Rotator Cuff Repair — Procedure Guide, Recovery & Risks | MyMedicPlus

Rotator cuff repair is an arthroscopic (or occasionally open) shoulder surgery designed to reattach a torn rotator cuff tendon — most commonly the supraspinatus tendon — back to its insertion on the greater tuberosity of the humeral head (upper arm bone) using biodegradable or titanium suture anchors. The rotator cuff is a group of four muscles and their tendons (supraspinatus, infraspinatus, teres minor, and subscapularis) that originate on the scapula and insert onto the humerus, providing dynamic stabilisation of the glenohumeral joint and enabling the full range of shoulder movements including overhead reaching, lifting, and rotation.

Rotator cuff tears are extremely common: partial or full-thickness tears are present in approximately 25% of individuals over age 60 and in over 50% of those over age 80. The supraspinatus tendon — which passes through a narrow space between the acromion and humeral head and is subject to repetitive mechanical impingement — accounts for more than 90% of all rotator cuff tears. Tears range from small (less than 1 cm) to massive (greater than 5 cm, involving two or more tendons). Not all tears require surgery; the decision depends on tear size, symptom severity, patient age, functional demands, and response to conservative treatment.

Surgery is recommended for specific patient groups based on evidence-based guidelines. Young active patients (typically under 60) with acute traumatic full-thickness tears sustained during sport or a fall are best managed with early surgical repair, as tendon edges are fresh and retraction is minimal — delay allows muscle atrophy and fatty infiltration that permanently compromises repair quality and outcome.

Patients of any age with persistent pain, weakness, and functional limitation despite a minimum of 3–6 months of structured physiotherapy, anti-inflammatory medication, and corticosteroid injections should be considered for surgical repair. Large or massive tears (greater than 3 cm) have low rates of spontaneous healing and tend to enlarge over time, making earlier surgery preferable before irreparable muscle atrophy and fatty infiltration develop.

Other indications include tears in the dominant arm of patients with high occupational or sporting demands, complete subscapularis tears causing profound internal rotation weakness and the ability to lift the arm, and tears accompanied by significant glenohumeral joint pathology (biceps tendon disease, labral tears) amenable to simultaneous arthroscopic treatment. Non-surgical management may be appropriate for elderly, low-demand patients with small tears and manageable symptoms.

Anaesthetic preparation: general anaesthesia combined with an interscalene brachial plexus nerve block (20 mL 0.5% ropivacaine) provides complete shoulder anaesthesia and 12–18 hours of post-operative analgesia, significantly reducing opioid requirements.

Patient positioning: the beach-chair position (upright, 45–70 degrees) is most commonly used in the UK and Australia, providing familiar anatomy and easy access; the lateral decubitus position (lying on the non-operated side with traction) provides excellent visualisation of posterior structures and is preferred by some surgeons.

Diagnostic arthroscopy: a 4.5 mm arthroscope is inserted through a posterior portal (2 cm below and medial to the posterolateral corner of the acromion). The joint is systematically inspected — glenohumeral cartilage, biceps tendon, labrum, subscapularis — and anterior and lateral portals established.

Subacromial bursectomy: the subacromial space is entered; inflamed bursa is excised with an arthroscopic shaver; any acromial spur or undersurface bone causing impingement is smoothed (acromioplasty).

Tear assessment and mobilisation: tear size, shape, retraction, and tissue quality are assessed. Peritendinous adhesions are released to allow tendon edges to be re-approximated without tension.

Anchor placement and suture repair: 4.75–5.5 mm biodegradable or titanium double-loaded suture anchors are drilled into the greater tuberosity footprint. Sutures are passed through the tendon using a suture-passing instrument and tied arthroscopically. A double-row or transosseous-equivalent (TOE) repair restores the full tendon footprint and provides the biomechanically strongest construct. A 'speed-bridge' technique uses medial and lateral row anchors to maximise tendon-bone contact area.

Immediate post-operative period: the arm is placed in a sling with an abduction pillow for 4–6 weeks to keep the repaired tendon in a low-tension position. The sling is removed only for supervised exercises and hygiene. Ice application (20 minutes every 2–4 hours) reduces swelling and pain. The nerve block provides excellent pain control for the first 12–18 hours; regular paracetamol and NSAIDs are taken thereafter.

Weeks 0–6 (protective phase): passive pendulum exercises and passive assisted range-of-motion exercises begin at 2–3 weeks under physiotherapist supervision. The priority is protecting the repair while maintaining mobility to prevent stiffness.

Weeks 6–12 (active motion phase): the sling is discontinued; active assisted and active range-of-motion exercises progress. Strengthening is not yet introduced — the repaired tendon, while macroscopically healed, has not yet achieved biological maturation.

Months 3–6 (strengthening phase): rotator cuff strengthening with resistance band and isotonic exercises begins. Scapular stabilisation and periscapular strengthening are equally important for overall shoulder function.

Months 6–12 (return to sport): sport-specific conditioning, proprioception training, and progressive return to overhead activities and sports. Full return to contact sports and heavy manual labour typically requires 9–12 months. Physiotherapy attendance throughout all phases is essential.

Re-tear of the repaired tendon is the most significant complication, occurring in 10–20% of small-to-medium tears and in 30–50% of massive tear repairs. Factors associated with re-tear include advanced patient age, large tear size, significant fatty infiltration of the muscle (Goutallier grade 3–4), non-compliance with post-operative sling restrictions, smoking (reduces tendon vascularity and healing), diabetes, and corticosteroid use. Many re-tears are asymptomatic and do not require revision surgery.

Shoulder stiffness (adhesive capsulitis/frozen shoulder) develops in 8–10% of patients, particularly when early passive mobilisation is delayed. Management includes physiotherapy, joint distension, or manipulation under anaesthesia in refractory cases.

Infection occurs in less than 1% of arthroscopic cases. Nerve injury, most commonly involving the axillary nerve (less than 1%), causes deltoid weakness and lateral shoulder numbness. Chondrolysis (cartilage damage) is associated with continuous intra-articular bupivacaine infusion, now abandoned. Anchor-related complications include pull-out (rare) and reactive synovitis from biodegradable anchor breakdown.

Arthroscopic rotator cuff repair achieves good or excellent patient-reported outcomes in 85–90% of cases. The Oxford Shoulder Score and Constant-Murley Score both demonstrate consistent improvement post-operatively, with pain scores reduced by 70–80% and shoulder function scores improved by 60–75% at 12 months.

Return to sport is achieved in approximately 85% of recreational and competitive athletes who undergo rotator cuff repair, with overhead athletes (swimmers, tennis players, throwers) achieving return-to-sport rates of 70–80% at their pre-injury level. Tendon healing confirmed on post-operative MRI at 6–12 months is demonstrated in 70–85% of repaired tendons, correlating with improved strength and functional outcomes.

The arthroscopic approach specifically offers advantages over traditional open repair: minimal surgical trauma to the deltoid muscle (which is split rather than detached), smaller incisions, lower infection risk, ability to address concurrent intra-articular pathology (SLAP lesions, biceps tendon disease, loose bodies) in the same operation, and equivalent or superior clinical outcomes with faster rehabilitation. Economic analyses demonstrate that early repair of young patients prevents the progression to massive irreparable tears, avoiding the significantly more complex and costly reverse shoulder arthroplasty.