Rotator Cuff Tears: Frequency of Tears

• - surgically demonstratable full thickness RTC tears are present in about            1/5 elderly patients;    - MRI studies have been published which note a much higher prevalence of RTC tear;    - complete supraspinatus tears may occur in upto 20% after age 32 yrs;            - after age 40 years of age, approximately 30% of patients will have cuff tears, and                    after age 60 yrs, there will be cuff tears in upto 80% of patients;    - in the study by SA TeefeyMD et al, 100 consecutive shoulders in 98 patients with shoulder            pain who had undergone preoperative US and subsequent arthroscopy were identified;            - arthroscopic diagnosis was a full-thickness rotator cuff tear in sixty-five shoulders, a                    partial-thickness tear in fifteen, rotator cuff tendinitis in twelve, frozen shoulder                    in four, arthrosis of the acromioclavicular joint in two, and a superior labral tear                    and calcific bursitis in one shoulder each;    - ultrasonography correctly identified all 65 full-thickness rotator cuff tears (a sensitivity of 100 percent);            - there were seventeen true-negative and three false-positive ultrasonograms (a specificity of 85 percent);            - overall accuracy was 96 percent;            - size of the tear on transverse measurement was correctly predicted in 86 percent of the shoulders with a full-thickness tear;            - ultrasonography detected a tear in ten of fifteen shoulders with a partial-thickness tear that was diagnosed on arthroscopy.            - 5 of 6 dislocations and seven of eleven ruptures of the biceps tendon were identified correctly;

Diff Dx of Rotator Cuff Tear

• Diff Dx:    - C5-C6 lesion    - suprascapular nerve palsy    - biceps tendon rupture    - biceps tendonitis    - calcific tendinitis:    - traumatic tear of rotator interval;          - this lesion will demonstrate extension of dye into subacromial space;    - axillary nerve palsy:          - may occur from previous shoulder dislocation or iatrogenic injury;          - will cause both deltoid and teres minor injury;    - os acromiale:    - posterior (internal) impingement: (see throwing shoulder)    - polymyalgia rhematica

Rotator Cuff Tears: Partial Rotator Cuff Tear

•   - etilogy of tear:            - impingement syndrome: (75%)            - shoulder instability (anterior or multi-directional) (15%) (should be considered in any                    young active patient);            - trauma:                    - occurs in 10% of patients;                    - note that a displaced greater tuberosity frx is a RTC tear equivolent;    - by definition, partial tears involve 50% or more of the tendon;    - in the study by SC Weber (Arthroscopy 1999), 32 patients with significant partial-thickness rotator cuff tears were treated with debridement and            acromioplasty versus 33 patients who were with mini-open repair;            - 88% of tears were on the articular sidee;            - acromiplasty and debridement group:            - significant number of the arthroscopic group had fair results by UCLA score criteria;            - 3 patients reruptured the remaining cuff later despite adequate acromioplasty;            - healing of the partial tear was never observed at second-look arthroscopy;            - acromioplasty alone did not prophylactically prevent rotator cuff tear progression;            - the good results of arthroscopic treatment of significant partial-thickness tears deteriorated with time;            - open repair group:            - although postoperative pain was significantly greater and recovery slower with open repair, no patient was reoperated on and rerupture of the repair did not occur;

Shoulder Impingement Syndrome

• Discussion:    - impingement syndrome describes pain in subacromial space when the humerus is elevated or internally rotated;    - during humeral flexion, the supraspinatus tendon and bursa become entrapped between the anteroinferior corner            of the acromion (and CA ligament) and the greater tuberosity;    - this syndrome is thought to precipitate attritional changes in the rotator cuff, leading to RTC tear;            - once the supraspinatus (and infraspinatus) tendon is disrupted there will often be further impingement                  and irritation which can lead to biceps tendonitis and subsequent rupture;

outlet impingement• :  - rotator cuff and subacromial bursa can be impinged between the greater

tuberosity and the:anterior 1/3 of acromion:    - greater tuberosity impinges anteriorly w/ forward flexion and laterally along undersurface of the acromion with modest abduction and neutral rotation;  - similar phenomenon can occur after displaced AC separations; coracoacromial ligament:                        - forced internal rotation in forward flexed position will drive greater tuberosity against the coracoacromial ligament;    - AC joint:                        - AC arthritis or AC joint osteophytes can result in impingement and mechanical irritation to the rotator cuff tendons;                  - misc causes:                        - greater tuburosity fractures can cause impingement on the rotator cuff if the fragment rotates superiorly;                        - humeral neck fractures that heal in a varus position will cause the greater tuberosity to tilt more superiorly;

non-outlet impingment:

• -           - loss of normal humeral head depression by the rotator cuff tear or weakness from a C5-6 lesion or suprascapular nerve palsy, or biceps tendon rupture;          - may occur due to thickening or hypertrophy of the subacromial bursa and rotator cuff tendons;          - may occur in the throwing athlete due to posterior impingement;                  - in these cases, patients may demonstrate excessive external rotation and/or recurrent anterior instability;

Clinical Findings• Clinical Findings: (see shoulder exam)

    - staging of impingement syndromes:    - pain will often become worse at night, as the subacromial bursa becomes hyperemic after a day of activity;    - impingement test is performed by 1st eliciting positive impingement sign;            - impingment sign: pain which occurs after forward flexing arm to 90 deg, and forcefully internally rotating the shoulder;            - 10-15 ml of 1% xylocaine are the injected into the subacromial space, and the   impingement sign is again sought;            - subacromial space should not be injected with steroids twice, because of the risk of tendon rupture;    - carefully test for shoulder contractures:            - patients w/ contracture of the posterior capsule (and loss of internal rotation) will be most                  likely to demonstrate signs of impingement (despite normal acromial anatomy);

Staging of Impingement Syndromes • Stage I:

    - edema and hemorrhage:    - reversible lesion usually seen in the second and third decade;    - exam:          - palpable tenderness over the greater tuberosity at supraspinitus              insertion          - palpalble tenderness along the anterior edge of the acromion;          - painful arc of abduction between 60 and 120 deg increased with              resistance at 90 deg;

- Stage II:    - chronic inflammation or repeated episodes of impingement leads to fibrosis &          thickening of supraspinatus, biceps, & subacromion bursa;    - at this stage there is inability to reverse process by activity modification;    - generally pts are between 25-40 years, however, age is less important          than the duration of symptoms, which is usually years;    - symptoms consist of an aching discomfort, often interfering w/ sleep          & work, and may progress to interfere w/ activities of daily living    - mild limitation to both passive and active range of motion;    - arthroscopic acromioplasty & subacromial decompression do not require          deltoid detachment & are assoc w/ cost savings & more rapid rehab;    - arthroscopic acromioplasty is perhaps most suited for type II lesions          (w/ partial tears), and is less useful for those with no tears or          complete tears;

- Stage III:    - rotator cuff tears, biceps ruptures, and bone changes;    - following a prolonged history of refractory tendinitis, significant          tendon degeneration is the hallmark of stage 3;    - pts are usually in the 5th or 6th decade, and often admit to prolonged          periods of pain, particularly at night;          - weakness can be bothersome;    - as further rotator cuff degeneration occurs:          - limitation to shoulder motion;          - infraspinatus atrophy;          - weakness of shoulder abduction and external rotation;          - biceps tendon involvement with rupture or degenerative changes              occurring in a high percentage of pts with rotator cuff tears;          - AC joint tenderness, esp if degenerative changes are present;    - although pain related weakness can be present at any stage, injection          of 1% lidocaine within the subacromial space in Stage 3 will not          eliminate weakness and limitation of active motion;    - radiographic changes:          - cystic changes about the greater tuberosity          - sclerotic changes beneath the anterior third of the acromion;          - osteophytes along the undersurface of acromion often associated              with the coracoacromial ligament;          - AC joint changes;          - late narrowing of the subacromial space;

• Impingement Radiographic Series:     - axillary view: may reveal an Os Acromiale, which is associated w/ impingment;     - scapular outlet view           - allows assessment of acromial morphology;           - examination of cadavera reveal:               - type 1, a flat acromion (17% of shoulders): 3% of all cuff tears have this type of acromion;               - type 2, a curved acromion (43%): 27% of all cuff tears have this type of acromion;               - type 3, a hooked acromion (40%): majority (70 - 90%) of rotator cuff tears may be seen in pts w/ type-2 or a type-3 acromion                       - type A: less than 8 mm in thickness;                       - type B: 8-12 mm thick;                       - type C: greater than 12 mm in thickness;               - references:                     - The morphology of the acromion and its relationship to rotator cuff disease. LU Bigliani et al.   Orthop. Trans. Vol 10. p 228. 1986.                     - The clinical significance of variations in acromial morphology. DS Morrison and LU Bigliani.   Orthop.. Trans. Vol 11. p 234. 1987.                     - A modified classification of the supraspinatus outlet view based on the configuration and anatomic thickness of the acromion. HC Wuh.   Orthop. Trans. Vol 16. p 767. 1992-1993.     - 30 deg Caudal Tilt AP View: is taken tangential to dome of acromion to assess size of anterior inferior acromial osteophyte;     - AP of the Shoulder             - note that normal acromiohumeral interval is 1 to 1.5 cm;             - other varients of the AP view is:                   - internal rotation view;                   - 35 deg external rotation;                   - 90 deg abduction view;                   - Grashey view:                         - obtained w/ 30 deg lateral oblique projection, tangential to glenohumeral joint, in order to obtain view directly down joint to reveal any degenerative changes;     - Active Abduction View:     - West Point View: may be indicated in younger patients w/ suspected anterior instability;

• Non-Operative Treatment:    - as noted by D.S. Morrison et al 1997, 2/3 of patients can expect to have significant relief of symptoms with non operative treatment;          - only half of patients who are over 60 years of age will have satisfactory result with non operative treatment;          - 91% of patients w/ a type I acromion will have satisfactory result;    - patients should specifically work on increasing specific deficits in their ROM such as loss of internal rotation (as compared to the normal side);    - specific techniques:          - internal rotation is improved by having the patient reach the good hand behind his neck and                  and simultaneously place his painful side in maximal internal rotation up the back;                  - a towel or a rope is used to connect the two hands, and the good hand raises up to the                        celing, forcing the other into maximal internal rotation;          - flexion is improved on by use of overhead pulleys and use of a meter stick;

• - Operative Treatment:    - cases that do not respond to above conservative measures after 6 months of treatment are candidates for surgery;    - choices include open acromioplasty or arthroscopic acromioplasty;            - note that Rockwood has expressed concern about arthroscopic decompression because it disrupts the lower half of the deltoid origin to the deltoid;                  - while this concern has not been borne out by clinical studies, it may be an important consideration for type III acromions, since an adequate                          decompression would require an extension amount of deltoid detachment both inferiorly and anteiorly;    - preoperative considerations:            - be clear with the patient about the expected results of surgery;                  - if the patient demonstrated excessive pain from the subacromial steroid injection (at the time of injection),                          then it is likely that the patient will demonstrate excessive postoperative pain;                  - likewise, if the results of the steroid injection did not provide significant relief, then a decompression may not satisfy the patient's expectations;    - cautions:            - in the case of massive rotator cuff tear, an acromioplasty (w/ CA ligament release) may precipitate additional superior migration;            - throwing athelets w/ impingment often do not benefit from acromionplasty;

Cas 1: h 54 ans imp sy depuis 2 ans

clini exam +++ 3 inj corti

arth-scan full thic tears sup spinat

Constant Shoulder Score   poor (27 )                  

4 mois P.O

• Pas doul

• Mobilité total très bien

• Constant Shoulder Score

good (55 )

Cas 2: h 35 ans Masson doul depuis 3 an 2 coté

clinic exa +++-3 inj cortiMRI: full thic tears sup spina

• Constant Shoulder Score                    fair (32)    

3 mois p.o• Constant Shoulder

Score Excellent(70)                

       

Cas 3:Une Dame 60 ansRCT full thickness

• 2 ans doul• 2 in corti• Épaule score

avt opé poor(27)

• Suture +acromio-plastie

Coraco acromial lig RCT

acromioplastie

RCT

Cas 4 :Une dame 44 ansCRT full thic