Rotator Cuff Tendinopathy - Physiotherapy Alberta Rotator Cuff Tendinopathy Tendinopathy Partial thickness

Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

2/12/2018

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Lori Michener, PhD, PT, ATC, SCS, FAPTA Director of Clinical Outcomes and Research

Director – COOR Lab University of Southern California; Los Angeles, CA

lmichene@pt.usc.edu http://pt.usc.edu/COOR/

Differential Diagnosis of Rotator Cuff Disease

COOR Lab

@LoriM_PT

Rotator Cuff Tendinopathy Tendinopathy  Partial thickness RC tear  Full Thickness RC tear • Tendinopathy • Partial thickness RC tear

– Articular, bursal, mid-substance • Full-thickness RC tear

– Complete rupture superior to inferior – Not necessarily side to side – “Hole’ in the sock

Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

2/12/2018

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Rotator Cuff Tendinopathy

• Full-thickness RC tear

• Partial thickness RC tear

• Tendon pathology without tear

• Subacromial impingement

Single clinical  diagnostic category:

Subacromial  pain syndrome

COOR Lab @ USC @LoriM_PT

Tendon  Pathology

What’s in a name…. • ‘subacromial impingement’

– Limited support for compression mechanism – Perpetuates flawed reasoning & treatment

• Subacromial Pain Syndrome (SPS) – Allows for uncertainty of the pain generator:

tendons, bursae, biceps, CNS, other… – Allows for mechanisms other than impingement

• Other names – ex: RC Related Shoulder Pain

COOR LabCOOR Lab @ USC @LoriM_PT

Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

2/12/2018

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Supraspinatus Tendon

Tendon overload & Degeneration

Mechanical Compression in

SA Space

Subacromial Impingement Syndrome RCT 2 predominant theories

If mechanical compression is the predominant mechanism, then….

… ALL would benefit from an acromioplasty • Acromioplasty + rehab was not clinically more

beneficial than rehab alone in multiple trials (Brox et al; 1993, 1999; Haahr, 2005, 2006; Ketola S, 2009, 2013)

• Bony pathology is not the only mechanism • ‘Impingement’ – May not be an appropriate

label (Cools AM and Michener LA, BJSM, 2017)

COOR LabCOOR Lab @ USC @LoriM_PT

Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

2/12/2018

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Mechanisms of RC (Tendon) Disease

• Mechanisms: – Overload and Compression

• Factors contributing to the mechanisms: – Intrinsic factors – within the tendon – Extrinsic factors – external to the tendon – Other factors –

• Personal and Environmental factors

COOR LabCOOR Lab @ USC @LoriM_PT

Intrinsic factors: Within the tendon

Vascularity Morphology Mechanical

Aging Genetics

SA space- impingement??

RCD

Extrinsic factors: Strength/ m. control Tightness & Laxity Posture: spine, sh Bony abnormalities

Scap & GH kinematics Neurophysiological

Brain / CNS

Load Load

COOR Lab @ USC

Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

2/12/2018

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Tendon overload • Neovascularization?

• Conflicting evidence (Lewis J, 2009; Kardouni JR, 2013)

• Is the tendon painful?

Tendon Degeneration with Overload • Inflammation present (Dean BJ, BJSM; 2015) • Abnormal collagen laydown • Tendon thickens initially  then thins

• Thicker in SPS (Michener LA, 2015; Joensen J, 2009; Leong HT, 2012) • Thins with progressive tendon disease • *Thickens response to use

Overhead athletes, Spinal Cord Injuires (SCI) (Belley AF, 2016; Maenhout A, 2012; Wang HK, 2005)

Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

2/12/2018

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Is compression in the SA Outlet causing tendon changes?

Compression or ‘impingement’ of RC tendons

- Subacromial (SA) space

SA space measured

Scapular al, 2012)

AHD= acromiohumeral distance 10 – 15 mm in healthy

AHD

Tendon compression – is it possible?

SA space and shoulder pain: – Space is smaller:  AHD in ‘impingement’

(Hekimoglu B, 2013; Leong H-T, 2012; Seitz AL, 2011, Hebert LJ, 2003, Graichen H, 1999)

– Tendon is thicker: initially with disease & ‘overuse’ – Occupation ratio > : supraspinatus tendon: AHD

• ‘Impingement’: tendon occupies > amount of AHD (Michener LA, 2013)

• Overhead athletes & Spinal Cord Injury (SCI) (Belley AF, 2016; Maenhout A, 2012; Wang HK, 2005)

COOR Lab @ USC @LoriM_PT

Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

2/12/2018

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Tendon compression – is it possible?

• Compression observed– cadaveric (Hughes PC, et al, 2012) • Compression risk:

– Smallest AHD: supraspinatus tendon 0 - 60° Smallest AHD: tendon footprint 30 - 90° (Lawrence R, JOR, 2017)

– Tendon is not ‘available’ for compression (under the acromion) above ~ 70 elevation (Giphart JE, 2012; Thompson MD, 2011; Bey MJ, 2007)

Tendon compression may occur @ < 70°

COOR Lab @ USC @LoriM_PT

Glenohumeral impingement

• Posterior / Internal – Compression between the

posterior glenoid and the humeral head

– Described in overhead athletes

– Recent evidence – maybe in non-overhead athletes (Lawence R, Ludewig P, et al; CSM, 2017)

Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

2/12/2018

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European Society of MSK Radiology: Shoulder MSK Technical Guidelines

Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

2/12/2018

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So is it compression or is it degeneration?

• Both compression AND degeneration are causes – Less support for compression

COOR LabCOOR Lab @ USC @LoriM_PT

Rotator Cuff Tendinopathy: What’s the Evidence for Diagnosis?

• Subacromial Pain Syndrome (SPS) – SPS – Partial- thickness RC tears

• Full-thickness Rotator Cuff Tear (FT-RCT)

COOR LabCOOR Lab @ USC @LoriM_PT

Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

2/12/2018

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Key Metrics for Dx Accuracy

• Diagnostic Accuracy values: – Sensitivity – Specificity – PPV: Predictive value of a positive test – NPV: Predictive value of a negative test – LR+: Positive likelihood ratio – LR- Negative likelihood ratio

COOR Lab

Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

2/12/2018

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Sensitivity and Specificity • Sensitivity

• SnNOut = When Sn is high, a Negative test rules Out the disease

• Specificity (SpPIn) • SpPIn = When Sp is high, a Positive test rules In the

disease.

• Interpretation: • Indicates if a test s or s disease probability • BUT: No set cut-off to quantify shift in probability

COOR Lab

Likelihood Ratios

• More helpful for Dx • Indicate by how much a given diagnostic test

result will  or  the probability of the disease. • Quantify shifts in probability of the diagnosis

• Ex: +LR= 5: a patient with a + test is 5x more likely in a patient with the disease as compared to a patient without the disease

• Minimal affect of prevalence

COOR Lab

Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

2/12/2018

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Likelihood Ratio “+” “—”

Interpretation

>10

Rotator Cuff Disease: Rehab and Surgery                                   Lori Michener, PhD, PT, ATC, SCS, FAPTA

2/12/2018

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Recommendations for Diagnostic Values Interpretation

Screen