2. Rotator cuff tearing and treatment
SAR Ebrahimzadeh MD

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…

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) .

5. Rotator cuff tear

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

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

8. Etiology Acute tear: Chronic (degenerative) 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.

9. etiology Factors contributes to degenerative or chronic tear:
Repetitive stress: such as
Baseball, tennis, weightlifting
lack of blood supply
Bone spurs

10. symptom Pain at rest, when lifting.
Weakness when lifting or rotating arm.

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

13. treatment Conservative:
In about 50% of patients nonsurgical treatment relives pain and improves function, but shoulder strength does not usually improve without surgery.

14. conservative Conservative options: Rest: Activity modification. Nsaid:
Rest and limiting overhead activities.
Activity modification.
Nsaid:
such as naproxen, ibuprofen.
Physical therapy.
Stroeid injection.

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

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.

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.

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.

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.

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.

21. MRI

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.

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.

24. Surgical treatments Techniques:
Open surgery.
Minimal invasive surgery.
Arthroscopic surgery.
Each of techniques available has its own advantage and disadvantage.

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.

26. Surgical treatment

27. Surgical treatment

28. Surgical treatment

29. Surgical treatment

30. 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.

31. Surgical treatment

32. 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.

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.

34. Surgical treatment

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.

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.

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.

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.

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.

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.

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