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.

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Slide 2 SAR Ebrahimzadeh MD Slide 3 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 Slide 4 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). Slide 5 Rotator cuff tear Slide 6 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 Slide 7 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 Slide 8 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. Slide 9 etiology Factors contributes to degenerative or chronic tear: Repetitive stress: such as Baseball, tennis, weightlifting lack of blood supply Bone spurs Slide 10 symptom Pain at rest, when lifting. Weakness when lifting or rotating arm. Slide 11 Slide 12 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 Slide 13 treatment Conservative: In about 50% of patients nonsurgical treatment relives pain and improves function, but shoulder strength does not usually improve without surgery. Slide 14 conservative Conservative options: Rest: Rest and limiting overhead activities. Activity modification. Nsaid: such as naproxen, ibuprofen. Physical therapy. Stroeid injection. Slide 15 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 Slide 16 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. Slide 17 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. Slide 18 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. Slide 19 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. Slide 20 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. Slide 21 MRI Slide 22 Surgical treatment Surgery is required: in patients under 60 years old. Failure to improve after 6-8 weeks of physiotherapy. Highly activity level demanded. Slide 23 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. Slide 24 Surgical treatments Techniques: Open surgery. Minimal invasive surgery. Arthroscopic surgery. Each of techniques available has its own advantage and disadvantage. Slide 25 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. Slide 26 Surgical treatment Slide 27 Slide 28 Slide 29 Slide 30 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. Slide 31 Surgical treatment Slide 32 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. Slide 33 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. Slide 34 Surgical treatment Slide 35 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. Slide 36 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. Slide 37 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. Slide 38 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. Slide 39 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. Slide 40 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. Slide 41