Rotator cuff tears.

Abstract

To the Editor:—I read with avid interest, the article entitled “Rotator Cuff Tears in Elderly: a Brief View of Two Cases,” by Paul Rousseau in the June 1992 issue of the Journal of the American Geriatrics Society.1 Dr. Rousseau's brief review of the literature on rotator cuff tears, specifically diagnostic features in terms of evaluation, was particularly educational. In the area of treatment, however, I found that his handling of the material was mostly inadequate. For example, to encourage the use of narcotic analgesics and non-steroidal anti-inflammatory agents, in lieu of some of the local modalities available from physical therapy, often is completely inappropriate for older patients. I refer you to the article by Matthew Liang and Paul Fortin in the July 11, 1991 issue of The New England Journal of Medicine.2 The authors discourage the use of non-steroidal anti-inflammatory agents for arthritis of the hip and knee and accentuate the positive benefits that can be gained from the use of local modalities and exercise supervised by physical therapy with minimal systemic side effects. If physical therapy intervention is begun early in the rehabilitation process, excellent results are obtained. A physical therapist can begin a patient on an active assistive pain-free range of motion and strengthening program early in the rehabilitation process to encourage function. The results are frequently very positive, but as the time between diagnosis or surgery and the onset of rehabilitative treatment is lengthened, so too is the recovery period lengthened. In my clinic, we have had very successful results with aggressive programs, using a patient's subjective complaints of pain as a means of moderating the aggressiveness of the program. The Codman (or pendulum) exercises are excellent rehabilitation exercises for elderly rotator cuff patients, as is initiating proper scapulo-humeral rhythm by means of mirror exercises in flexion and abduction while keeping the shoulder down. After establishing these activities, addition of eccentric and concentric components in the acquirable ranges of motion (from 150° to 120° and from 0° to 60°) in flexion and abduction may be very beneficial. In addition, simple active assisted-motion exercises and isometrics in any pain-free combination can help the patient toward the goal of a stronger, more functional arm. As much as the proper diagnosis of rotator cuff tears is a very intricate and specialized approach to be used by geriatricians, so is the treatment program by a trained physical therapist. It requires appropriate skill, monitoring and timed intervention, and understanding of the scapulo-humeral rhythm and its effect on progress in regard to the rotator cuff mechanism. I believe that, in most instances, geriatricians and physical therapists can establish very positive outcomes in a conservative management program for rotator cuff conditions without the use of drugs.