Conservative treatment of partial and complete tears of the rotator cuff

Abstracts

A lesão do manguito rotador é a mais freqüente patologia do ombro. Cerca de 180 pacientes foram tratados conservadoramente nos dois Serviços nos anos de 1996 e 1997. Este grupo recebeu uma ampla gama de tratamentos (apenas medicação, exercícios caseiros, infiltração, fisioterapia, etc.). Este estudo avaliou os resultados do tratamento conservador em 26 pacientes com rupturas parcial e total do manguito rotador. O protocolo consistiu de um programa com 6 meses de duração que incluiu terapia miofascial específica, exercícios ativos assistidos e de fortalecimento dos músculos do manguito rotador e da musculatura axioescapular. Os fatores de inclusão no estudo foram: 1) realizar todo o programa com apenas um reabilitador; 2) não ter recebido infiltração; 3) não ter tido cirurgia prévia; 4) não ter reumatopatia diagnosticada. Seis meses após a alta, dezoito pacientes (69,22%) apresentavam resultado satisfatório, enquanto que os demais 08 casos (30,78%) foram considerados insatisfatórios e tiveram indicação cirúrgica.

ARTIGO DE REVISÃO

Conservative treatment of partial and complete tears of the rotator cuff^*

Osvandré Lech^I; Cézar Valenzuela Neto^II; Antônio Severo^III

^IChefe do Serviço de Cirurgia da Mão e do Membro Superior do IOT-Passo Fundo, RS; presidente da SOT-RS

^IIFisioterapeuta, FISIOMASTER, Porto Alegre, RS

^IIIInstrutor da Residência Médica do IOT-Passo Fundo, RS

^{Endereço para correspondência}

SUMMARY

The lesion of rotator cuff is the most frequent lesion of the shoulder. Circa 180 patients were conservatively treated in both Clinics during the years of 1976 and 1997. This group of patients received a wide range of treatments (only medication, home exercises, infiltration, physiotherapy, etc). This study evaluated the results of the conservative treatment in 26 patients with partial and total rupture of the rotator cuff. The protocol consisted of a program with duration of 6 months including specific miofascial therapy, assisted active exercises and of strengthening of the muscles of the rotator cuff and axioscapular musculature. The inclusion criteria of the study were: 1) to carry the program with just one reabilitator; 2) no previous infiltration; 3) no previous surgery; 4) absence of diagnosed rheumatopathy. Six months after the end of treatment, eighteen patients (69,22%) presented with satisfactory results, while the other 8 cases (30,78%) were considered not satisfactory and were referred to surgery.

INTRODUCTION

The degenerative and traumatic lesions involving the rotator cuff (RC) are among the most frequent causes of shoulder pain, deserving increasing attention in the diagnosis and treatment, and is considered today as a pathology that should be treated by a multi-disciplinar team^{4, 32.}

Presently, a significant increase in life expectancy was seen thanks to the progress of the medicine. Besides that persons want to have a better quality of life, free of muscle-skeleton pains, and able to practice a wide variety of activities related to sport practice and others. The importance of an articulation of the shoulder with functional normality has increasing importance, nowadays.

The RC acts to stabilize dinamically and to balance the head of the humerus in relation to the glenoid, while the axial muscular group (deltoid and major pectoral, etc) act to move the humerus: the rupture of the RC can easily lead to the loss of the shoulder function^{17, 18} in various degrees.

According to Charles Neer, the pathology of RC can be classified in 3 stages²³: I ) edema, inflamation and hemorrage of the bursa and tendons of the RC, presenting mainly in young persons; II) thickening of the bursa and tendon fibrosis, occurring in persons between 25 and 40 years old; III) complete rupture of the RC, associated to bone alterations of the humerus head and acromium, occurring in persons with more than 40 year of age. These ruptures can also be classified according to the thickness of the involved tendon (partial articular, partial intra-tendon, partial bursal, and total), and also according to the ethiology (degenerative or traumatic)²³ . With respect to the size, the rupture can be small (less than 1,0 cm), medium (less than 3,0 cm), big (less than 5,0 cm) or massive (bigger than 5,0 cm) ²⁷

The conservative approach in patients with syndrome of shoulder impact is described as one of great therapeutic value in studies of several authors 7, 10, 23, 32, 35 .

The conservative treatment of the complete ruptures of RC can be successful in aged or sedentary patients; however, the surgical repair of the RC, be it open approach or arthroscopy, is the best choice for active subjects or in those cases of muscular weakness, persistent and progressive¹⁵. It is known that spontaneous repair of RC tendon is infrequent, due to the retraction of the damaged extremities^{8, 9}. However, in minor partial ruptures, vascular proliferation and local granulation are seen, what make possible an eventual spontaneous cicatrization³³. Brox et al. reported that the period of treatment in patients that underwent arthroscopy compared with those treated conservatively had the same duration ². Torstensen et al.³³ support that RC lesion can be treated conservatively with a program of supervised exercises controlled by echography, but the casuistic was scarce. Burkhart ³ reported satisfactory results with conservative treatment in patients with complete rupture of the supraspinatus when the infraspinatus was normal. Another study¹⁰ compared two groups of patients (with and without exercise) and concluded that treatment with exercises was efficacious to increase the function of the shoulder. Guimarães¹² treated conservatively 171 cases of syndrome of impact and lesion of the rotator cuff with thermotherapy and exercises, obtaining good results in 42,9% of patients after one year, and in 21,5% after two years.

The objective of the present study was to assess the clinical and functional results after a program of supervised exercises in a homogeneous group of patients.

MATERIAL AND METHODS

Twenty six patients, 9 male and 17 female with age between 34 and 84 years old (average 61,6 years), of which 12 with sedentary life and 14 considered active, were included in this study. Complaints were shoulder pain, cervical region, scapular region and lateral proximal third of the arm. From these, 8 (30,76%) had complete rupture of RC and 18 (69,23%) had partial rupture (Table 1). Examination showed that all patients had painful arc and positive "irritative" tests of Neer and Hawkins, painful pressure of trigger points of infraspinatus and supraspinatus due to secondary miofascial dysfunction. Additionally there was decrease of passive and active movement amplitude caused by pain ¹⁷. The average time of the condition was 6 months and all had tried before some kind of physiotherapy, without success. The echography or MNR had confirmed the clinical picture of rupture of RC.

Treatment was done with oral NSAIDs, miofascial specific therapy (criocinesis, isquemic compression and ultrasound applied to the trigger points), continuous ultrasound with frequency of 1,0 Mhz and dose of 1,5 w/cm² for 5 minutes to the subacromial region ²² ( model AVATAR US 873 - KLD Biossistemas Equip. Elet. Ltda.), exercises for stretching in external rotation in shoulder plan and horizontal abduction at 30 degrees of flexion, strengthning exercises with isometrics (Fig. 1), elastic bands (Fig. 2) and weights (Fig. 3) for shoulder external and internal rotators, muscles of the scapular waist (trapesius and anterior serratile) and deltoid (final phase) according to the protocol from Picture 1^{7, 16}. No patient received infiltration with corticoid or other therapy. The estimated time of treatment was 6 months, with a follow up evaluation 6 months after the end of treatment².

DISCUSSION

The procedure of miofascial therapy has its indication due to the satisfactory outcome to the inativation of the trigger points of the muscles corresponding to the ruptured tendons, however without the procedure of specific stretching ³⁴ . The supraspinatus and other muscles of RC work as stabilizers and as primary motors of the glenohumeral articulation, assuring that the movement occurs around a physiological axis¹³. Biomechanical and eletromiographic studies reinforce that the main action of the RC is to stabilize the glenohumeral articulation^{26, 31}. During the active abduction of the shoulder, the humeral head elevates superiorly in relation to the glenoid fossae due to the contraction of the deltoid. The muscle of RC contribute to articular stability, generating a force opposite to the force from deltoid, centering this way the humerus head²⁹. Jobe¹⁶ classifies the muscles of RC as protectors of the glenohumeral, the shoulder muscles as pivots (they align the scapula to mantain the physiological axis), the deltoid as positioner and the large dorsal and major pectoral as propulsors

During the movement of raising the arm to the level of the shoulder, the infraspinatus contracts with 20% of its maximum isotonic power (MIP); the supraspinatus has constant contraction of 40% of MIP²⁵. The balanced and simultaneous actions of the infraspinatus, minor round and subscapular limit with efficacy the superior translation of the humerus head when producing a momentum around the glenohumeral that helps in the movement of raising the arm^{24, 28}.

Burkhart ³ reported satisfactory results with the conservative treatment in patients with complete rupture of the supraspinatus with a normal infraspinatus, fact that coincides with the findings of this study.

It is possible that the strengthtening of the inferior RC muscles (infraspinatus, minor round and subscapular) result in increased capacity of resisting to the strength resulting from deltoid, allowing a recovery of activity in some patients with rupture of the supraspinatus tendon^{20, 30}.

This concept is reinforced by other authors that assure normal arthrocynematic of the glenohumeral in patients with rupture of the supraspinatus and efficient contraction of the muscles of inferior RC and pivots of the shoulder^{13, 21, 23}.Ferreira et al⁷ had 54% of good results in his patients and concluded that the presence of lesion to the RC causes minor functional limitation, not all with indication of surgery and that physiotherapy should precede the surgery.

Guimarães ¹² pointed as causes of bad results the low compliance of patients to exercises and also to the rupture of the RC.

Patients with bad results in this study were referred to surgical treatment. The reasons for bad results are many and include: a) non-compliance to the program of exercises; b) overuse of the affected member; c) persistence of the pain. Fukuda ⁸ states that the majority of cases of partial rupture involving the bursal surface of the RC do not have satisfactory results with the conservative treatment. Age did not influence good and excellent results. However, the occupational factor was more significant, since eight of the cases of bad and regular results, six (75%) have preserved the same level of professional activity.

It was also confirmed that patients with complete rupture of RC can present with normal active elevation of the arm, mainly after a program of rehabilitation with strengthtening of pivot and propulsive muscles of the shoulder. ^{14, 19}.

CONCLUSIONS

1. A rehabilitation program with supervised exercises is efficient and can be considered as the first option in patients with rupture of RC:

2. The occupational factor in patients with professional activity can indicate bad prognosis with the conservative treatment;

3. Surgery can be indicated in patients with strong pain and that do not respond to the treatment program in 3 to 6 months.

RESULTS

Using Mann-Whitney test ⁹, data was analysed according to the following functional criteria:

1. Active elevation iqual or superior to 135º ;

2. Raise the hand to the external occipital protuberance;

3. Move the hand till the thoracolumbar spine.

Considering the above movements, patients were classified using the scores below:

• Exccelent (E) - All movements without pain;

• Good (G) - Without spontaneous pain and with 2 normal movements;

• Regular (R) - Without spontaneous pain and with pain in 2 or more movements;

• Bad (B) - With spontaneous pain and pain to movements.

The results of this study can be seen in ^{Picture 1} and ².

A scale for classification of shoulder was also used - UCLA modified, as well as the criteria for scoring (^{Picture 3} and ⁴, respectively) ⁶. The scoring of this study casuistic is shown in Table 1.

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^*

Trabalho realizado na Fisiomaster, Porto Alegre/RS, Ortopedistas Reunidos, Porto Alegre/RS, e IOT-Passo Fundo/RS.

Publication Dates

• Publication in this collection
  07 May 2007
• Date of issue
  Sept 2000