Tag: rotator cuff tears

Categories : Injury & TraumaTags :

What are the Best Methods to Treat Rotator-cuff Tears?

On By ModernMedia
Photo by Kampus Production

Rotator-cuff disorders are the most common cause of shoulder symptoms. Tears of the rotator cuff can result from a substantial traumatic injury or can occur slowly over time. Most degenerative tears occur in the dominant arm of adults over the age of 40, and their prevalence increases with as you age. There are a variety of treatments.

In a recent publication in the New England Journal of Medicine, University of Michigan Health professor and chair of Physical Medicine and Rehabilitation, Nitin Jain, MD, MSPH, talks through the different treatments available for rotator-cuff tears to help bring together a better understanding of how to treat the issue for patients and providers.

Nonoperative treatment, such physical therapy, is the typical approach to treating rotator-cuff tears. However, surgery is considered in certain patients whose rotator-cuff tears don’t resolve with nonoperative treatments. Topical treatments also exist, such as glyceryl trinitrate (nitro-glycerine) gel which appears to have the greatest success.

Symptoms of rotator-cuff tears

“Patients with nontraumatic or degenerative rotator-cuff tears typically experience an onset of shoulder pain that seems to have no cause,” said Jain. 

“However, it is not uncommon for tears to be asymptomatic and become slowly painful over time, or even cause no pain at all.”

Jain says there are some activities that make the injury more painful as the tear worsens. This can include sleeping on your shoulder, overhead activities and/or lifting items above your shoulder level.

“Rotator-cuff tears may also grow over time, but there’s a lack of correlation between patient symptoms and the size and thickness of the tear,” explained Jain.

Your active range of motion and arm strength are usually affected by the tear, which gets assessed by using certain protocols when providers are searching for a diagnosis.

Rehabilitation and physical therapy for rotator-cuff tears 

This is the most common form of treatment for rotator-cuff tears, says Jain: “It is recommended that as the first line of specialist referral, patients seek care from a physical medicine and rehabilitation doctor (physiatrist) or sports medicine doctor.

“Rehabilitation and physical therapy routines address areas such as periscapular muscle weakness, correcting scapular posture and improve rotator cuff muscle strength and endurance.”

In observational studies, more than 80% of patients who received supervised physical therapy reported reduced pain and improved function between 6 months to a year. However, the trial populations consisted of patients with various types of rotator-cuff injuries and had no requirement for advanced imaging to confirm their diagnosis.

“One of the biggest factors in a successful rehabilitation was trust from patients that their physical therapy routine would improve their rotator-cuff condition,” said Jain. “The more patients leaned into the physical therapy routine, the better their outcomes were.”

Other nonpharmacologic therapies for rotator-cuff tears

Evidence suggests that psychosocial distress and depression are associated with shoulder pain and reduced function in patients with rotator-cuff tears.

“Despite this, though, there isn’t much data supporting psychosocial interventions in the treatment of rotator-cuff disorders, even though they show benefit in the treatment of other musculoskeletal disorders such as lower back pain,” said Jain.

In addition to the lack of data for psychological interventions for rotator-cuff repairs, there’s also a lack of high quality trials supporting the use of manual therapy, massage therapy, acupuncture, therapeutic ultrasonography, transcutaneous electrical nerve stimulation, shock-wave therapy or pulsed-electromagnetic-field therapy.

Topical and oral medications and injections for rotator-cuff tears

There isn’t a lot of evidence supporting the use of topical medications in treating rotator-cuff disorders. The topical treatment with the best outcomes so far has been glyceryl trinitrate.

In a small, randomised trial it showed short term benefits in the treatment of rotator-cuff disorders, but it also found there was a considerably high bias towards this treatment from participants in the study.

Topical nonsteroidal anti-inflammatory drugs such as diclofenac and ketoprofen have also been effective in providing pain relief in chronic musculoskeletal pain and tendinitis and have a better safety profile than oral, nonsteroidal anti-inflammatory drugs.

“But high quality evidence supporting their use in rotator-cuff disorders is still lacking,” explained Jain.

For oral medications, randomised research trials have shown that oral nonsteroidal anti-inflammatory drugs (NSAIDs) reduced pain, although modestly, in patients with rotator-cuff disorders. 

“Opioid drugs are generally not recommended due to risks associated with their use and lack of evidence of superiority to nonopioid therapy in a variety of musculoskeletal conditions,” said Jain.

Jain says acetaminophen hasn’t been studied specifically in rotator-cuff disorders, but what has been studied has shown little or no benefit regarding pain or function.

“Rigorous evidence is lacking to inform the use of pain-modulating drugs such as gabapentin, duloxetine, and pregabalin, specifically regarding the nonoperative treatment of rotator-cuff disorders,” said Jain.

Injection of a glucocorticoid, together with a local anaesthetic, has been reported to provide symptomatic pain relief in patients with rotator-cuff disorders.

Small trials have shown short term benefit, about four weeks long, of pain relief through using this method. The injections are performed in the subacromial space of the rotator-cuff for those with subacromial impingement syndrome. Some centres use ultrasound guidance to administer this treatment, which can reduce the risk of an inadvertent injection into the tendon.

Surgical interventions for rotator-cuff injuries

“Surgical interventions are not the initial recommendation when it comes to rotator-cuff repairs. However, they may be considered in some patients whose condition does not improve with conservative treatment,” said Jain.

Observational data supports that surgery is associated with better function and reduced pain in patients who are under 65 years of age and have smaller tears.

Surgical repairs are mostly performed arthroscopically, involving the repair of the torn tendon and resecuring it to the humerus to allow for tendon-to-bone healing as well as a low incidence of complications, explains Jain.

The hypothesis that surgical intervention can reduce the progression of muscle degradation has led some experts to recommend early surgical intervention, but data is still lacking on outcomes of early surgery compared to surgery later.

Source: Michigan Medicine – University of Michigan

Categories : Surgeries & ProceduresTags :

A Common Practice in Rotator Cuff Surgery may be Counterproductive

On By ModernMedia
Photo by Jafar Ahmed on Unsplash

A common practice of shoulder surgeons may be impairing the success of rotator cuff surgery, a new study from orthopaedic scientists and biomedical engineers at Columbia University suggests.

During the surgery, surgeons often remove the bursa, a cushion-like tissue, while repairing torn tendons in the shoulder joint – but the study, which is published in Science Translational Medicine, suggests that the small tissue in fact plays a role in helping the shoulder heal.

“It is common to remove the bursa during shoulder surgery, even for the simple purpose of visualising the rotator cuff,” says Stavros Thomopoulos, PhD, the study’s senior author and the Robert E. Carroll and Jane Chace Carroll Laboratories Professor of Orthopaedic Surgery at Columbia University Vagelos College of Physicians and Surgeons.

“But we really don’t know the role of the bursa in rotator cuff disease, so we don’t know the full implications of removing it,” Thomopoulos says. “Our findings in an animal model indicate that surgeons should not remove the bursa without carefully considering the consequences.”

The challenge of rotator cuff surgery

Most damage to tendons in the rotator cuff comes from wear and tear that accumulates over years of repetitive motions. Among people over 65, about half have experienced a rotator cuff tear, which can make simple daily tasks like combing one’s hair difficult and painful.

More than 500 000 rotator cuff surgeries are performed each year in the US to repair these injuries, restore range of motion, and alleviate pain, but failure is common – ranging from one in five surgeries in young patients to as high as 94% in elderly patients with large tears.

Rotator cuff repairs usually fail because of poor healing between tendon and bone where the tendon is reattached to the bone.

Bursa: friend or foe?

The bursa is a thin, fluid-filled sac originally thought to protect the tendons by providing a cushion between the tendons and adjacent bones.

The bursa often becomes inflamed, sometimes concurrently, when underlying tendons are injured, and surgeons often remove the tissue because they suspect it is a source of shoulder inflammation and pain. But recent studies suggest the tissue may be playing other biological roles besides mechanical cushioning, including promoting healing of injuries to the tendons in the shoulder.

To explore the role of the bursa in rotator cuff disease, Thomopoulos and graduate student Brittany Marshall examined rats with repaired rotator cuff injuries, with and without bursa removal.

Bursa removal impairs uninjured tendons

After the rats underwent repair of a rotator cuff injury, the researchers measured the mechanical properties of the repaired tendon and an adjacent undamaged tendon, the quality of the underlying bone, and changes to protein and gene expression.

The researchers found that the presence of the bursa protected the undamaged tendon by maintaining its mechanical properties and protected the bone by maintaining its morphometry. When the bursa was removed, strength of the undamaged tendon deteriorated and the bone quality deteriorated.

“The loss of mechanical integrity in the uninjured tendon in the absence of the bursa was striking,” Thomopoulos says. Uninjured tendons in the shoulder frequently degenerate over time after the initial injury, and “the animal data imply that retaining the bursa may prevent or delay progression of this pathology.”

In the damaged tendon, the researchers found that the bursa promoted an inflammatory response and activated wound healing genes, but no changes were seen in the mechanical properties of the repaired tendon two months after the repair. It’s possible that differences in mechanical properties would be detected after a longer healing period, Thomopoulos says, something that the research team is currently investigating.

“Overall, what we’re seeing is a beneficial role of the bursa for rotator cuff health, in contrast with the historical view that the inflamed bursa is detrimental,” says Thomopoulos.

The researchers documented similar changes to cells and proteins in bursa samples from patients who underwent surgery to repair rotator cuff injuries, suggesting comparable processes may occur in people.

The bursa as a drug delivery depot

If the bursa is not removed, the tissue could be used to deliver drugs to the repaired tendon to improve healing.

Thomopoulos and Marshall explored this possibility by injecting corticosteroid microspheres into the bursa of their rat model after tendon injury. Steroids are often used to treat musculoskeletal injuries and reduce inflammation.

“The treatment results are somewhat preliminary and require additional timepoints and mechanical characterisation before we can draw strong conclusions,” Thomopoulos says, “but our initial data supports the idea that the bursa can be therapeutically targeted to improve rotator cuff healing.”

Source: Columbia University Irving Medical Center

Categories : Gender Injury & TraumaTags :

Low Sex Hormone Levels Linked to Rotator Cuff Tears

On By ModernMedia
Photo by Harlie Raethel on Unsplash

Patients with lower levels of sex hormones are more likely to need to undergo surgery for rotator cuff tears, suggests a study in The Journal of Bone & Joint Surgery. 

Sex hormone deficiencies “was associated with a significantly increased incidence of RCR within [two] independent databases,” according to the new research by Peter N. Chalmers, MD, and colleagues at University of Utah. These findings add to previous evidence that hormone levels may be a systemic factor contributing to the development of rotator cuff tears, a common condition that is a major cause of shoulder pain.

The study used health insurance data for nearly 230 000 adults under age 65 who underwent surgery to repair a torn rotator cuff from 2008 through 2017. Patients were matched for age, sex, and type of insurance to patients who did not undergo rotator cuff surgery.

Patients undergoing rotator cuff repair had an average age of 54 years, and 58% were men. Most patient characteristics were similar between those who underwent rotator cuff repair and those who did not, except tobacco use, which was more common in the surgical cohort.

Dr Chalmers and colleagues found that 27% of women and 7% of men undergoing rotator cuff surgery had diagnosed sex hormone deficiency, compared with 20% and 4% respectively in the control group. Controlling for other factors, rotator cuff repair likelihood was 48% higher in women with oestrogen deficiency and 89% higher in men with testosterone deficiency.

To confirm their findings, the researchers then accessed the Veterans Administration Genealogy database which has data on millions of individuals. Here, they found that rotator cuff repair was about 2.5 times more likely for women with oestrogen deficiency and three times more likely for men with testosterone deficiency.

This study builds on a prior study by the same research group, which demonstrated that women with mutations in an oestrogen receptor gene were more likely to develop rotator cuff disease, with higher rates of failed rotator cuff surgery.

Despite limitations such as not accounting for hormone replacement therapy, the observed association between sex hormone deficiency and rotator cuff repair strongly supports the theory that low oestrogen and testosterone levels may contribute to the development of rotator cuff tears. The researchers concluded that “Future prospective studies will be necessary to understand the relationship of sex hormones to the pathophysiology of rotator cuff disease.”

Source: EurekAlert!