Transcript Rotator Cuff Tears - American Academy of Orthopaedic Surgeons

Rotator Cuff Tears
Daniel Penello
Upper Extremity Rounds
22 Feb 2006
Anatomy
Subscapularis
Long Head of
Biceps
Function
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“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
Pathophysiology
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Intrinsic Factors
– Vascular supply (? significance)
Distal 1cm of supraspinatus tendon
(early studies)
 Hypervascularity with tendonitis
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– Degenerative changes
Age related
 Change in proteoglycan and collagen
content in symptomatic tendons
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Pathophysiology
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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
Pathophysiology

Extrinsic factors
– Repetitive use
Tensile overload
 Muscle fatigue
 Microtrauma
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– Glenohumeral instability
Accentuates abnormal loading
 Can lead to internal impingement
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Incidence
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Lehman - Bull Hosp Jt Dis 1995
– 235 cadavers
– overall incidence full thickness tears 17%
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< 60 yo = 6%
> 60 yo = 30%
Yamanaka & Fukuda 1983
– partial thickness tears 13% incidence
– commonly intratendinous
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< 40 yo = 0%
> 40 yo = 30%
Incidence
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Sher et al. JBJS-A 1995
– MRI asymptomatic volunteers
Normal, painless function
 19 to 39
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– 0% full thickness
– 4% partial (1 of 96)
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40 to 60
– 4% full thickness
– 24% partial thickness
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Over 60 years old --> 54% incidence
– 28% full thickness
– 26% partial thickness
Classification
Partial
Bursal vs Articular
< 50% thickness
> 50% thickness
Complete
Organize by size
Number of muscles involved
Mechanism
Traumatic
vs
Chronic/Insiduous
Pitching
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As larger muscles
fatigue, the
posterior capsule
and rotator cuff
play a larger role
in decelerating the
arm.
Leads to tensile
overload and
fatigue
Pitching
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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
Pain and/or
fatigue of cuff
Rotator Cuff
dysfunction
Impingement
with motion
Posterior Capsular
Tightness
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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
History
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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
Physical Exam
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Inspection: atrophy, symmetry
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Palpation: AC, cuff tenderness
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Range of motion: active, passive
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Strength: ER and elevation power, lag
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Provocative: impingement sign, arc of
pain
Physical Exam
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Impingement testing
NEER SIGN
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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
Physical Exam
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Impingement testing
Hawkin's test
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With patient’s arm abducted to 90°, then
shoulder internally rotated, pushing the
supraspinatus against the anteroinferior
acromion, with increased shoulder pain
Physical Exam
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SUBSCAPLULARIS
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

Physical Exam
SUPRASPINATUS
 Jobe's
Test:
arm abducted in
the plane of the
scapula, thumb
pointing down .
Resist elevation of
the arm.
Physical Exam
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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.
Physical Exam
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TERES MINOR
Hornblower's sign:
90º shoulder
abduction,
elbow 90º,
resisted ER
(teres minor)
The Taking-the-oath Position
Physical Exam
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Long head of biceps testing
– Speed’s test
FF 90, elbow 0, supinated forearm
 resisted downward force
 biceps or SLAP
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– Yergason’s test
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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
Physical Exam
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Deltoid
– resisted abduction at 90
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Serratus anterior
– winging
Physical Exam
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AC joint testing
Horizontal adduction
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forced cross body
adduction in
90ºflexion, pain at
the extreme of
motion indicative
of ACJ pathology
Imaging
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Plain radiographs
– AP
 glenohumeral arthritis, calcific
tendonitis, migration of humeral head
superiorly, greater tuberosity changes
(cysts or sclerosis indicating chronic
tear)
– Transcapular lat
Imaging
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Plain radiographs
– Axillary
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subluxation, os acromiale (association with
rotator cuff tears - beware excision with
acromioplasty)
– Supraspinatus outlet
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10 to 15 degree caudal tilt of transcapular
lateral
can see acromial spurs well
– AC joint
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10 to 30 degree cephalad tilt of AP
Ultrasound
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Teefey JBJS-A 2000 - 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
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Full
thickness
Partial
thickness
Ultrasound
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Technician
dependent
Can be a dynamic
study
Easier to obtain
Hard to read
MRI vs Ultrasound
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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
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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
MRI
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Static study
More expensive
Longer wait-list
Can assess intraarticular pathology,
such a labral tears.
Easier to read
Differential Diagnosis
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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)
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
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Treatment
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Mainstay is conservative
Surgery reserved for significantly
symptomatic patients who have failed
conservative management > 6 -12
months
Younger patient (<60) with acute tear
– Cuff repair within 6 weeks
Non-Operative Treatment
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33-90% successful (Campbell’s)
Candidates:
– Partial thickness tears
– Older patients with chronic large tears and
extensive cuff muscle atrophy
NSAIDs
 Symptom control ± ↓ inflammation
Non-Operative Treatment
Therapy
- Stretch posterior capsule with Sleeper
Stretch
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WRONG
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
Subacromial Cortisone
Injection vs Lidocaine
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Corticosteroid injections
– Blair & Zuckerman JBJS-A 1996
– Subacromial impingement  RCT
– Subacromial corticosteroid vs lidocaine
Cortisone vs Lidocaine
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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
Indications for Surgery
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Failed conservative management
– 3 to 12 month course of NSAIDs, physio,
corticosteroid injections, activity modification
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Significant or progressive weakness, esp.
acute
– Early repair if <50 y.o. and full-thickness tear
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Differential diagnosis confirms weakness is
from rotator cuff tear (i.e. MRI findings
correlate with exam, rule out other causes)
Contraindications to
Surgery
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Asymptomatic tear
Chronic “massive” irreparable tears
– Tendon retraction past glenoid rim
– Fatty degeneration of muscle
– Increased width of subtrapezial fat pad
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Frozen shoulder
– Need ROM pre-op
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Unwilling or unable to participate in post-op
physio
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
Surgical Options
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Open repair
Arthroscopic-assisted Mini-open
Complete Arthroscopic
+/- subacromial decompression
Surgical complications
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Postoperative shoulder stiffness
Infection
Deltoid injury
Repair failure
Neurovascular injury
Partial thickness tears
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No RCT’s
– Usually on the articular surface of the
supraspinatus insertion
– Subacromial decompression ±
arthroscopic debridement
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Alone if <50% of cuff thickness, <1cm
– Repair if >50% of cuff thickness
(Gartsman)
Results of Surgery
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Open vs arthroscopically-assisted
– Baker & Liu 1995
similar results @ 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

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%
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.
Results of Surgery
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Arthroscopic vs open Acromioplasty: A
prospective, randomized, blinded study.
Spanghel et al. J Shoulder Elbow Surg.
2002. Vancouver
– 62 patients randomized
– F/U minimum 12 months (25 month avg)
– Primary outcome was visual analog scales
for pain and function
Results of Surgery
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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
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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.
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American Shoulder and Elbow Surgeons
Shoulder score
F/U 1 year
No Difference
Arthroscopic Repair
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Advantages
– deltoid preservation
– diagnose and treat glenohumeral
pathology
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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
Arthroscopic Repair
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Short-Term Advantages
– decreased immediate postoperative pain,
shorter hospital stay, earlier rehabilitation
– decreased postoperative stiffness
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adhesive capsulitis with mini-open?
Arthroscopic Repair
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Disadvantages
– concerns about fixation with suture
anchors?
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Ogilvie-Harris Am J Sports Med 1996
– suture anchor pullout > transosseous
– difficult to use tendon-grasping suture
– more difficult
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
287 N
Massive Cuff
250 N
Mason-Allen
212 N
Simple Stitch
191 N
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Results of Surgery
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Open repairs
– better results with smaller tears, and
better pre-op ROM
– older tears with more pre-op weakness
less likely to do well
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steroids, smoking, previous failed surgery
– lasting integrity of repair better with
smaller tears
Results of Surgery
Results of Surgery
Results of Surgery
Results of Surgery
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Arthroscpically-assisted repairs
– arthroscopic acromioplasty ± distal
clavicle excision if AC arthrosis
– deltoid-split mini-open repair of cuff
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Levy 1990
– <3cm tear = 100% satisfaction
– >3cm tear = 67% satisfaction