Rotator Cuff Tears Daniel Penello


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Rotator Cuff Tears

  • Daniel Penello

  • Upper Extremity Rounds

  • 22 Feb 2006


Anatomy







Function

  • “Fine-tuning” muscles

  • Keep the humeral head centered on the glenoid regardless of the arm’s position in space.

  • Generally work to depress the humeral head while powerful deltoid contracts





Pathophysiology

  • Intrinsic Factors

    • Vascular supply (? significance)
      • Distal 1cm of supraspinatus tendon (early studies)
      • Hypervascularity with tendonitis
    • Degenerative changes
      • Age related
      • Change in proteoglycan and collagen content in symptomatic tendons


Pathophysiology

  • Extrinsic factors

    • Impingement
      • Acromial spurs
        • Type III acromion and decreased geometric area of the supraspinatus outlet
          • Increased prevalance of symptomatic cuff disease
      • Coracoacromial ligament
      • AC joint osteophytes
      • Coracoid process
      • Posterior superior glenoid


Pathophysiology

  • Extrinsic factors

    • Repetitive use
      • Tensile overload
      • Muscle fatigue
      • Microtrauma
    • Glenohumeral instability


Incidence

  • Lehman - Bull Hosp Jt Dis 1995

    • 235 cadavers
    • overall incidence full thickness tears 17%
      • < 60 yo = 6%
      • > 60 yo = 30%
  • Yamanaka & Fukuda 1983

    • partial thickness tears 13% incidence
    • commonly intratendinous
      • < 40 yo = 0%
      • > 40 yo = 30%


Incidence

  • Sher et al. JBJS-A 1995

    • MRI asymptomatic volunteers
      • Normal, painless function
      • 19 to 39
      • 40 to 60
        • 4% full thickness
        • 24% partial thickness
      • Over 60 years old --> 54% incidence
        • 28% full thickness
        • 26% partial thickness


Classification

  • Partial Bursal vs Articular

  • < 50% thickness

  • > 50% thickness

  • Complete

  • Organize by size

  • Number of muscles involved



Mechanism

  • Traumatic vs Chronic/Insiduous



Pitching

  • As larger muscles fatigue, the posterior capsule and rotator cuff play a larger role in decelerating the arm.

  • Leads to tensile overload and fatigue



Pitching

  • As rotator cuff fatigues, it no longer performs it’s role in keeping the humeral head centered.

  • This leads to superior migration of the humeral head and impingement.

  • This leads to pain and muscle inhibition….

  • ……and the cycles repeats itself





Posterior Capsular Tightness

  • As a result of microtrauma and inflammation.

  • Capsule tightens and can no longer accommodate humeral head as it rotates.

  • Leads to obligatory anterior-superior migration of humeral head.

  • Reduces subacromial space



History

  • Pain on the lateral aspect of the shoulder

    • may radiate to deltoid insertion
    • anterior acromion with impingement
      • +/- biceps tendonitis
  • Stiffness, esp IR

  • Cannot lie on that side

  • Weakness, instability, crepitus

  • Partial tears more sore and stiffer

  • Acute tear may have inciting event



Physical Exam

  • Inspection: atrophy, symmetry

  • Palpation: AC, cuff tenderness

  • Range of motion: active, passive

  • Strength: ER and elevation power, lag

  • Provocative: impingement sign, arc of pain



Physical Exam

  • Impingement testing

    • NEER SIGN
      • Shoulder internally rotated, examiner forward flexes the patient’s arm, pushing the supraspinatus against the anteroinferior acromion, with increased shoulder pain signifying rotator cuff inflammation or tear


Physical Exam

  • Impingement testing

    • Hawkin's test
      • With patient’s arm abducted to 90°, then shoulder internally rotated, pushing the supraspinatus against the anteroinferior acromion, with increased shoulder pain


Physical Exam

  • SUBSCAPLULARIS

      • Gerber's lift off test: push examiner's hand away from 'hand behind back position'
      • Internal rotation lag sign: inability to hold hand away from back
      • Napoleon test: if pt cannot fully internally rotate, pt. pushes on their belly, elbow will drop backwards if +ve


Physical Exam

      • SUPRASPINATUS
      • Jobe's Test:
      • arm abducted in the plane of the
      • scapula, thumb pointing down .
      • Resist elevation of the arm.


Physical Exam

  • INFRASPINATUS

      • Resisted ER with arm by side activates both infra and Teres minor equally, therefore not specific.
      • Place arm by side, flex elbow 90 degrees, ER 45 degrees and resist internal rotation of arm.
      • Mostly infraspinatus


Physical Exam

  • TERES MINOR

  • Hornblower's sign:

  • 90º shoulder abduction, elbow 90º, resisted ER (teres minor)



The Taking-the-oath Position



Physical Exam

  • Long head of biceps testing

    • Speed’s test
      • FF 90, elbow 0, supinated forearm
      • resisted downward force
      • biceps or SLAP
    • Yergason’s test
      • With patient’s arm at side with elbow flexed 90° and forearm pronated, examiner resists supination of the forearm --> pain or tendon subluxation out of groove


Physical Exam

  • Deltoid

    • resisted abduction at 90
  • Serratus anterior

    • winging


Physical Exam

  • AC joint testing

    • Horizontal adduction
      • forced cross body adduction in 90ºflexion, pain at the extreme of motion indicative of ACJ pathology


Imaging

  • Plain radiographs

    • AP
      • glenohumeral arthritis, calcific tendonitis, migration of humeral head superiorly, greater tuberosity changes (cysts or sclerosis indicating chronic tear)
    • Transcapular lat




Imaging

  • Plain radiographs

    • Axillary
      • subluxation, os acromiale (association with rotator cuff tears - beware excision with acromioplasty)
    • Supraspinatus outlet
    • AC joint
      • 10 to 30 degree cephalad tilt of AP


Ultrasound

  • Teefey JBJS-A 2000 - Ultrasonography of the Rotator Cuff. A Comparison of Ultrasonographic and Arthroscopic Findings in One Hundred Consecutive Cases

  • CONCLUSIONS:

  • Highly accurate for full thickness tears

  • Poor accuracy for partial thickness tears





Ultrasound

  • Technician dependent

  • Can be a dynamic study

  • Easier to obtain

  • Hard to read



MRI vs Ultrasound

  • Detection and quantification of rotator cuff tears. Teefey et al. JBJS 2004

    • 71 patients with shoulder pain had imaging with U/S and MRI then underwent arthroscopy
      • 46 full thickness tears
      • 19 partial thickness tears
      • 6 had no tear
    • U/S and MRI had comparable accuracy for identifying and measuring size of partial and full thickness tears
    • MRI slightly more sensitive


MRI

  • Static study

  • More expensive

  • Longer wait-list

  • Can assess intra-articular pathology, such a labral tears.

  • Easier to read





Differential Diagnosis

  • Rotator Cuff Tendinitis

  • Partial Thickness Rotator Cuff Tear

  • Calcific Tendinitis

  • Acromioclavicular Joint Pain

  • Adhesive Capsulitis

  • Glenohumeral Joint Arthritis

  • Thoracic outlet syndrome

  • Suprascapular Nerve Entrapment or brachial neuritis (rarely)



Natural History

  • Yamanaka & Matsumoto - CORR 1994

    • 40 pts with partial thickness tears
    • avg age 61, conservative Rx
    • @ 1 year
      • 21 pts tear increased in size
      • 11 pts full thickness
      • OVERALL SHOULDER SCORES BETTER


Treatment

  • Mainstay is conservative

  • Surgery reserved for significantly symptomatic patients who have failed conservative management > 6 -12 months

  • Younger patient (<60) with acute tear

    • Cuff repair within 6 weeks


Non-Operative Treatment

  • 33-90% successful (Campbell’s)

  • Candidates:

    • Partial thickness tears
    • Older patients with chronic large tears and extensive cuff muscle atrophy
  • NSAIDs

      • Symptom control ± ↓ inflammation


Non-Operative Treatment

  • Therapy

  • - Stretch posterior capsule with Sleeper Stretch



Non-Operative Treatment

  • Therapy

  • Regain full, pain-free ROM

  • Strengthen all rotator cuff muscles

  • - Isometrics first

  • - Isotonics with theraband

  • Strengthen shoulder girdle muscles

  • Improve biomechanics and proprioception



Subacromial Cortisone Injection vs Lidocaine

  • Corticosteroid injections

    • Blair & Zuckerman JBJS-A 1996
    • Subacromial impingement  RCT
    • Subacromial corticosteroid vs lidocaine


Cortisone vs Lidocaine

  • At ~30 week F/U

    • Significant differences in pain, negative impingement sign, active forward elevation & external rotation
    • Insignificant differences in internal rotation, performance of activities of daily living


Indications for Surgery

  • Failed conservative management

    • 3 to 12 month course of NSAIDs, physio, corticosteroid injections, activity modification
  • Significant or progressive weakness, esp. acute

    • Early repair if <50 y.o. and full-thickness tear
  • Differential diagnosis confirms weakness is from rotator cuff tear (i.e. MRI findings correlate with exam, rule out other causes)



Contraindications to Surgery

  • Asymptomatic tear

  • Chronic “massive” irreparable tears

  • Frozen shoulder

    • Need ROM pre-op
  • Unwilling or unable to participate in post-op physio



Surgical Principles

  • Neer JBJS-A 1972

    • Repair Deltoid to Bone
    • adequate subacromial decompression
    • mobilization of muscle-tendon units
    • secure fixation of tendon to GT
    • closely supervised rehab




Surgical Options

  • Open repair

  • Arthroscopic-assisted Mini-open

  • Complete Arthroscopic

  • +/- subacromial decompression



Surgical complications



Partial thickness tears

  • No RCT’s

    • Usually on the articular surface of the supraspinatus insertion
    • Subacromial decompression ± arthroscopic debridement
      • Alone if <50% of cuff thickness, <1cm
    • Repair if >50% of cuff thickness
    • (Gartsman)


Results of Surgery

  • Open vs arthroscopically-assisted

    • Baker & Liu 1995
      • similar results @ 3 yrs
      • <3cm tears
        • earlier return to full fn
        • ↓ hospital stay
        • return to previous activities 1 month sooner
      • >3cm tears


Results of Surgery

  • Arthrosopic vs mini-open rotator cuff repair

  • Youm T, Zuckerman et al.

  • J. Shoulder Elbow Surg 2005

  • (small, medium and large)

  • 2 yr F/U. Used ASES and UCLA scores

  • No difference. 3 from each group required revision surgery. Satisfaction 98%



Results of Surgery

  • Arthroscocpic vs. Mini-open cuff repair

  • Sauerbrey et al. Arthroscopy 2005

  • Retrospective comparative study

  • Both groups similar.

  • 18+ month F/U. Used ASES score.

  • No Difference between groups.



Results of Surgery

  • Arthroscopic vs open Acromioplasty: A prospective, randomized, blinded study. Spanghel et al. J Shoulder Elbow Surg. 2002. Vancouver

    • 62 patients randomized
    • F/U minimum 12 months (25 month avg)
    • Primary outcome was visual analog scales for pain and function


Results of Surgery

  • Open Group had significantly better visual analogue scores for Pain and Function.

  • No Difference with respect to….

  • UCLA shoulder scores

  • Patient satisfaction

  • Strength

  • Feeling of Improvement



Subacromial Decompression?

  • Gartsman GM J Shoulder Elbow Surg 2004

  • RCT: Repair and SAD vs No SAD

  • Only studied those with complete tears involving only supraspinatus and with a type 2 acromion.

  • American Shoulder and Elbow Surgeons Shoulder score

  • F/U 1 year

  • No Difference



Arthroscopic Repair

  • Advantages

    • deltoid preservation
    • diagnose and treat glenohumeral pathology
      • Gartsman JBJS-A 1998
        • pre-op UCLA scores 10.9 with, 23.7 without intrarticular lesions
        • post-op 29.9, 31.2
    • mobilization and release of the cuff


Arthroscopic Repair

  • Short-Term Advantages

    • decreased immediate postoperative pain, shorter hospital stay, earlier rehabilitation
    • decreased postoperative stiffness
      • adhesive capsulitis with mini-open?


Arthroscopic Repair

  • Disadvantages

    • concerns about fixation with suture anchors?
      • Ogilvie-Harris Am J Sports Med 1996
        • suture anchor pullout > transosseous
    • difficult to use tendon-grasping suture
    • more difficult


Arthroscopic Stitch Type

  • JBJS (Am), Ma et al. Feb. 2006

  • Biomechanical study of repair strength of single row vs double row fixation for arthroscopic rotator cuff repair.

  • Double-row repair 287 N

  • Massive Cuff 250 N

  • Mason-Allen 212 N

  • Simple Stitch 191 N



Results of Surgery

  • Open repairs

    • better results with smaller tears, and better pre-op ROM
    • older tears with more pre-op weakness less likely to do well
      • steroids, smoking, previous failed surgery
    • lasting integrity of repair better with smaller tears


Results of Surgery



Results of Surgery



Results of Surgery



Results of Surgery

  • Arthroscpically-assisted repairs

    • arthroscopic acromioplasty ± distal clavicle excision if AC arthrosis
    • deltoid-split mini-open repair of cuff
  • Levy 1990

    • <3cm tear = 100% satisfaction
    • >3cm tear = 67% satisfaction



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