Retears - what to do

Given the relatively high incidence of rotator cuff retear among patients of repair surgery, little seems to be written about how you might tell if you've retorn it and what to do. I have seen this article a number of times as it crops up on medical websites and has even been used here in the UK by our NHS as an advice leaflet; however, it seems to contain no information of any use - not to me at least. So, if I may, here are some of my experiences of dealing with retears. I have retorn my repaired rotator cuff more than once and now have an intact repair. Here's how I got there.

What is a Retear?

Simply put, a retear of the rotator cuff is where an attempted repair has failed. You have to have had a tear repaired before you can have a retear, so if you've not had a repair, you can't retear. Sorry if this sounds obvious, but this question has cropped up a couple of times!

Types of retear

Much is written about how the rotator cuff gets torn in the first place (trauma, wear and tear etc), however, much less is written about how tears fail. There are two points at which a repair can fail - pre-healing and post-healing.

Pre-healing: Usually in the first 6-8 weeks from surgery. The repair can fail during this time if the repair construct fails - this includes:
    - Tendon pulls through the suture (the most common cause)
    - Anchor pull-out from bone (rare, but happens)
    - Suture failure (rarer still)
   
Post-healing: Any failure or retear after the 8 week mark is almost definitely due to a failure of the bone-to-tendon healing - includes:
    - Mechanical failure of the healed bone/tendon interface
    - Failure of the bone to heal to the tendon (less common and more likely to result in a pre-healing failure anyway)
   
Causes:
- Using the joint too early
- Bone/tendon have not healed
- Further trauma - e.g. a fall or impact to the joint

Indications of retear:
- A sudden sound (pop/click) in the joint
- Sudden onset of pain
- Return of familiar pain
- Clunking or clicking that is easy to replicate with certain movements.
- Loss of movement

This is to say then, if you've had a rotator cuff repair and you're doing well at three months post-op, then you raise your arm and suddenly feel a click in your shoulder, followed by a return of familiar pain which is accompanied by a repeatable clunk and a loss of movement, then you have probably retorn your rotator cuff. The more of these indications that are present, the more likely a retear.

Red-herrings i.e. things that are very unlikely to indicate a retear on their own:
- Pop or click with no pain - probably just some adhesive scar tissue giving way.
- Sudden onset of pain that comes and goes for a while - probably part of the healing process

Coming to terms with a retear

If you've suffered an injury to your shoulder, undergone a rotator cuff repair and begun the rehab, then the prospect of repeating this experience can be nothing short of harrowing. We all respond differently in these situations: some are optimistic and hope for the best, some are pessimistic and fear the worst. If like me, you are a combination of both of these, you'll want to get answers so you can plan what to do next. The only way to do this is to get it rescanned, either by ultrasound or MRI.

Rescanning after surgery:
Because of the cost of scans, some surgeons don't like to authorise them until many months after surgery, which can be very frustrating if you're worried that you may've retorn your repair. Unfortunately, scans are less reliable after surgery due to residual swelling, fluid and scarring. It is fairly pointless to request a scan prior to three months after surgery as the scan really won't show much and no surgeon will take it seriously. This means, even if you think you retore your shoulder at two weeks post-op, you will have to wait until three-months before an MRI or ultrasound is viable -- sorry about that!

So if you're at 3 months post surgery and your surgeon won't authorise an MRI, what do you do? Well, in my case I got my Osteopath to refer me for an MRI that I paid for myself. In the UK an Osteopath, Chiropractor or your GP/Family Doctor can refer you for a private MRI - only your GP or surgeon can refer you for an MRI on the NHS and they may or may not be willing to do this.

Following your MRI Scan:
When you've had your scan done, my advice is to get hold of a CD of the images and the radiologist report. The images are useless without the report. If the scan was done privately, you should be given a CD of images and the report should be made available to you via the person that referred you for the scan. Get a copy of the report as soon as you can because, as you will see from the following story, you may have to take these to a different surgeon.

My story

Having retorn my repaired rotator cuff more than once, the most typical response I have got from my surgeon when I have first raised this is, no you haven't. Even with an MRI that shows a tear, many surgeons will claim that MRIs after surgery are misleading and you're probably fine. This has happened to me more than once and each time I was proved right and they were proved wrong. The only solution I have found is to go to someone else - no really; for some reason they don't want to accept that their excellent work has somehow failed.

Finding another surgeon:
There really is no straightforward guide to finding the next surgeon. All surgeons are not made equal and each one has their own special thing they do, their own set of preferred methods and their own particular attitude towards your case. This is based on the experience of seeing at least twenty UK shoulder surgeons - a few of whom have gone on to operate on me!

The truth about revision rotator cuff repair:
If you have retorn your cuff, the chances are it will be be harder to repair again. This is because:
    - Your cuff tissue is likely to be of poorer quality
    - The tear is likely to be bigger
    - The presence of anchors in the bone can make the positioning of new anchors more difficult - you can't reuse old anchors.
   
Having seen a number of surgeons and had my cuff repair re-done (revised) more than once, there is one piece of advice that drops out that I would share with anyone looking for a new surgeon and that is:

- If your rotator cuff repair has failed and the surgeon is proposing that they repair it using the same or similar technique as was tried before, then there is no reason to expect a better outcome.

I went through a stage of making sure the next surgeon was the 'best' guy and that his reputation was better so therefore he must be a better surgeon so his repairs must just be better etc. This turned out to be b*llsh*t every single time and I simply ended up suffering the arrogance of some of the UK's biggest rock-star shoulder surgeons; none of whom I'd recommend by the way. Reputation and ability are rarely proportional, in my experience.

Knowing I had limited options, I began researching repair techniques themselves and learning who was doing what. This led me to research the use of allograft patches, in particular a product called GraftJacket. I had a repair with this patch five weeks ago and so far so good. However, finding this surgeon was a long road and whilst I could find plenty of surgeons who had done GraftJacket repairs before, I couldn't find anyone who would do it on me. The reason, it turns out, was because most of these surgeons had done a handful of repairs on a few cases so were unsure if it would help me. I learned this when I went to see one of the first surgeons to do these repairs in the UK, who by this time had between 100 and 200 operations to reflect on. Fortunately for me, he agreed to surgery.

Post surgical pain...and what to do about it.

Hi, week four here and things are still chugging along. I'm still doing passive exercises and I'm still wearing the sling for most of the time. There is still pain which hasn't changed a lot in the last week. Mostly this is due to getting a little bit more range each day so things are changing inside and as I said before, each new thing for the first time hurts a bit - sounds like a song title dunnit?!

 

Causes of Pain following Shoulder Surgery:

Like a lot of folks who have had shoulder surgery, I've spent many moments (too many) trying to figure out what's hurting and why so that I might be able to make it better. So as nothing much has changed with my recovery this week, I thought I'd share some of my ideas and research into these causes of pain. I am not a doctor, by the way. You're mileage may vary, the value of your investment may go down as well as up etc etc.

1. Incisions: These things hurt - even the little arthroscopic ones. Having had both arthroscopic and open surgery - and combinations of the two - my experience is that they all hurt. The medical profession sells us the benefits of arthoscopy (keyhole) as faster recovery, less scarring, but it's more complex than that. Arthroscopy carries lower risk of infection, less blood loss and less risk of the wound opening back up after surgery. Open surgery is typically one large incision whereas with Arthoscopy, between two and five separate incisions are made - that's up to five separate points of pain. The rise in the use of Arthroscopy has meant surgeons can visualise, diagnose and treat many more conditions than they could before - but I would still wager someone with five arthroscopic incisions has more pain than someone with two. Even when the incisions appear to be 'healing nicely' there is still the disruption to the deltoid muscle beneath and this can still cause some pain for two or three months.

How to minimise this pain: Gentle massage of the healed incisions (usually 3 weeks onwards) helps to break down and soften the scar tissue that forms beneath. Do this a couple of times a day for about 6 weeks - remember to wash hands first! Don't massage an incision that is bleeding, weeping or very painful to the touch otherwise you may introduce an infection or cause damage.

Open	Arthroscopic

2. Busa Removal: The soft lubricating sack that sits between the rotator cuff and the deltoid and allows these opposing surfaces to move smoothly against each other. The bursa is nearly always inflamed and scarred when a rotator cuff tear or sub-acromial impingement is present. The surgeon will remove most or all of it during surgery, however it grows back within about three months. I'm sure this hurts, although there is little research to back up this idea. Consider also that the deltoid (with incisions in it) and the rotator cuff (with sutures and anchors it) are now touching without the bursa to keep them apart, so there's bound to be some pain from this in the early stages of rehab.

How to minimise: This is pain that has to be worked through. Begin passive movements as early as you are allowed. Ask your physio about stretches to restore range of motion and stick to the program. Regular movement will encourage the regrowing bursa to find it's way back to where it needs to be.

3. Healing of the Repaired Tendon: Repairing a tendon back down to bone involves passing sutures (stitches) through the tendon that are fixed into the bone either with anchors or holes drilled into the bone. The bone is also abraded down to make it bleed slightly which promotes healing. In some cases, small holes are made in the bone (microfracture) where the tendon fixes down which promotes the release of bone-marrow which also promotes healing. All of this disruption to tissue and bone causes a healing response which results in pain and inflammation. This improves as the tissue and bone heal, but given the slow healing of rotator cuff tendons, this may take many months.

How to minimise: There is little one can do to minimise this pain, other than to follow the recovery protocol set by the surgeon to give the best chance of good healing. Generally this involves immobilisation for 3 to 4 weeks, followed by passive exercises to restore ROM, followed by active movement at around 6 weeks to restore function, with strength rehab beginning at around 10-12 weeks.

4. Capsular Tightness: Beneath the rotator cuff there is a capsule of ligament tissue surrounding the ball and socket joint. This helps stabilise the joint, but it can cause problems if the shoulder is kept immobile for a long time as the capsule can shrink. This results in a tight shoulder that is difficult and painful to mobilise. Some people with limited ROM at three months following surgery are told they have a frozen shoulder. This is because a frozen shoulder is caused by a tight and inflamed capsule, so the cause and symptoms are almost identical. However, even if you are able to coax your ROM back, you will still go through a period of stretching the capsule and this can be quite painful. I've encountered this myself as a deep aching that seems to lessen considerably once full range has been established.

How to minimise: Again, this is pain that has to be worked through. Begin passive movements as early as you are allowed. Regular stretching without undue force is key. Forceful stretching is likely to aggravate this pain and is never recommended prior to ten weeks post-surgery anyway.

5. Scar Tissue and Adhesions: As the soft tissue in the shoulder heals and recovers, it forms scar tissue, much in the same way as an old cut or burn may be visible on your skin. If you are immobile (in a sling) for a long time, the risk of some of these bits of scar sticking together (adhesions) increases. If they are allowed to establish, these adhesions can restrict range of motion - a condition known as captured shoulder; I have had this myself. In captured shoulder the bursa gets stuck to the healing cuff and literally gets dragged around inside the shoulder as you move, becoming inflammed and painful in the process. Adhesions that don't resolve with physiotherapy can be removed during an arthroscopic debridement, which usually works well. However, in the early stages of recovery you will always get a few adhesions which you can hear snapping and popping as they resolve; which is a good thing, as long as they continue to break up.

How to minimise: Pain from adhesions and scar is less obvious and can suddenly onset (and resolve) with certain movements. Very often you can feel adhesions break as you stretch (snap/pop) and they are followed by a sense of relief. Maintaining a good range of ROM as early as possible helps to stay on top of the formation of these bits of adhesive scar.

Brief Article describing Captured Shoulder: https://www.ncbi.nlm.nih.gov/pubmed/8864004


6. Trigger Points: Sometimes called muscle knots, these are painful little points of tension in a muscle or tendon. They can usually be resolved by applying pressure through the skin, either with the sharp point of a finger or by lying on a tennis ball, or better still, a lacrosse ball - but it is best to wait until you're out of the sling before trying this. An operated shoulder can be prone to these knots as the muscles suddenly find themselves unstretched for long periods or when certain muscles have to compensate for others. The infraspinatus muscle in the shoulder can be particularly prone to trigger points as it compensates for a torn or weakened supraspinatus. Sometimes these trigger points can be difficult to treat, especially if they are chronic or in muscles that are difficult to reach through the skin, such as the supraspinatus and the subscapularis. Dry needling or acupuncture is particularly effective at reaching these painful trigger points and I would recommend seeking the help of a chiropractor or osteopath who practises these techniques.

How to minimise: Ask your therapist about treating trigger points with a ball. There are numerous YouTube videos on this, but seek professional advice to avoid hurting yourself and wait until you're out of the sling.

 
In conclusion: I guess the mantra here is 'keep moving'. The longer a shoulder is immobilised, the harder it is to get it moving later. I have read a number of stories of surgeons who insist on keeping some patients immobilised for 8 or 9 weeks following rotator cuff repair. Their reasons for this are usually to do with poor tissue quality found at the time of surgery. However, the pulling and stretching required to get a shoulder moving after 8 weeks of immobilisation exposes a repair of poor quality tissue to even more risk of retear; as has been my own personal experience. Using an allograft to augment such repairs means the patient can mobilise their shoulder earlier with a better chance of a successful rehabilitation. If your surgeon doesn't do this kind of procedure, find one that does.