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Who needs a rotator cuff anyway? 1/4 ain't bad
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Who needs a rotator cuff anyway? 1/4 ain't bad - December 2, 2007 11:22:22 PM
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kiwi PT
Posts: 75
Joined: December 2, 2007
From: MI, USA (dreaming of New Zealand)
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Has anyone ever seen a patient like this before?
56 year old male, R sh
MRI:Full thickness tear with retraction of supraspinatus, full thickness tear with retraction of infraspinatus, full thickness tear with retraction of subscapularis, medially subluxed bicep tendon, and moderate degenerative changes.
Full painless AROM, and he golfs 100% painfree (and pretty well too according to him ), however has pain with cutting steak, putting his car in park, or holding any weight in 90 degrees flex.
Initially I did scapular strengthening, rhythmic stabilization and NMR in midrange flex and abd, and PRE/active in flex abd PNF flex patterns. Any sort of resisted flex abd or PNF really seemed to flare him up, so I d/c'd it after the first week stuck to the NMR like gently tossing catching a 500g ball in 90 deg flex and the scap strengthening. He has shown definate improvement in the 5 weeks I've seen him but I'm not sure what sort of level of improvement is realistic.
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RE: Who needs a rotator cuff anyway? 1/4 ain't bad - December 3, 2007 9:24:16 AM
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PTupdate.com
Posts: 1474
Joined: October 8, 2001
From: Pittsburgh, PA USA
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We've probably all seen these patients, and did not even realize it. The rate of cuff tearing as people age is quite high, but that does not mean they will always be symptomatic. This guy is a classic case where function and subjective reporting do not match the MRI, another reason not to push for that test early on.
He most likely has the degenerative changes due to his cuff issues, and they will likely progress. He is getting pain with the activities you listed due to superior migration of the humerus from lack of cuff stabilization. I'd strengthen (gently and safely) what's still attached and working, and focus on pain free scapular stabilization, lots of education (especially about the fact that this will most likely progress to full arthropathy) and avoidance of activities that cause pain
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: Who needs a rotator cuff anyway? 1/4 ain't bad - December 3, 2007 10:18:37 AM
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buckeye
Posts: 170
Joined: May 24, 2007
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Great advice from PTupdate. Definitely agree that education is crucial - modifying activities will be important to extend the life of what is left at the shoulder. Also work with patient on using trunk and hip/LE to contribute to reaching to give as much extra help to the deficient shoulder. I recall some literature a few years back that mentioned the importance of inferior trapezius and serratus anterior force couple for scapular stabilization. Good luck.
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RE: Who needs a rotator cuff anyway? 1/4 ain't bad - December 3, 2007 2:48:08 PM
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pappawheelie
Posts: 40
Joined: September 19, 2007
From: Vermont
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Am I correct in thinking that a full-thickness tear with retraction is not the same as a rupture?
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RE: Who needs a rotator cuff anyway? 1/4 ain't bad - December 3, 2007 8:26:32 PM
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kiwi PT
Posts: 75
Joined: December 2, 2007
From: MI, USA (dreaming of New Zealand)
Status: offline
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It is completely torn/ruptured whatever you want to call it, but the torn ends aren't even close together because they are old tears. The retraction would make repair more difficult and likely mean a VERY conservative post-op protocol. There would be a good chance he could lose a lot of that AROM permanently if he were to have surgery. Based on his current function I don't think surgery would make sense due to the risks. He is very happy about the fact that he can still play golf well and would be VERY upset if he had increased difficulty doing so. Plus this guy is ridiculously afraid of needles and proud of the fact that he has never been to an ER, had surgery, or broken a bone (or least went to a physician fot it!). He was first sent by his family doc to an orthopod who wanted to cut but when asked also told him there was a 1/3 or greater chance he'd be worse following surgery, so he sought a 2nd opinion from a physiatrist who sent him to me.
I told him he must have one hell of a teres minor!
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RE: Who needs a rotator cuff anyway? 1/4 ain't bad - December 5, 2007 11:55:18 PM
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jma
Posts: 2405
Joined: August 24, 2000
From: NY
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I take my hat off to that patient who can still play golf using a shoulder like that.
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RE: Who needs a rotator cuff anyway? 1/4 ain't bad - December 6, 2007 12:14:51 AM
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PTupdate.com
Posts: 1474
Joined: October 8, 2001
From: Pittsburgh, PA USA
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Actually, if he's a right handed golfer, and this is his right shoulder, he should be able to play fairly well. That's the guide arm, and the left is the power arm. I've seen others with either a right cuff tear, or a failed repair, and their golf game does not suffer much. Do the same thing to the other shoulder, and then they are in a jam
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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