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Year |
2001 |
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Question Number |
267) |
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Category |
Select |
Question
A 62 y/o woman who plays tennis underwent an acromioplasty and rotator cuff repair using four suture anchors 1 month ago. Three days ago she was allowed to begin using her arm to lift lightweights, but she now reports a dramatic increase in pain and is unable to elevate the arm. The next most appropriate step in management should consist of:
1) Further immobilization ad discontinuation of physical therapy
2) Plain radiography
3) MRI
4) Arthrography
5) Elecrtromyography of the axillary and suprascapular nerves
Figures
Answer (click for answer)
Preferred answer #2
The question is asking the initial management of a patient who is s/p rotator cuff surgery now with pain and the inability to lift her arm. The most important piece of information that needs to be obtained is whether the patient has a recurrent tear in her RTC. The author’s answer is plain radiography, which in the article cited includes ultrasonography. The article goes on to discuss in the hands of an experienced ultrasonographer it is extremely accurate in the diagnosis of recurrent RTC tears. The authors also note that it is quick, noninvasive and relatively inexpensive means to obtain information involving the RTC. With regards to the other answers further immobilization and discontinuation of P.T. would not be the best answer b/c it would not provide any information regarding if there was a retear. Thus, if there were not a tear you would want to resume PT to increase ROM and prevent shoulder stiffness. Arthrography is not the best diagnostic test to evaluate for recurrent tears because it was found in a large number of pts that there was leakage into the subacromial space thus indicating a rent in the RTC. The vast majority of these patients however had decreased pain and good functional outcomes. As a result it was concluded that a watertight repair of the RTC is not essential for a good functional outcome. MRI is an expensive test, difficult to obtain in a timely fashion and has problems with patient compliance thus making it not the best first option. EMG’s of the axillary and suprascapular nerves although possible is not the most logical first step in the workup of this patient just from a lack of mechanism for this type of injury.
Reference: Harryman, D.T., Mack, L.A., Wang, K.Y., Jackins, S.E., Richardson, M.L. Matsen, F.A. III: Repairs of the Rotator Cuff: Correlation of functional results with integrity of the cuff. J Bone Joint Surgery American 1991;73:982-989
Barber, F.A., Herbert, M.A., Click, J.N.: The ultimate strength of suture anchors. Arthroscopy 1995;11:21-28