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) 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 chronic impingement typically starts on the bursal surface or within the tendon acute avulsion injuries acute subscapularis tears seen in younger patients following a fall acute SIT (supraspinatus, infraspinatus, teres minor) 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. 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 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. 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) 6-7 mm tear corresponds to 50% partial thickness tear tear starts 15 mm posterior to the biceps tendon near the supraspinatus/infraspinatus junction 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 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 tangent sign failure of the supraspinatus to cross a line drawn between the superior borders of the scapular spine and coracoid process on a sagittal MRI slice 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 bursal sided tears treated more aggressively Nonoperative physical therapy, NSAIDS, subacromial corticosteroid injections first line of treatment for most tears partial tears often can be managed with therapy technique avoidance of overhead activities physical therapy with aggressive rotator cuff and scapular-stabilizer strengthening over a 3-6 month treatment course subacromial injections if impingement thought to be major cause of symptoms Operative subacromial decompression and rotator cuff debridement alone indications select patients with a low-grade partial articular sided rotator cuff tear rotator cuff repair (arthroscopic or mini-open) indications acute full-thickness tears bursal-sided tears >3 mm (>25%) in depth release remaining tendon and debride degenerative tissue partial articular-side tears>50% can be treated with tear completion and repair Partial articular-side tears <50% treated with debridement alone PASTA with >7mm of exposed bony footprint between the articular surface and intact tendon represents significant (>50%) cuff tear (must have at least 25% healthy bursal sided tissue) younger patients with acute, traumatic tears in situ repair leave bursal sided tissue intact older patients with degenerative tears tendon release, debridement of degenerative tissue and repair postoperative rate-limiting step for recovery is biologic healing of RTC tendon to greater tuberosity, which is believed to take 8-12 weeks peribursal tissue and holes drilled in greater tuberosity are major source of vascularity to repaired rotator cuff vascularity can increase with exercise postop with limited passive ROM (no active ROM) outcomes Worker's Compensation patients report worse outcomes higher postop disability and lower patient satisfaction patients should expect to return to full work duty by 6-10 months after surgery tendon transfer indications massive cuff tears techniques (see details below) pectoralis major transfer latissimus dorsi transfer best for irreparable posterosuperior tears with intact subscapularis superior capsular reconstruction indications massive irreparable rotator cuff tear with intact subscapularis reverse total shoulder arthroplasty indications massive cuff tears with glenohumeral arthritis with intact deltoid 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) 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 posterior lever push maneuver useful to identify insertional humeral footprint tears superolateral margin of subscapularis identified by the "comma sign" superior glenohumeral and coracohumeral ligaments attach to the subscapularis tendon absent MGHL may be suggestive of subscapularis tearing/retraction long head biceps tendon repair most studies show negligible difference between tenotomy vs. tenodesis after concurrent rotator cuff repair 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 (mattress sutures in medial row and simple sutures in lateral row) have been shown to create a more anatomic repair of the footprint lower retear rate compared with single row no difference in functional score, pain score, time to healing (compared to single row) 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 coracoacromial ligament release release leads to an increased anterior/inferior translation of the glenohumeral joint acromioclavicular joint arthritis no significant difference in long-term functional outcomes, shoulder range of motion, or reoperation rates when performing rotator cuff repair with concomitant distal clavicle resection compared to rotator cuff repair alone suprascapular nerve release more common in large and massive tears involves decompressing the nerve at the suprascapular and/or spinoglenoid notches existing literature reveals no significant improvement in pain or function compared to rotator cuff repair alone 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 radial nerve runs along anterior surface of latissimus dorsi, ~3cm medial to humeral insertion at risk during tenotomy posterior branch of the axillary nerve runs in deep fascia of posterior deltoid at risk during passage of tendon deep to deltoid to subacromial space 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 no difference in clinical outcomes or healing with early vs. delayed motion protocols multiple tendons involved concomitant AC and/or biceps procedures performed at time of repair treatment revision rotator cuff repair vs RTSA variables to consider when choosing revision RCR vs RTSA patient age (older age favors RTSA) etiology of re-tear quality of tissue / MRI findings static proximal humeral migration (favors RTSA) 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 Propionoibacterium acnes is the most commonly implicated organism in delayed or indolent cases 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