current concepts in rotator cuff management - nhafp.orgnhafp.org/pdf/nhafp cme.pdf · current...

Current Concepts in Rotator Current Concepts in Rotator Cuff ManagementCuff Management

Karen J. Boselli, MDKaren J. Boselli, MD

NHAFP Continuing Clinical ExcellenceNHAFP Continuing Clinical ExcellenceApril 5, 2014April 5, 2014

Mountain View Grand ResortMountain View Grand Resort

RC ManagementRC Management

OverviewOverview•• PrevalencePrevalence•• HistoryHistory•• PathogenesisPathogenesis•• AnatomyAnatomy•• Examination Examination •• Imaging Imaging •• TreatmentTreatment•• RehabilitationRehabilitation


IntroductionIntroduction

•• There is a LOT that we do not know There is a LOT that we do not know about rotator cuff tears, even in 2013!about rotator cuff tears, even in 2013!

•• CenturiesCenturies of research on anatomy, of research on anatomy, biomechanics, modes of failure, and biomechanics, modes of failure, and repair techniquesrepair techniques»» Can be frustrating for both surgeons and patients Can be frustrating for both surgeons and patients

alike, but also rewardingalike, but also rewarding


PrevalencePrevalence•• Prevalence of cuff tear quite Prevalence of cuff tear quite highhigh even even

in asymptomatic populationsin asymptomatic populations»» Increasing prevalence with ageIncreasing prevalence with age»» MRI in patients over 60 years MRI in patients over 60 years 54%54%

•• One of the most prevalentOne of the most prevalentorthopedic conditionsorthopedic conditions

•• 400,000 surgeries a year in US400,000 surgeries a year in US

Sher et al. JBJS 1995

•1st described in1834 by JG Smith•1st repair performed in 1909 by Codman•1st published results 1944 by McLaughlin


HistoryHistory

•• Originally thought to be due to Originally thought to be due to ““impingementimpingement””»» Impingement coined 1972 by Charles NeerImpingement coined 1972 by Charles Neer

•• Compression of rotator cuff on CA arch:Compression of rotator cuff on CA arch:»» Anterior edge acromion, CA ligament, AC jointAnterior edge acromion, CA ligament, AC joint

»» Chronic repetitive syndrome Chronic repetitive syndrome »» Leads to degeneration of tendonLeads to degeneration of tendon


PathogenesisPathogenesis

•• Newer understanding of pathogenesis Newer understanding of pathogenesis suggests rotator cuff disease as suggests rotator cuff disease as continuumcontinuum

Start with tendon strainStart with tendon strain

Progress to inflammation and fibrosisProgress to inflammation and fibrosis

Leads to tendon Leads to tendon failurefailure



•• Precise cause of degeneration unknownPrecise cause of degeneration unknown•• Other proposed causes include advanced Other proposed causes include advanced

age, elevated BMI, even high cholesterolage, elevated BMI, even high cholesterol•• Probable Probable decreased vascularitydecreased vascularity and ischemia and ischemia



•• Smoking Smoking »» Proposed to important risk factorProposed to important risk factor»» Nicotine is vasoconstrictorNicotine is vasoconstrictor»» Carbon monoxide decreases cellular oxygenCarbon monoxide decreases cellular oxygen»» Leads to tendon degenerationLeads to tendon degeneration

•• Smoking correlates with tear presence and Smoking correlates with tear presence and tear sizetear size



Baumgarten et al. CORR 2010

Carbone et al. JSES 2012

•• Controversy about interplay between Controversy about interplay between intrinsic intrinsic (cuff tissue) and (cuff tissue) and extrinsicextrinsic (impingement) (impingement) factors in rotator cuff diseasefactors in rotator cuff disease

•• Still Still not clear not clear what is the primary causewhat is the primary cause

•• Without knowing the Without knowing the cause it is difficult to know cause it is difficult to know the right solution!the right solution!



•• Subscapularis Subscapularis »» Largest tendonLargest tendon»» Anterior shoulderAnterior shoulder»» Lesser tuberosityLesser tuberosity»» Internal rotationInternal rotation


AnatomyAnatomy

•• SupraspinatusSupraspinatus»» Most commonly involvedMost commonly involved»» Large 23 x 16 mm footprint Large 23 x 16 mm footprint »» Greater tuberosityGreater tuberosity»» Forward flexion Forward flexion


AnatomyAnatomy

•• InfraspinatusInfraspinatus»» Second largest tendon, interdigitates w/ supraspinatusSecond largest tendon, interdigitates w/ supraspinatus»» External rotationExternal rotation


AnatomyAnatomy

•• Teres minorTeres minor»» Smallest muscleSmallest muscle--tendon unittendon unit»» External rotation of abducted armExternal rotation of abducted arm


AnatomyAnatomy

•• Pain Pain »» LocationLocation»» DurationDuration»» Factors that exacerbate Factors that exacerbate »» Factors that alleviateFactors that alleviate

•• WeaknessWeakness•• Traumatic versus insidious onsetTraumatic versus insidious onset•• Prior treatmentPrior treatment


HistoryHistory

•• Check cervical spine for referred painCheck cervical spine for referred pain•• Inspect for muscle atrophyInspect for muscle atrophy•• ROM and strength testingROM and strength testing•• MyMy red flagsred flags for RCT are:for RCT are:

»» History of traumaHistory of trauma»» Crepitus with motionCrepitus with motion»» RC weaknessRC weakness


ExaminationExamination

•• Special TestsSpecial Tests»»Neer and Hawkins for Impingement Neer and Hawkins for Impingement »»Jobe (empty can, drop arm) for RCTJobe (empty can, drop arm) for RCT»»External rotation lagExternal rotation lag


ExaminationExamination

•• Standard radiographsStandard radiographs•• ArthrogramArthrogram•• UltrasoundUltrasound•• MRIMRI

»» Best to assess early degeneration, Best to assess early degeneration, partial tear, other pathology in shoulderpartial tear, other pathology in shoulder


ImagingImagingAcromial Spur


ImagingImaging

Partial Articular Tear

Small Full Thickness

Large Full Thickness


ImagingImaging

Normal Muscle Belly

•• Controversy rotator cuff managementControversy rotator cuff management•• Consensus statement from Consensus statement from AAOS 2012AAOS 2012


TreatmentTreatment

•• Nonoperative MeasuresNonoperative Measures»» Physical therapyPhysical therapy»» NSAIDsNSAIDs»» InjectionInjection


TreatmentTreatment

Issue #1Issue #1»» Should we attempt nonoperative treatment Should we attempt nonoperative treatment

for for acuteacute tears?tears?•• Not often in my opinionNot often in my opinion•• Some exceptions includingSome exceptions includingelderly patients and small tearselderly patients and small tears


TreatmentTreatment

Issue #2Issue #2»» Should we attempt nonoperative treatment Should we attempt nonoperative treatment

for for chronic chronic tears?tears?

•• Depends on Depends on many many factorsfactors•• Size of the tearSize of the tear•• Duration of symptomsDuration of symptoms•• Patient characteristics including expectations Patient characteristics including expectations

and activity leveland activity level


TreatmentTreatment

Issue #3Issue #3»» Should we Should we injectinject known rotator cuff tears?known rotator cuff tears?

•• Not a black and white issueNot a black and white issue•• Each surgeon has preferenceEach surgeon has preference•• Depends on Depends on manymany factorsfactors


TreatmentTreatment

Issue #4Issue #4»» Should we recommend Should we recommend PTPT or home or home

exercise for full thickness rotator cuff tears?exercise for full thickness rotator cuff tears?•• In select patients yesIn select patients yes•• My opinion is that it may be effective in someMy opinion is that it may be effective in some


TreatmentTreatment

•• We know that tears have a high prevalence, We know that tears have a high prevalence, but know relatively little about progression of but know relatively little about progression of tear size or tear symptomstear size or tear symptoms

•• Large rotator cuff tearsLarge rotator cuff tears•• Motion stayed the Motion stayed the samesame butbut

»» ↑↑ arthritis, arthritis, ↑↑ size tear, size tear, ↑↑ atrophyatrophy•• 50% of tears became surgically 50% of tears became surgically irreparableirreparable


Natural HistoryNatural History

Zingg et al. JBJS 2007

•• 39%39% of tears even if non painful will progressof tears even if non painful will progress

•• Patients treated without surgery should be Patients treated without surgery should be followed regularlyfollowed regularly

•• Change in symptoms may indicate tear Change in symptoms may indicate tear enlargementenlargement


Natural HistoryNatural HistoryYamaguchi et al. JBJS 2006

•• With development of With development of painpain, size of cuff tear , size of cuff tear increased significantlyincreased significantly»» 40% of partial tears had progressed to full 40% of partial tears had progressed to full

•• Those who remained Those who remained asymptomaticasymptomatic had no had no change in tear sizechange in tear size»» Rate of tear progression Rate of tear progression 23%23% in symptomatic in symptomatic

group versus group versus 4%4% in asymptomatic groupin asymptomatic group


Natural HistoryNatural HistoryMall et al. JBJS 2010

•• Tear progression in Tear progression in symptomaticsymptomatic patients age patients age 60 or less over 29 months60 or less over 29 months»» Tear progression more than 5 mm in Tear progression more than 5 mm in 49%49%»» No change tear size No change tear size 43%43%

•• Found correlation between Found correlation between ↑↑ in pain and in pain and increase in tear size at final ultrasound evalincrease in tear size at final ultrasound eval


Natural HistoryNatural HistorySafran et al. AJSM 2011


Consensus GuidelinesConsensus Guidelines

•• Multiple ways to repair open and arthroscopicMultiple ways to repair open and arthroscopic•• More ways to fix something usually means More ways to fix something usually means

we donwe don’’t have the answert have the answer……


Surgical ManagementSurgical Management

•• Outcomes at 3 months better in mini openOutcomes at 3 months better in mini open•• Final follow up no difference Final follow up no difference


Surgical ManagementSurgical ManagementOPEN versus Mini OPEN

JBJS 2009

•• MiniMini--open good recordopen good record»» Reports of stiffnessReports of stiffness»» 8585--93% satisfaction93% satisfaction

•• Arthroscopic repairsArthroscopic repairs»» Less stiffnessLess stiffness»» Functional results Functional results

equal to openequal to open»» 90% Satisfied90% Satisfied


Mini Open versus Arthroscopic

•• Arthroscopic RepairArthroscopic Repair»» Started early 1990sStarted early 1990s»» Avoid open complicationsAvoid open complications»» Diagnostic and therapeutic benefitsDiagnostic and therapeutic benefits»» Decreased painDecreased pain»» Possible earlier rehabPossible earlier rehab


Arthroscopic RepairArthroscopic Repair

Arthroscopic RepairArthroscopic Repair

Tear ConfigurationTear Configuration

Arthroscopic Repair

Double Row Repair

•• Depends on tear size and surgeon preferenceDepends on tear size and surgeon preference•• New concern about failure of tendon healingNew concern about failure of tendon healing

Galatz et al. JBJS 2004Galatz et al. JBJS 2004»» 2 cm tears @12 months after arthroscopic repair2 cm tears @12 months after arthroscopic repair

»» ROM started POD #1ROM started POD #1»» 17 of 18 did 17 of 18 did notnot heal heal »» Excellent pain relief and functionExcellent pain relief and function

•• Results deteriorate at 2 yearsResults deteriorate at 2 years


RehabilitationRehabilitation



•• Compared ROM and healing rates between 2 Compared ROM and healing rates between 2 protocols after arthroscopic RCRprotocols after arthroscopic RCR

•• Group 1 Group 1 »» Early immediate rehab with unlimited PROMEarly immediate rehab with unlimited PROM»» Sling for 6 weeks then start AROMSling for 6 weeks then start AROM

•• Group 2 Group 2 »» Minimum PROM to prevent stiffnessMinimum PROM to prevent stiffness»» Sling for 6 weeks then AROMSling for 6 weeks then AROM

Lee et al. Arthroscopy 2012



•• Improved ROM @ 3 months In Group AImproved ROM @ 3 months In Group A•• NoNo significant differences @ 1 yearsignificant differences @ 1 year

•• Repeat MRI showed re tears in: Repeat MRI showed re tears in: »» 23.3%23.3% of cases in Group A of cases in Group A »» 8.8%8.8% of cases in Group Bof cases in Group B»» Difference Difference not not significant significant (p=0.1)(p=0.1)

Lee et al. Arthroscopy 2012

•• Very slow and all patient should be educated Very slow and all patient should be educated about this in advanceabout this in advance

•• Functional recovery Functional recovery startsstarts 3 months3 months•• Improvement over one year, then stabilizationImprovement over one year, then stabilization•• Negative predictors includeNegative predictors include

»» Female sexFemale sex»» Heavy upper body workHeavy upper body work»» Poor bone qualityPoor bone quality»» Lack of tendon healingLack of tendon healing


Return to ActivityReturn to Activity

•• Clinical outcomes of large tears less Clinical outcomes of large tears less satisfactory than small onessatisfactory than small ones

•• Re rupture rate Re rupture rate highhigh after large tearsafter large tears»» But to confuse the issue even moreBut to confuse the issue even more……

•• Structural failure does Structural failure does notnot necessarily define necessarily define clinical failureclinical failure»» Functional results in patient with healed tear are Functional results in patient with healed tear are

usually usually superior to those without healed tearsuperior to those without healed tear……but but not always! not always!


OutcomesOutcomes


OutcomesOutcomes

•• 46 46 small small tears with mean f/u 35 monthstears with mean f/u 35 months•• Good or excellent result 76.1%Good or excellent result 76.1%•• Satisfied or very satisfied in 91.3%Satisfied or very satisfied in 91.3%•• Supraspinatus completely healed in Supraspinatus completely healed in 71.8%71.8%

May 2012


OutcomesOutcomes

•• Retearing is relatively common Retearing is relatively common »» Has Has no effect no effect on clinical result i.e. satisfaction, on clinical result i.e. satisfaction,

range of motion, strength and painrange of motion, strength and pain»» Except patients who healed had better ability to Except patients who healed had better ability to

perform activities of daily livingperform activities of daily living

May 2012

Jost et al. JBJS 2006Jost et al. JBJS 2006•• Measured outcomes mean 7.6 years after Measured outcomes mean 7.6 years after

structurally structurally failedfailed rotator cuff repairrotator cuff repair•• Clinical outcomes remained Clinical outcomes remained significantlysignificantly

improved over the preoperative state improved over the preoperative state »» Including pain, function, strength, satisfactionIncluding pain, function, strength, satisfaction

•• In spite of these results most would agree In spite of these results most would agree functional results functional results better better with healed tearwith healed tear


OutcomesOutcomes

Harryman et al. JBJS 1991

•• Factors associated with poor results?Factors associated with poor results?»» SmokingSmoking»» DiabetesDiabetes»» Tear sizeTear size»» Older ageOlder age»» ObesityObesity»» Workers compensationWorkers compensation»» Cervical diseaseCervical disease»» Medical comorbiditiesMedical comorbidities


OutcomesOutcomes

Mallon et al. JSES 2004

•• Previous focus of research has been on repair Previous focus of research has been on repair construct (suture material, type of repair)construct (suture material, type of repair)

•• Weakest link = understanding Weakest link = understanding biologybiology•• Understand process of tendon degeneration in Understand process of tendon degeneration in

order to optimize healing order to optimize healing »» Natural historyNatural history»» Genetic predispositionGenetic predisposition»» Disease preventionDisease prevention»» Mechanism of failureMechanism of failure


Future DirectionsFuture Directions

•• Continued research on biology of treatment Continued research on biology of treatment »» BiologicsBiologics»» Gene therapyGene therapy»» Tissue engineeringTissue engineering


Future DirectionsFuture Directions

•• Case #1Case #1

•• 40 YO male40 YO male•• ““II’’m a dry waller, I was lifting a heavy m a dry waller, I was lifting a heavy

bucket of mud at work and felt a sudden bucket of mud at work and felt a sudden tearing sensation in my left shouldertearing sensation in my left shoulder…”…”


Case #1Case #1


Case #1Case #1•• Inspection normalInspection normal•• Active flexion to only 30Active flexion to only 30°°•• Crepitus with ROM Crepitus with ROM •• + Drop Arm Test+ Drop Arm Test•• Rotator cuff strength 4/5 Rotator cuff strength 4/5

•• MRI MRI

•• Large acute rotator cuff tearLarge acute rotator cuff tear•• Surgical managementSurgical management


Case #1Case #1

•• Case #2Case #2

•• 58 YO female58 YO female•• ““My right shoulder has been sore from My right shoulder has been sore from

repetitive use at the deli counterrepetitive use at the deli counter””•• Pain with repetitive use, significant night Pain with repetitive use, significant night

pain when sleeping on the rightpain when sleeping on the right


Case #2Case #2

•• Inspection normalInspection normal•• Good ROMGood ROM•• No crepitusNo crepitus•• + Neer + Hawkins + Neer + Hawkins •• Negative empty canNegative empty can•• 5 of 5 rotator cuff strength5 of 5 rotator cuff strength


Case #2Case #2

•• No weaknessNo weakness•• Chronic onset of painChronic onset of pain

•• Therapy and injectionTherapy and injection

•• If no improvement after 6 weeks consider If no improvement after 6 weeks consider MRI to rule out RCTMRI to rule out RCT


Case #2Case #2

•• Treatment algorithm for RCT even in 2013 is Treatment algorithm for RCT even in 2013 is constantly constantly evolvingevolving

•• Much we still do not know about rotator cuff Much we still do not know about rotator cuff tears and their treatmenttears and their treatment

•• Can be frustrating to patient and providersCan be frustrating to patient and providers•• Know your patient and their expectationsKnow your patient and their expectations•• Educate your patient about outcomesEducate your patient about outcomes•• Can be Can be rewardedrewarded with good resultswith good results


SummarySummary

THANK YOUTHANK YOU

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current concepts in rotator cuff management - nhafp.orgnhafp.org/pdf/nhafp cme.pdf · current...

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