In prior posts, I have discussed what rotator cuff tears are, what causes them and how they are best treated, both non operatively and with rotator cuff surgery. What I haven’t yet discussed, in detail, are the problems that can occur with rotator cuff tear treatment. Paramount among those problems is stiffness. Stiffness unfortunately often occurs after both nonoperative rotator cuff tear treatment and after rotator cuff surgery. Let’s take a look at the latter.
Rotator Cuff Surgery
Rotator Cuff Tear Repair
Surgery for a rotator cuff tear involves tying the torn rotator cuff tendon to the humerus where it has pulled off from. The tendon needs at least three months to heal to the humerus. Until then, it must remain securely tied to the bone. As a result, the postoperative treatment starts out slowly. Typically the arm is supported in a sling for 4-6 weeks. Although therapy is usually started shortly after surgery, it usually progresses cautiously for the first three months, limiting motion and stress on the repair. All of this is done to try to prevent a catastrophic failure of the repair.
Shoulder Stiffness
There are a number of reasons that the shoulder may become stiff after rotator cuff surgery. One of the leading reasons is the common post operative course that I described above. In essence, early on, your surgeon is trying to thread the needle between limiting shoulder activity so as to maximize tendon to bone healing while trying to move the shoulder as much as possible in order to reduce the risk of postoperative stiffness. This restriction, although giving a better chance for your rotator cuff to heal, can often lead to stiffness all by itself.
Why? Well joints in general tend to get stiff after trauma…and surgery is traumatic. Many of the joints’ soft tissues tend to shorten and stiffen. Why this happens, we don’t know. But it happens. Additionally, without much motion, scar tissue has time to develop. This can sometimes result in thick bands that may connect the humerus to other stable areas of the shoulder and restrict, or in some cases prevent, motion. Furthermore this phenomena is more common in some joints than others. For instance, the knee stiffens more than the hip. And as a general rule, the upper extremity more than the lower. Specifically, the shoulder tends to get really stiff after trauma…and surgery.
Secondly, there is also the potential for not only stiffness to develop as we discussed above but an actual secondary frozen shoulder may as well. Many of the groups susceptible to frozen shoulder, also commonly have rotator cuff tears and ultimately rotator cuff surgery: the middle aged, following trauma, and of course, following surgery, for example.
And finally…There is pain.
Rotator cuff surgery is very painful. We do many things to reduce the pain but the surgery and particularly the recovery, is still painful. Additionally, the recovery is long. Recovering from rotator cuff surgery is not a sprint but rather a marathon…and a painful one at that. Pain can prevent effort…or limit it. And recovering from rotator cuff surgery and reducing or preventing stiffness requires effort…and lots of it. So if you’re in pain and can’t perform the rehab that’s needed, your shoulder may stiffen from any or all of the reasons discussed above. As you stiffen, the greater your pain will be when moving your shoulder and the more effort that will be needed to overcome the stiffness. So pain can lead to a vicious cycle of progressive increased pain and stiffness, feeding on itself and causing even greater pain and stiffness.
What To Do?
So the question really isn’t “Why is my shoulder stiff after rotator cuff surgery?” but rather “Why isn’t it?”. Stiffness of some degree is common. Not having any stiffness at any time is not. Recovering from rotator cuff surgery is like swimming against the current. With the current being your shoulder’ tendency to get stiff.
Early Stiffness
With that said, stiffness early on is usually a good thing. Huh? Well the weak link in your repair is the repair. The tendon is attached to the bone by small stitches. Initially just tiny strings are holding your repair together. As the tendon heals to the bone, the repair becomes stronger and the stitches less relevant. But until then, if you gain too much motion, too soon, you probably gained that motion by pulling the repair apart. So stiffness early is usually a good thing.
Fortunately, this stiffness often will work its way out with time, effort and continued physical therapy. Over time, your pain will usually decrease and your tissues themselves will often slowly begin to lengthen and loosen on their own. After the tendon heals to the bone, the pace and intensity of your therapy can and should be increased….leading to further gains in your shoulder’s range of motion. So if your shoulder has not become too stiff before this point, much, if not all of your motion may be regained.
Late Stiffness
But when it isn’t, there are still other solutions. Sometimes the ultimate loss of motion is minimal. Most joints have extra motion. The shoulder more so than many. So a loss of some motion will often either not be noted or at least not be bothersome. Usually most activities, whether those needed for daily living or even recreation, will not be hampered. However if they are, a manipulation of your shoulder or a simple arthroscopic surgery can almost always restore your motion to satisfactory levels. Fortunately, this surgery is much simpler and easier to recover from than the initial rotator cuff surgery.
Two Boneheads Video Series
For more about this common, complex issue, watch the following video in which The Two Boneheads, Dr. Howard Luks and myself, have another hopefully informative discussion in which we discuss this issue in detail.
Hello,
The real questions are as follows:
When do you start to get more aggressive with stiff shoulders post op? Iannotti, Williams, just about all surgeons now like 6 weeks in a sling/abduction splint, little to no movement. Start PT (PROM) there, add AAROM at 8 weeks for everything not “massive” (small to large tears). By 9-10 weeks patients are pretty stiff… all be it that at 3 months there is a pretty good tendon to bone healing mechanism established in a successful repair. Do you wait for 12 weeks or do you start more aggressive stretches at 8-10 weeks?
I use the first three months to just keep the patient “in the game”, going very slow as you outlined. Not really trying to make gains but rather just keeping the patient as “close” as possible. At three months, when as you noted, there is expected satisfactory tendon to bone healing, I start to get more aggressive. With this approach, I expect to see improvements in range of motion and functional
improvement…and patient happiness…by 4-5 months. If I don’t see satisfactory and improving range of motion by 5 months, I confirm satisfactory tendon healing by MRI and if confirmed, I perform a manipulation. If unclear, I perform an arthroscopy and assess the rotator cuff repair integrity and lysis of adhesions.
I had rotator cuff surgery 3/21/19, I’m 2 months post-op in physical therapy, my question is my shoulder is stiff, I can’t raise my arm barely 100 degrees when seated and standing, when laying on my side I can is easily raise at 140 degrees. Once I get to that point when raising my arm standing it don’t go no higher.
Ms. Saunder’s it is very common to have stiffness at this point after surgery. It many ways the stiffness is protective. The weak link in the repair for the first three months is the repair site. For some, if they have regained too much motion too soon, they may have disrupted the reair, not stretched out the muscle. I find for many of my patients, they may not begin to regain their motion until 4+ months after surgery. I have my patient’s continue PT throughout and if their ROM fails to be improving by 5 months, I consider addressing the stiffness surgically. I would suggest discussing your individual status with your surgeon, as every case is unique.
My email address is: laraine.weaver@yahoo.com and my question is. I do not have stiffness I have a muscle that sticks and pops, I can not move my arm until it pops and yes the popping is painful. Will it stop? Can I take PT to make it stop? And most important what is going on in my arm?
Ms. Harris Weaver unfortunately I do not have enough information to make any reasonable guess as to what may be bothering you. Therefore very difficult to say what the best treatment or prognosis is. The best I can suggest is to have a discussion with your surgeon or if for some reason that would not be desired, then to obtain a second opinion. They can be very helpful. https://www.jeffreybergmd.com/two-boneheads-video-series-second-opinions/
I am post- op almost 9 months and still have stiffness with some pain. I’m 65 with arthritis will my shoulder be ok?
Kristian obviously without knowing all the details and examining you, it is hard to give you specific information. In general terms, usually full recovery from that surgery can take a full year. Typically however by 9 months patients should feel good and have nearly normal range of motion. Depending on the degree of your arthritis, this alone can explain persistent pain and stiffness and may not respond to surgery for a rotator cuff repair. I suggest going back to your surgeon and discussing this with him or her.
Does arthritic pain seem like overall tightness? Had Rotator cuff surgery 8 months ago and have gained good ROM but recently getting to the last full bit of ROM shoulder has been stiff and achy. Once stretched a bit, no pain and ROM is continued good
I am sure that if you had arthritis, your doctor would have noted that and mentioned. Stiffness can take a full year to resolve and sometimes need further surgery to help. Speak with your surgeon.
Hey Doc,
I am 10 weeks post op for a posterior labrum repair requiring 4 anchors, everything else was fine. Im still very stiff. I have about 35 degrees external rotation (straight out in front), and have almost no internal rotation (cant even get my arm behind my back). Abduction i can actively raise to shoulder height however still feels and has the “locked up” look about it. Flexion is around 120-130 degrees. Hurts the most to reach arm across the front of my body. I started pt at the 4 week mark for twice a week and am now going once a week. It is mostly sore and stiff in the morning. I can use it for most tasks below shoulder level but have been trying to use it pain free at its extremities to help progress. I had the exact same operation on my left shoulder a couple of years ago and contracted some degree of frozen shoulder requiring a second surgery a year later. Helped alot with pain and have at least 90 percent rom back in that arm after second op. I am a 31 year old male btw.
My question, is my current progress for this type of procedure “normal” or would you consider me behind? When should i expect to achieve my max rom?
Thanks for your time
Kim
Kim,
I’m sorry to say that not all labral repairs are the same or even behave the same after surgery. So it is impossible to give you specific thoughts on your particular case. In general, being stiff at this point would not be uncommon but rather would be quite common. The labrum does not heal to the bone firmly for ~3 months and therefore aggressive stretching before then can, in some cases, be detrimental to the repair. I find that most patients “turn the corner” around 4 – 5 months. But complete ROM can take longer and even up to 1 year in some. You may want to discuss with your surgeon about their thoughts on your specific case.
Hope this helps. Best of luck.
I am five months post left rotor cuff repair for full thickness tear. I didn’t get to therapy until 6/21//2019 almost a full month post surgery. at this point I have been in therapy for 5 months. I have some ability to raise the arm but not overhead for very long and, not without assistance of the right hand, my main concern is the constant daily pain and stiffness of the left arm. As the day progresses the arm feels heavy from hanging down and very painful (dull achy feeling). I am still unable to sleep on the left side and stll on no lifting restriction.
I am sorry to hear that you are having trouble. Obviously I do not know enough about your particular situation but in general terms, by this point I would expect fewer symptoms and better function. The two things I would be concerned most about with a patient having your symptoms at this point post-op would be postop stiffness (arthrofibrosis) and inadequate tendon healing. The treatment for these two entities differs and therefore I recommend returning to your surgeon so that they can determine the specific issue and the best treatment going forward. be well.
I am almost 4 months out from full thickness tear and bicep re-attach with two anchors. I had good range of motion after about two months and still have good ROM. The pain and soreness emanates from my neck, bicep and scapula muscles. Also my “good” arm is developing pain and getting achy from overuse. Is this scenario typical and is there anything I should guard against at this stage? If I re-tore the repair at any stage- would I know it with painful movements? I am literally pain-free around the rotator cuff surgery site when I do my PT excercises? Thank you!
Often symptoms in these locations are due to over-use and inappropriate use of accessory muscles around the shoulder due to the limits of motion at the ball socket joint of your shoulder. Usually as the motion in the ball-socket (glenohumeral) joint improves, these symptoms improve. As for knowledge of retearing, it depends on the time after surgery. If it is shortly after the surgery, the tissue is not yet healed to the bone and so if it pulls away from the bone at this point, you would not know.
Hi my name is Haidi, I am 47 yrs old.
In my right dominant arm, I had a full thickness tare 6mmx9mm (on MRI) of my supraspinatus from a fall that happened on 26th July 2019.
My surgeon told me that I was not presenting like a patient with a tare, holding the shoulder up toward my ear & my ROM hadn’t changed from before the fall. I also saw a Physiotherapist, who said the same as my surgeon on presentation. He said I may not need to have the surgery.
As the fall happened at work, I was covered by work cover & I was thinking long term when it came to my arm. I am A Dental Assistant.
I had surgery on 10th September 2019.
At 5 weeks post op I noticed that my right arm, when doing the pully exercise was sticking out like a chicken wing & restriction in my wrist. My ROM was & still is terrible at 3months post op. I could not bring my arms together. eg/ when doing pecdec upon bringing your arms together. I have not been doing pecdec, it is not in my rehab.
I would like to know if this is part of having a stiff shoulder & a lack of external rotation?
Kind regards
It is not uncommon to have a reduced range of motion at three months after a rotator cuff repair. Often people who are stiff at 3 months after surgery can recover normal or near-normal motion with further therapy. Sometimes, unfortunately, this is not possible and patients require further surgery in order to regain better motion. I would discuss all of this with your surgeon.
Thank you Jeffrey for your reply.
I am really concerned that my chicken wing effect will never disappear. I never had that with my right arm before the surgery.
So it is because I have a stiff shoulder & lack of external rotation that my right arm when holding both arms up at a 90 degree bend from the elbow sticks out at the elbow looking like a chicken wing? I can not bring my right elbow down to meet my left elbow to touch elbow to elbow. If my shoulder comes good, the chicken wing should dissappear?
I’m sorry. I am unable to give you any reliable info without knowing all the details of your case. You may be discussing “Hornblowers sign”. I would suggest discussing your concerns with your surgeon or perhaps considering getting a second opinion. They can be very helpful sometimes. See this post: https://www.jeffreybergmd.com/two-boneheads-video-series-second-opinions/
It is Haidi again Dr Berg.
You have been the only person who has been able to maybe, identify my problem with my shoulder “Hornblowers sign”. No one is listening to me & after googling “Hornblowers Sign” & reading about it & seeing photo’s, it is the only thing that comes close to my problem. I’m not sure how I ended up with this, if it is what I have? The MRI report only mentioned full thickness tare 6mmx9mm to Supraspinatus. No mention of Infraspinatus or Terris minor? Did something happen during surgery?? Who knows. I am definitely going to seek a second opinion in Brisbane, the Capital City of the state I live in Queensland Australia. In the mean time, as it is Christmas & clinics will be closed, are there any exercises/stretches that I am doing for post-op rehab that I should avoid until my second opinion? I truely appreciate your feed back & only wish you were in Australia. I have been suffering with depression since the first time I noticed my arm, & not having any answers from my surgeon, or first Physio, upon raising these concerns with my arm, back in October 2019 have only made me worse. My working career is on the line & my job means the world to me as a Dental Assistant. Not being able to reach my head to brush, wash & put my hair up gets me down as well. I have been visiting my hairdresser once a week for the past 3months since my surgery. I am lucky though as I do have an arm that still kinda works & fingers that work, however, this is not what I expected. I have lost trust in my surgeon & have been told by him that I am overthinking things, I have a previous injury in that arm (I have never had any injury to my right arm for 47 years until I fell at work back in July 2019). He has a duty of care to his patients & that also includes answering any questions his patients may have & to allay their fears. I truely appreciate your feedback. Kind regards & Have a Merry Christmas.
Sorry Haidi for the delayed response. I am just getting back in town. It would be atypical To have a hornblower’s sign with the type of tear you describe. However without knowing all the details of your particular case, it would be hard to say. It’s possible you just have persistent weakness and stiffness after surgery which is common. If so, over time this could improve. I think it is wise to seek a second opinion. You may wish to also see someone for the “depression” you describe. These types of surgery as well as the difficult and lengthy recovery can be very disruptive to ones life on many levels. It is not uncommon for people to feel isolated, anxious and depressed. I wrote a little about it it in the context of recovering from knee ligament surgery here: https://www.jeffreybergmd.com/acl-recovery-and-returning-to-your-sport-after-acl-surgery-jeffrey-h-berg-m-d/ – but there is also quite a bit of research detailing this same issue after shoulder surgery. It is very important to maintain a positive outlook and to stay focused and engaged for optimal recovery. This can be very difficult if not impossible, if you are suffering from depression. Often assistance from professionals is needed and can be very helpful. Best of luck.
Hi. I’m almost 49 years old, and I had shoulder issues for about 7 years (no acute injury) before discovering I needed surgery. I am 14 weeks post-op rotator cuff (medium, full-thickness tear) repair and bicep tenodesis as well as extensive debridement. Wore the sling for 6 weeks (fun times!), and then started physical therapy after that. So, I’m currently 8 weeks into physical therapy and my shoulder capsule is just so very tight. I still can’t raise my arm enough to put my hair in a ponytail or shampoo the top of my head properly. Lying flat, the PT can move my arm to about 120 degrees. “Wall walks” are still pretty painful at my max ROM. I’ve been stuck in this “place” for a few weeks, although I do notice tiny improvements. Your comments on the video that “stiffness is our friend” make me feel encouraged, but I feel that I should be progressing much more quickly. I realize that rotator cuff recovery is the long game, but thought I would be “crushing it” more. Doc says 6-8 weeks more of PT, asking for more “aggressive” therapy and stretching. Also mentioned some procedure, if needed in the future, to break up scar tissue. (I really don’t want to think about this.) At what point should I be concerned that my ROM is not going to improve?
Kir, I often see people start to regain their motion at 4 months and 5 months postop. As a result, I do not get too worried before then. If a patient comes in at 5 months and there hasn’t been improvement in their motion from their 4 month visit and they have inadequate motion, that is when I consider a second procedure to help regain motion. It sounds like your surgeon and I are on the same page. Best of luck.
get PT. I had reverse shoulder surgery and have had several PT visits. Those visits have worked and I am doing other exercises at home. PT and exercise is AMAZING!!!!!!
Glad that has worked for you.