1. Evidence Based Medicine and the Rotator Cuff Chris Pullen

2. Introduction 1 UK (Linsell et al 2006 Rheumatology) 2.4% primary care consultations are shoulder based USA (US Dept Health & Human Services) 4.5 million physician visits rotator cuff problems

4. Natural History ?

5. When to & when not to operate ?

7. Prevalence MRI asymptomatic (Sher et al 1995 JBJS) Supported by US and cadaver studies Why RCT become symptomatic ??? Ageing process ?

8. Natural History 1 Asymptomatic RCT 40% asymptomatic tear 51% symptomatic 39% increase in size (Yamaguchi et al 2001 JSES)

9. Natural History 2 Partial thickness tears Arthrography on 40 of 61 patients with PTT (Yamanaka et al 1994 CORR) Full thickness tears do not heal (Fukuda et al 1994 CORR)

10. Pathogenesis Mechanical (Neer 1972 JBJS) Vascular (Moseley & Goldie 1963 JBJS) Genetic (Harvie et al 2004 JBJS) Cellular (Nirschl 1989 Instr Course Lect)

11. Non-operative Treatment 1 Impingement/Tendinitis High success rate approx 70% Retrospective study 616 patients (Morrison et al 1997 JBJS) Prospective trial 100 patients impingement (Cummins et al 2009 JSES)

12. Non-operative Treatment 2 Rotator cuff tears Some patients have successful outcome No reliable method of predicting outcome Need for well-planned randomized controlled trials (Ainsworth & Lewis 2007 Br J Sports Med.) Irreversible changes within cuff muscles after a tear (Coleman et al 2003 JBJS)

14. Exercises

15. Manual therapy

16. Corticosteroid injections

17. Ultrasound

18. Phonophoresis

19. Iontophoresis

20. Ice/Heat

22. Exercise 2 Systematic review Physical Therapy modalities used ROM Stretching & flexibility Strengthening Manual therapy (Kuhn 2009 JSES)

23. Exercise 3 Pain (Bang 2000, Brox et al 1993, Ludewig & Borstad 2003, Senbursa 2007, Walther 2004) Strength (Bang 2000, Haahr et al 2005, Walther et al 2004) Function (Bang 2000, Conroy & Hayes 1998)

24. Exercise 4 Two studies compared supervised physical therapy with home exercise (Walther et al 2004, Werner et al 2002) Neither could show a statistically significant difference between the 2 exercise groups

25. Manual Therapy The effect of manual therapy has been evaluated in a number of studies (Bang 2000, Conroy & Hayes 1998, Senbursa et al 2007)

26. Corticosteroid Injections 1 For 50y CSI have been used for treatment of shoulder problems Survey 96% practitioners believe CSI effective Adverse effects well know Rat model (Tillander et al 1999 JSES)

27. Corticosteroid Injections 2 (Koester et al 2007 JAAOS)

28. Corticosteroid Injection 3 Pain (Adebajo et al 1990 J Rheum, Akgun et al 2004 Clin Rheum, Blair et al 1996 JBJS) ROM (Adebajo et al 1990 J Rheum, Blair et al 1996 JBJS) Predictor for surgery (Cummins et al 2009 JSES) MRI study accuracy of injection 24-31% CSI inaccurately placed Only injections into SA bursa helpful (Henkus et al 2006 Arthroscopy)

29. Corticosteroid Injections 4 ‘little evidence to support or refute the efficacy of common interventions for shoulder pain’ (Buchbinder et al 2003 Cochrane Database) ‘best evidence indicates that subacromial CSI is not efficacious in the treatment of rotator cuff disease’ (Koester et al 2007 JAAOS)

30. NSAID Integral to most non-operative treatment protocols Systematic review 19 Randomized controlled trials Shoulder pain Useful in short term only (4 weeks) No benefit seen for a particular NSAID (van der Windt et al 1995 J Clin. Epid.)

31. Other US (Green et al 2003 Cochrane Database) Phonophoresis (Klaiman et al 1998 Med Sci Sports Exerc) Iontophoresis Heat/Cold (Haahr et al 2005, Conroy et al 1998, Senbursa et al 2007)

33. Surgical Treatment 2 Dorrestijn et al 2009 JSES

34. Surgical Treatment 3 Rotator cuff tear Systemic review (Wolf et al 2007 Am J Sports Med) Despite possibility of re-tear RCR reduces pain & improves strength & function in symptomatic patients (Jost et al 2000 JBJS)

35. Surgical Treatment 4 Variables Duration of symptoms (Habernek et al 1999 Br J Sports Med) Age (Feng et al 2003 J Ortho Surg, Hattrup 1995 JSES)

36. Surgical Treatment 5 Variables Gender (Romeo et al 1999 CORR) Weakness (Bartolozzi et al 1994 CORR) Tear size (Bartolozzi et al 1994 CORR)

37. Surgical Treatment 6 Variables Acromiohumeral distance (Ellman et al 1986 JBJS, Gerber et al 2000 JBJS) Atrophy & Degeneration (Goutallier et al 2003 JSES)

39. Conclusions 1 Non-operative treatment Trial minimum 6-12 weeks Physical therapy

40. Conclusions 2 Exercises ROM Postural exercises Shoulder shrugs & retraction Glenohumeral motion Pendular exercises

41. Conclusions 3 Exercises Stretches Anterior and posterior capsule Strengthening Rotator cuff & scapular stabilizers Theraband

42. Conclusions 4 MRI scan Surgery

43. Conclusions 5

44. Conclusion 6

45. The End