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

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Presentation on theme: "Rotator Cuff Tears Daniel Penello Upper Extremity Rounds 22 Feb 2006."— Presentation transcript:

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

2 Anatomy Long Head of Biceps Subscapularis

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5 Function Fine-tuning muscles Fine-tuning muscles Keep the humeral head centered on the glenoid regardless of the arms position in space. Keep the humeral head centered on the glenoid regardless of the arms position in space. Generally work to depress the humeral head while powerful deltoid contracts Generally work to depress the humeral head while powerful deltoid contracts

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

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

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

10 Incidence Lehman - Bull Hosp Jt Dis 1995 Lehman - Bull Hosp Jt Dis 1995 –235 cadavers –overall incidence full thickness tears 17% < 60 yo = 6% < 60 yo = 6% > 60 yo = 30% > 60 yo = 30% Yamanaka & Fukuda 1983 Yamanaka & Fukuda 1983 –partial thickness tears 13% incidence –commonly intratendinous < 40 yo = 0% < 40 yo = 0% > 40 yo = 30% > 40 yo = 30%

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

12 Classification Partial Bursal vs Articular < 50% thickness < 50% thickness > 50% thickness > 50% thicknessComplete Organize by size 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. As larger muscles fatigue, the posterior capsule and rotator cuff play a larger role in decelerating the arm. Leads to tensile overload and fatigue Leads to tensile overload and fatigue

15 Pitching As rotator cuff fatigues, it no longer performs its role in keeping the humeral head centered. As rotator cuff fatigues, it no longer performs its role in keeping the humeral head centered. This leads to superior migration of the humeral head and impingement. This leads to superior migration of the humeral head and impingement. This leads to pain and muscle inhibition…. This leads to pain and muscle inhibition…. ……and the cycles repeats itself ……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. As a result of microtrauma and inflammation. Capsule tightens and can no longer accommodate humeral head as it rotates. Capsule tightens and can no longer accommodate humeral head as it rotates. Leads to obligatory anterior-superior migration of humeral head. Leads to obligatory anterior-superior migration of humeral head. Reduces subacromial space Reduces subacromial space

18 History Pain on the lateral aspect of the shoulder Pain on the lateral aspect of the shoulder –may radiate to deltoid insertion –anterior acromion with impingement +/- biceps tendonitis +/- biceps tendonitis Stiffness, esp IR Stiffness, esp IR Cannot lie on that side Cannot lie on that side Weakness, instability, crepitus Weakness, instability, crepitus Partial tears more sore and stiffer Partial tears more sore and stiffer Acute tear may have inciting event Acute tear may have inciting event

19 Physical Exam Inspection: atrophy, symmetry Inspection: atrophy, symmetry Palpation: AC, cuff tenderness Palpation: AC, cuff tenderness Range of motion: active, passive Range of motion: active, passive Strength: ER and elevation power, lag Strength: ER and elevation power, lag Provocative: impingement sign, arc of pain Provocative: impingement sign, arc of pain

20 Physical Exam Impingement testing Impingement testing NEER SIGN Shoulder internally rotated, examiner forward flexes the patients arm, pushing the supraspinatus against the anteroinferior acromion, with increased shoulder pain signifying rotator cuff inflammation or tear Shoulder internally rotated, examiner forward flexes the patients arm, pushing the supraspinatus against the anteroinferior acromion, with increased shoulder pain signifying rotator cuff inflammation or tear

21 Physical Exam Impingement testing Impingement testing Hawkin's test With patients arm abducted to 90°, then shoulder internally rotated, pushing the supraspinatus against the anteroinferior acromion, with increased shoulder pain With patients arm abducted to 90°, then shoulder internally rotated, pushing the supraspinatus against the anteroinferior acromion, with increased shoulder pain

22 Physical Exam SUBSCAPLULARIS SUBSCAPLULARIS Gerber's lift off test: push examiner's hand away from 'hand behind back position' 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 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 Napoleon test: if pt cannot fully internally rotate, pt. pushes on their belly, elbow will drop backwards if +ve

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

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

25 Physical Exam TERES MINOR 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 Long head of biceps testing –Speeds test FF 90, elbow 0, supinated forearm FF 90, elbow 0, supinated forearm resisted downward force resisted downward force biceps or SLAP biceps or SLAP –Yergasons test With patients arm at side with elbow flexed 90° and forearm pronated, examiner resists supination of the forearm --> pain or tendon subluxation out of groove With patients 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 Deltoid –resisted abduction at 90 Serratus anterior Serratus anterior –winging

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

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

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32 Imaging Plain radiographs Plain radiographs –Axillary subluxation, os acromiale (association with rotator cuff tears - beware excision with acromioplasty) subluxation, os acromiale (association with rotator cuff tears - beware excision with acromioplasty) –Supraspinatus outlet 10 to 15 degree caudal tilt of transcapular lateral 10 to 15 degree caudal tilt of transcapular lateral can see acromial spurs well can see acromial spurs well –AC joint 10 to 30 degree cephalad tilt of AP 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 Teefey JBJS-A Ultrasonography of the Rotator Cuff. A Comparison of Ultrasonographic and Arthroscopic Findings in One Hundred Consecutive Cases CONCLUSIONS: CONCLUSIONS: Highly accurate for full thickness tears Poor accuracy for partial thickness tears

34 Full thickness Partial thickness

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

36 MRI vs Ultrasound Detection and quantification of rotator cuff tears. Teefey et al. JBJS 2004 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 46 full thickness tears 19 partial thickness tears 19 partial thickness tears 6 had no tear 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 Static study More expensive More expensive Longer wait-list Longer wait-list Can assess intra- articular pathology, such a labral tears. Can assess intra- articular pathology, such a labral tears. Easier to read Easier to read

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39 Differential Diagnosis Rotator Cuff Tendinitis Rotator Cuff Tendinitis Partial Thickness Rotator Cuff Tear Partial Thickness Rotator Cuff Tear Calcific Tendinitis Calcific Tendinitis Acromioclavicular Joint Pain Acromioclavicular Joint Pain Adhesive Capsulitis Adhesive Capsulitis Glenohumeral Joint Arthritis Glenohumeral Joint Arthritis Thoracic outlet syndrome Thoracic outlet syndrome Suprascapular Nerve Entrapment or brachial neuritis (rarely) Suprascapular Nerve Entrapment or brachial neuritis (rarely)

40 Natural History Yamanaka & Matsumoto - CORR 1994 Yamanaka & Matsumoto - CORR 1994 –40 pts with partial thickness tears –avg age 61, conservative Rx 1 year 21 pts tear increased in size 21 pts tear increased in size 11 pts full thickness 11 pts full thickness OVERALL SHOULDER SCORES BETTER OVERALL SHOULDER SCORES BETTER

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

42 Non-Operative Treatment 33-90% successful (Campbells) 33-90% successful (Campbells) Candidates: Candidates: –Partial thickness tears –Older patients with chronic large tears and extensive cuff muscle atrophy NSAIDs NSAIDs Symptom control ± inflammation Symptom control ± inflammation

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

44 Non-Operative Treatment Therapy Regain full, pain-free ROM Regain full, pain-free ROM Strengthen all rotator cuff muscles Strengthen all rotator cuff muscles - Isometrics first - Isometrics first - Isotonics with theraband - Isotonics with theraband Strengthen shoulder girdle muscles Strengthen shoulder girdle muscles Improve biomechanics and proprioception Improve biomechanics and proprioception

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

46 Cortisone vs Lidocaine At ~30 week F/U 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 Pain

47 Indications for Surgery Failed conservative management Failed conservative management –3 to 12 month course of NSAIDs, physio, corticosteroid injections, activity modification Significant or progressive weakness, esp. acute 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) 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 Asymptomatic tear Chronic massive irreparable tears Chronic massive irreparable tears –Tendon retraction past glenoid rim –Fatty degeneration of muscle –Increased width of subtrapezial fat pad Frozen shoulder Frozen shoulder –Need ROM pre-op Unwilling or unable to participate in post-op physio Unwilling or unable to participate in post-op physio

49 Surgical Principles Neer JBJS-A 1972 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

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

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

53 Partial thickness tears No RCTs No RCTs –Usually on the articular surface of the supraspinatus insertion –Subacromial decompression ± arthroscopic debridement Alone if <50% of cuff thickness, <1cm Alone if <50% of cuff thickness, <1cm –Repair if >50% of cuff thickness (Gartsman) (Gartsman)

54 Results of Surgery Open vs arthroscopically-assisted Open vs arthroscopically-assisted –Baker & Liu 1995 similar 3 yrs similar 3 yrs <3cm tears <3cm tears –earlier return to full fn – hospital stay –return to previous activities 1 month sooner >3cm tears >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 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. Open Group had significantly better visual analogue scores for Pain and Function. No Difference with respect to…. 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. Only studied those with complete tears involving only supraspinatus and with a type 2 acromion. American Shoulder and Elbow Surgeons Shoulder score American Shoulder and Elbow Surgeons Shoulder score F/U 1 year F/U 1 year No Difference No Difference

60 Arthroscopic Repair Advantages Advantages –deltoid preservation –diagnose and treat glenohumeral pathology Gartsman JBJS-A 1998 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 Short-Term Advantages –decreased immediate postoperative pain, shorter hospital stay, earlier rehabilitation –decreased postoperative stiffness adhesive capsulitis with mini-open? adhesive capsulitis with mini-open?

62 Arthroscopic Repair Disadvantages Disadvantages –concerns about fixation with suture anchors? Ogilvie-Harris Am J Sports Med 1996 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 JBJS (Am), Ma et al. Feb 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

64 Results of Surgery Open repairs 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 steroids, smoking, previous failed surgery –lasting integrity of repair better with smaller tears

65 Results of Surgery

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68 Arthroscpically-assisted repairs Arthroscpically-assisted repairs –arthroscopic acromioplasty ± distal clavicle excision if AC arthrosis –deltoid-split mini-open repair of cuff Levy 1990 Levy 1990 –<3cm tear = 100% satisfaction –>3cm tear = 67% satisfaction


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