Evidence Update- Rotator Cuff Disorders

Mr Puneet MongaConsultant Orthopaedic Shoulder Surgeon

Wrightington Hospital

The Rotator Cuff

Image Courtesy- www.patient.info

Understanding Cuff Function & Tears

Kinematics -Vectors

Supraspinatus

Subscap + Infra

Deltoid

Text

Denard PJ et al. 2012 Nov;28(11):1587-91.Inman et l 1996

Equatorial Concept

Burkhart et al. Partial repair of irrepairable rotator cuff tears. Arthroscopy. 10; 363Jost, Gerber et al. Long term outcome of structure after structural failure of rotator cuff repairs. JBJS Am; 88: 472

Equatorial Concept

Burkhart et al. Partial repair of irrepairable rotator cuff tears. Arthroscopy. 10; 363Jost, Gerber et al. Long term outcome of structure after structural failure of rotator cuff repairs. JBJS Am; 88: 472

Transverse plane couple

Restoring RC function is all about keeping the ball under water !

(and not just “covering the Hole”)

The Pathology of RC disease

Rotator Cuff Disorders

• Impingement - • Tendonitis / Tendinosis / Bursitis / Tendon

Entrapment

• Rotator Cuff Tears• Calcific Tendonitis

Causation of Cuff Disease

• Mechanical (Extrinsic)• Degenerative / Vascular

(Intrinsic)

Progression• Stage 1- Edema and Hemorrhage.

• Age <25 year• Stage 2- Fibrosis and Tendinosis.

• Age 25-40 years• Stage 3 - Bone spurs and Tendon

rupture.• Age>40 years

Cuff Disease Progression

BursitisTendinosis

ImpingementCalcific Tendonosis

OedemaHemorrha

gePartial Tears Spurs

Full Thickness Tears

Cuff tear Arthritis

Acromial shapes

Bigliani, L. U.; Morrison, D. S.; and April, E. W.: The morphology of the acromion and its

relationship to rotator cuff tears. Orthop. Trans.,10: 228, 1986.10228  1986  

Higher proportion of RC tears seen in Curved and Hooked Acromions

Image courtesy- Shoulderdoc.co.uk

Sub-acromial Wringer

Coronal Plane Patho-anatomy

AbductionNeutral Position

Post- Decompression

Sagittal - oblique Plane Pathoanatomy

Sub-Acromial volume

Arch Decompression

Sub-Acromial volume

Intrinsic TheoryExtrinsic Theory doesn’t explain• RCT- Bursectomy vs Bursectomy + acromioplasty- No

Difference • Articular surface tendon damage more common• No direct relation between acromial shape and

impingement symptoms• Outcomes not proportional to extent of acromioplasty

Lewis J. Subacromial impingement syndrome: a musculoskeletal condition or a clinical illusion? Physical Therapy Reviews. 16(5):388-

98. 2011

Hence Tendon degeneration likely to play important role

Making a Diagnosis

Positive Special Test = Diagnosis!

Using a Cluster approach recommended

• History• Look Feel Move + Special

Tests• Investigations

Making a Diagnosis

History and physical examination provide little

guidance on diagnosis of rotator cuff tears.

Jain NB, Yamaguchi K. Evid Based Med. 2014 Jun;19(3):108.

Cochrane Database Syst Rev. 2013 Apr 30;4:CD007427. doi: 10.1002/14651858.CD007427.pub2.

Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may

accompany impingement.Hanchard NC, Lenza M, Handoll HH, Takwoingi Y.

Cochrane Database review33 Studies - 4002 shoulders170 Target Conditions / test

combinations !

Only 6 instances where the test was performed and interpreted similarly

No Clear Evidence to support a test

Subscapularis• Bear Hug Sensitivity 60% Specificity 100%

• Belly Press Sensitivity 40% Specificity 97.9%

• Napolean Sensitivity 25% Specificity 97.9%

• Lift off Sensitivity 17.6% Specificity 91.7%

• Internal Rotation Resistance test at Maximal Abduction (IRRTM) 76.5% sensitivity

Bear Hug Test: A new and sensitive test for subscap tears. Barth et al. Arthroscopy 2006Lin Et al 2015 Internal rotation resistance test at abduction and external rotation: a new clinical test for diagnosing subscapularis lesions.

Supraspinatus

• Hug Up Test 94% sensitivity, 76% specificity

• Empty Can 84% sensitivity 74% specificity

• Full Can 74% sensitivity 81% specificity

• Lag Signs are not conclusive

The Hug-up Test: A New, Sensitive Diagnostic Test for Supraspinatus Tears. Chin Med J (Engl). 2016 20th Jan;129(2):147-153. doi:

10.4103/0366-6999.173461. Liu YL, Ao YF, Yan H, Cui GQ

Miller CA1, Forrester GA, Lewis JS The validity of the lag signs in diagnosing full-thickness tears of the rotator

cuff: a preliminary investigation. . Arch Phys Med Rehabil. 2008 Jun;89(6):1162-8.

Infraspinatus

• Ext Rotation Resistance• Lag sign

Merolla, G., De Santis, E., Campi, F., Paladini, P., & Porcellini, G. (2010). Infraspinatus scapular

retraction test: a reliable and practical method to assess infraspinatus strength in overhead

athletes with scapular dyskinesis.Journal of Orthopaedics and Traumatology : Official Journal of the

Italian Society of Orthopaedics and Traumatology, 11(2), 105–110.

Teres Minor

• ER Lag sign >40’ 100% sensitivity 92% specificity

• ER Lag Sign >10’ 100% sensitivity 52% specificity

• Patte Sign (Hornblower) 93% Sensitivity 72% specificity

• Drop Sign 87% sensitivity 88% specificity

Collin P1, Treseder T, Denard PJ, Neyton L, Walch G, Lädermann A. What is the Best Clinical Test for Assessment of the Teres Minor in Massive Rotator Cuff Tears?

Clin Orthop Relat Res. 2015 Sep;473(9):2959-66.

Role of Investigations• Ultrasound - Good for soft tissues &

dynamic

• Xray- Good screening tool for Bone / joint

• CT- Good for bone

• MRI- Good for soft tissues and cross sectional

Ultrasound Versus MRI

Ultrasound• One Stop clinic

• Operator dependent

• Post op assessment

• Interactive

• Dynamic

MRI• Cross sectional anatomy

• Bone and Joint

• Partial Thickness & Interstitial Tears

• Visual record

• Muscle wasting and Fatty Atrophy

When to use Ultrasound

• “Go-to” Investigation for Impingement and Rotator Cuff Syndrome.

• Check integrity of Cuff repair within 1 year of surgery

• Guided injections

When to use MRI scan

• Pre-operatively to assess for Muscle Wasting and Fatty atrophy

• Atypical symptoms• Large patients

Management

First line Management

• Rest• Simple Analgesia• NSAIDs• Physiotherapy- Posture, motor

control, stretching, strengthening, Manual therapy- 6 weeks

• Sub-acromial Steroid Injection- 1 onlyBOA/ BESS commissioning guide

Indications for Surgery

Failure of First line treatment

Notable ExceptionAcute Rotator Cuff Tears

Early surgery has better outcomes

Duncan NS, Booker SJ, Gooding BW, Geoghegan J, Wallace WA, Manning PA Surgery within 6 months of an acute rotator cuff tear significantly improves

outcome. J Shoulder Elbow Surg. 2015 Dec;24(12):1876-80.

Factors affecting Outcomes

Age

Age > 65 years associated with relatively inferior outcomes

Cho NS, Lee BG, Rhee YG. Arthroscopic cuff repair using suture bridge technique: is the repair integrity actually maintained? Am J Sports Med 2011; 39: 2108-16

Tendon VascularityHypovascular Zone 10-15 mm prox to insertion (Codman)

Vascularity at edge of torn tendon normal...? artifact in earlier studies (Goodmurphy et al)

Codman EA. The shoulder; rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa. Boston, Mass.: T. Todd company; 1934: 123-37

Goodmurphy CW, Osborn J, Akesson EJ et al. An immunohistochemical analysis of torn rotator cuff tendon taken at the time of repair. J Shoulder Elbow Surg 2003; 12:368-74.

Tear Size

Large / Massive tear have inferior healing / poorer outcomes

Good function still possible in cases of non healing repairs

D Factor and B Dale. Current concepts of rotator cuff tendinopathy. The International Journal of sports physical therapy 2014; 9(2): 274-82.

Chung SW et al. Arthroscopic repair of massive rotator cuff tears: outcome and analysis of factors associated with healing failure or poor postoperative function. Am J Sports Med 2013; 41: 1674-83.

Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of Orthopaedics 2015; 6(2): 211-20.

Tendon RetractionInitial retraction due to Muscle contraction and secondarily involves tendon shortening

Increasing Gap associated with inferior outcomes

Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of Orthopaedics 2015; 6(2): 211-20.

Meyer DC, Wieser K, Farshad M, Gerber C. Retraction of supraspinatus muscle and tendon as predictors of success of rotator cuff repair. Am J Sports Med 2012; 40:2242-2247

Fatty Atrophy / Wasting

Fatty Atrophy, Muscle Wasting

Both independent risk factors

Higher re-operation rates, poor outcomes and poor tendon healing in presence of fatty atrophy

Goutallier D, Postel JM, Gleyze P, Leguillox P, Van Driessche S. Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full thickness tears. J Shoulder Elbow Surg 2003; 12:550-554.

Gladstone JN, Bishop JY, Lo IK, Flatow EL. Fatty infiltration and atrophy of the rotator cuff do not improve after cuff repair and correlate with poor functional outcome. Am J Sports Med 2007; 35: 719-728.

Liem D, Litchenberg S, Magosch P, Habermeyer P. Magnetic resonance imaging for arthroscopic supraspinatus repair. J Bone Joint Surg 2007; 89:1770-76.

Reversibility of FA/ Wasting

Fatty Atrophy Irreversible but halts after successful RC Healing

Muscle wasting potentially reversible but usually halts after successful RC healing

Fatty Atrophy / Wasting worsen in cases where RC does not heal.

Chung SW et al. Arthroscopic repair of massive rotator cuff tears: outcome and analysis of factors associated with healing failure or poor postoperative function. Am J Sports Med 2013; 41: 1674-83.

Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of Orthopaedics 2015; 6(2): 211-20.

Liem D, Litchenberg S, Magosch P, Habermeyer P. Magnetic resonance imaging for arthroscopic supraspinatus repair. J Bone Joint Surg 2007; 89:1770-76.

Smoking

Higher Risk of Cuff DiseaseInferior Outcome

Baumgarten KM, Gerlach D, Galatz LM, et al. Cigarette smoking increases the risk for rotator cuff tears. Clinical orthopaedics and related research. Jun 2010;468(6):1534-1541.

Mallon WJ, Misamore G, Snead DS, Denton P. The impact of preoperative smoking habits on the results of rotator cuff repair. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.]. Mar-Apr 2004;13(2):129-132.

Acromial Shape

Related to Risk of RC tears

No difference in outcomes of decompression with / out acromioplasty

Bigliani LU, Ticker JB, Flatow EL, Soslowsky LJ, Mow VC. The relationship of acromial architecture

to rotator cuff disease. Clinics in sports medicine. 1991;10(4):823-838

Henkus HE1, de Witte PB, Nelissen RG, Brand R, van Arkel ER. Bursectomy compared with acromioplasty in the management

of subacromial impingement syndrome: a prospective randomised study.J Bone Joint Surg Br. 2009 Apr;91(4):504-10.

Single vs Double Row repair

Double Row has better biomechanical characteristics- decreased gap formation and higher load to failure Improved outcomes in large / massive tears

No difference in clinical outcomes in small / medium size tears

Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of Orthopaedics 2015; 6(2): 211-20.

Park JY, Lhee SH, Choi JH, Park HK, Yu JW, Seo JB. Comparison of the clinical outcomes of single- and double-row repairs in rotator cuff tears. Am J Sports Med 2008; 36: 1310-1316

Repair configurations

Knotted / KnotlessNumber of suturesDifferent Suture configuations

No difference

Kim KC, Shin HD, Lee WY. Repair integrity and functional outcomes after arthroscopic suture-bridge rotator cuff repair. J Bone Joint Surg Am 2012; 94: e48

Barber FA, Herbert MA, Schroeder FA, Aziz-Jacobo J, Mays MM, Rapley JH. Biomechanical advantages of triple-loaded suture anchors compared with double-row rotator cuff repairs. Arthroscopy 2010; 26: 316-323

Post op Rehab

Early vs DelayedNo Difference

Better pain relief and ROM in short term

Slightly higher retear in early mobilization in large / massive tears

Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of Orthopaedics 2015; 6(2): 211-20.

Kim YS, Chung SW, Kim JY, Ok JH, Park I, Oh JH. Is early passive motion exercise necessary after arthroscopic rotator cuff repair? Am J Sports Med 2012; 40: 815-821

Cuff DJ, Pupello DR. Prospective randomized study of arthroscopic rotator cuff repair using an early versus delayed postoperative physical therapy protocol. J Shoulder Elbow Surg 2012; 21:1450-1455

Parsons BO, Gruson KI, Chen DD, Harrison AK, Gladstone J, Flatow EL. Does slower rehabilitation after arthroscopic rotator cuff repair lead to long-term stiffness? J Shoulder Elbow Surg 2010; 19: 1034-1039.

Lee BG, Cho NS, Rhee YG. Effect of two rehabilitation protocols on range of motion and healing rates after arthroscopic rotator cuff repair: aggressive versus limited early passive exercises. Arthroscopy 2012; 28: 34-42

Addition of Growth factors

BMP

PDGF - Promising

FGF

TGF-β - Promising

Gulotta LV, Kovacevic D, Packer JD, Ehteshami JR, Rodeo SA. Adenoviral mediated gene transfer of human bone morphogenic protein -13 does not improve rotator cuff healing in rat model. Am J Sports Med 2011.; 39: 180-7

Rodeo SA, Potter HG, Kawamura S, Turner AS, Kim HJ, Atkinson BL Biologic augmentation of rotator cuff tendon-healing with use of a mixture of osteoinductive growth factors. J Shoulder Elbow Surg 2007; 89:2485–2497

Uggen JC, Dines J, Uggen C.W et al.Tendon gene therapy modulates the local repair environment in the shoulder. The Journal of the American Osteopathic Association 2005, 105: 20–21

M. Kobayashi, E. Itoi,H.Minagawa et al. Expression of growth factors in the early phase of supraspinatus tendon healing in rabbits. Journal of Shoulder and Elbow Surgery 2006; 15: 371–377.

Thomopoulos S, Harwood FL, Silva MJ, Amiel D, Gelberman RH. Effect of several growth factors on canine flexor tendon fibroblast proliferation and collagen synthesis in vitro. J Hand Surg Am 2005; 30: 441–7.

Gulotta LV, Rodeo SA. Growth factors for rotator cuff repair. Clin Sports Med 2009; 28:13–23

C. N. Manning, H. M. Kim, S. Sakiyama-Elbert, L. M. Galatz, N. Havlioglu, and S. Thomopoulos, Sustained delivery of transforming growth factor beta three enhances tendon-to bone healing in a rat model. Journal of Orthopaedic Research 2011; 29: 1099–1105.

Kovacevic D, Fox A J, Bedi A et al. Calcium-phosphate matrix with or without TGF-𝛽3 improves tendon-bone healing after rotator cuff repair. American Journal of Sports Medicine 2011; 39: 811–819

PRPNo difference (2) / improved

outcomes (2)

Currently role unclear

Rodeo SA, Potter HG, Kawamura S, Turner AS, Kim HJ, Atkinson BL Biologic augmentation of rotator cuff tendon-healing with use of a mixture of osteoinductive growth factors. J Shoulder Elbow Surg 2007; 89:2485–2497

Weber SC, Kauffman JI, Parise C, Weber SJ, Katz SD. Platelet rich fibrin matrix in the management of arthroscopic repair of the rotator cuff: a prospective, randomized, double-blinded study. Am J Sports Med 2013; 41: 263-270

Barber FA, Hrnack SA, Snyder SJ, Hapa O. Rotator cuff repair healing influenced by platelet-rich plasma construct augmentation. Arthroscopy 2011; 27: 1029-1035

Jo CH, Shin JS, Lee YG, Shin WH, Kim H, Lee SY, Yoon KS, Shin S. Platelet-rich plasma for arthroscopic repair of large to massive rotator cuff tears: a randomized, single-blind, parallel-group trial. Am J Sports Med 2013; 41: 2240-2248

Mesenchymal stem cells

Bone Marrow injection - promising45 patients10 year FU

Hernigou P, Flouzat Lachaniette CH, Delambre J, Zilber S, Duffiet P, Chevallier N, Rouard H. Biologic augmentation of rotator cuff repair with mesenchymal stem cells during arthroscopy improves healing and prevents further tears: a case-controlled study. Int Orthop 2014; 38: 1811-1818

Augmentation / scaffolds

• Biological (Type I Collagen) /Artificial

• Higher Resistance to Failure

• RCT - Better Scores and healing when Graftjacket Augmentation used along with Cuff repair

Barber FA, Burns JP, Deutsch A, et al. A prospective, randomized evaluation of acellular human dermal matrix augmentation for arthroscopic rotator cuff repair. Arthroscopy. 2012; 28(1):8-15

Massive Cuff tears

Massive Cuff TearsBiceps tenotomy/Tenodesis Boileau et al 2007 68 78%good Good for pain relief.

Tendon Transfer Tauber et al, 2010 42 10-27% poor resultsNot applicable with subscap / teres minor tears

Dermal Subsitute Gupta et al, 2012 24 76% intact All reported pain relief. Costly.

InSpace Balloon Savarese et al 20 ? Scores improved on average. Under trial.

Suprascapular nerve ablation Nizian et al 2009 20 75% good to excellent Indication intractable shoulder pain

Superior Capsular Reconstruction Mihata et al 2013 24 83% healing. ? early days

Partial Repair Monga et al personal audit 19 82% reversal of psudoparalysis Practical

Reverse geometry Ek et al, 2013 46 37.5% had complications Salvage option

Over to Julia, Chrissy and Tanya…

Credits- A Desai