Friday, November 1, 2013

Management of an athlete with a cuff tear - real life story

Here is a real life dialogue demonstrating some of the complexities of rotator cuff tear management. We've not examined the patient or seen the imaging, but the story gives a point of departure for a bit of discussion.

The individual is a 54 year old world class triathlete who was injured this fall when a pedestrian crashed into her right shoulder after a competition. A MRI showed tears of the supra and infraspinatus. However, the shoulder had had lingering pain on and off the prior summer making it difficult for her to swim. She received 4 cortisone shots that got her through the major triathlons over the summer; the first two helped but the last two had no beneficial effect.

Question 1 is whether this is an acute tear or an acute extension of a chronic tear.  The antecedent 'lingering' pain on swimming and the transient response to steroid injections would suggest the cuff had damage prior to the 'crash'.

Question 2 is whether steroid injections are a good idea to 'help through the season'. One would think that rotator cuff imaging prior to considering injections would be helpful to make sure of the diagnosis. Steroid injections into deteriorating tendons of a highly competitive athlete need careful consideration.

Question 3 is how urgent is surgery in a case like this. Our view is that a sudden increase in weakness after an injury merits an urgent imaging study, such as an MRI or ultrasound. If the patient and the shoulder seem good candidates for repair, sooner surgery may be better than waiting to minimize the chances of bone, tendon and muscle deterioration.

Question 4 is whether open vs arthroscopic repair is better. While most surgeons now prefer arthroscopic cuff repair, we continue to use open repair to a trough in the tuberosity with multiple sutures to distribute the load. We recall that the time to recovery does not depend on the surgical approach but on the quality of the fixation.

Question 5 is what if the cuff cannot be repaired with good tendon approximated to bone without undue tension with the arm at the side. Our approach is shown here: rotator cuff surgery.

There are no absolute right and wrong answers, but the discussion of alternatives is important.

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