The rotator cuff is formed from four muscles and tendons that attach your arm to the top of your shoulder blade (acromion). The rotator cuff lies just below your collar bone (see figure 1). It is difficult to feel because it is covered by a large muscle. If the rotator cuff becomes weak or tears, you can get pain and weakness.

Your surgeon has recommended shoulder surgery. However, it is your decision to go ahead with the operation or not. This document will give you information about the benefits and risks to help you make an informed decision.

If you have any questions that this document does not answer, you should ask your surgeon or any member of the healthcare team.

There are usually two types of damage that can happen to the rotator cuff.

• Impingement - The area where the rotator cuff moves is protected by special soft tissue called the bursa. The rotator cuff and the bursa can rub on, or get squeezed by, the collar bone or shoulder blade. Over time this can gradually weaken your shoulder and cause pain when you raise your arm above shoulder height or lie down on the shoulder. Impingement (also called painful arc syndrome or supraspinatus tendonitis) can make it easier to damage or tear a tendon.
• Rotator-cuff tear - This is often caused by a fall or lifting something heavy. You will often feel sudden pain and have weakness in your shoulder straightaway.

If the surgery is successful, you should have less pain and be able to use your shoulder more easily. However, you are unlikely to get back the same strength that you had before you damaged your shoulder.

Most people with impingement or a small tear can get back good function in their shoulder by changing their activities, and with the help of exercises and physiotherapy. It is usually helpful to not hold your arm above shoulder height.

Simple painkillers such as paracetamol and anti-inflammatory painkillers such as ibuprofen can also help.

A steroid and local-anaesthetic injection into your shoulder can sometimes reduce pain for several months but may cause side effects if repeated too often.

All of these measures usually become less effective because impingement tends to get worse over time.

If you have a large tear and your shoulder is weak, it is likely that surgery is your only option to get back some strength in your shoulder.
 

Your surgeon may recommend physiotherapy to help strengthen any muscles in your shoulder that have not been damaged.

Sometimes the symptoms improve with time. However, if you have symptoms for longer than nine to twelve months, the problem is likely to continue.

Impingement increases the risk of you tearing one of the rotator-cuff muscles or tendons. Some tears cannot be repaired by surgery.
 

You may need to have an ultrasound scan or MRI scan of your shoulder to find out the type of damage you have to your rotator cuff. The results of the scan will help your surgeon plan the operation.

Impingement is usually treated by arthroscopy (‘keyhole’ surgery) which involves only making small cuts and using a small telescope to see inside your shoulder. If you have a tear, you may need to have open surgery which involves a larger cut.

Shoulder surgery is usually performed under a general anaesthetic. However, a variety of anaesthetic techniques are possible. Your anaesthetist will discuss the options with you and will recommend the best form of anaesthesia for you.

The operation usually takes between three-quarters of an hour and an hour.

Arthroscopy

If possible, your surgeon will use the keyhole technique, as this is associated with less pain, less scarring and a faster return to normal activities.

Your surgeon will make three or four small cuts at the front and back of your shoulder and on the side of your upper arm.
They will place surgical instruments through the cuts along with a telescope so they can see inside your shoulder and perform the operation.

Your surgeon will use the instruments to remove any thickened tissue, release any tight tissue and to shave off some bone so there is more room for your rotator cuff to move. This procedure is called subacromial decompression.

Your surgeon may also be able to repair any small tears using the keyhole technique.

Open surgery

You will usually need open surgery if there is a large tear to your rotator cuff. Your surgeon will make a single cut on the front of your shoulder. They will repair the rotator cuff using special stitches that anchor into the bone (see figure 2).

At the end of the operation, your surgeon will close any cuts with stitches or clips. 

You should continue your normal medication unless you are told otherwise. Let your surgeon know if you are on warfarin or clopidogrel. Follow your surgeon’s advice about stopping this medication before the operation.

Lifestyle changes

If you smoke, try to stop smoking now. Stopping smoking several weeks or more before an operation may reduce your chances of getting complications and will improve your long-term health.

For help and advice on stopping smoking, go to www.gosmokefree.co.uk.

You have a higher chance of developing complications if you are overweight.

For advice on maintaining a healthy weight, go to www.eatwell.gov.uk.

Exercise

Regular exercise can reduce the risk of heart disease and other medical conditions, improve how your lungs work, boost your immune system, help you to control your weight and improve your mood. Exercise should help to prepare you for the operation, help with your recovery and improve your long-term health.

For information on how exercise can help you, go to www.eidoactive.co.uk.

Before you start exercising, you should ask a member of the healthcare team or your GP for advice.
 

The healthcare team will try to make your operation as safe as possible. However, complications can happen. Some of these can be serious and can even cause death. You should ask your doctor if there is anything you do not understand. Any numbers which relate to risk are from studies of people who have had this operation. Your doctor may be able to tell you if the risk of a complication is higher or lower for you.

The complications fall into three categories.

1. Complications of anaesthesia
2. General complications of any operation
3. Specific complications of this operation

Complications of anaesthesia

Your anaesthetist will be able to discuss with you the possible complications of having an anaesthetic.

General complications of any operation

• Pain, which happens with every operation. The healthcare team will try to reduce your pain. They will give you medication to control the pain and it is important that you take it as you are told so you can move about as advised.
• Bleeding during or after surgery. The risk increases if the wound is left open. If the wound was closed with stitches, bleeding can cause a blood clot (haematoma) which appears as a lump under the wound (risk: 3 in 50).
• Unsightly scarring of the skin. It is common for the shape of the natal cleft to be deliberately changed, to help prevent the problem coming back.
• Blood clots in the legs (deep-vein thrombosis), which can occasionally move through the bloodstream to the lungs (pulmonary embolus), making it difficult for you to breathe. This is rare.

Specific complications of this operation

• Bleeding into the shoulder (risk: 1 in 100). This causes swelling and pain. You may need a further arthroscopy to wash out the shoulder.
• Restricted shoulder movement (frozen shoulder). Treatment for a frozen shoulder may involve physiotherapy, medication and injections.
• Infection in the shoulder. If this happens, you will need antibiotics and sometimes another operation to clean out the shoulder.
• Blood clot (thrombosis) in the axillary vein, which is just under the shoulder joint. If this happens, you will get a swollen arm and will need further treatment.
• Severe pain, stiffness and loss of use of the arm and hand (Complex Regional Pain Syndrome) (risk: 1 in 200). The cause is not known. If this happens, you may need further treatment including painkillers and physiotherapy. It can take months or years to improve.
• Damage to nerves around the shoulder, leading to weakness, numbness or pain in the shoulder or arm (risk: less than 1 in 100). This usually settles on its own but may be permanent.
   

In hospital

After the operation you will be transferred to the recovery area and then to the ward. If you had keyhole surgery, you will need to keep your arm in a sling. If you needed open surgery, you may have a special foam support that keeps the tension away from your shoulder joint. Your surgeon and physiotherapist will tell you how long you need to keep your shoulder supported.

You should be able to go home the same day. However, your doctor may recommend that you stay a little longer. If you do go home the same day, a responsible adult should take you home in a car or taxi, and stay with you for at least 24 hours.

If you are worried about anything, in hospital or at home, ask a member of the healthcare team. They should be able to reassure you or identify and treat any complications.

Returning to normal activities

Any stitches or clips are usually removed about one to two weeks after the operation.

Your physiotherapist may give you exercises and advice to help you to recover from the operation. Follow any instructions carefully to improve the chances of getting strength and movement back in your shoulder.

Your surgeon, physiotherapist and occupational therapist will tell you when you can return to normal activities.

You should avoid contact sports and lifting anything heavy until they have advised you that it is safe. It can take up to a year to get back enough strength in your shoulder to return to normal activities.

Regular exercise should help you to return to normal activities as soon as possible. Before you start exercising, you should ask a member of the healthcare team or your GP for advice.

Do not drive until you are confident about controlling your vehicle and always check with your doctor and insurance company first. If your surgeon repaired a tear in your rotator cuff, you should not drive for at least two months.

The future

8 out of 10 people have a major improvement. However, it does take time for pain to reduce and movement to increase. You are unlikely to get back the same strength that you had before you damaged your shoulder.

The shoulder is a complex joint and often symptoms come back with time. If this happens, you may need another operation.

Sometimes the rotator-cuff can tear again (risk: 1 in 3). This usually happens if the tissues in the shoulder are poor quality and do not heal well.

Rotator-cuff problems can cause pain and weakness in your shoulder. An operation can help to reduce any pain and to get back some strength in your shoulder.

Surgery is usually safe and effective. However, complications can happen. You need to know about them to help you make an informed decision about surgery. Knowing about them will also help to detect and treat any problems early.

• NHS smoking helpline on 0800 169 0 169 and at www.gosmokefree.co.uk
• www.eatwell.gov.uk – for advice on maintaining a healthy weight
• www.eidoactive.co.uk – for information on how exercise can help you
• www.aboutmyhealth.org - for support and information you can trust
• American Academy of Orthopaedic Surgeons at www.aaos.org
• North American Spine Society at www.spine.org
• NHS Direct on 0845 46 47 (0845 606 46 47 - textphone)
• www.eidohealthcare.com

If you have any questions or concerns about your care, please contact the nurse in charge at the hospital.