Rotator Cuff Treatment.

Last updated Wednesday, January 26, 2005

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Subacromial abrasion

Nonoperative treatment

Patients in whom the primary complaint is symptomatic subacromial crepitance (see figure 7) will usually benefit from reassurance and a home program of gentle stretching and strengthening exercises. Various nonoperative rotator cuff programs have been described for the general population and for athletes, including throwers. (Albright, Jokl, 1978, Atwater, 1979, Berry, Fernandes, 1980, Binder, Parr, 1984, Cofield, 1985, Cofield and Simonet, 1984, Fowler, 1979, Hawkins and Kennedy, 1980, Jobe and Moynes, 1982, Kerlan, Jobe, 1975, Neer, 1983, Neviaser, Neviaser, 1982, Pappas, Zawacki, 1985a, Pappas, Zawacki, 1985b, Richardson, Jobe, 1980, Rocks, 1979, Scheib, 1990) Exercises must address specifically any shoulder stiffness, which may cause obligate translation and loss of concentricity on shoulder movement (see figure 8). The effectiveness of nonoperative treatment was recognized many years ago by Neer who, in his initial article on anterior acromioplasty, pointed out that "Many patients . . . were suspected of having impingement, but responded well to conservative treatment." (Neer, 1972) Furthermore, he stated that patients were advised not to have an acromioplasty until the stiffness of the shoulder had disappeared and the disability had persisted for at least nine months. As a result of these conservative surgical indications, during the period covered by his report, this most active shoulder surgeon operated on an average of only ten shoulders a year with this diagnosis: the effectiveness of nonoperative management is worthy of emphasis!

The low success rate in returning athletes to competition after acromioplasty (Tibone, Jobe, 1985) reinforces the importance of nonoperative management in this population. Similar principles apply to workers who are required to use their shoulders in positions aggravating subacromial abrasion.

Subacromial injections of corticosteroids have been reported by some to produce symptomatic relief. (Hollingworth, Ellis, 1983) However, Withrington and coworkers (Withrington, Girgis, 1985) reported a double-blind trial of steroid injections and found no evidence of the efficacy of such treatment. Valtonen (Valtonen, 1978) found no difference between subacromial and gluteal injections of steroids. Berry and colleagues (Berry, Fernandes, 1980) compared acupuncture, physiotherapy, steroid injections, and anti-inflammatory medications and found no difference among these treatments.

Steroid injections in or near the cuff and biceps tendons may produce tendon atrophy or may reduce the ability of damaged tendon to repair itself. Such changes have been well documented in other tissues. (Lund, Donde, 1979, Rostron, Orth, 1979, Uitto, Teir, 1972) Uitto and colleagues, (Uitto, Teir, 1972) demonstrated corticosteroid-induced inhibition of the biosynthesis of collagen in human skin. The harmful effects of repetitive intra-articular injection of steroids have been noted. (Behrens, Shepherd, 1975, Cruess, Blennerhassett, 1968, Mankin and Conger, 1966, Salter, Gross, 1967, Sweetnam, 1969)

Ford and DeBender (Ford and DeBender, 1979) reported 13 patients who developed 15 ruptured tendons subsequent to nearby injection of steroids. Other authors have reported spontaneous ruptures of the Achilles tendon and patellar tendon after steroid injection. (Bedi and Ellis, 1970, Ismail, Balakishnan, 1969, Lee, 1957, Melmed, 1965, Smaill, 1961) Although Matthews and colleagues (Matthews, Sonstegard, 1974) failed to find a deleterious effect of corticosteroid injections on rabbit patellar tendons, Kennedy and Willis (Kennedy and Willis, 1976) found a substantial effect in the rabbit Achilles tendon. They concluded that physiological doses of local steroid placed directly in a normal tendon weaken it significantly for up to 14 days following the injection.

Watson (Watson, 1985) reviewed the surgical findings in 89 patients with major ruptures of the cuff. He found that all 7 patients who had had no local steroid injections had strong residual cuff tissue. Thirteen of 62 patients having one to four steroid injections had soft cuff tissue that held suture poorly; 17 of the 20 patients having more than four steroid injections had very weak cuff tissue; these shoulders with weak cuff tissue had poorer results after surgical repair. In this light, one can appreciate the potential hazard of making a diagnosis of "bursitis" or "bicipital tendinitis" and treating the situation with repeated steroid injections until the reality of a major cuff tendon deterioration becomes inescapable. (Darlington and Coomes, 1977, Kennedy and Willis, 1976)

The patient with subacromial abrasion is informed that this condition can usually be resolved with nonoperative management directed toward the restoration of normal mobility, strength, coordination and fitness.

Authors' preferred method of nonoperative management of subacromial abrasion

In our approach to subacromial abrasion, we recognize the important interplay between cuff weakness, stiffness of the posterior capsule, and subacromial roughness. We use a program designed by Sarah Jackins, a physical therapist who has worked with the University of Washington Shoulder and Elbow Service since its inception in 1975. This treatment regimen is analogous to one that would be used for managing a tennis elbow or Achilles tendinitis and includes:

1. avoidance of repeated injury,
2. restoration of normal flexibility,
3. restoration of normal strength,
4. aerobic exercise, and
5. modification of work or sport.

The emphasis is on simple, low-tech exercises that the patient can perform unassisted.

The Jackins Program

Step 1: Avoidance of Repeated Injury

Although it seems obvious that an affected shoulder must be rested, we see patients each week who are trying to continue vigorous overhead work or swimming hundreds of miles per week in the presence of cuff symptoms. It is difficult to treat these symptoms when the affected area is repeatedly irritated; activities may need to be temporarily modified--light duty, reducing mileage, less throwing, using the kickboard for a major part of the workout rather than continuing to try to "swim through" the problem, or working on the forehand and footwork rather than beating away at the serve. Once symptoms have subsided, the activity is progressively resumed with an emphasis on proper technique and a paced resumption of normal levels of performance.

Step 2: Restoration of Normal Flexibility

The goal of Step 2 is to stretch out all directions of tightness. Shoulders with subacromial abrasion are frequently stiff, especially in the posterior capsule. As described above for posterior capsular tightness, the most effective program is one that taught by the surgeon or therapist, but is carried out by the patient. The goal of the flexibility program is to restore the range of motion to that of the unaffected shoulder. The recommended treatment consists of gentle stretches performed five times a day by the patient (see figures 9-14). Each stretch is performed to the point where the patient feels a pull against the shoulder tightness, but not to the point of pain. Each stretch is performed for one minute, so that the patient invests about 30 minutes per day in their shoulder. Obvious improvement commonly occurs within the first month, but three months may be required to completely eliminate the condition.

Step 3: Restoration of Normal Strength

When near-normal passive flexibility of the shoulder is restored, the patient's attention is directed toward regaining muscle strength. As is the case in managing tennis elbow, it is most effective to delay strengthening exercises until normal range of motion is achieved. As with the flexibility exercises, the patient is given the responsibility for strengthening the shoulder. Internal and external rotator-strengthening exercises are carried out with the arm at the side (see figures 15 and 16) to strengthen the anterior and posterior cuff muscles without the potential for subacromial grinding that exists with exercises in abduction and flexion. These exercises are most conveniently performed against the resistance of rubber tubing, sheet rubber, bike inner tubes, springs or weights. It is convenient if the resistance device can be carried in a pocket or purse for frequent use through the day. As strength increases, the patient is advanced to more resistance: thicker tubing, tougher rubber sheets, or more springs. Deltoid strengthening is added when it can be performed comfortably (see figure 17) as are exercises to strengthen the scapular motors (see figure 18). Athletes are not returned to full activity until the shoulder has full mobility and strength.

Step 4: Aerobic Exercise

If a patient has gotten out of shape as a result of the shoulder problem, it is important to emphasize the need to regain normal fitness. To get back in shape and to improve the sense of well-being, a half hour of "sweaty" exercise five days a week is recommended. Brisk walking may be the safest and most effective type of aerobic exercise, but other suitable forms include jogging, biking, stationary biking, and so on. Aerobic calisthenics as usually defined must be carefully reviewed to ensure that they do not require arm positions which aggravate the patient's symptoms.

Step 5: Modification of Work or Sport

Obviously, the purpose of the program is to return the patient to the comfortable pursuit of normal activities. Not infrequently this requires some analysis of working and recreational techniques. Occasionally this is as simple as having the short grocery clerk stand on a platform at work. The technique of swimmers is reviewed to ensure, for example, adequate roll on the freestyle stroke. Throwers are taught the importance of body position and rotator cuff strength. Adequate knee bend and lumbar extension is reinforced in the execution of the tennis serve. If the patient has an occupation that requires vigorous or repeated use of the shoulder in painful positions, vocational rehabilitation to a different job may be required.

Subsequent Steps

It may take six weeks before substantial benefit is realized. As long as the patient is making progress, we continue this program. If improvement is not forthcoming, the program is reviewed to be sure it is being conducted in an ideal way. The shoulder and the patient are also reevaluated to make sure there are no other factors that may be interfering with recovery. If repeat clinical evaluation indicates positive tendon signs (see figure 19) or other evidence of cuff fiber failure, tendon imaging studies may be considered if their results would change the patient's management. If a well-motivated patient continues to have symptomatic subacromial abrasion after six months of a well-conducted program, subacromial smoothing may be discussed as an alternative to continued non-operative management. Poor compliance with an exercise program may foretell an equally poor result from surgical treatment.

Operative treatment

Open acromioplasty

In his classic description of acromioplasty, Neer (Neer, 1972) described approaching the shoulder through a 9 cm incision made in Langer's lines from the anterior edge of the acromion to a point just lateral to the coracoid. The deltoid is split for 5 cm distal to the acromioclavicular joint in the direction of its fibers. It is then dissected from the front of the acromion and the acromioclavicular joint capsule. The stump of the deltoid's tendinous origin is elevated upward and preserved for the deltoid repair. Using an osteotome, a wedge-shaped piece of bone .09 cm by 2.0 cm is resected from the anterior undersurface of the acromion, along with the entire attachment of the coracoacromial ligament. If acromioclavicular osteophytes are present, the distal 2.5 cm of the clavicle are also excised along with the prominences on the acromial side of the joint. After the procedure, the deltoid is carefully repaired to the acromioclavicular joint capsule, the trapezius, and its tendon of origin.

Many reports regarding the results of open acromioplasty have been published. (Armstrong, 1949, Diamond, 1964, Ha'eri, Orth, 1982, Hammond, 1962, Hammond, 1971, Hawkins and Kennedy, 1980, Jackson, 1976, Kessel and Watson, 1977, McLaughlin, 1944, Michelsson and Bakalim, 1977, Moseley, 1969, Neer, 1972, Neer, 1983, Neviaser, Neviaser, 1982, Penny and Welsh, 1981, Pujadas, 1970, Skoff, 1995, Smith-Petersen, Aufranc, 1943, Thorling, Bjerneld, 1985, Watson-Jones, 1960) However, the interpretation of these reports is made difficult by the admixture of patients with intact cuffs, partial thickness cuff lesions, and full thickness cuff tears as well as by the inclusion of a wide range of additional elements to the surgery. Stuart et al (Stuart, Azevedo, 1990) reported a series which included acromioplasty with or without cuff repair, distal clavicle excision, and biceps tenodesis; 23% were still painful. Rockwood and Lyons (Rockwood and Lyons, 1993) reported on a series of 71 patients who had a modified acromioplasty with or without cuff repair and concluded that cuff repair did not influence the percentage of excellent results. Bosley (Bosley, 1991) reported on 35 patients with total acromionectomy, including patients with and without long standing massive cuff tears; most failures were attributed to either the underlying pathology or to failure of deltoid reattachment. Bjorkenheim et al (Bjorkenheim, Paavolainen, 1990) reported a failure rate of over 25%, attributing the failures to "associated bony as well as soft-tissue subacromial lesions". Oglvie-Harris et al (Ogilvie-Harris, Wiley, 1990) evaluated 67 shoulders in 65 patients who had pain and dysfunction for more than two years after an initial acromioplasty for impingement syndrome without a rotator cuff tear. In almost half of the cases there were "diagnostic errors" and even in those where there was a correct diagnosis and no operative errors, the failure rate was almost 20%.

Arthroscopic acromioplasty

Ellman, (Ellman, 1987) in 1987, published the first large series of fifty patients (average age 50 years) with mixed shoulder pathology who under went arthroscopic acromioplasty; ten had full thickness tears. At an average follow-up of seventeen months, 88% had good or excellent results. These results persisted at 2.5 year followup of the same treatment group. (Ellman and Kay, 1989)

Since then others have reported results of arthroscopic acromioplasty. (Ellman, 1987, Esch, Ozerkis, 1988) Gartsman, (Gartsman, 1990) Speer et al, (Speer, Lohnes, 1991) Altchek et al, (Altchek, Warren, 1990) and Roye et al (Roye, Grana, 1995) reported series of arthroscopic acromioplasties on shoulders without cuff tears; each finding 83-94% of the results were satisfactory. Approximately 75% of the patients were able to return to sports activity. Recovery times in these series ranged from 2 to 4 months. Most authors describe the procedure as technically demanding. The control of bleeding and the determination of the amount of bone to resect are two commonly technical difficulties in performing arthroscopic subacromial decompression. Many describe a learning curve associated with this technique and have recommended this procedure be performed on cadaver shoulders before it is used clinically.

In early years, after the introduction of the arthroscopic technique of acromioplasty, controversy arose as to whether a subacromial decompression performed arthroscopically was technically equivalent to that performed open. Gartsman et al. (Gartsman, 1990, Gartsman, Blair, 1988) in a cadaver study, was able to perform arthroscopic bony resection with release of the coracoacromial ligament equivalent to the open technique described by Neer. He suggested criteria for the technical adequacy of the acromioplasty: (1) the entire anterior acromial protuberance is resected, (2) the undersurface of the acromion is flattened, (3) the deltoid fibers are visible from the acromioclavicular joint to the lateral edge of the acromion, (4) the inferior aspect of the acromioclavicular joint is debrided to remove any downward protrusion, (5) the coracoacromial ligament is completely released from the anterior portion of the acromion and the acromioclavicular joint, (6) a portion of the ligament is resected, (7) an adequate subacromial bursectomy is performed to allow complete inspection of the bursal surface of the rotator cuff, and (8) finally, no subacromial abrasion is observed when the arm is taken through a range of motion at the completion of the procedure.

Most authors state that the indications for arthroscopic acromioplasty should be identical to those for the open procedure described by Neer in 1972. However, compared to the rate with which Neer used open acromioplasty in his practice, it is apparent that arthroscopic acromioplasty is performed much more commonly with broader indications. Although overall "satisfactory" results were obtained in the majority of reports, some authors were uncertain whether relief was obtained from the modifications of the acromial shape or other aspects of the treatment.

To keep things in perspective, Brox et al (Brox, Staff, 1993) compared the effectiveness of arthroscopic acromioplasty, an exercise program and a placebo in a randomized clinical trial. The study group consisted of 125 patients aged 18-66 who had had rotator cuff disease for at least three months and whose condition was resistant to treatment. The authors concluded that surgery or a supervised exercise regimen significantly, and equally, improved rotator cuff disease compared with placebo; however the surgical treatment was substantially more costly.

Comparison of open and arthroscopic acromioplasty

In 1994, Sachs et al (Sachs, Stone, 1994) reported on a series of 44 patients with stage II impingement prospectively randomized into open (22 patients/average age 49) and arthroscopic treatment groups (19 patients/average age 51). In both groups, full recovery took at least 1 year for the majority of patients. In both groups over 90% of patients achieved a satisfactory result (good or excellent). Final analysis showed that the main benefits of arthroscopic acromioplasty were evident in the first 3 months postoperatively with the arthroscopic patients regaining flexion and strength more rapidly than did patients treated with open decompression.

Furthermore, the arthroscopic treatment group had shorter hospitalizations, used less narcotics, and returned more quickly to both work and activities of daily living, leading the authors to suggest arthroscopic acromioplasty may have significant economic advantages.

In 1992, Van Holsbeeck et al (van Holsbeeck, DeRycke, 1992) compared their results of 53 patients treated by arthroscopic acromioplasty and 53 patients treated by an open acromioplasty. Based on the UCLA rating scale, good or excellent results were identical for both groups at a 2 year followup. The authors suggested arthroscopic acromioplasty was associated with a shorter recovery time, however, in the long term there was no difference in strength of forward flexion between the open and arthroscopic groups.

Hawkins at al (Hawkins, Saddamis, 1992) reported 40% satisfactory results with arthroscopic subacromial decompression, while they reported 87% satisfactory results with a concurrent series of open acromioplasty.

Roye et al (Roye, Grana, 1995) reported a series of 90 arthroscopic acromioplasties and found that the most of the patients who were not throwing athletes obtained satisfactory results and that the presence or absence of a cuff tear did not affect the result.

Lindh et al, in 1993, reported on a series of 20 patients who were randomly selected for either open or arthroscopic acromioplasty (10 patients in each group). The average duration of symptoms before surgery was over 5 years. Functional results in both the arthroscopic and open surgery groups were good and similar. Patients in the arthroscopic group were observed to demonstrate earlier restoration of full range of motion and reduction in time away from work.

Proponents of arthroscopic acromioplasty have argued this procedure requires less surgical dissection and produces less scarring and less post operative morbidity. In most instances the procedure can be performed on an outpatient basis. Post operative discomfort is moderate, and can usually be controlled by oral analgesics. Additionally, cosmesis is good, and patient acceptance is high.

A countervailing advantage of open acromioplasty is the advantage of being able to observe directly the subacromial space during motions which preoperatively caused the patient's symptomatic subacromial crepitance and the ability to assure that the crepitance is resolved before the procedure is concluded.

Deltoid retraction can be a significant problem after open procedures which require detachment and subsequent reattachment of the deltoid to the anterior acromion. (Bigliani, Cordasco, 1988) Arthroscopic acromioplasty has the theoretical advantage of leaving the deltoid origin almost totally undisturbed. However, in a recent report Torpey et al (Torpey, McFarland, 1996) it was pointed out that much of the deltoid arose from the anterior acromion. Their analysis indicated that a 4 mm anterior acromioplasty would detach approximately half of the deltoid fibers, whereas a 6 mm anterior acromioplasty would detach approximately 75% of the fibers. They conclude that neither an open nor an arthroscopic acromioplasty can be performed without substantial compromise of the anterior deltoid origin.

Arthroscopy offers the ability to directly inspect the glenohumeral joint as well as subacromial space. During an open acromioplasty, the deep surface of the cuff (where most cuff lesions begin) is not visible. By contrast at arthroscopy, partial or complete thickness tears of either surface of the rotator cuff as well as other findings can be identified by the experienced observer. However, even with arthroscopy the common intratendinous lesions remain inaccessible. Paulos and Franklin (Paulos, Harner, 1988) in their series of 80 arthroscopic acromioplasties reported a high number of unsuspected diagnoses that were made during arthroscopy. These included twenty-six (26) partial rotator cuff tears, twelve (12) labral tears; eight (8) instances of humeral chondrosis; four (4) cases of biceps tendon fraying; and two (2) loose bodies in the glenohumeral joint. They reported that for most of these shoulders these findings would have been missed with the open technique.

Altchek et al (Altchek, Warren, 1990) in their series of forty-four (44) patients treated by arthroscopic acromioplasty, eleven (11) patients had lesions of the glenoid labrum. Preoperatively, these patients had no evidence of instability, either by history or physical exam in action. Five (5) of these patients had a tear involving the inferior part of the labrum and failed to recover completely after the acromioplasty and were unable to return to full participation in sports. The authors felt that undetected slight instability may have played a role in the production of these patients' symptoms. The authors argued that arthroscopic inspection of the glenohumeral joint makes it possible to detect such problems providing information that is important for prognosis. Others have reported a higher than anticipated percentage of unsuspected associated lesions in those shoulder being treated arthroscopically for impingement symptoms. (Jobe and Kvitne, 1989) Burns and Turba (Burns and Turba, 1992) reported on their findings in 29 patients treated with arthroscopic acromioplasty which included anterior glenoid labrum tear (15), undersurface rotator cuff tear (8), chondromalacia of the humerus (3), biceps rupture (1), posterior glenoid labrum tear (1), and acromioclavicular arthritis (1).

These results indicate that the preoperative diagnosis of "impingement syndrome" has been associated with a wide range of shoulder pathologies. They leave unanswered the question of the prevalence of these same findings in asymptomatic shoulders and the role played by each of the findings in producing clinical symptoms. Hopefully in the future methodical clinical-pathological correlation will lead to improved accuracy in preoperative diagnosis and greater specificity in treatment.

The primary difficulty in interpreting these studies on open and arthroscopic acromioplasty is that, although the outcome of the procedure is characterized in terms such as of "good" or "excellent", the effectiveness of the procedure is often undetermined because the preoperative status, or ingo was not characterized in the same way. Ideally, a "good" result from surgery would indicate the change in the patient's condition as a result of the procedure, rather than the status of the shoulder post operatively.

The definition of the indications for and the effectiveness of acromioplasty must await multipractice studies which define accurately the pretreatment clinical findings and shoulder functional status, the nature of and compliance with a non-operative program, the nature of the surgery, and the change in the shoulder function realized after the procedure using the same parameters of comfort and function before and after surgery. The effectiveness of a treatment is the difference between the outcome and the ingo.

Authors' preferred method for subacromial smoothing

In our experience, the results of subacromial smoothing are likely to be best in the following circumstances:

1. a well-motivated patient over 40,
2. absence of posterior capsular stiffness,
3. presence of symptomatic subacromial crepitus (see figure 20) which the patient agrees is the dominant clinical problem,
4. absence of tendon signs (see figure 21) and other shoulder pathology and
5. symptoms which are not associated with a work-related injury.

Poor prognostic signs include:

1. age less than 40,
2. stiffness,
3. absence of subacromial crepitus,
4. presence of tendon signs or evidence of other shoulder pathology,
5. attribution of problem by the patient to his or her occupation,
6. concomitant evidence of glenohumeral instability, and
7. neurogenic cuff muscle weakness.

We use an open approach to subacromial smoothing. The patient is positioned with the head up at 30 and the arm draped free. Before making the incision, we note the positions and motions in which subacromial crepitus can be palpated through the acromion. The shoulder is approached through an incision in the skin lines over the anterolateral corner of the acromion (see figure 22). The acromion is exposed striving to maintain the continuity of the deltoid fascia, the acromial periosteum and the trapezius fascia. The deltoid tendon is split in line with its fibers along the strong tendon of origin that divides the anterior and middle deltoid. This allows two strong "handles" on the deltoid for repair. This split is deepened under direct vision until the bursa is entered. Rotating the humerus provides easy differentiation between the deltoid (which does not move with humeral rotation) and the superficial surface of the cuff (which does).

On entering the subacromial aspect of the humeroscapular motion interface (see figures 23 and 24), the subacromial space is observed while the preoperatively identified crepitus-producing movements are carried out. This step reveals the cause of the crepitance, which is usually some combination of roughness on the undersurface of the acromion, hypertrophic bursa, adhesions between the cuff and acromion, roughness of the superior surface of the rotator cuff or a prominent tuberosity. By gently rotating the arm, most of the cuff can be brought to the incision as pointed out by Codman. The rotator cuff is thoroughly explored and palpated for evidence of superior surface blisters, partial tears, thinning, or full-thickness defects. Although deep surface cuff fiber failure cannot be seen through this approach, it is also true that such fiber disruption cannot be causing the subacromial crepitance. The methylene blue "dye test" of Hiro Fukuda (Fukuda, Mikasa, 1983) or more recently the "Fukuda-lite" test with saline is used to evaluate shoulders with suspicious cuff integrity. In this test fluid is injected to distend the glenohumeral joint to further explore suspected thinning or small cuff defects.

Hypertrophic bursa is resected. Superior surface cuff defects are smoothed by either resection of their protruding aspects or occasionally by reattaching a superior surface cuff flap. Prominences of the tuberosity are smoothed so that the tuberosity passes easily beneath the coracoacromial arch. The undersurface of the coracoacromial arch is palpated to identify areas of roughness or prominence. These are smoothed with a "pine cone" burr, although an osteotome or rongeur may be useful for larger lesions. No attempt is made to resect the coracoacromial ligament unless it can be demonstrated to be the cause of the subacromial roughness.

If a substantial amount of bone needs to be removed, a thin-bladed osteotome is used (see figure 25). The osteotomy is oriented in line with the extrapolated undersurface of the posterior acromion (identified by palpation and direct vision). Care is taken that the osteotomy does not continue into the posterior acromion or scapular spine. The undersurface of the acromion is then smoothed using a "pine cone" power bur, taking care that no spurs are left laterally in the deltoid origin or medially at the acromioclavicular joint. The shoulder is thoroughly irrigated to remove all bone fragments.

Additional surgery is avoided unless clearly indicated. Inferiorly directed acromioclavicular osteophytes are resected if they scrape on the cuff. The biceps is left undisturbed unless it appears to be seriously inflamed, obviously unstable, or doomed to imminent rupture, in which case we perform a tenodesis to the proximal humerus.

The shoulder is gently manipulated through a complete range of motion to assure the absence of stiffness or additional adhesions. The entire humeroscapular motion interface (see figures 23 and 24) is inspected to assure absence of adhesions and for other pathology. Before the procedure is concluded, the upper surface of the cuff and tuberosities and the undersurface of the coracoacromial arch are carefully palpated to assure the absence of residual roughness. The entire range of passive shoulder motion must be free of subacromial crepitance.

On closure, a secure deltoid reconstitution is top priority so that early postoperative motion may be instituted. The deltoid is repaired by side-to-side closure of the medial and lateral aspects of the tendon split using No. 2 nonabsorbable suture (see figure 26). The tendon is secured to the acromion, using suture to bone as necessary. Suture from the medial hole is passed through the lateral part of the deltoid tendon and suture from the lateral hole is passed through the medial part of the deltoid tendon to effect a crisscross closure. This avoids the "telltale V" defect that reveals a poor deltoid closure. All knots are placed on the superficial aspect to avoid recreating subacromial roughness.

Postoperative program

After any type of subacromial surgery, there is a great potential for adhesions between the cuff and the arch. In cases of failed acromioplasty, such scarring seems to be a dominant feature and appears to be often related to delay in the institution of motion following the surgery. To avoid such problems, we begin motion as soon as possible, preferably with continuous passive motion in the recovery room (figure 27). CPM is set to move the arm slowly through an arc of 0 to 90 degrees of elevation and from 50 to 0 degrees of internal rotation. CPM is applied whenever the patient is in bed during their hospitalization, but is not continued after discharge. On the day of surgery, the patient is instructed in the "140/40 passive program" in which the opposite hand is used to assist the operated shoulder in achieving 140 degrees of elevation (see figure 9) and 40 degrees of external rotation (see figure 11). Emphasis is also placed on posterior capsular stretching, including cross body adduction (see figure 14), reaching up the back (see figure 13) and internal rotation of the abducted arm.

The early implementation of passive motion is facilitated if the procedure is performed under brachial plexus block (Tetzlaff, Yoon, 1994), which lasts from 12 to 18 hours. The post operative exercises are already familiar to the patient, having been performed as part of the preoperative trial of the Jackins program. The patient is allowed active use of the shoulder within the realm of comfort unless there is concern for the strength of the deltoid reattachment. Internal (see figure 15) and external rotation (see figure 16) strengthening exercises are also begun immediately. Deltoid strengthening is initiated at 6 weeks after the repair is secure (see figure 17). As soon as they can be performed comfortably, exercises to strengthen the scapular motors are added (see figures 18 and 18). Athletics are not allowed for three months after surgery and until normal motion and strength are regained.

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