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

Anatomy Subscapularis Long Head of Biceps

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

Pathophysiology 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 Glenohumeral instability Accentuates abnormal loading Can lead to internal impingement

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

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

Classification Partial Bursal vs Articular < 50% thickness Complete Organize by size Number of muscles involved

Mechanism Traumatic vs Chronic/Insiduous

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

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

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

Physical Exam 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. Mostly infraspinatus

Physical Exam TERES MINOR Hornblower's sign: 90º shoulder abduction, elbow 90º, resisted ER (teres minor)

The Taking-the-oath Position

Physical Exam Long head of biceps testing Speed’s test Yergason’s test FF 90, elbow 0, supinated forearm resisted downward force biceps or SLAP Yergason’s test 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 Deltoid Serratus anterior resisted abduction at 90 winging

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

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

Imaging Plain radiographs Axillary Supraspinatus outlet AC joint subluxation, os acromiale (association with rotator cuff tears - beware excision with acromioplasty) Supraspinatus outlet 10 to 15 degree caudal tilt of transcapular lateral can see acromial spurs well AC joint 10 to 30 degree cephalad tilt of AP

Ultrasound 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

Full thickness Partial thickness

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

MRI vs Ultrasound 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 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 Static study More expensive Longer wait-list Can assess intra-articular pathology, such a labral tears. Easier to read

Differential Diagnosis 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

Treatment 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 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 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 Corticosteroid injections Blair & Zuckerman JBJS-A 1996 Subacromial impingement  RCT Subacromial corticosteroid vs lidocaine

Cortisone vs Lidocaine Pain 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

Indications for Surgery Failed conservative management 3 to 12 month course of NSAIDs, physio, corticosteroid injections, activity modification 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)

Contraindications to Surgery Asymptomatic tear Chronic “massive” irreparable tears Tendon retraction past glenoid rim Fatty degeneration of muscle Increased width of subtrapezial fat pad Frozen shoulder Need ROM pre-op 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 Open repair Arthroscopic-assisted Mini-open Complete Arthroscopic +/- subacromial decompression

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

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

Results of Surgery 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 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 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

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. American Shoulder and Elbow Surgeons Shoulder score F/U 1 year No Difference

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

Arthroscopic Repair Disadvantages concerns about fixation with suture anchors? 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

Results of Surgery 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 lasting integrity of repair better with smaller tears

Results of Surgery

Results of Surgery

Results of Surgery

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