Surgical Treatment

Surgery

Surgery can be helpful in the management of rotator cuff tear arthropathy (shoulder arthritis associated with massive rotator cuff defects). The surgical procedures can range from a simple smoothing of the roughened bone [Figure 11] to a resurfacing of the humeral head with a smooth prosthesis , such as a CTA head, fixed to the shaft of the arm bone (humerus) [Figure 12]. If the joint is unstable, a reversed prosthesis, such as the reverse Delta [Figure 13] may be needed. Consultation by the Shoulder and Elbow Service at the University of Washington regarding the diagnosis and treatment of cuff tear arthropathy may be requested by using our online referrals website.

If exercises do not improve the comfort and function of the shoulder, surgery may be necessary to create a smooth gliding surface on the humeral head (ball of the arm bone). This surgery may consist of rounding off any rough edges on the joint surface and removing interfering soft tissue as was performed for the individual whose shoulder is shown in the x-ray.

Surgical Procedure

Open Repair

· Intraoperative photograph of an open rotator cuff repair illustrating the typical size of a surgical incision.

· (Courtesy of Louis Rizio, MD.)

· Open repair is performed without arthroscopy.

· The surgeon makes an incision over the shoulder and detaches the deltoid muscle to gain access to and improve visualization of the torn rotator cuff.

· The surgeon reaches the rotator cuff by dissecting through muscle and other tissues.

· The surgeon will usually perform an acromioplasty (removal of bone spurs from the undersurface of the acromion) as well.

· The incision is typically several centimeters long. the surgeon makes a 10 to 12 centimetre incision in the side of the shoulder.

· Skin incisions are closed with stitches and dressings applied.

· Open repair was the first technique used to repair a torn rotator cuff;

The tendon is anchored to the bone in one of two ways:

1. small holes are drilled in the prepared area of bone.

Strong stitches are placed in the end of the torn tendon and then looped through the holes to anchor the tendon to the bone.

2. small, strong suture anchors, with stitches attached, are fixed into the bone.

These suture anchors are made of metal, plastic or a synthetic material that is eventually absorbed by the body.

The stitches are then passed through the torn end of the tendon and tied down to the anchors

http://www.rafflesmedicalgroup.com/web/Contents/Contents.aspx?ContId=1078

Mini-Open Repair

· In this intraoperative photograph, the typical incision size for a mini-open rotator cuff repair is shown in black on a patient''s left shoulder. The yellow area indicates the incision used to perform the arthroscopy.

· (Courtesy of Louis Rizio, MD.)

· As the name implies, mini-open repair is a smaller version of the open technique.

· The incision is typically 3 cm to 5 cm in length.

· This technique also incorporates arthroscopy to visualize the tear and assess and treat damage to other structures within the joint (it is used to asses the Shoulder Surgery Exercise Guide and remove the spurs under the acromion). Arthroscopic removal of spurs (acromioplasty) avoids the need to detach the deltoid muscle. The arthroscope is used to locate the tear.

· Once the arthroscopic portion of the procedure is completed, the surgeon proceeds to the mini-open incision to repair the rotator cuff.

^· Mini-open repair can be performed on an outpatient basis. Currently, this is one of the most commonly used methods of treating a torn rotator cuff; results have been equal to those for open repair. The mini-open repair has also proven to be durable over the long-term.¹⁴

All-Arthroscopic Repair

· Arthroscopic photographs of a rotator cuff tear (left) and the final repair (right). This was performed all-arthroscopically. Sutures (green) were used to reattach the tendon back to bone (arrow).

· (Courtesy of Louis Rizio, MD.)

· This technique uses multiple small incisions (portals) and arthroscopic technology to visualize and repair the rotator cuff.

· All-arthroscopic repair is usually an outpatient procedure. The technique is very challenging, and the learning curve for surgeons is steep. It appears that the results are comparable to those for mini-open repair and open repair.

The Surgical Procedure

Arthroscopy with small incisions: This is done through several small incisions, each less than one centimetre long. The arthroscope is a thin instrument containing a miniature video camera and light source. It allows the surgeon to see inside of the shoulder joint and perform the procedure while watching a video monitor.

The arthroscope is inserted through a small incision in the shoulder. Working through another small incision, the surgeon uses tiny cutting instruments to trim the edges of the tendon and then removes fragments of torn cuff tendon. Small grinding instruments may be used to remove a bone spur from the acromion and prevent further damage to a tendon. Small tears in the tendon are then repaired.

http://orthoinfo.aaos.org/topic.cfm?topic=a00406

http://www.rafflesmedicalgroup.com/web/Contents/Contents.aspx?ContId=1078

http://www.aafp.org/afp/980215ap/fongemie.html

http://www.orthop.washington.edu/UserFiles/File/matsen/2006_RR_Matsen_ReverseShoulder.pdf

If exercises do not improve the comfort and function of the shoulder, surgery may be necessary to create a smooth gliding surface on the humeral head (ball of the arm bone). This surgery may consist of rounding off any rough edges on the joint surface and removing interfering soft tissue as was performed for the individual whose shoulder is shown in the x-ray. [Figure 8].

Alternatively, the situation may require replacing the joint surface with a smooth metal prosthesis with a stem that is fixed by a press fit in the shaft of the bone as is shown in the diagram. [Figure 9].

In cases where rotator cuff tear arthropathy (shoulder arthritis associated with massive rotator cuff defects) is associated with instability of the joint, a reversed or “reverse Delta” prosthesis, may be needed to fix the fulcrum of shoulder movement. [Figure 10]

Causes of Rotator Cuff Injuries & Tendonitis

by Sandhya


Causes of Rotator Cuff Injuries (some are more like Risk Factors)

1.Age-related degeneration
2.Compromised microvascular supply
3.Outlet impingement
4.Instability
5.Other causes- e.g. falling, lifting and repetitive arm activities — especially those done overhead

1. Intrinsic tendinopathy is an age-related degenerative process.

Increase in frequency of partial-thickness and full-thickness tears with increasing age.

Increasingly after age 40, normal wear and tear on the rotator cuff can cause a breakdown of fibrous protein (collagen) in the cuff's tendons and muscles. This makes them more prone to degeneration and injury.

With age, one may also develop calcium deposits within the cuff or arthritic bone spurs that can pinch or irritate the rotator cuff.


2. Shoulder - tendinous area that receives very little blood supply.

The tendons of the rotator cuff muscles receive very little oxygen and nutrients from blood supply, and as a result are especially vulnerable to degeneration with aging. This is why shoulder problems in the elderly are common. This lack of blood supply is also the reason why a shoulder injury can take quite a lot of time to heal.

The bursal side of the supraspinatus tendon has a higher blood supply compared to the articular surface. This difference in blood supply causes the increase in articular surface tears compared with bursal tears.

3. Rotator cuff tendonitis is also known as impingement syndrome or shoulder bursitis

The shape of the acromion
3 types of acromions
Type I – Flat
Type II – Curved
Type III – Hooked

The rotator cuff contacts the coracoacromial arch undersurface in the normal shoulder.

The coracohumeral ligament is often resected in order to decompress the supraspinatus outlet, which can lead to increased superior translation of the humeral head, particularly in the young athlete.
Rotator cuff abrasions and fiber failure occur when repeated and excessive compression from humeral head migration is present.
This occurs secondary to underlying muscular imbalance and loss of rotator cuff depressor effects.

4. Most people with ligamentous laxity are functionally stable. In patients with inherent shoulder or generalized laxity, instability may develop with minimal or no injury.
Ligamentous laxity may be acquired by repetitive stretching of the joint, as observed in swimmers, gymnasts, and tennis players.
Dynamic stability may be lost if the shoulder becomes deconditioned. As a result, a vicious self-perpetuating cycle occurs :
Instability  less use more muscle weakness More instability present

These patients frequently have relative rotator cuff muscle weakness, particularly the external rotators and scapular stabilizers.
Subtle instability patterns may contribute to the impingement development.
Increased anterior and superior translation of the humeral head, as observed in athletes with generalized laxity and multidirectional instability of the shoulder, may predispose to impingement along the coracoacromial arch, resulting in rotator cuff injury.

5. Other causes
Poor posture.
When slouching neck and shoulders forward, the space where the rotator cuff muscles reside can become smaller. This can allow a muscle or tendon to become pinched under the shoulder bones (including the collarbone), especially during overhead activities, such as throwing.

Falling.
Using arm to break a fall or falling on your arm can bruise or tear a rotator cuff tendon or muscle.
Lifting or pulling.
Lifting an object that's too heavy or doing so improperly — especially overhead — can strain or tear the tendons or muscles. Likewise, pulling something, such as a high-poundage archery bow, may cause an injury.

Repetitive stress.
Repetitive overhead movement of arms can stress the rotator cuff muscles and tendons, causing inflammation and eventually tearing. Common among athletes and people in the building trades, such as painters and carpenters


Tendinitis

Repetitive strain on the tendon
Most common cause of tendonitis. Tendonitis of the elbow, bicep, shoulder and hand is often developed by individuals that work on factory production lines and sports professionals.

Age related tendon changes
As the human body gets older the tendons get harder and lose their elasticity. This means that the joint is no longer as free to move and often flexibility is lost. As individuals get older they are much more prone to develop tendonitis. The cause of tendonitis from age is still not fully understood. It's suggested that as the body ages the change in blood vessels effects the tendons.

Putting the tendon under too much strain/ Overuse
This is the leading cause of tendonitis amongst strength athletes and bodybuilders. Tendonitis is developed when the individual puts the tendon under too much strain without properly warming up or under strain that the tendon simply cannot handle. This tendonitis cause can easily be avoided by using correct training techniques and exercise form

As a result of injury
It is not uncommon for tendonitis to develop as a result of another tendon or joint injury. For example, shoulder tendonitis is often developed after a rotator cuff injury and knee tendonitis can be developed after having knee surgery. In these cases tendonitis usually develops because the injury has not completely healed. This cause of tendonitis can easily be avoided by getting sufficient rest for the joint to recover from an injury completely.

As a result of another condition
In some cases diseases like rheumatoid arthritis or diabetes may cause tendonitis to occur. These cases are often rare and only occur when the individual puts the tendon under an unusual amount of pressure or strain.

Thermal injury to the tendon
A very uncommon cause of tendonitis and is often experienced by outdoor mountain climbers, rock climbers and hikers. In most cases the affected areas are the hands, wrists, ankles and feet.

Anatomical cause of tendonitis
Rare cause of tendonitis. If the tendon does not have a smooth surface area in which to work against it will often become inflamed and irritated quite easily. In these situations surgery is often required to realign the tendon.


References:
http://orthoinfo.aaos.org/topic.cfm?topic=A00064
http://emedicine.medscape.com/article/92814-overview

http://www.thestretchinghandbook.com/archives/rotator-cuff-injury.php#causes
http://www.creekayaker.com/shoulder/rotatorcuff-injury/Rotator%20Cuff%20Injury_files/image001.gifhttp://orthopedics.about.com/cs/sportsmedicine/a/tendonitis.htmhttp://www.itendonitis.com/shoulder-tendonitis.html
http://www.mlcmarlins.com.au/content/training/coaching_clinic/shoulders/images/image008.gif
http://www.creekayaker.com/shoulder/rotatorcuff-injury/Rotator%20Cuff%20Injury_files/image002.gif

Pathophysiology and complications of tendonitis and tendinosis

zhimei and shakir

Rotator cuff injury
The rotator cuff is the network of four muscles and several tendons that form a covering around the top of the upper arm bone (humerus). These muscles form a cover around the head of the humerus. The rotator cuff holds the humerus in place in the shoulder joint and enables the arm to rotate.
Rotator cuff tear is a common cause of pain and disability among adults. Most tears occur in the supraspinatus muscle, but other parts of the cuff may be involved.
The terms tendinitis, tendinosis, and tendinopathy all refer to tendon injuries. These terms are commonly confused and misused. The term paratenonitis refers to an injury of the outer layer of tendon; this newer term replaces the older terms peritendinitis, tenosynovitis, and tenovaginitis.
tendinitis The suffix "itis" means inflammation. The term tendinitis should be reserved for tendon injuries that involve larger-scale acute injuries accompanied by inflammation. (Tendinitis is often misspelled as tendonitis, but the preferred spelling used in most of the medical literature is tendinitis.)
tendinosis The suffix "osis" implies a pathology of chronic degeneration without inflammation. Doctors prefer the term tendinosis for the kind of chronic tendon injuries that most of us have. The main problem for someone with tendinosis is failed healing, not inflammation; tendinosis is an accumulation over time of microscopic injuries that don't heal properly. Although inflammation can be involved in the initial stages of the injury, it is the inability of the tendon to heal that perpetuates the pain and disability. Most of the pain associated with tendinosis probably comes not from inflammation but from other irritating biochemical substances associated with the injury
tendinopathy The suffix "opathy" implies no specific type of pathology, so the term tendinopathy is more general than either tendinitis (inflammation) or tendinosis (failed healing). The term tendinopathy just means tendon injury, without specifying the type of injury.
degeneration of the tendon itself, tendinosis, and degeneration/inflammation of the tendon sheath, paratenonitis).

Tendinopathy
Pathophysiology
· Tendinits
o inflammation or irritation of a tendon — any one of the thick fibrous cords that attach muscles to bones. The condition, which causes pain and tenderness just outside a joint, can occur in any of your body's tendons. Tendinitis is common around your shoulders, elbows, wrists and heels.
· Tendinosis
o Internal tendon degeneration due to imbalance in tendon repair and tendon breakdown (increase in breakdown or decrease in healing response)
o Tendinosis is an accumulation over time of small-scale injuries that don't heal properly; it is a chronic injury of failed healing. Although you can't see the tendinosis injury on the outside of your body, researchers have seen what the injury looks like on the cellular scale by viewing slides of tendons under the microscope.
Complications
· Tendonitis
o Leads to rupture of a tendon
o Cause permanent damage to the tissue that makes up tendons
o May progress to tendinosis or other tendinopathy
o This may change the structure of the tendon to weaker more fibrous tissue
· Tendinosis
o lead to reduced tensile strength
o increasing the chance of tendon rupture
o

http://www.mayoclinic.com/health/rotator-cuff-injury/DS00192
http://orthoinfo.aaos.org/topic.cfm?topic=A00064
http://www.sosmed.org/pdffiles/patientguides/PatGuideCuffTendinosis.pdf

non-surgical treatment and management of rotator cuff injury

Treatment and management for rotator cuff injury
Treatment recommendations vary from rehabilitation to surgical repair of the torn tendon(s). The best method of treatment is different for every patient. The decision on how to treat rotator cuff tears is based on the patient's severity of symptoms, functional requirements, and presence of other illnesses that may complicate treatment.
Treatment may include:
1) Non-surgical treatment@ conservative treatment ..(focuses on pain control and reducing the inflammation)
• rest
• nonsteroidal anti-inflammatory (NSAIDs) medications & corticosteroid injection
• strengthening and stretching exercises
• ultrasound therapy
2) Surgical treatment (needed when there are severe shoulder injuries and no improvement after 3-6 months of non-surgical treatment)
• surgery
3) Alternative treatment

4) Follow up
• management@maintainance
http://www.healthsystem.virginia.edu/UVAHealth/adult_spine/rotator.cfm
Non surgical treatment
Rest.
[Rehabilitation program]
- Relative rest of involved area (the injured shoulder.)
- Have the patient sleep with a pillow between the trunk and arm to decrease tension on the supraspinatus tendon and to prevent blood flow compromise in its watershed region.
- Alternating application of cold and heat….. Apply ice for 15-20-minute periods at least three times a day for the first two days after the injury. A helpful hint for applying ice to the shoulder would be to use a large Ace bandage to wrap over the top of the ice on the shoulder. The wrap can be taken around the injured arm and across the body.
Apply heat after two days of applying ice. Warmth may be helpful. You can lay a heating pad over the shoulder while sitting up.
http://www.emedicinehealth.com/rotator_cuff_injury/article_em.htm#Rotator%20Cuff%20Injury%20Overview
This nonsurgical treatment typically involves activity modification (avoidance of activities that cause symptoms). Nonsurgical management of a rotator cuff tear can provide relief in approximately 50% of patients.
Nonsurgical treatment has both advantages and disadvantages.

Advantages:
• Patient avoids surgery and its inherent risks:
o a. Infection
o b. Permanent stiffness
o c. Anesthesia complications
• Patient has no "down time"

Disadvantages:
• Strength does not improve
• Tears may increase in size over time
• Patient may need to decrease activity level

Conservative treatment of the degenerative rotator cuff involves pain relief; avoidance of painful motions and activities; simple analgesics and NSAIDs; manual physical therapy for the glenohumeral, scapulothoracic, acromioclavicular, and sternoclavicular joints and the parascapular and scapula-stabilizer muscles; subacromial corticosteroid injection; bupivacaine suprascapular nerve block; restoration of motion and normal scapulohumeral rhythm; stretching of the glenohumeral capsule and muscles; and manual therapy of the cervicodorsal spine (often necessary because of its close relationship with the shoulder).
http://emedicine.medscape.com/article/1262849-overview
Rest the shoulder in a sling for a short period of time. Prolonged use of the sling can cause stiffness, weakness, and loss of motion of the shoulder joint (frozen shoulder).
Medications.
Simple analgesics
Ibuprofen (Ibuprin, Advil, Motrin), Acetaminophen (Tylenol, Feverall, Aspirin-Free Anacin), Nonsteroidal anti-inflammatory drugs, Celecoxib (Celebrex), Ketoprofen (Orudis, Actron, Oruvail)
• Pain control and inflammation reduction usually are the goals of treatment. This can be accomplished with rest and acetaminophen (Tylenol), aspirin, or ibuprofen.
• NSAIDs have analgesic and antipyretic activities. The mechanism of action of these agents is not known, but they may inhibit cyclooxygenase (COX) activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions. Treatment of pain tends to be patient specific.
• Corticosteroids delivered directly to the site via injection can be considered to allow further progression of the rehabilitation program. Place injections into the subacromial space, avoiding direct injection into the rotator cuff tendon. Advise the patient to limit activity that involves high-tensile loads (eg, maximal overhead throwing) for 2-3 weeks while the tendon is potentially at risk after injection, particularly if the patient exhibits rotator cuff muscle weakness. These injections need not be given to patients with complete rotator tears, especially if surgery is being considered.
http://www.emedicinehealth.com/rotator_cuff_injury/article_em.htm#Rotator%20Cuff%20Injury%20Overview

Strengthening and stretching exercises
• Perform Codman exercises. These are passive range-of-motion exercises (often initially done with a physical therapist). These exercises are done to increase slowly the amount of motion of the shoulder while putting a low amount of stress on the rotator cuff itself. The exercises are performed as the person leans toward the injured side with the arm hanging freely and slowly moving the arm in a circle. Initially, the circles are small. With improvement and decrease in pain, the circles enlarge.
• Also, holding a broomstick with both hands and moving them in a large arc while relaxing the affected shoulder can passively stretch the soft tissues. Later, active motion may be achieved by walking your fingers up a wall with the affected arm.
• This rehabilitation program also primarily focuses on the muscles surround the damaged area in order to compensate with the lost of function of the damaged area.
http://www.emedicinehealth.com/rotator_cuff_injury/article_em.htm#Rotator%20Cuff%20Injury%20Overview

Ultrasound therapy
In patients with symptomatic calcific tendinitis of the shoulder, ultrasound treatment helps resolve calcifications and is associated with short-term clinical improvement.
It also helps in warming the injured area and improve blood circulation of the stiffen muscles.
(Patients were assigned to receive 24 15-minute sessions of either pulsed ultrasound (frequency, 0.89 MHz; intensity, 2.5 W per square centimeter; pulsed mode, 1:4) or an indistinguishable sham treatment to the area over the calcification.)
http://content.nejm.org/cgi/content/abstract/340/20/1533

Management @ maintainance
• Inpatient care: Admit the patient to an orthopedic service in preparation for the operating room (only required if surgery is the treatment of choice).
• Outpatient care: Arrange outpatient follow-up care to an orthopedic surgeon and rehabilitation services to continue conservative therapy. A follow-up reassessment examination 6 weeks after beginning conservative therapy is essential to determine if treatment is successful or if further surgical treatment is needed.
• Inpatient or outpatient medications: All NSAIDs are equally effective.
• Deterrence and prevention: Instruct patients to limit activities to ensure rest of the affected shoulder.
• Complications: Failure of conservative treatment requires surgical intervention. Decreased ROM may occur.
• Prognosis: An estimated 4% of cuff ruptures develop a cuff arthropathy. Various authors report the success rate of conservative treatment to be 33-90%, with longer recovery time required in older patients. Surgery results in better function regardless of the patient's age.
• Patient education: Refer patients to a physical therapist for conservative treatment and postoperative therapy.

Rotator Cuff Injury Treatment

this is the normal treament stuff i shall post up the surgical stuff later tonight or early morning

Self-Care at Home

• Rest the injured shoulder.
• Apply ice for 15-20-minute periods at least three times a day for the first two days after the injury. A helpful hint for applying ice to the shoulder would be to use a large Ace bandage to wrap over the top of the ice on the shoulder. The wrap can be taken around the injured arm and across the body.
• Apply heat after two days of applying ice. Warmth may be helpful. You can lay a heating pad over the shoulder while sitting up.
• Take an antiinflammatory medication such as ibuprofen or naproxen sodium to decrease the pain and swelling. Do not take if you have an allergy to it or certain other medical concerns, such as stomach or kidney problems

Chronic tear

• Pain control usually is the goal of treatment. This can be accomplished with rest and acetaminophen (Tylenol), aspirin, or ibuprofen.
• Occasionally, injections of steroids into the shoulder joint are helpful.
• Perform passive range-of-motion exercises (often best initially done with aphysical therapist).
• People with continued pain may require surgery and follow-up with an orthopedicsurgeon.

Acute tear

• Apply ice to decrease swelling. Wrap the ice in a cloth to avoid freezing the skin. Apply the wrapped ice 15-20 minutes at a time. This is most helpful in the first one to two days.
• Antiinflammatory medications may help reduce pain and swelling. Medicines such as ibuprofen (Advil, Motrin) or naproxen sodium (Aleve) are examples available over the counter.
• Support the arm in a sling to rest the rotator cuff muscles. The sling may be taken off at night.
• The emergency physician may ask you to be seen for follow-up, either by a primary-care doctor or an orthopedic surgeon (specialist).
• Further imaging may be required to determine the degree and involvement of muscle tear. This is often done via magnetic resonance imaging.
• Early surgery (within three weeks) to repair the tendon is often needed, especially for younger, more active people.
• Indications for surgical treatment
• Usually for people younger than 60 years of age
• For complete tears
• An option after failure to improve after six weeks of proper treatment
• If the person has a job that requires constant shoulder use

Tendinitis

• Beginning care
• Apply ice packs for 20-minute periods several times a day.
• Rest the shoulder in a sling for a short period of time. Prolonged use of the sling can cause stiffness, weakness, and loss of motion of the shoulder joint.
• Take antiinflammatory medicines, such as ibuprofen or naproxen sodium.
• More severe cases
• Use the techniques described for beginning care.
• Injections of steroids may be given into the shoulder joint.
• As things improve (two to three days), discontinue the use of ice. Apply heat packs with massage.
• Perform Codman exercises. These are passive range-of-motion exercises (often initially done with a physical therapist). These exercises are done to increase slowly the amount of motion of the shoulder while putting a low amount of stress on the rotator cuff itself. The exercises are performed as the person leans toward the injured side with the arm hanging freely and slowly moving the arm in a circle. Initially, the circles are small. With improvement and decrease in pain, the circles enlarge.
• Also, holding a broomstick with both hands and moving them in a large arc while relaxing the affected shoulder can passively stretch the soft tissues. Later, active motion may be achieved by walking your fingers up a wall with the affected arm.

http://www.emedicinehealth.com/rotator_cuff_injury/page7_em.htm#Medical Treatment

How does physical therapy help rotator cuff tears?
The goal of physical therapy is to improve the function of the muscles that surround the shoulder. Most people, athletes and weight-lifters included, only strengthen a few of the large muscles around the shoulder. Physical therapy targets the smaller, but important muscles around the shoulder that are commonly neglected. By strengthening these muscles, therapy can help compensate for damaged tendons and improve the mechanics of the shoulder joint.

http://orthopedics.about.com/od/rotatorcuff/f/therapy.htm

How does the cortisone injection help?
Cortisone is a powerful anti-inflammatory medication. Cortisone is not a pain relieving medication, it only treats the inflammation. When pain is decreased from cortisone it is because the inflammation is diminished. By injecting the cortisone into a particular area of inflammation, very high concentrations of the medication can be given while keeping potential side-effects to a minimum. Cortisone injections usually work within a few days, and the effects can last up to several weeks.

http://orthopedics.about.com/cs/paindrugs/a/cortisone.htm

Therapeutic Injections
Therapeutic injections (lidocaine plus a corticosteroid) are useful both because they are therapeutic and also because they can help the physician differentiate impingement from other problems. Indications for therapeutic injections include the following:

· Rotator cuff impingement that does not improve with conservative treatment, including NSAIDs and physical therapy.

· Older patients with clearly operable lesions, such as subacromial spurs, who are not good surgical candidates. Frequently, older, poor surgical candidates can be helped with periodic injections.

· As a diagnostic technique. If a patient fails to improve following a subacromial space injection and has normal radiographs with an ambiguous physical examination, the rotator cuff may not be the problem. Thus, after the injection, repeat impingement testing will verify the diagnosis if the pain is ameliorated.^12-14

· For temporary pain relief in a patient with an operable lesion.

http://www.aafp.org/afp/980215ap/fongemie.html

Extracorporeal shockwave lithotripsy (ESWT) is used to treat calcific tendonitis, where crystalline calcium phosphate is deposited in a tendon. This most commonly occurs in the shoulder joint, specifically in the supraspinatus tendon of the rotator cuff. When calcific tendonitis is symptomatic, it may present as chronic, relatively mild pain in the shoulder, with sporadic episodes of pain radiating down the arm or to the neck, with mechanical symptoms or with severe acute pain due to an inflammatory response.

http://www.nice.org.uk/nicemedia/pdf/ip/IPG021guidance.pdf

Phonophoresis is the use of ultrasound (US) to enhance the delivey of topically applied drugs. this also can be used instead of steroid injection. http://www.ptjournal.org/cgi/reprint/75/6/539.pdf

What is it iontoporesis?

Iontophoresis is an effective, method for delivering medication across the skin using electricity as a motive force. A direct current is applied to an electrode containing an ionized medication (meaning that it has an electric charge to it, either positive or negative) and utilizing the principle that “like repels like”, the electric current acts as a force to “push” the medication across the skin barrier to the affected area.

What medication is used?

In the physical therapy setting, we use dexamethasone during our iontophoresis treatments. This medication is a corticosteroid that has potent anti-inflammatory action. What conditions is it used for?

We typically use iontophoresis on localized, soft-tissue and other musculoskeletal inflammatory conditions. Some of the conditions we commonly treat with iontophoresis are tennis and golfer’s elbow, jumper’s knee, achilles tendonitis, rotator cuff injuries, plantar fasciitis, and even temporomandibularjoint (TMJ) dysfunction.

What are the advantages of iontophoresis versus an injection?

Iontophoresis is a safe alternative to the patient receiving a steroid injection. This method avoids the skin damage and risk of infection as well as the discomfort of delivering an anti-inflammatory medication by injection. Iontophoresis delivers a greater concentration of medication to a localized area as compared to oral medications. This helps avoid systemic side affects altogether by delivering a very low amount of medication to the internal systems.

How long does the treatment last?

The anti-inflammatory actions of dexamethasone typically last for approximately 48-72 hours.

http://www.waltonpt.com/index.php?option=com_content&view=article&id=23:iontophoresis-with-dexamethasone&catid=2:articles&Itemid=4

Table 1. Phases of Shoulder Rehabilitation

Phase I

Rest from painful activity

Anti-inflammatory therapy

Passive range-of-motion and active-assisted range-of-motion

exercises

Joint mobilization

Strengthening (submaximal 3 maximal)

Scapulothoracic strengthening

Aerobic conditioning

Phase II

Progress range of motion and flexibility

Strengthening (submaximal 3 maximal)

manual, elastic band, and isotonic

multiangle isometrics

short-arc 3 full-arc excursion

Aggressive scapulothoracic strengthening and integration

Aerobic conditioning

Phase III

Prophylactic stretching

Strengthening and endurance (to full range and emphasize

eccentrics, then progress to sport-specific positions)

Variable or free weight resistance, or both

Bodyblade (Hymanson Inc, Playa Del Ray, CA)

isokinetics

plyometrics

Phase IV

Return to sport

http://www.nata.org/jat/readers/archives/jt0300/jt030000300p.pdf

INVESTIGATION

BY- SYUKRIAH

The medical tests that may be needed to diagnose a rotator cuff injury include:

· X-ray
An X-ray may show a bone spur or injury to the shoulder joint's ball and socket.

· Magnetic resonance imaging (MRI)
To determine whether the rotator cuff is inflamed or has a partial or full tear, an MRI may be needed. An MRI uses magnets and computers to create detailed, three-dimensional images of the shoulder area.

· Ultrasound
Ultrasound involves the use of a transducer (wand) placed on the skin to transmit internal, moving video images inside the shoulder. Mayo Clinic uses high-resolution ultrasound equipment to produce detailed internal images, and ultrasound can assess shoulder muscle tendon integrity.

· Arthrography

· Uses Iodine containing contrast material which is injected into the shoulder to demonstrate leakage by plain XRAY. These tests are used in different circumstances, but arthrography is less accurate at defining cuff tear, is more invasive, but demonstrates capsular tear more reliably. Arthrography should not be used with shellfish allergy or known iodine allergy

http://www.mayoclinic.com/health/rotator-cuff-injury/DS00192/DSECTION=tests-and-diagnosis