EXAMPLE CASE OF ROTATOR CUFF TEAR ARTHROPATHY (RTA)

Case Examination

 

A 65-year-old male came to orthopaedic consultation with chief complaint of the right shoulder pain especially at night and weakness. He was a right dominant, retired mathematics teacher at favorite high school and NSAID treated without improvement. He had gout arthritis problem since 15 years ago. Inspection of the right shoulder of patient was asymmetric, atrophy of the right side of upper extremity and tenderness in the anterior aspect especially on subacromial of the right shoulder. Active and passive movement (ROM) of the right shoulder was limited

 

Part A: The objectives examination evaluation of the history taking and physical examination data collection for some possibilities or accurate diagnosis determination

 

Learning Objectives Evaluation in Examination

 

1.    History taking

 

The Examiners should be able to assess: 

The Candidate ability of the explanation in history taking determination about gender of the male patient, 65 years of age (elderly), complaint of pain at night and weakness of the right shoulder (dominance) especially during activities. Onset of the illness was 5 years ago (chronic process and he denies any trauma, infection, allergy, family and malignancy history). Occupation history was a high school teacher retired. The patient’s taking gout medicine routinely based on physician recommendation.   

 

2.    The physical examination

 

The Examiner should be able to assess

a.      The Candidate ability of the general condition patient status and gait analysis determination such as good patient’s condition without limping, and vital signs and body mass index are normal limited.

b.      The Candidate ability of the local examination data:

Look: The Candidate can describe that the muscle is atrophy and asymmetric in the right shoulder compare to the left side and there’s a lump at coracoid process. He/she shows a bit bulging at antero-lateral aspect. The right upper extremity seems like pseudoparalysis (fig. 1).

·      Feel: The Candidate determines muscle defect at supraspinatus insertion, subacromial tenderness and crepitation with tenderness around humeral head.

 

·      Move: The Candidate measures range of motion (ROM) of the right shoulder is 0-45⁰ actively but passive is full combined with crepitation. ROM of the left shoulder is normal limit actively and passively (fig. 2).

·      Muscle Power and vascular examination: The Candidate evaluates muscle power decreases, pulse and capillary-refill test are within normal limit or no vascular disturbance.

 

·      Neurology evaluation: Candidate explains the physiological and pathological reflex and the sensations of upper extremity are still normal.

 

c.       The Candidate ability to demonstrate special clinical test demonstration: Candidate informs positive Neer, and Howkin test and the weakness of the subscapularis plus infraspinatus muscle maneuver test and so on.

 

d.      Candidate is able to describe the shoulder radiographic images in detail, including a bit superior migration of the humerus head, narrowing of subacromial space, destruction of the glenohumeral articular and acromioclavicular joint surface, acetabularization on below acromion space and femoralization on the greater tuberosity combined with medial migration of rotation center of glenohumeral joint (Fig.3). According to radiographic data, x-ray examination supports the degeneration process of the glenohumeral joint caused by aging process.

 

After Candidate presents the conclusion, firstly the Examiner must always ask a question “are there any key data you should report from history taking and physical examination that you omit or incorrect maneuvers?’ If Candidate does not respond and no correct maneuver was done in physical examination, the Examiner will give a stimulation question.

 

SUMMARY:

 

Physical examination revealed muscle atrophy of the right shoulder, and asymmetric of the right shoulder compare the left side with lump at coracoid process and a bit bulging at antero-lateral aspect. The right upper extremity is likely as pseudoparalysis. Muscle defect at supraspinatus insertion, subacromial tenderness and crepitation with tenderness around humeral head. Range of motion (ROM) of the right shoulder is 0-45⁰ actively but passive is full combined with crepitation. Muscle power of the right upper extremity is decrease, pulse and capillary-refill test are normal limit or no vascular disturbance, sensation and capillary-refill test are normal limit or no vascular disturbance. Positive Neer, and Howkin test and the weakness of the subscapularis plus infraspinatus muscle maneuver test. The radiographic findings see above.

 

e.       The Candidate ability to integrate and analyze the key data for clinical diagnosis or differential diagnosis and the accurate diagnosis

 

The Candidate should be able to conclude the rotator-cuff muscle problem based on risk factors of female, elderly, suffering from gout arthritis, pain and weakness of dominant right shoulder information. The Examiners discuss the possible abnormalities based on the patient’s complaint and risk factors (chronic pain (illustration 3 and referred pain/table 9 & 10 with various possible abnormalities, anatomy and function of the rotator-cuff muscle, static and dynamic shoulder stability). The Candidate predicts pathology of rotator-cuff muscle problem (impingement syndrome, and partial/total ruptures of the rotator-cuff muscle).

 

Table 9: Referred Pain

Conditions	Clinical signs
1.      Cervical lesions	Pain is related with activities, tenderness on the neck, pain spread to the elbow
2.      Abnormalities at chest wall	Tenderness at rib during inspiration activity (deep inspiration)
3.      Cardiac abnormalities	Coroner risk factor, pain related with activities, dyspnea, perspiration, nausea, palpitation, pallor, fever, tachycardia, hypo/hypertension and etc.
4.      Lung lesions	Fever, decrease body weight, lethargy, coughing, hemoptysis
5.      Diaphragm irritation	Fever, abdomen pain, guarding or rebound, systematically unwell, toxic

 

Tabel 10: Systemic lesions

Conditions	Clinical signs
1.      Malignant tumor (Breast, lung, gaster and kidney cancer,  or myeloma	History of cancer, body weight loss and loss of appetite, lump, skin infiltration, x-ray radiographs positive of cancer
2.      Polymyalgia rheumatic	Morning stiffness, elevated temperature, lethargy and loss of appetite
3.      Brachial Neuritis	Pain combined with weakness and sensory problem, loss of physiological reflect especially young age, accompanied viral infection, self-limiting
4.      Herpes Zoster	Pain at the lesion site with  vesicles formation, comorbid and elderly
5.      Paget disease	Pain at other sites, kyphosis, and cranial nerves disturbances, bowing of tibia bone, elderly and x-rays changes appearance.
6.      Fibromyalgia	Pain under trapezius muscle, trigger points, guarded cervical ROM spine, difficult to sleep, fatigue, depression, and abnormal investigation result

 

Illustration 3: Chronic pain caused by trauma/non-trauma.

Firstly, the Examiner asks the Candidate “what’s your clinical diagnosis of the patient?”

 

Before answering the Examiner’s question, Candidate should formulate his/her summary of history taking, physical examination and investigation data in the case. The Candidate should focus on the important data while appropriately omitting the irrelevant information for a fundamental skill in clinical problem solving. The Candidate should be able to analyze the objectives of case and discusses of the relevant points to the specific patient.

 

The Examiner discusses about clinical diagnosis of the patient based on patient’s complaint, history, physical examination and special clinical test data. According to pain and weakness on the abduction of the right upper extremity, tenderness and crepitation around head of the humerus and muscle atrophy, the Candidate should be able to conclude the rotator cuff muscle problem or subscapularis and infraspinatus muscles weakness. It could be a syndrome impingement or the rotator cuff rupture possibilities (see table 11).  

 

Table 11. The possible clinical diagnosis caused by weakness of

rotator cuff muscle

Problem	Radiographic finding
1.      Impingement Syndrome	X-rays show are normal or outlet obstruction with spur formation
2.      Rotator cuff ruptures	Narrowing acromiohumeral space, superior migration of humeral head, and acetabularization and femoralizartion   to support rotator cuff tear arthropathy (RTA) clinical diagnosis. Characteristic of advanced statge RTA shows destruction of the joint and rupture on MRI investigation.

 

Note: Questions discussed by the Examiner depend on his/her experiences for getting the objective, valid and reliable marking.

 

The diagnosis is made by careful evaluation and analysis of the information data and assessment of the risk factors combined with the list possibilities. Candidate experience and knowledge are able to support accurate diagnosis and he/she also understands how to answer/respond the same question in several ways and use a different medical terminology accurately. Reaching a diagnosis could be achieved by a systemic knowledge reading about each possible cause and abnormality.

 

According to the scenario, the Candidate is able to explain the relation to the rotator cuff tear arthropathy (RTA) in elderly patient. There is a publication about MRI investigation to asymptomatic shoulder pain volunteers result in 34% rotator full-thickness ruptures and 54% for age > 60 years old.  Other publication by using ultrasound for 411 asymptomatic volunteers (50-59 years old) the result in 13% but > 80 years old was 51% rotator-cuff full thickness ruptures. Rotator cuff full-thickness ruptures never recovers spontaneously.

 

“What should be the next step?”

 

This Examiner question is open ended and the question is difficult because the next step has many possibilities. According this question, Candidate should be able to explain more information data, the stage of the illness or to introduce management. Candidate is also able to explain RTA process from impingement syndrome based on the scenario above.

 

 

Table 12: List of part A evaluation

Part A: The objectives examination evaluation of the history taking, physical examination and investigation data collection for other possibilities or accurate diagnosis determination	10 Com-plete presen-tation & correct statement	6 Incom-plete presenta-tion or Correct response to stimula-tion question	0 Inco-rrect response or no response	Marks
a.       Ability to gather information of the RTA history taking includes:  ·      Identity and patient’s complaint, history of the illness and risk factors,   ·      Past medical history or comorbidities (when, how and who makes the diagnosis), allergy, severity of the abnormalities, ·      The information of the family, social, culture and occupation history, and  pregnancy history (if relevant to the present illness), management and progress or organ function evaluation
b.      Ability to collect the physical examination of the RTA illness such as: ·         The data of the  general condition, ambulatory or gait evaluation(crutch/cane/wheel-chair using), and body mass index, ·         Local examination (look, feel, move and ·         Muscle power & neurovascular, the special  clinical test or maneuver evaluation and the investigations
a.     Investigation reasoning Interpret, analyzing key data for RTA diagnosis determination
TOTAL MARK  of Part A

 

 

 

MARKS OF PART A:

§  Mark 10: Candidate presents: (a) the history taking or (b) physical examination or (c) investigation and analyze key data for some possibilities or RTA diagnosis determination in discussion completely and correctly

§  Mark 6: Incomplete data presentation or the Candidate is able to respond the examiner’s stimulation question about a mistake or omission of the interesting (a) history taking or (b) physical examination and (c) investigation needed or a mistake analyzing data for some possibilities or RTA diagnosis determination in discussion correctly.

§  Mark 0: Candidate’s response is  not correct or he/she does not respond to the examiner’s stimulation question of (a) history taking, (b) physical examination, (c) investigation and analyzing of the key data for some possibilities or RTA diagnosis determination in discussion

§  Maximal marks of part A is 30

 

 

OTHER ALTERNATIVE EVALUATION LIST (table 13)

 

Part A. The objectives examination evaluation of the history taking, physical examination and investigation data collection for some possibilities or accurate diagnosis

Learning Objectives Evaluation in Examination

The Examiner should be able to assess

The Candidate ability to recognize the RTA abnormality

Discussion between the Examiner and the Candidate is how the Candidate make the most likely diagnosis of RTA based on the key data in the scenario (history taking, physical examination and investigation finding) to support diagnosis and how he/she integrates and of analyze all data  and last is problem issues of RTA patient. The Examiner questions are varying depends on the Examiner experience for achieving objective, valid and reliable marking.

 

 

Table 13: List of the evaluation marks of part A 

CONTENTS OF EVALUATION	Marks
Part A: The objectives examination evaluation of the history taking, physical examination and investigation data collection for some possibilities or accurate diagnosis determination	30 Complete & correct presentation	20 Incomplete presentation  or correct response of stimulation question	0 (incorrect or no response)	Marks
Ability to collect the key data of the history taking, physical examination and investigation data collection for some possibilities or RTA diagnosis determination in discussion

 

MARKS:

§  Marks 30: Candidate presents the history taking, physical examination and investigation and analyze key data for some possibilities or RTA diagnosis determination completely and correctly

§  Marks 20: Incomplete data presentation or the Candidate is able to respond the examiner’s stimulation question about a mistake or omission of the interesting history taking or physical examination, investigation needed and analyzing data for some possibilities or RTA diagnosis determination correctly.

§  Marks 0: Candidate’s response is  not correct or he/she does not respond to the examiner’s stimulation question of history taking, physical examination, investigation and analyzing of the key data for some possibilities or RTA diagnosis determination.

 

 

Part B: The objectives examination evaluation of the patient’s problem, management and complications  

 

Learning Objectives Evaluation in Examination

 

The Examiner evaluates the Candidate’s ability:

1.       To determine the problem of medical issues (acute and long-term) of the patient

2.       To plan the management and progress of the surgery treatment or conservative procedures (outcomes)

3.       To predict the complications.

 

The Candidate competency

 

1.       The Candidate ability to determine the problem of medical issues (acute and long-term) of the patient

 

Candidate should be able to inform chronic process of rotator-cuff rupture muscles may lead to retraction and adhesion that can cause fatty infiltration, atrophy and irreversible muscle damage. Fatty infiltration and atrophy are also result in decrease activity function of the shoulder and cartilage degeneration of glenohumeral joint. This syndrome involves anterior acromion, coracoacromial ligaments, and claviculo-acromial joint. There are three stages of the impingement syndrome including inflammation, fibrosis and rotator-cuff muscles ruptures especially posterior aspect of supraspinatus muscle and anterior aspect of the infraspinatus muscle. Candidate should be able to inform the acute and long-term problem of RTA and others investigation (MRI, CT-scan and others).

 

2.       The Candidate ability to plan the management and progress of the surgery treatment or conservative procedures (outcomes)

 

Examiner asks the Candidate “how do you manage this problem?” or “what management do you plan for this problem?” or “What is the best management according to evidence?”

 

The answer to these questions needs the correct diagnosis and the severity of the illness.  Based on the scenario above, the diagnosis is RTA. There are two principles of RTA management including conservative and surgery interventions. Therefore, Candidate should able to communicate his/her rational therapy. A common error by Candidate is to jump to surgical treatment directly. Candidate should be able to decide the priority of RTA management, specific patient’s needs, and patient complaint based on medical knowledge.

 

 

1.      Conservative Management

 

Candidate should be able to inform the goal of conservative management, which includes:

a.       Painkillers,

b.      Teach the patient about the disease, and

c.       Optimize and maintain physical function and prevent serious (progression) of harmful structural changes to cartilage, bones, ligaments and muscle of RTA patient.

 

Management decision depends on the attitude and professionalism of the Candidate that includes whether the patient is in a non-surgical group with minimal irrepressible changes process. This patient has a minor complaint and good function (rotator muscle is still intact). He has only a strain, tendinitis or bursitis, impingement or a small partial-thickness rupture. Management of this patient is a conservative strategy with NSAIDs, physical therapy, ice or warm management, or ultrasound or massage/manipulation intervention. But degeneration process, the expansion of rotator-cuff muscle rupture and fatty infiltration on RTA still develop. The conservative management outcome of RTA by pain relievers and recovering normal function of shoulder for daily activities, showed by 90^o elevation and 20^o external rotation of the upper extremity, also accompanied by more comfortable feeling of patient

 

2.      Surgery

 

Candidate should be able to discuss on group 2 if conservative management is unsuccessful. Candidate explains that the RTA surgery indication based on full-thickness rupture, acute rupture of any size or rupture with loss of the shoulder function. Therefore, early surgical intervention is an indication for surgery, but some publications reported that outcome early and late surgery are still a controversy or unclear.

Examiners discuss about group 3 that includes total chronic full-thickness ruptures and age of patient is >70 years old, irreversible glenohumeral joint changes, atrophy and fatty infiltration in rotator-cuff muscle. This patient is an indication for surgery intervention for example:

·         Rotator cuff repair,

·         Tendon transfers,

·         Humeral head replacement,

·         Glenohumeral arthrodesis, and

·         Arthroscopy procedures.

 

Candidate should be able to clarify the outcomes after management or inadequate therapy of symptomatic or asymptomatic RTA patient. The result of inadequate management includes disability, uncomfortable patient during sleeping, shoulder and upper-extremity muscles atrophy (pseudoparalysis) and unstable glenohumeral joint. Asymptomatic RTA patient will continue pathologic process based on age of the patient.

 

The Candidate is also able to inform the complication of the conservative and surgery intervention for RTA patient for instance pathologic fracture, re-rupture of the tendons, disturbances of healing process, and prosthesis loss. The Candidate should be able to explain promotion and prevention of RTA, including risk factors comorbidities, DM, COPP and rheumatoid arthritis.

 

3.      The Candidate ability to predict the complications

 

Examiner asks the Candidate:  “What complications are going to happen to the patient? What is the prognosis? or what complications are associated with this illness or condition and its treatment?”

 

The Candidate should be able to explain the complications of a disease and associated intervention, so that he/she will understand how to follow, monitor and prevent the patient from new problems.

 

Table 14: List of part B evaluation

PART B: The objectives examination evaluation of the patient’s problem, management and complications	20 complete & correct statement	15 Incomplete presentation or Correct response to stimulation question	0 Incorrect response or no response	Marks
a.       Candidate ability of determination of the problem (acute and long-term) RTA patient in discussion
b.       Candidate ability of the management planning of RTA patient and outcome in discussion
c.       Candidate ability to decide the complications of the RTA in discussion
TOTAL MARKS of  Part B

 

MARKS OF PART B:

§  Mark 20: Candidate presents: (a) the determination of acute and long-term problem or (b) management planning, or (c) complications prediction of the RTA diagnosis in discussion completely and correctly.

§  Mark 15: Incomplete data presentation or the Candidate is able to respond the examiner’s stimulation question about a mistake or omission of the interesting of (a) the acute and long-term problem determination or (b) management planning or (c) complications prediction of the RTA diagnosis in discussion correctly.

§  Mark 0: Candidate’s response is not correct or he/she does not respond to the examiner’s stimulation question of (a) the acute and long-term problem determination, or (b) management planning or (c) complications prediction of the RTA diagnosis during discussion.

§  Maximal marks of part B is 60

 

 

OTHER ALTERNATIVE EVALUATION LIST (table 15)

 

Part B. The objectives examination evaluation of the accurate diagnosis determination or possibilities of the abnormalities, patient’s problem, management and complications

Learning Objectives Evaluation in Examination

The Examiner should be able to assess

1.      The Candidate capability to decide the acute and long-term problem of RTA illness. The Candidate should be able to explain the problem of RTA illness patient. The Examiner questions are varying depends on the Examiner experience for achieving objective, valid and reliable marking.

2.      The Candidate ability to plan the management decision of RTA illness based on evidence (treatment algorithm)

The Candidate should be able to understand that the based on treatment depends on accurate diagnosis, treatment options according to evidence of medicine, patient need and facilities. The Examiner questions are varying depends on the Examiner experience for achieving objective, valid and reliable marking.

3.      The Candidate ability to predict the common complication of RTA illness, promotion and prevention issues

The Candidate should be able to explain complication of RTA illness, management complications, promotion and prevention of RTA illness patient. The Examiner stimulates a few questions for achieving objective, valid and reliable marking.

Table 15: List of the evaluation marks of part B

CONTENTS OF EVALUATION	Marks
Part B: The objectives examination evaluation of the patient’s problem, management and complications	60 Complete & correct presentation	45 Incomplete presentation  or correct response of stimulation question	0 (incorrect or no response)	Marks
Ability to determine acute and long-term problem, select the best option of the management  and to decide the complication of RTA illness in discussion

 

MARKS:

• Marks 60: Candidate presents the acute and long-term problem, the management and complications prediction planning of RTA illness completely and correctly
• Marks 45: Incomplete data presentation or the Candidate is able to respond the examiner’s stimulation question about a mistake or omission of the interesting of the acute and long-term problem, management planning and complications prediction determination of RTA illness correctly.
• Marks 0: Candidate’s response is not correct or he/she does not respond to the examiner’s stimulation question of the acute and long-term problem determination, management planning, and complications prediction of RTA illness.

 

 

Part C: The objectives examination evaluation of a good Candidate’s attitude and professionalism. 

 

Learning Objectives Evaluation in Examination

 

The Examiner should be able to assess:

 

o   The Candidate ability to take action good attitude in health care services to the RTA patient:

·         What is the Candidate’s focus on communication with RTA patient? Does the Candidate rarely interrupt patient’s story during history taking?

·         What is the Candidate’s plan for the beneficence (beneficial) management orientation and to avoid maleficence in RTA health care intervention on discussion section B?

·         What is the Candidate social justice in health care services for RTA patient? Candidate should ask several questions to patient that he/she may show prejudice and discrimination in health care management. What is Candidate’s perspective in consideration to health care disparities to the RTA patient?

·         How the candidate tries to improve communication and awareness regarding RTA health care disparities through cultural competency education that can lead to better racial and ethnic harmony in health care to RTA patient

 

o   The Candidate ability to take action good professionalism in health care to RTA patient

·         Does the Candidate enhance the quality of medical care delivered based on biopsychosocial-cultural knowledge for RTA patient in discussion section..

·         How does the Candidate make decision of which management is the best management based on EBM of RTA illness? What is the Candidate’s decision of management in health care? Does the Candidate explain the reasoning, the advantage and disadvantage to the patient clearly and knowledgeable enough?

 

Note: Questions discussed by the Examiner depend on his/her experienced for getting the objective, valid and reliable marks

 

Table 16: List of part C evaluation

 

PART C: The objectives examination evaluation of a good Candidate’s attitude and professionalism.  .	5 complete & correct statement	3 Incomplete presentation or Correct response to stimulation question	0 Incorrect response or no response	Marks
a.       Ability to show a good attitude in communication in RTA health care services
b.      Ability to show a good professionalism in discussion of RTA health care services
TOTAL MARKS of Part C

 

MARKS OF PART C:

•      Mark 5: Candidate ability to show a good attitude (a) and basic medical and clinical knowledge to decide management based on evidence or (b) professionalism in health care services of the RTA illness in discussion

•      Mark 3: Impolite attitude in discussion between Candidate and patient/Examiners but the Candidate is a good attitude (a) basic medical and clinical knowledge and management decision based on evidence in health care services of the RTA illness or (b) professionalism in discussion.  

•      Mark 0: Impolite attitude and Candidate is also a bad attitude (a) basic medical and clinical knowledge without evidence management decision in health care services of the RTA illness  or bad professionalism (b) in discussion  

•      Maximal marks of part C is 10

 

 

OTHER ALTERNATIVE EVALUATION LIST (Table 17)

 

Part C: The objectives examination evaluation of a good Candidate’s attitude and professionalism. 

 

Learning Objectives Evaluation in Examination

 

The Candidate must have good attitude and professionalism in solution of RTA illness problem. The Examiner should be able to evaluate the Candidate attitude & professionalism based the response in the discussion above. If the Candidate responses are doubtfulness, the Examiner stimulates a few questions for achieving objective, valid and reliable marking.

Table 17: List of the evaluation marks of part C

CONTENTS OF EVALUATION	Marks
Part C: The objectives examination evaluation of a good Candidate’s attitude and professionalism.	10 Complete & correct presentation	6 Incomplete presentation  or correct response of stimulation question	0 (incorrect or no response)	Marks
Ability to show a good attitude and professionalism in discussion

 

MARKS:

•      Marks 10: Candidate ability to show a good attitude and basic medical and clinical knowledge to decide management based on evidence (professionalism) in health care services of RTA illness

•      Marks 6: Impolite attitude in discussion between Candidate and patient/Examiners but the Candidate is a good basic medical and clinical knowledge and management decision based on evidence in health care services of RTA illness.  

·         Marks 0: Impolite attitude and Candidate is also a bad basic medical and clinical knowledge without evidence management decision in health care services of RTA illness 

 

CONCLUSION:  Total marks = Part A + Part B + Part C.

·         Marks 85-90 is superior ·         Marks 79-84 is excellent ·         Marks 69-78 is pass; and ·         Marks 60-68 is fail

·         Marks 85-90 is superior ·         Marks 76-86 is excellent ·         Marks 65-75 is pass; and ·         Marks ≤ 65 is fail

 

KEPUSTAKAAN:

 

1.      Armis (2005). Musculoskeletal Competency: Guidelines for Medical Students, PCPs (Primary Care Physician) and Residents in Training. Unit Pelayanan Kampus. FK UGM. Jogjakarta.

2.      Matsen III FA (2008). Rotator-Cuff Failure. N Engl J Med. www.NEJM. May 15 2008, Jan. 1015

3.      Nho SJ, Brown BS, Lyman S, et al (2009). Prospective analysis of arthroscopic rotator cuff repair: Prognostic factors affecting clinical and ultrasound outcome. J Should-Elbow S 18: 13-20.Curr Orthop Practice 23: 10-13

4.      Oh LS, Wolf BR, Hall MP et al (2007). Indication for Rotator Cuff Repair. Clin Othop Rel Reseach 455: 52-63.

5.       Pitt D, Rowley DI, and Sher JL (2005). Assessment of performance in orthropaedic training. JBJS B 87: 1187-1191.

6.      Robinson PM, Wilson J, Dalal S, et al (2013). Upper Limb. Rotator cuff repair in patient over 70 years of age. JBJS-B 2: 199-205

7.      Toy EC, Rosenbaum AJ, Robert, TT and Dines JS (2013). Case Files: Orthopaedic Surgery. McGraw Hill Education. New York.

8.      Vassalo K (2008). Shoulder pain in general practice. Mala Med J 20: 28-36.

9.      Verma NN, Bhatia S Baker III CL, et al (2010). Outcome of Arthroscopy Rotator Cuff Repair in Patient Aged 70 Years or Older. J Arthr Real Surg. 26: 1273-1280.

Wright JB- editor (2009). EVIDENCE-BASED ORTHOPAEDICS: THE BEST ANSWERS TO CLINICAL QUESTIONS. Sauder-elsevier, Phildelphia.