1. When to repair the rotator cuff?
Mr Simon Holland
Ringwood Private Hospital

2. Take home messages The rotator cuff has limited healing potential
Untreated rotator cuff tears may result in cuff tear arthropathy
Consider in all patients less than 60 y.o.
Need a mobile shoulder

3. The rotator cuff has limited healing potential
The tendon typically tears in a hypovascular zone of the supraspinatus tendon
Poor blood supply = poor healing potential
Once a full thickness tear, the tendon retracts across the humeral head with minimal chance to adhere to this surface

4. Untreated rotator cuff tears may result in cuff tear arthropathy
This can be painful or painless
Often in patients with previous surgery
Difficult treatment options dependent on bone anatomy and pain
Treatment aims to maximize function vs loss of pain

5. Consider in all patients less than 60 y.o.
60% of 60 year olds will have a rotator cuff tear on imaging
Most will will be asymptomatic
Most 70 year old rotator cuff tissue is of questionable quality

6. Need a mobile shoulder
A rotator cuff repair in a frozen shoulder is unlikely to be successful
Aim for passive range of motion
Physio - Jackin’s program
Hydrodilatation
Time
Surgical release

7. Case 1 F53 Hairdresser self employed
Night pain, struggling with work (shoulder height) for 12 months
Failed physio
Good ROM
Weak SS (4/5)
Acromioclavicular joint non tender

8. Rotator Cuff Examination
Tenderness - tendon insertion, AC joint
If AC joint, ? cross arm or O’Brien’s aggravates
If posterior joint line, ? degenerative joint
ROM - exclude adhesive picture
Power (out of 5)
SS, IS, Subsc, Biceps

9. Imaging Ultrasound (not particularly useful)
Suggested no tear, and patient delayed in presentation
Xrays - arranged - every patient
AP, true AP, Scapular Lateral and Axillary Lateral
Exclude other causes - OA, AC joint, fracture, cancer

10. Glenohumeral Arthritis

13. True AP

14. AP

15. Scapula Lateral

16. Axillary Lateral

17. Imaging
MRI scans
When diagnosis is in doubt such as when pain is severe and patient wishes to know now, and not wait for time
Suspect multiple pathologies / limited equipment inventory
When third parties have an interest. Check and acknowledge other pain generators

18. Management Diagnosis SS full thickness tendon tear Treatment Options
More of the same with subacromial cortisone injections
Surgical

19. Treatment Non Operative
Much research into why most tears are asymptomatic
EMG studies suggest poor subscap function in painful tears, but subscap directed treatment has not produced clinical nor EMG results
Equatorial theories - tear extends beyond a certain latitude, defunctioning the intact tendons

20. Treatment Operative Options Subacromial Decompression
Rotator Cuff Repair
Acromioclavicular joint excision
Biceps Tenodesis

21. Subacromial Decompression
Arthroscopic or open
Assess coracoacromial ligament and undersurface of acromion
Smooth and débride
Resect subacromial bursa
Débride partial thickness tears of the undersurface(articular sided) of the rotator cuff

22. Rotator Cuff Repair Arthroscopic, Open or Combination
Complete and incomplete
Anchors vs no anchors
Single vs double row repairs
Can serialize footprint

23. Acromioclavicular Joint Excision
Often co-existing pathology
May contribute to SS impingement
Open or Arthroscopic

24. Biceps Tenodesis
Biceps often involved, especially with subscap tears where it subluxates and impinges against the coracoid process with adduction and internal rotation
Reattach or tenotomize
Can be trouble in its own rite

25. Principle Risks Unintentional stiffness - compared to stabilization
Infection - < 1% for arthroscopic procedures
Repair failure, often asymptomatic
Healing of collagen is weakest at 4 months

26. Procedure Overnight Home exercise program Analgesia and ice
Oxycontin, oxycodone/p. forte/digesic, NSAID
Sling for 6 weeks

27. Recovery 0 - 10 days - standard exercises, keep away from work
11d to 6 weeks - sling, light duties
weeks - no sling, light duties
> 12 weeks - start to see a physio
> 6 months - aim for normal duties
18 month before full recovery

28. Recovery 0 - 2 weeks - will not think I am a friend
6 weeks - suspect I have helped
3 months - certain that I have helped and frustrated at the speed of healing
6 months - about 90% when look back

29. Case 1
Uneventful double row arthroscopic supraspinatus repair

30. Case 2 M45, truck driver Fall 2 months ago while unloading truck
Sudden pain, unable to lift away from body and not responding to non op measures
Smoker

31. Case 2 Slight loss ROM Tender - B, SS, Subsc
SS 4+. Subsc 3 (belly press), B 4
Prominent AC, non tender

32. Case 2 US - aPTT of SS (hoped for a clue with biceps - need good ROM)
XR and MRI
SS and Subsc FTT with Biceps Subluxation
AC arthropathy

33. Case 2 3 cm subsc tear, < 1 cm SS tear
Arthroscopic Subacromial decompression
Arthroscopic AC Joint excision
Open Subscap and SS repair with biceps tenodesis

34. Case 2

35. Case 3 F47 Office work Fall in garden 8 months ago
Initially not able to actively move, sling for two weeks, gradual loss of movement
CSI of no value
NIDDM

36. Case 3 Poor ROM and global cuff weakness 4/5 Tender - general, AC 
US - SS tear
XR - no OA

37. Case 3 MRI - not going to change management.
Treat as adhesive capsulitis and when motion restored, reassess rotator cuff clinically and radiologically as indicated.

38. Case 4 M35, sales representative
Mountain bike accident on single trail
? dislocation, self reduced 6 weeks ago
Unable to elevate arm

39. Case 4 Tender SS, posterior humeral head, anterior joint line
Full passive ROM, reduced active (< 60 FE)
Anterior laxity and positive apprehension signs
3/5 SS power

40. Case 4
General Rule
50% of those > 40 y.o. with a first time traumatic dislocation will have a rotator cuff tear.
Treatment is directed at the rotator cuff first and the instability second.
MRI is often helpful

41. Case 4

42. Case 5
M63, farmer
Longstanding ache that was at nuisance level for years, tripped at home and worsening pain and function
SS 4/5, IS 3/5

43. Case 5 Diagnosis = Massive Rotator Cuff tear Xray to exclude fracture
Likely longstanding tear that extended.
Arthroscopic techniques offer less morbidity and better access to tendons
Discuss possible irreparable tendon

44. Case 5
> 5 cm tear (massive)
Double row repair

45. Questions ?

46. Summary
When symptoms are more than a nuisance and non operative measures have been explored, surgical management and possible repair are viable treatment options.

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