Beware of that fall !

There is a higher incidence of falls in the winters when ground is often wet and slippery. It is quite common to sustain a shoulder injury from a simple fall, and whilst a vast majority of falls will result in minimal or no long term damage, others can sustain injuries ranging from a simple sprain to fracture dislocation.

All falls are not innocuous – the so called ‘soft tissue injury’ often gets scant attention and is usually treated with benign neglect. Most people would wait for a few days if not weeks to let the symptoms settle down, which is a completely reasonable approach. However, one should seek a more urgent appointment if the pain does not seem to be improving after the first week. A blunt fall on the shoulder may not show any fracture on X-rays, but can result in rotator cuff tear, that can cause significant functional deterioration if not addressed in time. Unfortunately all too often months if not years may elapse by the time patients get to the specialist, by which time it may be too late to repair.

One needs to have a high index of suspicion for rotator cuff tears especially in middle age or older group of patients. The injury can be picked up relatively easily by an Ultrasound examination and very rarely MRI may be needed for further evaluation. Clinically they may have severe pain that may preclude a meaningful examination in the initial few days. Later findings may include local bruise, restricted movements, weakness of the cuff muscles and a positive ‘drop arm test’ in a massive cuff tear. Patients presenting to GP surgeries and A&E departments need to be referred promptly to a shoulder specialist if there are any signs of rotator cuff tear.

Usually there is a degree of inflammation soon after the cuff tear that may cause stiffness of the shoulder and mask the symptoms of actual cuff tear. The Ultrasound is not helpful in such cases and an MRI is advisable. In all cases physiotherapy is recommended initially to restore biomechanics and movements. Most patients benefit from a tendon repair, unless the bone is too osteoporotic to hold bone anchors necessary for repair. It is especially important to repair in younger patients as the consequences can be disastrous. The rotator cuff, if not repaired in time, will retract over time and may lead to fatty infiltration of muscle bellies thus making it almost impossible to achieve a primary repair. This may in turn lead to cuff tear arthropathy which can usually only be treated by a complex joint replacement operation. With a timely diagnosis, the rotator cuff tear can be treated by relatively straightforward repair that can be achieved arthroscopically most of the times. It will still take 6-12 months to make a full recovery. On the other hand, a delayed diagnosis may lead to irreparable tear and potentially catastrophic consequences.

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