Rotator Cuff Tears Daniel Penello Upper Extremity Rounds 22 Feb 2006

Rotator Cuff Rotator Cuff TearsTears

Daniel PenelloDaniel Penello

Upper Extremity RoundsUpper Extremity Rounds

22 Feb 200622 Feb 2006

AnatomyAnatomy

Long Head of Biceps

Subscapularis

FunctionFunction

““Fine-tuning” musclesFine-tuning” muscles

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

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

PathophysiologyPathophysiology

Intrinsic FactorsIntrinsic Factors– Vascular supply (? significance)Vascular supply (? significance)

Distal 1cm of supraspinatus tendon Distal 1cm of supraspinatus tendon (early studies)(early studies)

Hypervascularity with tendonitisHypervascularity with tendonitis

– Degenerative changesDegenerative changes Age relatedAge related Change in proteoglycan and collagen Change in proteoglycan and collagen

content in symptomatic tendonscontent in symptomatic tendons

PathophysiologyPathophysiology Extrinsic factorsExtrinsic factors

– ImpingementImpingement Acromial spursAcromial spurs

– Type III acromion and Type III acromion and decreased geometric decreased geometric area of the area of the supraspinatus outletsupraspinatus outlet

Increased Increased prevalance of prevalance of symptomatic cuff symptomatic cuff diseasedisease

Coracoacromial ligamentCoracoacromial ligament AC joint osteophytesAC joint osteophytes Coracoid processCoracoid process Posterior superior Posterior superior

glenoidglenoid

PathophysiologyPathophysiology

Extrinsic factorsExtrinsic factors– Repetitive useRepetitive use

Tensile overloadTensile overload Muscle fatigueMuscle fatigue MicrotraumaMicrotrauma

– Glenohumeral instabilityGlenohumeral instability Accentuates abnormal loadingAccentuates abnormal loading Can lead to internal impingementCan lead to internal impingement

IncidenceIncidence

Lehman - Bull Hosp Jt Dis 1995Lehman - Bull Hosp Jt Dis 1995– 235 cadavers235 cadavers– overall incidence full thickness tears 17%overall incidence full thickness tears 17%

< 60 yo = 6%< 60 yo = 6% > 60 yo = 30%> 60 yo = 30%

Yamanaka & Fukuda 1983Yamanaka & Fukuda 1983– partial thickness tears 13% incidencepartial thickness tears 13% incidence– commonly intratendinouscommonly intratendinous

< 40 yo = 0%< 40 yo = 0% > 40 yo = 30%> 40 yo = 30%

IncidenceIncidence Sher et al. JBJS-A 1995Sher et al. JBJS-A 1995

– MRI asymptomatic volunteersMRI asymptomatic volunteers Normal, painless functionNormal, painless function 19 to 3919 to 39

– 0% full thickness0% full thickness– 4% partial (1 of 96)4% partial (1 of 96)

40 to 6040 to 60– 4% full thickness4% full thickness– 24% partial thickness24% partial thickness

Over 60 years old --> 54% incidenceOver 60 years old --> 54% incidence– 28% full thickness28% full thickness– 26% partial thickness26% partial thickness

ClassificationClassification

PartialPartial Bursal vs Articular Bursal vs Articular

< 50% thickness< 50% thickness

> 50% thickness > 50% thickness

CompleteComplete

Organize by sizeOrganize by size

Number of muscles involvedNumber of muscles involved

MechanismMechanism

Traumatic vs Traumatic vs Chronic/InsiduousChronic/Insiduous

PitchingPitching

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

Leads to tensile Leads to tensile overload and overload and fatiguefatigue

PitchingPitching

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

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

This leads to pain and muscle This leads to pain and muscle inhibition….inhibition….

…………and the cycles repeats itselfand the cycles repeats itself

Pain and/or fatigue of cuff

Rotator Cuff dysfunction

Impingement with motion

Posterior Capsular Posterior Capsular TightnessTightness As a result of microtrauma and As a result of microtrauma and

inflammation.inflammation. Capsule tightens and can no longer Capsule tightens and can no longer

accommodate humeral head as it accommodate humeral head as it rotates.rotates.

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

Reduces subacromial spaceReduces subacromial space

HistoryHistory

Pain on the lateral aspect of the Pain on the lateral aspect of the shouldershoulder– may radiate to deltoid insertionmay radiate to deltoid insertion– anterior acromion with anterior acromion with

impingementimpingement +/- biceps tendonitis+/- biceps tendonitis

Stiffness, esp IRStiffness, esp IR Cannot lie on that sideCannot lie on that side Weakness, instability, crepitusWeakness, instability, crepitus Partial tears more sore and stifferPartial tears more sore and stiffer Acute tear may have inciting eventAcute tear may have inciting event

Physical ExamPhysical Exam

Inspection: atrophy, symmetryInspection: atrophy, symmetry Palpation: AC, cuff tendernessPalpation: AC, cuff tenderness Range of motion: active, passive Range of motion: active, passive Strength: ER and elevation power, Strength: ER and elevation power,

lag lag Provocative: impingement sign, Provocative: impingement sign,

arc of pain arc of pain


Impingement testingImpingement testingNEER SIGNNEER SIGN

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

Physical ExamPhysical Exam Impingement testingImpingement testing

Hawkin's testHawkin's test With patient’s arm abducted to 90°, then shoulder With patient’s arm abducted to 90°, then shoulder

internally rotated, pushing the supraspinatus against internally rotated, pushing the supraspinatus against the anteroinferior acromion, with increased shoulder the anteroinferior acromion, with increased shoulder painpain


SUBSCAPLULARISSUBSCAPLULARIS

Gerber's lift off testGerber's lift off test: push : push examiner's hand away from examiner's hand away from 'hand behind back position' 'hand behind back position'

Internal rotation lag sign: Internal rotation lag sign: inability to hold hand away inability to hold hand away from back from back

Napoleon testNapoleon test: if pt cannot : if pt cannot fully internally rotate, pt. fully internally rotate, pt. pushes on their belly, pushes on their belly, elbow will drop backwards elbow will drop backwards if +veif +ve


SUPRASPINATUSUPRASPINATUSS

Jobe's TestJobe's Test: :

arm abducted in arm abducted in the plane of the plane of the the

scapula, thumb scapula, thumb pointing pointing down .down .

Resist elevation Resist elevation of the arm.of the arm.

Physical ExamPhysical Exam INFRASPINATUSINFRASPINATUS

Resisted ER with arm by side Resisted ER with arm by side activates both infra and Teres minor activates both infra and Teres minor equally, therefore not specific.equally, therefore not specific.

Place arm by side, flex elbow 90 Place arm by side, flex elbow 90 degrees, ER 45 degrees and resist degrees, ER 45 degrees and resist internal rotation of arm.internal rotation of arm.

Mostly infraspinatusMostly infraspinatus


TERES MINORTERES MINOR

Hornblower's signHornblower's sign::

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

The Taking-the-oath The Taking-the-oath PositionPosition


Long head of biceps testingLong head of biceps testing– Speed’s testSpeed’s test

FF 90, elbow 0, supinated forearmFF 90, elbow 0, supinated forearm resisted downward forceresisted downward force biceps or SLAPbiceps or SLAP

– Yergason’s testYergason’s test With patient’s arm at side with elbow flexed With patient’s arm at side with elbow flexed

90° and forearm pronated, examiner resists 90° and forearm pronated, examiner resists supination of the forearm --> pain or tendon supination of the forearm --> pain or tendon subluxation out of groovesubluxation out of groove


DeltoidDeltoid– resisted abduction at 90resisted abduction at 90

Serratus anteriorSerratus anterior– wingingwinging


AC joint testingAC joint testingHorizontal Horizontal

adductionadduction forced cross body forced cross body

adduction in adduction in 90ºflexion, pain 90ºflexion, pain at the extreme of at the extreme of motion indicative motion indicative of ACJ pathology of ACJ pathology

ImagingImaging

Plain radiographsPlain radiographs– APAP

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

– Transcapular latTranscapular lat

ImagingImaging

Plain radiographsPlain radiographs– AxillaryAxillary

subluxation, os acromiale (association subluxation, os acromiale (association with rotator cuff tears - beware excision with rotator cuff tears - beware excision with acromioplasty)with acromioplasty)

– Supraspinatus outletSupraspinatus outlet 10 to 15 degree caudal tilt of transcapular 10 to 15 degree caudal tilt of transcapular

laterallateral can see acromial spurs wellcan see acromial spurs well

– AC jointAC joint 10 to 30 degree cephalad tilt of AP10 to 30 degree cephalad tilt of AP

UltrasoundUltrasound

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

CONCLUSIONSCONCLUSIONS::Highly accurate for full thickness tearsHighly accurate for full thickness tearsPoor accuracy for partial thickness tearsPoor accuracy for partial thickness tears

Full thickness

Partial thickness

UltrasoundUltrasound

Technician Technician dependent dependent

Can be a Can be a dynamic studydynamic study

Easier to obtainEasier to obtain Hard to readHard to read

MRI vs UltrasoundMRI vs Ultrasound

Detection and quantification of rotator Detection and quantification of rotator cuff tears. Teefey et al. JBJS 2004cuff tears. Teefey et al. JBJS 2004– 71 patients with shoulder pain had imaging 71 patients with shoulder pain had imaging

with U/S and MRI then underwent with U/S and MRI then underwent arthroscopyarthroscopy

46 full thickness tears46 full thickness tears 19 partial thickness tears19 partial thickness tears 6 had no tear6 had no tear

– U/S and MRI had comparable accuracy for U/S and MRI had comparable accuracy for identifying and measuring size of partial and identifying and measuring size of partial and full thickness tearsfull thickness tears

– MRI slightly more sensitiveMRI slightly more sensitive

MRIMRI

Static studyStatic study More expensiveMore expensive Longer wait-listLonger wait-list Can assess intra-Can assess intra-

articular articular pathology, such a pathology, such a labral tears.labral tears.

Easier to readEasier to read

Differential DiagnosisDifferential 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 ArthritisGlenohumeral Joint Arthritis Thoracic outlet syndromeThoracic outlet syndrome Suprascapular Nerve Entrapment or Suprascapular Nerve Entrapment or

brachial neuritis (rarely) brachial neuritis (rarely)

Natural HistoryNatural History

Yamanaka & Matsumoto - CORR Yamanaka & Matsumoto - CORR 19941994– 40 pts with partial thickness tears40 pts with partial thickness tears– avg age 61, conservative Rxavg age 61, conservative Rx– @ 1 year@ 1 year

21 pts tear increased in size21 pts tear increased in size 11 pts full thickness11 pts full thickness OVERALL SHOULDER SCORES OVERALL SHOULDER SCORES

BETTERBETTER

TreatmentTreatment

Mainstay is conservativeMainstay is conservative Surgery reserved for significantly Surgery reserved for significantly

symptomatic patients who have symptomatic patients who have failed conservative management > failed conservative management > 6 -12 months6 -12 months

Younger patient (<60) with Younger patient (<60) with acuteacute teartear– Cuff repair within 6 weeksCuff repair within 6 weeks

Non-Operative Non-Operative TreatmentTreatment 33-90% successful (Campbell’s)33-90% successful (Campbell’s)

Candidates:Candidates:– Partial thickness tearsPartial thickness tears– Older patients with chronic large Older patients with chronic large

tears and extensive cuff muscle tears and extensive cuff muscle atrophyatrophy

NSAIDsNSAIDs Symptom control Symptom control ±± ↓ inflammation↓ inflammation

Non-Operative Non-Operative TreatmentTreatment TherapyTherapy

- Stretch posterior capsule with - Stretch posterior capsule with Sleeper StretchSleeper Stretch

WRONG

Non-Operative Non-Operative TreatmentTreatment

TherapyTherapy Regain full, pain-free ROMRegain full, pain-free ROM Strengthen all rotator cuff musclesStrengthen all rotator cuff muscles

- Isometrics first- Isometrics first

- Isotonics with theraband- Isotonics with theraband Strengthen shoulder girdle musclesStrengthen shoulder girdle muscles Improve biomechanics and Improve biomechanics and

proprioceptionproprioception

Subacromial Cortisone Subacromial Cortisone Injection vs LidocaineInjection vs Lidocaine

Corticosteroid injectionsCorticosteroid injections– Blair & Zuckerman JBJS-A 1996Blair & Zuckerman JBJS-A 1996– Subacromial impingement Subacromial impingement RCT RCT– Subacromial corticosteroid Subacromial corticosteroid vsvs

lidocainelidocaine

Cortisone vs LidocaineCortisone vs Lidocaine

At ~30 week F/UAt ~30 week F/U– Significant Significant

differences in differences in pain, negative pain, negative impingement sign, impingement sign, active forward active forward elevation & elevation & external rotationexternal rotation

– Insignificant Insignificant differences in differences in internal rotation, internal rotation, performance of performance of activities of daily activities of daily livingliving

Pain

Indications for SurgeryIndications for Surgery

Failed conservative managementFailed conservative management– 3 to 12 month course of NSAIDs, physio, 3 to 12 month course of NSAIDs, physio,

corticosteroid injections, activity modificationcorticosteroid injections, activity modification

Significant or progressive weakness, esp. Significant or progressive weakness, esp. acuteacute– Early repair if <50 y.o. and full-thickness tearEarly repair if <50 y.o. and full-thickness tear

Differential diagnosis confirms weakness Differential diagnosis confirms weakness is from rotator cuff tear (i.e. MRI findings is from rotator cuff tear (i.e. MRI findings correlate with exam, rule out other correlate with exam, rule out other causes)causes)

Contraindications to Contraindications to SurgerySurgery Asymptomatic tearAsymptomatic tear Chronic “massive” irreparable tearsChronic “massive” irreparable tears

– Tendon retraction past glenoid rimTendon retraction past glenoid rim– Fatty degeneration of muscleFatty degeneration of muscle– Increased width of subtrapezial fat padIncreased width of subtrapezial fat pad

Frozen shoulderFrozen shoulder– Need ROM pre-opNeed ROM pre-op

Unwilling or unable to participate in Unwilling or unable to participate in post-op physiopost-op physio

Surgical PrinciplesSurgical Principles

Neer JBJS-A 1972Neer JBJS-A 1972– Repair Deltoid to BoneRepair Deltoid to Bone– adequate subacromial adequate subacromial

decompressiondecompression– mobilization of muscle-tendon unitsmobilization of muscle-tendon units– secure fixation of tendon to GTsecure fixation of tendon to GT– closely supervised rehabclosely supervised rehab

Surgical OptionsSurgical Options

Open repairOpen repair Arthroscopic-assisted Mini-openArthroscopic-assisted Mini-open Complete ArthroscopicComplete Arthroscopic

+/- subacromial decompression+/- subacromial decompression

Surgical complicationsSurgical complications

Postoperative shoulder stiffness Postoperative shoulder stiffness Infection Infection Deltoid injuryDeltoid injury Repair failure Repair failure Neurovascular injury Neurovascular injury

Partial thickness tearsPartial thickness tears

No RCT’sNo RCT’s– Usually on the articular surface of the Usually on the articular surface of the

supraspinatus insertionsupraspinatus insertion– Subacromial decompression Subacromial decompression ± ±

arthroscopic debridementarthroscopic debridement Alone if <50% of cuff thickness, Alone if <50% of cuff thickness,

<1cm<1cm

– Repair if >50% of cuff thicknessRepair if >50% of cuff thickness ((Gartsman)Gartsman)

Results of SurgeryResults of Surgery

Open vs arthroscopically-assistedOpen vs arthroscopically-assisted– Baker & Liu 1995Baker & Liu 1995

similar results @ 3 yrssimilar results @ 3 yrs <3cm tears<3cm tears

– earlier return to full fnearlier return to full fn– ↓ ↓ hospital stayhospital stay

– return to previous activities 1 month soonerreturn to previous activities 1 month sooner >3cm tears>3cm tears

– arthroscopic = arthroscopic = 50% satisfaction50% satisfaction

– open = open = 80% satisfaction80% satisfaction


Arthrosopic vs mini-open rotator cuff repairArthrosopic vs mini-open rotator cuff repair

Youm T, Zuckerman et al.Youm T, Zuckerman et al.J. Shoulder Elbow Surg 2005J. Shoulder Elbow Surg 2005

(small, medium and large)(small, medium and large)

2 yr F/U. Used ASES and UCLA scores2 yr F/U. Used ASES and UCLA scores

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


Arthroscocpic vs. Mini-open cuff Arthroscocpic vs. Mini-open cuff repairrepair

Sauerbrey et al. Arthroscopy 2005Sauerbrey et al. Arthroscopy 2005

Retrospective comparative study Retrospective comparative study

Both groups similar.Both groups similar.

18+ month F/U. Used ASES score.18+ month F/U. Used ASES score.

No Difference between groups.No Difference between groups.


Arthroscopic vs open Acromioplasty: A Arthroscopic vs open Acromioplasty: A prospective, randomized, blinded prospective, randomized, blinded study.study. Spanghel et al. Spanghel et al. J Shoulder Elbow J Shoulder Elbow Surg. 2002. VancouverSurg. 2002. Vancouver– 62 patients randomized62 patients randomized– F/U minimum 12 months (25 month F/U minimum 12 months (25 month

avg)avg)– Primary outcome was visual analog Primary outcome was visual analog

scales for pain and functionscales for pain and function


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

No Difference with respect to….No Difference with respect to….UCLA shoulder scoresUCLA shoulder scoresPatient satisfactionPatient satisfactionStrengthStrengthFeeling of ImprovementFeeling of Improvement

Subacromial Subacromial Decompression?Decompression?Gartsman GM Gartsman GM J Shoulder Elbow Surg J Shoulder Elbow Surg

20042004RCT: Repair and SAD vs No SADRCT: Repair and SAD vs No SAD Only studied those with complete tears Only studied those with complete tears

involving only supraspinatus and with a involving only supraspinatus and with a type 2 acromion.type 2 acromion.

American Shoulder and Elbow Surgeons American Shoulder and Elbow Surgeons Shoulder scoreShoulder score

F/U 1 yearF/U 1 year No DifferenceNo Difference

Arthroscopic RepairArthroscopic Repair

AdvantagesAdvantages– deltoid preservationdeltoid preservation– diagnose and treat glenohumeral diagnose and treat glenohumeral

pathologypathology Gartsman JBJS-A 1998Gartsman JBJS-A 1998

– pre-op UCLA scores 10.9 with, pre-op UCLA scores 10.9 with, 23.7 without intrarticular lesions23.7 without intrarticular lesions

– post-op 29.9, 31.2post-op 29.9, 31.2

– mobilization and release of the cuffmobilization and release of the cuff


Short-Term AdvantagesShort-Term Advantages– decreased immediate postoperative decreased immediate postoperative

pain, shorter hospital stay, earlier pain, shorter hospital stay, earlier rehabilitationrehabilitation

– decreased postoperative stiffnessdecreased postoperative stiffness adhesive capsulitis with mini-open?adhesive capsulitis with mini-open?


DisadvantagesDisadvantages– concerns about fixation with suture concerns about fixation with suture

anchors?anchors? Ogilvie-Harris Am J Sports Med Ogilvie-Harris Am J Sports Med

19961996– suture anchor pullout > transosseoussuture anchor pullout > transosseous

– difficult to use tendon-grasping difficult to use tendon-grasping suturesuture

– more difficultmore difficult

Arthroscopic Stitch Arthroscopic Stitch TypeType JBJS (Am), Ma et al. Feb. 2006JBJS (Am), Ma et al. Feb. 2006Biomechanical study of repair Biomechanical study of repair

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

Double-row repair 287 NDouble-row repair 287 NMassive Cuff 250 NMassive Cuff 250 NMason-Allen 212 NMason-Allen 212 NSimple Stitch 191 NSimple Stitch 191 N


Open repairsOpen repairs– better results with smaller tears, better results with smaller tears,

and better pre-op ROMand better pre-op ROM– older tears with more pre-op older tears with more pre-op

weakness less likely to do wellweakness less likely to do well steroids, smoking, previous failed steroids, smoking, previous failed

surgerysurgery

– lasting integrity of repair better with lasting integrity of repair better with smaller tearssmaller tears





Arthroscpically-assisted Arthroscpically-assisted repairsrepairs– arthroscopic acromioplasty ± distal arthroscopic acromioplasty ± distal

clavicle excision if AC arthrosisclavicle excision if AC arthrosis– deltoid-split mini-open repair of cuffdeltoid-split mini-open repair of cuff

Levy 1990Levy 1990– <3cm tear = 100% satisfaction<3cm tear = 100% satisfaction– >3cm tear = 67% satisfaction>3cm tear = 67% satisfaction

Documents

Rotator Cuff Tears Daniel Penello Upper Extremity Rounds 22 Feb 2006