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  • 9/22/2017

    1

    Evaluation and Treatment of Rotator Cuff Disorders

    William Paterson, MDOctober 7, 2017

    Anatomy

    DifferentialDiagnosis

    Patientage Mechanismofinjury

    Acuteorchronic Locationofthepain Associatedsymptoms

    Swelling/bruising/deformity Numbness/tingling Popping Feelingsofinstability

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    LocationofPainOnefinger,onespot

    Anterior Biceps,labrum,glenohumeral joint,subscapularis,coracoid,ACjoint,

    nerve

    Posterior Labrum,supraspinatus/infraspinatus,scapuladyskinesia,nerve

    Lateral Supraspinatus/infraspinatus,capsulitis,nerve

    Vague Scapuladyskinesia,nerve

    Radiatestohand Nerve,biceps,labrum

    Inspection

    Abrasions,edema,ecchymosis

    Deformity Scapulapositioning Men:shirtoff Women:tubetopexamgown

    Palpation Codmanspoint supraspinatus

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    Palpation Biceps

    Palpation Glenohumeral joint

    Palpation Coracoid

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    Palpation Acromioclavicular joint

    RangeofMotion

    Elevation/Flexion

    RangeofMotion Externalrotation

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    RangeofMotion

    Internalrotation

    Strength Supraspinatus about30degreeselevation

    Strength Infraspinatus nearmaximumexternalrotation

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    Strength Subscapularis

    Stability Anterior

    Stability Posterior

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    Stability Inferior

    Neer ImpingementSign

    Speeds

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    SLAPrehension

    FullExam

    Anatomy

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    RotatorCuffTears:FactorsInvolved Intrinsic tocufftendon Avascularity Aging Overuse questionable Steroids Smoking riskfortearprogression1 Hypercholesterolemia2

    Extrinsic Acromialmorphology Acromioclavicularjointosteophytes usuallytoomedialtodamagecuff Scapulohumeralkinematics,scapularlag Inflammatoryprocesses

    Acromialspurcausescufftear 1986Bigliani classification

    However,only42%ofTypeIIIacromions hadcufftear3

    17%pts3%oftears

    43%pts24%oftears

    40%pts73%oftears

    Cufftearcausesbonespur Neer 19724:acromialspuriscommonlylocatedintheCAligament,andmaybecausedbytractionresultingfromsuperiormigrationofthehumeralheadinacuffdeficientshoulder

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    TendonVascularity

    Codmanscriticalzone

    Relativehypovascularity ofdeepcomparedtosuperficialsupraspinatusinsertion

    RothmanandParke5

    CriticalShoulderAngle6

    Glenohumeralosteoarthritis:282

    Rotatorcufftear:Supraspinatus:363

    SupraandInfra:403.5

    Noarthritisorrotatorcufftear:343

    CriticalShoulderAngle7

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    Steroids 2009Mikolyzk etal.10

    Afterone week:decreasesinmaxload(27%),maxstress(25%)andstiffness(32%)inratinfraspinatustendonexposedtosubacromial methylprednisolone Nodifferenceat

    threeorfiveweeks

    Incidence 2006Yamaguchietal.13 588patientshadbilateralUSforunilateralshoulderpain

    Avg ageof376ptswithanycufftear62.8yrs,65%onrightside

    50%likelihoodofbilateraltearsatage66yrs Inptswithsymptomatic FTtear,56.3% chanceofPTorFTcontralateraltear

    Inptswithnormaltendoninpainfulshoulder,2.3%chanceofPTorFTtear(5of217)incontralateralshoulder

    Incidence

    0(age4049)10%(age5059)20%(age6069)40.7%(age>70)

    Partialthicknesstearsabouttwiceascommonasfullthicknesslesions Cadavers:1332%incidenceofpartialthicknesstears,719%fullthicknesstears11

    2009Kimetal.12 237Asymptomatic patients.Avg59.6yr

    Ultrasound:41(17.3%)hadcufftearinatleastoneshoulder

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    Incidence

    Korea:486asymptomatic volunteers14

    Meanage53.1(2082) Fullthicknesstear:4.7%incidenceoverall 5059:3.5% 6069:13.3% >70:11.1% Increasedinpatientswithdiabetesandsmoking

    TreatmentOptions

    Conservative OTCmedicationsforpain Physicaltherapy

    75%successfulforatraumaticrotatorcufftear15

    Corticosteroidinjection Temporaryweakeningoftendon10 Increasedfailurerateandinfection1619 aftersurgery

    Toradolinjection Maybesaferthancortisone?

    Plateletrichplasmainjection Poordata Mayactuallyhelpforintratendinous partialtear20

    RiskFactorsforRepairFailure21

    Age Inflammatoryarthritis Sizeoftear FattyinfiltrationStage2orgreater22,23

    Singlerowrepair Earlymotion(Lessthan3weekspostop)24

    Other:smoking,diabetes,osteoporosis TendonLength

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    CriticalShoulderAngle Cadaverstudy9:5mmlateralresectionoftheacromionpreservesthedeltoidattachmentanddecreasesCSAfrom34.32.1to31.51.7

    FattyInfiltration22 isDifferentfromAtrophy25,26

    PositivetangentNegativetangent

    RepairMethod 2009Nho etal.27 single vsdoublerowreview

    Equivalentclinicaloutcomes(notransosseous equivalent) Evidencetosupportimprovedtendonhealingwithdoublerowfixation

    2009Krishnanetal.28 116pts,arthroscopictransosseous cuffrepair,avg 56yrs,f/u624mos 96%returnedtopremorbidactivitylevelby6months.

    2010Penningtonetal.29 78singlerowvs54DRtransosseous equivalent Highpt satisfaction:SR95%,DR92% MRIat1228mos:DRbetterhealingratefortears2.5cmto3.5cm

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    WhatIDo

    Conservativetreatmentage>70,irreparabletear Toradol/cortisoneinjectionforpain,PT

    Generallyrecommendsurgicalrepairtopatients

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    ArthroscopicEvaluationSubacromial

    Transosseous RotatorCuffRepairPreparethetendonandtuberosity

    Transosseous RotatorCuffRepair

    Tornier,Inc.Edina,MN

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    Transosseous RotatorCuffRepairDrilltunnels

    Transosseous RotatorCuffRepairShuttlesutures

    Transosseous RotatorCuffRepairPassandtiesutures

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    Rehab

    Slingfor6weeks(smallertear),8weeks(largetear)

    Week23:PassiveROM Week7:ActiveROM Week10:Painfreestrengthening

    References

    1.YamamotoN1,Mineta M1,KawakamiJ1,SanoH2,Itoi E1.RiskFactorsforTearProgressioninSymptomaticRotatorCuffTears:AProspectiveStudyof174Shoulders.AmJSportsMed. 2017Jun1:363546517709780.doi:10.1177/0363546517709780.[Epub aheadofprint]

    2.RaynorMB1,KuhnJE2.Utilityoffeaturesofthepatient'shistoryinthediagnosisofatraumaticshoulderpain:asystematicreview.JShoulderElbowSurg. 2016Apr;25(4):68894.

    3.Liotard JP,Cochard P,Walch G.Criticalanalysisofthesupraspinatusoutletview:rationaleforastandardscapularYview.JShoulderElbowSurg,1998;7(2):134139.

    4.Neer CS.Anterioracromioplastyforthechronicimpingementsyndromeintheshoulder:apreliminaryreport.JBoneJointSurg,1972;54:4150.

    5.RothmanRHandWWParke.Thevascularanatomyoftherotatorcuff.Clin Orthop,1965;41:17686. 6.DavideBlonna,AndreaGiani,EnricoBellato,LorenzoMattei,MichelCal,RobertoRossi,FilippoCastoldi.

    Predominanceofthecriticalshoulderangleinthepathogenesisofdegenerativediseasesoftheshoulder.JournalofShoulderandElbowSurgery,Vol.25,Issue8,p13281336.

    7.Gerber,Christian.AnatomyandTreatmentoftheRotatorCuff.PresentationattheSanDiego ShoulderInstituteMeeting,2014.AccessedviaVuMedi.comAugust2017.

    8.GrantH.Garcia,JosephN.Liu,RyanM.Degen,ChristineC.Johnson,AlexanderWong,DavidM.Dines,LawrenceV.Gulotta,JoshuaS.Dines.Highercriticalshoulderangleincreasestheriskofretear afterrotatorcuffrepair.JournalofShoulderandElbowSurgery,Vol.26,Issue2,p241245

    9.Katthagen JC1,MarchettiDC1,Tahal DS1,TurnbullTL1,MillettPJ2.TheEffectsofArthroscopicLateralAcromioplastyontheCriticalShoulderAngleandtheAnterolateralDeltoidOrigin:AnAnatomicCadavericStudy.Arthroscopy. 2016Apr;32(4):56975.

    References 10.Mikolyzk DK,WeiAS,Tonino P,Marra G,WilliamsDA,HimesRD,Wezeman FH,Callaci JJ.Effectofcorticosteroidson

    biomechanicalstrengthofratrotatorcufftendon.JBoneJointSurg Am,2009;91:11721180. 11.FukudaH.Reviewarticlethemanagementofpartialthicknesstearsoftherotatorcuff.JBoneJointSurg Br,2003;85B:311. 12.KimMH,Teefey SA,ZeligA,GalatzLM,KeenerJ,YamaguchiK.Shoulderstrengthinasymptomaticindividualswithintact

    comparedwithtornrotatorcuffs.JBoneJointSurg,2009;91:289296. 13.YamaguchiK,Ditsios K,MiddletonWD,Hildebolt CF,GalatzLM,Teefy SA.Thedemographicandmorphologicalfeaturesof

    rotatorcuffdisease.Acomparisonofasymptomaticandsymptomaticshoulders.JBoneJointSurg Am,2006;88:16991704. 14.Jeong J1,ShinDC2,KimTH3,KimK4.PrevalenceofasymptomaticrotatorcufftearandtheirrelatedfactorsintheKorean

    population.JShoulderElbowSurg. 2017Jan;26(1):3035. 15.KuhnJE1,DunnWR,SandersR,AnQ,Baumgarten KM,BishopJY,BrophyRH,CareyJL,HollowayBG,JonesGL,MaCB,Marx

    RG,McCartyEC,PoddarSK,SmithMV,SpencerEE,VidalAF,WolfBR,WrightRW;MOONShoulderGroup.Effectivenessofphysicaltherapyintreatingatraumaticfullthicknessrotatorcufftears:amulticenterprospectivecohortstudy.JShoulderElbowSurg. 2013Oct;22(10):13719.

    16.Gupta,M.N.,Sturrock,R.D.,andField,M.Aprospective2yearstudyof75patientswithadultonsetsepticarthritis.Rheumatology(Oxford).2001;40:2430

    17.Kaandorp,C.J.,Dinant,H.J.,vandeLaar,M.A.,Moens,H.J.,Prins,A.P.,andDijkmans,B.A.Incidenceandsourcesofnativeandprostheticjointinfection:acommunitybasedprospectivesurvey.AnnRheumDis.1997;56:470475

    18.Kaandorp,C.J.,VanSchaardenburg,D.,Krijnen,P.,Habbema,J.D.,andvandeLaar,M.A.Riskfactorsforsepticarthritisinpatientswithjointdisease.Aprospectivestudy.ArthritisRheum.1995;38:18191825

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    References 19.Mathews,C.J.,Kingsley,G.,Field,M.,Jones,A.,Weston,V.C.,Phillips,M.etal.Managementofseptic

    arthritis:asystematicreview.AnnRheumDis.2007;66:440445 20. Ldermann A,Zumstein MA,Kolo FC,Grosclaude M,Koglin L,Schwitzguebel AJ.Invivoclinicaland

    radiologicaleffectsofplateletrichplasmaoninterstitialsupraspinatuslesion:Caseseries.Orthop TraumatolSurg Res. 2016Dec;102(8):977982.

    21.LeeYS1,Jeong JY1,ParkCD1,KangSG1,Yoo JC1.EvaluationoftheRiskFactorsforaRotatorCuffRetear AfterRe