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26

Rotator Cuff Tears

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Topic updated on 09/08/14 2:04pm
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
        • partial tears often 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 (>25%) 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) compared to open repair
        • stabilize biceps tendon with tenodesis
        • superolateral margin of subscapularis identified by the "comma sign"
          • superior glenohumeral and coracohumeral ligaments attach to the subscapularis tendon
      • 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
  • Infection 
    • less than 1% incidence
    • Usually common skin flora: staph aureus, strep, p.acnes 
    • Propionoibacterium acnes is the most commonly implicated orgnism in delayed or indolent cases 
  • Stiffness
    • Physical therapy and guided early range of motion exercises are not shown to reduce stiffness one-year post-operatively 
 
 

 

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Qbank (26 Questions)

TAG
(OBQ13.125) Figure A shows an arthroscopic picture of a 62-year-old male undergoing repair of a torn subscapularis tendon. In the image shown, G represents the glenoid, H represents the humeral head, and the dotted line represents the superolateral border of the subscapularis tendon. Which two ligaments form the structure marked with the asterisk? Topic Review Topic
FIGURES: A          

1. Inferior and middle glenohumeral ligaments
2. Middle and superior glenohumeral ligaments
3. Coracohumeral and coracoacromial ligaments
4. Coracohumeral and superior glenohumeral ligaments
5. Superior and inferior glenohumeral ligaments

PREFERRED RESPONSE ▶
TAG
(OBQ12.52) A 68-year-old right-hand dominant female presents with the right shoulder injury shown in Figure A. She denies having any shoulder pain prior to a fall at work after slipping on some water 4 weeks ago. She smokes a half-pack of cigarettes per day. Which of the following characteristics of this patient confer the highest risk of not healing the injury following surgical repair? Topic Review Topic
FIGURES: A          

1. Half-pack of cigarette smoking per day
2. Surgical repair 4 weeks after injury
3. Worker's compensation case
4. 68 years of age
5. Right-handed dominance

PREFERRED RESPONSE ▶
TAG
(OBQ12.84) Which of the following statements regarding rotator cuff repair is true? Topic Review Topic

1. Bone anchor drilling enhances vascularity following rotator cuff repair
2. Shoulder motion following rotator cuff repair should be restricted to enhance blood flow to repair site
3. Double row rotator cuff repairs have better clinical results when compared to single row repairs
4. Subacromial decompression increases rates of successful rotator cuff repair
5. Failure to heal the rotator cuff tendon to bone consistently results in poor patient outcomes

PREFERRED RESPONSE ▶
TAG
(OBQ12.132) A 45-year-old patient presents with pain and swelling after undergoing an arthroscopic rotator cuff repair 10 weeks ago. On physical exam the portal sites are healed and there is no drainage. Testing of the integrity of the rotator cuff is limited secondary to pain. He has a WBC of 11.0 (reference range, 3-11 cells/mL), ESR of 40 mm/hr (reference range, 0-22 mm/hr), and CRP of 1.5 mg/dL (reference range, 0-1 mg/dL). An aspiration is completed and no organisms are seen on the gram stain. Twelve days after the aspiration, positive cultures are reported. Which organism is most likely to have grown in culture medium? Topic Review Topic

1. Staphylococcus aureus
2. Propionibacterium acnes
3. Corynebacterium sp.
4. Staphylococcus epidermidis
5. Pseudomonas aeruginosa

PREFERRED RESPONSE ▶
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 ▶
TAG
(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 ▶
TAG
(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 ▶
TAG
(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   B   C   D   E  

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

PREFERRED RESPONSE ▶
TAG
(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 ▶
TAG
(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 abduct his arm. Which of the following studies will best confirm the most likely diagnosis in this patient? Topic Review Topic
FIGURES: A   B   C      

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 ▶
TAG
(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. Perform acromioplasty only

PREFERRED RESPONSE ▶
TAG
(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 ▶
TAG
(OBQ09.212) A 50-year-old man sustains a left shoulder injury after falling from a motorcycle. A physical examination test to examine for this shoulder injury is found in Figure A. What is the most likely diagnosis? Topic Review Topic
FIGURES: A          

1. SLAP tear
2. Supraspinatus tear
3. Infraspinatus tear
4. Teres minor tear
5. Subscapularis tear

PREFERRED RESPONSE ▶
TAG
(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

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TAG
(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 ▶
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 ▶
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 ▶
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 ▶
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 ▶
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 ▶
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 ▶
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 ▶
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 ▶
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