summary Rotator cuff tears are a very common source of shoulder pain and decreased motion that can occur due to both traumatic injuries in young patients as well as degenerative disease in the elderly patient. Diagnosis can be suspected clinically with provocative tests of the supraspinatous, infraspinatous, teres minor and subscapularis, but confirmation requires an MRI of the shoulder. Treatment can be nonoperative or operative depending on the chronicity of symptoms, severity of the tear, degree of muscle fatty atrophy, patient age and patient activity demands. Epidemiology Prevalence age >60: 28% have full-thickness tear age >70: 65% have full-thickness tear Risk factors age smoking hypercholesterolemia family history Etiology Pathophysiology mechanisms of tear includes chronic degenerative tear ( intrinsic degeneration is the primary etiology) login to view 2 more bullets chronic impingement login to view 1 more bullet acute avulsion injuries login to view 3 more bullets iatrogenic injuries login to view 2 more bullets 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 Associated conditions AC joint pathology proximal biceps subluxation proximal biceps tendonitis internal impingement seen in overhead throwing athletes associated with partial thickness rotator cuff tears deceleration phase of throwing leads to tensile forces and potential for rotator cuff tears Anatomy Rotator cuff 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 login to view 1 more bullet transverse plane login to view 1 more bullet this maintains a stable fulcrum for glenohumeral motion. the goal of treatment in rotator cuff tears is to restore this equilibrium in all planes. Rotator cuff footprint supraspinatus inserts on anterosuperior aspect of greater tuberosity medial-lateral width at insertion supraspinatus is 12.7mm (covers superior facet of greater tuberosity) login to view 2 more bullets infraspinatus is 13.4mm subscapularis is 17.9mm teres minor is 13.9mm distance between articular cartilage to medial footprint of rotator cuff is 1.6-1.9 mm AP dimension of footprint is 20mm corresponds to insertion of supraspinatus and anterior infraspinatus Rotator cuff histologic areas (5 layers) important because articular side has only half the strength of bursal side explains why most tears are articular sided Layer I most superficial layer (1 mm thick) and composed of fibers from the coracohumeral ligament which extend posteriorly and obliquely Layer II composed of densely packed fibers that parallel the long axis of the tendon (3-5 mm thickness) Layer III smaller loosely organized bundles of collagen at 45° angle to the long axis of the tendon (3 mm thick) Layer IV loose connective tissue and thick collagen bands and merges with fibers from coracohumeral ligament Layer V shoulder capsule (2 mm thick) Rotator cuff blood supply from subscapular, suprascapular and humeral circumflex arteries branching within layer II and layer III (see above for layers) bursal side is more vascular than the articular side (which is hypovascular) zone of critical hypovascularity adjacent to most lateral portion of supraspinatus insertion Anatomic features associated with rotator cuff rotator interval includes the capsule, long head of the biceps tendon, 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. Complete glenohumeral anatomy Classification Anatomic Classification Supraspinatus, infraspinatus, teres minor (SIT) tears Make up the 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 suggests 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 iatrogenic 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 2 or more tendons) Ellman Classification of Partial-Thickness Rotator Cuff Tears Grade Description I < 3mm (< 25% thickness) II 3-6 mm (25-50%) III > 6 mm (>50%) Location A Articular sided B Bursal sided C Intratendinous Goutallier Classification of Rotator Cuff Atrophy 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 pain typically insidious onset of pain exacerbated by overhead activities pain located in deltoid region night pain, which is a poor indicator for nonoperative management can have acute pain and weakness with an traumatic tear weakness loss of active ROM with greater or intact passive ROM 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 views true AP, AP in internal/external rotation, axillary outlet view to assess acromion findings calcific tendonitis calcification in the coracohumeral ligament cystic changes in greater tuberosity proximal migration of humerus seen with chronic RCT (acromiohumeral interval <7 mm) Type III (hooked) acromion Arthrogram indications not commonly used in isolation; used when MRI contraindicated findings rotator cuff tear present if dye leaks from glenohumeral joint into subacromial joint MR arthrogram may improve sensitivity and specificity MRI indications diagnostic standard for rotator cuff pathology obtain when suspicion for pain or weakness attributable to a rotator cuff tear findings important to evaluate muscle quality login to view 2 more bullets medial biceps tendon subluxation login to view 1 more bullet cyst in humeral head on MRI seen in almost all patients with chronic RCT tangent sign login to view 1 more bullet sensitivity and specificity in asymptomatic patients 60 yrs and older, 55% will have a RCT Ultrasound indications suspicion of rotator cuff pathology need for dynamic examination advantages include allows for dynamic testing inexpensive readily available at most centers helpful to confirm intraarticular injections disadvantages include highly user dependent limited ability to evaluate other intraarticular pathology sensitivity/specificity 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, depth, retraction, muscle atrophy) partial thickness tears vs. complete tear articular sided (PASTA lesion) vs. bursal sided login to view 1 more bullet Nonoperative physical therapy, NSAIDS, subacromial corticosteroid injections login to view 2 more bullets technique login to view 3 more bullets Operative subacromial decompression and rotator cuff debridement alone indications login to view 1 more bullet rotator cuff repair (arthroscopic or mini-open) indications login to view 10 more bullets postoperative login to view 4 more bullets outcomes login to view 5 more bullets tendon transfer indications login to view 1 more bullet techniques (see details below) login to view 5 more bullets superior capsular reconstruction indications login to view 1 more bullet reverse total shoulder arthroplasty indications login to view 1 more bullet Technique Mini-open rotator cuff repair once was gold standard but has been largely been replaced by arthroscopic techniques approach small horizontal variant of shoulder lateral (deltoid splitting) approach advantages over open approach decreased risk of deltoid avulsion faster rehabilitation (do not need to protect deltoid repair) login to view 2 more bullets Arthroscopic rotator cuff repair advantages studies now show equivalent results to open or mini-open repair important concepts margin convergence login to view 1 more bullet anterior interval slide login to view 1 more bullet posterior interval slide login to view 1 more bullet subscapularis repair login to view 6 more bullets long head biceps tendon repair login to view 1 more bullet footprint restoration login to view 6 more bullets coracoacromial ligament release login to view 1 more bullet subacromial decompression login to view 1 more bullet acromioclavicular joint arthritis login to view 1 more bullet suprascapular nerve release login to view 3 more bullets Tendon transfer indicated for massive and irreparable rotator cuff tears pectoralis major transfer indicated in chronic subscapularis tears transferring pectoralis major under the conjoined tendon more closely replicates the vector forces of the native subscapularis requires 4-6 weeks of rigid immobilization 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. nerves at risk login to view 6 more bullets Superior capsular reconstruction with biologic or synthetic grafts some recent evidence of improved outcomes with the use of xenograft, allograft, or synthetic patches for massive cuff tears limited human and long-term studies xenograft from bovine dermis or intestine mixed functional outcomes and graft incorporation allograft from human skin or muscular fascia some evidence of good function and survival at short-term synthetics concern for foreign body reaction mixed functional results Lateral acromionectomy historic significance only contraindicated due to high complication rate Complications Recurrence / repair failure most common cause of failed RCR is failure of cuff tissue to heal, resulting in suture pull out from repaired tissue patient risk factors for repair failure patient age >65 years is a risk factor for non-healing of rotator cuff repair and subsequent failure large tear size (>5 cm) muscle atrophy diabetes smokers tear retraction medial to glenoid poor compliance with post-op protocol login to view 1 more bullet multiple tendons involved concomitant AC and/or biceps procedures performed at time of repair treatment revision rotator cuff repair vs RTSA login to view 5 more bullets Deltoid detachment complication seen with open approach AC pain Axillary nerve injury Suprascapular nerve injury may occur with aggressive mobilization of supraspinatus during repair Lateral femoral cutaneous nerve injury Secondary to beach chair positioning without appropriate padding Infection less than 1% incidence Usually common skin flora: staph aureus, strep, p.acnes login to view 1 more bullet risk factors patients who underwent an injection within 3 months of surgery Stiffness Physical therapy and guided early range of motion exercises are not shown to reduce stiffness one-year post-operatively Pneumothorax Can be a complication of regional anesthesia (interscalene or supraclavicular block) or the arthroscopy itself Prognosis 50% of asymptomatic tears become symptomatic in 2-3 years 50% of symptomatic full-thickness tears progress at 2 years and bigger tears progress faster