evaluation and treatment of rotator cuff...
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Evaluation and Treatment of Rotator Cuff Disorders
William Paterson, MDOctober 7, 2017
Anatomy
DifferentialDiagnosis
Patientage Mechanismofinjury
Acuteorchronic Locationofthepain Associatedsymptoms
Swelling/bruising/deformity Numbness/tingling Popping Feelingsofinstability
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LocationofPainOnefinger,onespot
Anterior Biceps,labrum,glenohumeral joint,subscapularis,coracoid,ACjoint,
nerve
Posterior Labrum,supraspinatus/infraspinatus,scapuladyskinesia,nerve
Lateral Supraspinatus/infraspinatus,capsulitis,nerve
Vague Scapuladyskinesia,nerve
Radiatestohand Nerve,biceps,labrum
Inspection
Abrasions,edema,ecchymosis
Deformity Scapulapositioning Men:shirtoff Women:tubetopexamgown
Palpation Codmanspoint supraspinatus
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Palpation Biceps
Palpation Glenohumeral joint
Palpation Coracoid
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Palpation Acromioclavicular joint
RangeofMotion
Elevation/Flexion
RangeofMotion Externalrotation
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RangeofMotion
Internalrotation
Strength Supraspinatus about30degreeselevation
Strength Infraspinatus nearmaximumexternalrotation
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Strength Subscapularis
Stability Anterior
Stability Posterior
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Stability Inferior
Neer ImpingementSign
Speeds
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SLAPrehension
FullExam
Anatomy
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RotatorCuffTears:FactorsInvolved Intrinsic tocufftendon Avascularity Aging Overuse questionable Steroids Smoking riskfortearprogression1 Hypercholesterolemia2
Extrinsic Acromialmorphology Acromioclavicularjointosteophytes usuallytoomedialtodamagecuff Scapulohumeralkinematics,scapularlag Inflammatoryprocesses
Acromialspurcausescufftear 1986Bigliani classification
However,only42%ofTypeIIIacromions hadcufftear3
17%pts3%oftears
43%pts24%oftears
40%pts73%oftears
Cufftearcausesbonespur Neer 19724:acromialspuriscommonlylocatedintheCAligament,andmaybecausedbytractionresultingfromsuperiormigrationofthehumeralheadinacuffdeficientshoulder
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TendonVascularity
Codmanscriticalzone
Relativehypovascularity ofdeepcomparedtosuperficialsupraspinatusinsertion
RothmanandParke5
CriticalShoulderAngle6
Glenohumeralosteoarthritis:282
Rotatorcufftear:Supraspinatus:363
SupraandInfra:403.5
Noarthritisorrotatorcufftear:343
CriticalShoulderAngle7
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Steroids 2009Mikolyzk etal.10
Afterone week:decreasesinmaxload(27%),maxstress(25%)andstiffness(32%)inratinfraspinatustendonexposedtosubacromial methylprednisolone Nodifferenceat
threeorfiveweeks
Incidence 2006Yamaguchietal.13 588patientshadbilateralUSforunilateralshoulderpain
Avg ageof376ptswithanycufftear62.8yrs,65%onrightside
50%likelihoodofbilateraltearsatage66yrs Inptswithsymptomatic FTtear,56.3% chanceofPTorFTcontralateraltear
Inptswithnormaltendoninpainfulshoulder,2.3%chanceofPTorFTtear(5of217)incontralateralshoulder
Incidence
0(age4049)10%(age5059)20%(age6069)40.7%(age>70)
Partialthicknesstearsabouttwiceascommonasfullthicknesslesions Cadavers:1332%incidenceofpartialthicknesstears,719%fullthicknesstears11
2009Kimetal.12 237Asymptomatic patients.Avg59.6yr
Ultrasound:41(17.3%)hadcufftearinatleastoneshoulder
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Incidence
Korea:486asymptomatic volunteers14
Meanage53.1(2082) Fullthicknesstear:4.7%incidenceoverall 5059:3.5% 6069:13.3% >70:11.1% Increasedinpatientswithdiabetesandsmoking
TreatmentOptions
Conservative OTCmedicationsforpain Physicaltherapy
75%successfulforatraumaticrotatorcufftear15
Corticosteroidinjection Temporaryweakeningoftendon10 Increasedfailurerateandinfection1619 aftersurgery
Toradolinjection Maybesaferthancortisone?
Plateletrichplasmainjection Poordata Mayactuallyhelpforintratendinous partialtear20
RiskFactorsforRepairFailure21
Age Inflammatoryarthritis Sizeoftear FattyinfiltrationStage2orgreater22,23
Singlerowrepair Earlymotion(Lessthan3weekspostop)24
Other:smoking,diabetes,osteoporosis TendonLength
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CriticalShoulderAngle Cadaverstudy9:5mmlateralresectionoftheacromionpreservesthedeltoidattachmentanddecreasesCSAfrom34.32.1to31.51.7
FattyInfiltration22 isDifferentfromAtrophy25,26
PositivetangentNegativetangent
RepairMethod 2009Nho etal.27 single vsdoublerowreview
Equivalentclinicaloutcomes(notransosseous equivalent) Evidencetosupportimprovedtendonhealingwithdoublerowfixation
2009Krishnanetal.28 116pts,arthroscopictransosseous cuffrepair,avg 56yrs,f/u624mos 96%returnedtopremorbidactivitylevelby6months.
2010Penningtonetal.29 78singlerowvs54DRtransosseous equivalent Highpt satisfaction:SR95%,DR92% MRIat1228mos:DRbetterhealingratefortears2.5cmto3.5cm
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WhatIDo
Conservativetreatmentage>70,irreparabletear Toradol/cortisoneinjectionforpain,PT
Generallyrecommendsurgicalrepairtopatients
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ArthroscopicEvaluationSubacromial
Transosseous RotatorCuffRepairPreparethetendonandtuberosity
Transosseous RotatorCuffRepair
Tornier,Inc.Edina,MN
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Transosseous RotatorCuffRepairDrilltunnels
Transosseous RotatorCuffRepairShuttlesutures
Transosseous RotatorCuffRepairPassandtiesutures
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Rehab
Slingfor6weeks(smallertear),8weeks(largetear)
Week23:PassiveROM Week7:ActiveROM Week10:Painfreestrengthening
References
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biomechanicalstrengthofratrotatorcufftendon.JBoneJointSurg Am,2009;91:11721180. 11.FukudaH.Reviewarticlethemanagementofpartialthicknesstearsoftherotatorcuff.JBoneJointSurg Br,2003;85B:311. 12.KimMH,Teefey SA,ZeligA,GalatzLM,KeenerJ,YamaguchiK.Shoulderstrengthinasymptomaticindividualswithintact
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RG,McCartyEC,PoddarSK,SmithMV,SpencerEE,VidalAF,WolfBR,WrightRW;MOONShoulderGroup.Effectivenessofphysicaltherapyintreatingatraumaticfullthicknessrotatorcufftears:amulticenterprospectivecohortstudy.JShoulderElbowSurg. 2013Oct;22(10):13719.
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radiologicaleffectsofplateletrichplasmaoninterstitialsupraspinatuslesion:Caseseries.Orthop TraumatolSurg Res. 2016Dec;102(8):977982.
21.LeeYS1,Jeong JY1,ParkCD1,KangSG1,Yoo JC1.EvaluationoftheRiskFactorsforaRotatorCuffRetear AfterRepairSurgery.AmJSportsMed. 2017Jul;45(8):17551761.
22.Goutallier D,Postel JM,Bernageau J,Lavau L,Voisin MC.FattymuscledegenerationincuffrupturespreandpostoperativeevaluationbyCTscan.Clin Orthop Relat Res,1994;304:7883.
23.Melis B,DeFranco MJ,Chuinard C,Walch G.Naturalhistoryoffattyinfiltrationandatrophyofthesupraspinatusmuscleinrotatorcufftears.Clin Orthop Relat Res,2010;468:14981505.
24.BryanM.Saltzman,WilliamA.Zuke,BeatriceGo,RandyMascarenhas,NikhilN.Verma,BrianJ.Cole,AnthonyA.Romeo,BrianForsythe.Doesearlymotionleadtoahigherfailurerateorbetteroutcomesafterarthroscopicrotatorcuffrepair?Asystematicreviewofoverlappingmetaanalyses.DOI:http://dx.doi.org/10.1016/j.jse.2017.04.004 Publicationstage:InPressCorrectedProof.JournalofShoulderandElbowSurgery.Publishedonline:June14,2017.
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