Saturday, December 3, 2011

Rotator cuff tears - how do the symptoms relate to the treatment?

Reflecting on all the patients I've seen for the last 40 years with rotator cuff tears a few observations emerge. While these may seem obvious, they continue to emerge as elements of our discussions with patients about the management of their cuff tear.

Acute traumatic cuff tear: A forceful tear of previously healthy rotator cuff tendon in an otherwise healthy shoulder and patient does best if a technically excellent rotator cuff repair is performed soon after the injury.

Atraumatic cuff tear: Tendons that fail with minimal force are by definition of suboptimal quality. "Repairing" these tears does not restore the tendon to normal quality any more than sewing up holes in worn jeans restores them to their original quality. Furthermore, repairing large tears when there is tissue missing comes at the expense of tightening and putting the repair under tension which may, in turn, challenge the repair.

Chronic cuff tear: A rotator cuff tear that has been present for over several months is chronic. The longer the duration of the tear, the more likely that tendon quantity and quality have been lost. The longer the duration of the tear, the more likely that the muscle attached to the tendon has atrophied. So, in this situation we have time to consider what is causing the symptoms. Is the patient's problem primarily weakness, catching/popping, stiffness, or cuff tear arthropathy.? The thing to realize is that with chronic rotator cuff tears, we've got time to try non-operative management. If the shoulder is weak, we can try home exercises for the weak shoulder. These are often surprisingly helpful even in the presence of a rotator cuff tear. If the shoulder is stiff, we can try home exercises for the stiff shoulder.
If the shoulder remains stiff or if catching/popping is troublesome for patient, a 'smooth and move' is a strong consideration when the tendon lacks the quantity and quality for a robust and durable rotator cuff repair. This procedure may not only release adhesions and resolve subacromial roughness, it may also lessen pain by removing the inflamed synovium associated with full thickness tears. The smooth and move has the advantage of allowing active use of the shoulder immediately after surgery, without the prolonged period of immobilization that is necessary to protect a rotator cuff repair. In performing this procedure we do not perform a 'decompression' or 'acromioplasty' in that these procedures put the shoulder at risk for instability, anterosuperior escape, and pseudoparalysis as shown below.

In the presence of anterosuperior escape and pseudoparalysis, salvage of the situation may require a reverse total shoulder arthroplasty.


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