Last month, I discussed the operative technique of repair rotator cuff tears to the bone of the humerus. Today, I’m going to discuss the post-operative period and what needs t be done to get motion and yet protect the repair while doing so.
After I made tendon repairs on my patients, I insisted they wear an immobilizer for three weeks, keeping the hand and arm pointing straight ahead rather than across the chest. I felt that letting the arm rest in a sling across the chest allowed the postoperative scar tissue to occur in the most inappropriate position thereby causing a longer rehabilitation for my patients.
What happens after the sling is removed is as important as the operation itself. Before the surgery, I always took time to teach my patients how to do the passive-motion exercises they would need to begin three weeks after the operation. It was important for them to know ahead of time how to do these exercises because many folks have trouble grasping them and needed practice to prepare. After I instructed them, I had them practice with me observing to be sure they understood.
With passive-motion exercises, the arm is moved about but without using the shoulder muscles connected to the repaired tendons. The person is taught to bend from the waist, which relieves tension on the tendon repair, and sway the body to swing the totally limp arm forward and backward like a pendulum and then in a circular motion. Another passive-motion exercise calls for a rope-and-pulley system. With this method, the patient grasps the rope’s handle with the hand on the same side as the repaired shoulder, keeping the shoulder limp, and uses the opposite arm to pull the affected arm up and down (Fig. 15).
Still another method calls for lying on one’s back, holding a short pole or stick with both hands pointed at the ceiling, and, using the opposite arm, pushing or rotating the operated arm into an externally rotated (outward) position.
I always told my patients that once they completed their exercises, they should make a habit of keeping their hand on the operated side in a pocket rather than holding the arm across the chest. I stressed this because most people instinctively hold the affected arm across the chest to protect it and avoid any pain, but as scar tissue develops, motion can be severely restricted in this position. This is also why I immobilized the arm in a neutral position after surgery. Patients’ rehabilitation times were substantially reduced with this.
Remember, surgery always involves some bleeding—not massive, just an inevitable slight oozing during the operation and for a short time afterward—so the resultant clotted blood eventually becomes scar tissue or fibrosis. Once that happens, if the arm is held too still across the chest, the scar tissue becomes rigid and tight, limiting motion away from the body and causing pain, somewhat like a rubbery glue that gives when stretched but draws back to its original length afterward. So if long periods pass without moving the arm from the cross-chest position, that rigid scar tissue will cause moving the arm freely in all directions difficult if not impossible.
After three weeks in the immobilizer, followed by nine more weeks of only passive-motion exercises, I had my patients begin active motions and exercises to strengthen the shoulder muscles. With active motion, the patient is encouraged to strengthen the shoulder muscles and regain a full range of motion by using those muscles. There’s no point in continuing to protect the surgical area, because if the repair hasn’t healed after three months, protecting it further will usually be useless.