Sunday, September 18, 2011

Rotator Cuff 9 - Management of rotator cuff tears

As you can imagine, many factors go into the decision regarding management of rotator cuff tears. On one hand, acute rotator cuff tears from a major injury resulting in major weakness in a young healthy active person are often viewed as matters of surgical urgency. On the other hand, chronic rotator cuff tears of insidious onset in a relatively inactive person with conditions that may increase the risk of surgery often deserve a trial of gentle range of motion exercises to resolve any shoulder stiffness followed by some gentle shoulder strengthening exercises before surgery is considered.

Partial Thickness Tears
Partial thickness rotator cuff tears produce symptoms because the muscle is pulling on an unstable tendon attachment to bone resulting in uneven distribution of force. As in the case of the conditions known as tennis elbow (lateral ‘epicondylitis’), biceps ‘tendonitis,’ Achilles ‘tendonitis,’ and patellar ‘tendonitis,’ the primary pathology is not inflammation as the suffix ‘itis’ might imply, but rather a partial tendon detachment from bone. In these situations a disproportionate share of the load is borne by the fibers at the edge of the tear – as when a zipper is pulled apart, the load is on the last intact link. When load is applied to the affected tendon, the area of the partial tear becomes painful – a positive tendon sign. If the detachment were complete, as in a complete rupture of the biceps or Achilles tendons, pull on the tendon would be painless. Often these conditions are associated with stiffness of the joint in the direction that stretches the tendon – lack of extension of the elbow in tennis elbow, lack of ankle dorsiflexion in Achilles tendonitis, or lack of internal rotation in partial thickness cuff tears.

For each of these conditions, treatment may include (1) stretching the tendon until the stiffness is resolved and the load at the tendon attachment is distributed evenly among the fibers remaining intact, (2) release of insecurely attached fibers so that the load is only borne by those that robustly connect the tendon to bone (as in a tennis elbow release), or (3) reattachment of the partially detached fibers. The difficulty with the latter approach lies in reconstructing the isometry of the tendon attachment. Taking the Achilles tendon with a lateral one-third tear as an example, reattachment of the torn portion of tendon is likely to result in its being disproportionately tight, so that when the attached muscle contracts, the repaired part of the tendon takes the preponderance of the load and risks retear. For the same reason, repairs of tennis elbow are less successful in relieving symptoms than selective releases.

Full Thickness Tears
Acute full thickness tears merit consideration for early repair before tendon resorption and muscle atrophy can occur. Chronic tears merit consideration for repair if there is evidence of good residual muscle and tendon. Symptoms from irreparable tears may respond to smoothing of the humeroscapular motion interface.


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