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Douglas Carlan, MDHand and Upper Extremity

Eaton Orthopaedics, LLCCarillon Outpatient Center

Overcoming Rotator Cuff Injuries

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• Anatomy• Impingement• Rotator Cuff Tear• Rehab• Prevention

Overcoming Rotator Cuff Disease

Rotator Cuff Disease

• Common cause of disability in adults• Simple tasks may be painful• 2,000,000 doctor visits• 400,000 Americans/yr - surgery for RC dz• 200,000 Repairs

• Prevalence • Asx adults >60yo - 28% tear• Asx adults >80yo - 51% tear 3

What is the Shoulder?

• Shoulder -• 3 bones• 4 joints• 4 rotator cuff muscles• Multiple tendons, muscles, capsule

structures

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“Shoulder” function is coordinated relationship between 4 articulations

SternoclavicularAcromioclavicularGlenohumeralScapulothoracic

Functional Anatomy

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Clavicle - Subcutaneous s-shaped boneMuscle attachmentProtective roof over thoracic outlet (vessels, brachial plexus)

Bony Anatomy

Scapula - Large, flattened triangle boneNumerous muscle attachments

Glenohumeral Joint - Formed by humeral head and glenoid surfaceLarge ROM at expense of stability“Golf ball and tee” analogyStability relies on static and dynamic restraints (Rotator Cuff)

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Glenohumeral MusclesRotator cuff muscles

Supraspinatus -Abd

Infraspinatus - ER

Teres minor - ER

Subscapularis - IR

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Glenohumeral MusclesDeltoid

• Large bulky muscle

• Tripennate origin (clavicle, acromion, scapular spine)

• Insertion: deltoid tubercle

• Very important abduction

• Flexion and extension

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• Impingment• Rotator Cuff Tear

Rotator Cuff Disease

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• Most common cause of pain in the adult shoulder

• Imflamed or degerative tissues between humeral head and acromion

• Causes pain and limits movement

Impingement

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• Pain due to inflammation or degenerative tissue

• Bursistis• Tendonitis• Tendonopathy• Partial tear of rotator cuff

Impingement

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• Risk Factors

• Idiopathic• Minor Trauma • Athletes in overhead sports– Swimming, baseball, tennis

• Repetitive lifting or overhead work– construction, painting

Impingement

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• Symptoms• Minor pain – activity and at rest• Pain in anterior and lateral shoulder• Pain with reaching or lifting• Night pain• Pain when lowering arm from elevation• Pain with overhead sports• Tenderness• Loss of Motion

Impingement

Impingement

• Diagnosis– History– Physical exam– X-rays – outlet view– MRI – inflammation

or partial tearing

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• Treatment – non-surgical– Rest, avoid overhead activity– NSAID’s– RC Strengthening Program– Corticosteroid Injection– Takes several weeks to months to resolve

Impingement

Impingement• Treatment – surgical– Failed non-op treatment– Goal is to create more space

for the rotator cuff. Avoid “impinging”

– Subacromial Decompression• Arthroscopically remove

the anterior edge of the acromion, remove bursal tissue, evaluate the remainder of the shoulder

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Impingment

• Post-surgical– Sling for 1-2 weeks as

needed– Begin exercises in

first or second week– 2-4 months for

complete relief of pain

– May take up to 1 year

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Impingement

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• Common source of pain• Incidence increases with age 50-60’s• Caused by degeneration of the tendon• Can be caused by acute trauma – usually

younger population• Incidence is up to 50% in people without

symptoms – highest in older population• Can have tear with normal, functioning

shoulder

Rotator Cuff Tear

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• Extrinic causes• Mechanical wear, scapular dyskinesia

• Intrinsic causes• Tendon hypovascularity, age-related

degeneration, micro or macro trauma

Rotator Cuff Tear

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• Acute • Event, Younger Patient

• Acute extension of Chronic Tear• Event, Older

• Chronic• insidious

Rotator Cuff Tear

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Rotator Cuff Tear

• Natural History• A high number of patients over 60 have RCT• Not all symptomatic• 40% of those with tears with enlarge• 80% of enlarging tears become symptomatic• Once symptoms develop, likely to worsen

Treatment

• Repair

• younger age• acute• muscle quality

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• Nonop

• elderly• chronic• muscle atrophy• comorbidities

• DM, smoking, osteoporosis

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• Treatment – non-surgical• Activity modification, Gentle therapy• 50% of patients with relief.• Better in pts with shorter duration of

symptoms and small tears.• May become symptomatic in the future, tear

may enlarge• Nonop vs repair study (<3cm)- better

outcome in repair group but small difference

Rotator Cuff Tear

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• Treatment – surgical• Younger patients• Weakness• Traumatic tears• Large tears• Repair tendon back to humeral head• Many methods, all have shown success

• Open versus Arthroscopic

Rotator Cuff Tear

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• Arthroscopic Repair• 80-95% satisfactory results – pain relief and

functional gains• Rehab – long and slow

• 6 weeks in sling• 3 months until strengthening• 4-6 months until functional recovery

Rotator Cuff Tear

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MRI

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MRI

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Arthroscopic Repair

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Arthroscopic Repair

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Arthroscopic Repair

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Arthroscopic Repair

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• Rehab• Much debate• When?• How much?• Protocol?• Sling duration?

Recovery

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• Early PT• Better early function, motion, pain level • Equivalent @ 24weeks• Slightly higher retear rate

• Conclusion• Tailor plan to meet individual needs

Rehabilitation