Thursday, April 21, 2016

Rotator cuff tears and shoulder stiffness

The effect of concomitant glenohumeral joint capsule release during rotator cuff repair-a comparative study.

These authors reviewed 25 patients who had rotator cuff repairs along with management of concomitant shoulder stiffness (manipulation without or with capsular release). These shoulders were different than a group of shoulders having cuff repair only:

The stiff patients tended to have smaller and partial thickness tears, to have diabetes and to have shorter symptom duration.

The patients with cuff repair and concurrent management had results comparable to those of the patients without stiffness. 

Stiffness can be a major part of the symptomatology of cuff pathology as shown in this article:

These authors used MRI to investigate the prevalence of rotator cuff lesions in a a series of 379 patients with stiff shoulders (excluding those with traumatic etiology, diabetes, or radiographic abnormalities).
Group 1 included 89 shoulders with severe and global loss of passive motion (≤100° of forward flexion, ≤10° of external rotation with the arm at the side, and internal rotation not more cephalad than the L5 level).  91% of these patients had an intact rotator cuff and 9% had a partial-thickness rotator cuff tear
Group 2 included 290 shoulders with severe but not global loss. 44% of these patients had intact cuffs, 17% had partial thickness tears and 39% had full thickness tears.
Group 3 included 179 shoulders with mild to moderate limitation. 35% of these had intact cuffs, 16% had partial thickness tears, and 50% had full thickness tears.

The results are easier to see in this chart we prepared from their data

The take home message is that shoulders with  cuff tears can have mild, moderate or severe stiffness. This stiffness may be as much a contribution to the patient's loss of comport and function as the tear itself. If a cuff repair is attempted on a stiff shoulder, there is a real risk that the stiffness will be exacerbated as a result of the surgical tightening and the post operative protection of the repair, unless it is addressed at the time of surgery.

We often use the smooth and move procedure (see this link) in chronic degenerative tears and failed prior repair attempts. This is a procedure that does not attempt to repair the cuff, but instead includes a lysis of adhesions and a manipulation under anesthesia, followed by immediate post-operative full passive motion stretching exercises. Prior to the manipulation we are often impressed by the amount of stiffness in these shoulders. We are also impressed by the rapid recovery of function and comfort after this procedure that treats the stiffness but not the cuff defect.


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