can be found here.

Sleeping well will help your recovery and support your training programme. More advice about sleeping better can be found here: https://sleepcouncil.org.uk/advice-support/

How long should I keep doing these exercises for?

You can continue these exercises for as long as you like. Shoulder problems are notoriously slow at improving, therefore they may take time to respond to your rehabilitation (advice, exercises and lifestyle changes).

 

If I do all of this, will I still need to have surgery?

Realistically, there will be some people who have rotator cuff tears that won’t respond to rehabilitation and will have to then go on to have repair surgery.

Even if you have tried your very best with your rehabilitation and things don't feel as though they have improved, your time, effort and perseverance would have helped make sure all of the other muscles/tendons around your shoulder are in better shape leading into your surgery.

 

I’ve decided I’m going to have the surgery regardless, can I still do these exercises?

Absolutely. Anything is better than nothing and as we’ve said earlier, if you: spend some time looking at the things that make your shoulder sore and adjust them, look at your lifestyle such as good quality sleep and general fitness, and try a few shoulder exercises as well, then you are getting you and your shoulder in a position to get the best out of your surgery.

 

If I go for the surgery, what should I expect?

If you feel that you have explored all of the things outlined on this self-help page for a decent amount of time and that your shoulder is still no better, you can check out the ‘After Your Rotator Cuff Surgery’ page.

Exercise tip

As a general rule, you should aim to complete the exercises (as many or as few as you want to) about 3 to 4 times a week.

Each exercise should be completed between 8-12 times (or repetitions) for 3 to 4 sets. Make sure you have about 1 minute's rest in between each set.

In order to change your muscles, you need to challenge them. In other words, you should really feel the effort with each set of exercises and should really not be able to do more than 12 each time around.

Early phase:

 

Aim to explore these exercises little and often throughout the day:
Exercise 1
Exercise 2
Exercise 3
Exercise 4
Exercise 5
Exercise 6
Exercise 7
Exercise 8
Exercise 9

More advanced phase:

 

Exercises with band:
Exercise 1
Exercise 2
Exercise 3
Exercise 4
Exercise 5
Exercise 6
Exercise 7
Exercise 8
Exercise 9
Exercise 10
Exercise 11
Exercise 12
Exercise 13
Exercise 14
Exercise 15
Exercise 16

Exercises with weights:

Exercise 1
Exercise 2
Exercise 3
Exercise 4
Exercise 5
Exercise 6
Exercise 7
Exercise 8
Exercise 9
Exercise 10
Exercise 11

Bodyweight exercises:

Exercise 1
Exercise 2
Exercise 3
Exercise 4
Exercise 5
Exercise 6
Exercise 7
Exercise 8
Exercise 9
Exercise 10
Exercise 11
Exercise 12
Exercise 13
Exercise 14
Exercise 15
Exercise 16

Download our blank gym programme here.

Need more help? Refer yourself here.

References:

Chester, R., Jerosch-Herold, C., Lewis, J and Shepstone, L. (2018). Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: a multicentre longitudinal cohort study. British Journal of Sports Medicine. 52 (4) http://dx.doi.org/10.1136/bjsports-2016-096084. Accessed 05/05/2021.

Connor, P.M. (2003). Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: a 5-year follow-up study. American Journal of Sports Medicine. 31(5):724-7.

Holgram, T., Bjornsson Hallgren, H., Oberg, B., Adolfsson, L. and Johansson, K., (2012). Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. British Medical Journal. 344:e787. doi: https://doi.org/10.1136/bmj.e787. Accessed 05/05/2021.

Ketola, S., Lehtinen, J., Rousi, T., Nissinen, M., Huhtala, H., Konttinen, Y, T. and Arnala, I. (2013). No evidence of long-term benefits of arthroscopicacromioplasty in the treatment of shoulder impingement syndrome: Five-year results of a randomised controlled trial. Bone and Joint Research. 2(7): 132-9. doi: 10.1302/2046-3758.27.2000163. Accessed 05/05/2021.

Kukkonen, J., Joukaninen, A., Lehtinen, J., Mattila, K, T., Tuominen, E, K, J., Kauko, T and Aarimaa, V. (2014). Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results. The Bone and Joint Journal. 96-B(1):75-81. doi: 10.1302/0301-620X.96B1.32168. Accessed 05/05/2021.
Minagawa H (2013) Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: From mass-screening in one village. Journal of Orthopaedics. Feb 26;10(1):8-12.

Mohamadi, A., Chan, J, J., Claessen, F, M, A, P., Ring, D. and Chen, N,C. (2016). Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis. Clinical Orthoapaedic Related Research. 475(1):232-243. doi: 10.1007/s11999-016-5002-1. Accessed 05/05/2021.
MOON Shoulder Group (2014). The duration of symptoms does not correlate with rotator cuff tear severity or other patient-related features: a cross-sectional study of patients with atraumatic, full-thickness rotator cuff tears. Journal of Shoulder and Elbow Surgery. 23(7):1052-8.

Tashani, O.A., Astita, R., Sharp, D. & Johnson, M.I. (2017). Body mass index and distribution of fat can influence sensory detection and pain sensitivity. European Journal of Pain. 21(7):1186-1196.
doi: 10.1002/ejp.1019 (accessed 16/12/2020).