Rotator Cuff Disease: Implication for Healing.
Rotator Cuff Disease: Implication for Healing
Hermawan Nagar Rasyid, M.D
Department of Orthopaedic Surgery
Faculty of Medicine Universitas Padjadjaran
Hasan Sadikin Hospital, Bandung, Indonesia
Function of the rotator cuff
The rotator cuff functions as a depressor of the humeral head to counteract the
longitudinal pull of the deltoid, triceps, pectoralis minor and coracobrachialis. It plays its
biggest role as a stabilizer between 30 and 75 degrees of humeral elevation, and by 120
degrees of elevation it is no longer a stabilizer.
Contraction of the rotator cuff compresses the humeral head in the glenoid, improving
stability. Both the anterior and posterior cuffs must work to maintain stability; if one is
dysfunctional increased translation ensues and compression is lost.
The supraspinatus is particularly important in compressing the humeral head into the
glenoid. Note that it has been shown that abduction through a full range can occur after
a suprascapular nerve block (Van Linge 1963). The long head of biceps functions as a
humeral head depressor,
Notes on applied anatomy
The vascular supply to supraspinatus is via the suprascapular artery. The blood supply is
more tenuous on the articular side, and the collagen bundles there are also less regular
and smaller. The thickness of the rotator cuff is around 9-12mm.
Incidence
Cadaver studies show rate of 5-30%. Increasing frequency with increasing age. Partial
thickness tears are more common in younger patients, implying progression to full
thickness tear as the patient ages. Patients older than 77 have greater than 50% rate of
full thickness cuff tears which indicates to Rockwood that cuff tears may be a normal
part of aging. Rotator cuff disease is uncommon in primary glenohumeral osteoarthritis.
Aetiology
May be due to impingement of the rotator cuff on the coraco-acromial arch, particularly
in the so-called impingement position (flexion, abduction and internal rotation). Neer
felt that impingement occurs against the undersurface of the anterior 1/3 of the
acromion and at times the AC joint. (Previously it had been suggested that the lateral
acromion was responsible). Neer felt that the arm was used in a position of forward
elevation rather than abduction.
Presented at The Indonesian Orthopaedic Association, 51th Continuing Orthopaedic Education
Balik Papan May 5-6, 2006.
Page 1
The factors that cause impingement can be classified as intrinsic (intratendinous) and
extrinsic (extratendinous). They can be further classified as primary, or secondary (the
result of another process, such as instability).
Anatomical factors that predispose to cuff pathology include:
1.
Acromial shape – increasing curvature leads to increased pressure on the cuff.
2.
Anterior acromial spurs – seen in 7% of patients up to 50, but 30% of patients
older than 50.
3.
Os acromiale - found in 8% of patients, 1/3 of these are bilateral.
May also be due to ischaemia, in the critical area of hypovascularity which is in the
supraspinatus tendon around 1cm proximal to its insertion (demonstrated by Rathburn
and Macnab). Hawkins points out that these theories are complementary, with
mechanical impingement on an area of hypovascular tissue. Jobe suggested that in
athletes involved in sports with overhead actions subtle glenohumeral instability could
be the cause of rotator cuff tendinosis. Muscle weakness, particularly in the
supraspinatus, may lead to impingement. Tendon degeneration may allow the humeral
head to migrate superiorly, leading to impingement (Uhthoff).
Pathology
Apley describes a sequence of “wear, tear and repair”. Young patients with cuff tears
have a vigorous healing response which is very painful (acute tendonitis) but relatively
short lived. Older patients have a less vigorous response which is not as painful but
more chronic (chronic tendonitis). A complete tear (which usually occurs in the elderly)
becomes painless quickly but never repairs.
Neer describes three stages of impingement:
1.
Oedema and haemorrhage
a. Typical age less than 25
b. DDx subluxation or AC joint arthritis
c. Reversible clinical course
d. Conservative treatment
2.
Fibrosis and tendinitis
a. Typical age 25-40
b. DDx frozen shoulder, calcific tendinitis
c. Recurrent pain with activity
d. Consider bursectomy, CA ligament division
3.
Bone spurs and tendon rupture
a. Typical age >40
b. DDx cervical radiculitis or neoplasm
c. Progressive disability
d. Anterior acromioplasty and cuff repair
Presented at The Indonesian Orthopaedic Association, 51th Continuing Orthopaedic Education
Balik Papan May 5-6, 2006.
Page 2
Tears may develop acutely in young patients after trauma, or after degeneration in older
patients. Large tears of the cuff may eventually lead to serious impairment of shoulder
biomechanics and eventually cuff tear arthropathy in 4% (Neer). A rapidly progressive
cuff tear arthropathy is referred to as a Milwaukee shoulder.
Clinical features
Subacute tendonitis
Shoulder pain develops after strenuous activity. The pain is worse with overhead
activity. The shoulder is acutely tender along the anterior edge of the acromion, and
tenderness over the greater tuberosity can be demonstrated particularly with the
shoulder extended. When the humerus is flexed the supraspinatus tendon disappears
under the acromion and the tenderness is diminished. There is disruption of
scapulothoracic rhythm with a painful arc which is improved if the arm if held in full
external rotation throughout. Note that both Neer and Hawkins’ signs have low
specificity.
Chronic tendonitis
The patient is older, usually 40-50. May have had a history of recurrent subacute
tendonitis. Pain is characteristically worse at night; the patient can’t lie on the affected
side and often finds it more comfortable to sit. Pain is worse with overhead activities.
Signs are similar to those of subacute tendonitis plus there is often involvement of
biceps with rupture of the LHB. Neer commented that 50% of his patients with cuff tear
were unable to remember a definite injury. An injury may predispose to an “acute
extension” of the tear, where prior to the injury there may have been only an
incomplete thickness tear.
Cuff disruption
Patients with a partial tear may be able to abduct when the tear is injected with
lignocaine. Diminishment of pain after injection with LA is referred to as a positive
impingement test. Patients with a complete tear will have the drop arm sign.
Radiology
Plain XR
Standard views are anteroposterior, trans-scapular lateral and an axillary view. The
supraspinatus outlet view (Neer 1987) is a lateral radiograph of the erect scapula with a
downward (caudal) tilt of 10 degrees, and this can help assess acromial morphology.
Bigliani classified acromial morphology as:
Type I – straight
17%
Type II – curved
43%
Type III – hooked
40%
Type III acromions have a much higher rate of RCT.
Presented at The Indonesian Orthopaedic Association, 51th Continuing Orthopaedic Education
Balik Papan May 5-6, 2006.
Page 3
Wuh and Snyder have classified the acromion by thickness at the junction of anterior
and middle thirds
Type A less than 8mm thick
Type B 8 to 12 mm thick
Type C –
more than 12mm thick
This is helpful in avoiding iatrogenic acromion fracture during acromioplasty.
Ultrasound
This is operator dependent. Van Holsbeek quotes a 100% Sn and Sp for FTRCT and for
PTRCT Sn 93% and Sp 100%. The diagnosis of a large retracted tear is made when there
is nonvisualization of the SS tendon and the deltoid muscle is closely opposed to the
humeral cortex. This is a very reliable sign with a 100% PPV. A focal full thickness tear is
seen as a hypoechoic area extending through the rotator cuff; with subdeltoid bursal
fluid supporting the diagnosis. If the tear is large enough the adjacent deltoid muscle
may herniate into the tendon gap. Partial thickness tears may appear hypoechoic or of
mixed echogenicity.
MRI
Provides information about the state of the cuff, but up to 1/3 of individuals will have
asymptomatic cuff tears on MRI. MRI is better than ultrasound in diagnosing partial
thickness tears, but the two are similar in full thickness tears. Rotator cuff tear size is
graded as: small – less than 1cm; medium 1-3cm; large 3-5cm; massive – greater than
5cm. MRI is useful in assessing the degree of atrophy and fibrosis in the cuff in the
setting of massive cuff tears; if the muscle is fibrosed and retracted it is not likely to be
repairable. If the patient has grade 3 rotator cuff strength and the MRI shows the cuff
retracted to the glenoid rim with severe muscular atrophy this is almost certainly
irreparable.
Differential diagnosis
Glenohumeral instability
Degenerative joint disease
AC joint pathology
Adhesive capsulitis
Nerve compression syndromes – particularly suprascapular nerve
Cervical spondylosis
Treatment
Conservative treatment
Patients should avoid the impingement position
Strengthening of the rotator cuff in the non-painful position
NSAIDS
Steroid injections
Icing
Presented at The Indonesian Orthopaedic Association, 51th Continuing Orthopaedic Education
Balik Papan May 5-6, 2006.
Page 4
Ultrasound
The first phase of rehabilitation in tendinosis is rest and avoidance of the impingement
position. Anti-inflammatories are prescribed. Subacromial lignocaine and steroid
injections can be effective in pain relief. After the inflammation has settled range of
motion exercises are started. Stretching is taught. The last phase is the strengthening
phase, where rotator cuff, deltoid and scapula stabilizing exercises are prescribed.
Overhead activities should be avoided, particularly initially. Any muscle imbalance,
especially between external and internal humeral rotators, is addressed. Non-surgical
treatment is effective in up to 90% of patients. Poorer results are found in older patients
and patients with curved acromions. Nonoperative treatment should be pursued for at
least 6 months except for full thickness cuff tears. Bursal sided PTRCTs do not do well
when treated non-operatively. If non-operative treatment is being pursued, it is
reasonable to get an US after 6-12 months to rule out progression of the tear which may
make cuff repair impossible. Around 50% will progress.
Surgical treatment
Indicated in:
1. Failure to respond to conservative treatment in tendinitis (Neer’s stage II).
2. Full thickness rotator cuff tears with pain or symptomatic weakness
Impingement
Neer advocates subacromial bursal excision and division of the CA ligament from the
medial acromial border for stage II impingement if disability persists for one year, and
doesn’t advocate acromioplasty unless there is overhang and prominence of the
underside of the acromion. Hawkins mentions division of the CA ligament in patients
with ongoing sx in Stage I who fail one year of conservative treatment, but emphasizes
that the patient should have a period off sports first. If the AC joint is symptomatic or
preventing adequate view of the supraspinatus it needs debridement or excision.
Acromioplasty can be open or arthroscopic, and it has been shown on cadavers that a
full and accurate arthroscopic decompression can be done. The results are similar.
Cuff tears
Surgery can be open or arthroscopic. Arthroscopic surgery allows visualization of both
sides of the cuff, and the ability to deal with other glenohumeral or labral pathology
which is frequently co-existent. The mini-open technique uses arthroscopy first to locate
the tear, plus or minus deal with intra-articular pathology; a small deltoid splitting
incision is then used to get access to the cuff. It minimizes detachment of the deltoid
from the acromion. This decreases the risk of catastrophic deltoid dysfunction, but
doesn’t shorten the rehabilitation time, because this is dependent on rotator cuff
healing. The tear should be small and easily mobilizable.
Presented at The Indonesian Orthopaedic Association, 51th Continuing Orthopaedic Education
Balik Papan May 5-6, 2006.
Page 5
In open surgery bursal side PTRCTs can be seen, but not articular sided partial tears.
Fukuda describes the colour test, where methylene blue is injected into the
glenohumeral joint, and diffuses preferentially into areas of bursal sided partial tears.
Open surgery is usually combined with acromioplasty and provides around 80-90%
satisfactory results.
Partial thickness tears have a tendency to progress, with one study demonstrating 80%
progression on ultrasound. Tears up to 50% cuff width should be treated with
debridement (however note that after debridement there was no evidence of healing at
second look arthroscopy); tears bigger than this should be treated with excision of the
degenerate portion and cuff repair. This is backed up by a study looking at tears >50%
thickness, where there were no recurrences in the group undergoing excision and repair,
but progression to complete tear in 10% of patients treated only with debridement.
Debridement should usually be combined with subacromial decompression;
acromioplasty if the acromion is hooked, CA ligament division and bursectomy if type I
acromion. This leads to 75-80% satisfactory results. Acromioplasty is contraindicated in
elite throwing athletes less than 35 who have a low rate of return to elite competition if
this is done.
Surgery should be considered early in patients with complete cuff tears. Treatment
consists of acromioplasty; excision of the coraco-acromial ligament and repair of any
associated cuff tears. Surgery should only be considered if the patient is willing and able
to undergo prolonged physiotherapy post-operatively. Debridement has inferior results
compared with repair of the cuff; thus the trend is to repair any tear that causes pain or
significant loss of function.
Technique of open cuff repair
Beach chair position
Variable skin incision – sabre cut vs. horizontal. Matsen prefers an oblique incision
centred on the anterolateral corner of the acromion, perpendicular to the deltoid fibres.
Deltoid split for 2-3 cm from anterolateral corner of acromion, then along acromion to
ACJ. The split should be in the tendon of origin found between the anterior and middle
thirds. This tendon arises from the anterior lateral corner of the acromion. The spit is
carried over the acromion and into the trapezius insertion.
Anteroinferior acromioplasty, to level of ACJ AFTER INSPECTION OF THE CUFF. If the cuff
is not amenable to repair an acromioplasty will be deleterious. In this situation, the
undersurface of the coracoacromial arch is smoothed off, and any debris, scar or
thickened bursa in the subacromial space is removed. The top of the humeral head may
also be smoothed off.
Presented at The Indonesian Orthopaedic Association, 51th Continuing Orthopaedic Education
Balik Papan May 5-6, 2006.
Page 6
Excision of ACJ if:
1.
Symptomatic
2.
Osteophytes inferiorly
3.
Inadequate view
Bursectomy, Identification of tear, Debridement to adequate tissue.
Mobilize tendons:
1.
Release subacromial adhesion
2.
Release intraarticular adhesions
3.
May need to release capsule
4.
Divide coracohumeral ligament
5.
Release rotator interval to base of coracoid. The complete release of the
coracohumeral ligament and rotator interval is called the interval slide and
should allow the supraspinatus to be mobilized 1-1.5cm laterally.
Repair with arm at side into bone trough. The modified Mason-Allen stitch is preferred
for attachment to the cuff. Tendon to bone fixation with transosseous sutures. Sutures
need to be braided, non-absorbable, pass through bone at least 1.5 to 2cm distal to tip
of tuberosity with at least 1cm separation. Knots should be buried or tied laterally to
avoid impingement. If the biceps is torn, the proximal stump is resected and the distal
stump tenodesed in the bicipital groove. Reattach deltoid with nonabsorbable sutures.
Postoperative management
Passive ROM exercises are started immediately and continued for 6 weeks while the
bone tendon interface heals. 140-40 aimed for. Active ROM exercises are then
continued for another 6 weeks, before formal strengthening starts. Patients who have
arthroscopic decompression and debridement alone can start active ROM immediately
because the deltoid hasn’t been detached and no tendon repairs need to be protected.
Results of open repair
85-95% satisfactory pain relief
85-95% significant improvement in shoulder function.
Patient satisfaction correlates most closely with pain relief
Salvage of massive cuff tears
A massive cuff tear is defined as one more than 5cm or involving two or more tendons.
Prospective studies show these are worth repairing, with one study of 30 patients having
significant improvements in pain, function and ROM at 6 ½ years. Can the tear be
repaired? This depends on whether the retracted tendon can be advanced. This is
probably best assessed via an open procedure, where subdeltoid, subacromial and
Presented at The Indonesian Orthopaedic Association, 51th Continuing Orthopaedic Education
Balik Papan May 5-6, 2006.
Page 7
intraarticular adhesions can be looked for and addressed. The supraspinatus can only be
advanced 3cm before excessive tension develops in the neurovascular bundle.
Neer mentions transferring half of the subscapularis and infraspinatus tendons
superiorly. If unreconstructable an acromioplasty is contra-indicated because this will
remove the remaining restraints to superior translation of the humeral head, and result
in possible superomedial humeral head dislocation (Flatow). Degenerate cuff tissue
should be debrided. Ellman and Gartsman have reported “reasonable” pain relief at up
to 5 years with debridement alone, and emphasize that thorough debridement and
synovectomy are needed, plus debridement of any acromial or AC joint spurs. If
reconstruction is required, then supraspinatus advancement, latissimus dorsi transfer,
rotator cuff transposition, fascia lata autograft or synthetic tendon graft may be
performed. The best results appear to be with latissimus dorsi transfer; auto and
allografts have poor success rates.
The biceps tendon
This can be debrided or repaired as required. Tenodesis is recommended if the tendon
is subluxing into the joint, or has more than 50% attenuation.
Treatment of rotator cuff arthropathy
Hemiarthroplasty with a large head, if the anterior deltoid is preserved. This fits into the
acetabularized glenoid-coracoacromial arch, and provides predictable pain relief,
although function isn’t great. The glenoid should not be resurfaced.
Complications of acromioplasty/cuff repair
1.
Acromial fracture
2.
Deltoid dehiscence
3.
Weakness
4.
Failure of repair
5.
Deep and superficial wound infection
6.
Adhesive capsulitis
Subcoracoid impingement
This is associated with a laterally placed coracoid process that can impinge on the
proximal humerus with forward flexion and internal rotation. Patients tend to have more
medial pain, referred to the arm and forearm. The diagnosis can be made by performing
a CT with the arm in the provocative position or by injection of local anaesthetic into the
area. Treatment is by resection of the lateral aspect of the coracoid process.
Internal impingement
Impingement of the posterior labrum and cuff can occur in throwing athletes with
external rotation and anterior translation.
Presented at The Indonesian Orthopaedic Association, 51th Continuing Orthopaedic Education
Balik Papan May 5-6, 2006.
Page 8
Isolated tears of the subscapularis tendon
Note: most subscapularis tears are associated with traumatic anterior dislocation and
are often followed by symptoms of recurrent instability.
Gerber reported on 16 cases of isolated rupture in the JBJS(B) in 1991. All were in men
and the average age was 50. The mechanism of injury was forceful hyperextension or
external rotation of the adducted arm. The tear was associated with pain when using the
arm overhead and also below shoulder level. The tear was usually associated with
increased external rotation of the shoulder, weakness of internal rotation and a
pathological lift off test. The patient complained of anterior shoulder pain and weakness
of the arm when it was used above and below shoulder level (the latter would be
unusual in supraspinatus tears). There was no associated shoulder instability. The tear
of the subscapularis was usually associated with medial subluxation of
the biceps.
Presented at The Indonesian Orthopaedic Association, 51th Continuing Orthopaedic Education
Balik Papan May 5-6, 2006.
Page 9
Hermawan Nagar Rasyid, M.D
Department of Orthopaedic Surgery
Faculty of Medicine Universitas Padjadjaran
Hasan Sadikin Hospital, Bandung, Indonesia
Function of the rotator cuff
The rotator cuff functions as a depressor of the humeral head to counteract the
longitudinal pull of the deltoid, triceps, pectoralis minor and coracobrachialis. It plays its
biggest role as a stabilizer between 30 and 75 degrees of humeral elevation, and by 120
degrees of elevation it is no longer a stabilizer.
Contraction of the rotator cuff compresses the humeral head in the glenoid, improving
stability. Both the anterior and posterior cuffs must work to maintain stability; if one is
dysfunctional increased translation ensues and compression is lost.
The supraspinatus is particularly important in compressing the humeral head into the
glenoid. Note that it has been shown that abduction through a full range can occur after
a suprascapular nerve block (Van Linge 1963). The long head of biceps functions as a
humeral head depressor,
Notes on applied anatomy
The vascular supply to supraspinatus is via the suprascapular artery. The blood supply is
more tenuous on the articular side, and the collagen bundles there are also less regular
and smaller. The thickness of the rotator cuff is around 9-12mm.
Incidence
Cadaver studies show rate of 5-30%. Increasing frequency with increasing age. Partial
thickness tears are more common in younger patients, implying progression to full
thickness tear as the patient ages. Patients older than 77 have greater than 50% rate of
full thickness cuff tears which indicates to Rockwood that cuff tears may be a normal
part of aging. Rotator cuff disease is uncommon in primary glenohumeral osteoarthritis.
Aetiology
May be due to impingement of the rotator cuff on the coraco-acromial arch, particularly
in the so-called impingement position (flexion, abduction and internal rotation). Neer
felt that impingement occurs against the undersurface of the anterior 1/3 of the
acromion and at times the AC joint. (Previously it had been suggested that the lateral
acromion was responsible). Neer felt that the arm was used in a position of forward
elevation rather than abduction.
Presented at The Indonesian Orthopaedic Association, 51th Continuing Orthopaedic Education
Balik Papan May 5-6, 2006.
Page 1
The factors that cause impingement can be classified as intrinsic (intratendinous) and
extrinsic (extratendinous). They can be further classified as primary, or secondary (the
result of another process, such as instability).
Anatomical factors that predispose to cuff pathology include:
1.
Acromial shape – increasing curvature leads to increased pressure on the cuff.
2.
Anterior acromial spurs – seen in 7% of patients up to 50, but 30% of patients
older than 50.
3.
Os acromiale - found in 8% of patients, 1/3 of these are bilateral.
May also be due to ischaemia, in the critical area of hypovascularity which is in the
supraspinatus tendon around 1cm proximal to its insertion (demonstrated by Rathburn
and Macnab). Hawkins points out that these theories are complementary, with
mechanical impingement on an area of hypovascular tissue. Jobe suggested that in
athletes involved in sports with overhead actions subtle glenohumeral instability could
be the cause of rotator cuff tendinosis. Muscle weakness, particularly in the
supraspinatus, may lead to impingement. Tendon degeneration may allow the humeral
head to migrate superiorly, leading to impingement (Uhthoff).
Pathology
Apley describes a sequence of “wear, tear and repair”. Young patients with cuff tears
have a vigorous healing response which is very painful (acute tendonitis) but relatively
short lived. Older patients have a less vigorous response which is not as painful but
more chronic (chronic tendonitis). A complete tear (which usually occurs in the elderly)
becomes painless quickly but never repairs.
Neer describes three stages of impingement:
1.
Oedema and haemorrhage
a. Typical age less than 25
b. DDx subluxation or AC joint arthritis
c. Reversible clinical course
d. Conservative treatment
2.
Fibrosis and tendinitis
a. Typical age 25-40
b. DDx frozen shoulder, calcific tendinitis
c. Recurrent pain with activity
d. Consider bursectomy, CA ligament division
3.
Bone spurs and tendon rupture
a. Typical age >40
b. DDx cervical radiculitis or neoplasm
c. Progressive disability
d. Anterior acromioplasty and cuff repair
Presented at The Indonesian Orthopaedic Association, 51th Continuing Orthopaedic Education
Balik Papan May 5-6, 2006.
Page 2
Tears may develop acutely in young patients after trauma, or after degeneration in older
patients. Large tears of the cuff may eventually lead to serious impairment of shoulder
biomechanics and eventually cuff tear arthropathy in 4% (Neer). A rapidly progressive
cuff tear arthropathy is referred to as a Milwaukee shoulder.
Clinical features
Subacute tendonitis
Shoulder pain develops after strenuous activity. The pain is worse with overhead
activity. The shoulder is acutely tender along the anterior edge of the acromion, and
tenderness over the greater tuberosity can be demonstrated particularly with the
shoulder extended. When the humerus is flexed the supraspinatus tendon disappears
under the acromion and the tenderness is diminished. There is disruption of
scapulothoracic rhythm with a painful arc which is improved if the arm if held in full
external rotation throughout. Note that both Neer and Hawkins’ signs have low
specificity.
Chronic tendonitis
The patient is older, usually 40-50. May have had a history of recurrent subacute
tendonitis. Pain is characteristically worse at night; the patient can’t lie on the affected
side and often finds it more comfortable to sit. Pain is worse with overhead activities.
Signs are similar to those of subacute tendonitis plus there is often involvement of
biceps with rupture of the LHB. Neer commented that 50% of his patients with cuff tear
were unable to remember a definite injury. An injury may predispose to an “acute
extension” of the tear, where prior to the injury there may have been only an
incomplete thickness tear.
Cuff disruption
Patients with a partial tear may be able to abduct when the tear is injected with
lignocaine. Diminishment of pain after injection with LA is referred to as a positive
impingement test. Patients with a complete tear will have the drop arm sign.
Radiology
Plain XR
Standard views are anteroposterior, trans-scapular lateral and an axillary view. The
supraspinatus outlet view (Neer 1987) is a lateral radiograph of the erect scapula with a
downward (caudal) tilt of 10 degrees, and this can help assess acromial morphology.
Bigliani classified acromial morphology as:
Type I – straight
17%
Type II – curved
43%
Type III – hooked
40%
Type III acromions have a much higher rate of RCT.
Presented at The Indonesian Orthopaedic Association, 51th Continuing Orthopaedic Education
Balik Papan May 5-6, 2006.
Page 3
Wuh and Snyder have classified the acromion by thickness at the junction of anterior
and middle thirds
Type A less than 8mm thick
Type B 8 to 12 mm thick
Type C –
more than 12mm thick
This is helpful in avoiding iatrogenic acromion fracture during acromioplasty.
Ultrasound
This is operator dependent. Van Holsbeek quotes a 100% Sn and Sp for FTRCT and for
PTRCT Sn 93% and Sp 100%. The diagnosis of a large retracted tear is made when there
is nonvisualization of the SS tendon and the deltoid muscle is closely opposed to the
humeral cortex. This is a very reliable sign with a 100% PPV. A focal full thickness tear is
seen as a hypoechoic area extending through the rotator cuff; with subdeltoid bursal
fluid supporting the diagnosis. If the tear is large enough the adjacent deltoid muscle
may herniate into the tendon gap. Partial thickness tears may appear hypoechoic or of
mixed echogenicity.
MRI
Provides information about the state of the cuff, but up to 1/3 of individuals will have
asymptomatic cuff tears on MRI. MRI is better than ultrasound in diagnosing partial
thickness tears, but the two are similar in full thickness tears. Rotator cuff tear size is
graded as: small – less than 1cm; medium 1-3cm; large 3-5cm; massive – greater than
5cm. MRI is useful in assessing the degree of atrophy and fibrosis in the cuff in the
setting of massive cuff tears; if the muscle is fibrosed and retracted it is not likely to be
repairable. If the patient has grade 3 rotator cuff strength and the MRI shows the cuff
retracted to the glenoid rim with severe muscular atrophy this is almost certainly
irreparable.
Differential diagnosis
Glenohumeral instability
Degenerative joint disease
AC joint pathology
Adhesive capsulitis
Nerve compression syndromes – particularly suprascapular nerve
Cervical spondylosis
Treatment
Conservative treatment
Patients should avoid the impingement position
Strengthening of the rotator cuff in the non-painful position
NSAIDS
Steroid injections
Icing
Presented at The Indonesian Orthopaedic Association, 51th Continuing Orthopaedic Education
Balik Papan May 5-6, 2006.
Page 4
Ultrasound
The first phase of rehabilitation in tendinosis is rest and avoidance of the impingement
position. Anti-inflammatories are prescribed. Subacromial lignocaine and steroid
injections can be effective in pain relief. After the inflammation has settled range of
motion exercises are started. Stretching is taught. The last phase is the strengthening
phase, where rotator cuff, deltoid and scapula stabilizing exercises are prescribed.
Overhead activities should be avoided, particularly initially. Any muscle imbalance,
especially between external and internal humeral rotators, is addressed. Non-surgical
treatment is effective in up to 90% of patients. Poorer results are found in older patients
and patients with curved acromions. Nonoperative treatment should be pursued for at
least 6 months except for full thickness cuff tears. Bursal sided PTRCTs do not do well
when treated non-operatively. If non-operative treatment is being pursued, it is
reasonable to get an US after 6-12 months to rule out progression of the tear which may
make cuff repair impossible. Around 50% will progress.
Surgical treatment
Indicated in:
1. Failure to respond to conservative treatment in tendinitis (Neer’s stage II).
2. Full thickness rotator cuff tears with pain or symptomatic weakness
Impingement
Neer advocates subacromial bursal excision and division of the CA ligament from the
medial acromial border for stage II impingement if disability persists for one year, and
doesn’t advocate acromioplasty unless there is overhang and prominence of the
underside of the acromion. Hawkins mentions division of the CA ligament in patients
with ongoing sx in Stage I who fail one year of conservative treatment, but emphasizes
that the patient should have a period off sports first. If the AC joint is symptomatic or
preventing adequate view of the supraspinatus it needs debridement or excision.
Acromioplasty can be open or arthroscopic, and it has been shown on cadavers that a
full and accurate arthroscopic decompression can be done. The results are similar.
Cuff tears
Surgery can be open or arthroscopic. Arthroscopic surgery allows visualization of both
sides of the cuff, and the ability to deal with other glenohumeral or labral pathology
which is frequently co-existent. The mini-open technique uses arthroscopy first to locate
the tear, plus or minus deal with intra-articular pathology; a small deltoid splitting
incision is then used to get access to the cuff. It minimizes detachment of the deltoid
from the acromion. This decreases the risk of catastrophic deltoid dysfunction, but
doesn’t shorten the rehabilitation time, because this is dependent on rotator cuff
healing. The tear should be small and easily mobilizable.
Presented at The Indonesian Orthopaedic Association, 51th Continuing Orthopaedic Education
Balik Papan May 5-6, 2006.
Page 5
In open surgery bursal side PTRCTs can be seen, but not articular sided partial tears.
Fukuda describes the colour test, where methylene blue is injected into the
glenohumeral joint, and diffuses preferentially into areas of bursal sided partial tears.
Open surgery is usually combined with acromioplasty and provides around 80-90%
satisfactory results.
Partial thickness tears have a tendency to progress, with one study demonstrating 80%
progression on ultrasound. Tears up to 50% cuff width should be treated with
debridement (however note that after debridement there was no evidence of healing at
second look arthroscopy); tears bigger than this should be treated with excision of the
degenerate portion and cuff repair. This is backed up by a study looking at tears >50%
thickness, where there were no recurrences in the group undergoing excision and repair,
but progression to complete tear in 10% of patients treated only with debridement.
Debridement should usually be combined with subacromial decompression;
acromioplasty if the acromion is hooked, CA ligament division and bursectomy if type I
acromion. This leads to 75-80% satisfactory results. Acromioplasty is contraindicated in
elite throwing athletes less than 35 who have a low rate of return to elite competition if
this is done.
Surgery should be considered early in patients with complete cuff tears. Treatment
consists of acromioplasty; excision of the coraco-acromial ligament and repair of any
associated cuff tears. Surgery should only be considered if the patient is willing and able
to undergo prolonged physiotherapy post-operatively. Debridement has inferior results
compared with repair of the cuff; thus the trend is to repair any tear that causes pain or
significant loss of function.
Technique of open cuff repair
Beach chair position
Variable skin incision – sabre cut vs. horizontal. Matsen prefers an oblique incision
centred on the anterolateral corner of the acromion, perpendicular to the deltoid fibres.
Deltoid split for 2-3 cm from anterolateral corner of acromion, then along acromion to
ACJ. The split should be in the tendon of origin found between the anterior and middle
thirds. This tendon arises from the anterior lateral corner of the acromion. The spit is
carried over the acromion and into the trapezius insertion.
Anteroinferior acromioplasty, to level of ACJ AFTER INSPECTION OF THE CUFF. If the cuff
is not amenable to repair an acromioplasty will be deleterious. In this situation, the
undersurface of the coracoacromial arch is smoothed off, and any debris, scar or
thickened bursa in the subacromial space is removed. The top of the humeral head may
also be smoothed off.
Presented at The Indonesian Orthopaedic Association, 51th Continuing Orthopaedic Education
Balik Papan May 5-6, 2006.
Page 6
Excision of ACJ if:
1.
Symptomatic
2.
Osteophytes inferiorly
3.
Inadequate view
Bursectomy, Identification of tear, Debridement to adequate tissue.
Mobilize tendons:
1.
Release subacromial adhesion
2.
Release intraarticular adhesions
3.
May need to release capsule
4.
Divide coracohumeral ligament
5.
Release rotator interval to base of coracoid. The complete release of the
coracohumeral ligament and rotator interval is called the interval slide and
should allow the supraspinatus to be mobilized 1-1.5cm laterally.
Repair with arm at side into bone trough. The modified Mason-Allen stitch is preferred
for attachment to the cuff. Tendon to bone fixation with transosseous sutures. Sutures
need to be braided, non-absorbable, pass through bone at least 1.5 to 2cm distal to tip
of tuberosity with at least 1cm separation. Knots should be buried or tied laterally to
avoid impingement. If the biceps is torn, the proximal stump is resected and the distal
stump tenodesed in the bicipital groove. Reattach deltoid with nonabsorbable sutures.
Postoperative management
Passive ROM exercises are started immediately and continued for 6 weeks while the
bone tendon interface heals. 140-40 aimed for. Active ROM exercises are then
continued for another 6 weeks, before formal strengthening starts. Patients who have
arthroscopic decompression and debridement alone can start active ROM immediately
because the deltoid hasn’t been detached and no tendon repairs need to be protected.
Results of open repair
85-95% satisfactory pain relief
85-95% significant improvement in shoulder function.
Patient satisfaction correlates most closely with pain relief
Salvage of massive cuff tears
A massive cuff tear is defined as one more than 5cm or involving two or more tendons.
Prospective studies show these are worth repairing, with one study of 30 patients having
significant improvements in pain, function and ROM at 6 ½ years. Can the tear be
repaired? This depends on whether the retracted tendon can be advanced. This is
probably best assessed via an open procedure, where subdeltoid, subacromial and
Presented at The Indonesian Orthopaedic Association, 51th Continuing Orthopaedic Education
Balik Papan May 5-6, 2006.
Page 7
intraarticular adhesions can be looked for and addressed. The supraspinatus can only be
advanced 3cm before excessive tension develops in the neurovascular bundle.
Neer mentions transferring half of the subscapularis and infraspinatus tendons
superiorly. If unreconstructable an acromioplasty is contra-indicated because this will
remove the remaining restraints to superior translation of the humeral head, and result
in possible superomedial humeral head dislocation (Flatow). Degenerate cuff tissue
should be debrided. Ellman and Gartsman have reported “reasonable” pain relief at up
to 5 years with debridement alone, and emphasize that thorough debridement and
synovectomy are needed, plus debridement of any acromial or AC joint spurs. If
reconstruction is required, then supraspinatus advancement, latissimus dorsi transfer,
rotator cuff transposition, fascia lata autograft or synthetic tendon graft may be
performed. The best results appear to be with latissimus dorsi transfer; auto and
allografts have poor success rates.
The biceps tendon
This can be debrided or repaired as required. Tenodesis is recommended if the tendon
is subluxing into the joint, or has more than 50% attenuation.
Treatment of rotator cuff arthropathy
Hemiarthroplasty with a large head, if the anterior deltoid is preserved. This fits into the
acetabularized glenoid-coracoacromial arch, and provides predictable pain relief,
although function isn’t great. The glenoid should not be resurfaced.
Complications of acromioplasty/cuff repair
1.
Acromial fracture
2.
Deltoid dehiscence
3.
Weakness
4.
Failure of repair
5.
Deep and superficial wound infection
6.
Adhesive capsulitis
Subcoracoid impingement
This is associated with a laterally placed coracoid process that can impinge on the
proximal humerus with forward flexion and internal rotation. Patients tend to have more
medial pain, referred to the arm and forearm. The diagnosis can be made by performing
a CT with the arm in the provocative position or by injection of local anaesthetic into the
area. Treatment is by resection of the lateral aspect of the coracoid process.
Internal impingement
Impingement of the posterior labrum and cuff can occur in throwing athletes with
external rotation and anterior translation.
Presented at The Indonesian Orthopaedic Association, 51th Continuing Orthopaedic Education
Balik Papan May 5-6, 2006.
Page 8
Isolated tears of the subscapularis tendon
Note: most subscapularis tears are associated with traumatic anterior dislocation and
are often followed by symptoms of recurrent instability.
Gerber reported on 16 cases of isolated rupture in the JBJS(B) in 1991. All were in men
and the average age was 50. The mechanism of injury was forceful hyperextension or
external rotation of the adducted arm. The tear was associated with pain when using the
arm overhead and also below shoulder level. The tear was usually associated with
increased external rotation of the shoulder, weakness of internal rotation and a
pathological lift off test. The patient complained of anterior shoulder pain and weakness
of the arm when it was used above and below shoulder level (the latter would be
unusual in supraspinatus tears). There was no associated shoulder instability. The tear
of the subscapularis was usually associated with medial subluxation of
the biceps.
Presented at The Indonesian Orthopaedic Association, 51th Continuing Orthopaedic Education
Balik Papan May 5-6, 2006.
Page 9