Saturday, December 6, 2008

More with less: Conservative management of massive rotator cuff tears

Massive rotator cuff tears within the medically unfit population are a difficult clinical scenario for the medical profession. The nature of the pathology often indicates a surgical intervention, but the procedure is often deemed to be too high risk. The present investigation prospectively assessed 17 patients with massive rotator cuff tears after treatment with an anterior deltoid rehabilitation program. Patients were videotaped attempting active shoulder elevation both before and after the rehabilitation program.

Each patient was given a standardized instruction that involved 12 weeks of daily pendulum exercises and supine active flexion. The protocol was to be performed 3 -5 times daily. As the patient tolerated, they were instructed to gradually increase the resistance of the flexion along with progressively moving to an inclined position. At a minimum follow up of 9 months following the rehabilitation program, the patients were reevaluated. All components of shoulder motion were improved with particular emphasis on forward elevation which improved from 40° at baseline (range 30°-60°) to a mean of 160° at follow up (range 150°-180°). Although seemingly clinically significant, the statistical significance of these findings was not reported. The authors recommend a structured deltoid rehabilitation program for elderly patients with massive rotator cuff repairs.

Massive rotator cuff repairs are clinically challenging even in younger populations. Medically unfit patients with this condition present with even more challenges. While the results of the study speak for themselves, the underlying mechanisms provide some impressive insight into the potential and paradoxical role of the deltoid in normal shoulder elevation. The deltoid has traditionally been thought of as a superior translator of the humeral head within the subacromial space. In the absence of an intact rotator cuff drawing the humeral head inferiorly, augmenting deltoid activity should impair the individual’s ability to comfortably elevate the shoulder. However both this and other recent evidence seriously questions the traditionally-held belief that the deltoid is a humeral head elevator. In fact, a report in Clinical Orthopedics by Gagey found the deltoid to prevent superior migration of the humeral head.

The implications of these findings are significant to say the least. First and foremost, if massive rotator cuff tears can be effectively rehabilitated in the medically unfit population, what about the medically fit population? Would this not make the case for a retooling of our current approach to conservative management of rotator cuff pathology prior to considering surgical intervention?

Secondly, as clinicians we are traditionally cautioned against “biasing the deltoid” during active shoulder movements in the presence of rotator cuff pathology. The present investigation provides further evidence against the notion that feed forward biasing of selected muscles may not be necessary to achieve a significant functional improvement. In fact, in this case the patients were only given verbal instruction to follow a written protocol and given no specific feedback regarding their performance of the activity. Again the implication is that the patient’s inherent feedback mechanisms were sufficient to perform and progress the activities.

This fairly straightforward study is not without limitations, but the implications for our daily practice are important. Therapists should be increasingly aware that patients can achieve significant improvements in motor control and function in the presence of severe mechanical impairments, and that these improvements can occur without micromanagement of specific movement patterns as traditionally outlined. This doesn’t negate the potential role of the therapist in the rehabilitative process, but it should raise questions as to the exact nature of our role in our patient’s recovery of this condition.

O LEVY, H MULLETT, S ROBERTS, S COPELAND (2008). The role of anterior deltoid reeducation in patients with massive irreparable degenerative rotator cuff tears Journal of Shoulder and Elbow Surgery, 17 (6), 863-870 DOI: 10.1016/j.jse.2008.04.005

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