Q: My client had a rotator cuff repair after a work related injury and re-tore the tendon when he returned to work. What went wrong?
A: The short answer is – maybe nothing. Anybody that deals with shoulder injuries, rotator cuff tears in particular, knows they can be very temperamental. Even if everything goes right with the surgery and rehab, a significant number will either not heal or re-tear. The rates of non-healing and/or re-tear sited in the literature range from around 6% all the way up to 94%! Just as the causes of a primary cuff tear are multifactorial, the risks of re-injury and failure can be difficult to pinpoint. The one factor that correlates most closely with recurrent cuff tears is the size of the original tear. Large and massive tears have the worst rates of healing with studies consistently showing 30-50% failure rates.
Getting a rotator cuff tendon to heal is not a straight forward process and, in addition to tear size, is influenced by many factors including cause of the tear, condition of the tendon, bone density and smoking, to name a few. The cuff is also prone to tear without trauma. In fact, the majority of rotator cuff tears occur without an injury due to tendon breakdown. The tendon is subject to high stress, has a limited blood supply and poor capacity to heal itself. In order to get a tear to heal these issues have to be dealt with and often a natural process has to be reversed.
Persistent and recurrent tears can be present as early as six weeks from the time of surgery. The majority of these occur within the first three months, but high risk continues out to 6 months from repair. Injured workers with cuff repairs should be counseled to expect at least three months off work or very light duty. Construction work and other high demand jobs will typically require work restrictions for 6-9 months.
If there is any good news it’s that small tears caused by trauma, as in an on-the-job injury, that are treated relatively soon after the injury have the highest rates of healing. Studies also show that not all tendons that fail to heal completely will remain painful and can have good outcomes.
These types of injuries can obviously have a significant physical, mental and financial impact on the injured worker. Repairs that fail and cause persistent pain and disability requiring revision surgery can mean a year or more recovery.