Dr Michell Ruiz

Dr Michell Ruiz
Cirugía de hombro y del Manguito rotador

martes, 31 de diciembre de 2013

Shoulder Arthritis / Rotator Cuff Tears: causes of shoulder pain: Vancomycin, is there a better way to give it for i...

Shoulder Arthritis / Rotator Cuff Tears: causes of shoulder pain: Vancomycin, is there a better way to give it for i...: The Mark Coventry Award: Higher Tissue Concentrations of Vancomycin With Low-dose Intraosseous Regional Versus Systemic Prophylaxis in TKA ...

Thursday, December 26, 2013

Vancomycin, is there a better way to give it for infection prophylaxis?

The Mark Coventry Award: Higher Tissue Concentrations of Vancomycin With Low-dose Intraosseous Regional Versus Systemic Prophylaxis in TKA : A Randomized Trial.

Because of our concern about Proprionibacterium and Coagulase negative Staph in shoulder arthroplasty, we now use IV perioperative  Ceftriaxone and Vancomycin X 24 hours as our preferred antibiotic prophylaxis.

However, as these authors point out, routine use of IV Vancomycin carries with it the risk of eventual antibiotic resistance and systemic toxicity (red man syndrome, renal toxicity, otic toxicity, for example). They have explored the use of intraosseous regional administration (IORA) in arthroplasty infection prophylaxis.

They randomized 30 patients undergoing primary knee arthroplasty to receive 250 or 500 mg vancomycin via IORA or 1 g via systemic administration. IORA was performed as a bolus injection into a tibial intraosseous cannula below an inflated thigh tourniquet immediately before skin incision. 

They found that the overall mean tissue concentration of vancomycin in subcutaneous fat was 14 μg/g in the 250-mg IORA group, 44 μg/g in the 500-mg IORA group, and 3.2 μg/g in the systemic group. Mean concentrations in bone were 16 μg/g in the 250-mg IORA group, 38 μg/g in the 500-mg IORA group, and 4.0 μg/g in the systemic group. One patient in the systemic group developed red man syndrome during infusion.

While these authors used preoperative infusion via a cannula inserted into the tibia before surgery, it is possible that shoulder surgeons could administer Vancomycin during impaction autografting of the medullary canal and achieve a similar effect. Topical administration may have the advantages of increased local levels of antibiotic and diminished systemic effects as well as diminished chance of inducing resistance.

domingo, 29 de diciembre de 2013

Rotator cuff. Posterior view


Shoulder Arthritis / Rotator Cuff Tears: causes of shoulder pain: What can be done for rotator cuff tears without su...

Shoulder Arthritis / Rotator Cuff Tears: causes of shoulder pain: What can be done for rotator cuff tears without su...: With the exception of an acute traumatic cuff tear that results in an abrupt loss of strength, there is usually an opportunity for non-opera...

Saturday, December 28, 2013


What can be done for rotator cuff tears without surgery?

With the exception of an acute traumatic cuff tear that results in an abrupt loss of strength, there is usually an opportunity for non-operative management. This is particularly the case for partial thickness tears on one hand and larger atraumatic tears on the other.

We recall that rotator cuff tears may be associated with symptoms of stiffness, weakness, crepitance and instability. We also know that rotator cuff repair requires prolonged protection of the repair so that the individual often cannot return to work or even activities of daily living for months after repair surgery. Therefore, we offer those individuals with non-acute cuff tears a trial of non-operative management emphasizing gentle stretching exercises - especially those directed at achieving a full range of passive motion (see here, especially exercises E,F, and G). It is always of interest to us that individuals with cuff pathology lack internal rotation with the arm in abduction and that the 'sleeper stretch' (G) can go a long way to resolving this tightness and the associated shoulder pain. These exercises often help resolve the crepitance as well.

Shoulder Arthritis / Rotator Cuff Tears: causes of shoulder pain: Surgery for rotator cuff tears: repair, smooth and...

Shoulder Arthritis / Rotator Cuff Tears: causes of shoulder pain: Surgery for rotator cuff tears: repair, smooth and...: There two basic surgical procedures that are considered in the management of a rotator cuff tear: (1) An attempt at surgical repair of the...

Sunday, December 29, 2013

Surgery for rotator cuff tears: repair, smooth and move, CTA arthroplasty, reverse total shoulder

There two basic surgical procedures that are considered in the management of a rotator cuff tear:

(1) An attempt at surgical repair of the tendon back to the area on the humerus from which it was torn

(2) A smooth and move procedure, in which the thickened bursa and scar tissue are removed along with the rough edges of the residual cuff and prominent humeral bone leaving a smooth convex surface to articulate with the concave coracoacromial arch coupled with a gentle manipulation of the shoulder to restore complete passive range of motion. Importantly, to preserve the stabilizing effect of the coracoacromial arch, we avoid acromioplasty or sectioning of the CA ligament.

The strongest indication for a surgical repair is a traumatic rotator cuff tear in an otherwise healthy patient and shoulder. When a fall or other injury results in weakness or inability to use the arm normally x-rays are necessary to exclude a fracture and an MRI or ultrasound should be considered to evaluate the possibility of a rotator cuff tear. This evaluation needs to take place promptly, in that if a significant acute tear is present, the optimal time for repair is within the first six weeks before atrophy of the tendon, muscle and bone begins.

Aside from this situation, there is no urgency in considering or performing surgery for a rotator cuff tear - there is ample time for a gentle rehabilitation program and for consideration of the surgical options. 

With a chronic cuff tears, the surgeon and the patient need to consider the likelihood that a durable repair can be achieved. We've found that some straightforward characteristics can be very informative about the quantity and quality of the tendon available for a repair attempt and have posted them here.  A thorough review of the literature indicates that the quantity and quality of the residual tendon (not the surgical technique used) is the primary determinant of the durability of a surgical repair. It is also recognized that if a repair is undertaken, the shoulder needs to be protected from loading (i.e. not used for work, play or activities of daily living) for months afterwards. From this we can see that a repair attempt should not be undertaken unless the condition of the tendon is amenable for a durable repair. We inform patients desiring rotator cuff surgery that we will perform a repair if the quantity and quality of the tendon allows good quality cuff to be reattached to the anatomical footprint without undue tension with the arm at the side; otherwise we perform a smooth and move which allows them immediate postoperative use of the arm. This approach is supported by the many articles reviewed in this blog demonstrating that the results of attempted repair are similar whether or not the repair remains intact.

We prefer a minimally invasive open approach to rotator cuff surgery in that it is expeditious, allows examination of the shoulder throughout a full range of motion, and (because the deltoid remains intact) does not delay recovery. Our technique for cuff tendon reattachment is shown here. Basically, we use an 'inlay' technique in which the tendon is securely inserted into a groove made at the normal cuff attachment site and held there securely with multiple sutures to distribute the load. We prefer this method to 'onlay' techniques because it exposes the tendon edge to the stem cells and growth factors activated by the creation of the bony groove, because it allows for multiple sutures to create the strongest possible repair and because it allows for the possibility of some stress relaxation in the repair without loss of contact between the tendon edge and bone.

Shoulder Arthritis / Rotator Cuff Tears: causes of shoulder pain: Failed cuff surgery: What can be done if rotator c...

Shoulder Arthritis / Rotator Cuff Tears: causes of shoulder pain: Failed cuff surgery: What can be done if rotator c...: In our practice we see many patients referred or self-referred because the results of a previous attempt at a rotator cuff repair were not s...

Sunday, December 29, 2013


Failed cuff surgery: What can be done if rotator cuff surgery fails to give the desired result?

In our practice we see many patients referred or self-referred because the results of a previous attempt at a rotator cuff repair were not satisfactory. Common problems include, in addition to pain, (1) stiffness, (2) crepitance (popping and snapping), (3) weakness, (4) instability, (5) infection, and (6) detachment or denervation of the deltoid.

In addition to a good history and physical examination, high quality plain x-rays are important in the evaluation, seeking evidence of glenohumeral arthritis, upward displacement of the humeral head in relation to the glenoid, prominent suture anchors, and unwanted bone.

Unless there is some obvious contraindication (such as a prominent suture anchor), it is usually worthwhile giving the shoulder the benefit of a gentle exercise program. 

If the shoulder does not respond to non-operative management, and if the primary mechanical problems include some combination of crepitance or stiffness, a smooth and move procedure is usually helpful. In many cases we've found loose suture and prominent anchors or prominent tuberosities as the cause of the stiffness and crepitance. These can be removed and trimmed back to leave a smooth upper surface to the proximal humeral convexity. Again, we preserve the acromion and coracoacromial ligament as important stabilizers of the shoulder.   It is rare that a failed repair offers a good opportunity for a re-repair in that the quality and quantity of cuff tendon are usually compromised.

Infection is managed by a good smooth and move after cultures are obtained followed by copious irrigation and appropriate antibiotic management. It is now recognized that Propionibacterium can not infrequently be recovered from failed cuff repairs.

Failed cuff repairs leaving the shoulder unstable or with less than 90 degrees of active elevation may be candidates for a reverse total shoulder. 

sábado, 28 de diciembre de 2013

Injury: Rotator Cuff Tear

FUENTE: http://sportsinjuryadvice.com/injuries/shoulder/rotatorcufftear


Injury: Rotator Cuff Tear

What is a Rotator Cuff Tear?
A rotator cuff tear or torn rotator cuff is very common in a wide range of sports such as baseballtennisgolfvolleyballhockey, and footballThe rotator cuff is a group of muscles and tendons that serve as the primary stabilizer for the shoulder.These sports all put athletes in positions where the arm is over-extended from the body causing these tendons and rotator cuff muscles to become less stable and more susceptible to a rotator cuff tear. In most cases a shoulder injury such as a torn rotator cuff can be suspected due to pain and weakness in the back of the shoulder and typically when raising your arm or extending it from the body. It is important to consult with a physician if a rotator cuff tear is suspected because the only way to get an official diagnosis is to determine the extent of the shoulder injury is through Magnetic Resonance Imaging (MRI).
Medical Definition of a Rotator Cuff Tear
Their are four rotator cuff muscles: the supraspinatus, the infraspinatus, the subscapularis, and the teres minor. These muscles form a cover around the head of the humerus and function to rotate the arm and stabilize the humeral head against the glenoid. A rotator cuff tear can occur with an acute injury, but most are the result of age-related degeneration, chronic mechanical impingement, and altered blood supply to the tendons. A torn rotator cuff generally originates in the supraspinatus tendon and can progress posteriorly and anteriorly. Full-thickness tears are uncommon in individuals younger than 40 years of age, but are present in 25% of individuals over 60 years of age. Most older people are asymptomatic or have only mild, nondisabling symptoms.
Synonyms
- Rotator Cuff Rupture
- Rotator Cuff Tendinitis
- Torn Rotator Cuff


What are the symptoms of a Rotator Cuff Tear?
- Recurring shoulder pain with specific injury that triggered onset of pain.
- Difficulty sleeping due to increased pain at night.
- Arm catches when lifting arm over the head.
- Weakness in the shoulder is a commonly seen rotator cuff tear symptom.
- Individual tends to hold arm on affected side.


Related Injuries
Shoulder Impingement
Labrum Tear
Frozen Shoulder
Treatment of Rotator Cuff Tear
- Proper usage of NSAIDS.
Strengthening exercises of the rotator cuff muscles and arm.
- Light 
stretching exercises of the rotator cuff muscles to help maintain range of motion.
Corticosteroid injection may be used to provide short term relief of pain.
Surgery
Rotator Cuff Surgery

Related Anatomy
Rotator Cuff
Shoulder Blade
Sports
Football
Baseball
Hockey
Golf
Tennis
Volleyball

Related Articles
How to Rehab the Shoulder After Rotator Cuff Surgery
References
Greene W.B. (Ed). (2001). Essentials of Musculoskeletal Care.Rosemont, Il: American Academy of Orthopaedic Surgeons (141-143)

preop xray, male 81 years old with all severe medical conditions that you can think, now what?


jueves, 26 de diciembre de 2013

Rechazar la cirugía es algunas veces la opción mas costosa

http://blog.anklefootmd.com/2013/12/26/refusing-surgery-can-sometimes-be-the-more-expensive-option/

Rechazar la cirugía es algunas veces la opción mas costosa


Refusing Surgery Can Sometimes Be The More Expensive Option


December 26, 2013



According to researchers at Duke Orthopedic Surgery, the lifetime costs of forgoing a surgical operation to repair a torn rotator cuff may be more expensive than undergoing a procedure to fix the issue.

When all factors were accounted for, researchers noted that among patients between the ages of 30 and 79, the average societal savings associated with surgical repairs was $13,771.

Some non-operatives costs that arose as a result of neglecting to have the injury corrected that factored into the total cost savings were:
Fewer employment options
Lower income
Missed work days
Disability payments

Although the operation was no longer cost saving if the patient was over the age of 61, the operation was still cost effective.

“The findings provide a rationale for payer coverage of rotator cuff repair after an initial trial of non-operative treatment,” the researchers wrote in their findings.

The surgery-related savings were even more pronounced if the patient was young. In patients between the ages of 30 and 39, the lifetime societal cost savings was $77,662. Researchers also noted that patients who elected to have the surgery reported a higher quality of life than those who did not undergo the corrective operation.

Despite the encouraging results, the authors cautioned that each patient should be evaluated on a case-by-case basis.

“The results of this study should not be interpreted as suggesting that all rotator cuff tears require surgery. Rather, the results show that rotator cuff repair has an important role in minimizing the societal burden of rotator cuff disease,” researchers wrote.
Dr. Silverman comments

As doctors, we assume that our treatments improve the quality of life, decrease pain, and improve function. What we don’t know is the cost effectiveness.

I like when studies show the cost effectiveness of a procedure. I would be truly troubled by a study which found that an operation was pain relieving and improved patient function that was not cost effective. How could I fulfill my obligation to relieve pain and suffering when my hands are tied by cost efficacy?

I provide the same three options to patients.

1. Live with it and do nothing (and I tell them the long-term and natural history of the disorder).

2. Manage the problem non-surgically. Again, I reiterate the natural history and when it can and cannot be altered by nonsurgical choices.

3. Fix the problem surgically. I share with them the likely outcomes of the surgery as well as the risks involved.

How does one move cost efficacy into this discussion? Where are the ethical implications?

Can you imagine a doctor saying, “Well, this would relieve your pain, but since it’s not cost efficacious, your insurance won’t cover it. Here are some pills instead.”

Ugg!

Related source: Medscape

miércoles, 25 de diciembre de 2013

Comprehensive Operative Management of Clavicle Fractures | Colorado Shoulder Specialist

http://www.youtube.com/watch?v=KkwqVVcYT7s&feature=share

Comprehensive Operative Management of Clavicle Fractures

Publicado el 13/12/2013
http://drmillett.com

This video discusses the mid-shaft clavicle fractures in the shoulder. There are varying levels of clavicle fractures. Colorado shoulder specialist, Dr. Peter Millett demonstrates the two different surgical techniques to treat clavicle fractures.

domingo, 15 de diciembre de 2013

Arthroscopic Rotator Cuff Repair at Reconstructive Orthopaedics

A complete arthroscopic rotator cuff repair is demonstrated from a live surgery, performed at Reconstructive Orthopaedics & Sports Medicine in Cincinnati, OH.

An untreated rotator cuff injury will lead to limited strength in mobility as well as pain.

http://youtu.be/u9ZTBYa22AU 

sábado, 14 de diciembre de 2013

Nuevo video Capsulorrafia Anterior y Posterior de Hombro por Inestabilidad


Réponse à la QUESTION N°08: PROFIL DE BLOOM et OBATA


Human Interactive Shoulder Anatomy in 3D

By Video:
Human Interactive Shoulder Anatomy in 3D

Watch Video:
http://doctorsvideos.blogspot.com/2011/06/human-interactive-shoulder-anatomy-in.html 


una publicación de Victor Ravens.

http://VisuMedical.com - View the shoulder in detailed 3D with this teaching, training and reference tool. A choice of 3D models include all areas of the shoulder joint and shoulder girdle. Peel away layers of anatomy from skin to bone and rotate the model at any stage to view and identify any anatomical structure.

http://youtu.be/NGcbKaSRiEk 

 


EPICONDILITIS, CODO DE TENISTA

http://depiesymanos.wordpress.com/2013/10/04/epicondilitis-codo-de-tenista/


EPICONDILITIS, CODO DE TENISTA

DENTRO DE TODAS LAS TENDINITIS QUE SE PUEDEN SUFRIR EN EL CUERPO, LA DEL EPICÓNDILO DEL CODO ES DE LAS MÁS COMUNES.

Una persona sufre de epicondilitis cuando experimenta una inflamación de las inserciones musculares en el epicóndilo del codo, esta es una variedad de tendinitis en donde el dolor puede aparecer a nivel de la inserción muscular en el hueso del codo o se puede irradiar hacia los músculos del antebrazo y ocasionalmente hasta la muñeca.

293797_453466204710091_674193846_n

La epicondilitis generalmente se relaciona con el sobre uso o con un traumatismo directo sobre la zona. El dolor es más intenso después de un uso efusivo de la extremidad en cuestión. Las actividades que suponen presión fuerte o rotaciones del antebrazo agravan dicho traumatismo (deportes como el tenis)
Podemos encontrar dos tipos de tratamientos, uno no quirúrgico y el quirúrgico, la realización de uno u otro variara según la complejidad y la edad de la epicondilitis.
Dentro del tratamiento no quirúrgico podemos citar las técnicas manuales osteopáticas, quiromasaje, vendaje neuromuscular, acupuntura, protección, disminución de la inflamación, y fortalecimiento de los músculos y tendones, en su conjunto apuntan a la modificación de aquellas actividades que agravan el dolor, la disminución del tiempo o intensidad de la actividad, realización de descansos y estiramientos.También es muy efectiva la utilización de una codera elástica.
Un programa de estiramientos puede ser útil para disminuir la tensión del músculo sobre el tendón implicado. Los estiramientos incluyen el brazo afectado, el cuello, parte superior de la espalda y hombro, mano, muñeca, antebrazo y tríceps.
La desinflamación puede lograrse mediante la realización de crioterapia/hielo
Ocasionalmente es necesaria la cirugía si la epicondilitis no responde al tratamiento conservador. La técnica no es tan eficaz como muchas otras intervenciones y no se recomienda a menos que se haya completado un programa adecuado de tratamiento no quirúrgico.
Tras la cirugía, es conveniente continuar con los ejercicios de estiramiento para prevenir recaídas. La recuperación completa se consigue generalmente entre seis semanas y cuatro meses tras un arduo trabajo de rehabilitación.
“Extraído de blogdefarmacia.com” Editado por de Pies y Manos

jueves, 12 de diciembre de 2013

Técnicas de movilización





Medical Monday: Rotator Cuff Tears - Summit Medical Group

Rotator cuff tears are one of the most common shoulder injuries for participants in baseball, bowling, cricket, swimming, tennis, and kayaking, or other activities that may overuse the shoulder. The rotator cuff is the group of muscles and tendons that stabilize the shoulder. When torn, symptoms can range from a acute pain to gradual weakness and decreased shoulder motion. Summit Medical Group orthopedics surgeon, Matthew Garberina, M.D., discusses treatment and prevention of rotator cuff tears.

http://youtu.be/8PjjY8FN3J8


Physical Therapist's Guide to Rotator Cuff Tear

FUENTE:
http://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=95bd746b-b25f-46f5-8373-fb56c9f6b46a


Physical Therapist's Guide to Rotator Cuff Tear

The "rotator cuff" is a group of 4 muscles that are responsible for keeping the shoulder joint stable. Unfortunately, injuries to the rotator cuff are very common, either from injury or with repeated overuse of the shoulder. Injuries to the rotator cuff can vary as a person ages. Rotator cuff tears are more common later in life, but they also can occur in younger people. Athletes and heavy laborers are commonly affected; older adults also can injure the rotator cuff when they fall or strain the shoulder, such as when walking a dog that pulls on the leash. When left untreated, this injury can cause severe pain and a decrease in the ability to use the arm.


What is a Rotator Cuff Tear?

The "rotator cuff" is a group of 4 muscles and their tendons (which attach them to the bone). These muscles connect the upper-arm bone, or humerus, to the shoulder blade. The important job of the rotator cuff is to keep the shoulder joint stable. Sometimes, the rotator cuff becomes inflamed or irritated due to heavy lifting, repetitive arm movements, or a fall. A rotator cuff tear occurs when injuries to the muscles or tendonscause tissue damage or disruption.
Rotator cuff tears are called either "full-thickness" or partial-thickness," depending on how severe they are. Full-thickness tears extend from the top to the bottom of a rotator cuff muscle/tendon. Partial-thickness tears affect at least some portion of a rotator cuff muscle/tendon, but do not extend all the way through.
Tears often develop as a result of either a traumatic event or long-term overuse of the shoulder. These conditions are commonly called acute or chronic:
  • An acute rotator cuff tear is one that just recently occurred, often due to a trauma such as a fall or lifting a heavy object.
  • Chronic rotator cuff tears are much slower to develop. These tears are often the result of repeated actions with the arms working above shoulder level—such as with ball-throwing sports or certain work activities.
People with chronic rotator cuff injuries often have a history of rotator cuff tendon irritation that causes shoulder pain with movement. This condition is known as shoulder impingement syndrome (SIS).
Rotator cuff tears also may occur in combination with injuries or irritation of the biceps tendon at the shoulder, or with labral tears (to the ring of cartilage at the shoulder joint).
Rotator Cuff Tear-SmallRotator Cuff Tear: See More Detail

How Does it Feel?

Rotator cuff tears can cause:
  • Pain over the top of the shoulder or down the outside of the arm
  • Shoulder weakness
  • Loss of shoulder motion
The injured arm often feels heavy, weak, and painful. In severe cases, tears may keep you from doing your daily activities or even raising your arm. People with rotator cuff tears often are unable to lift the arm to reach high shelves or reach behind their backs to tuck in a shirt or blouse, pull out a wallet, or fasten a bra.

How Is It Diagnosed?

Your physical therapist will review your health history, perform a thorough examination, and conduct a series of tests designed specifically to help pinpoint the cause of your shoulder pain.
Physical therapists perform specialized tests--such as the Hawkins-Kennedy impingement test, Neer's impingement sign, and the external rotation lag sign-- to diagnose an impingement or a tear. For instance, your therapist may raise your arm, move your arm out to the side, or raise your arm and ask you to resist a force, all at specific angles of elevation. These tests may cause you to feel some temporary discomfort, but don't worry—that's normal and part of what helps the therapist identify the exact source of your problem.
In some cases, the results of these tests might indicate the need for a referral to an orthopedist or for imaging tests, such as ultrasound imaging, magnetic resonance imaging (MRI), or computed tomography (CT).

How Can a Physical Therapist Help?

Once a rotator cuff injury has been diagnosed, you will work with your orthopedist and physical therapist to decide if you should have surgery or if you can try to manage your recovery without surgery. If you don't have surgery, your therapist will work with you to restore your range of motion, muscle strength, and coordination, so that you can return to your regular activities. In some cases, your therapist may help you learn to modify your physical activity so that you put less stress on your shoulder. If you decide to have surgery, your therapist can help you both before and after the procedure.
Regardless of which treatment you have—physical therapy only, or surgery and physical therapy—early treatment can help speed up healing and avoid permanent damage.

If You Have an Acute Injury

If a rotator cuff tear is suspected following a trauma, seek the attention of a physical therapist or other health care provider to rule out the possibility of serious life- or limb-threatening conditions. Once serious injury is ruled out, your physical therapist will help you manage your pain and will prepare you for the best course of treatment.

If You Have a Chronic Injury

A physical therapist can help manage the symptoms of chronic rotator cuff tears as well as improve how your shoulder works. For large rotator cuff tears that can't be fully repaired, physical therapists can teach special strategies to improve shoulder movement.

If You Have Surgery

Once a full-thickness rotator cuff tear develops, you may need surgery to restore use of the shoulder or decrease painful symptoms. Physical therapy is an important part of the recovery process. The repaired rotator cuff is vulnerable to reinjury following shoulder surgery, so it's important to work with a physical therapist to safely regain full use of the injured arm. After the surgical repair, you will need to wear a sling to keep your shoulder and arm protected as the repair heals. Once you are able to remove the sling for exercise, the physical therapist will begin your exercise program.
Your physical therapist will design a treatment program based on both the findings of the evaluation and your personal goals. He or she will guide you through your postsurgical rehabilitation, which will progress from gentle range-of-motion and strengthening exercises and ultimately to activity- or sport-specific exercises. Your treatment program most likely will include a combination of exercises to strengthen the rotator cuff and other muscles that support the shoulder joint. Your therapist will instruct you in how to use therapeutic resistance bands. The timeline for your recovery will vary depending on the surgical procedure and your general state of health, but full return to sports, heavy lifting, and other strenuous activities might not begin until 4 months after surgery. Your shoulder will be very susceptible to reinjury, so it is extremely important to follow the postoperative instructions provided by your surgeon and physical therapist.
Physical therapy after your shoulder surgery is essential to restore your shoulder's function. Your rehabilitation will typically be divided into 4 phases:
  • Phase I (maximal protection). This phase lasts for the first few weeks after your surgery, when your shoulder is at the greatest risk of reinjury. During this phase, your arm will be in a sling. You will likely need assistance or need strategies to accomplish everyday tasks such as bathing and dressing. Your physical therapist will teach you gentle range-of-motion and isometric strengthening exercises, will provide hands-on techniques such as gentle massage, will offer advice on reducing your pain, and may use cold compression and electrical stimulation to relieve pain.
  • Phase II (moderate protection). This next phase has the goal of restoring mobility to the shoulder. You will reduce the use of your sling, and your range-of-motion and strengthening exercises will become more challenging. Exercises will be added to strengthen the "core" muscles of your trunk and shoulder blade (scapula) and "rotator cuff" muscles that provide additional support and stability to your shoulder. You will be able to begin using your arm for daily activities, but will still avoid any heavy lifting with your arm. Your physical therapist may use special hands-on mobilization techniques during this phase to help restore your shoulder's range of motion.
  • Phase III (return to activity). This phase has the goal of restoring your strength and joint awareness to equal that of your other shoulder. At this point, you should have full use of your arm for daily activities, but you will still be unable to participate in activities such as sports, yard work, or physically strenuous work-related tasks. Your physical therapist will advance the difficulty of your exercises by adding more weight or by having you use more challenging movement patterns. A modified weight-lifting/gym-based program may also be started during this phase.
  • Phase IV (return to occupation/sport). This phase will help you return to sports, work, and other higher-level activities. During this phase, your physical therapist will instruct you in activity-specific exercises to meet your needs. For certain athletes, this may include throwing and catching drills. For others, it may include practice in lifting heavier items onto shelves, or instruction in raking, shoveling, or housework.

Can this Injury or Condition be Prevented?

A physical therapist can help you decrease your risk of developing or worsening a rotator cuff tear, especially if you seek assistance at the first sign of shoulder pain or discomfort. To avoid developing or progressing to a rotator cuff tear from an existing shoulder impingement, it is imperative to avoid future exacerbations. Your physical therapist can help you strengthen your rotator cuff muscles, train you to avoid potentially harmful positions, and determine when it is appropriate for you to return to your normal activities.
General Tips:
  • Avoid repeated overhead arm positions that may cause shoulder pain. If your job requires such movements, seek out the advice of a physical therapist to learn arm positions that may be used with less risk.
  • Apply rotator cuff muscle and scapular strengthening exercises into your normal exercise routine. The strength of the rotator cuff is just as important as the strength of any other muscle group. To avoid potential detriment to the rotator cuff, general strengthening and fitness programs may improve shoulder health.
  • Practice good posture. A forward position of the head and shoulders has been shown to alter shoulder blade position and create shoulder impingement syndrome.
  • Avoid sleeping on your side with your arm stretched overhead, or lying on your shoulder. These positions can begin the process that causes rotator cuff damage.
  • Avoid carrying heavy objects at your side; this can strain the rotator cuff.
  • Avoid smoking; it can decrease the blood flow to your rotator cuff.
  • Consult a physical therapist at the first sign of symptoms.

Real Life Experiences

Over the past 3 weeks, Jonathan has felt pain in his shoulder while repainting his house. Now, every time he raises his arm overhead, it hurts. He notices that the pain has been steadily getting worse.
What should he do?
  • Rest. Avoid activities that require reaching overhead and rest his elbow on an armrest when sitting. This may allow the irritated muscles and tendons to heal.
  • Ice. Apply ice to the shoulder to help decrease any irritation and swelling.
Jonathan has stopped reaching overhead to paint and puts ice on his shoulder in the evening. But he still feels pain and stiffness in the area, and he can't move his arm without pain or weakness. He contacts his physical therapist, who prescribes exercises to strengthen his rotator cuff muscles and improve postural habits, and provides education to avoid exacerbating activities.
This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat patients who have a rotator cuff tear, but you may want to consider:
  • A physical therapist who is experienced in treating people with musculoskeletal problems. Some physical therapists have a practice with an orthopedic focus.
  • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedics physical therapy has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
  • Get recommendations from family and friends or from other health care providers.
  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with labral tears.
  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
APTA has determined that the following articles provide some of the best scientific evidence for how to treat rotator cuff tears. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free access of the full article, so that you can read it or print out a copy to bring with you to your health care provider.
APTA has determined that the following articles provide some of the best scientific evidence for how to treat rotator cuff tear. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are listed by year and are linked either to a PubMed* abstract of the article or to free access of the full article, so that you can read it or print out a copy to bring with you to your health care provider.
Longo UG, Franceschi F, Berton A, et al. Conservative treatment and rotator cuff tear progression. Med Sport Sci. 2012;57:90–99. Article Summary on PubMed.
Düzgün I, Baltacı G, Atay OA. Comparison of slow and accelerated rehabilitation protocol after arthroscopic rotator cuff repair: pain and functional activity. Acta Orthop Traumatol Turc. 2011;45:23–33.Free Article.
Pedowitz RA, Yamaguchi K, Ahmad CS, et al. Optimizing the management of rotator cuff problems. J Am Acad Orthop Surg. 2011;19:368–379. Article Summary on PubMed.
Parsons BO, Gruson KI, Chen DD, et al. Does slower rehabilitation after arthroscopic rotator cuff repair lead to long-term stiffness? J Shoulder Elbow Surg. 2010;19:1034-1039. Article Summary on PubMed.
Oh JH, Kim SH, Ji HM, et al. Prognostic factors affecting anatomic outcome of rotator cuff repair and correlation with functional outcome. Arthroscopy. 2009;25:30-39. Article Summary on PubMed.
Millar AL, Lasheway PA, Eaton W, Christensen F. A retrospective, descriptive study of shoulder outcomes in outpatient physical therapy. J Orthop Sports Phys Ther. 2006;36:403–414. Article Summary on PubMed.

Acknowledgment: Charles Thigpen, PhD, PT, ATC and Lane Bailey, PT, DPT, CSCS
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI).  PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.