Rotator Cuff Tears
Rotator cuff tears (RTCs) are common and the prevalence of RCTs increase with patient age.
Not all tears are symptomatic but nonsurgically treated painful partial-thickness and full-thickness RCTs become 25% to 50% larger within 3 to 4 years.
Tears can be associated with aging as a result of changes in collagen and blood supply to the tendon.
Mechanical irritation of the tendon with movement of the shoulder causing repetitive contact of the tendons underneath the coracoacromial (CA) arch.
Patients older than 60 years often have no history of trauma.
Some patients age 50 to 60 years may have no history of trauma, but this presentation is less frequent.
Patients younger than 40 years often have a history of high-energy injury.
Pain in the shoulder occurs during overhead activities and when reaching behind the back.
Night pain is also common
In more severe cases with larger tears, weakness of the shoulder and inability to lift the arm above shoulder level can occur.
It is usual to obtain plain x-rays of the shoulder to rule out arthritis and other causes such as fracture or bone tumour as a cause of shoulder pain. Often the x-rays look normal as the this condition is related the tendon which does not show up on x-ray imaging. Sometimes the x-ray shows spurring of the acromion (bone overlying the shoulder joint) or arthritis affecting the acromioclavicular joint.
Ultrasound scanning is useful as it assesses the tendon in real time and the ultra sonographer can assess for impingement of the shoulder as it is moved. Thickened bursa with increasing fluid can be seen as well as torn rotator cuff tendons.
MRI scanning is useful for accurately assessing the rotator cuff and other structures within and around the shoulder joint.
1. Acute—An RCT is considered acute when the injury or inciting event occurred less than 3 months before presentation in a previously asymptomatic shoulder.
2. Chronic—Symptoms lasting longer than 3 months from the time of injury.
3. Acute on chronic—Enlargement of a smaller tear.
4. RCTs are classified as full thickness or partial thickness.
Figure 5. T2-weighted coronal oblique MRI demonstrates a supraspinatus tear (arrow).
5. Full-thickness tears are often classified further by size: small (< 1 cm); medium (1 to 3 cm); large (3 to 5 cm); massive (> 5 cm), complete twotendon tears, or tears with retraction to the glenoid.
6. Partial-thickness RCTs most commonly are classified by location (articular side or bursal side) and size (greater or less than 50% thickness).
1. Nonsurgical treatment—Older and less active patients may do well with nonsurgical treatment, which includes the following:
a. Avoidance of provocative motions
b. Application of ice
c. Administration of NSAIDs
d. Physical therapy, including rotator cuff and periscapular stabilizer strengthening as well as terminal stretching exercises. (Extension and internal rotation should be avoided.)
e. Subacromial injection of corticosteroid. Risks include tendon atrophy, infection, decreased tendon quality for repair. Benefits include diminished night pain, improved motion.
2. Surgical treatment
• Full-thickness and partial-thickness RCTs that fail nonsurgical treatment
• Consideration for surgery should be given to acute, traumatic tears in young (< 60 years), functional patients.
• Acute loss of strength or motion at any age
• Good-quality muscle on MRI, with absence of severe fatty infiltration
• No substantial glenohumeral arthritis
• Chronic infection
• Glenohumeral arthritis
• Chronically retracted tendons and atrophic rotator cuff muscles
• Fixed proximal migration, acromiohumeral interval smaller than 7 mm
• Deltoid, axillary nerve dysfunction
3. Surgical procedures
a. Arthroscopic—Appropriate arthroscopic portals are established.
• Posterior portal: 1 cm medial and 1 cm inferior to the posterolateral corner of the acromion.
• Rotator interval portal (used for intraarticular work): just lateral to the coracoid process.
• Anterolateral portal (used to access the subacromial space): 2 cm lateral/inferior to the lateral acromion
• Posterolateral subacromial portals: 2 cm lateral/inferior to the posterolateral border of the acromion
b. Mini-open cuff repair (lateral portal extension approach)
• Deltoid-splitting (without deltoid takedown) open rotator cuff repair
• Appropriate for small to medium tears and the superior third of the subscapularis
c. Open rotator cuff repair
• Deltoid detachment from the acromion—Subsequent repair is important.
• Splitting the deltoid more than 5 cm from the anterolateral corner of the acromion should be avoided, to protect the patient from axillary nerve injury.
• Open rotator cuff repair is appropriate for all sizes of tears.
• Massive rotator cuff repairs—Reparability should be assessed with preoperative MRI. Evidence of end-stage cuff fatty atrophy might preclude repair. The integrity of the coracoacromial (CA) ligament should be maintained to prevent iatrogenic anterosuperior escape.
• No evidence currently exists that allograft augmentation (allograft, xenograft, dermal grafts, and so forth) improves functional outcomes.
• Partial-thickness, articular-side RCTs: If greater than 50%, the tear is completed and repaired (open or arthroscopically); if less than 50%, the tuberosity and undersurface of the rotator cuff are débrided.
• When the remaining attached tissue is healthy, repairing the tendon in situ (partial articular supraspinatus tendon avulsion repair) is an option.
d. Rotator cuff repair constructs—A large meta-analysis has indicated essentially equivalent results with these techniques.
• Single-row repair—Suture anchors are based in the greater tuberosity. May be placed anywhere in prepared tuberosity with simple sutures or mattress or combination for fixation.
• Double-row repair—Medially based suture anchors with sutures passed in a mattress fashion; laterally based anchors repair lateral cuff tissue in simple suture fashion, followed by tying medially based mattress sutures.
• Transosseous equivalent: Medially based suture anchors with sutures passed in mattress fashion; sutures left long and captured by laterally based humeral anchors for a compression-type rotator cuff repair.
e. Tendon transfers
• Irreparable posterior RCTs: The latissimus dorsi and/or the teres major are transferred to the greater tuberosity. An intact subscapularis tendon is required for latissimus dorsi tendon transfer.
• Tendon transfer should be considered for the younger adult patient who has difficulty elevating the affected shoulder and is too young and active for arthroplasty options (for example, a manual laborer); helpful for external rotation weakness and pain
• Irreparable subscapularis tear: The pectoralis major should be transferred to the lesser tuberosity or the anteromedial greater tuberosity.
a. The incidence of infection as a complication of surgery is less than 1% overall.
b. Propionibacterium acnes is the most common infecting organism. Other organisms include coagulase-negative Staphylococcus, Peptostreptococcus, and S aureus.
2. Deltoid dehiscence after arthroscopic and/or open rotator cuff repair
3. Recurrent tears are more common with larger tears and in patients older than 65 years.
4. Iatrogenic suprascapular nerve injury
5. Stiffness is common early; however, refractory stiffness complicates less than 5% of cases.
6. Missed pathologic conditions include biceps tendinitis, AC arthritis or synovitis, instability, capsulitis/stiffness, glenohumeral arthritis, cervical radiculopathy, and brachial plexitis or Parsonage-Turner syndrome.
G. Pearls and pitfalls
1. Multiple corticosteroid injections should be avoided.
2. Open surgical procedures that involve deltoid detachment require meticulous deltoid repair.
3. Deltoid dehiscence is a devastating complication of open rotator cuff repair.
4. Specific complications associated with arthroscopy include severe edema, peripheral nerve neurapraxia, and failure of the rotator cuff repair.
5. Elderly patients often do well with nonsurgical treatments, including deltoid-strengthening protocols.
6. Larger or massive rotator cuff repairs require slower, modified therapy, often with a period of immobilization.
II. Cuff Tear Arthropathy
A. Epidemiology and overview
1. Cuff tear arthropathy (CTA) is a common cause of symptomatic shoulder arthritis. Other causes and types include localized rheumatoid arthritis, rapidly destructive shoulder arthritis, hemorrhagic shoulder of the elderly, and Milwaukee shoulder (crystalline-induced arthropathy).
2. CTA usually affects the dominant shoulder.
3. The mean patient age is 69 years.
4. Female-to-male ratio is 3:1.
1. The pathogenesis of CTA is unknown.
2. Neer described mechanical and nutritional pathways to CTA (Figure 6).
3. Crystalline-induced arthropathy
a. Synovial-based matrix degradation proteins destroy rotator cuff tendons and cartilage.
b. Calcium phosphate crystal deposition is found in end-stage disease.
4. Characteristics of CTA
a. A massive chronic RCT resulting in altered glenohumeral mechanics
b. Destruction of glenohumeral cartilage
c. Osteoporosis of subchondral bone
d. Humeral head collapse
C. Physical examination
1. Inspect for muscle (supraspinatus, infraspinatus) atrophy, anterior prominence of humeral head from "anterosuperior escape" with arm elevation, and subcutaneous effusion.
2. Range of motion
a. Subacromial/glenohumeral crepitus
b. End-stage CTA has "pseudoparalysis," that is, no or poor glenohumeral elevation, a lack of active external rotation, and an incompetent subscapularis.
c. Usually, chronic long head biceps rupture is present
1. Radiographs—Features seen on radiographs include:
a. Acetabularization of the acromion (seen on AP view)
b. Femoralization of the humeral head (seen on AP view)
c. Eccentric superior glenoid wear (seen on AP view)
d. Absence of the typical peripheral osteophytes of osteoarthritis
f. Subarticular sclerosis (snowcap sign)
g. Loss of the CA arch (indicates anterosuperior escape)
2. MRI or CT
a. Establishes the extent of rotator cuff disease
b. May be helpful to quantify bone stock in cases of advanced arthropathy
c. Not routinely necessary
Figure 6. Illustrations depict the nutritional and mechanical pathways involved in cuff tear arthropathy (CTA). A, Nutritional factors include the loss of a so-called watertight joint space and a reduction in the pressure of the joint fluid that is required for the perfusion of nutrients to the articular cartilage. Both contribute to the atrophy of cartilage and disuse osteoporosis in the subchondral bone of the humeral head. B, Mechanical factors include upward, anterior, and posterior instability of the humeral head. Upward instability escalates wear into the anterior part of the acromion, the acromioclavicular (AC) joint, and the coracoid.
E. Classification—CTA has been classified by Seebauer (Table 1).
1. Nonsurgical treatment
a. Activity modification
b. Physical therapy
c. Subacromial corticosteroid injection
d. Modalities (ice, ultrasound) may be beneficial for pain relief
e. If pseudoparalysis is not present, a deltoid-strengthening protocol may provide good function and pain relief.
Table 1. Seebauer Classification of Cuff Tear Arthropathy
2. Surgical treatment
• Failed nonsurgical treatment
• A pseudoparalytic, painful shoulder
• A functioning deltoid is necessary.
• Patient compliance with postoperative treatment
• Deltoid dysfunction
• Chronic infection
• Poor glenohumeral bone stock
3. Surgical procedures
a. Arthroscopic débridement
• Results are unpredictable
• The CA arch must be maintained; acromioplasty or CA ligament release should be avoided.
Figure 7. AP radiograph of a shoulder after reverse shoulder arthroplasty.
• Greater tuberosity "tuberoplasty" creates a smooth tuberosity-acromion interface.
b. Hemiarthroplasty (humeral head replacement)
• The goal is to restore the anatomic humeral head size
• The component is medialized under the CA arch with concentric glenoid reaming.
• The deltoid and CA arch/ligament must be maintained.
• Goals for rehabilitation are limited (for example, pain relief)
c. Reverse shoulder arthroplasty (RSA) (Figure 7)
• Pseudoparalytic CTA shoulder
• Elderly (older than70 years) patients (controversial)
• Shoulders with anterosuperior escape
• Prerequisites—A functioning deltoid and adequate glenoid bone stock
• The center of rotation is moved inferiorly and medially to assist the deltoid fulcrum (Grammont-style prosthesis).
• A fixed center of rotation from the semiconstrained implant allows elevation without proximal migration.
• Outcomes—Early results are promising for improved elevation and pain relief, but RSA may not improve external or internal rotation.
d. Resection arthroplasty—Indicated in salvage situations only, for patients with a history of osteomyelitis, chronic infections, multiple previous operations, or a poor soft-tissue envelope.
e. Total shoulder arthroplasty (TSA)—Contraindicated in shoulders with severe rotator cuff deficiency; leads to glenoid loosening via the "rocking horse" phenomenon.
f. Arthrodesis—Indicated in salvage situations only; in general, it is poorly tolerated by older patients (other than 60 years).
1. Sling is worn for 3 to 6 weeks, followed by gradual active and active assisted range of motion in all planes.
2. Deltoid strengthening from supine to sitting is instituted at 6 to 8 weeks.
3. Many patients are taught a home exercise program and do not require formal physical therapy.
1. Prosthetic replacement (RSA and hemiarthroplasty) complications
b. Anterosuperior escape after hemiarthroplasty
c. Prosthetic instability
2. RSA complications: RSA has a relatively higher complication rate compared with TSA and hemiarthroplasty.
c. Component wear, including inferior scapular notching
d. Acromial stress reaction and/or fractures
e. Long-term durability is unknown.
I. Pearls and pitfalls
1. Nonsurgical treatment should be maximized with physical therapy and NSAIDs.
2. Anterosuperior escape is an iatrogenic complication secondary to loss of the CA arch after aggressive acromioplasty in conjunction with rotator cuff insufficiency. To avoid anterosuperior escape, the CA arch should be preserved with arthroscopic débridement and arthroplasty.
3. Glenoid implantation, which leads to early glenoid failure (TSA), should be avoided.
4. Anterior deltoid strengthening may provide good function in elderly patients with massive RCTs.