Rotator Cuff Tears

Author: Derek Moore

Topic updated on 05/02/13 5:59pm

Introduction

Impingement and rotator cuff disease are a continuum of disease including
- subacromial impingement
- subcoracoid impingement
- calcific tendonitis
- rotator cuff tears (this topic)
- rotator cuff arthropathy
Rotator cuff tears may involve individual tendons or a combination of tendons
- often associated with AC joint pathology
Overhead throwing athletes
- partial thickness rotator cuff tears are associated with internal impingement
- deceleration phase of throwing leads to tensile forces and potential for rotator cuff tears
Mechanisms include
- chronic degenerative tear
  - usually seen in older patients
  - usually involves the SIT (supraspinatus, infraspinatus, teres minor) muscles but may extend anteriorly to involve the superior margin of subscapularis tendon in larger tears
- acute avulsion injuries
  - acute subscapularis tears seen in younger patients following a fall
  - acute SIT tears seen in patients > 40 yrs with a shoulder dislocation
  - full thickness rotator cuff tears need to be repaired in throwing athletes
- iatrogenic injuries
  - due to failure of surgical repair
    - often seen in repair failure of the subscapularis tendon following open anterior shoulder surgery.

Anatomy

Terminology
- rotator interval
  - includes the capsule, SGHL, and the coracohumeral ligament that bridge the gap between the supraspinatus and the subscapularis.
- rotator crescent
  - thin, crescent-shaped sheet of rotator cuff comprising the distal portions of the supraspinatus and infraspinatus insertions.
- rotator cable
  - thick bundle of fibers found at the avascular zone of the coracohumeral ligament running perpendicular to the supraspinatous fibers and spanning the insertions of the supra- and infraspinatus tendons.
Function
- the primary function of the rotator cuff is to provide dynamic stability by balancing the force couples about the glenohumeral joint in both the coronal and transverse plane.
  - coronal plane
    - the inferior rotator cuff (infraspinatus, teres minor, subscapularis) functions to balance the superior moment created by the deltoid
  - transverse plane
    - the anterior cuff (subscapularis) functions to balance the posterior moment created by the posterior cuff (infraspinatus and teres minor)
  - this maintains a stable fulcrum for glenohumeral motion.
  - the goal of treatment in rotator cuff tears is to restore this equilibrium in all planes.
Complete glenohumeral anatomy

Classification

Anatomic Classification
Supraspinatus, infraspinatus, teres minor (SIT) tears	Make up majority of tears Associated with subacromial impingement Mechanism is often a degenerative tear in older patients or a shoulder dislocation in patients > 40 yrs.
Subscapularis tears	New evidence suggest higher prevalence than previously thought Associated with subcoracoid impingement Mechanism is often an acute avulsion in younger patients with a hyperabduction/external rotation injury or an iatragenic injury due to failure of repair

Cuff Tear Size
Small	0-1 cm
Medium	1-3 cm
Large	3-5 cm
Massive	> 5 cm (involves multiple tendons. In the European classification a massive tear is defined as involving 2 or more tendons)

Cuff Atrophy (Goutallier)
0	Normal
1	Some fatty streaks
2	More muscle than fat
3	Equal amounts fat and muscle
4	More fat than muscle

Cuff Tear Shape
Crescent ....................	Usually do not retract medially, are quite mobile in the medial to lateral direction, and can be repaired directly to bone with minimal tension.
U-shape	Similar shape to crescent but extend further medially with apex adjacent or medial to the rim of the glenoid. Must be repaired side-to-side using margin convergence first to avoid overwhelming tensile stress in the middle of the rotator cuff repair margin.
L-shape	Similar to U shape except one of the leaves is more mobile than the other. Use margin convergence in repair.
Massive & immobile	May be u-shaped or longitudinal. Difficult to repair and often requires and interval slide.

Presentation

Symptoms
- insidious onset of pain exacerbated by overhead activities
- night pain, which is a poor indicator for nonoperative management

Physical exam (complete exam of the shoulder

)

Overview of Physical Exam of Rotator Cuff
Cuff Muscle	Strength Testing	Special Tests
Supraspinatus	Weakness to resisted elevation in Jobe position	Drop arm test Pain with Jobe test
Infraspinatus	ER weakness at 0° abduction	ER lag sign
Teres minor	ER weakness at 90° abduction and 90° ER	Hornblowers
Subscapularis	IR weakness at 0° abduction	Excessive passive ER Belly press Lift off IR lag sign

Imaging

Radiographs
- AP may show
  - calcific tendonitis
  - calcification in the coracohumeral ligament
  - proximal migration of humerus seen with chronic RCT
- outlet view may show a
  - Type III (hooked) acromion
  - os acromiale
Arthrogram
- not commonly used in isolation; used when MRI contraindicated
- rotator cuff tear present if dye leaks from glenohumeral joint into subacromial joint
- MR arthrogram may improve sensitivity and specificity
MRI
- diagnostic of rotator cuff pathology
  - in asymptomatic patients 60 yrs and older, 55% will have a RCT
- important to evaluate muscle quality
  - size, shape, and degree of retraction of tear
  - degree of muscle fatty atrophy (best seen on sagittal image)
- medial biceps tendon subluxation
  - indicative of a subscapularis tear
- cyst in humeral head on MRI seen in almost all patients with chronic RCT
Ultrasound
- another option for imaging the rotator cuff
- advantages include:
  - allows for dymanic testing
  - inexpensive
  - readily available at most centers
- disadvantages include:
  - highly user dependent
  - limited ability to evaluate other intraarticular pathology
- similar sensitivity, specificity, and overall accuracy for diagnosis of rotator cuff disease as compared to MRI
- 23% of asymptomatic patients had a rotator cuff tear on ultrasound in one series

Treatment

Treatment considerations
- activity and age of patient
- mechanism of tear (degenerative or traumatic avulsion)
- characteristics of tear (size, retraction, muscle atrophy)
  - partial thickness tears vs. complete tear
  - articular sided (PASTA lesion) vs. bursal sided
Nonoperative
- physical therapy, NSAIDS, and subacromial corticosteroid injections
  - indications
    - first line of treatment for most tears
    - grade 1 & 2 partial tears can be managed with therapy
  - technique
    - physical therapy with aggressive rotator cuff and scapular-stabilizer strengthening
    - subacromial injections if impingement thought to be major cause of symptoms
Operative
- arthroscopic or open rotator cuff repair
  - indications
    - bursal-sided tears >3 mm in depth
    - articular sided supraspinatous tears with >7mm of exposed bone between the articular surface and intact tendon represent significant (>50%) cuff tear that should be repaired if recalcitrant to conservative measures
  - postoperative
    - rate-limiting step for recovery is biologic healing of RTC tendon to greater tuberosity, which is believed to take 8-12 weeks
      - holes drilled in greater tuberosity are major source of vascularity to repaired rotator cuff
    - postop with limited passive ROM (no active ROM)
  - outcomes
    - Worker's Compensation patients report worse outcomes
      - higher postop disability and lower patient satisfaction
- tendon transfers
  - indications
    - massive cuff tears
    - Latissimus Dorsi transfer: best for irreparable posterosuperior tears with intact subscapularis

Surgical Technique

Arthroscopic subacromial decompression
- indications
  - impingement (subacromial and subcoracoid) )
- outcomes
  - poorer subjective outcomes associated with active workers’ compensation claim
Mini-open rotator cuff repair
- once was gold standard but has been largely been replaced by arthroscopic techniques
- advantages over open approach
  - decreased risk of deltoid avulsion
  - faster rehabilitation (do not need to protect deltoid repair)
    - may begin passive ROM immediately to prevent adhesive capsulitis
    - most surgeons wait ~6 weeks before initiating active ROM
Arthroscopic rotator cuff repair
- advantages
  - studies now show equivalent results to open or mini-open repair
- important concepts
  - margin convergence
    - shown to decrease strain on lateral margin in U shaped tears
  - anterior interval slide
    - release supraspinatus from the rotator interval (effectively incising coracohumeral ligament). This increases the mobility of supraspinatus and allows it to be fixed to the lateral footprint.
  - posterior interval slide
    - release supraspinatus from infraspinatus. This further increases the mobility of supraspinatus and allows it to be fixed to the lateral footprint. Then repair supraspinatus to infraspinatus with margin convergence.
  - subscapularis repair
    - although arthroscopic repair is technically challenging, new studies show superior outcomes (motion and pain) than open repair
    - stabilize biceps tendon with tenodesis
  - biceps tendon repair
    - tenodesis to lateral humerus provides greater return of function than tenotomy and should be performed whenever possible
  - footprint restoration
    - it is hypothesized that a larger footprint will improve healing and the mechanical strength of the rotator cuff repair
    - double row suture techniques (matress sutures in medial row and simple sutures in lateral row) have been shown to create a more anatomic repair of the footprint
    - addition of a trough in the greater tuberosity to allow tendon-to-cancellous bone interface as opposed to tendon-to-cortical bone has NOT show increased repair strength in animal models
Tendon transfers
- indicated for massive and irreparable rotator cuff tears
- pectoralis major transfer
  - indicated in chronic subscapularis tears
  - transferring pectoralis major under the conjoined tendon leads more closely resembles the vector forces of the native subscapularis
- latissimus dorsi transfer
  - indicated in large supraspinatus and infraspinatus tears
  - best candidate is young laborer
  - attach to cuff muscles, subscapularis, and GT
  - brace immobilize for 6 wks. in 45° abduction and 30° ER.
Lateral acromionectomy
- historic significance only
- contraindicated due to high complication rate
Coracoacromial ligament release
- Should be minimized in order to limit bleeding and anterosuperior escape
- Release leads to an increased anterior/inferior translation of the glenohumeral joint

Complications

Recurrence
- patient age >65 years is a risk factor for non-healing of rotator cuff repair
Deltoid detachment
- complication seen with open approach
AC pain
Axillary nerve injury
Suprascapular nerve injury
- may occur with aggressive mobilization of supraspinatus during repair

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Qbank (21 Questions)

TAG

(OBQ11.94) The rotator cuff in an overhead throwing athlete is most susceptible to tensile failure due to eccentric loading during which of the phases of throwing shown in Figure A? Topic

Review Topic

FIGURES: A

1. A
2. B
3. C
4. D
5. E

PREFERRED RESPONSE ▶

DISCUSSION: Label E is the deceleration phase of throwing in the overhead athlete. During this phase of throwing, the rotator cuff is the principle decelerator of the arm. The rotator cuff is susceptible to tensile failure due to eccentric loading during this phase. In throwers, these tears often occur on the articular side of the posterior supraspinatus or the infraspinatus. They may complain of posterior shoulder pain that is worse after ball release.

Illustration A is labelled to show the names of all of the phases of the overhead throwing cycle.

Illustrations: A

REFERENCES:

1. Kibler WB. Integrated biomechanics of the shoulder and elbow. In: Garrick JG, ed. Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2004:47-51.

2. Ponce B, Tokish JM. Arthroscopic reconstruction for anterior glenohumeral instability. In: Galatz LM, ed. Orthopaedic Knowledge Update: Shoulder and Elbow 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:113-133.

Question Authors:

Michael Hughes MD, Dave Marcu MD, Patrick McCulloch MD,

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(OBQ11.120) A worker's compensation patient is scheduled for rotator cuff repair. His case manager asks you to comment on the expected outcomes of worker's compensation patients. In general, when compared to those of non-worker's compensation patients, the worker's compensation group shows which of the following? Topic

Review Topic

1. Better functional outcomes and equivalent patient satisfaction
2. Less functional improvement and lower patient satisfaction
3. Equivalent functional outcomes and patient satisfaction
4. Equivalent functional outcomes and lower patient satisfaction
5. Less functional improvement and equivalent patient satisfaction

PREFERRED RESPONSE ▶

DISCUSSION: In general, worker's compensation patients undergoing shoulder surgery have been shown to have less functional improvement and lower patient satisfaction than non-worker's compensation patients.

Holtby et al looked at workers undergoing rotator cuff repair or subacromial decompression with acromioplasty. Compared to historical controls, they showed that injured workers reported a higher level of disability both before and after surgery. They did still show significant improvement from their baseline at 1-year follow-up, just not to the same level as non-work comp patients.

In a rotator cuff repair study by Misamore et al, of the 24 patients who were receiving worker's compensation, 54% rated themselves as good or excellent, compared with 92% of the patients who were not receiving worker's compensation. Only 42% of the worker's compensation patients returned to full activity, compared with 94% of the non-work comp patients.

REFERENCES:

1. Holtby R, Razmjou H. Impact of work-related compensation claims on surgical outcome of patients with rotator cuff related pathologies: a matched case-control study. J Shoulder Elbow Surg. 2010 Apr;19(3):452-60. PMID:19766021 (Link to Abstract)

2. Misamore GW, Ziegler DW, Rushton JL 2nd. Repair of the rotator cuff. A comparison of results in two populations of patients. J Bone Joint Surg Am. 1995 Sep;77(9):1335-9. PMID:7673282 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, John Badylak MD, Ben Taylor MD,

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(OBQ11.200) Which patient has the best indication for latissimus dorsi transfer? Topic

Review Topic

1. 55-year-old man with cuff tear arthropathy and proximal humeral migration
2. 85-year-old man with irreparable posterosuperior rotator cuff tear and 60 degrees of forward elevation and 0 degrees of active external rotation at his side
3. 45-year–old man with complete irreparable supraspinatus and subscapularis tears with 90 degrees of active forward elevation
4. 50-year-old man with large irreparable posterosuperior rotator cuff tear with 100 degrees of forward elevation and -10 degrees of external rotation
5. 35-year-old with an acute traumatic complete posterosuperior cuff tear with 0 degrees of active external rotation

PREFERRED RESPONSE ▶

DISCUSSION: The best indication for latissimus dorsi tendon transfer is a younger adult patient with an irreparable posterosuperior rotator cuff tear, lack of advanced glenohumeral arthritis, has an intact subscapularis function to stabilize the humeral head after latissimus transfer, and who maintains some active forward elevation.

Gerber demonstrated that a dysfunctional subscapularis is a relative contraindication as those patients without a subscapularis did poorly. The functional value of subscapularis deficient shoulders valued only 48% clinically while those with intact subscapularis were at 84%.

A biomechanical study by Werner et al also confirmed the importance of the subscapularis. He found that the glenohumeral joint lost stability with a deficient subscapularis and a latissimus transfer.

Incorrect Answers:
Answer 1: Cuff tear arthropathy may continue to be painful after a latissimus dorsi transfer.
Answer 2: An elderly patient >80 with a pseudoparalytic shoulder may not regain enough strength from a latissimus dorsi transfer.
Answer 3: A deficient subscapularis has poor results after latissimus transfer likely because of imbalance and instability.
Answer 5: An acute cuff tear in a young patient should have an attempted repair prior to any transfer.

REFERENCES:

1. Gerber C. Latissimus dorsi transfer for the treatment of irreparable tears of the rotator cuff. Clin Orthop Relat Res. 1992 Feb;(275):152-60. PMID:1735206 (Link to Abstract)

2. Werner CM, Zingg PO, Lie D, Jacob HA, Gerber C. The biomechanical role of the subscapularis in latissimus dorsi transfer for the treatment of irreparable rotator cuff tears. J Shoulder Elbow Surg. 2006 Nov-Dec;15(6):736-42. PMID:17126245 (Link to Abstract)

Question Authors:

Charles Jobin MD, John Badylak MD, Dave Marcu MD,

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(OBQ11.275) A 55-year-old carpenter presents with 6 weeks of right shoulder pain after installing ceiling drywall. He has no symptoms of night pain. His examination reveals 30 degrees lack of full flexion and abduction. He has full strength of the right shoulder. Radiographs are shown in Figures A and B. Coronal and Abduction-external rotation (ABER) MR images are shown in Figures C-E. What is the next most appropriate stem in management? Topic

Review Topic

FIGURES: A

1. Physical therapy
2. Platelet rich plasma (PRP) injection
3. Arthroscopic rotator cuff repair
4. Arthroscopic SLAP repair
5. Arthroscopic subacromial decompression

PREFERRED RESPONSE ▶

DISCUSSION: The history, examination, and imaging are consistent with a partial articular-sided supraspinatus tendon avulsion (PASTA). Physical therapy including shoulder range of motion and rotator cuff/periscapular stabilizer strengthening is the most appropriate initial treatment for the options provided.

Partial-thickness rotator cuff tears are most commonly classified by location (articular- or bursal-sided) and size (greater or less than 50% thickness). If conservative treatment options fail, then partial-thickness, articular-sided rotator cuff tears >50% can be treated with completion and repair (open or arthroscopic). If the tear is <50% then treatment consists of débridement of the tuberosity and undersurface rotator cuff. Repair of the tendon in situ (ie, partial articular supraspinatus tendon avulsion [PASTA] repair) is possible when remaining attached tissue is healthy. There are several studies that describe the anatomy of the supraspinatus footprint with an average maximum insertional length and width of 23 x 16 mm. The ABER position for MRI reduces the effacement of its articular surface on the humeral head. This reduced tension allows intra-articular contrast to flow into the defect and increases the sensitivity of detecting partial-thickness tears.

Sher et al performed MR examinations of 94 subjects with asymptomatic shoulders. When including both partial and full-thickness tears, they found the overall prevalence in all age-groups was 34%, and that this increased with patient age. Over 50% of the patients older than 60 years old and 28% of patients 40-60 years old had evidence of a rotator cuff tear. Only 4% of the patients aged 19-39 had a rotator cuff tear.

Illustration A depicts a PASTA lesion of the supraspinatus of a left shoulder as viewed from a posterior portal in the lateral decubitus position. Video A demonstrates a partial articular-sided supraspinatus tendon avulsion (PASTA) undergoing side-to-side repair.

Illustrations: A

REFERENCES:

1. Keener JD. Partial-thickness rotator cuff tears. In: Galatz LM, ed. Orthopaedic Knowledge Update: Shoulder and Elbow 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:161-171.

2. Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995 Jan;77(1):10-5. PMID:7822341 (Link to Abstract)

Question Authors:

Michael Hughes MD, Dave Marcu MD, Patrick McCulloch MD,

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(OBQ10.30) Rotator cuff tears (full thickness and partial thickness) in asymptomatic individuals are seen on MRI or ultrasound in what percentage of patients over the age of 60? Topic

Review Topic

1. 0-5%
2. 5-30%
3. 30-55%
4. 55-80%
5. 80-100%

PREFERRED RESPONSE ▶

DISCUSSION: The prevalence of asymptomatic rotator cuff tears diagnosed with MRI or ultrasound is quite high, with most studies noting tears in 30-55% of patients over the age of 60. The paper by Tempelhof et al utilized ultrasound and found tears in 30% of patients over 60. The study by Sher et al noted an overall prevalence of 54% on MRI in patients older than 60 (28% had full thickness and 26% with partial thickness). In both studies the frequency of tears increased substantially with increasing age.

REFERENCES:

1. Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg. 1999 Jul-Aug;8(4):296-9. PMID:10471998 (Link to Abstract)

Question Authors:

Robert Boykin MD, Patrick McCulloch MD, John Badylak MD,

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(OBQ10.92) A 64-year-old male suffers a fall while working on his farm and presents to the ER with the shoulder injury noted in Figure A. He undergoes reduction without complications, and post-reduction radiographs are shown in Figures B and C. At his 10 day clinic follow-up is noted to have an inability to raise his arm. Which of the following studies will best confirm the most likely diagnosis in this patient? Topic

Review Topic

FIGURES: A

1. MRI of the shoulder
2. EMG
3. CT-angiogram of the affected extremity
4. Repeat shoulder x-rays
5. MRI of the brachial plexus

PREFERRED RESPONSE ▶

DISCUSSION: This patient is most likley suffering from a massive rotator cuff tear which is accounting for his inability to raise his arm. The incidence of rotator cuff tear after acute dislocation in patients older than age 40 ranges from 35% to 86%. However, the incidence of rotator cuff pathology before the initial dislocation is not known. Axillary nerve injury can happen after acute shoulder dislocations, but usually are not severe enough to account for the significant weakness noted in this patient. Brachial plexus injuries are rare, and vascular injuries are associated with ischemic changes to the affected extremity. Shoulder fracture is unlikley in this case as the post-reduction radiographs show no bony injury. Stayner et al discuss the associated injuries, complications, and potential urgencies in diagnosis and treatment protocols of shoulder dislocations in the patient older than age 40. Simank et al documented the incidence of additional injuries in shoulder dislocations and compared the results of conservative to operative therapy for rotator cuff tears. In 54% of the patients enrolled a cuff tear was documented; the frequency increased with advancing age to 100% in patients over the age of 70. Symptomatic cuff tears did better with surgery than non-operative management.

REFERENCES:

1. Stayner LR, Cummings J, Andersen J, Jobe CM. Shoulder dislocations in patients older than 40 years of age. Orthop Clin North Am. 2000 Apr;31(2):231-9. PMID:10736392 (Link to Abstract)

2. Simank HG, Dauer G, Schneider S, Loew M. Incidence of rotator cuff tears in shoulder dislocations and results of therapy in older patients. Arch Orthop Trauma Surg. 2006 May;126(4):235-40. Epub 2005 Sep 8. PMID:16151824 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Patrick McCulloch MD, Patrick McCulloch MD,

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(OBQ10.152) During shoulder arthroscopy of a 58 year old female recreational golfer, the rotator cuff is examined and is seen to be intact on the articular side. After a bursectomy is performed in the subacromial space, a bursal sided tear is found measuring 1.5 cm in width and 4 mm in depth with surrounding cuff softening. What is the appropriate management? Topic

Review Topic

1. Debride the tear and perform an acromioplasty
2. Abort surgery and start a physical therapy program
3. Convert it to a full-thickness tear and repair it with suture anchors
4. Consider it incidental, as this is a common finding in this age group
5. Gently debride the tear only

PREFERRED RESPONSE ▶

DISCUSSION: Partial thickness rotator cuff tears on the articular side are more common than their bursal counterparts; however, the bursal tears are typically more symptomatic. Grading is based on depth (<25
%, 25-50%, >50% for Grades 1, 2, and 3 respectively) and side (articular (A) or bursal (B)). Cordasco et al performed a retrospective review of their patients who underwent acromioplasty and debridement without rotator cuff repair. Included were patients who had Grade 1 and 2 partial thickness rotator cuff tears. They found a 38% failure rate due to continued pain and functional disability for those patients who had Grade 2 bursal-sided rotator cuff tears. The patients who failed never had improvement of their symptoms, even immediately after surgery. Wolff et al provide a succinct review of partial rotator cuff tears including incidence, pathogenesis, presentation, evaluation and workup, natural history, and treatment. They conclude the literature suggests that for articular-sided tears >6 mm in depth and for bursal-sided tears of >3 mm in depth, the surgeon should consider repair.

REFERENCES:

1. Cordasco FA, Backer M, Craig EV, Klein D, Warren RF. The partial-thickness rotator cuff tear: is acromioplasty without repair sufficient? Am J Sports Med. 2002 Mar-Apr;30(2):257-60. PMID:11912097 (Link to Abstract)

2. Wolff AB, Sethi P, Sutton KM, Covey AS, Magit DP, Medvecky M. Partial-thickness rotator cuff tears. J Am Acad Orthop Surg. 2006 Dec;14(13):715-25. PMID:17148619 (Link to Abstract)

Question Authors:

Aaron Bott MD, Patrick McCulloch MD,

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(OBQ10.197) What is the average medial-to-lateral distance of the supraspinatus tendon insertion at its footprint on the greater tuberosity? Topic

Review Topic

1. 6-8mm
2. 14-16mm
3. 20-22mm
4. 24-26mm
5. 30-32mm

PREFERRED RESPONSE ▶

DISCUSSION: Cadaveric studies have shown the average medial-to-lateral distance of the supraspinatus tendon footprint on the greater tuberosity is 14-16mm.

Curtis et al dissected 20 fresh-frozen cadavers in order to identify the length and width of each rotator cuff muscle insertion on the humerus. They found that the average maximum insertional length (anterior to posterior distance, distance Y in Illustration A) and width (medial to lateral distance, distance X in Illustration A) of the supraspinatus insertion was 23 x 16mm respectively.

Dugas et al dissected 20 cadaveric specimens to determine an accurate and reproducible method of measuring the area and dimensions of the rotator cuff tendon insertions and their distance from the articular surface. They found that the mean minimum medial-to-lateral distance across the rotator cuff insertion occurred at the mid-portion of the supraspinatous, and measured 14.7mm. They also determined that area of insertion of the 3 tendons on the greater tuberosity averaged 6.24 cm2, and that the rotator cuff inserts very closely to the articular margin along the anterior 2.1cm of the greater tuberosity.

Illustrations: A

REFERENCES:

1. Dugas JR, Campbell DA, Warren RF, Robie BH, Millett PJ. Anatomy and dimensions of rotator cuff insertions. J Shoulder Elbow Surg. 2002 Sep-Oct;11(5):498-503. PMID:12378171 (Link to Abstract)

2. Curtis AS, Burbank KM, Tierney JJ, Scheller AD, Curran AR. The insertional footprint of the rotator cuff: an anatomic study. Arthroscopy. 2006 Jun;22(6):609.e1. PMID:16762697 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Patrick McCulloch MD, John Badylak MD, Mark Miller MD,

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(OBQ09.273) During diagnostic arthroscopic evaluation of a patient's shoulder, you identify a thickened portion of the coracohumeral ligament, near its avascular zone, running perpendicular to the supraspinatous tendon. The structure is identified in Figure A with black arrows. What is the name for this structure? Topic

Review Topic

FIGURES: A

1. Middle glenohumeral ligament
2. Rotator interval
3. Coracoid process
4. Rotator cable
5. Rotator crescent

PREFERRED RESPONSE ▶

DISCUSSION: The black arrows in Figure A identify the rotator cable, while the asterix identifies the rotator cresent.

The rotator crescent and rotator cable are two anatomic structures closely associated with the rotator cuff that form the shoulder's "suspension bridge." The rotator crescent is a thin, crescent-shaped sheet of rotator cuff comprising the distal portions of the supraspinatus and infraspinatus insertions. The crescent is bounded at its proximal margin by a thick bundle of fibers called the rotator cable, and thickened portion of supraspinatus. This cable-crescent spans the insertions of supraspinatus and infraspinatus tendons. The rotator cable is over 2.5 times thicker than the rotator crescent as measured by digital micrometer.

Clark and Harryman describe the complex anatomy of the rotator cuff including the "suspension bridge" of the rotator cuff and crescent in their anatomical sectioning of 32 grossly intact cuffs.

Burkhart and Lo review the anatomy, biomechanics, surgical techniques, and outcomes of the arthroscopic rotator cuff repair. They emphasize that achieving a biomechanically stable construct is critical to biologic healing, and discuss the different variables to obtain such a construct.

Illustration A shows an arthroscopic photo annotated with the rotator cable (arrows), rotator cresent (asterix), biceps tendon (BT), and humeral head (HH). Illustration B illustrates the relationship between the rotator cresent (CRES) and rotator cable (Label C). Illustration C shows a coronal cut of the suprespinatus, and how a thickened portion contributes to the rotator cable.

Incorrect Answers:
1) Middle glenohumeral ligament - anterior shoulder capsular thickening which provides resistance to anterior translation with the arm in 45 degrees of abduction
2) Rotator interval - the "space" between the anterior leading edge of the supraspinatus tendon and the superior border of the subscapularis tendons.
3) Coracoid process - the "light-house" of the shoulder, a bone projection off the anterior portion of the scapula, just medial to the glenoid.
5) Rotator crescent - thin sheet of rotator cuff comprising the distal portion of the supraspinatus and infraspinatus tendon insertions.

Illustrations: A

REFERENCES:

1. Clark JM, Harryman DT 2nd. Tendons, ligaments, and capsule of the rotator cuff. Gross and microscopic anatomy. J Bone Joint Surg Am. 1992 Jun;74(5):713-25. PMID:1624486 (Link to Abstract)

2. Burkhart SS, Lo IK. Arthroscopic rotator cuff repair. J Am Acad Orthop Surg. 2006 Jun;14(6):333-46. Review PMID:16757673 (Link to Abstract)

Question Authors:

Patrick O'Donnell MD/PhD, Patrick McCulloch MD, Eric Shirley MD, Mark Miller MD,

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(OBQ08.172) A latissimus dorsi tendon transfer is a well established procedure for treatment of massive irreparable posterosuperior rotator cuff tears. All of the following factors have been shown to result in worse clinical outcomes after a transfer EXCEPT? Topic

Review Topic

1. Nonsynergistic action of the transferred muscle
2. Fatty atrophy of the supraspinatus and infraspinatus
3. Deficiency of the subscapularis
4. Absence of the coracoacromial ligament
5. Deltoid weakness

PREFERRED RESPONSE ▶

DISCUSSION: A latissimus dorsi tendon transfer can be utilized in patients with a massive, irreperable rotator cuff tear involving the supraspinatus and infraspinatus. It has been reported to relieve pain and improve function in a carefully selected patient population. Those patients with deficiency of the deltoid or subscapularis, nonsynergistic muscle action after transfer, or fatty infiltration of the posterosuperior cuff have worse clinical outcomes. Absence of the CA ligament may allow anterosuperior escape in RC deficient shoulders but has not been shown to lead to worse outcomes after a tendon transfer. The paper by Warner, et. al demonstrated that poor tendon quality, stage 3/4 muscle fatty degeneration, and detachment of the deltoid insertion each had a statistically significant effect on the Constant score noting that salvage reconstruction of a previous cuff repair had more limited gains as compared to primary. The reference by Ianotti, et. al showed that synchronous in-phase contraction of the transferred latissimus dorsi is associated with a better clinical result while improved preoperative shoulder function and general strength also positively influence the clinical result.

REFERENCES:

1. Warner JJ, Parsons IM 4th: Latissimus dorsi tendon transfer: A comparitive analysis of primary and salvage reconstruction of massive, irreparable rotator cuff tears. J Shoulder Elbow Surg 2001; 10: 514-521 PMID:11743528 (Link to Abstract)

2. Iannotti JP, Hennigan S, Herzog R, Kella S, Kelley M, Leggin B, Williams GR. PMID:16452746 (Link to Abstract)

Question Authors:

Robert Boykin MD, Patrick McCulloch MD, Dave Marcu MD,

Please Rate Educational Value!

3.0

Average 3.0 of 15 Ratings

TAG

(OBQ07.10) Which of the following may be seen during arthroscopy in a patient with a subscapularis tear? Topic

Review Topic

1. Uncovered lesser tuberosity
2. Retraction of the subscapularis tendon to the level of the glenoid
3. Avulsed superior glenohumeral ligament
4. Medial biceps subluxation
5. All of the above

PREFERRED RESPONSE ▶

DISCUSSION: Degenerative subscapularis tears often involve only the superior portions of the tendon, however complete retacted tears also occur especially traumatic tears and after previous open surgery. All of the findings mentioned may be encountered.

The superior glenohumeral ligament(SGHL)/coracohumeral ligament(CHL) complex may show a partial tear which has been called the "comma sign" by Lo and Burkhart.

The David et al reference describes an arthroscopic technique to improve visualization of subscapularis pathology.

Illustration A shows an arthroscopic image with a retracted subscapularis tear and a superimposed comma present (H = humerus, G = glenoid, SSc = subscapularis tendon, M = medial sling of the biceps formed by the SGHL and the medial aspect of the CHL).

Illustrations: A

REFERENCES:

1. Lo IK, Burkhart SS. The comma sign: An arthroscopic guide to the torn subscapularis tendon. Arthroscopy. 2003 Mar;19(3):334-7. PMID:12627163 (Link to Abstract)

2. David TS, Bravo H, Scobercea R. Arthroscopic visualization of subscapularis tendon lesions.Orthopedics. 2009 Sep;32(9). PMID:19751026 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Ben Taylor MD, Robert Boykin MD,

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TAG

(OBQ06.179) The lift-off test evaluates internal rotation of the shoulder with the hand placed behind the back. During this test, which muscle exhibits the highest percent of maximal contraction? Topic

Review Topic

1. Subscapularis
2. Pectoralis major
3. Pectoralis minor
4. Latissimus dorsi
5. Supraspinatus

PREFERRED RESPONSE ▶

DISCUSSION: The lift off test is an examination of the internal rotators of the shoulder, and in particular, the subscapularis muscle (innervated by the upper and lower subscapular nerves). A clinical photo is shown in Illustration A. The referenced study by Gries et al reviewed the EMG findings of periscapular musculature during shoulder examination and found that the lift-off test achieves a higher proportion of subscapularis contraction as compared to the other answers above. No differences were seen in contraction of the upper or lower segments of the subscapularis. In contrast, the referenced article by Decker et al found that the upper and lower parts of the subscapularis are activated and work differently depending on humeral abduction.

Illustrations: A

REFERENCES:

1. Greis PE, Kuhn JE, Schultheis: Validation of the lift-off test and analysis of subscapularis activity during maximal internal rotation. Am J Sports Med 1996;24:589-593. PMID:8883677 (Link to Abstract)

2. Decker MJ, Tokish JM, Ellis HB, et al: Subscapularis muscle activity during selected rehabilitation exercises. Am J Sports Med 2003;31:126-134. PMID:12531769 (Link to Abstract)

Question Authors:

Ben Taylor MD, Patrick McCulloch MD, Dave Marcu MD,

Please Rate Educational Value!

4.0

Average 4.0 of 8 Ratings

TAG

(OBQ06.181) Which of the following patients is the optimal candidate for a latissimus dorsi transfer? Topic

Review Topic

1. 36-year-old laborer with massive rotator cuff tear and associated supraspinatus atrophy
2. 67-year-old non-laborer with rotator cuff tear arthropathy and pseudoparalysis
3. 34-year-old laborer with massive rotator cuff tear and thoracodorsal nerve palsy
4. 63-year-old with supraspinatus rotator cuff tear and subacromial impingement
5. 37-year-old non-laborer with extensive chondrolysis following a rotator cuff repair and indwelling pain catheter placement for postoperative pain

PREFERRED RESPONSE ▶

DISCUSSION: The most appropriate candidate for a latissimus transfer is the young laborer with a massive rotator cuff tear and atrophy of the supraspinatus fossa.

In 1988, Gerber et al described the technique of latissimus dorsi tendon transfer as a reconstructive option for irreparable posterosuperior rotator cuff defects. This procedure is predicated on restoring an active external rotation and flexion moment at the glenohumeral joint, as these motions constitute the primary functional deficits for this configuration of massive cuff tear.

Miniaci and Mcleod present Level 4 evidence of 17 patients who underwent latissimus dorsi tendon transfer after failed repair of a massive tear of the rotator cuff and found significant relief of pain (p<0.0001) and a significant improvement in function (p<0.001 for all activities except lifting more than fifteen pounds).

Warner and Parsons present Level 3 evidence of 16 patients who underwent latissimus dorsi transfer as a salvage procedure compared to 6 patients who had transfer as a primary procedure. They concluded that salvage reconstruction of failed prior rotator cuff repairs yields more limited gains in satisfaction and function than primary latissimus dorsi transfer.

REFERENCES:

1. Miniaci A, MacLeod M. Transfer of the latissimus dorsi muscle after failed repair of a massive tear of the rotator cuff. A two to five-year review. J Bone Joint Surg Am. 1999 Aug;81(8):1120-7. PMID:10466644 (Link to Abstract)

2. Warner JJ, Parsons IM 4th. Latissimus dorsi tendon transfer: a comparative analysis of primary and salvage reconstruction of massive, irreparable rotator cuff tears. J Shoulder Elbow Surg. 2001 Nov-Dec;10(6):514-21. PMID:11743528 (Link to Abstract)

3. Gerber C, Vinh TS, Hertel R, Hess CW. Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff. A preliminary report. Clin Orthop Relat Res. 1988 Jul;(232):51-61. PMID:3383502 (Link to Abstract)

Question Authors:

Michael Hughes MD, Patrick McCulloch MD, Dave Marcu MD,

Please Rate Educational Value!

4.0

Average 4.0 of 8 Ratings

TAG

(OBQ05.36) A large rotator cuff tear is repaired through 3 trans-osseous tunnels by a mini-open approach. What is the most appropriate post-operative therapy protocol? Topic

Review Topic

1. early passive range-of-motion
2. early active range-of-motion
3. early isometric exercises
4. early plyometric execises
5. sling immobilization for 8 weeks, followed by delayed active-assisted range-of-motion

PREFERRED RESPONSE ▶

DISCUSSION: With repair of a large rotator cuff tear with tendon-bone tunnels, early passive range of motion exercises are initiated to prevent adhesive capsulitis. Active range of motion exercises should be initiated no earlier than 6 weeks postoperatively.

Craig et al looked at open versus mini-open repairs for full thickness tears, and found that mini-open approaches lead to smaller incisions, a less involved recovery, as as well as intra-articular evaluation and management of pathology within the glenohumeral joint with the arthroscope that is used in the beginning of the case.

REFERENCES:

1. Craig EV. Mini-open and open techniques for full thickness rotator cuff repairs, in Craig EV, Thompson RC Jr (eds). Master Techniques in Orthopaedic Surgery. The Shoulder, ed 2. Philadelphia PA. Lippincott Williams & Wilkins, 2004, pp 309-340.

2. Brems JJ: Repair of massive rotator cuff tears, in Craig EV, Thompson RC Jr(eds): Master Techniques in Orthoapedic Surgery: the shoulder, ed 2. Philadelphia, PA, Lippincott William & Wilkins, 2004, pp 341-360.

Question Authors:

Greg Galano MD, Patrick McCulloch MD, John Badylak MD,

Please Rate Educational Value!

3.0

Average 3.0 of 8 Ratings

TAG

(OBQ05.71) A 50-year-old recreational league baseball pitcher reports that 3 months ago he started having right shoulder pain after every game he had pitched. One month ago he injured his shoulder further when he fell off of a ladder. He has attempted to participate in a shoulder rehabilitation program but could not return to pitching secondary to pain and weakness. Figure A demonstrates an arthroscopic image taken from a lateral portal in the subacromial space (HH= humeral head, LHB= long head of the biceps) while in the beach-chair position. What is the injury pattern sustained as highlighted by the injured structure labeled with the asterisk in Figure A? Topic

Review Topic

FIGURES: A

1. Humeral avulsion of the glenohumeral ligament (HAGL lesion)
2. Superior labrum anterior-posterior (SLAP) tear
3. Rotator cuff tendon tear
4. Anterior-inferior capsulolabral lesion (Bankart lesion)
5. Anterior labral periosteal sleeve avulsion (ALPSA lesion)

PREFERRED RESPONSE ▶

DISCUSSION: The arthroscopic camera is said to be positioned in a lateral subacromial portal in the beachchair position, however the intra-articular structures are visualized indicating a rotator cuff (asterisk) tear with retraction. Illustration A depicts an arthroscopic soft tissue grasper pulling the rotator cuff back over the humeral head. Full thickness rotator cuff tears need to be repaired (not debrided) in the throwing athlete. The rotator cuff is the primary dynamic stabilizer of the glenohumeral joint and is placed under significant stress during overhead and contact sports. Mechanisms of injury include repetitive microtrauma, usually seen in the athlete involved in overhead sports, and macrotrauma associated with contact sports. Rotator cuff injury and dysfunction in the overhead athlete may be classified based on etiology as primary impingement, primary tensile overload, and secondary impingement and tensile overload resulting from glenohumeral instability.

The 4-part series of articles by Burkhart et al published in Arthroscopy is an excellent overview of the biomechanics, pathoanatomy, kinetic chain considerations, surgical treatment, and rehabilitation of the throwing athlete. The article by Blevins is a Level 5 review of rotator cuff pathology in athletes participating in contact and/or throwing sports.

Illustrations: A

REFERENCES:

1. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics. Arthroscopy. 2003 Apr;19(4):404-20. Review. PMID:12671624 (Link to Abstract)

2. Blevins FT. Rotator cuff pathology in athletes. Sports Med. 1997 Sep;24(3):205-20. Review. PMID:9327536 (Link to Abstract)

Question Authors:

Michael Hughes MD, Patrick McCulloch MD, Robert Boykin MD,

Please Rate Educational Value!

3.0

Average 3.0 of 14 Ratings

TAG

(OBQ05.217) A 65-year-old male reports acute right shoulder pain and inability to lift his arm over his head after a glenohumeral dislocation. Physical exam reveals active forward elevation to 30 degrees and 3/5 external rotation strength. An MRI is contraindicated due to a pacemaker, and therefore an arthrogram is performed and shown in Figure A. What is the most appropriate treatment option? Topic

Review Topic

FIGURES: A

1. shoulder hemiarthroplasty
2. rotator cuff repair
3. proximal humerus ORIF
4. total shoulder arthroplasty
5. sling immobilization

PREFERRED RESPONSE ▶

DISCUSSION: The clinical presentation is consistent with an acute rotator cuff tear following a shoulder dislocation, so the most appropriate treatment is a rotator cuff repair.

A shoulder dislocation in a patient >40 years-old commonly results in a rotator cuff tear. An arthogram may be helpful to confirm the diagnosis when an MRI is contraindicated. The arthrogram shows extravasation of the dye into the subacromial space with no evidence of arthritis. A rotator cuff tear allows the dye to leak into the subacromial space, whereas in a normal arthrogram the dye is contained within the joint capsule (Illustration A).

Craig et al described the geyser sign (Illustration B), which is when dye from a shoulder arthrogram leaks into the subacromial space as well as into the AC joint. This is indicative of a long-standing full-thickness RCT that has now involved the AC joint.

Jensen et al review the pathogenesis of rotator cuff arthropathy which they define as the end point in the continuum of severe degenerative changes in the glenohumeral joint.

Illustrations: A

REFERENCES:

1. Craig EV. The geyser sign and torn rotator cuff: clinical significance and pathomechanics. Clin Orthop Relat Res. 1984 Dec;(191):213-5. PMID:6499313 (Link to Abstract)

2. Jensen KL, Williams GR Jr, Russell IJ, Rockwood CA Jr. Rotator cuff tear arthropathy. J Bone Joint Surg Am. 1999 Sep;81(9):1312-24. PMID:10505528 (Link to Abstract)

Question Authors:

Doug Nowak MD, Patrick McCulloch MD, Derek Moore,

Please Rate Educational Value!

4.0

Average 4.0 of 8 Ratings

TAG

(OBQ05.237) A 34-year-old carpenter has left shoulder pain for the past 3 months following a fall from a ladder. Figure A displays a coronal T2 MR image. Which of the following diagnoses most appropriately describes this patient's lesion? Topic

Review Topic

FIGURES: A

1. Anterior labral periosteal sleeve avulsion (ALPSA)
2. Partial articular surface tendon avulsion (PASTA)
3. Humeral avulsion of the glenohumeral ligament (HAGL)
4. Superior labral anterior to posterior tear (SLAP)
5. Glenolabral articular disruption (GLAD) lesion

PREFERRED RESPONSE ▶

DISCUSSION: The MR image shown in Figure A demonstrates a partial articular surface tendon avulsion (PASTA) lesion of the supraspinatus. PASTA lesions can be difficult to diagnose and intra-articular contrast can help to delineate the pathology as seen in Illustration A. Disrupted anterior scapular periosteum differentiates a Bankart lesion from its variants where periosteum remains intact. An ALPSA lesion (Illustration B) is where the labral-ligamentous complex is displaced medially and shifted inferiorly, rolling up on itself underneath intact periosteum. A GLAD lesion (Illustration C) is a tear of the anterior inferior labrum (nondisplaced) with avulsion of the adjacent glenoid cartilage. A HAGL lesion (Illustration D) is where the inferior glenohumeral ligament avulses from the inferior humeral neck. Superior labral tears anterior to posterior to the biceps root are known as SLAP tears (Illustration E) .

Gartsman et al provide Level 4 evidence of 85 shoulders taken to the OR for impingement symptoms and found a partial tear of the rotator cuff. These shoulders were treated with debridement of the tear and arthroscopic subacromial decompression and had greater than 80% success rate.

The study by Snyder et al reviews 31 patients with partial thickness rotator cuff tears that were treated by arthroscopic debridement of the lesion. They concluded that 84% of the patients had satisfactory results.

Illustrations: A

REFERENCES:

1. Gartsman GM, Milne JC. Articular surface partial-thickness rotator cuff tears. J Shoulder Elbow Surg. 1995 Nov-Dec;4(6):409-15. PMID:8665284 (Link to Abstract)

2. Snyder SJ, Pachelli AF, Del Pizzo W, Friedman MJ, Ferkel RD, Pattee G. Partial thickness rotator cuff tears: results of arthroscopic treatment. Arthroscopy. 1991;7(1):1-7. PMID:2009105 (Link to Abstract)

Question Authors:

Michael Hughes MD, Patrick McCulloch MD, Patrick McCulloch MD,

Please Rate Educational Value!

4.0

Average 4.0 of 15 Ratings

TAG

(OBQ04.241) Resection of the coracoacromial ligament during shoulder arthroscopy results in which of the following? Topic

Review Topic

1. Increased glenohumeral joint translation
2. Increased passive shoulder internal rotation
3. Increased axillary recess volume
4. Decreased acromioclavicular joint reactive forces
5. Decreased resting tension in the long head of the biceps

PREFERRED RESPONSE ▶

DISCUSSION: The CA ligament provides a suspension function and restrains anterior and inferior translation through an interaction with the coracohumeral ligament. Resection of the coracoacromial ligament results in increased glenohumeral joint translation.

Lee et al, in a cadaveric study, showed that at 0 degrees and 30 degrees of abduction, release of the coracoacromial (CA) ligament resulted in a significant increase in glenohumeral joint translations, in both the anterior and inferior directions. The authors state that caution should be exercised in the release of the coracoacromial ligament in those with rotator cuff pain associated with glenohumeral instability. This is especially crucial in patients who may later undergo shoulder arthroplasty, as anterosuperior escape leads to significantly worse clinical outcomes.

Illustration A shows the anatomy of the region, including the CA ligament. Illustration B is a radiograph showing anterosuperior escape after CA ligament resection.

Illustrations: A

REFERENCES:

1. Lee TQ, Black AD, Tibone JE, McMahon PJ. Release of the coracoacromial ligament can lead to glenohumeral laxity: a biomechanical study. J Shoulder Elbow Surg. 2001 Jan-Feb;10(1):68-72. PMID:11182739 (Link to Abstract)

Question Authors:

Ben Taylor MD, Patrick McCulloch MD, Derek Moore,

Please Rate Educational Value!

4.0

Average 4.0 of 9 Ratings

Cases

http://upload.orthobullets.com/cases/1201/mri prior to repair.jpg

http://upload.orthobullets.com/cases/1201/mri prior to repair subscap.jpg

Failed cuff repair in 45 yr old. Massive retracted (C1201)

Sports - Treatment Consult - Rotator Cuff Tears

HPI - 45 yr old female with hx of shoulder pain had mini open cuff repair (anterior su...

What are her current options?

5/8/2012

167 responses

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Posts

	Arthroscopic Repair of Full-thickness Tears of the Supraspinatus: Does the Tendon Really Heal? Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG J Bone Joint Surg Am. 2005 Jun;87(6):1229-40. PMID: 15930531 (Link to Pubmed) Sports - Journal Club - Rotator Cuff Tears	4/10/2013 33 responses 0
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Evidence & References Show References

Level of Evidence 3 (Retrospective Cohort Study or Case-Control Study)

Fealy S, Adler RS, Drakos MC, Kelly AM, Allen AA, Cordasco FA, Warren RF, O’Brien SJ. Patterns of vascular and anatomical response after rotator cuff repair. Am J Sports Med. 2006 Jan;34(1):120-7. Epub 2005 Oct 31. PMID:16260468 (Link to Abstract)
Holtby R, Razmjou H. Impact of work-related compensation claims on surgical outcome of patients with rotator cuff related pathologies: a matched case-control study. J Shoulder Elbow Surg. 2010 Apr;19(3):452-60. PMID:19766021 (Link to Abstract)
Misamore GW, Ziegler DW, Rushton JL 2nd. Repair of the rotator cuff. A comparison of results in two populations of patients. J Bone Joint Surg Am. 1995 Sep;77(9):1335-9. PMID:7673282 (Link to Abstract)
Gerber C. Latissimus dorsi transfer for the treatment of irreparable tears of the rotator cuff. Clin Orthop Relat Res. 1992 Feb;(275):152-60. PMID:1735206 (Link to Abstract)
Warner JJ, Parsons IM 4th. Latissimus dorsi tendon transfer: a comparative analysis of primary and salvage reconstruction of massive, irreparable rotator cuff tears. J Shoulder Elbow Surg. 2001 Nov-Dec;10(6):514-21. PMID:11743528 (Link to Abstract)

Level of Evidence 4 (Case Series)

Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG. Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal? J Bone Joint Surg Am. 2005 Jun;87(6):1229-40 PMID:15930531 (Link to Abstract)
Bishop J, Klepps S, Lo IK, Bird J, Gladstone JN, Flatow EL. Cuff integrity after arthroscopic versus open rotator cuff repair: a prospective study. J Shoulder Elbow Surg. 2006 May-Jun;15(3):290-9. PMID:16679227 (Link to Abstract)
Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995 Jan;77(1):10-5. PMID:7822341 (Link to Abstract)
Cordasco FA, Backer M, Craig EV, Klein D, Warren RF. The partial-thickness rotator cuff tear: is acromioplasty without repair sufficient? Am J Sports Med. 2002 Mar-Apr;30(2):257-60. PMID:11912097 (Link to Abstract)
Lo IK, Burkhart SS. The comma sign: An arthroscopic guide to the torn subscapularis tendon. Arthroscopy. 2003 Mar;19(3):334-7. PMID:12627163 (Link to Abstract)
David TS, Bravo H, Scobercea R. Arthroscopic visualization of subscapularis tendon lesions.Orthopedics. 2009 Sep;32(9). PMID:19751026 (Link to Abstract)
Miniaci A, MacLeod M. Transfer of the latissimus dorsi muscle after failed repair of a massive tear of the rotator cuff. A two to five-year review. J Bone Joint Surg Am. 1999 Aug;81(8):1120-7. PMID:10466644 (Link to Abstract)
Gerber C, Vinh TS, Hertel R, Hess CW. Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff. A preliminary report. Clin Orthop Relat Res. 1988 Jul;(232):51-61. PMID:3383502 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Kibler WB. Integrated biomechanics of the shoulder and elbow. In: Garrick JG, ed. Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2004:47-51.
Ponce B, Tokish JM. Arthroscopic reconstruction for anterior glenohumeral instability. In: Galatz LM, ed. Orthopaedic Knowledge Update: Shoulder and Elbow 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:113-133.
Werner CM, Zingg PO, Lie D, Jacob HA, Gerber C. The biomechanical role of the subscapularis in latissimus dorsi transfer for the treatment of irreparable rotator cuff tears. J Shoulder Elbow Surg. 2006 Nov-Dec;15(6):736-42. PMID:17126245 (Link to Abstract)
Wolff AB, Sethi P, Sutton KM, Covey AS, Magit DP, Medvecky M. Partial-thickness rotator cuff tears. J Am Acad Orthop Surg. 2006 Dec;14(13):715-25. PMID:17148619 (Link to Abstract)
Clark JM, Harryman DT 2nd. Tendons, ligaments, and capsule of the rotator cuff. Gross and microscopic anatomy. J Bone Joint Surg Am. 1992 Jun;74(5):713-25. PMID:1624486 (Link to Abstract)
Burkhart SS, Lo IK. Arthroscopic rotator cuff repair. J Am Acad Orthop Surg. 2006 Jun;14(6):333-46. Review PMID:16757673 (Link to Abstract)
Greis PE, Kuhn JE, Schultheis: Validation of the lift-off test and analysis of subscapularis activity during maximal internal rotation. Am J Sports Med 1996;24:589-593. PMID:8883677 (Link to Abstract)
Decker MJ, Tokish JM, Ellis HB, et al: Subscapularis muscle activity during selected rehabilitation exercises. Am J Sports Med 2003;31:126-134. PMID:12531769 (Link to Abstract)
Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics. Arthroscopy. 2003 Apr;19(4):404-20. Review. PMID:12671624 (Link to Abstract)
Blevins FT. Rotator cuff pathology in athletes. Sports Med. 1997 Sep;24(3):205-20. Review. PMID:9327536 (Link to Abstract)
Lee TQ, Black AD, Tibone JE, McMahon PJ. Release of the coracoacromial ligament can lead to glenohumeral laxity: a biomechanical study. J Shoulder Elbow Surg. 2001 Jan-Feb;10(1):68-72. PMID:11182739 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Keener JD. Partial-thickness rotator cuff tears. In: Galatz LM, ed. Orthopaedic Knowledge Update: Shoulder and Elbow 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:161-171.

Undefined

Cadet ER, Adler RS, Gallo RA, Gamradt SC, Warren RF, Cordasco FA, Fealy S. Contrast-enhanced ultrasound characterization of the vascularity of the repaired rotator cuff tendon: short-term and intermediate-term follow-up. J Shoulder Elbow Surg. 2011 Jul 21. PMID:21783386 (Link to Abstract)
Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg. 1999 Jul-Aug;8(4):296-9. PMID:10471998 (Link to Abstract)
Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995 Jan;77(1):10-5. PMID:7822341 (Link to Abstract)
Stayner LR, Cummings J, Andersen J, Jobe CM. Shoulder dislocations in patients older than 40 years of age. Orthop Clin North Am. 2000 Apr;31(2):231-9. PMID:10736392 (Link to Abstract)
Simank HG, Dauer G, Schneider S, Loew M. Incidence of rotator cuff tears in shoulder dislocations and results of therapy in older patients. Arch Orthop Trauma Surg. 2006 May;126(4):235-40. Epub 2005 Sep 8. PMID:16151824 (Link to Abstract)
Dugas JR, Campbell DA, Warren RF, Robie BH, Millett PJ. Anatomy and dimensions of rotator cuff insertions. J Shoulder Elbow Surg. 2002 Sep-Oct;11(5):498-503. PMID:12378171 (Link to Abstract)
Curtis AS, Burbank KM, Tierney JJ, Scheller AD, Curran AR. The insertional footprint of the rotator cuff: an anatomic study. Arthroscopy. 2006 Jun;22(6):609.e1. PMID:16762697 (Link to Abstract)
Sanders TG, Miller MD: A systematic approach to magnetic resonance imaging interpretation of sports medicine injuries of the shoulder. Am J Sports Med 2005;33:1088- 1105 PMID:15983127 (Link to Abstract)
Tennent TD, Beach WR, Meyers JF: A review of the special tests associated with shoulder examination: Part I: The rotator cuff tests. Am J Sports Med 2003;31:154-160 PMID:12531773 (Link to Abstract)
Warner JJ, Parsons IM 4th: Latissimus dorsi tendon transfer: A comparitive analysis of primary and salvage reconstruction of massive, irreparable rotator cuff tears. J Shoulder Elbow Surg 2001; 10: 514-521 PMID:11743528 (Link to Abstract)
Iannotti JP, Hennigan S, Herzog R, Kella S, Kelley M, Leggin B, Williams GR. PMID:16452746 (Link to Abstract)
Craig EV. Mini-open and open techniques for full thickness rotator cuff repairs, in Craig EV, Thompson RC Jr (eds). Master Techniques in Orthopaedic Surgery. The Shoulder, ed 2. Philadelphia PA. Lippincott Williams & Wilkins, 2004, pp 309-340.
Brems JJ: Repair of massive rotator cuff tears, in Craig EV, Thompson RC Jr(eds): Master Techniques in Orthoapedic Surgery: the shoulder, ed 2. Philadelphia, PA, Lippincott William & Wilkins, 2004, pp 341-360.
Craig EV. The geyser sign and torn rotator cuff: clinical significance and pathomechanics. Clin Orthop Relat Res. 1984 Dec;(191):213-5. PMID:6499313 (Link to Abstract)
Jensen KL, Williams GR Jr, Russell IJ, Rockwood CA Jr. Rotator cuff tear arthropathy. J Bone Joint Surg Am. 1999 Sep;81(9):1312-24. PMID:10505528 (Link to Abstract)
Gartsman GM, Milne JC. Articular surface partial-thickness rotator cuff tears. J Shoulder Elbow Surg. 1995 Nov-Dec;4(6):409-15. PMID:8665284 (Link to Abstract)
Snyder SJ, Pachelli AF, Del Pizzo W, Friedman MJ, Ferkel RD, Pattee G. Partial thickness rotator cuff tears: results of arthroscopic treatment. Arthroscopy. 1991;7(1):1-7. PMID:2009105 (Link to Abstract)

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Rotator Cuff Tears

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