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Daniel Penello Upper Extremity Rounds 22 Feb 2006

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Presentation on theme: "Daniel Penello Upper Extremity Rounds 22 Feb 2006"— Presentation transcript:

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

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

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

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