Archives

Rotator Cuff Tendon Tears

Rotator Cuff Tendon Tears

 

Background

Rotator cuff tendon tears can be a considered to be part of a group of conditions that also affect the rotator cuff: subacromial/subcoracoid impingement, calcific tendonitis, rotator cuff tendinosis, and rotator cuff arthropathy (arthritis). Despite the myriad of names, all of the above cause pain within the shoulder and often prompt a visit to a family physician. Almost everyone will experience shoulder pain sometime within their lifetime – and we hope the following information will be useful for those who have been told they have a ‘rotator cuff tear’.

It should first be stated that not all rotator cuff tendon tears are structurally the same: they vary in size, width of the tear (partial thickness vs. full thickness), or tendons involved (i.e. subscapularis vs. supraspinatus). When adding in the complexity of dominant vs non-dominant hand, occupation, athletic activity, location of pain, and medical status – it is not surprising that patients often hear very different accounts from friends, acquaintances, or loved-ones about how their rotator cuff tendons tears were treated.

 

General Information

 

The rotator cuff often accumulates wear and tear as we age. If we were to MRI people without shoulder pain, we would find that almost 30% of people over 60 have a full-thickness tear, while 65% of patients over 70 have a full-thickness tear. This is to say that the presence of a tear on ultrasound or MRI does not mean you need an operation. The bulk of people with rotator cuff tears are able to recover without the need for surgery.

The majority of people seeking treatment for rotator cuff problems can be classified as ‘chronic’ in nature, that is the tendons have progressively torn (or degenerated) over time. A small subset of patients can be attributed to an ‘acute’ injury, such as a severe fall or a shoulder dislocation.  There is at times a combination of both chronic and acute pain, where someone describes a lengthy but mild pain within their shoulder that became severe after an injury.

It is unclear (even to shoulder surgeons) why some people develop rotator cuff tears and others do not. It is also unclear to us why some people with large rotator cuff tears have no pain, while others with very small tears do. Although research is currently looking at anatomic factors that may predict the chance of shoulder problems later in life, there is no iron-clad measurement or test to predict which tears will ultimately require surgery.

People often come to see us concerned that their tears will progress to arthritis later in life. Although there is a type of arthritis termed ‘rotator cuff arthropathy’ that is related to tendons which have been torn for a long period of time, the possibility of arthritis should not warrant immediate surgical management without first trying to improve with physical therapy. Similarly, people are also concerned that the tear will continue to increase in size if no surgery is performed. Although there is data to suggest that tears do get larger as we age, there is no evidence to suggest that they will be guaranteed to become painful if surgery is not done. Regardless of what the future may bring, the purpose of surgery is for relief of pain that persists in spite of attempts at non-operative treatments.

 

Treatment

Physical Therapy

Anyone with shoulder pain, regardless of cause, should be started on a shoulder conditioning program to maintain or improve range of motion while working on strengthening.  This is incredibly important for multiple reasons:

  • Therapy can help avoid shoulder stiffness. After an injury, there is a tendency of the shoulder to stiffen up during the healing processes. This will be made worse if a shoulder is not used. Even if therapy is unable to fully alleviate shoulder pain, it will help maintain motion. I often comment: ‘A painful shoulder I can help with, a stiff and painful shoulder is much more difficult to treat’.
  • Therapy can improve pain. By working on muscular strengthening, posture and shoulder kinematics (how the shoulder moves in space), therapy may be able to allow you to recover from injury or pain without the need for surgery or more invasive therapies.
  • Therapy is Time Dependent. It is intuitive that the quicker someone starts physical therapy, the faster they will recover. What most people realize is that delay in start of physical therapy leads to deconditioning, abnormal shoulder movements, and chronic pain. Immediate therapy can avoid a ‘downward spiral’, where a painful shoulder becomes a deconditioned shoulder, which in turn causes more pain (and so on). Shoulder specialists often cringe when a patient says the phrase “I didn’t want to start physical therapy until I was seen by a surgeon” as we know recovery will likely be longer because of it. With very few exceptions, therapy should be started as soon as a physician provides a prescription for it!

 

Cortisone Injection

Cortisone injections can provide short-term pain relief in most patients. It is important to note that cortisone is not a curative therapy. What this means is that once the injection wears off, the shoulder pain will return unless something is done in the meantime. With that said, I use cortisone in patients for one of three reasons:

  • To Help with Physical Therapy: pain prevents us from rehabilitating to our full potential. If cortisone is able to provide short-term relief of discomfort, therapy may be more successful.
  • To Help Establish a Diagnosis: pain around the shoulder may be caused by many things. It can occasionally be difficult to pinpoint the exact cause with certainty or to determine how painful one problem is relative to another. By targeting one potential source of pain with an injection, we may be able to achieve greater accuracy of diagnosis and thus a greater success rate with treatment.
  • To Predict Results of Surgery: the relief achieved with cortisone is often very similar to that obtained by surgery. These injections can serve as a guide regarding the outcomes of a given surgical procedure.

 

Surgical Rotator Cuff Repair

Surgery to reattach torn rotator cuff tendons can be performed through open or arthroscopic (i.e. minimally invasive) techniques. The tendon can be anchored to bone through sutures alone, or with suture anchors. If indicated, your surgeon will describe their preferred technique. Regardless of how the operation is performed, the following considerations are all the same:

  • No surgery is without discomfort – and is often worse within the first 2 weeks of a procedure. Discuss pain control with your surgeon prior to the operation. In our practice, we seek to limit post-operative pain through a multi-modal pain regimen.
  • Surgery only if needed – surgery is considered only in those that have failed attempts at physical therapy. Even if it comes to an operation, efforts with therapy beforehand (so called pre-rehabilitation) will help hasten your post-operative recovery.
  • Successful surgery requires post-operative therapy – To maximize your results with shoulder surgery, we consider formal physical therapy a must. Each surgeon has their own set of post-operative therapy instructions, and working with your own therapist following an operation is well worth the investment.

 

Irreparable Rotator Cuffs

Occasionally it is not possible to repair a rotator cuff using sutures or anchors as outlined above. A shoulder specialist can outline other options, including tendon transfer or shoulder replacement, based on a patients’ functional requirements and medical status.

 

Expected Follow-up and Recovery

Recovery with a rotator cuff tear is variable but can be accelerated by starting immediately on a physical therapy program. Should surgery be ultimately required, recovery follows a standardized post-operative ‘protocol’ with key stages along the way. Return to work is variable and depends on the type of job performed.  Likewise, return to sport depends on the activity and level of competition.

 

General Information

  • All slings should be kept clean and dry.
  • Swelling is common following an injury. To decrease swelling consider icing it 15 minutes at a time every 1-2 hours. Ice should be wrapped in a tea-towel to avoid frost-bite.
  • You may find it more comfortable to sleep in a reclining chair for the first 2-5 weeks following the injury. Ensure the chair is placed close to washrooms and away from any tripping hazards.

 

General Therapy Instructions

Please note: this alone does not constitute as a formal referral to a physical therapy. The following guidelines are for non-operatively treated shoulders. Therapy should be initiated, conducted and monitored by trained professionals.

  • Stage 1 – Motion: The first goal is to achieve and maintain the maximal amount of range of motion possible, ideally back to pre-injury state. Active and active assisted range of motion of the glenohumeral and scapulothoracic joints (along with neck, elbow, wrist and fingers) occurs at this stage.
  • Stage 2 – Light Strengthening: To start when 80% of expected range of motion is achieved. Recommend starting with light bands and progress to cables and finally free weights. Focus is on low weight with higher repetition.
  • Stage 3 – Strengthening and Conditioning: This stage involves increasing weight to regain pre-injury strength. Exercises are tailored towards job-specific or sport-specific tasks. Care should be taken to maintain proper form and avoid re-injury.
  • Stage 4 – Maintenance: An often forgotten or neglected component of the rehabilitation program. Exercises from Stage 3 should be incorporated into a weekly fitness regimen with the goal of avoiding re-injury.

Rotator cuff tears that undergo surgery progress through the above four stages of recovery at a pace that is dependent on the extent of surgery.

 

Expected Outcomes

Rotator cuff injuries have a good to excellent prognosis. Our goal for non-operatively treated shoulders is 90-95% return of function when compared to the pre-injury state.  The time to achieve this is variable but recovery is aided by an immediate start to physical therapy.

Operatively treated rotator cuff injuries also have a good to excellent prognosis. Our goal for operatively treated shoulders is a 90-95% reduction in pain. Strength and endurance return with time and physical therapy, but may not fully return to that of the pre-injury state.

 

Notable Challenges

  • Post-Operative Pain: Shoulder surgery is painful, especially in the first two weeks following an operation. We utilize a multi-modal pain management strategy to keep a patient comfortable while also decreasing narcotic medication consumption.
  • Shoulder Stiffness and Weakness: Stiffness around the shoulder is to be expected, especially in operatively managed shoulders requiring post-operative immobilization in a sling. It can take upwards of a year to maximize gains in shoulder range of motion and strength. Physical therapy and ongoing exercises are critical for recovery during this time.
  • Complex Regional Pain Syndrome: a challenging adverse pain response associated with some fractures. Requires time, physical therapy and occasionally medications to treat.

 

Summary of Common Treatment/Rehabilitation Pathway

Clavicle Fractures

Background

Clavicle fractures are one of the more common fractures of the upper extremity. Also known as the ‘collar bone’, the clavicle acts as a strut to hold out the shoulder from the chest wall. Clavicle fractures commonly occur because of falls onto a shoulder, although they may occur due to a direct blow to the collar bone or due to high-energy trauma (i.e. a car accident). They can occur in any age group.

 

Treatment

Patients are often seen first in the Emergency Room, where the diagnosis is made. A sling is applied to help with pain control and to avoid movement around the shoulder. In contrast to many other fractures, it is not possible to ‘cast’ clavicle fractures, nor is it necessary in this instance to allow for healing.

Patients are then referred to a fracture clinic where they are seen by an Orthopaedic surgeon. The X-rays obtained and the cause of the injury will help the surgeon determine how severe the injury is. As treatment decisions depend on the size of the fracture and how far it has moved away from its normal (or ‘anatomic’) location. To aid in treatment decision making, a CT scan may be obtained if necessary.

Clavicle fractures with minimal movement from their anatomic location can be treated without surgery. The clavicle will often heal with a robust ‘callus’, resulting in a bump that often smooths out with time.

In the event the bone has moved, many factors will determine the best course of action, including fracture location, hand-dominance, age, occupation, activity level, and medical status. For example, fractures on the inner or outer third of the clavicle can be prone to delayed or non-healing, which needs to be considered in the context of a patient as a whole. If surgery is recommended, the main goal of the procedure is to recreate normal anatomy by fixing the clavicle with a plate and screws. The plate and screws will hold the bone in place while it heals together. However, it is important for patients to know that clavicle surgery comes with a few notable and unique surgical risks. Firstly, the surgical scar is permanent and can be noticeable given the location on the body. Additionally, two skin nerves cross the surgical site, and because of this the surgery may result in some numbness of the chest wall. Thirdly, major blood vessels, nerves and the lung are close to the clavicle, and very rarely may be injured during surgery. Finally, the plate used during clavicle surgery may become bothersome and cause irritation. Should this occur, hardware removal at a later date may be considered.

As each of the above considerations will differ from patient to patient, It is important that treatment options be discussed with your treating surgeon, including the risks and benefits of each. It is important to remember that clavicles have been treated without surgery for all but the last few decades. The orthopaedic goal of achieving the best possible function with the least risk is very well represented when considering treatment for a fractured clavicle.

 

Delayed or Non-Union

Approximately 5-10% of clavicle fractures take longer then 6 weeks to heal. Excessive time to heal is referred to as delayed union, while a bone that does not heal is referred to as a non-union. Factors involved in excessive healing time or non-union of the clavicle include smoking, fracture location (close to the end of the bone), severe fractures, and excessive movement through the fracture. Delayed or non-united clavicle fractures may benefit from more time, physical therapy, bone stimulation or surgery.

 

Expected Follow-up and Recovery

Expected recovery is not notably different between non-surgery and surgery groups, although is delayed in those whose clavicles take a while to heal:

  1. No Surgery: Sling for comfort for 4 weeks. During this time finger, wrist and elbow motion may occur, but no motion at the shoulder. Following this, physical therapy can be started in an active/assisted fashion, with fully active motion starting at 6 weeks and strengthening starting at 2 months.
  2. Surgery: Sling for comfort for 4 weeks. During this time finger, wrist and elbow motion may occur, but no motion at the shoulder. Following this, physical therapy can be started in an active/assisted fashion, with fully active motion starting at 6 weeks and strengthening starting at 2 months.
  3. Delayed Healing: Initial treatment as above. If the clavicle is taking an excessive amount of time to heal, contributing factors will be explored. Patients who smoke will be encouraged to quit. Those who are putting too much motion through their shoulder will be asked to modify their activity. The potential benefit of a bone stimulator will be discussed if felt relevant. Finally, surgery may be an option. Time to recovery will ultimately depend on the cause of the delayed healing.

 

General Information

  • All slings should be kept clean and dry.
  • Swelling is common following an injury or fracture. To decrease swelling consider icing it 15 minutes at a time every 1-2 hours. Ice should be wrapped in a tea-towel to avoid frost-bite.
  • Bruising down the arm or across the chest is expected following any fracture around the shoulder
  • Occasional numbness that resolves quickly is to be expected. Persistent numbness in the arm is not common and should be mentioned to your physician.
  • Chest pain or shortness of breath is not normal and should prompt immediate return to the emergency room.
  • You may find it more comfortable to sleep in a reclining chair for the first 2-5 weeks following the injury. Ensure the chair is placed close to washrooms and away from any tripping hazards.

 

General Therapy Instructions

Please note: this alone does not constitute as a formal referral to a physical therapy. As each injury is unique, the below may not apply to everyone.

  • While in a sling: Work on active and active assisted range of motion of your fingers/thumb, wrist and elbow to prevent stiffness. As long as your elbow is close to your body, non-weight bearing exercises are safe to perform for the above joints.
  • 4-5 weeks following injury: As pain subsides, you can begin to perform light pendular exercises. To do this, you let your arm hang and have gravity rotate your hand around. This allows for some motion through your shoulder without excessive stress on the fracture.
  • 5-6 weeks following injury: Once your fracture is healed you will begin to wean the sling and start physical therapy. The goal is to regain 80% of your shoulder motion by 12 weeks post injury.
  • 12 weeks post injury: Add in strengthening of the shoulder, with sport or job specific exercises as needed.
  • At all times: Let pain be your guide. Excessive discomfort or therapist concern should prompt you to contact your Orthopaedic Surgeon or Family Physician.

 

Expected Outcomes

Clavicle fractures can cause stiffness and weakness around the shoulder. Depending on the severity, your treating physician will comment on your expected recovery. In general, we aim to return people to 90-95% of their previous function and back to work before the 12-week mark. Office workers are often able to return to work 2-4 weeks following injury, and may use a keyboard and mouse in a sling with their elbow at their sides.

 

Notable Challenges

  • Wrist/Finger Stiffness: May require formal physical therapy over 6 months to resolve. Chance of finger/wrist stiffness can be greatly decreased by keeping both joints moving.
  • Shoulder Stiffness and Weakness: Stiffness around the shoulder is to be expected. It can take upwards of a year to maximize gains in shoulder range of motion and strength. Physical therapy and ongoing exercises are critical for recovery during this time.
  • Complex Regional Pain Syndrome: a challenging adverse pain response associated with some fractures. Requires time, physical therapy and occasionally medications to treat.
  • Non-Union or Delayed Union: See the above section.

 

Summary of Common Treatment/Rehabilitation Pathway

Proximal Biceps Tendon Ruptures

Biceps Anatomy and Function

The biceps muscle is a collection of two muscular bodies (one termed ‘short’ and another ‘long’) which join at the elbow to form a single tendon. This tendon crosses the elbow and attaches to the radius bone in a region termed the radial tuberosity. Collectively, the biceps muscle works mainly as an elbow supinator (the motion involved in turning a screw driver or a door knob) and also an elbow flexor.

One of two components of a biceps tendon may rupture. The long head of the biceps tendon can rupture at the shoulder. This most commonly occurs in suddenly in middle-aged or older individuals. This tendon is most susceptible to injury due to the anatomic course of the tendon. The long head of the biceps tendon attaches to the muscle belly of the lateral (or outer) biceps. As the tendon moves towards the shoulder, it is held in place by a boney indent known as the bicipital groove. Entering the shoulder, the tendon makes a nearly 90 degree turn towards its final attachment on the glenoid labrum. At this 90 degree turn, the biceps is guided by a sling of tissue and one of the rotator cuff tendons – the subscapularis. The long head of the biceps tendon may rupture anywhere along its course. Thankfully, proximal biceps ruptures require no surgical treatment as research studies have shown no deficit in strength or function at 1 year following injury. We believe this to be because the other muscle belly remains attached to the short head of the biceps tendon, thereby preventing complete retraction of the muscle. Despite this, patients will still notice a so-called ‘Pop-Eye’ muscle on one side after injury.

In contrast, the biceps tendon may rupture at the elbow. This injury more commonly occurs in younger individuals and commonly requires surgical repair for optimal results. For more information on distal biceps tendon ruptures, please click here.

 

Work-Up

Patients are often seen first in either the emergency room or their family physician’s office. For any patient with shoulder pain where a fracture has been ruled out, clinical exam will dictate how quickly additional imaging should be considered. If a clinical exam is very highly suggestive of a proximal biceps injury, an ultrasound can be quickly arranged to assess for the possibility of a tendon tear. The diagnosis of a proximal biceps tendon rupture often prompts a referral to an Orthopaedic surgeon, which can occur on a non-urgent fashion.

After being assessed by an Orthopaedic surgeon, an MRI may be arranged. Although the MRI will confirm the proximal biceps rupture, the main purpose of arranging for an MRI is to evaluate for other issues within the shoulder that may explain ongoing pain, discomfort, or functional limitation.

 

Treatment

Proximal biceps tendon ruptures do not require surgical management. Even in young individuals, we do not recommend repair. Simply stated, available evidence suggests the only benefit to surgery in proximal biceps tendon ruptures is a mild to moderate improvement in arm cosmesis. Given the risk of ongoing pain, the possibility of an unsightly scar, and muscular tethering to the skin, we do not recommend, nor perform repairs, for proximal biceps tendon ruptures.

 Physical Therapy

Anyone with shoulder pain, regardless of cause, should be started on a shoulder conditioning program to maintain or improve range of motion while working on strengthening.  This is incredibly important for multiple reasons:

  • Therapy can help avoid shoulder stiffness. After an injury, there is a tendency of the shoulder to stiffen up during the healing processes. This will be made worse if a shoulder is not used. Even if therapy is unable to fully alleviate shoulder pain, it will help maintain motion. We often comment: ‘A painful shoulder I can help with, a stiff and painful shoulder is much more difficult to treat’.
  • Therapy can improve pain. By working on muscular strengthening, posture and shoulder kinematics (how the shoulder moves in space), therapy may be able to allow you to recover from injury faster and prevent future injury.
  • Therapy is Time Dependent. It is intuitive that the quicker someone starts physical therapy, the faster they will recover. What most people realize is that delay in start of physical therapy leads to deconditioning, abnormal shoulder movements, and chronic pain. Immediate therapy can avoid a ‘downward spiral’, where a painful shoulder becomes a deconditioned shoulder, which in turn causes more pain (and so on). Shoulder specialists often cringe when a patient says the phrase “I didn’t want to start physical therapy until I was seen by a surgeon” as we know recovery will likely be longer because of it. With very few exceptions (such as a fracture), therapy should be started as soon as a physician provides a prescription for it!

 

General Therapy Instructions

Please note: this alone does not constitute as a formal referral to a physical therapy. The following guidelines are for non-operatively treated distal biceps tendon ruptures. Therapy should be initiated, conducted and monitored by trained professionals.

  • Stage 1 – Motion: The first goal is to achieve and maintain the maximal amount of range of motion possible, ideally back to pre-injury state. Active and active assisted range of motion of the elbow, shoulder, wrist and fingers is started.
  • Stage 2 – Light Strengthening: To start when 80% of expected range of motion is achieved. Recommend starting with light bands and progress to cables and finally free weights. Focus is on low weight with higher repetition.
  • Stage 3 – Strengthening and Conditioning: This stage involves increasing weight to regain pre-injury strength. Exercises are tailored towards job-specific or sport-specific tasks. Care should be taken to maintain proper form and avoid re-injury.
  • Stage 4 – Maintenance: An often forgotten or neglected component of the rehabilitation program. Exercises from Stage 3 should be incorporated into a weekly fitness regimen with the goal of avoiding re-injury.

 

Notable Challenges

  • Post-Injury Pain: Proximal biceps tendon ruptures are painful, especially in the first two weeks following an injury. Pain does subside, and muscular cramping often resolves by 3 months post injury. Ongoing pain and discomfort within the shoulder beyond 3 months may be related to other structural injuries within the shoulder.
  • Shoulder Stiffness and Weakness: Stiffness around the shoulder is to be expected, especially in operatively managed shoulders requiring post-operative immobilization in a sling. It can take upwards of a year to maximize gains in shoulder range of motion and strength. Physical therapy and ongoing exercises are critical for recovery during this time.
  • Complex Regional Pain Syndrome: a challenging adverse pain response associated with some fractures. Requires time, physical therapy and occasionally medications to treat.

 

Summary of Common Treatment/Rehabilitation Pathway

 

Proximal Humerus Fractures

Background

Proximal humeral neck fractures are also more generally known as proximal humerus fractures. Although some people refer to them as shoulder fractures, we prefer to avoid that term as there are many bones around the shoulder. Proximal humerus fractures are among the most common fractures seen by our Orthopaedic surgeons. They can occur in any age group, although they are most commonly due to a fall in older individuals. We pay particular attention to proximal humerus fractures occurring from relatively minor injuries in patients 50 years or older, as they may be a sign of osteoporosis.

 

Treatment

Patients are often seen first in the Emergency Room, where the diagnosis is made. The emergency room physician may attempt to reduce (or ‘set’) the fracture prior to immobilizing it a sling, collar/cuff or hanging arm cast. The purpose of all of forms of immobilization are to allow gravity to pull down on the elbow, which helps align the proximal humerus fracture while it is healing.  In contrast to many other fractures, it is not possible to ‘cast’ a proximal humerus fracture, nor is it necessary in this instance to allow for healing.

Patients are then referred to a fracture clinic where they are seen by an Orthopaedic surgeon. The X-rays obtained and the cause of the injury will help the surgeon determine how severe the proximal humerus fracture is. In general, 98-99% of all proximal humerus fractures can be managed without an operation. Although several surgeries are available to treat these fractures, clinical studies are increasingly showing that surgery is often unnecessary and comes with significant risk with little (if any) clinical benefit.  The exceptions to this are severe fractures in young individuals (often due to high-energy or workplace injuries), or in instances with a proximal humerus fracture is associated with a dislocation of the glenohumeral (or shoulder) joint.

In the rare circumstance that surgery is recommended, the two options that will be discussed are:

  1. Internal Fixation with Plates and Screws: The purpose of this is to better align the bones and hold them with stainless steel plates/screws while your body heals. It is important to note that surgery is not in itself designed to return someone back to function quicker.  Instead, it is designed to hold the bones in a better position while your body heals the break.
  2. Shoulder Arthroplasty: Severe shoulder fractures that cannot be held with plates and screws may require a shoulder arthroplasty (or shoulder replacement). A shoulder arthroplasty is a metal prosthesis that replaces broken bones within your shoulder. It is used when your surgeon is unable to fix your bones with plates and screws. Recovery and timing of therapy will depend on the type of prosthesis used.

 

Expected Follow-up and Recovery

No Surgery: Patients are followed at week 1 and/or week 2 at the discretion of surgeon. X-rays will be taken at each visit. Early X-rays assess alignment but cannot determine healing. It is important to note that the first two weeks following injury can be incredibly painful. Sleeping and finding a comfortable position can be challenging, even in a well-fitting sling. As pain subsides, we encourage elbow, wrist and finger range of motion to avoid stiffness. Pendular exercises (or ‘pot-stirrer exercises’) can begin at week 3 or 4. At 5-6 weeks following injury an X-ray is obtained to assess for healing of the fracture. Additional time in the sling may be required should the fracture not be fully healed. Once healed, we recommend physical therapy to regain motion and progressively build up strength.

After Surgery: Patients are seen at 2 weeks post up for removal of staples. We encourage immediate elbow, wrist and finger range of motion exercises but no lifting weights beyond 1lb for 6 weeks. Shoulder range of motion will depend on the type of surgery performed. Regardless of surgery, physical therapy is started at 6 weeks post operatively with the short-term goal of regaining shoulder range of motion.

 

General Information

  • All slings should be kept clean and dry.
  • Swelling is common following an injury or fracture. To decrease swelling consider icing it 15 minutes at a time every 1-2 hours. Ice should be wrapped in a tea-towel to avoid frost-bite.
  • Bruising down the arm or across the chest is expected following proximal humerus fractures
  • Occasional numbness that resolves quickly is to be expected. Persistent numbness in the arm is not common and should be mentioned toyour physician.
  • You may find it more comfortable to sleep in a reclining chair for the first 2-5 weeks following the injury. Ensure the chair is placed close to washrooms and away from any tripping hazards.

 

General Therapy Instructions

Please note: this alone does not constitute as a formal referral to a physical therapy. As each injury is unique, the below may not apply to everyone.

  • While in a sling: Work on active and active assisted range of motion of your fingers/thumb, wrist and elbow to prevent stiffness. As long as your elbow is close to your body, non-weight bearing exercises are safe to perform for the above joints.
  • 3-4 weeks following injury: As pain subsides, you can begin to perform light pendular exercises. To do this, you let your arm hang and have gravity rotate your hand around. This allows for some motion through your shoulder without excessive stress on the fracture.
  • 5-6 weeks following injury: Once your fracture is healed you will begin to wean the sling and start physical therapy. The goal is to regain 80% of your shoulder motion by 12 weeks post injury.
  • 12 weeks post injury: Add in strengthening of the shoulder, with sport or job specific exercises as needed.
  • At all times: Let pain be your guide. Excessive discomfort or therapist concern should prompt you to contact your Orthopaedic Surgeon or Family Physician.

 

Expected Outcomes

Shoulder fractures can cause significant stiffness and weakness around the shoulder. Depending on the severity, your treating physician will comment on your expected recovery. In general, we aim to return people to 80% of their previous function, with a goal of return to work before the 12-week mark.

 

Notable Challenges

  • Wrist/Finger Stiffness: May require formal physical therapy over 6 months to resolve. Chance of finger/wrist stiffness can be greatly decreased by keeping both joints moving.
  • Shoulder Stiffness and Weakness: Stiffness around the shoulder is to be expected. It can take upwards of a year to maximize gains in shoulder range of motion nd strength. Physical therapy and ongoing exercises are critical for recovery during this time.
  • Complex Regional Pain Syndrome: a challenging adverse pain response associated with some fractures. Requires time, physical therapy and occasionally medications to treat.

 

Please note: this information is designed to enhance the care provided to patients by the surgeons of Simcoe-Muskoka Orthopaedics. Medical and surgical management will differ on a case by case basis and should not be undertaken without guidance from a trained medical practitioner who assumes the responsibility for a given patient’s care. While each information package is peer reviewed, we cannot guarantee the absolute accuracy of this information nor its relevance to a patient’s specific medical situation.

Greater Tuberosity Fractures

Background

Greater Tuberosity Fractures are a unique type of proximal humerus fractures.  Although some people refer to them as shoulder fractures, we prefer to avoid that term as there are many bones around the shoulder. Greater Tuberosity Fractures may occur due to trauma or shoulder dislocation, and represent a boney disruption to the rotator cuff tendons around the shoulder. They can occur in any age group, although they are most commonly due to a fall in older individuals or due to athletic injuries. As the boney piece dislodges, the attached rotator cuff muscles/tendons tend to pull the piece backwards and towards the center of the body.

 

Treatment

Patients are often seen first in the Emergency Room, where the diagnosis is made. A sling is applied to help with pain control and to avoid movement around the shoulder. In contrast to many other fractures, it is not possible to ‘cast’ fractures around the shoulder, nor is it necessary in this instance to allow for healing.

Patients are then referred to a fracture clinic where they are seen by an Orthopaedic surgeon. The X-rays obtained and the cause of the injury will help the surgeon determine how severe the injury is. As treatment decisions depend on the size of the fracture and how far it has pulled away from its normal (or ‘anatomic’) location, a CT scan is often obtained.

Fractures with minimal movement from their anatomic location can be treated without surgery. In contrast, if the boney piece is pulled 5mm away or more, surgery is recommended. Pieces that have travelled between 1-4mm require close observation.

If surgery is recommended, the main goal of the procedure is actually to repair the rotator cuff tendons as close to their normal attachment as possible. The boney fracture is secured using strong suture and either a screw or a suture anchor. The combination of the suture and the screw/suture anchor will hold the bone in place to allow for the rotator cuff to heal.

 

Expected Follow-up and Recovery

Although unique circumstances exist (i.e. 1-4mm of boney movement in the dominant extremity of a worker who performs overhead activity), the following treatment recommendations commonly hold true:

  1. Stable (0mm of boney movement): Sling for comfort for 4 weeks. During this time finger, wrist and elbow motion may occur, but no motion at the shoulder. Following this, physical therapy can be started in an active/assisted fashion, with fully active motion starting at 6 weeks and strengthening starting at 2 months.
  2. Observe (0-4mm of boney movement): Sling is an absolute requirement for 6 weeks. The goal of the sling is to prevent further displacement of the fracture. During this time finger, wrist and elbow motion may occur, but no motion at the shoulder. Following this, physical therapy can be started in an active fashion. Strengthening is avoided until range of motion of the injured shoulder is nearly as good as the uninjured side.
  3. 5mm or more of boney movement: Surgery is often recommended for fractures with this amount of movement. Following surgery, a sling is an absolute requirement for 6 weeks. The goal of the sling is to allow for healing of both the bone and the rotator cuff tear. During this time finger, wrist and elbow motion may occur, but no motion at the shoulder. Following this, physical therapy can be started in an active fashion. Strengthening is avoided until range of motion of the injured shoulder is nearly as good as the uninjured side, typically at 3 months.

 

General Information

  • All slings should be kept clean and dry.
  • Swelling is common following an injury or fracture. To decrease swelling consider icing it 15 minutes at a time every 1-2 hours. Ice should be wrapped in a tea-towel to avoid frost-bite.
  • Bruising down the arm or across the chest is expected following any fracture around the shoulder
  • Occasional numbness that resolves quickly is to be expected. Persistent numbness in the arm is not common and should be mentioned to your physician.
  • You may find it more comfortable to sleep in a reclining chair for the first 2-5 weeks following the injury. Ensure the chair is placed close to washrooms and away from any tripping hazards.

 

General Therapy Instructions

Please note: this alone does not constitute as a formal referral to a physical therapy. As each injury is unique, the below may not apply to everyone.

  • While in a sling: Work on active and active assisted range of motion of your fingers/thumb, wrist and elbow to prevent stiffness. As long as your elbow is close to your body, non-weight bearing exercises are safe to perform for the above joints.
  • 4-5 weeks following injury: As pain subsides, you can begin to perform light pendular exercises. To do this, you let your arm hang and have gravity rotate your hand around. This allows for some motion through your shoulder without excessive stress on the fracture.
  • 5-6 weeks following injury: Once your fracture is healed you will begin to wean the sling and start physical therapy. The goal is to regain 80% of your shoulder motion by 12 weeks post injury.
  • 12 weeks post injury: Add in strengthening of the shoulder, with sport or job specific exercises as needed.
  • At all times: Let pain be your guide. Excessive discomfort or therapist concern should prompt you to contact your Orthopaedic Surgeon or Family Physician.

 

Expected Outcomes

Shoulder fractures can cause significant stiffness and weakness around the shoulder. Depending on the severity, your treating physician will comment on your expected recovery. In general, we aim to return people to 80% of their previous function and back to work before the 12-week mark. Office workers are often able to return to work 2-4 weeks following injury, and may use a keyboard and mouse in a sling with their elbow at their sides.

 

Notable Challenges

  • Wrist/Finger Stiffness: May require formal physical therapy over 6 months to resolve. Chance of finger/wrist stiffness can be greatly decreased by keeping both joints moving.
  • Shoulder Stiffness and Weakness: Stiffness around the shoulder is to be expected. It can take upwards of a year to maximize gains in shoulder range of motion and strength. Physical therapy and ongoing exercises are critical for recovery during this time.
  • Complex Regional Pain Syndrome: a challenging adverse pain response associated with some fractures. Requires time, physical therapy and occasionally medications to treat.

 

Summary of Common Treatment/Rehabilitation Pathway