A tear of the rotator cuff does not, in itself, call for surgery. Plenty of tears are found by chance in patients whose shoulder does not hurt at all, and I never operate on an image. What I treat is pain that resists, strength that is missing, a shoulder that no longer does its job.
I offer a repair when the pain persists despite several months of medical treatment and well conducted physiotherapy, when the loss of strength gets in the way of everyday life or of your work, and when the imaging shows a tendon that is still repairable.
There are also situations where I suggest operating sooner, without waiting for medical treatment to fail: a recent traumatic tear in an active patient, a tear that grows from one scan to the next, or a subscapularis tear, which repairs badly once it has been left to age.
The factor that really decides is the state of the muscle on the MRI or the CT arthrogram, far more than the size of the tear or the age on your passport. A muscle that has turned to fat will not get its strength back even if the tendon is reattached. That degeneration is not reversible, and it is the real reason not to wait years before seeing a shoulder surgeon.
The repair is done arthroscopically, that is through small incisions of less than a centimetre, through which I pass a camera and the instruments. There is no large scar and the muscles are not opened.
The operation is carried out under general anaesthetic, almost always combined with a nerve block that numbs the shoulder for the first few hours and makes waking up comfortable.
I start by exploring the joint, because arthroscopy shows things imaging does not: the true state of the tendon, the state of the long head of biceps, the quality of the muscle. I then release the retracted tendon so that it can be brought back to its bony footprint without tension, I freshen the bone bed, and I fix the tendon with anchors. The tendon is not stitched to another tendon, it is laid back against the bone, and it has to heal onto that bone.
Depending on what I find, I often add other steps in the same operation: treating the long head of biceps when it is inflamed or dislocated, an acromioplasty when the acromion is attacking the tendon, or treating an associated calcification. These steps do not lengthen the recovery.
You go home the same day or the next morning. You leave with a prescription for painkillers and a written rehabilitation protocol, with exercises dated week by week.
It has to be said plainly: a rotator cuff repair is more painful in the first few days than a shoulder replacement. The tendon has just been put back under tension against the bone, and it protests.
The first three or four days are the hardest, with pain that is often worse at night, well covered first by the nerve block and then by painkillers. Icing regularly and sleeping propped up in a semi seated position genuinely make a difference during that period.
Between the second and the sixth week, the background pain drops clearly. After that, many patients still have end of day soreness and intermittent night waking for two to three months. This is normal and it does not mean the repair has failed.
Pain that increases instead of easing, a fever, redness or any discharge are not normal after surgery, and you should call me straight away.
This is the essential difference with a shoulder replacement. When I implant a prosthesis, I detach no muscle, so there is nothing to protect and no immobilisation at all. When I repair a rotator cuff, a tendon has been laid back against the bone and has to heal onto it. That biological healing takes about three months, and the first weeks are decisive.
During that time, the tendon must not work actively against resistance. You use your arm for simple things, getting dressed, eating, washing, but you do not lift, you do not pull, and you do not push up on it. This is the one moment in the whole journey where patience matters more than willpower.
It is progressive and it follows a written timetable that I hand you when you leave hospital. The self rehabilitation exercises build on one another week after week, around the fourth to the sixth week, then the fifth to the eighth, then the sixth to the tenth, then the seventh to the twelfth week after the operation.
Physiotherapy starts with passive mobilisation, to keep the shoulder supple without stressing the repair. Active movement comes next, and strengthening comes last, once the tendon has healed.
Movement generally comes back before strength. It is common to have a supple shoulder at three months and to keep gaining strength up to a year. The result is therefore judged over time, and I never pass judgement on a rotator cuff repair before six months.
Driving starts again when you can hold the wheel with both hands and manoeuvre without pain or apprehension, which depends a great deal on which side was operated and on your car.
Going back to work depends entirely on the job. A desk job resumes far sooner than heavy work or a trade that means working with your arms above shoulder height. We set that date together in consultation, based on the movements you actually make, and I will support you with occupational health if your role needs adjusting.
As for sport, walking and the exercise bike are possible early on. Swimming, racket sports and weight training come last, once healing is complete and strength has returned.
The risk specific to this surgery is not infection, which is very rare in arthroscopy, but healing. The tendon may not take on the bone, which is what we call a retear or a failure of healing.
Four factors weigh heavily: the size of the tear, the state of the muscle before surgery, age, and smoking. Smoking is the only one you can act on, and that is why I always ask patients to stop before the operation.
One reassuring point: a retear does not mean a functional failure. Many patients whose tendon has not healed perfectly keep a pain free, usable shoulder, because releasing the tendon, treating the biceps and rehabilitation have changed the balance of the shoulder.
The other risks are those of any shoulder surgery: post operative stiffness, more frequent here than after a shoulder replacement, temporary nerve irritation, haematoma. I go through them one by one with you in consultation.
Sometimes the tendon is too retracted or the muscle too degenerated to hope for healing. That is not a dead end. Depending on your age, your functional demands and the state of the joint, we then discuss a non prosthetic treatment, a tendon transfer, or a reverse shoulder replacement, which gives back the ability to lift the arm without needing the tendons.
It is a decision that is taken by two, after looking at the images together and talking about what you expect from your shoulder.
The operation is done arthroscopically and generally takes less than an hour, longer if the tear is extensive or if several procedures are combined. You go home the same day or the next morning.
Not necessarily. A tear does not by itself require surgery: we operate on pain that resists or strength that is missing, not on an image. That said, a torn tendon never reattaches on its own and the muscle degenerates over time, which can close the door on a repair if you wait too long.
The first three or four days are the most painful, then the background pain drops clearly between the second and the sixth week. End of day soreness and intermittent night waking can persist for two to three months without being a cause for concern.
Rehabilitation follows a written timetable over about three months, with exercises added week after week and strengthening later on. Movement often comes back around three months, while strength keeps improving up to a year.
Yes, that is the risk specific to this surgery. It depends on the size of the tear, the state of the muscle before surgery, age and smoking. A retear does not mean failure: many patients keep a pain free, usable shoulder.
It clearly compromises healing. Smoking impoverishes the blood supply to the tendon and reduces the chance that it takes on the bone. It is the only risk factor a patient can act on, and I always ask patients to stop before the operation.
It is not a dead end. Depending on your age, your functional demands and the state of the joint, we discuss a non prosthetic treatment, a tendon transfer or a reverse shoulder replacement, which gives back the ability to lift the arm without needing the tendons.
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