ROTATOR CUFF TEAR

Dr V K Pandey Kalyani knee & shoulder Clinic

What is Rotator cuff?

Rotator cuff is a hood formed over the ball of the shoulder joint. It is formed by joining together of tendons of four muscles inside the shoulder. These muscles form the deeper layer of shoulder muscles. Their function is to stabilize the shoulder so that the other strong muscles of the shoulder can perform their function. It is only by synchronized action of the deeper (cuff muscles) and those of the strong (superficial) muscles that we are able to position our arm in so many different positions.

Why does it get torn?

There are two main reasons. One is that due to aging process, the tendons forming the cuff become weak. In such cases, just a minor trauma, or sometimes even no trauma, can cause rupture. On the other hand, the rupture could occur due to the strong force with which the muscle is pulled while trying to avoid a fall.

How does one recognizes that the cuff has ruptured?

Usually, there is acute pain and inability to lift the arm. One may just feel weak in trying to lift the arm to pick things up with the hand. An examination by a shoulder specialist, and MRI can detect the rupture for sure.

What is the treatment of rotator cuff tear?

Partial rupture has the potential to heal by itself. Full thickness tear involving a small portion may not progress if aggressive use of the shoulder is avoided. All other tears have

a tendency to progress with time, and repair is the best option. Upto a certain stage, a patient may feel only little disability, and the tear may be diagnosable only on MRI examination. After that pain on using the shoulder, pain at all the time, and weakness of the shoulder occurs. In an extreme case, one may find it difficult to lift the shoulder altogether. The healing of primarily traumatic tears is better than that of the degenerative tear(which occurred without much trauma). The sequelae of long term rotator cuff tear is joint degeneration. This causes continuous pain, and the only remedy is shoulder replacement.

What are the different methods of repairing the rotator cuff tear?

There are three methods:

Open surgery: This is a conventional technique being done for nearly half a century. It involves making a 8-10 cm cut, opening the shoulder by detaching the muscles on it, and then repairing. The disadvantages (common to any open surgery): Bigger scar, More pain, More stiffness etc.

Mini- Open Surgery: In this, most of the operation and assessment is done by looking through arthroscope. The last step of fixing the torn tendons to the bone is done by making a small cut (3-5 cm). The muscles are not detached, hence the disadvantage is not there.

Arthroscopic surgery: In this technique the whole repair is conducted Arthroscopically, through only a few small cuts. It has all the advantage s except that it may not be possible

to do a good repair in all the cases. Wherever possible, this is the method of choice these days.

What is the success rate of the operation?

If done for purely traumatic tears the success rate is nearly 95%. As the age advances, and there is a component of degeneration as the background cause, the success rate drops to 70%. In those cases, where the tear occurred without much injury, which means these are mainly degenerative tears, the repair may fail. Tear at a younger age, injury as the main cause of tear, small to medium size tear, repair done within a short time after the tear, surgical technique, and post operative physiotherapy has lot to do with achieving success in these cases. In most cases, it is possible to use the shoulder fully. You can drive the car after 3 months, and resume normal activities by 4 months.

What are the possible complications of surgery?

The possible complications are as follows:

• Inability to achieve a good repair: This happens due to poor quality of the tendons to be repaired (due to degenerative nature of the tear), or due to inability to bring the torn edge to the bone (if the delay in repairing has been substantial). Sometimes this could be due to technical failure.
• Failure of healing of the tendons: this is sometimes not in control of the surgeon, depends upon the condition of the case.
• Stiffness: this happens in 30% of cases, takes 4-6 months of home physiotherapy. In some cases it may take longer.
• Infection: this can occur in any operation, but we take due care, and the infection rate matches with the best in the world.
• Not able to achieve optimum power back: this is due to inherent weakness of muscles due to lapsed time before repair.

How much does it cost?

The cost of surgery varies from 40 thousand to 60 thousand. You may discuss this in detail when you come for fixing the date.

How long does it take to recover?

It takes 6-8 months for the complete recovery. The arm is rested for 6 weeks in a sling. This is required for healing of the tendon to the bone. During this period the person can do all his activities, but cannot use the shoulder. In the subsequent 6 weeks, the shoulder is mobilized with support. It is after 3 months that the shoulder can be used for day to day activities. The muscle power builds up over the next 2-3 months. Most patients do well with home physiotherapy, some need supervised physiotherapy in the clinic.

For more information contact us via email or telephone: Mobile: 09554066663, 09554066664, 09554066665

Email: kneeandshoulder2010@gmail.com

Dr V K Pandey

Kalyani knee & shoulder Clinic

The shoulder joint is the most mobile joint in the body. Such mobility is possible because of the unique design of the joint- a small socket and a big ball. It is for this reason that the ball often comes out of the socket with ease. Once the shoulder dislocates the tissues keeping the ball inside the socket get ripped off. In 40 percent of cases, the tissues fall back in place and heal up once the ball is relocated. In the rest the healing does not occur. There remains a weak spot through which the ball can come out repeatedly. After the first dislocation, there are 60% chances that it will dislocate again. Once it has dislocated twice, it will definitely dislocate sometime in the future.

What are the treatment options?

Surgery is the only option to fix this problem. One may decide to live with it but this has its own fallouts. Physiotherapy alone is of no help, as it does nothing to undo the basic defect.

What if does not get operated?

The shoulder will continue to dislocate. With each dislocation shoulder becomes more unstable and consequently dislocates with minor, even day –to-day movements (even during sleep). The dislocation may happen at the wrong time. For example, while trying to hold something to avoid a fall. After sometime, the bones get damaged and the joint becomes painful.

What is done in the surgery?

The surgery consists of repairing the defect. This was done in the past by open method, in which the joint is opened through a 12 cm in front of the shoulder. There are a number of ways to correct the defect by open surgery. The operation is currently done by arthroscopic surgery.

What is arthroscopic surgery?

Arthroscopic surgery is a new technique of key-holes surgery. It is done under general anaesthesia. A thin pencil-like telescope is introduced into the shoulder from behind and the inside of the shoulder examined. Once the defect is identified, it is repaired through two more key-holes. Ultimately you have only three key holes on your shoulder and not a

10 cm cut. The advantages of arthroscopic surgery are no need to immobilize the shoulder for 4-6 weeks, no prolonged physiotherapy and almost no residual stiffness.

What is it like getting the surgery done?

You will be admitted for one day, check up done will be done for fitness for anaesthesia. In case you have any allergy or other issues, inform your doctor. The surgery is done under general anaesthesia, and takes about one hour. You will be in the operation theatre

complex for about four hours for pre and post operative care. Once you are out of anaesthesia, your arm will be in a sling and there will be dressing on your shoulder. You can start eating, walking after about 6 hours and if fit can go home the same evening. You will be given an appointment to see us after 3 days, when the dressing will be replaced with waterproof dressing. You can bath and wear regular clothes after this.

You will remain in the sling for two weeks, but can walk around freely. After two weeks, you will be able to use the hand for day-to-day activities. You can drive car after 4  weeks. Some restriction of activities will be there for 6 weeks. You can go back to normal activities including sports after about 3-6 months.

How long will I need to do physiotherapy after surgery?

Most patients do very well with a 6-8 weeks home physiotherapy programme. In this, our physiotherapist teaches the patients exercises to be done at home twice a day. Some need physiotherapy under supervision and have to visit the clinic.

How much will the surgery cost?

The surgery costs Rs. 75 thousand in general ward category. In some cases, depending upon the complexity of the operation, the cost may be higher. The cost of arthroscopic surgery is more than that of the open surgery as it requires sophisticated equipment and technical expertise. A number of imported disposable items are used in this surgery, which makes it more expensive. Open surgery costs approximately 45 thousand.

What are the chances of recurrence?

The success of operation depends upon three factors

1. How bad the joint is to start with
2. How accurately the repair has been done
3. The healing potential of the patient.

Inspite of the best techniques, there is a 2-4 percent recurrence rate even in the best centres in the world. The recurrence rate is the same whether the procedure is done by open arthroscopy method. There are more chances of the shoulder getting stiff after open surgery.

In case you have any queries, you are welcome to contact us at the following number

09554066663, 09554066664, 09554066665

E-mail us at kneeandshoulder2010@gmail.com

Kalyani knee & shoulder clinic

Dr V K Pandey

Do’s & Don’ts for patient with Patello-Femoral pain

Do’s:

1. Use knee support or tapping, as advised.
2. Wear shoes with well cushioned soles.
3. Apply heat for symptomatic pain relief.
4. Do regular exercises to strengthen the muscles around the joint and achieve a proper balance of various muscle groups around the knee joint.

• Quads setting: straighten your legs and tighten both the knees together, hold for 5 seconds and then relax. Repeat this 20-25 times in one go, and 4-5 times in a day. This is an anytime anywhere exercise and can be done in sitting, lying, or even in standing position.

• SLR: Lie down straight on a bed, bend the unaffected knee to about 90 degrees and lift the other straight up in the air till the level of the bent knee. Hold here for 5 sec and then bring the leg down. Do 3 sets of 10 repetitions twice in a day. Gradually increase upto 5 sets of 10 repetitions, twice in a day. And then start doing with weights or exercise band.

• VMO Exercise: Cross the affected leg over the other and press down as if crushing something between the legs, hold for 5 sec and then relax. Repeat this 20-25 times. Twice in a day.

Don’ts

Some activities in day to day life cause excessive pressure on the knee- cap joint (Patello- Femoral Joint). This leads to further increase in pain and other symptoms. To avoid, the following precautions should be observed:

1. Avoid squatting
2. Avoid sitting on floor, and sitting cross- legged.
3. Avoid stairs as much as possible
4. Avoid footwear with more than 1 inch heel.
5. Avoid activities like jumping, jogging, running. Walking and swimming are good and can be persued.

For more information contact us via email or telephone: Mobile: 09554066663, 09554066664, 09554066665

Email: kalyanikneeshoulderclinic@gmail.com

Kalyani knee & shoulder clinic

Patient information Series ACL Rehabilitation Protocol

The following is your expected progress of your recovery after ACL reconstruction:

Hospitalization: 2 days

Bed rest: Only for one day, on the day of surgery. From the second day of surgery, you will be able to go to the toilet with the support of a knee brace and a walking aid.

Up & About in the house: For two weeks after surgery you will be required

to be in the house. You will be able to walk inside the house with a knee brace and a walking aid.

Brace: Your leg will be in a knee brace(leg immobilizer), from the middle of the  thigh to just above the ankle, for the first two weeks. This long brace will be used only while walking, and not while you are in bed. You will be able to  walk with a small brace with hinges, in which you can bend your knee, from third week onwards. This small brace will be needed for about 6-8 weeks.

Out of house for sitting job: From 3^rd week with the help of a hinged knee

brace.

Car driving: After 4 weeks.

Normal stair climbing: In about 6 weeks.

Field work: After 6 weeks.

Jogging: After 3 months

Running: After 4 months.

Light sports: After 6 months.

Unrestricted sports: After 1 year.

Rehabilitation after ACL reconstruction involves a progressive exercise program. We will teach you the exercises on your post- op visits as per the stage of rehabilitation. You would need to do these exercises at home, yourself for 3-6 months depending on your requirements. Most patients do well with home therapy program, some need closer supervision by frequently visiting our therapist.

The following are the expected goals of recovery:

1. To get the knee completely straight (not even slightly bent) – About 1 week
2. To reduce knee swelling – 2 weeks, sometime aspiration of fluid from the knee may be needed to reduce the swelling.
3. To achieve knee bending – Upto 90 degrees in 3 weeks, and full in 6-8 weeks.
4. To build up the muscles around the knee joint – Takes upto 6 months to 1 year

Schedule of visits for Surgeon’s consultation

1^st visit: Approx. 5 days after surgery, for dressing change.

2^nd visit: 2weeks after surgery, for stitch removal

3^rd visit: 4 weeks after surgery, monitor exercises.

4^th visit: 6 weeks after surgery, monitor progress.

5^th visit: 3 months after surgery.

5^th visit onwards Follow-up every 3 months is recommended till 1 year post surgery.

Schedule of visits for Therapy

One visit before surgery for assessment and to understand the rehabilitation protocol. After surgery it is advisable that the therapy be done under supervision 3 times per week for the first six weeks, and then once in a week for the next six weeks.

Please note: The above information presents an approximate picture of recovery after surgery. Exact progress varies from patient to patient.

For more information contact us via email or telephone: Mobile: 09554066663, 09554066664, 09554066665

Email: kneeandshoulder2010@gmail.com