Roger G. Pollock
Pathology involving the subacromial soft tissues (the subacromial bursa and rotator cuff) constitutes the most common cause of shoulder pain. This pathology encompasses a spectrum of disease ranging from acute bursitis and tendinitis to chronic tendinitis and finally to tears of the rotator cuff, either partial thickness or full thickness. Considerable debate continues concerning the underlying cause of rotator cuff tears and also concerning their management. Treatment options for full-thickness rotator cuff tears include nonoperative treatment with exercises, subacromial decompression with debridement of the tear, and rotator cuff repair, either through arthroscopic, arthroscopically assisted (mini-open), or open surgical techniques. In addition, some massive rotator cuff tears are treated with tendon transfers, involving the use of latissimus dorsi, teres major, and/or pectoralis major tendons. This chapter will focus on mini-open and open repair of full-thickness rotator cuff tears.
Pathogenesis
The pathogenesis of rotator cuff tears likely involves both intrinsic tendon factors as well as the extratendinous anatomy of the subacromial space. Histologic studies of tendons have demonstrated degenerative changes in older specimens. Moreover, the tendon fibers undergo differential strains, with the articular-side fibers undergoing significantly greater tensile strain with the arm in abduction. This perhaps explains why tear initiation usually occurs on the undersurface or articular side of the tendon. Others have pointed to the relative avascularity of the “critical zone” of the supraspinatus as another intrinsic factor predisposing this region of the tendon to tear.
Others have emphasized the role of the extratendinous structures of the subacromial space, specifically, the coracoacromial arch in the pathogenesis of rotator cuff tears. Neer postulated that the overwhelming majority of rotator cuff tears were the result of attritional wear from excrescences on the undersurface of the anterior third of the acromion and to a lesser extent, the undersurface of the distal clavicle. Narrowing of the supraspinatus outlet by excrescences or spurs on the acromial undersurface resulted in frictional wear on the region of the supraspinatus, where most tears initiate. Several biomechanical studies have demonstrated that contact pressures between the acromial undersurface and the rotator cuff are maximal in this region of the supraspinatus with the shoulder abducted between 60 and 120 degrees. Moreover, cadaver studies have correlated acromial morphology with the incidence of rotator cuff tears and found that those with a type III or hooked morphology had the highest incidence of tears.
Trauma can play a role in the initiation or progression of rotator cuff tears. A hard fall can certainly result in tearing of the rotator cuff. An anterior dislocation in a patient older than 40 years of age can be associated with a rotator cuff tear. In younger patients, such dislocations result in stretching of the glenohumeral ligaments, avulsion of the anteroinferior labrum, or rarely, a fracture of the anteroinferior glenoid rim, but almost never in a full-thickness rotator cuff tear. A traumatic episode may also result in the progression of a previously existing rotator cuff tear, causing an acute onset of shoulder weakness. Such an acute extension of a chronic tear may turn an asymptomatic shoulder into one with acute pain and weakness. This is not infrequently seen in elderly patients.
Although trauma may be involved in the cause of rotator cuff tears, most tears probably are owing to attritional wear.
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Full-thickness tears are rarely seen in those younger than 40 years of age and are likely caused by repetitive microtrauma involved with work and recreational sports activities. The incidence of full-thickness rotator cuff tears rises in those older than 40 years of age, and they occur more commonly in the dominant shoulder, supporting the notion that attrition is an important etiologic factor.
Diagnosis
The diagnosis of subacromial pathology is made on the basis of a thorough history and physical examination of the shoulder. A subacromial injection of lidocaine can be used to confirm the diagnosis, and radiographs can provide supportive evidence and rule out other diagnoses. Staging of disease in the rotator cuff, ranging from tendinitis to partial tears to full-thickness tears can be precisely achieved through magnetic resonance imaging or ultrasonography.
Patients with rotator cuff pathology typically present with pain in the anterosuperior aspect of the shoulder. The pain usually radiates to the deltoid region, but not distally past the elbow. Pain, which is located predominantly in the posterior shoulder or trapezius region or which radiates into the forearm or hand or which is accompanied by paresthesias is more likely due to cervical radiculopathy than to subacromial pathology. In rotator cuff disease, the pain is usually increased with overhead use of the arm and with active abduction and reaching behind the body. Often the pain is increased at night with the supine position, perhaps because this increases compression of the inflamed tendon and bursa beneath the acromion. Patients may complain of a catching sensation and of shoulder weakness, particularly with activities performed above shoulder height. Frequently affected tasks include work activities that require lifting or repetitive overhead use and sports activities, such as tennis, golf, and swimming.
Several conditions involving the cervical spine and shoulder may present with symptoms similar to those of rotator cuff disease and should be considered in the differential diagnosis. Cervical radiculopathy, specifically a herniated cervical disc at the C5–C6 level, can present with pain in the deltoid and biceps regions. Acromioclavicular arthritis causes pain in the superior aspect of the shoulder and trapezial region and may coexist with rotator cuff disease. Adhesive capsulitis, particularly in its early prestiffness phase, may be mistaken for rotator cuff disease, as pain in the deltoid region is often the earliest symptom. Subtle glenohumeral instability may present as anterosuperior shoulder pain without frank episodes of subluxation or sensation of instability, particularly in young overhead athletes. These patients may have both an underlying instability problem and a secondary subacromial bursitis or tendinitis and may be difficult to diagnose precisely. Finally, calcific tendinitis can mimic a rotator cuff tear, as the anatomic distribution of pain is similar, and the intensity of pain may cause a pseudoparalysis, which can resemble the weakness seen with large rotator cuff tears. The history of an acute atraumatic onset and the presence of a calcific deposit on plain radiographs serve to differentiate these diagnoses.
Physical examination is usually quite helpful in the diagnosis of rotator cuff disease. In cases of chronic large or massive tears, simple inspection of the shoulder may suggest the diagnosis, as there is usually atrophy of the supraspinatus and infraspinatus muscles, and sometimes a visible rupture of the tendon of the long head of the biceps. There may be a diffuse swelling around the shoulder—a so-called fluid sign or a localized fluid collection at the acromioclavicular joint. Occasionally, with an acute traumatic tear, ecchymosis may be present. However, with smaller tears or more acute tears, the appearance of the shoulder is usually normal.
In rotator cuff disorders, there is frequently tenderness over the subacromial bursa and greater tuberosity. Approximately 10% to 15% of patients with a rotator cuff tear will also have symptomatic acromioclavicular arthritis, which is diagnosed clinically by tenderness directly over the acromioclavicular joint and by painful adduction of the shoulder. With full-thickness rotator cuff tears, subacromial crepitation can often be appreciated with passive range of motion of the shoulder. Usually, passive range of motion is preserved with rotator cuff tears, although a small percentage of shoulders with tears will develop stiffness. Active range of motion is often normal with smaller tears, but loss of active motion can occur with larger tears.
Shoulder strength, as measured with manual muscle testing, may be normal with partial-thickness tears and even with smaller full-thickness tears. However, larger tears usually produce shoulder weakness, which can be detected by resistance testing or in more severe cases, by lag signs or “drop-arm” signs. Thus, the patients may not be able to actively elevate or externally rotate the shoulder fully, producing a lag between their active and passive motion. In a similar manner, loss of infraspinatus function will cause a shoulder that is placed into an externally rotated position to fall into internal rotation, producing a drop-arm sign. Subscapularis deficiency results in an inability to lift the arm off the lumbar spine when it is placed into internal rotation, producing a positive “lift-off” sign, as described by Gerber.
Several other provocative tests are quite helpful in diagnosing rotator cuff problems. The Neer impingement sign, which is tested by stabilizing the patient's scapula while fully passively elevating the arm, is nearly always positive in patients with subacromial pathology. The Hawkins sign, tested by fully internally rotating the shoulder at 90 degrees of flexion, is also quite useful in detecting subacromial problems. Resisted testing of the supraspinatus, as popularized by Jobe, can further suggest rotator cuff pathology. Finally, the injection of 10 mL of 1% lidocaine into the subacromial space will reliably reduce or eliminate pain that is caused by subacromial pathology and can be helpful in confirming the diagnosis of a rotator cuff disorder.
Plain radiographs can provide anatomic data that support the diagnosis of a rotator cuff disorder. Excrescences on the acromion, greater tuberosity, and undersurface of the distal clavicle can be seen on an anteroposterior radiograph in a shoulder with rotator cuff pathology. Moreover, a diminished acromiohumeral interval is suggestive of a rotator cuff tear, and some would suggest that an acromiohumeral interval of <6 mm is indicative of an irreparable tear. In the supraspinatus outlet view, a lateral radiograph with a 10-degree caudal tilt, the morphology of the acromion, and
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any associated spurring can be clearly visualized. This information can be helpful in surgical planning, concerning the extent of the subacromial decompression that will be required in a particular shoulder. An axillary radiograph will reveal the presence of an unfused acromial epiphysis or os acromiale. Finally, plain radiographs are useful in ruling out other painful shoulder conditions, such as glenohumeral arthritis and calcific tendinitis.
Although a thorough history and physical examination supplemented by plain radiographs can allow the diagnosis of a rotator cuff or subacromial disorder, magnetic resonance imaging or ultrasonography can help to stage the problem accurately. These imaging techniques can differentiate between tendinitis, partial-thickness tears, and full-thickness tears of the rotator cuff. When a tear is present, these studies indicate which tendon or tendons are involved, the size of the tear, and the degree of tendon retraction. Magnetic resonance imaging is also quite useful in providing data about the rotator cuff muscles, such as information about the degree of muscle atrophy or fatty infiltration. Such structural information can help the surgeon choose an appropriate surgical technique for rotator cuff repair and provide insight about the reparability of a tear. In the United States, magnetic resonance imaging has replaced the arthrogram as the test of choice in most centers for staging rotator cuff disease. Ultrasonography, while relatively inexpensive and allowing bilateral examination in a cost-effective way, is less familiar to most North American surgeons and requires greater expertise to perform and interpret accurately.
Treatment
Treatment options for full-thickness rotator cuff tears include nonoperative treatment with exercises and various surgical techniques of repair. Nonoperative treatment has been shown to result in pain relief and functional improvement, but these results are less predictable than those of surgical repair and may deteriorate over time with tear extension. Older, more sedentary patients, who put less demand on the shoulder for overhead work or sports activities, appear to benefit more consistently from nonoperative treatment than younger, more active patients. Patients in their 70s and 80s are also more likely to present with chronic large or massive tears with a significant degree of muscle atrophy and fatty degeneration on magnetic resonance imaging. Such patients are less likely to achieve functional improvement after rotator cuff repair and are probably best managed with nonoperative treatment.
Younger, more active patients in their fifth, sixth, and seventh decades with a symptomatic full-thickness rotator cuff tear are best served by early rotator cuff repair. Numerous studies on the results of rotator cuff repair have reported a satisfactory outcome in 85% to 95% with predictable pain relief and functional improvement in most patients. Although complete healing of the tendons did not appear necessary to achieve satisfactory pain relief, the best functional results were seen in patients in whom the repair was intact at follow-up in studies by Harryman et al. and Gerber et al. Moreover, work by Yamaguchi et al. has suggested that the natural history of rotator cuff tears is extension of the tear in a considerable percentage of these tears. This information, combined with other recent data that demonstrate that muscle atrophy is only partially reversible and fatty infiltration of the muscles appears to be irreversible, would suggest that early repair of a symptomatic rotator cuff tear is the optimal treatment for an active, healthy patient.
The surgical techniques for rotator cuff repair continue to evolve. Since Neer's description of anterior acromioplasty in 1972, most of those techniques have combined subacromial decompression with tendon repair, although a few authors have recently questioned the use of acromioplasty. In addition to the traditional method of open rotator cuff repair, newer techniques combining arthroscopic acromioplasty with mini-open rotator cuff repair and completely arthroscopic repair have become more popular. For dealing with some of the massive irreparable tears, tendon transfer techniques and the use of synthetic grafts have been used. The remainder of this chapter will focus on the techniques of mini-open and open rotator cuff repair.
Arthroscopically Assisted or Mini-Open Repair
This technique combines arthroscopic subacromial decompression with open tendon repair through a small deltoid split. Since the anterior acromioplasty is performed arthroscopically, this technique allows preservation of the deltoid origin during the repair of the torn rotator cuff. Other advantages for this procedure compared with traditional open rotator cuff repair include lower perioperative morbidity and shorter hospital stays, superior cosmesis with smaller incisions, easier rehabilitation, and the ability to treat associated intra-articular pathology, such as labral tears or biceps lesions, during the arthroscopic portion of the procedure. In comparison with wholly arthroscopic repair, the mini-open procedure is technically easier to perform and has a lower learning curve.
Arthroscopically assisted or mini-open repair is most appropriate for small to medium-sized tears (i.e., <3 cm) without significant retraction. These tears usually involve the supraspinatus tendon alone or the supraspinatus and upper portion of the infraspinatus. Larger tears or those with extensive retraction can be treated with this technique, but are more easily treated with traditional open techniques, as these tears require more extensive tissue mobilization and transposition, which can be difficult to achieve through the limited exposure afforded by the small deltoid split. Subscapularis tears are also difficult to access through the mini-open approach and are usually treated using an open approach.
The procedure is performed with the patient in the beach-chair position under interscalene block regional anesthesia. Arthroscopic examination of the glenohumeral joint is carried out through a standard posterior portal. This allows for inspection of the intra-articular structures and treatment of associated pathology of the labrum or biceps tendon, as well as debridement of the undersurface of the rotator cuff, using arthroscopic instruments introduced
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through a standard anterior portal. The arthroscope is then removed from the glenohumeral joint and is introduced into the subacromial space. An arthroscopic acromioplasty is performed to create a smooth undersurface of the anterior third of the acromion. As this technique has been extensively reviewed elsewhere in this text, we will focus on the details of the mini-open tendon repair.
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Figure 39-1 A: Limited 3- to 4-cm skin incision, which includes the anterolateral portal and is directed along the skin lines for cosmesis. B: Deltoid split (dotted line), starting from the anterolateral acromion and extending 4 cm distally. C: Arm rotation allows the tear to be positioned below the deltoid split. (From Post M, Bigliani LU, Flatow EL, et al. Rotator cuff repair. In: Post M, Bigliani LU, Flatow EL, et al., eds. The Shoulder: Operative Technique. Lippincott Williams & Wilkins; 1998 , with permission.) |
After the arthroscopic acromioplasty has been completed, the arthroscope and burr are removed from the subacromial space. The anterolateral portal incision is extended to a total length of 3 to 4 cm and is directed horizontally along the skin lines (approximately parallel to the lateral border of the acromion) (Fig. 39-1A). This yields a more cosmetically pleasing scar than vertically oriented incisions. The subcutaneous tissue is incised and undermined to expose the deltoid fascia. The deltoid is then split from the anterolateral corner of the acromion to a point 4 to 5 cm distally, incorporating the previous puncture site through the deltoid in the split (Fig. 39-1B). Care is taken proximally not to release or avulse the deltoid from the anterior acromion and distally not to exceed 4 to 5 cm and thereby jeopardize the axillary nerve. Further bursectomy is then performed to allow better visualization of the torn rotator cuff. The torn portion of the rotator cuff can be delivered directly below the deltoid split by varying the rotation of the arm (Fig. 39-1C).
With the torn tendon now accessible for repair, sutures are placed into the tendon along the perimeter of the tear to assist with mobilization of the torn rotator cuff. A blunt periosteal elevator is used to release adhesions on both the articular and bursal surfaces of the cuff. The tendon is mobilized until it easily reaches its insertion on the greater tuberosity without significant tension. Occasionally, this may require a sharp release of the coracohumeral ligament at the base of the coracoid if this structure is tethering the retracted tendon. However, with most of the smaller tears selected for repair through this approach, mobilization is usually easily achieved without the need for sharp releases.
The region of the greater tuberosity that will receive the repaired rotator cuff is then prepared using a rongeur to remove any bony excrescences or fibrous tissue and to yield a bleeding bony base. Either suture anchor devices or sutures passed through bone tunnels in the greater tuberosity can be used to repair the cuff. It is this author's preference to use sutures passed through bone tunnels, as this technique allows more uniform compression of the tendon to the surface of the tuberosity than the suture anchor method, which provides more of a point contact type of fixation between the tendon and bone. One to three bone tunnels are then created, depending on the size of the tear to be repaired. The technique used by the author to create these tunnels in the greater tuberosity involves the use of a curved awl to start the tunnel proximally and then the use of a sharp trocar-tipped needle to pierce the lateral cortex of the tuberosity distally. Through each tunnel, two no. 1 or no. 2 braided nonabsorbable sutures are passed, thus doubling the number of sutures available for the repair. Each of the sutures is then passed through the torn tendon. The sutures are usually placed in simple fashion, although the modified Mason-Allen stitch is used for repairs of tissue of lesser quality. The sutures are tied with the arm at the side in neutral to slight internal rotation. After the tendon has been repaired, the deltoid split is repaired, and the skin is closed with a subcuticular repair.
Postoperatively, passive and assistive exercises are begun immediately to maintain the range of motion. Extension is deferred early on to avoid unduly stressing the tendon repair. A sling is used to prevent active use of the arm for approximately 6 weeks to protect the tendon repair. Active use for activities of daily living is allowed after 6 weeks, and
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resistive exercises are begun at 10 to 12 weeks postoperatively. Although the rehabilitation may proceed more easily and less painfully than after open repair (especially during the first few weeks), the rate of tendon healing to bone is not affected by the technique of repair. The biology of tendon healing still requires a period during which stresses across the repair must be minimized to avoid rerupture of the repaired tendon.
Open Rotator Cuff Repair
Since the first reported rotator cuff repair by Codman in 1911, open repair has been the standard method. During the first half of the twentieth century, the results of rotator cuff repair were unpredictable, probably largely owing to the acromionectomy procedures and transacromial approaches that were used. These procedures produced damage to the deltoid and alteration of its normal fulcrum, resulting in poor function and even inconsistent pain relief. Since the introduction of anterior acromioplasty by Neer and the abandonment of earlier acromionectomy techniques, the results of rotator cuff surgery have improved significantly, yielding satisfactory outcomes in 85% to 90% of patients.
A major advantage of open rotator cuff surgery is that it affords wide exposure for access to even massive tears of the rotator cuff. Such exposure is necessary when attempting to mobilize the chronically contracted tendons in a large or massive tear. The major disadvantage of this technique is that it involves incision of the anterior deltoid to gain exposure and to perform the anterior acromioplasty. This has the potential risk of deltoid dehiscence, though this complication is uncommon when the deltoid is repaired and protected properly in the early postoperative period. Greater perioperative morbidity, as measured by the need for narcotic analgesics and by longer hospital stays, is also cited as a relative disadvantage of open repair. There has been a shift to arthroscopically assisted rotator cuff repair for treating smaller tears and even more recently to arthroscopic repair of many tears. Although patient satisfaction and pain relief appear to be comparable for the results of open repair and those of arthroscopic repair, the structural results (i.e., anatomic healing of the repaired tendons to bone) of arthroscopic repair appear to be inferior to those of open repair for large and massive tears.
Open rotator cuff repair is performed with the patient in the semisitting or beach-chair position using regional interscalene block anesthesia. The patient is positioned so that the shoulder protrudes over the side of the operating table so that the arm can be extended and rotated during the procedure, particularly to gain access to retracted posterior cuff tendons. The shoulder is gently manipulated through a full passive range of motion to break up any capsular adhesions that occasionally may be present. An anterosuperior deltoid-splitting approach is used for the repair of most tears, although a deltopectoral approach is favored for isolated subscapularis tears. The preferred incision for most open repairs is a 6- to 7-cm incision, which starts over the lateral aspect of the acromion and proceeds to a point just lateral to the coracoid process. This yields a cosmetically acceptable scar, as the incision approximates the skin lines. A needle-tip electrocautery is used to incise the subcutaneous layer and to widely undermine this layer to expose the underlying deltoid fascia. The deltoid split starts anterior to the acromioclavicular joint and extends laterally 4 cm distal to the anterolateral corner of the acromion (Fig. 39-2A). A cuff of deltoid is left superiorly on the acromion to allow for a secure deltoid repair. This split in the deltoid is centered over the greater tuberosity to allow better exposure to the posterior cuff (Fig. 39-2B).
Subacromial decompression is next performed to remove any spurs or excrescences from the acromial undersurface. The coracoacromial ligament is released from the anterior aspect and undersurface of the acromion. This ligament is typically partially excised when there is a smaller tear but is preserved and later repaired back to the acromion in massive tears, where there is concern about the possibility of cuff failure and subsequent anterosuperior instability. After the anterior acromion has been exposed and adherent cuff and bursal tissue have been cleaned from its undersurface, a beveled osteotome (with the bevel facing upward) is used to perform an acromioplasty. The aim is to produce a smooth acromial undersurface, and the amount of bone removal varies according to the anatomy. By resecting only the downward projecting undersurface, effective decompression can be achieved with minimal shortening of the acromion. Osteophytes on the undersurface of the acromioclavicular joint are removed with a rongeur. Excision of the distal clavicle is performed only for preoperative acromioclavicular symptoms, and this is necessary in only 10% to 15% of cases. When this is necessary, the author prefers to resect the distal clavicle from below using a burr and rongeur so that the superior ligamentous envelope can be preserved to avoid microinstability of the acromioclavicular (AC) joint.
After the subacromial decompression, attention turns to mobilization and repair of the torn tendons. At this point, the characteristics of the tear are noted: size, shape, tendon involvement, degree of retraction, and quality of the tissue available for repair. The torn tendons are tagged with nonabsorbable sutures to assist with mobilization. A blunt periosteal elevator is used to release bursal adhesions, as well as to release adhesions between the tendons and capsule on the articular side. With acute tears, where there are no fixed contractures, mobilization proceeds quite easily. In large or massive chronic tears, these blunt releases may not be sufficient to restore mobile musculotendinous units to their insertion on the greater tuberosity. The torn tendon may be tethered by the adjacent intact tendon. Sharp release of the coracohumeral ligament at the base of the coracoid may assist with mobilization of the supraspinatus tendon. Additionally, as described by Bigliani, an “anterior interval slide” or sharp release of the interval between the supraspinatus and subscapularis tendons is performed when necessary (Fig. 39-2C). A similar release between the infraspinatus and supraspinatus is also occasionally needed.
The greater tuberosity is prepared by removing bony excrescences and residual fibrous tissue down to a bleeding bony base. The lesser tuberosity is similarly prepared if the subscapularis tendon is torn. Multiple bone tunnels are constructed, as previously described, using a sharp curved awl and a trocar-tipped needle. The location and number of tunnels varies according to the size of the tear. Through each
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of the tunnels, two no. 1 or no. 2 braided nonabsorbable sutures are passed to maximize the number of sutures available for tendon-to-bone repair and to disperse the stresses in the repaired tendons. Simple sutures are preferred if the tendon is of stout quality, but modified Mason-Allen sutures may also be used if the tissue is of poorer quality. The sutures are tied with the arm at the side in slight flexion and neutral to slight internal rotation. Tendon-to-tendon sutures are passed to repair the intervals that have been released. If the biceps tendon is intact in its groove, it is left alone. If there is significant fraying of the tendon (>50% of the tendon thickness) or if it is subluxed, tenodesis is performed, and the intra-articular portion is excised. Using the techniques described, complete repair can usually be achieved. However, occasionally with three- and four-tendon tears, this is not possible, and partial repair is performed. In these rare cases, the emphasis is on restoring tissue both anteriorly and posteriorly, and there may be a residual defect superiorly. When the tendon repair has been completed, the split in the deltoid is repaired with no. 1 nonabsorbable braided sutures. A subcuticular skin closure is then performed.
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Figure 39-2 A: The deltoid split starts anterior to the acromioclavicular joint and extends in an anterolateral raphe for 4 cm distal to the anterolateral corner of the acromion. B: This deltoid split is centered over the greater tuberosity and affords good access to the torn tendons (especially posteriorly). C: A sharp release of the rotator interval and coracohumeral ligament to the base of the coracoid or “interval slide” assists with mobilization of a chronically retracted supraspinatus tendon. (From Post M, Bigliani LU, Flatow EL, et al. Rotator cuff repair. In: Post M, Bigliani LU, Flatow EL, et al., eds. The Shoulder: Operative Technique. Lippincott Williams & Wilkins; 1998 , with permission.) |
Postoperatively, passive range of motion exercises are begun on the first postoperative day. These consist of pendulum exercises, as well as passive elevation in the scapular plane and passive external rotation (with the arm at the side). The degree of motion allowed depends on several factors, such as which tendons were involved, the tension on the repair, and the quality of the repaired tissue. With most tears, approximately 140 degrees of elevation and 40 degrees of external rotation are allowed in the early postoperative period. With subscapularis involvement, external rotation is usually limited to zero to 20 degrees. A sling is used for 6 weeks to prevent active use of the shoulder. More advanced stretching exercises, as well as light active use of the arm for activities of daily living, are added after 6 weeks. Resistive exercises are deferred for 3 months and are progressed gradually. Appropriate rehabilitation, which is supervised and directed by the surgeon, plays a crucial role in achieving a satisfactory outcome and avoiding complications, such as deltoid dehiscence and cuff tendon failure, after rotator cuff repair.
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