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.
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.
The most common symptoms which cause a patient to seek medical advice are:
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.
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.
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.
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.
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.
When you return to the ward you will have:
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.
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.
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.