Your shoulder has numerous muscles and tendons controlling movement and stability of the shoulder. Among these are the tendons of the rotator cuff. The rotator cuff is composed of four tendons that blend together to help stabilize and move the shoulder. The rotator cuff is the collective term for a group of tendons, which includes the supraspinatus, infraspinatus, teres minor, biceps and subscapularis. These tendons pass under a bony-ligamentous arch.
Loss of integrity of any of these tendons is a common cause of shoulder weakness. After an injury, the subscapularis tendon alone can be torn or it can tear along with other tendons around your shoulder such as the biceps tendon and the supraspinatus tendon.
What causes problems with the subscapularis tendon?
Tearing of the subscapularis usually results from trauma. The most common cause is a fall on an outstretched hand or if the arm is suddenly abducted away from the body as a result of a fall.
It is very unusual to get a full thickness degenerative tear of the subscapularis in isolation. One can however, get a small partial tear of the subscapularis tendon with time and age, and this then generally causes pain in your biceps tendon (which runs next to the subscapularis tendon) as it slips out of its groove and starts to rub. This is very similar to the analogy of a rope rubbing and starting to fray.
What are the symptoms?
The most common symptoms which cause a patient to seek medical advice are:
- Pain and weakness
- Difficulty putting your arm behind your back
How is a diagnosis made and what investigations are required?
In determining the diagnosis it is most important to take a thorough history from the patient and also to examine them to assess their range of motion and ability to use and raise their arm.
After this, one or more of the following tests may be ordered – a plain xray, ultrasound or MRI in order to assess the condition of the bones, tendons and ligaments. An MRI scan is the best test to show a subscapularis tear. It will also show if you have an associated problem with your biceps tendon.
How are these problems treated?
In patients who have an acute rupture of their subscapularis after a fall, surgical management is generally indicated to reattach the torn tendon back to the bone and thus restore function to the arm. The decision regarding surgery also depends on the age of the patient and their loss of function.
Generally patients with acute tears have weakness of internal rotation and of pushing their arm into their stomach. Pain down your arm may also be present due to associated problems with the biceps tendon.
The goal of the surgical repair of the subscapularis tendon, is to re-establish the connection between the torn tendon and the bone. If the tendon heals securely and durably to the bone, the force of the muscle can be effectively transmitted to the arm. This subsequently decreases pain and increases the strength of the arm.
How is the operation done?
While the purpose of the surgery is to reattach the torn tendon back to the bone, in some cases it is necessary to firstly introduce an arthroscope to assess the shoulder joint to look for other pathology which may be contributing to the shoulder problem. This is done through two small puncture holes around the shoulder. If other problems are identified at the time of arthroscopy then they often can be corrected at the same time.
Under a general anaesthetic, the arthroscope is firstly introduced into the shoulder joint and all pathology is identified. Any surgery that can be done through the arthroscope is done at that time.
Generally I prefer to repair the subscapularis tendon through a small incision 3 to 4 cm long at the front of the shoulder. This is called a mini open repair and gives excellent exposure of the tendon.
The subscapularis tendon attaches and runs at the front of the shoulder. The subscapularis tear is then repaired by suturing it back to the bone using stitches as shown in the diagram below.
If the biceps is affected, then a biceps tenodesis is also performed at the same time. A biceps tenodesis involves re-anchoring the biceps in a better position to stop it slipping out of its groove or becoming irritated.
The operation to repair the subscapularis and biceps tendons involves coming into hospital for usually one night. After surgery you will be placed in a sling to protect your repair.
As this tendon attaches to the front of your humerus it is important not to move your arm outwards as this would re-tear the repair. It generally takes 3 months for this tendon to heal back to the bone.
What happens after surgery?
Healing of the repaired tendon is slow and the loads applied to the tendon when doing normal activities are large, therefore protection of your repair is required for many months (at least 6 months) after the repair. Even the best surgical repair is too weak to allow the muscle to raise the arm from the side. One must wait for full healing of the tendon before actively lifting their arm unassisted.
Having said that, it is important to reduce the risk of scarring and adhesions within the shoulder and this is done by early passive motion of the arm. This means that the shoulder may be moved using the other arm for support, but the muscles of the repaired shoulder must not be used to lift the arm or rotate it against resistance for fear of disrupting the repair.
These passive, rehabilitating exercises will be taught to you at your first post-operative visit. This is usually one week after your surgery. During this time we encourage you to come out of your sling while at home so that you can begin to gradually and gently use your arm. As soon as you are comfortable, you can begin to do up shirt buttons, cut up your food, write and work on a keyboard i.e. any activities that are at desk or table level. You MUST NOT raise your arm that has been operated on at all or lift anything heavier than the weight of a full coffee cup / can of drink with this arm. Always put your sling on when you go out.
It is important to realize that the tendons that were initially torn and then repaired may be of poor quality. While a satisfactory repair can usually be performed at the time of surgery there is the possibility that the tendon repair may fail and pull apart. This may occur during the rehabilitation period or even later if an excessive load is placed onto the shoulder. If this occurs, there is a possibility that repeat surgery is required.
Complications related to the surgery can occur but are quite rare. A general anaesthetic is used and there are risks related to this. Some of the risks include infection, nerve and blood vessel damage. Occasionally the shoulder may develop some transient stiffness called capsulitis. This usually resolves itself however it delays the time taken till the shoulder recovers.
Despite surgery, it is always difficult to re-establish a shoulder to 100% working condition. Although a repair can be performed, the tendon may not be of perfect quality, causing mild pain and weakness overhead in the long term. The majority of patients are generally happy after undergoing such a procedure. It is important to note that it can take up to six months to achieve the desired result.
If you feel you would like more clarification, please ask me at your consultation.
What happens on the day of the operation?
When the staff at the rooms book you in for surgery, they will advise you of when you must fast (stop eating and drinking) and present at the hospital. These times may change and you will be notified by either the hospital or the rooms a day or two before the surgery of any changes.
At the hospital, you will be seen by your anaesthetist who will ask questions about your health and talk to you about the anaesthetic he/she will give you.
Once in the operating suite, your shoulder may be shaved/ hair clipped and the area “prepped” with betadine and covered with a sterile towel. The anaesthetic nurse will place ECG electrodes (stickers with gel on them) on your chest and a blood pressure cuff on your arm. The anaesthetic is administered through a small needle in the back of the hand/arm. This sends you to sleep quickly.
The operation to repair a rotator cuff tear takes about 60-75 minutes, however you will probably be away from the ward for about two and a half hours as there is usually a short wait before the surgery and then when the operation is over you will be cared for in the recovery room for some time before returning to the ward.
In the recovery room, a nurse will be there at all times. You will have a drip in your arm, an oxygen mask on your face and your arm will be in a sling. You will remain in the recovery room until the staff is satisfied that your condition is stable and your pain is controlled. This is usually about an hour.
What happens when I get back to the ward?
When you return to the ward you will have:
- a drip in your arm
- your arm in a sling
- regular pain relief
The nurses are going to check on you very regularly especially during the next four hours. They will check your pulse, blood pressure, temperature, number of breaths you are taking, and your dressing. They will also ask if you are comfortable.
There are a variety of methods of pain relief in use these days and it will be your anaesthetist who prescribes your analgesia. Regardless of the type of pain relief prescribed, it is wise to have something for pain regularly in order to avoid highs and lows in your pain management.
You will be able to drink and eat as soon as you are awake and alert. The regular checking will continue overnight so please do not be concerned and think there is something wrong.
What happens during the rest of my stay in hospital?
You will be given regular pain relieving tablets (usually Panadeine Forte, Digesic or Tramadol). It is important to have these regularly in order to keep your pain at a tolerable level to enable you to move about and exercise. The codeine in some tablets can make you constipated however it is wiser to avoid or treat the constipation rather than going without the pain relievers. This can be done by drinking at least 8 glasses of water or juice per day (tea and coffee do not count), eating a high-fibre diet including fresh fruit and vegetables each day and walking around rather than confining yourself completely to bed. Mild laxatives are available should you feel you need them.
What can I expect at home?
Deborah, my nurse will call you within a couple of days of coming home. While the main purpose of her call is to check that all is going well, this is also an opportunity to ask any questions and also to confirm your follow-up appointment to have your stitches taken out.
For those patients who come from the country, it may be more convenient to have your stitches removed by your local doctor.
Frequently Asked Questions
You will have pain but this should be relieved by the pain relief medication you are discharged from hospital with. Please let the hospital staff know of any allergies or sensitivities you have to any medication. You will need to take these regularly for the first week and then decrease them as the pain lessens. Patients who have had this surgery describe a similar pattern of pain: it is sore day and night for a few days then the pain settles during the day but is sore again at night until eventually (and this may take up to six weeks) the night pain settles.
In addition to medication, the following tips may help you to get comfortable more quickly:
1. Ice. This may help to numb your shoulder for the first 48 hours though after this is may be of less benefit. Remember to always cover the icepack with a cloth so that it never makes direct contact with your skin.
2. For others heat works well. It is a good idea to assess the effect of heat on your shoulder under the shower – if the warm water is soothing, you know a hot pack will help, but again, remember to cover the hot pack before applying it to your shoulder and / or neck area
3. Come out of your sling. Often straightening your arm out and taking the pressure if the strap off your neck is a great way to ease discomfort.
4. Use your hand, wrist and elbow to do small movements at desk level. The gentle return to normal activities is beneficial in avoiding stiffness which can cause pain.
5. Avoid lying flat in bed at night. Arrange either 3 or 4 pillows into a “boomerang” shape behind you so that when you lie back, your shoulders are off the mattress and well supported by the pillows.
Please advise us at the rooms if your pain is not relieved by taking the tablets regularly or if it suddenly becomes worse or severe.
You should not need to change or remove the dressing that will be on your wound. These dressings are waterproof enabling you to shower and wash without worrying about wetting the wound. You may see some blood beneath the dressing but this will not cause any harm and can remain as is until you are seen about one week after your operation. If this dressing should come off do not worry, just replace it with another waterproof dressing.
We do not recommend soaking in a bath until your wound has healed completely but showering is perfectly fine. Please take your sling off to shower. You may prefer to have some assistance with showering until you become more confident. As you are unable to raise your arm to wash under it, you should bend forward so that your arm gently swings forward enabling you to wash your armpit.
Many patients have told us that they find it difficult to get comfortable. Try setting up a “tri-pillow” or boomerang-shaped arrangement so that your back and shoulders are supported by pillows and also remember to take your pain relievers before going to bed. Note that if you are sleeping a lot during the day it is unlikely that you will be able to have a full night’s sleep.
Your arm is rested in a sling for comfort and to rest it while it heals. If the sling is not comfortable please let the staff know as soon as possible. - The sling will be worn for a period of 6 weeks after the surgery, however if at home, just resting or watching TV, you can come out of the sling so that your arm is resting in a more natural position. - It is OK to straighten your arm out just DO NOT LIFT IT UP BY ITSELF OR LIFT ANYTHING IN THAT HAND WHICH IS HEAVIER THAN THE WEIGHT OF A FULL COFFEE CUP. Doing these things can tear the tendon off the bone again. - It is imperative that you wear the sling on the outside of your clothes when going out of doors so that it is clearly visible to others and to therefore avoid being knocked or bumped. - While wearing a sling, you may find it easier to wear button-up shirts as these can be put on easily with minimal movement of your operated shoulder. - It is recommended when dressing that you place the arm that has been operated on into the sleeve of your clothing first. Thus when undressing, take your un-operated arm out first.
You will see Dr Duckworth when your stitches are removed and then further follow-up will be determined according to your rate of progress. You should expect to see him one week after the surgery, 5 weeks later, 2 months later then 3 months after that.
Driving a motor vehicle is usually not recommended for 6 weeks after the surgery, when the arm is comfortable and the vehicle can be safely controlled in an emergency. Driving with one arm in a sling is NOT recommended. We recommend you check with the RTA regarding the legalities and requirements for driving while your arm is in a sling.
Patients can usually return to office work as soon as they are comfortable. You should be able to perform table/desk level duties after a couple of weeks so long as the elbow is kept at your side. Some employers will not allow a worker to return wearing a sling and therefore in those circumstances you should expect to be off work for 6 weeks. Patients needing to go back to light manual tasks would need to allow an average 4-6 months recovery. They would not be able to lift overhead or do repetitive actions above shoulder level for about 6-12 months.
You cannot return to contact sports until your shoulder has been reassessed 6 months after surgery, and then only if you have excellent strength and coordinated control of your shoulder.
Yes, though a formal physiotherapy programme does not usually commence until you come out of your sling completely 6 weeks post op. For the first 6 weeks, you are the best physiotherapist and at your first visit after surgery, you will be shown some simple exercises to do at home. Even though your arm is to remain in a sling for the next few weeks, you must remove the sling 3 times a day for passive motion exercises. These exercises must be performed passively, which means all the effort is made by the muscles of your un-operated arm. It is important to try to relax while doing these and it is much easier to relax if your pain is under control. The repair that will be made will remain quite weak until your body has time to complete the bonding of tissue to bone. As previously stated this may take as long as 6 months. Using the arm before the healing is complete can cause the repair to fail. On the other hand, immobilising the shoulder for a long period to protect the repair can cause shoulder stiffness. For these reasons careful postoperative rehabilitation is an essential part of your surgery. There are two aspects of the rehabilitation programme; preventing unwanted scar formation and protecting your repair. Protect your repair by being careful that your arm does not participate in lifting, pushing or pulling and that it is not raised away from your body under its own power. Raising the arm even a small amount places tension on your repair and should be avoided. If you have had biceps surgery, you need to protect this repair by performing no resistance elbow flexion for 4 weeks. Your doctor will advise you about this.
The secret to successful subscapularis repair surgery is for you to be patient in order to achieve the desired result. The tendon generally takes 3 months to reattach to the bone and then it takes you another 3 months or longer for you to achieve a functional range of motion and strength. I always tell patients that the result of surgery depends on the patient’s tendon quality not my surgery. If you have a thin and poor quality tendon then the result will not nearly be as good as someone that has a thick and robust tendon that can easily be reattached to its anatomical position. Patients also have to understand that pain can continue over the first 3 months and then it generally settles with time. Be patient as there are no shortcuts in this surgical procedure. It will take 6 to 12 months to get over the procedure and the majority of patients are glad they have had the operation.