How are impingement and rotator cuff tears treated?

Impingement and rotator cuff tears can be treated non-operatively or with surgery.

Treatment for both injuries usually begins with a non-operative treatment plan. More than 2/3 of impingement patients can expect significant improvement in their symptoms with a physical therapy program alone. These results are lower in older patients and in those with large bone spurs.

When trauma causes a tear in younger patients, surgery is often the first choice of treatment. Patients with this type of injury recover best if surgery is done early. Generally, this pertains to those patients under the age of fifty with tears less than four weeks old.

Non-Operative Treatment

Non-operative treatment is similar for both impingement and rotator cuff tears. A vast majority of patients improve with this primary treatment alone. The goals of a physical therapy program include:

  • strengthening the rotator cuff tendons.
  • stretching and regaining lost motion caused by pain and inflammation.
  • allowing the humerus to be better positioned under the acromion, thus reducing compression of the bursa.

 
External Rotation
 
Cross Arm Push
Standing parallel to an elastic resistance cord, the elbow should be bent 90 degrees at the side. The hand should slowly rotate away from the body, using the elbow as a hinge. Rotation should continue until the arm is in a neutral position.
 
The hand is placed on the opposite shoulder. The other hand is used to pull the elbow across the body until a good stretch is felt on the back of the shoulder.
Anti-inflammatory medication may be prescribed to help reduce pain and inflammation. Many patients with rotator cuff tears can function quite well if pain and inflammation are controlled with medication and physical therapy. This is especially true for the elderly and those with low demands on the shoulder.
If symptoms have not improved with this program, the doctor may recommend a steroid injection into the bursa. Cortisone, or a similar steroid, is often combined with a local anesthetic to help control the pain and inflammation of the bursa. Steroid injections are used with caution. Damage to the rotator cuff tendons may occur with more than two or three injections over several months. Patients with diabetes are generally not good candidates for steroid injections because of problems with glucose control.

Operative Treatment

Impingement

A non-operative treatment plan is often all that is necessary for most patients with impingement syndrome. However, the small percentage of patients whose symptoms have not improved after 6 months of dedicated physical therapy may be candidates for surgery. The shoulder should be reevaluated to make sure no other problems exist.

Subacromial decompression expands the space between the acromion and rotator cuff tendons. This can be done either arthroscopically or with open incisions, depending on the preference of the surgeon. During an arthroscopy, a tiny fiberoptic instrument is inserted into the joint. In many cases, the doctor can assess and repair the damage through this scope without making large incisions. Scar tissue or bone spurs can successfully be removed with either technique. If a rotator cuff tear is found at the time of surgery, it can also be repaired if necessary.

Rotator cuff tear

Not all rotator cuff tears require surgery. Many patients are content with their progress following a non-operative treatment plan. Patients who have been unable to regain lost motion and strengthen the surrounding muscles sufficiently may need a rotator cuff repair. This is often the case for the younger, more active patients who want to address continued weakness following physical therapy.

Rotator cuff repairs can be performed either arthroscopically or with open incisions. Arthroscopic techniques are new and limited to specific types of tears. An open repair that secures the rotator cuff tendons back to the humerus remains the surgical treatment of choice.

What types of complications may occur?

Complication rates after surgery are generally low. Pre-operative antibiotics are given to reduce the slight risk of infection after surgery. Infection tends to occur a little less often when arthroscopic techniques are used. Risks of major bleeding or nerve damage are extremely small. Postoperative stiffness is the major complication of both impingement and rotator cuff tears.



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