Background

Definition

 

Full thickness tear (FTT)

- variable amount retraction from insertion

 

Rotator Cuff Tear Large

 

Partial thickness tear (PTT)

- incomplete

- bursal or articular sided

 

Articular sided tearBursal Tear

 

Epidemiology

 

Older patients

- average age 60

- uncommon < 40

- cadavers  30%

 

Milgrom & Schaffer JBJS Am 1995

- rotator cuff changes In asymptomatic adults

- 50% at 50 years

- 80% at 80 years

 

Anatomy

 

Blood Supply

 

Proximal from muscle belly

- suprascapular artery

- subscapular artery

 

Distal from bone

- branch of anterior circumflex humeral

 

Vessels more abundant on bursal side than articular side

 

NHx

 

1.  Healing

- full thickness tears don't heal because of presence of synovial fluid

 

2.  Progression

- tears do not necessarily extend

 

3.  OA

- 5% FTT go on to cuff arthropathy if untreated

 

Pathogenesis

 

Chronic Tears

- 95% 

- abnormal tendon

 

Acute tears

- trauma 

- 5% 

- normal tendon

 

Pathology

 

No evidence inflammation at tear site

- tendinosis / angiofibrotic dysplasia

 

Involvement

- most common involves supraspinatus

- infraspinatus / T minor maybe torn

- subscapularis seldom torn

 

Classification

 

1.  Size 

 

Cofield

- Small       < 1 cm

- Moderate  1-3 cm

- Large       3-5 cm

- Massive    > 5 cm

 

2.  Extent

 

Partial Thickness

 

Quite common

- patients present with pain, not weakness

- difficult to differentiate from impingement

- MRI with gadolinium

 

A.  Intra-tendinous

- in tendon

- no communication with bursa / joint

 

Supraspinatous Tendinosis MRISubscapularis TendinosisInfraspinatous Tendinosis

 

B.  Articular side

- most common

- blood supply poor

- healing decreased by synovial fluid 

- seen post traumatic in young

- probably due to intrinsic causes in elderly

 

Supraspinatous articular sided tear

 

C.  Bursal side

- on subacromial surface

- less common

- likely to be secondary to impingement

 

Full Thickness

 

One tendon 

- supraspinatus only

 

Multiple Tendons 

- more likely OA if multiple tendons involved

 

3.  Topography

 

Sagittal Plane

 

Superior - SS alone

Anterosuperior - SS & SSC

Posterosuperior - SS & IS

Total cuff - All 3 tendons

 

Coronal Plane

 

A. Minimal retraction

- close to insertion

 

Supraspinatous Tear Minimal Retraction

 

B. Moderate retraction

- humeral head

 

Supraspinatous Tear Moderate Retraction 1Supraspinatous Tear Moderate Retraction 2

 

C.  Significant retraction

- at glenoid

 

Supraspinatous Tear Retraction to GlenoidSupraspinatous Tear Retracted to Glenoid T1

 

History

 

Pain

 

Weakness

- 2° to tear

- can be limited by pain

- can use LA to differentiate

 

History of injury, especially dislocation

- minimal pre-injury symptoms

- suggests acute tear of normal tendon

 

Chronic Tear 95%

-  long history impingement

-  no history of injury

 

Examination

 

SS IS Clinical Photo 1SS IS Clinical Photo 2

 

Wasting

- supraspinatus & infraspinatus

- rapid wasting with acute tears

- gradual wasting with chronic tears

 

Weakness related to

- size of lesion

- amount of pain

- grade 3 (MRC) or less indicates large tear

 

Supraspinatus

 

1.  Patient's arm held elevated at 90°

- arm in 30° forward flexion with thumb down

- test resistance to inferior pressure

- palpate

 

2.  Drop arm sign

- passively abduct arm

- get them to put it back to their side slowly

- apply small amount of pressure

- will drop arm at 30o

 

3.  Shoulder hiking

- usually means massive cuff tear

 

Shoulder Hiking

 

Infraspinatus

 

1.  Resisted ER

 

2.  Lag

- put in arm in maximum ER

- ask patient to hold that position and release arm

- unable to maintain ER / arm lags

 

3.  Hornblowers

- abduct and ER arm

- arm drops as unable to maintain ER

- Teres minor

 

Involvement of IS can often indicate a large or massive tear

 

Subscapularis

 

1.  Gerber lift-off test

- IR hand to back pocket

- patient should be able to maintain hand away from bottom if SSC intact

- need sufficient IR for this test

- otherwise need belly press test

 

2.  Belly press test

- fists on belly

- elbows forward / to eliminate deltoid

- resist force lifting fists away from belly

 

3. Increased ER compared with other arm

 

Subscapularis tear increased ER

 

HCLA

 

Improves pain and allows physio

 

Diagnostic

- ensures pain from shoulder pathology

 

Xray

 

Views as for impingement

- assess acromion / GHJ OA / high riding head

 

Ultrasound

 

Advantages

- non invasive

- cost effective

- dynamic image

- can be used in orthopedic office

- useful and simple for assessment of cuff integrity post surgery

 

Disadvantage

- user dependant

- accuracy increases with skill and experience

- may miss small tears / partial thickness tears

- still images not easily interpreted by surgeon (c.f. MRI)

 

Evidence

 

O de Jesus Am J Roentengology meta-analysis MRI v MRA v US

- MRA most accurate

- MRI and US comparable

 

Normal

 

Shoulder Ultrasound Normal SupraspinatousShoulder Ultrasound Infraspinatous NormalShoulder Ultrasound Subscapularis Normal

 

Tears

 

Shoulder Ultrasound Supraspinatous Tear

 

Arthrogram

 

Arthrogram Intact RC

 

MRI

 

Look for

- SS / IS / SSC / biceps

- PT v FT

- size of tear

- retraction

- atrophy / fatty infiltration 

 

Shoulder MRI Supraspinatous Fatty Infiltration

 

Partial thickness tears 

- best seen on T1 with gadolinium 

- see if communicates from GHJ to SA space

 

For more MRI see

- massive tears

- partial thickness tears

- full thickness tear

 

Arthroscopy

 

Gold Standard

- assess for partial articular tears in GHJ

- assess for bursal sided tears in subacromial space

 

Management Guidelines

 

1. Repair all acute full thickness tears

 

2 Repair chronic full thickness tears

- young patients

- after failure non operative management

- with disability 2° weakness or pain

 

3. Observe chronic tears with no disability

- especially in elderly

 

Non-operative Management

 

As per impingement

- satisfactory outcome in 50%

- no symptoms of pain or weakness

- both PT and FT tears