Rotator Cuff Injury

Hi, my mother in law injured her shoulder approx 18 months ago probably shoveling snow but she is not sure. She treated it herself with ice and tylenol, not thinking is was anything serious that maybe she just pulled a muscle. At first the tylenol was enough and the pain was tolerable however this pain has progressively gotten worse over the last year, especially the last few months. She went to see her doctor who recommended physio therapy as he suspects a tear in her rotator cuff. She has gone to physio approx 2 times and has found it very painful. She is having difficulty functioning at work and at home. The physiotherapist has said she will not recommend her for surgery as she believes that if my mother in law continues with physio she will see improvement in 12 to 16 months. My mother in law is quite upset. She would rather have surgery than wait 12 to 16 months to have her quality of life back. Is this amount of physio normal for this kind of injury? When would a physiotherapist recommend surgery? Thank you

This is a difficult one - I can tell you that at present we do not have enough research evidence to decide whether surgery or conservative treatment (physio, injections, medications) is the best option for rotator cuff tears.
I have copied and pasted the "plain language summary" of the latest Cochrane review below (this is a very high quality review of all the research in this area).


Coghlan JA, Buchbinder R, Green S, Johnston RV, Bell SN. Surgery for rotator cuff disease. Cochrane Database of Systematic Reviews 2008, Issue 1.

This summary of a Cochrane review presents what we know from research about the effect of surgery for rotator cuff disease.
The review shows that surgery may not lead to any difference in pain compared with different exercise programs.
There was not enough information in the included studies to tell whether surgery would make a difference in the ability to use your shoulder normally, your quality of life, your shoulder's range of motion, your strength, the chance that your symptoms might come back, the time it takes to return to work or sports and whether people are satisfied with surgery. Side effects that occurred in the studies included pain, infection, difficulty moving the shoulder after the operation, wasting of the shoulder muscle, and the need to have another surgical procedure.

It would be of benefit for your mother to have some imaging done (MRI or ultrasound) to gauge the actual amount of damage to her rotator cuff (full thickness or partial thickness tear), which may help with the decision making. Clinical tests that doctors or physios do give a less reliable estimation of this.

If pain is limiting your mother's ability to participate in her rehabilitation an injection into her shoulder may help - injection combined with excerise and manual therapy generally has as high a long-term success rate as surgery for these kinds of shoulder problems. However the exercise rehab may take quite a few months as the muscles will have wasted and weakened a lot - remember your mother would have to do this exact same (or even tougher) exercise programme after surgery. It really is worth trying the non-surgical approach for 6 months, and re-assessing at this point.
Best of luck to her!

Hi - are you sure she is seeing a physio? 12-16 months MORE is unreasonable UNLESS she has "frozen shoulder".

Otherwise there is another diagnosis that has been missed.

It sounds like the physio and physician are guessing because MRI has not been mentioned by you. As physio.irl mentions, it is best to get an MRI to see what is going on in there.

To give you an idea, i expect my patients to get better in 3-5 treatments over the course of 6 weeks. If i can't make a change in that time, then there is something there i don't know about (needs further scans etc) or it is something i can't help - it needs surgery. There are of course conditions which are clearly outlined which need more time than that but if it is really a muscular issue, it will respond in that time. I have a personal aim of helping first visit patients achieve 70% improvement after the first treatment.

All that is just to say that i would almost never recommend someone come to see me for 12-16 months to get better...

Good luck!

Get MRI and another opinion from a surgeon or another physio...

I don't know what the situation in other countries is but the waiting lists for orthopedic specialists / surgeons is lengthy at best in Canada (varies from province to province). That may be the reason that your mother-in-law's doctor is delaying a referral. If the doc feels it is a partial tear, the doc knows that many surgeons will choose not to do surgery anyway (also depends on her age and other factors specific to her). Unfortunately for your mother-in-law, she is up for a lengthy rehab process. 12-18 months? That sounds excessive but sorry "alophysio", I wouldn't expect 6 weeks to do the trick. That being said, if I were the therapist, if the treatment took weeks or months, I wouldn't necessarily be seeing them that whole time. There is a lot that a physiotherapist can offer, there is some that time can offer, and a huge amount that can be offered by the client being compliant with their home program (i.e. definitely NOT a quick fix).

Indeed. Agreed.

6 weeks is a good goal time though for every patient then it gets modified based on their diagnosis.

We obviously don't know everything about the case and it is second hand information at that.

To add to my usual protocol, if i can improve someone's condition in 3 treatments where i have to diagnose the problem (i.e. not surgery or other clearly defined problem), then i tend to refer on for more investigations...

Just my opinion...

Below please find the usual recommended treatments:

The injured shoulder should be at rest from the activities that caused the problem and causing the pain. The implementation of intermittent ice towel on the injured shoulder and non steroidal anti-inflammatory (e.g. Voltaren) help reduce pain and inflammation.

Step 2 (don’t wait to long) should be the rotator cuff strengthening exercises. Start with the basic (as presented in my previous posts) then gradually introduce more exercises.

If pain persists or if severe pain prevents you from doing the required rotator cuff strengthening exercises, you could consider an injection of steroids directly to the injured tendon which effectively reduces pain and inflammation which will allow you to start an effective therapy strengthening therapy.

In rare cases surgery will be necessary. The usual incidents are where the rotator cuff has suffered a complete rupture or if symptoms persist despite a conservative therapy. Surgery can effectively remove bone spurs and inflamed tissue around the shoulder.

The small breaks or tears can be treated with arthroscopic surgery. The newest techniques allow even large tears are repaired in arthroscopic, although some of these big tears requiring open surgery to repair the torn tendon.

Prognosis (Successful healing):

Most people fully recover after a combination of medication, physiotherapy and injections of steroids. In patients with tendonitis and a bone spur, arthroscopic surgery is very effective in restoring the level of activity they had before the injury.

People who have a ruptured rotator cuff tend to improve, although the results depend highly on the size and length of the rupture or tear, as well as the age and level of functioning prior to the injury.

Complications:

Bursitis
Complete rupture of the rotator cuff

I recommend consulting with your mother in law's doctor with regard to the above proposed treatments.

For more information you are invited to visit my blog at:

rotator cuff injury exercise

Hi,

just a few comments...

1. injection of steroid into the tendon can actually make it weaker even though it can lessen the pain. There is a study i think that shows even 1 injection into the achilles tendon can increase the incidence of rupture by up to 50%. Usually the injection is into the subacromical space to get the subacromial bursa to settle down...

2. What are your previous posts? Your profile suggests that the above is your first one ;)

For Sharileedahl... i forgot to add to our little discussion above...i expect my patients to improve within six weeks - not complete recovery but "get better" than what they were. I don't think 6 weeks is unreasonable then... it just struck me that we might have had a word/phrase misunderstanding ;)

Cheers

Injection of steroids:

If used correctly, the injection of steroids can actually be a useful tool in the healing process of rotator cuff injuries.

You are correct that doctors usually inject to the subachromial area however, sometimes, the best approach (depending on the severity of the injury) is an injection targeted to the injured area.

The only good thing about steroids is the temporary pain relief that allows the patient to begin the necessary physical therapy and strengthening exercises.

Certainly, steroids have complications and I would not recommend getting steroid shuts for rotator cuff injuries - unless - the pain and discomfort prevent the patient from undergoing physical therapy

Studies suggest that 3 injections of steroids in the shoulder may have adverse effects.
NO substantial studies that I am aware of suggest otherwise. Please post a link

You can read my previous posts at:

Rotator Cuff strengthening

Hi,

Some quick results from Medline (tendon+steroid+shoulder) about tendon injuries from direct injection. Been an issue since the 70s.

Also, some evidence to suggest that injection with cortisone not any more effective than local anaesthetic.

If i had more time, i would check for more evidence - i am pretty sure there is evidence for 50% increased chance of tear in the Achilles after just ONE injection into the tendon...just not sure who did the research.

Enjoy the light reading below!

Alvarez, C. M., R. Litchfield, et al. (2005). "A prospective, double-blind, randomized clinical trial comparing subacromial injection of betamethasone and xylocaine to xylocaine alone in chronic rotator cuff tendinosis." Am J Sports Med 33(2): 255-62.
BACKGROUND: Rotator cuff tendinosis is a common problem with significant health and economic effects. Nonoperative management includes the widespread use of subacromial steroid injections despite the lack of evidence of its efficacy. HYPOTHESIS: A subacromial injection of betamethasone will be more effective than xylocaine alone in improving the quality of life, impingement sign, and range of motion in patients who have chronic rotator cuff tendinosis or partial rotator cuff tears. STUDY DESIGN: Randomized controlled clinical trial; Level of evidence, 1. METHODS: Patients with rotator cuff tendinosis or partial cuff tear with symptoms longer than 6 months, with failure of 6 weeks of physical therapy and 2 weeks of nonsteroidal anti-inflammatory drugs, who were older than 30 years of age, and who showed >50% improvement with the Neer impingement test were stratified for Workplace Safety and Insurance Board status and previous injection. Outcome measures--the Western Ontario Rotator Cuff Index; American Shoulder and Elbow Surgeons standardized form; Disabilities of the Arm, Shoulder and Hand; active forward elevation; active internal rotation; active external rotation; and the Neer impingement sign--were assessed at 2, 6, 12, and 24 weeks after injection. The injection into the subacromial space contained either 5 mL of 2% xylocaine alone or 4 mL of 2% xylocaine and 1 mL (6 mg) of betamethasone in an opaque syringe. RESULTS: In 58 patients (betamethasone group, n = 30; xylocaine group, n = 28), the authors found no statistically significant difference between the 2 treatment groups for all outcomes and time intervals. The scores for the Western Ontario Rotator Cuff Index at 3 months were xylocaine = 45.4% +/- 13% and betamethasone = 56.3% +/- 17% (P = .13). At 6 months, the scores were xylocaine = 51% +/- 32% and betamethasone = 59% +/- 26% (P = .38). All other outcomes showed similar values. As well, similar results were found for 2 and 6 weeks after injection. Both groups showed improvement from baseline in all outcomes. CONCLUSIONS: With the numbers available for this study, the authors found betamethasone to be no more effective in improving the quality of life, range of motion, or impingement sign than xylocaine alone in patients with chronic rotator cuff tendinosis for all follow-up time intervals evaluated.

Fisher, P. (2004). "Role of steroids in tendon rupture or disintegration known for decades." Arch Intern Med 164(6): 678.

Csizy, M. and B. Hintermann (2001). "[Rupture of the Achilles tendon after local steroid injection. Case reports and consequences for treatment]." Swiss Surg 7(4): 184-9.
It is known that Steroids increase the risk for tendon ruptures. Despite this local steroids are still used in the treatment of achilles tendinitis. Three cases are demonstrated. All of them show an unusual rupture mechanism. Intraoperatively necrotic tendon changes are seen. All patients receive an open tendon reconstruction with healthy, autologous material. Although there is a delayed healing in one case, all patients show favourable results one year postoperatively with return to full range activity levels and are able to participate in sports.

Kotnis, R. A., J. C. Halstead, et al. (1999). "Atraumatic bilateral Achilles tendon rupture: an association of systemic steroid treatment." J Accid Emerg Med 16(5): 378-9.
A case of bilateral Achilles tendon rupture associated with steroid use is reported. This case illustrates the importance of taking a thorough drug history in cases of tendon rupture. In lower limb tendon rupture all patients, especially those on steroids, should be warned of the increased risk of contralateral injury.

Smith, D. L. and S. M. Campbell (1992). "Painful shoulder syndromes: diagnosis and management." J Gen Intern Med 7(3): 328-39.
Painful shoulder conditions are common primary care problems. Providers should learn the topographical landmarks about the shoulder and understand shoulder mechanics. A careful clinical evaluation will usually provide a likely diagnosis. In unclear cases with marked pain, weakness, and reduced mobility, or with a suspected rotator cuff tear or rupture, arthrography or MRI will usually establish a diagnosis. Therapy of bursitis/tendinitis consists of a steroid injection into the inflamed subacromial area or a 14-day trial of an NSAID. Therapy of bicipital tendinitis, largely empiric because definitive studies are unavailable for any specific treatment, includes judicious peritendinous steroid injections and avoiding aggravating activities. In the management of patients with suspected tendon tears or rupture, primary care practitioners can confirm the diagnosis by ordering MRI or arthrography before referring these patients to an orthopedist for definitive surgical therapy. Optimal management of adhesive capsulitis remains unclear, but an intraarticular steroid injection appears beneficial at least in temporarily diminishing pain. Pendular motion exercising is also an integral part of therapy. Deleterious effects of peribursal or intraarticular steroid infiltration appear minimal; but injections into the tendon or frequent, repetitive injections are contraindicated. Each shoulder condition has a variable course, depending on the structure(s) and extent of involvement.

Watson, M. (1985). "Major ruptures of the rotator cuff. The results of surgical repair in 89 patients." J Bone Joint Surg Br 67(4): 618-24.
Major ruptures of the rotator cuff were repaired in 89 patients over a six-year period, using an approach through the split deltoid muscle and the bed of the excised outer centimetre of the clavicle. Review of these patients showed that poor results were associated with larger cuff defects, with more pre-operative steroid injections and with pre-operative weakness of the deltoid muscle. A randomised prospective study showed that repair followed by splinting in abduction gave no better results than repair followed by resting the arm at the side. Excision of the coraco-acromial ligament was associated with worse results than leaving its divided halves in situ. Follow-up showed that the results continued to improve for two years after operation; their quality was maintained in patients less than 60 years old, but in those over 60 there was deterioration with time.

Karpman, R. R., J. E. McComb, et al. (1980). "Tendon rupture following local steroid injection: report of four cases." Postgrad Med 68(1): 169-74.

Ford, L. T. and J. DeBender (1979). "Tendon rupture after local steroid injection." South Med J 72(7): 827-30.
Thirteen patients who developed 15 ruptured tendons subsequent to injection of a depository steroid in or about the tendons are described. Eight were treated surgically. Ruptures were encountered in three Achilles tendons, two supraspinati, one lateral epicondylar attachment at the elbow, eight tendons of the long head of the biceps at the shoulder, and one anterior tibial tendon. Measures designed to lessen this complication are described. In most cases triamcinolone hexacetonide was used as the depository steroid, mixed with procaine or lidocaine. Patients with this complication who were not treated surgically were the older patients who had ruptures of the tendon of the long head of the biceps.

Darlington, L. G. and E. N. Coomes (1977). "The effects of local steroid injection for supraspinatus tears." Rheumatol Rehabil 16(3): 172-9.

Very interesting discussion. Anybody can give us one case example how you treat rotator cuff tear patients including the progression during the treatment?

First time participant to this forum. My husband aged 69 has according to an MRI a 3 mm. tendon tear! Orthopedic Surgeon says, no way, there is more to it than that but... given his age just physio treatments to try and prevent scar tissue. well, the injury is already two months old and the wait here in Canada is to blame for that. Saw physio yesterday who says she can't work with the shoulder just yet it is too inflamed! So cold/heat and TENS with a couple of exercises that my spouse finds very painful. He has had one cortisone treatment. How likely is he to end up with a frozen shoulder? He is now depressed as he loves his golf .

hi Hoptoit,

What can and can't your husband do?

Hi
I hope I am on the right track here, I am new at this and it seems very complex.
As for your question... My husband can not lift his left arm above his waist, he can not push or pull and he can not lift anything with this arm. He can bend at the elbow and use his hand but no weight ...
It is in my humble (30 years as an RN) opinion, my husband did some kind of injury to his left shoulder once night when he went to turn over to the left side, he hopped out of be literally screaming ! Next day, I said, see your physician... but, no... then we golfed for a few weeks, twice he winced when his club hit the ground, I said... meanwhile he finally caved in after a major miss-hit golf shot and was in bad pain.
He then saw his physician, who left on vacation that day and nothing was done while he was gone... yes, he had a replacement but he did nothing more than change the pain medication. Incidentally, my husband has a very slight frame for a male, and he now weighs 210 lbs, which in my opionion puts a lot of strain on his shoulder joint when he rolls over in a dead sleep???