.
Mr Lee Van Rensburg
May 2014
.
.
J Bone Joint Surg Am. 2014;96:265
.

Farmer
Falls from tractor

Pain and weakness in shoulder

.
.



Diffuse pain in upper arm, following fall
X rays show some arthritis
Weakness and pain
No firm diagnosis
.
Rheumatology 2006;45:215–221
.

See’s physio - 2 weeks later




Pain slightly better
Affecting sleep
Still struggling with elevation 90°
? Rotator cuff tear
.
Why ? tear
 Jobe’s

.
.
- 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
.
175
J Shoulder Elbow Surg. 2009 Jul-Aug;18(4):529-34
.

Send back to GP ? Tear
 Refer on
 Image
 Inject

Start rehab?
.

? Tear in tendon
Special scan
Stop using it tear get worse……

Keep it moving !


.

Full thickness tear


Supraspinatus
Infraspinatus
.
1953 - 61
60-69 =30% FTRCT
1936 - 78
70-79 = 50% FTRCT
1930 - 84
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
.
Surgery
Rehabilitation
.
Agency for healthcare research and quality
USA July 2010
.

1 study
.
Age 59 (44-75)
Age 61 (46-75)
Symptoms 10 - 12 months
+- 50:50 traumatic and atraumatic
J BJS - Br January 2010 vol. 92-B no. 1 83-91
.
J BJS - Br January 2010 vol. 92-B no. 1 83-91
.
Constant score
Satisfaction
Physiotherapy 7.2 (1-10)
Surgery 9 (1-10)
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
J BJS - Br January 2010 vol. 92-B no. 1 83-91
.
Surgery did better
BUT
42 Happy not surgery
9 no surgery
constant score 7.5 less
J BJS - Br January 2010 vol. 92-B no. 1 83-91
.
.

N = 37





F/U ave. 7.0 years (range, 1 - 21 years)
Abduction





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)
Group 1 = 168°
Group 2 = 126°
Group 3 = 129°
Pain relief good for all
Repair best within 3 weeks
Clin Orthop 1983;175:18-24.
.


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
J Shoulder Elbow Surg (2011) 20, 62-68
.
Surgery
Rehabilitation
.







Anaesthetic
Infection
Stiffness
Incomplete resolution
Recurrence
Re tear
Rehab
.



Day case overnight stay
60-80% better
Sling
3 weeks
 6 weeks social protection



Nothing heavier cup of tea 6 weeks
Drive 6-8 weeks (2 weeks)



Desk top 4-6 weeks
Manual work 3 months
Healed


6 weeks 60%
3 months 80%
.

Non operative
Relative rest
 NSAID
 Physio
 Steroid injection (controversial)
 Supra scapular nerve block


Operative
3 months
JSES - 2008;17:863-870
.


Non operative
Operative

Arthroscopic
 Debridement
 Reverse decompression
 Biceps tenotomy
 Suprascapular nerve ablation

Open
 Reverse shoulder replacement
3 months
JSES - 2008;17:863-870
.
.
.
.
.

Many different types of procedures

Standard anaesthetic
Wound closure
Initial recovery


.



Sling till arm awake
Stay out of kitchen
Most wear off 8 Hours

Pre emptive analgesia
.

Subcuticular prolene suture
.

Steristrips
.

Mepore Dressings
.

Pad
.

Sling (Rotator Cuff Repair)
.
J Shoulder Elbow Surg (2011) 20, 326-332
.
J Shoulder Elbow Surg (2012) 21, 61-65