Shoulder and Elbow cases chronic, rotator cuff tear
A 59-year-old, right-hand-dominant man presents to clinic complaining of right shoulder pain due to a worker’s compensation injury. He has night pain and pain with overhead movement. He takes no medications, is otherwise healthy, and works as a mechanical engineer. His examination shows normal passive and active range of motion, a positive Neer impingement sign, positive Hawkins test, and a positive Jobe test with pain and weakness. His right arm is neurovascularly intact. Plain radiographs are normal.
What is the first step in treatment in this patient?
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Arthroscopic rotator cuff repair
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Physical therapy to strengthen the rotator cuff and stabilize the scapula
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Subacromial corticosteroid injection
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Expectant management
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Arthroscopic rotator cuff debridement
Discussion
The correct answer is (B). Several factors are involved when deciding whether a patient should receive operative treatment versus a trial of nonoperative treatment for their rotator cuff injury. Some of these include: age and functional demands of the patient, duration of tear, mechanism of injury (if any), size and type of tear, retraction of tendons, atrophy of muscles, etc. In the majority of cases, however, conservative therapy is the initial modality of choice.
This patient has been clinically diagnosed with a chronic, degenerative rotator cuff tear. Chronic degenerative tears almost always should receive a trial of nonoperative, conservative treatment; the less active and older the patient is, the more one should consider a conservative approach. In this situation, conservative treatment should be instituted prior to obtaining an MRI as advanced imaging is extremely unlikely to change your decision.
The first step in conservative treatment is a regimen of physical therapy to strengthen the rotator cuff muscles and the periscapular muscles in order to restore normal biomechanical shoulder movement. Additional nonoperative modalities include: NSAIDs, activity modification, ice, heat, iontophoresis, massage, transcutaneous electrical nerve stimulation (TENS), pulsed electromagnetic field (PEMF), and phonophoresis (ultrasound). A recent AAOS Guideline found that no recommendation can be made for or against the use of these modalities.
Medications include NSAIDs and subacromial corticosteroid injections (Answer C). NSAIDs and corticosteroid injections serve to reduce inflammation and
associated pain. They not only alleviate pain but also allow for more efficacious physical therapy. Corticosteroid injections are particularly used if there is thought to be rotator cuff tendon impingement. While commonly used, the AAOS guidelines once again state that no recommendation can be made for or against the use of corticosteroid injections.
Arthroscopic rotator cuff repair or debridement (Answers A and E) can be performed after failure of physical therapy to alleviate pain and restore function with subsequent MRI diagnosis of a rotator cuff tear. The choice of which operation to perform depends on the characteristics of the tear such as depth, retraction, and atrophy, which will be discussed in more detail below. However, one instance in which surgery should be considered before conservative treatment is in the case of acute, traumatic avulsion rotator cuff tears. Acute, traumatic avulsion tears should be surgically repaired if they are less than 3 weeks old because at that time they will not have retracted or atrophied. They can thus be relatively easily repaired to the greater tuberosity with good outcomes. If a person has an acute avulsion tear but waits longer than 4 to 6 weeks to present to an orthopaedic surgeon, this should then be treated like a chronic, degenerative tear because the tear will have had time to atrophy and retract.
Offering the patient no treatment (Answer D) would be inappropriate because the treatments discussed above would be helpful in alleviating pain and restoring function.
After consistently receiving physical therapy, taking NSAIDs, and having subacromial corticosteroid injections for 3 months, the patient’s symptoms continue to worsen. An MRI confirms a full-thickness rotator cuff tear, and the decision is made to perform an arthroscopic rotator cuff repair. Compared to a nonworker’s compensation patient, what are workers’ compensation patients more likely to experience postoperatively?
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Lower rate of returning to work and lower patient satisfaction
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Higher rate of returning to work and lower patient satisfaction
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Lower rate of returning to work and higher patient satisfaction
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Higher rate of returning to work and higher patient satisfaction
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Lower rate of returning to work and similar patient satisfaction
Discussion
The correct answer is (A). One study by Misamore et al. found that 94% of nonworker’s compensation patients returned to work postoperatively compared to
42% of worker’s compensation patients. They also found that 92% of nonworkers’ compensation patients rated their shoulder as good or excellent postoperatively compared to 54% of worker’s compensation patients.
Objectives: Did you learn...?
Conservatively treat a chronic, rotator cuff tear?
Identify postoperative differences in workers’ compensation patients?