1. Daniel Penello Upper Extremity Rounds 22 Feb 2006
Rotator Cuff Tears
Daniel Penello
Upper Extremity Rounds
22 Feb 2006

2. Anatomy
Subscapularis
Long Head of Biceps

5. 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

7. 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

8. 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

9. Pathophysiology Extrinsic factors Repetitive use
Tensile overload
Muscle fatigue
Microtrauma
Glenohumeral instability
Accentuates abnormal loading
Can lead to internal impingement

10. Incidence Lehman - Bull Hosp Jt Dis 1995 Yamanaka & Fukuda 1983
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%

11. Incidence Sher et al. JBJS-A 1995 MRI asymptomatic volunteers
Normal, painless function
19 to 39
0% full thickness
4% partial (1 of 96)
40 to 60
4% full thickness
24% partial thickness
Over 60 years old --> 54% incidence
28% full thickness
26% partial thickness

12. Classification Partial Bursal vs Articular < 50% thickness
Complete
Organize by size
Number of muscles involved

13. Mechanism
Traumatic vs Chronic/Insiduous

14. 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

15. 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

16. Pain and/or fatigue of cuff
Rotator Cuff dysfunction
Impingement with motion

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

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

24. 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

25. Physical Exam
TERES MINOR
Hornblower's sign:
90º shoulder abduction, elbow 90º, resisted ER (teres minor)

26. The Taking-the-oath Position

27. Physical Exam Long head of biceps testing Speed’s test Yergason’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

28. Physical Exam Deltoid Serratus anterior resisted abduction at 90
winging

29. Physical Exam AC joint testing Horizontal adduction
forced cross body adduction in 90ºflexion, pain at the extreme of motion indicative of ACJ pathology

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

32. Imaging Plain radiographs Axillary Supraspinatus outlet AC joint
subluxation, os acromiale (association with rotator cuff tears - beware excision with acromioplasty)
Supraspinatus outlet
10 to 15 degree caudal tilt of transcapular lateral
can see acromial spurs well
AC joint
10 to 30 degree cephalad tilt of AP

33. Ultrasound
Teefey JBJS-A 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

34. Full thickness
Partial thickness

35. Ultrasound Technician dependent Can be a dynamic study
Easier to obtain
Hard to read

36. 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

37. MRI Static study More expensive Longer wait-list
Can assess intra-articular pathology, such a labral tears.
Easier to read

39. 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)

40. 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

41. Treatment Mainstay is conservative
Surgery reserved for significantly symptomatic patients who have failed conservative management > months
Younger patient (<60) with acute tear
Cuff repair within 6 weeks

42. 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

43. Non-Operative Treatment
Therapy
- Stretch posterior capsule with Sleeper Stretch
WRONG

44. 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

45. Subacromial Cortisone Injection vs Lidocaine
Corticosteroid injections
Blair & Zuckerman JBJS-A 1996
Subacromial impingement  RCT
Subacromial corticosteroid vs lidocaine

46. Cortisone vs Lidocaine
Pain
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

47. 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)

48. Contraindications to Surgery
Asymptomatic tear
Chronic “massive” irreparable tears
Tendon retraction past glenoid rim
Fatty degeneration of muscle
Increased width of subtrapezial fat pad
Frozen shoulder
Need ROM pre-op
Unwilling or unable to participate in post-op physio

49. 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

51. Surgical Options Open repair Arthroscopic-assisted Mini-open
Complete Arthroscopic
+/- subacromial decompression

52. Surgical complications
Postoperative shoulder stiffness
Infection
Deltoid injury
Repair failure
Neurovascular injury

53. 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)

54. Results of Surgery Open vs arthroscopically-assisted Baker & Liu 1995
similar 3 yrs
<3cm tears
earlier return to full fn
↓ hospital stay
return to previous activities 1 month sooner
>3cm tears
arthroscopic = 50% satisfaction
open = 80% satisfaction

55. 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%

56. 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.

57. Results of Surgery
Arthroscopic vs open Acromioplasty: A prospective, randomized, blinded study. Spanghel et al. J Shoulder Elbow Surg Vancouver
62 patients randomized
F/U minimum 12 months (25 month avg)
Primary outcome was visual analog scales for pain and function

58. 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

59. 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

60. 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

61. Arthroscopic Repair Short-Term Advantages
decreased immediate postoperative pain, shorter hospital stay, earlier rehabilitation
decreased postoperative stiffness
adhesive capsulitis with mini-open?

62. 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

63. 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 N
Massive Cuff N
Mason-Allen N
Simple Stitch N

64. 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

65. Results of Surgery

66. Results of Surgery

67. Results of Surgery

68. Results of Surgery Arthroscpically-assisted repairs Levy 1990
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