SAR Ebrahimzadeh MD
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…
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)
.
Rotator cuff tear
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
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
Etiology
 Acute 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.
etiology
 Factors contributes to degenerative or chronic tear:
 Repetitive stress: such as
Baseball, tennis, weightlifting
 lack of blood supply
 Bone spurs
symptom
 Pain at rest, when lifting.
 Weakness when lifting or rotating arm.
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
treatment
 Conservative:
 In about 50% of patients nonsurgical treatment relives
pain and improves function, but shoulder strength does
not usually improve without surgery.
conservative
 Conservative options:
 Rest:

Rest and limiting overhead activities.
 Activity modification.
 Nsaid:

such as naproxen, ibuprofen.
 Physical therapy.
 Stroeid injection.
 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
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.
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.
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.
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.
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.
MRI
Surgical treatment
 Surgery is required:
 in patients under 60 years old.
 Failure to improve after 6-8 weeks of physiotherapy.
 Highly activity level demanded.
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.
Surgical treatments
 Techniques:
 Open surgery.
 Minimal invasive surgery.
 Arthroscopic surgery.
 Each of techniques available has its own advantage
and disadvantage.
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.
Surgical treatment
Surgical treatment
Surgical treatment
Surgical treatment
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.
Surgical treatment
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.
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.
Surgical treatment
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.
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.
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.
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.
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.
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.
‫با تشكر‬