---

 - Discussion: 
    - rotator cuff anatomy 
    - frequency of tear 
    - diff dx of cuff tears; (partial rotator cuff tear) 
    - etilogy of tear 
          - ref: Association between alcohol consumption and rotator cuff tear
    - how do RTC tears heal?

- Shoulder Exam:
    - impingement sign and test:
    - it is essential to document ROM deficits, since rotator cuff repair would not be expected
             to yield a good outcome in the face of fixed shoulder contractures;

- Radiographic Findings:
    - scapular outlet view 
    - 30 deg caudal tilt view AP view 
    - arthrography 
    - MRI of Shoulder: Coronal Oblique View of Shoulder 

               

- Non Operative Management

- Surgical Management: 
          - assessment of cuff tear / mobilization of cuff / restoration of  the foot print 
                   - note intervening bare area between the articular margin and the infraspinatus and teres minor
                   - partial rotator cuff tear:
                   - management of massive rotator cuff tear 
    - tears due to impingement and trauma: (see: impingement syndrome) 
          - arthroscopic rotator cuff repair
                      - arthroscopy (arthroscopic acromioplasty) followed by rotator cuff repair
                      - allows accurate assesment of rotator cuff tear;
                      - look for hypervascularity at the base of the biceps tendon as well as fraying of the cuff just lateral to the biceps tendon;
                      - does not require elevation of the deltoid off the acromioplasty;
                      - allows a more lateral incision, directly over the rotator cuff tear, (avoid deltoid detachment);
                      - w/ restricted motion, consider arthroscopic capsular release prior to rotator cuff tear; 
          - open rotator cuff repair and open acromioplasty
          - concomitant procedures:
                      - biceps tenodesis;
                      - distal clavicle excision (w/ concomitant arthrosis)
                      - ref: The influence of distal clavicle resection and rotator cuff repair on the effectiveness of anterior acromioplasty.
          - precautions:
               - rotator cuff repair should not be performed in the face of a fixed contracture;
               - consider aggressive PT to restore motion or arthroscopic release of rotator interval (for loss of external rotation in
                          adduction) or release of the posterior capsule (for loss of internal rotation);

    - tears due to instability:
          - requires anterior reconstruction in addition to rotator cuff repair;
          - ref: Occult anterior subluxations of the shoulder in noncontact sports.  

---

- Complications:
    - Failed Acromioplasty / Rotator Cuff Surgery:
    - Fatty Muscle Atrophy:
           - Muscle regeneration following repair of the rotator cuff

    - Captured Shoulder:
          - refers to restrictive subdeltoid adhesions which develop following surgery and which limit ROM;
          - may occur in about 5% of patients;
          - treatment relies arthroscopic lysis of adhesions;
    - references:
          - Failed Repair of the Rotator Cuff. Evaluation and Treatment of Complications.  
          - Superior Humeral Dislocation: A Complication Following Decompression and Debridement for Rotator Cuff Tears.
          - Operative Treatment of failed repairs of the rotator cuff.  
          - Captured Shoulder: a complication of rotator cuff surgery. 

- References

 

........................................................................................................................................................................................................................................................................................