1. Rotator Cuff injuries Assignment

2. Rotator Cuff injuries : is a common cause of pain and disability among adults. In 2008, close to 2 million people in the United States went to their doctors because of a rotator cuff problem. A torn rotator cuff will weaken your shoulder. This means that many daily activities, like combing your hair or getting dressed, may become painful and difficult to do.

3. Anatomy : Shoulder is made up of three bones: Upper arm bone (humerus), Shoulder blade (scapula), and your collarbone (clavicle). The shoulder is a ball- and-socket joint: The ball, or head, of your upper arm bone fits into a shallow socket in your shoulder blade.

5. Humerus is kept in shoulder socket by rotator cuff. The rotator cuff is a network of four muscles that come together as tendons to form a covering around the head of the humerus. The rotator cuff attaches the humerus to the shoulder blade and helps to lift and rotate arm.

7. There is a lubricating sac called a bursa between the rotator cuff and the bone on top of your shoulder (acromion). The bursa allows the rotator cuff tendons to glide freely when you move your arm. When the rotator cuff tendons are injured or damaged, this bursa can also become inflamed and painful.

8. Causes: There are two main causes of rotator cuff tears: injury and degeneration. Acute Tear If you fall down on your outstretched arm or lift something too heavy with a jerking motion, you can tear your rotator cuff. This type of tear can occur with other shoulder injuries, such as a broken collarbone or dislocated shoulder.

10. Degenerative Tear Most tears are the result of a wearing down of the tendon that occurs slowly over time. This degeneration naturally occurs as we age. Rotator cuff tears are more common in the dominant arm. If you have a degenerative tear in one shoulder, there is a greater risk for a rotator cuff tear in the opposite shoulder -- even if you have no pain in that shoulder.

11. Several factors contribute to degenerative, or chronic, rotator cuff tears. Repetitive stress. Repeating the same shoulder motions again and again can stress your rotator cuff muscles and tendons. Baseball, tennis, rowing, and weightlifting are examples of sports activities that can put you at risk for overuse tears. Many jobs and routine chores can cause overuse tears, as well. Lack of blood supply. As we get older, the blood supply in our rotator cuff tendons lessens. Without a good blood supply, the body's natural ability to repair tendon damage is impaired. This can ultimately lead to a tendon tear.

12. Bone spurs. As we age, bone spurs (bone overgrowth) often develop on the underside of the acromion bone. When we lift our arms, the spurs rub on the rotator cuff tendon. This condition is called shoulder impingement, and over time will weaken the tendon and make it more likely to tear.

13. Signs and symptoms: Pain Weakness Decreased range of motion Clicking Catching Stiffness Crepitus

14. Diagnosis: Examination of a patient with suspected rotator cuff injuries includes a systematic approach to the shoulder, cervical spine, and upper extremity involving the following: Inspection: Look for any scars, color, edema, deformities, muscle atrophy, asymmetry Palpation of the bony and soft-tissue structures: Note any areas of tenderness Range of motion (active and passive): Note any pain elicited and loss of motion Strength testing: Compare bilaterally, and note any differences Special shoulder tests

15. MRI

16. Management: The goals of treatment for rotator cuff injuries are to reduce inflammation, relieve stress on the rotator cuff, and correct any biomechanical dysfunction. Conservative therapy Patients with chronic injuries that have progressed to a rotator cuff tear may be treated conservatively with the following : Rest and activity modification Shoulder sling Nonsteroidal anti-inflammatory drugs (NSAIDs) Corticosteroid injections Basic shoulder-strengthening programs If NSAIDs alone do not provide adequate pain relief, consider adding acetaminophen to the treatment regimen.

17. Corticosteroids Injections

18. Physical therapy Patients with pain, whose function is reasonably maintained, are suitable candidates for non- operative management which includes oral medications that provide pain relief such as anti- inflammatory agents, topical pain relievers such as cold packs. An alternative to injection is iontophoresis, a battery-powered patch which "drives" the medication to the target tissue. A sling may be offered for short-term comfort, with the understanding that undesirable shoulder stiffness can develop with prolonged immobilization.

19. Early physical therapy may afford pain relief with modalities (e.g. iontophoresis) and help to maintain motion. Ultrasound treatment is not efficacious. As pain decreases, strength deficiencies and biomechanical errors can be corrected. A conservative physical therapy program begins with preliminary rest and restriction from engaging in the event which gave rise to the symptoms.

20. Under normal situations, inflammation can usually be controlled within one to two weeks, using a Non-steroidal anti-inflammatory drug (NSAID) and subacromial steroid injections to decrease inflammation, to the point that pain has been significantly decreased to make stretching tolerable. After this short period of one to two weeks rapid stiffening and an increase in pain can result if sufficient stretching has not been implemented.

21. A gentle, passive range-of-motion program should be started to help prevent stiffness and maintain range of motion during this resting period. Exercises, for the anterior, inferior, and posterior shoulder, should be part of this program. Codman exercises (giant, pudding, stirring), to "permit the patient to abduct the arm by gravity, the supraspinatus remains relaxed, and no fulcrum is required," are widely used..

22. The use of NSAIDs; hot and cold packs; and physical therapy modalities, such as ultrasound, phonophoresis, or iontophoresis, can be instituted during this stretching period, if effective.Injections are recommended two to three months apart with a maximum of three injections. Multiple steroid injections (four or more) have been shown to compromise the results of rotator cuff surgery which result in weakening of the tendon. Before any rotator cuff strengthening can be started, the shoulder must have a full range of motion

23. After a full, painless range of motion is achieved, the patient may advance to a gentle strengthening program. Rockwood coined the term orthotherapy to describe this program. The program is aimed at creating an exercise regimen that initially gently improves motion, then gradually improves strength in the shoulder girdle. Each patient is given a home therapy kit, which includes elastic bands of six different colors and strengths; a pulley set; and a three piece, one meter-long stick.

24. The program is customized to each individual patient, fitting the needs of the patient and altering when necessary. Patients are asked to do all their home exercise program on their own whether that be at home, at work, or when traveling.

25. Surgery There are several instances in which non- operative treatment would not be suggested. The first is the 20 to 30-year-old active patient with an acute tear and severe functional deficit from a specific event. The second is the 30 to 50-year- old patient with an acute rotator cuff tear secondary to a specific event. The third instance is the highly competitive athlete who is primarily involved in overhead or throwing sports.

26. These patients need to be treated operatively because rotator cuff repair is necessary for restoration of the normal strength required to return these athletes to the same competitive preoperative level of function. Patients who do not respond or are unsatisfied with conservative treatment should seek an opinion concerning surgery.

27. Emergent orthopedic evaluation is warranted in acute injuries or even severe extension of chronic rotator cuff injuries, because they have a poor prognosis with conservative modalities.

28. The three general surgical approaches are arthroscopic, mini open, and open-surgical repair. In the recent past small tears were treated arthroscopically, while larger tears would usually require an open procedure. Advances in the procedure now allow arthroscopic repair of even the largest tears, and arthroscopic techniques are now required to mobilize many of the retracted tears.

29. The results now match open surgical techniques, while permitting a more thorough evaluation of the shoulder at the time of surgery, increasing the diagnostic value of the procedure, as other conditions may simultaneously cause shoulder pain. Arthroscopic surgery allows for a shorter recovery time and predictably less pain in the first few days following the procedure.

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