1. 1 Douglas Carlan, MD Hand and Upper Extremity Eaton Orthopaedics, LLC Carillon Outpatient Center Overcoming Rotator Cuff Injuries

2. 2 Anatomy Impingement Rotator Cuff Tear Rehab Prevention Overcoming Rotator Cuff Disease

3. 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

4. What is the Shoulder? Shoulder - 3 bones 4 joints 4 rotator cuff muscles Multiple tendons, muscles, capsule structures 4

5. 5 “Shoulder” function is coordinated relationship between 4 articulations Sternoclavicular Acromioclavicular Glenohumeral Scapulothoracic Functional Anatomy

6. 6 Clavicle - Subcutaneous s-shaped bone Muscle attachment Protective roof over thoracic outlet (vessels, brachial plexus) Bony Anatomy Scapula - Large, flattened triangle bone Numerous muscle attachments Glenohumeral Joint - Formed by humeral head and glenoid surface Large ROM at expense of stability “Golf ball and tee” analogy Stability relies on static and dynamic restraints (Rotator Cuff)

7. 7 Glenohumeral Muscles Rotator cuff muscles Supraspinatus -Abd Infraspinatus - ER Teres minor - ER Subscapularis - IR

8. 8 Glenohumeral Muscles Deltoid Large bulky muscle Tripennate origin (clavicle, acromion, scapular spine) Insertion: deltoid tubercle Very important abduction Flexion and extension

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18. 18 Impingment Rotator Cuff Tear Rotator Cuff Disease

19. 19 Most common cause of pain in the adult shoulder Imflamed or degerative tissues between humeral head and acromion Causes pain and limits movement Impingement

20. 20 Pain due to inflammation or degenerative tissue Bursistis Tendonitis Tendonopathy Partial tear of rotator cuff Impingement

21. 21 Risk Factors Idiopathic Minor Trauma Athletes in overhead sports – Swimming, baseball, tennis Repetitive lifting or overhead work – construction, painting Impingement

22. 22 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

23. Diagnosis – History – Physical exam – X-rays – outlet view – MRI – inflammation or partial tearing 23

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25. 25 Treatment – non-surgical – Rest, avoid overhead activity – NSAID’s – RC Strengthening Program – Corticosteroid Injection – Takes several weeks to months to resolve Impingement

26. 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 26

27. 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 27

28. Impingement 28

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30. 30 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

31. 31 Extrinic causes Mechanical wear, scapular dyskinesia Intrinsic causes Tendon hypovascularity, age-related degeneration, micro or macro trauma Rotator Cuff Tear

32. 32 Acute Event, Younger Patient Acute extension of Chronic Tear Event, Older Chronic insidious Rotator Cuff Tear

33. 33 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

34. Treatment Repair younger age acute muscle quality 34 Nonop elderly chronic muscle atrophy comorbidities DM, smoking, osteoporosis

35. 35 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

36. 36 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

37. 37 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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40. 40 MRI

41. 41 MRI

42. 42 Arthroscopic Repair

43. 43 Arthroscopic Repair

44. 44 Arthroscopic Repair

45. 45 Arthroscopic Repair

46. 46 Rehab Much debate When? How much? Protocol? Sling duration? Recovery

47. 47 Early PT Better early function, motion, pain level Equivalent @ 24weeks Slightly higher retear rate Conclusion Tailor plan to meet individual needs Rehabilitation