Evaluation and treatment of stiffness in patients with rotator cuff tears (SS-02)

      The independent problems of shoulder stiffness and rotator cuff tearing have been extensively studied. In this study, a subgroup of patients who have both problems simultaneously is evaluated. This was a prospective evaluation of 72 consecutive arthroscopic rotator cuff repair patients. Preoperative range of motion (ROM) deficits in abduction, forward flexion, external rotation (ER) and internal rotation (IR) were recorded. These measurements were then added together to calculate the total ROM deficit (TROMD). The patients were then divided into three groups depending on their TROMD. In group 1 there were 42 patients with a 0° to 20° TROMD. In group 2 there were 24 patients with a 25° to 70° TROMD. In group 3 there were 6 patients with greater than a 75° TROMD. Patients in group 3 initially had standard frozen shoulder treatment consisting of intra-articular cortisone injections and physical therapy. The relative sizes of the RCT in each group were compared using a “cuff tear index” (CTI) which is the A/P dimension times the M/L dimension of the tear. The CTI in group 1 was 3.7, in group 2 it was 7.7 and in group 3 it was 12. In group 1, 33% of the patients had hypertension or heart disease, 42% in group 2 and 50% in group 3. In group 1, 5% of the patients had diabetes, 8% in group 2 and 50% in group 3. Preoperative Modified UCLA scores were the highest in group 1 (total score 25) and lowest in group 3 (total score 17). Bursal inflammation was seen in 76% of group 1 patients, 83% of group 2 patients and 100% of group 3 patients. Capsular abnormalities were common in all of the groups but a thick and contracted capsule was found only in group 3 patients (3 out of 6 patients). Acromioplasty and an arthroscopic RCR was performed in all cases. There were no manipulations under anesthesia, nor any capsular releases except to improve cuff mobility. One year postoperatively, TROMD in group 1 was reduced to an average of 4°, in group 2 to 12°, and in group 3 to 31°. However, three patients in this group required a second arthroscopy with a capsular release in order to achieve their final level of improvement. The release was performed at an average of 5 months postoperative after poor return of ROM. All had intact repairs and did well after capsular release. All 3 patients had thick, contracted capsules at the time of the initial RCR and at the time of capsular release. Based on this study, patients with TROMD up to 75° will do well with rotator cuff repair and postoperative rehabilitation. Even patients with greater than 75° TROMD will do well if they do not have true capsulitis. Stiff RCT patients who have capsulitis will not do well. We are currently performing a simultaneous RCR and complete capsular release on these patients with very good early clinical results.