Rotator Cuff Rotator Cuff TearsTears

Thomas J Kovack DOThomas J Kovack DO

Rotator Cuff Rotator Cuff TearsTears

AnatomyAnatomy

4 Muscles4 Muscles 1 in front1 in front 1 on top1 on top 2 behind2 behind

ImpingementImpingement

Rotator Cuff TearsRotator Cuff Tears

What we know…What we know…

Rotator Cuff Tears are commonRotator Cuff Tears are common By age of 60 over 50% of people By age of 60 over 50% of people

have a tearhave a tear Most tears are degenerative Most tears are degenerative

tearstears Some are traumaticSome are traumatic

Larger tears have loss of greater Larger tears have loss of greater shoulder functionshoulder function

What we know…What we know…

Rotator Cuff Tears Rotator Cuff Tears do notdo not heal on heal on their owntheir own

Rotator Cuff Tears get Rotator Cuff Tears get largerlarger over over time time

Some patients with rotator cuff tears Some patients with rotator cuff tears do not have paindo not have pain Many patients Many patients will eventuallywill eventually have pain have pain

(Yamagucci, (Yamagucci, JSESJSES 2001) 2001)

Non-operative TreatmentNon-operative Treatment Anti-inflammatory Anti-inflammatory

MedicationsMedications Physical TherapyPhysical Therapy Cortisone Injections*Cortisone Injections* Modification ofModification of activitiesactivities 60-70% will show 60-70% will show some improvementsome improvement Best for low demand Best for low demand

patientspatients Rotator cuff will not Rotator cuff will not

healhealBartolozzi et al (Bartolozzi et al (CORRCORR 1994), Hawkins & Dunlop ( 1994), Hawkins & Dunlop (CORRCORR 1995)1995)

Activity LevelsActivity Levels

Decision of surgery based Decision of surgery based on activity levelon activity level

““Age” is relative to Age” is relative to activity levelactivity level

Goals of high activity Goals of high activity levelslevels Need maximal function Need maximal function

from rotator cuff from rotator cuff Consider surgery earlierConsider surgery earlier

Surgical TreatmentSurgical Treatment

OptionsOptions Surgical Treatment – Rotator Cuff Surgical Treatment – Rotator Cuff

RepairRepair Opportunity to heal tendonOpportunity to heal tendon Arthroscopic surgeryArthroscopic surgery OutpatientOutpatient Well-toleratedWell-tolerated Small-medium size tears have 90-95% Small-medium size tears have 90-95%

chance of improvementchance of improvement

(Wolf, Arthroscopy 2004) (Gartzman, JBJS, 1998) (Tauro, Arthroscopy, 1998)

ChallengesChallenges

What makes successful repair more What makes successful repair more difficultdifficult

SmokingSmoking DiabetesDiabetes Large/Massive rotator cuff tearsLarge/Massive rotator cuff tears

88-95% improvement 88-95% improvement Savoie (Arthroscopy 2003), Savoie (Arthroscopy 2003),

Burkhart et al (Arthroscopy 2001) Burkhart et al (Arthroscopy 2001)

Recurrent tearsRecurrent tears Multiple Cortisone Injections Multiple Cortisone Injections (Watson JBJS (Watson JBJS

1985)1985)

Arthroscopic Rotator Arthroscopic Rotator Cuff RepairCuff Repair Small Small

incisionsincisions

ArthroscopeArthroscope Under Under

WaterWater

Arthroscopic RepairArthroscopic Repair

Post-operative Post-operative RehabilitationRehabilitation Phase 1 (0-6 Phase 1 (0-6

weeks)weeks) Shoulder Shoulder

ImmobilizerImmobilizer Pendulum Pendulum

exercises onlyexercises only Pool therapyPool therapy

Post-operative Post-operative RehabilitationRehabilitation Phase 2 (6-12 Phase 2 (6-12

weeks)weeks) StretchingStretching Sling when out of Sling when out of

househouse Begin to use armBegin to use arm

Golf put, no swingGolf put, no swing No liftingNo lifting

Post-operative Post-operative RehabilitationRehabilitation Phase 3 (3 months+)Phase 3 (3 months+)

More vigorous activitiesMore vigorous activities No strength training until 6 monthsNo strength training until 6 months

ComplicationsComplications

Rotator Cuff Re-tear Rotator Cuff Re-tear 29% 29% (Boileau et al (Boileau et al JBJSJBJS 2005) 2005)

StiffnessStiffness InfectionInfection ArthritisArthritis Nerve InjuryNerve Injury Suture or Anchor related Suture or Anchor related

complicationscomplications Anesthesia risksAnesthesia risks

AppointmentsAppointments

Pre-operative VisitPre-operative Visit Post-operative Visit (1 week)Post-operative Visit (1 week) 11stst Follow-up (6 weeks) Follow-up (6 weeks) 22ndnd Follow-up (12 weeks) Follow-up (12 weeks) 33rdrd Follow-up (6 months) Follow-up (6 months) 44thth Follow-up (1 year) Follow-up (1 year) Annual VisitsAnnual Visits