1. . Mr Lee Van Rensburg 2014

2. .

3. . J Bone Joint Surg Am. 2014;96:265

4. .  Farmer  Falls from tractor  Pain and weakness in shoulder

5. .

6. .  Diffuse pain in upper arm, following fall  X rays show some arthritis  Weakness and pain

7. .  See’s physio - 2 weeks later  Pain slightly better  Affecting sleep  Still struggling with elevation 90°  ? Rotator cuff tear

8. .  Why ? tear  Jobe’s

9. .

10. . - Apley's Scratch Test - Jobes Supraspinatus test - Dawburn's sign - Sherry Party sign - Codman's Sign (Drop Arm Sign) - Rent Test - Zero Degree Abduction Test - Burkhead's Thumbs down & Burkhead's Thumbs up

11. . J Shoulder Elbow Surg. 2009 Jul-Aug;18(4):529-34 175

12. .  Image  Inject  Start rehab?

13. .  ? Tear in tendon  Special scan  Stop using it tear get worse……  Keep it moving !

14. .  Full thickness tear  Supraspinatus  Infraspinatus

15. . 60-69 =30% FTRCT 70-79 = 50% FTRCT 80-89 = 80% FTRCT Age-related prevalence of rotator cuff tears in asymptomatic shoulders; Tempelhof et al; JSES July 1999 (Vol. 8, Issue 4, Pg 296-299 1953 - 61 1930 - 84 1936 - 78

16. . Surgery Rehabilitation

17. . Agency for healthcare research and quality USA July 2010

18. .  1 study

19. . J BJS - Br January 2010 vol. 92-B no. 1 83-91 Age 59 (44-75) Age 61 (46-75) Symptoms 10 - 12 months +- 50:50 traumatic and atraumatic

20. . J BJS - Br January 2010 vol. 92-B no. 1 83-91

21. . Constant score Satisfaction Physiotherapy 7.2 (1-10) Surgery 9 (1-10)

22. . J BJS - Br January 2010 vol. 92-B no. 1 83-91 Secondary surgery group Delay in surgery 5 months Final outcome 7.5 points less constant score

23. . J BJS - Br January 2010 vol. 92-B no. 1 83-91 42 Happy not surgery 9 no surgery constant score 7.5 less Surgery did better BUT

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25. . Clin Orthop 1983;175:18-24.  N = 37  Group 1 – Operated within 3 weeks (n=12)  Group 2 – Operated within 3 to 6 weeks (n=6)  Group 3 – Operated within 6-12 weeks (n=19)  F/U ave. 7.0 years (range, 1 - 21 years)  Abduction  Group 1 = 168°  Group 2 = 126°  Group 3 = 129°  Pain relief good for all  Repair best within 3 weeks

26. . J Shoulder Elbow Surg (2011) 20, 62-68  N= 36  3 groups  Group 1 - 0-8 weeks  Group 2 - 8-16 weeks  Group 3 - > 16 weeks All improved Pain 7 down to 1 Elevation 55 to 133

27. . Surgery Rehabilitation

28. .  Anaesthetic  Infection  Stiffness  Incomplete resolution  Recurrence  Re tear  Rehab

29. .  Day case overnight stay  60-80% better  Drive 6-8 weeks (2 weeks)  Desk top 4-6 weeks  Manual work 3 months  Healed  6 weeks 60%  3 months 80%

30. .

31. .  Sling till arm awake  Stay out of kitchen  Most wear off 8 Hours  Pre emptive analgesia

32. .  Many different types of procedures  Single row Vs double row  Multiple anchor variations  Knotless anchors  Metal vs PEEK Vs Absorbable  Biological, vented

33. .

34. . - “footprint” (Smith & Nephew)

35. .  Double-row have  Significantly lower re-tear rate  Higher ASES score  Greater range of motion of internal rotation  Particularly in tears >30 mm J Shoulder Elbow Surg (2014) 23, 182-188

36. .  Single row resulted in significantly higher re- tear rates compared with double-row repairs  No detectable differences in improvement in outcomes scores between single-row and double-row repairs Shoulder Elbow Surg (2014) 23, 586-597

37. .  Sling  3 weeks all time  except when doing physio/ bath or shower  6 Weeks or social protection  Assisted range of movement  “Nothing heavier than a cup of tea 6 weeks”  No strengthening 6 weeks

38. . J Shoulder Elbow Surg (2014) 23, 1631-1639

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40. .

41. .  Mepore Dressings

42. .  Pad

43. . J Shoulder Elbow Surg (2011) 20, 326-332

44. . J Shoulder Elbow Surg (2012) 21, 61-65

45. .  Non operative  Relative rest  NSAID  Physio  Steroid injection (controversial)  Supra scapular nerve block  Operative JSES - 2008;17:863-870 3 months

46. .  Non operative  Operative  Arthroscopic  Debridement  Reverse decompression  Biceps tenotomy  Suprascapular nerve ablation  Open  Reverse shoulder replacement JSES - 2008;17:863-870 3 months