Survey Results What questions can we answer for you about rotator cuff problems? An evidence-based approach 1. How to do a good exam (5) 2. Indications for operation vs PT (4) to rotator cuff disease 3. Differential for shoulder pain (3) Brian Feeley, MD 4. PRP/steroids—are they safe, effective? (2) UCSF Sports Medicine Also—treatment algorithm, age differentials, is surgery needed? 1 Presentation Title and/or Sub Brand Name Here 12/9/2016 2 Survey Results What we will cover today? � How can you use recent studies to improve your outcomes for rotator cuff What questions can we answer for you about rotator cuff problems? patients? 1. How to do a good exam (5) (this talk, next talk, afternoon hands on) • How can I diagnose rotator cuff tears accurately? 2. Indications for operation vs PT (4) (this talk) 3. Differential for shoulder pain (3) (Dr. Allen, next talk) • What happens if the patient doesn’t have surgery? 4. PRP/steroids—are they safe, effective? (2) (this talk) • What non operative management options work? • What are the indications for surgery? Also—treatment algorithm, age differentials, is surgery needed? • How do patients do after surgery? 3 12/9/2016 12/9/2016 1 12/9/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Outline What is the best physical exam test for a rotator cuff problem? � How can you use recent studies to improve your outcomes for rotator cuff patients? A. Jobe’s test 37% • How can I diagnosis rotator cuff tears accurately? B. Gerber’s test 32% • What happens if the patient doesn’t have surgery? C. Painful arc test • What non operative management options work? 19% D. Range of motion • What are the indications for surgery? 10% E. Neer’s test • How do patients do after surgery? 3% t t t n t s s s s e o e e i e t t t t t c o s s s ’ ’ r m ’ e r a r e e b f b u l o e o r f N J e e n G g a i n P a R 12/9/2016 6 12/9/2016 How can I diagnose rotator cuff tears accurately? How do I diagnose rotator cuff tears accurately? � History: Was there an acute injury? � Yes � No • Is there pain at night? Is there pain at night? � Yes � No • Is there pain with overhead activity? Pain with overhead activity? � Yes � No � Past Medical History Pain at rest? � Yes � No • Cuff —hypercholesterolemia, overhead activity, age over 60 years, history • Is there pain at rest? Pain with quick movements? � Yes � No of cuff tear in self or family Does the pain localize to one spot? � Yes � No • Where is the pain located? • OA— prior history of dislocation, age over 75 years Was there a dislocation? � Yes � No • Frozen Shoulder —diabetes or thyroid disorder, age 45-60 years 7 12/9/2016 8 12/9/2016 2 12/9/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
What’s the best way for PCPs to examine the shoulder for Rotator cuff disease exam RCD? � Pain provocation tests � Pain and strength tests � Often the pain radiates to lateral shoulder/proximal arm (“deltoid”) We concluded that there is insufficient evidence upon which to base selection of physical tests for shoulder impingement, and potentially related conditions, in primary care. Pain test: Painful arc Pain/strength test: Drop arm test If painful, positive LR 3.7 for RCD. Positive LR 3.3, If not painful, negative LR 0.36 for negative LR 0.82 RCD. for rotator cuff disease. JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013. JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013. 3 12/9/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Rotator Cuff Impingement Supraspinatus � Hawkins’ Test � Jobe’s test 30° • 75% sensitive • 90º abduction • 30º anterior flexion • 49% specific • Internal rotation (palms down) • Pain/weakness � Neer’s Test • 85% sensitive • 53% sensitive/82% spec. • 44% specific • (Park, et al. JBJS 12) Park, et al. JBJS 2012 Infraspinatus Pain & Strength test: Subscapularis = internal rotation lag test aka ‘lift off’ � External rotation strength 0º abduction & 45º ER � Positive LR 5.6, negative LR 0.04 for subscapularis tear. Infraspinatus JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013. 4 12/9/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
How can I diagnosis rotator cuff tears accurately? Outline � How can you use recent studies to improve your outcomes for rotator cuff � Get a clear history (night pain, pain with overhead activity, weakness) patients? � Painful arc test • How can I diagnosis rotator cuff tears accurately? � Drop arm test • What happens if the patient doesn’t have surgery? � Lift off test • What non operative management options work? • What are the indications for surgery? • How do patients do after surgery? Focus on recent studies where available 12/9/2016 Defining the Natural History A patient presents with a partial thickness rotator cuff tear on MRI. What is the likelihood that the tear gets bigger in the next 5 years? � Defines disease progression A. 0% 42% 2008 B. 15% � Often interrupted by 33% treatment C.35% D.55% � Study painless tears E. 75% 12% 2012 6% 6% % % % % % 0 5 5 5 5 1 3 5 7 20 12/9/2016 5 12/9/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Knowns and unknowns regarding the natural history of cuff tears � Partial tears and full thickness tears are common (Yamamoto JSES 2009) � Many patients are asymptomatic with rotator cuff tears (Yamaguchi 2000, 2007, 2010) � Tears tend to get larger over time (Keener JBJS 2015) � Muscle quality deteriorates over time (Gladstone AJSM 2006, Keener JBJS 2015) � Does location matter? � Are some tears at higher risk for progression than others? 22 12/9/2016 23 12/9/2016 Critical Tear Size? Tear Enlargement Risks FTRCT’s >= 5 mm enlargement 2 yr 22% � Tear size not independent 5 yr 50% predictor of future enlargement risk! PTRCT’s CI Tear, 69% 2 yr 11% � Location was important: 5 yr 35% � Cable integrity may affect future enlargement risks Hand dominance • 52% vs. 67% enlargement associated with risk cable intact vs cable enlargement, HR=1.53 CD Tear, 31% deficient FTRCT, p=0.09 Keener et al JSES 2015 Keener et al JBJS 2015 6 12/9/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Critical Tear Size – Muscle Degeneration Tear size and distance to biceps important for muscle degeneration SS Distance from biceps Small anterior tear-grade II FI Medium tear in crescent—muscle healthy 27 12/9/2016 Kim et al JBJS 2009, 2015 What else affects muscle degeneration? Summary of Natural History Studies � Lower risk tears � Risks Greater For: • Partial tears 35% will get bigger at 5 years • Larger tears >15mm • FTRCT’s < 15 mm width with an intact anterior cable • Recent tear enlargement – double risk (44% vs 20%) � Higher risk tears • Enlargement > 1cm • FTRCT’s • Disruption of anterior cable ‒ >15-20 mm width attachment – triple risk ‒ Recent tear enlargement • Muscle changes seen within 1 ‒ Disruption of anterior cable year of enlargement Keener et al JBJS 2015 7 12/9/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
How can you use recent studies to improve your outcomes What is the best predictor that physical therapy will work for rotator cuff patients? for a patient with a full thickness rotator cuff tear? A. Size of the tear 37% 33% B. Age of the patient 1. How can I diagnosis rotator cuff tears accurately? C. Sex of the patient 2. What happens if the patient doesn’t have surgery? D. Location of the tear 3. What non operative management options work? 14% 11% E. Patient attitude of physical therapy 4. What are the indications for surgery? F. Physical therapist experience with rotator cuff tear 4% 1% 5. How do patients do after surgery? t r r t a a n n . . e . e e e . . t h . t i i x t t e p e a a e h f h p p t t o s t e e f e i f h p o h o d t a t n u e r f f o t e z o o i i h S t i t e x t t a a g e l Focus on recent studies where available A S c a o t n c L e i s i y t a h P P 12/9/2016 31 12/9/2016 Non Operative Management Options for Cuff Disease Exercise for Rotator Cuff Tears � Many Case Reports in Literature � MOON Data Largest Series N=450 patients • Symptomatic Atraumatic Full Thickness Rotator Cuff Tears • Evidence Based Rehabilitation Program • Prospective Cohort Study 32 12/9/2016 8 12/9/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
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