Rotator Cuff Repair
PATHOPHYSIOLOGY
Wells K (2013) defined rotator cuff injury as a condition involving damage to the rotator cuff tendons because of continuous irritation and tear. There are two factors that can predispose a person to this type of injury. The first type is intrinsic factor which means coming from within, this includes poor blood supply to an organ, normal attrition or degeneration with ageing and calcification of tendons. The other factor is called extrinsic factor which means coming from the outside. Some of the factors considered extrinsic are injury from accidents, falls and too much stress on the shoulders as a result of different movements involving exertion (Bilal, 2013). The injury is frequently associated with athletes who move their arms above the head in a repetitive manner like pitching, swimming, tennis and weight lifting (Wells, 2013).
Paul’s occupation which is carpentry work and the repeated pitching and lifting of the ball during the rugby game eventually contributed to the irritation of his tendons from excessive pressure on the acromion process or bony knob of the shoulder. This also resulted to the swelling of bursa which is the lubricating sac between the tendons and the bones from subsequent rubbing against the acromion. Consequently, the shoulder becomes painful and if left untreated can lead to a tear in the rotator cuff and eventual injury to the shoulders (NMA News Direct, 2011).

Predisposing Factors:
Carpentry (repetitive lifting and pushing or pulling of the shoulders)
Repeated arm rotation from pitching and passing of rugby ball

Tendons tend to move in tight spaces.

Continuous irritation of tendons and swelling of bursa (lubricating sac between the tendons and bones)

If left untreated, may lead to rotator cuff tear.

Figure 1: Pathophysiology of Rotator Cuff Tear based on Paul’s Condition.

Current Treatment Options
Pharmacological
Surgical Intervention
A surgical procedure called shoulder arthroscopy is one of the main treatments for a rotator cuff tear. It involves the removal of the injured tissue and bone surrounding the rotator cuff lessening the pressure on the area. The surgeon inserts an arthroscope through a small incision into the shoulder. The device is connected to a video monitor inside the theatre. This is used to view and inspect all the tissues of the shoulder joint and above the area of the joint. Additionally, around 1-3 incisions are made to insert other instruments that will repair any damaged tissues and fix the tear in the muscle, tendon or cartilage. A damaged tissue is then removed out of the injured area. The surgeon may also do a rotator cuff repair by bringing together the edges of the tendon thru small rivets called suture anchors that are attached to the bones. These anchors are made of metals or plastic. They remain inside the shoulder and may not be removed after surgery. Incisions will be closed by stitches and covered with bandages as dressing. Some injuries may require an open surgery due to a lot of damage to the rotator cuff. This would mean that a large incision should be made for a direct access to the bones and tissues (Ma, 2013).
Medications
Aside from surgery, medications will be administered to minimise the symptoms brought about by the injury and the surgery itself. One of the medications administered following surgery is acetaminophen.It is indicated for postoperative pain reduction. It acts by inhibiting the central prostaglandin production resulting to an increase in the patient’s pain threshold. Another treatment will also include analgesics such as Non-steroidal Anti-inflammatory Drugs. These drugs work by minimising the sensitisation of sensory neuron that enhances inflammation associated with pain and prevents the pain sensation from reaching the brain. Opioids such as Morphine are often used to treat moderate to severe pain. This medication can imitate the action of natural opioids in the brain which in return produce the analgesic effect. Tramadol can also be used in conjunction with acetaminophen for effective pain control (Ruiz-Suarez & Barber, 2008).There are also other medications that can be administered to minimise symptoms other than pain. Analgesics such as Ibuprofen and Naproxen can help in decreasing the swelling and pain which often follows a rotator cuff tear. Corticosteroid injection to the shoulder may also be given to decrease inflammation and for pain reduction (Ma, 2013). Constant Infusion devices may also be administered for pain control.
Furthermore, post-surgical pain may result to anxiety and sleep deprivations. Hyperalgesia can cause sleep disturbances therefore sleeping medications are also advisable 24 hours post surgery. Promotion of sleep may result to improvement of patient’s health (Ruiz-Suarez & Barber, 2008).
Non-Pharmacological
Cryotherapy Cryotherapy is an alternative pain reliever following rotator cuff tear. The first application of cold as analgesia was observed in the time of Hippocrates several centuries ago (Ruiz-Suarez & Barber, 2008). A number of methods may be used for cold application to enhance pain relief together with medication therapy. Cryotherapy is best applied within the first 48 hours after rotator cuff repair.
Ruiz-Suarez and Barber (2008) confirmed that (cited Singh et al.) a significant decrease in post operative pain are exhibited in both open and arthroscopic shoulder surgery patients following continuous cold therapy with temperatures between 10-15 degrees Celsius.
Exercise
Based on a study conducted regarding the effect of exercise to the treatment of rotator cuff impingement, results show that exercise has statistical and clinical effect on pain reduction and improvement of function in a rotator cuff impingement. However, the results of the study also show that exercise does not improve strength on the affected shoulder.
Hitch (2013) also cited several recommendations for non surgical interventions in a fracture or joint injury. One of these is the use of splints or casts to increase Range of Motion(ROM) exercises following a joint injury or immobilisation. The use of Continuous Passive Motion (CPM) also brought a positive effect in performing ROM and more importantly, it is safe to use. If combined with physical therapy, the use of steroid injection can also improve shoulder ROM following surgery.
According to Ellenbecker and Cools (2010), exercise programs that involve resistance enhances balance in muscles. These exercises are also aimed at enabling activity involving rotator cuff activation and scapular muscle involvement which can also develop the strengthening of the injured rotator cuff and promoting muscular balance. The main goal is to use of movements and positions that do not create substantial contact of tendions on the acromion process or pressure towards joints. First, on a side-lying external rotating position, the shoulders are extended in a prone position and then they are externally rotated. It will then progress by abducting the shoulders horizontally and externally rotating the scapulars to a prone position. This is only applicable if the patient show a significant tolerance to the first two exercises. Abducting the shoulders to a prone position will only be at a 90 degree angle to lessen the effects of subacromial contact. Studies show that these exercises can initiate high levels of muscular activation compared to other exercises that frequently result to irritation to the bursa because of continuous contact to the bony knob in the shoulders resulting from the combination of internal rotation and elevation.The “empty can” exercise is not any more used for patients having rotator cuff injury. The response aimed is targeted on muscular tolerance which can be created after three sets of 15-20 repetitions of these exercises. Ellenbecker and Cools (2010) also noted that (cited Moncrief et al.) the success and efficiency of the rehabilitation program which was done for a duration of 4 weeks has resulted to 8-10% increase in muscle strength when performing internal and external rotation exercises on healthy subjects. Another report conducted to female athletes (cited Niederbracht et al.) exhibited significant gains in rotator cuff strength specifically external and internal rotation balance strength after external rotation exercises.The use of towel rolls while doing isotonic exercises can also help in avoiding unwanted movements when doing the exercise and it will also prevent the flow of blood in the supraspinatus tendon creating a substantial space while doing the exercise to avoid subacromial contact with tendons. Exercise load and intensity are also keys to any resistive exercise programme.
Ellenbecker and Cools (2010) stressed out that rehabilitation program for patients who have undergone rotator cuff repair can be optimised by integrating physical examination techniques and evidence-based concepts focusing on rotator cuff strengthening and enhancing normal function and physiology. With scientific research and clinical application, additional insights and standards in treating shoulder and rotator cuff injury can be highly achieved.
Area of Assessment
Activity
Post Rotator Cuff repair may require immobilisation and application of an arm sling. It will be applied for 4-6 weeks following surgery. The affected arm should not be positioned lower than the position when it is inside the sling. A carer may be needed for assistance in taking full control of the arm. This sling must be applied for the whole time, day or night with exception on exercising or taking a shower (Tan, 2010). In Paul’s case, he may need assistance in his ADL’s since he may have restrictions in moving his affected arm.
Respiration
In relation to Paul’s case, immediately after surgery, he was oxygenated via laryngeal mask on 02 at 6l/min and his breathing was shallow. Unusual breath sounds were also observed when his status was monitored at the PACU.
A study on the effect of shoulder arthroscopic surgery on respiratory mechanics by Gwak Mi Sook of the Samsung Medical Centre in 2011 found out that during rotator cuff arthroscopy, extravasation of irrigation fluid can occur around the shoulder and trachea causing compression of the upper airway. Although 12 hours post procedure the irrigation fluid will be absorbed systematically, some cases could lead to reintubation or life-threatening complications. Additionally, soft tissue oedema around the shoulder may extend to the thoracic resulting to the compression of the chest and may induce respiratory distress immediately after surgery.
Circulation
While at PACU, Paul shivered and had cool to touch extremities, postoperative observations recorded a capillary refill of more than 2 seconds. Upon return to the ward, he complained of chest tightness while his capillary refill improved and is now less than 2 seconds.Two factors can affect the circulation status of patients undergoing rotator cuff repair: patient positioning and anaesthesia. Impaired cerebral blood flow may result from impaired venous return of blood from the lower extremities and vasodilation due to anaesthetic agents used during the procedure (Marecek & Saltzman, 2010).
Consciousness
On Paul’s arrival to PACU, he was unconscious. It was also noticed during PACU monitoring that waking him up was increasingly becoming difficult to do. Sinclair and Faleiro (2006) has stated key points in the delay of recovery from consciousness after anaesthesia. The cause can be multifactorial. Age, genetic variations, disease processes such as renal and hepatic failure classified as patient factors should be considered. Another factor is surgical which involves duration of surgery, utilisation of regional techniques, degree of pain or stimulation and requirement for muscle relaxation. Lastly, drug factor can also contribute to this delay, it includes the dose, absorption, distribution, metabolism and excretion of the anaesthetic agent. All these three factors can affect the delay of awakening of the patient following the surgical procedure.
Discharge Plan
The main focus in Paul’s discharge plan is to provide him instructions appropriate to his current condition making sure that he can return to his Daily Activities with comfort and ease as much as possible . Restrictions may also be advised since the surgery involves an injury to his extremity. According to McFarland (2010), the patient is not allowed to drive until he can discuss it with his doctor on his first return to the office for a follow-up check up. When the patient is no longer using narcotic pain medications for pain relief and he feels as if he can now control the wheel then he can do so. Usually this is around 3-4 weeks after the surgery for most patients.The reason for this is to avoid any kind of accident that may occur due narcotic side effects and pain upon exertion of his shoulders while driving. Restrictions on exercises like running, biking and any lower body workouts may also be applied until he sees his surgeon. All precautions done must be towards avoiding falls.There are several things that Paul has to be educated about prior to his discharge from the hospital. Firstly, he has to be informed about his take home medications. A prescription will be provided by his doctor prior to discharge. The nurse should serve as the patient’s advocate while instructions are given by his physician, making sure that Paul understands what these medications are for, the right dose to take, right route, right time of administration, any significant adverse effects and interactions to look out for and the indications on when these medications can be taken. He should also be informed to immediately inform his physician in case of any adverse reactions or drug interactions to the prescribed medications. Secondly, one of the main focus in discharge is the care for his dressing. Immediately after his surgery, the dressing will be changed with clean dry gauze and tape, he should be informed on when the next dressing should be done and how often he should do it. Bathing and showering may also become a challenge post surgery. McFarland (2010) states that it is advisable to keep the incision site dry 5 days after surgery. Furthermore, it is also advised to avoid bathing, swimming and using of hot tubs at least 3 weeks following the surgery. A clean dry cloth may be applied to the underarm between showers to keep it dry and free from sweat thus preventing skin infections. Lastly, an immobiliser such as an arm brace will also be applied. This should be worn outside of clothes to avoid rashes.It should not be too tight and must easily fit to the four fingers from the opposite hand between the straps and the skin. This immobiliser should be worn most of the day unless showering, feeding or exercising and must be worn at night for the first 5-6 weeks after surgery (McFarland, 2010). Basing on Paul’s condition, he will also be referred to several allied health professionals upon his discharge. A physiotherapist will work with him so that they can develop a plan of daily activities and appropriate exercises that can help him recover faster. Secondly, he should also be referred to a general practitioner in his community to whom he can have access to whenever he develops unusual symptoms and drug reactions following his discharge. The GP can communicate with his physician and surgeon regarding any complications that may rise following his discharge. A community nurse can also help with regard to Paul’s care. The nurse can make visits to Paul’s home and can check his condition from time to time. A personal care assistant can also be there for Paul in assisting him on his day to day activities like bathing, changing clothes, feeding and going to the toilet since he has some restrictions related to his condition. Lastly, a social worker must be there for Paul from the time of admission until he is discharged from the hospital. The social worker can help him in his financial and social status since he has missed work and he is the sole provider for his family. The social worker can help him gain access to financial aids while he is still recovering from his condition. Generally, any kind of surgical procedure may cause stress to the patient. The health care team can make a difference in the patient’s experience from the time of admission, surgery towards discharge. It depends on the kind of care the patient receives and the kind of treatment the team gives ensuring the patient’s health and safety throughout the experience.

References
Bilal, R. H. (2013). Rotator cuff pathology. Retrieved on March 20, 2015 from http://emedicine.medscape.com/article/1262849-overview#aw2aab6b4 Ellenbecker,T., & Cools, A. (2010). Rehabilitation of shoulder impingement syndrome from rotator cuff injuries: an evidenced-based review. Br J Sports Med 44:319-327.doi:10.1136/bjsm.2009.058875
Fitzpatrick, R. (2010). Patient guide: post rotator cuff repair. An Occupational Therapy Guide. Retrieved on March 20, 2015 from http://stvincentssportsmed.com.au/wp-content/uploads/Living-with-a-sling-after-surgery.pdf
Hitch, D. (2013). Fracture/joint injury (range of motion): non surgical interventions. The Joanna Briggs Institute. Retrieved on March 20, 2015 from http://ovidsp.tx.ovid.com.ezproxy2.acu.edu.au/sp-3.15.1b/ovidweb.cgi
Kuhn, J. (2008). Exercise in the treatment of rotator cuff impingement: A systematic review and a synthesised evidence-based rehabilitation protocol. Journal of Shoulder and Elbow Surgery 18(1):138-60. doi:10.1016/j.jse.2008.06.004.
Ma, B. C (2013). Shoulder arthroscopy. Retrieved on March 20, 2015 from http://www.nlm.nih.gov/medlineplus/ency/article/007206.htm McFarland, E. (2010). Rotator cuff surgery discharge instructions. The Johns Hopkins Hospital Patient Information. Retrieved on March 21, 2015 from http://www.hopkinsortho.org/orthopedicsurgery/RotatorCuffDischarge.pdf
Marecek, G., & Saltzman, M. (2010). Complications in shoulder arthroscopy. Helio Orthopaedics 33(7): 492-497.doi:10.3928/01477447-20100526-15
NMA News Direct (2011). How rotator cuff injuries occur. Retrieved on March 20, 2015 from http://newsdirect.nma.com.tw/SingleItem.aspx?asset_id=OEM_20110831_OINT_003.
Ruiz-Suarez, M., & Barber, A.F. (2008). Postoperative pain control after shoulder arthroscopy. Helio Orthopaedics 31(11). doi: 10.3928/01477447-20081101-25
Sinclair, R.C.F., & Faleiro, R. (2006). Delayed recovery of consciousness after anaesthesia. Continuing Education in Anaesthesia,Critical Care & Pain 6(3): 114-118. doi:10.1093/bjaceaccp/mkl020