Rotator Cuff Repair

What the rotator cuff is

Four muscles wrap your shoulder blade and their tendons blend into a single sleeve — a cuff — over the top of your arm bone. Their job is not mainly to lift. It is to hold the ball centered in its shallow socket so the big deltoid muscle can lift without the joint sliding around.

The tendon on top, the supraspinatus, sits in a tight space between two bones and takes the most wear. It is the one that tears most often.

What a tear is, and why it does not heal itself

A rotator cuff tear is a tendon pulled off its attachment to the bone. Not a strain, not inflammation — detached.

Tendon does not reattach itself to bone. There is nothing holding the torn edge against the surface it needs to heal to, and the muscle pulls it steadily further away. Over years, a tear that started small gets bigger, the muscle shortens, and eventually it becomes unrepairable — at which point the options change entirely, usually to a reverse shoulder replacement.

Tears come two ways. Some are an injury — a fall, catching yourself, hauling something you should not have. Many more are wear: the tendon frays over years and finally gives out doing something ordinary. Plenty of people over 60 have a tear on imaging and no symptoms at all, which is why the scan never decides this by itself.

How you know it is the cuff

• Pain on the outside of the upper arm, often down to the middle of the arm — not usually deep in the joint.
• Night pain. This is the one that finally brings people in. Lying on that side becomes impossible.
• Weakness reaching overhead or out to the side, especially lifting something with a straight arm.
• Trouble with specific motions — a seatbelt, a back pocket, a shelf.

Who needs surgery — and who does not

Not every tear needs repairing. Many people do very well with therapy alone, because the other cuff muscles and the shoulder blade can be trained to compensate. I lean toward repair when:

• The tear came from an injury in an otherwise healthy shoulder, particularly in someone younger. These do best repaired, and sooner rather than later.
• Real weakness is limiting work or daily life — not just pain.
• Months of good therapy have not settled things.
• The tear is likely to get worse and the tissue is still healthy enough to hold stitches.

I lean away from repair when the tear is old and retracted, the muscle has already thinned and turned to fat on the scan, or the shoulder is arthritic on top of it. Repairing a tendon that cannot heal buys pain and a sling and nothing else. In those shoulders a different operation is the honest answer.

How the operation goes

1. Anesthesia. A nerve block in the side of the neck numbs the whole arm, plus a general anesthetic so you are asleep.
2. Arthroscopy. A camera goes in through a small puncture, and instruments through two or three more. No large incision.
3. Look at everything. I inspect the whole joint first — the biceps tendon, the labrum, the cartilage — because the tear is often not the only thing going on.
4. Prepare the footprint. The patch of bone the tendon tore off is cleaned back to a surface that will heal.
5. Set the anchors. Small anchors loaded with heavy suture go into the bone.
6. Pull the tendon down and tie it. The stitches draw the torn edge back onto its footprint and hold it there under compression — the position it needs to grow back on.
7. Make room if needed. Often I shave a little bone off the underside of the arch above, so the repaired tendon is not rubbing on it.

Recovery: why I start motion early

The old way was to lock the shoulder in a sling for six weeks so the repair could heal undisturbed. The trouble is that a shoulder held still for six weeks gets stiff, and stiffness after a cuff repair is its own miserable problem to solve.

I use an early motion pathway instead. The rule is simple: move, but never into pain, and never against resistance. Gentle early motion keeps the shoulder supple without pulling on the repair.

• Days 0–7Sling on. Once the block has worn off and you are comfortable, you may come out of it — adjust to your pain, not to a calendar. Start gentle motion when comfortable, going nowhere near pain. Pendulums (let the arm hang and sway). Ice often. Nothing heavier than a pencil.
• Weeks 1–4The sling is no longer required — use it if it is comfortable. Keep up the gentle motion and the pendulums. Therapy starts one to two weeks after surgery. Follow-up visit around two weeks. Aspirin 81 mg twice daily for two weeks.
• Weeks 4–6No sling. The goal is full motion with the therapist doing the moving for you — stretching, pulleys, gentle end-range work. You are still not lifting.
• Weeks 6–12Now you move it yourself, actively. Around weeks 9 to 11, light resistance begins — bands, small weights, work for the muscles around the shoulder blade.
• Weeks 14–16Real strengthening. Light sport-specific work if you are doing well — chipping and putting before a full swing.
• ~Week 20Maintenance strengthening, and back to activities as tolerated.

Two honest notes about that timeline. First, it is guided by comfort, not the calendar — a large repair or poor tissue means I hold you back longer, and I will tell you if that is you. Second, five months sounds long, and it is; but the tendon needs roughly three of those months just to attach to bone, no matter how motivated you are.

The risks, honestly

• The repair does not heal (retear) This is the real risk of this operation, and it depends almost entirely on the tear. Small and medium tears in healthy tissue usually heal. Large and massive tears in older, thinner tendon fail to fully heal a substantial share of the time — in some studies a third or more. Here is the part people find surprising: even shoulders whose repair does not fully heal are often much better than they were, because the pain settles and the mechanics improve. It is still not what we are aiming for.
• Stiffness The reason we start moving early. Some shoulders get tight anyway, and occasionally that needs extra therapy or a procedure to release it.
• Infection Uncommon after arthroscopic surgery — the punctures are small.
• Nerve irritation from the block Numbness or a weak patch for days to weeks happens and nearly always settles. A lasting injury is rare.
• Ongoing pain Some shoulders ache even after a repair that healed well, particularly if there is arthritis or biceps trouble alongside.
• Blood clots Much less common after shoulder surgery than after leg surgery, but not zero.

What to expect afterward

• Night pain usually improves early — often the first thing patients notice.
• Strength is the last thing to return. Motion comes back months before power does.
• You will be tempted to do too much at about six weeks, when the shoulder starts feeling good and the tendon is still only partly attached. That is the moment repairs fail. Do not lift the feed bag.
• Sleeping is easier propped up in a recliner for the first week or two.