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Rotator cuff tearing and treatment. SAR Ebrahimzadeh MD. Rotator cuff tearing and treatment. A rotator cuff tear is a common cause of pain and disability among adults Difficulties are: Dressing Combing Painting Swimming ETC…. Anatomy.
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Rotator cuff tearing and treatment SAR Ebrahimzadeh MD
Rotator cuff tearing and treatment • A rotator cuff tear is a common cause of pain and disability among adults • Difficulties are: • Dressing • Combing • Painting • Swimming • ETC…
Anatomy • Rotator cuff made by tendons of four muscles covering around the head of humerous • These muscles are supraspinatous, infraspinatous, tress minor (back),subscapularis (anterior) • .
Anatomy • A lubricating sac (bursa) is between the rotatorcuff and acromion, the bursa allowes the rotatorcuff tendons to glide freely during arm movement • When the rotatorcuff injured or damaged this borsa can become inflamed and painfull
Rotatorcuff tearing and treatment • The tendon may tear partialy or complet • Most tears occure in supraspinatous but other parts of rotatorcuff may also be involved
Etiology • Acute tear: • Fall on out streched arm • Heavy lifting with jerking motion • Fx dislocation • Chronic (degenerative) tear • Most tears are result of a wearing down over time especially in dominant arm. • If we have a degenerative tear in one shoulder there is a greater risk for a rotator cuff tear in opposite shoulder even if there is no pain in that shoulder.
etiology • Factors contributes to degenerative or chronic tear: • Repetitive stress: such as Baseball, tennis, weightlifting • lack of blood supply • Bone spurs
symptom • Pain at rest, when lifting. • Weakness when lifting or rotating arm.
treatment • Goal of any treatment is to: • Reduce pain • Improve function • A rotator cuff tear can get larger over time. • Several treatment options are for a rotator cuff tear and the best option is different for every patient. • Because there is no evidence of better results from early or later surgery, many doctors first recommend nonsurgical management
treatment • Conservative: • In about 50% of patients nonsurgical treatment relives pain and improves function, but shoulder strength does not usually improve without surgery.
conservative • Conservative options: • Rest: • Rest and limiting overhead activities. • Activity modification. • Nsaid: • such as naproxen, ibuprofen. • Physical therapy. • Stroeid injection.
Stroeid injection • If rest, activity modification, medication, physical therapy do not relieve pain, an injection of a local anesthetic and cortisone preparation may be helpful
Stroeid injection • Injection are recommended 2 to 3 months a part with a maximum of three injection. • Multiple injection 4 or more compromise the results. • However patients are re-evaluated through the course of treatment and may move from one group to the other.
Conservative treatment • After trauma a sling may be offered for comfort for a day or two. With the awareness that the shoulder can become stiff with prolonged immobilization the duration of rest is short. • After short period of immobilization rapid stiffening and an increase in pain can result if sufficient stretching has not done.
Conservative treatment • Codman exercise permit patient to abduct the arm by gravity. • Home therapy is very important by a especially kit. • Patient are asked to do during be, at home, at work, or when traveling.
Surgical treatment • Indication: • Continued pain in spite of conservative treatment is the main indication for surgery. 1)Symptoms have lasted 6 to 12 months . 2)Tear in more than 3cm or complex. 3)Significant weakness and loss of function. 4)Tear was caused by a recent acute injury.
Treatment • Surgical treatment: • Surgery is reattaching the tendon to the humeral head or suturing two sides of tendon back together. • In partial tearing may need only debridement.
Surgical treatment • Surgery is required: • in patients under 60 years old. • Failure to improve after 6-8 weeks of physiotherapy. • Highly activity level demanded.
Surgical treatment • Goal of treatment in all techniques is : • Pain relief. • Strength improvement. • Overall patients satisfaction. • Traditional open repair: • If tear is large or complete, after incision (6-10cm) over the shoulder and detachment deltoid muscle we have to remove spurs from the under surface of the acromion (acromioplasty) . • Sub acromial decompression consist of removal of a small portion of acromial hoping to relieve pressure on the rotator cuff and promote healing and recovery. • So combining acromioplasty and repairing of the tear produces better results.
Surgical treatments • Techniques: • Open surgery. • Minimal invasive surgery. • Arthroscopic surgery. • Each of techniques available has its own advantage and disadvantage.
Surgical treatment • Techniques: • Type of repair depends on several factor includes: • Experience of surgeon. • The size of tear. • Anatomy and quality of tendon tissue and bone. • In addition to a rotator cuff tear each shoulder may have other problems such as: • Osteoarthritis. • Bone spurs. • Other soft tissue tears.
Surgical treatment • Traditional open repair is a good option if the tear is large or additional reconstruction such as a tendon transfer is indicated. • Open repair was the first technique used for rotator cuff tear for years. • If the tissue quality is poor we may use a mesh to reinforce the repair. • Fatty atrophy in the rotator cuff shown by MRI (the best technique for diagnosis rotator cuff tear) prior to surgery is predicative of a poor surgical outcome.
Surgical treatment • Minimal invasive: • Over the years new technology and improved surgeon experience has led to less invasive procedures. • Through the mini incision (3-5cm) we repair the rotator cuff and view the shoulder structures directly . • In this type we avoid to detach the deltoid muscle and by arthroscope we assess and treat damage to structures with in the joint for example bone spur.
Surgical treatment • Arthroscopic repair: • This type of repair is a least invasive method to repair a torn rotator cuff and usually is an out patient procedure.
complications • In addition to the risks of surgery in general blood loss or problems related to anesthesia complication are include: • Nerve injury. • Infection. • Deltoid detachment. • Stiffness: this complication will improve with more aggressive therapy and exercise. • Tendon re-tear: the larger the tear the higher the risk of re-tear, repeat surgery is needed if there is sever pain or loss of function.
Rehabilitation • Rehabilitation plays a vital role to getting back daily activities: • Immobilization, nearly 4 to 6 weeks sling and avoid moving shoulder. • This time of immobilization depends upon the severity of injury. • Passive exercise: • When it is safe to move shoulder physiotherapist can help with passive exercise to improve rang of motion. • We usually begin passive exercises with in the firs 4 to 6 weeks after surgery.
Rehabilitation • Active exercises: • After 4-6 weeks we progress active exercises by moving arm muscles gradually increases strength and improves arm control. • At 8-12 weeks patients can start on a strengthening exercise program. • Expect a complete recovery take several months.
Rehabilitation • Most patients have a functional range of motion and adequate strength by 4-6 months after surgery. Although it is a slow process. • Commitment of patients to rehabilitation is key to a successful outcome.
Rehabilitation • Each surgical technique (open, mini open, arthroscopic) has similar results in term of: • Pain relief. • Improvement in strength. • Improvement function. • Patient satisfaction. • Surgeon experience is more important than the choice of technique.
Rehabilitation • Factors that can decrease a satisfaction results include: • Poor tendon quality. • Large tear. • Poor patient compliances with rehabilitation. • Patient age (older than 65 years). • Smocking. • Workers compensation claims.
