“One of the things that we are working on and we need to better understand is, who is going to progress, and we need to act on now, as opposed to later,” he said.
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Explore This IssueJanuary 2017
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Treating patients even with full-thickness rotator cuff tears with physical therapy rather than surgery was validated in a study that found that only a quarter of the patients went on to surgery over two years.
Reasons for surgery should be pain, functional problems that don’t improve with physical therapy, possibly the risk of progression and the risk of developing fatty infiltrates into the rotator cuff muscle when the tear of the tendon from the rotator cuff muscle allows more space for lipocytes to get into the muscle, causing irreversible damage.
Adhesive capsulitis—also known as frozen shoulder, a term that Dr. Neviaser recommends against using because it doesn’t describe the disorder as well—is another problem that rheumatologists may have to recognize. It’s a painful loss of active and passive motion, caused by a thickening and tightening of the shoulder capsule, with stiff bands of tissue developing.
“It’s really that mechanical restriction of passive range of motion with external rotation at the side that gives the diagnosis away,” Dr. Neviaser said.
“There’s a natural course to this problem that we don’t seem to actually change too much. And if you manage to make the diagnosis in the early phase before they’ve lost a lot of motion and they just have diffuse pain, they will probably lose motion later,” he said. So if a patient worsens during physical therapy, they need to be reminded that it’s not the therapy that’s causing it; it’s just the natural course of the disease.
After physical therapy, he said, many patients are left with residual deficits, but usually not to the point that it affects their daily lives.
It’s reasonable to refer these patients to surgery if they have shown literally no improvement after four months. If they’ve shown modest improvement that’s still unsatisfactory for the patient, it’s reasonable to wait eight or even 12 months.
- Gerber C, Snedeker JG, Baumgartner D, et al. Supraspinatus tendon load during abduction is dependent on the size of the critical shoulder angle: A biomechanical analysis. J Orthop Res. 2014 Jul;32(7):952–957.
- Moor BK, Weiser K, Siankamenac K, et al. Relationship of individual scapular anatomy and degenerative rotator cuff tears. J Shoulder Elbow Surg. 2014 Apr;23(4):536–541.