Management of Rotator Cuff Disease Tal Lassiter MD,MHA Director, Bassett Healthcare Shoulder and Sports Medicine Research Institute Shoulder and Sports Medicine Research Institute • Research • Teach • Treat History • 50 + yo male • Pain and weakness in dominant arm • Sub‐acute on chronic • H/O physical labor • Smoker + History Anatomy Physical exam MRI vs. US Natural history Conservative Rx Urgent referrals Surgical Rx options Uncertainty Physical Exam Active ROM Active IR History Anatomy Physical exam MRI vs. US Natural history Conservative Rx Urgent referrals Surgical Rx options Uncertainty Tests for RCTs PPD 80+% • Impingement tests (3) • Ext. Rotation Weakness Findings Drop Arm Test Biceps Rupture High association with RCT! Anatomy A SS CL Co SSc BT RC Humerus When to refer to surgeon? • All tears do not need surgery (i.e. little pain and good function) • No improvement w/ 6 wks PT • Young <50 yo or UE active • Acute onset of sxs • Intractable pain History Anatomy Physical exam MRI vs. US Natural history Conservative Rx Urgent referrals Surgical Rx options Uncertainty MRI $1,200 Imaging: MRI or Ultrasound? US $150 Ultrasound Accuracy BT Rotator Cuff Tears: Natural Hx* • Don’t heal • Get bigger with time • Become irreparable • Cause increased pain and limit function *Ken Yamaguchi History Anatomy Physical exam MRI vs. US Natural history Conservative Rx Urgent referrals Surgical Rx options Uncertainty Completely Normal Population • Incidence of Cuff Tears Cuff tear by age: •46% > 70 yo, •10% 60‐69 yo •7% 50‐59 yo H. Mike Kim, JBJS ‘09 Asymptomatic Rotator Cuff Tears • no pain • normal function Results Asymptomatic 2 Years •18% had tear progression •None had tear healing Results Symptomatic •50% had tear progression •None had tear healing Which rotator cuff tears hurt? •Dominant arm •Size History Anatomy Physical exam MRI vs. US Natural history Conservative Rx Urgent referrals Surgical Rx options Uncertainty Journal of Bone and Joint Surgery ’06; 88‐A, 1699‐1704 Demographics of Shoulder Pain Presence of unilateral shoulder pain (n=588) • Bilateral intact cuffs (n=212) • Unilateral tear* (n=191) • Bilateral tears* (n=185) * tear: partial-thickness or full-thickness Cuff failure allows humeral head to ride up • Normals Ball & socket kinematics • Symptomatic RCT’s Superior head migration • Asymptomatic RCT’s Superior head migration (greater variability) Results –Cuff disease increased with age • No tear – 48.7 yo • Unilateral tear – 58.7 yo • Bilateral tear – 67.8 –50% likelihood of bilateral tear after age 66 yr if present with painful tear, (p<0.01) Conclusions 1. Over a 2 year period 21% of patients with an asymptomatic rotator cuff tear became symptomatic 2. Symptomatic transition of asymptomatic cuff tears is associated with significant increases in pain and loss of function 3. Tear size progression may play a significant role in symptomatic transition. Fatty atropy of the rotator cuff muscles Normal rotator cuff Fat-infiltrated infra-spinatus Fatty degeneration of the rotator cuff muscles Normal Supra-spinatus Fat-infiltrated Supra-spinatus Smoking is bad for rotator cuffs Rotator Cuff Tear • Risks ‐ Chronic Changes – retraction with adhesion – tendon morphology – muscle atrophy – fatty degeneration – degenerative changes Conservative RX • Heat/ice • Acetominophen NSAIDs • Physical Therapy • Steroid Injection History Anatomy Physical exam MRI vs. US Natural history Conservative Rx Urgent referrals Surgical Rx options Uncertainty Physical Therapy MOON Protocol • • • • Patient directed Stretching Strengthening 85% success controlling sxs @ 2 years Shoulder Rehab: Strengthen and Stretch Early Operative Treatment • Benefits History Anatomy Physical exam MRI vs. US Natural history Conservative Rx Urgent referrals Surgical Rx options Uncertainty –halt chronic changes? • Most pertinent to younger pt. • Important for acute, small or medium sized tears • Important for tears at risk for fatty degeneration or altered kinematics Arthroscopic Rotator Cuff Repair • • • • • Better cosmesis Less pain Gleno‐humeral Joint Inspection Equal long‐term results Costs less* History Anatomy Physical exam MRI vs. US Natural history Conservative Rx Urgent referrals Surgical Rx options Uncertainty Outpatient Arthroscopic Repair • • • • • • • Your arm is numbed Asleep or not Punctures, not incisions Same day surgery Sling 4 weeks no lifting overhead 6 months unlimited activity TOOLS: Scorpion Suture Passer Identify the Tear Lateral Portal‐ Large Tear 50 Yard Line Suture Passed @ Apex Dead Man’s Angle Anchor Insertion‐ Metal? Pass Suture thru Cuff Double Row Technique Double Row Techniques Uncertainty Partial Cuff Tears Chronic Tear “Tweeners” History Anatomy Physical exam MRI vs. US Natural history Conservative Rx Urgent referrals Surgical Rx options Uncertainty • <50% thickness‐ SAD • >50%‐ repair Which patients do you just keep injecting? 79 yo veteran Reverse Total Shoulder SUMMARY Rotator Cuff Tears: Natural Hx* Don’t heal Get bigger with time Become irreparable Cause increased pain and limit function • Early surgery often likely beneficial • • • • *Ken Yamaguchi History Anatomy Physical exam MRI vs. US Natural history Conservative Rx Urgent referrals Surgical Rx options Uncertainty Dr. Jocelyn Wittstein • Cornell gymnastics • Duke Ortho and Sports And Shoulder fellowship • AOSSM Clinical Science Research Award • Research Director, Bassett Shoulder and Sports Research Institute Management of Rotator Cuff Disease Tal Lassiter, MD/MHA Sports Medicine and Shoulder Bassett Healthcare Cell: (919) 360‐4584