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.