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  • 1

    Rotator Cuff Dysfunction: Surgical Intervention and

    Postoperative Rehab

    B r i a n S c h i f f , P T , O C S , C S C S

    Provider Disclaimer

    • Allied Health Education and the presenter of this webinar do not have any financial or other

    associations with the manufacturers of any products or suppliers of commercial services that may be

    discussed or displayed in this presentation. • There was no commercial support for this

    presentation. • The views expressed in this presentation are the views

    and opinions of the presenter. • Participants must use discretion when using the

    information contained in this presentation.

    Background

    • Supervisor - Raleigh Orthopaedic Performance Center

    • Practiced since 1996 in outpatient sports/ortho clinics

    • S & C coach for MLS - Columbus Crew 2002-2006

    • Owned my own training facility 2000-2010

    • FMS certified, board certified orthopaedic clinical specialist (OCS), credentialed in dry needling

    • Write for PFP Magazine

    • PT consultant for Carolina Hurricanes

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    www.apcraleigh.com

    Objectives

    • Understand basic surgical intervention and considerations

    • Review outcome data for RC repair • Recognize post-op precautions and

    contraindications

    • Apply sound evidenced-based rehab strategies to ensure optimal outcomes

    Rotator Cuff Tears

    • Not always traumatic

    • Traumatic tend to be larger & should be fixed sooner

    • Partial tears > 50% of tendon behave more like full thickness tear

    • Arthroscopic repair is the standard of care in 2015

    http://www.apcraleigh.com

  • 3

    Rotator Cuff Tears

    • Partial vs. full thickness • Articular vs. bursal sided • Pain level varies • Size of tear does not always predict

    amount of dysfunction

    Classification

    • Small = < 1 cm • Medium = 1 - 3 cm • Large = 3-5 cm • Massive = > 5 cm

    RC Tear

    HH

    IS

    SS

  • 4

    Symptoms of RCT

    • Painful arc of motion • Crepitus • Weakness • Positive impingement signs • Difficulty with overhead activities or

    overhead sports

    • Nocturnal pain

    Partial Thickness Tears

    • Articular surface partial tear • Bursal surface partial tear • Grade 1 ( 6 mm deep, or more than 50% of the thickness of the tendon)

    Risk factors - PTRCTs

    Intrinsic

    • Age (risk increases over time)

    • Decreased vascularity

    Extrinsic

    • Subacromial impingement

    • GH instability

    • Internal impingement

    Matthewson et al. Adv Orthop. 2015

  • 5

    Subacromial Impingement

    In many cases, there is an anatomical reason for persistent pain

    Internal Impingement

    • Cocking phase

    Pathomechanics . . .

    • humeral ER

    • horizontal extension

    • anterior translation

    Pinches undersurface RC & labrum between GT and glenoid

    Prevalence of PTRCT

    • MRI of asymptomatic shoulders • Overall prevalence of PTRCTs was

    20%

    • In patients under the age of 40, the prevalence was approximately 4%

    • In patients over the age of 60, the prevalence was 26%

    Sher et al. JBJS 1995

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    Overhead Athletes

    • In 2003, Connor et al. performed MRIs in the shoulders of asymptomatic

    elite overhead athletes.

    • In 20 athletes, the overall prevalence of rotator cuff tears (i.e., partial or full

    thickness) was 40% in the

    dominant throwing shoulder.

    • Importantly, at a 5-year follow-up, none of the athletes developed shoulder

    symptoms requiring treatment, and none of them

    had appreciable decreases in

    their level of play.

    Throwing athletes

    In the throwing athlete, due to the time off,

    stiffness, and decreased range of motion

    associated with surgery, conservative management is the treatment of choice for

    tears involving up to 75% of the tendon

    thickness

    Rudzki & Shaffer Clin Sports Med. 2008

    Imaging

    • While MRI has limits in its ability to accurately detect PTRCTs, MR

    arthrography remains the imaging modality of choice

    • Its high mean sensitivity (85.9%) and specificity (96.0%) place it superior to

    other imaging modalities

    de Jesus et al. Am. J. Roent. 2009

  • 7

    MRI - Rotator Cuff Tear

    Image Source - Centeno-Schultz Clinic

    • Despite advances in imaging technologies, arthroscopy remains the gold standard for diagnosing PTRCTs

    • Arthroscopy allows direct visualization of the bursal and articular surfaces of the rotator cuff as well as the anatomic footprint

    • Arthroscopy provides the ability to probe the soft tissues to identify areas of tearing that would otherwise be undetectable

    Finnan & Crosby JSES 2010

    PRP - No Surgery

    • In 2013, Kesikburun et al. evaluated the effect of PRP in patients with chronic rotator cuff tendinopathy (i.e., tendinosis or partial thickness rotator cuff tears excluding full thickness rotator cuff tears)

    • In this study, 40 patients were randomized to receive a PRP injection versus saline placebo control

    • At a one-year follow-up, there was no significant difference in pain, disability, or shoulder range of motion between PRP and saline controls

    AJSM 2013

  • 8

    PRP During Surgery

    • At 3 months of follow-up, there were initially significantly better pain scores and improved forward elevation in patients treated with PRP. However, by 6 months there was

    no significant difference between PRP treated patients and control patients

    • Prospective randomized trial of 80 patients undergoing rotator cuff repair by Castricini et al., there was no significant difference in Constant score between patients

    treated with a platelet rich fibrin matrix and controls at a minimum of 16-month follow-up

    Randelli et a. JSES 2011

    Castricini et al. AJSM 2011

    PRP Conclusions

    More Questions Than Answers

    Debride vs. Repair

    • Percentage of tendon torn • Age • Tear configuration • Concomitant pathologies (i.e., labral

    tear and impingement)

    • Work or sport-related factors • Disease process/projection

  • 9

    Arthroscopic Repair

    • Advantages = no detachment of deltoid, less pain and likely shorter OR time

    • Disadvantages = larger learning curve on part of the surgeon

    Arthroscopy

  • 10

    Open Repair

    • Take down anterior deltoid • Open acromioplasty • Advantages = great exposure • Potential complications = deltoid

    dehiscence and slower rehab allowing for healing of deltoid

    Open repair

    Mini-Open RC Repair

    • Arthroscopic acromioplasty

    • Split middle deltoid

    • Open rotator cuff repair

    Advantages

    • Avoid take down of deltoid

    • Less post-op pain

    Complications

    • Deltoid retraction

    • Limited exposure

  • 11

    Surgical videos

    Double-Row vs. Single-row

    • Systematic review of 8 meta-analyses comparing SR and DR RCR to elucidate the cause of discordance and determine

    which meta-analysis provides the current best available evidence

    • Six meta-analyses found no differences between SR and DR RCR for patient outcomes, whereas 2 favored DR RCR for tears greater than 3 cm. Two meta-analyses found no

    structural healing differences between SR and DR RCR, whereas 3 found DR repair to be superior for tears greater than 3 cm and 2 found DR repair to be superior for all tears

    • Current highest level of evidence suggests that DR RCR provides superior structural healing to SR RCR

    Mascarenhas et al. Arthroscopy 2014

    Outcomes: re-tear rates

    • Re-tear rates after arthroscopic single-row, double- Row, and suture bridge rotator cuff repair at a

    minimum of 1 year of imaging follow-up

    • Thirty-two studies met the inclusion criteria, yielding a total of 2,048 repairs

    • Both DR and SB have lower re-tear rates than SR in most tear size categories

    • No differences in re-tear rates were found between DR and SB.

    Hein et al. Arthroscopy 2015

  • 12

    Outcomes: re-tear rates

    • Systematic review and meta-analysis of all available level I randomized controlled trials comparing single-row w/double-row repair to statistically compare clinical outcomes and imaging-diagnosed re-tear rates

    • Single-row repairs resulted in significantly higher re-tear rates compared with double-row repairs, especially with regard to partial-thickness re-tears

    • No detectable differences in improvement in outcomes scores between single-row and double-row repairs

    Millett et al. JSES 2014

    Return to Sport After Rotator Cuff Tear Repair

    • Twenty-five studies were reviewed, including 859 patients (683 athletes), all treated surgically after a mean follow-up of 3.4 years (range, 0.3-13.4 years)

    • The level of sports was recorded in 23 studies or 635 (93%) athletes and included 286 competitive or professional athletes an

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