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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

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

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

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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 AfterRepairSurgery.AmJSportsMed. 2017Jul;45(8):17551761.

22.Goutallier D,Postel JM,Bernageau J,Lavau L,Voisin MC.FattymuscledegenerationincuffrupturespreandpostoperativeevaluationbyCTscan.Clin Orthop Relat Res,1994;304:7883.

23.Melis B,DeFranco MJ,Chuinard C,Walch G.Naturalhistoryoffattyinfiltrationandatrophyofthesupraspinatusmuscleinrotatorcufftears.Clin Orthop Relat Res,2010;468:14981505.

24.BryanM.Saltzman,WilliamA.Zuke,BeatriceGo,RandyMascarenhas,NikhilN.Verma,BrianJ.Cole,AnthonyA.Romeo,BrianForsythe.Doesearlymotionleadtoahigherfailurerateorbetteroutcomesafterarthroscopicrotatorcuffrepair?Asystematicreviewofoverlappingmetaanalyses.DOI:http://dx.doi.org/10.1016/j.jse.2017.04.004 Publicationstage:InPressCorrectedProof.JournalofShoulderandElbowSurgery.Publishedonline:June14,2017.

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26.GerberC,MeyerDC,FreyE,vonRechenberg B,Hoppeler H,FriggR,Jost B,Zumstein MA.Neer Award2007:Reversionofstructuralmusclechangescoused bychronicrotatorcufftearsusingcontinuousmusculotendinoustraction.Anexperimentalstudyinsheep.JShoulderElbowSurg,2009;18:163171.

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30.AtsushiUrita,Tadanao Funakoshi,Tatsunori Horie,MutsumiNishida,NorimasaIwasaki.Differenceinvascularpatternsbetweentransosseousequivalentandtransosseous rotatorcuffrepair.JournalofShoulderandElbowSurgery,Vol.26,Issue1,p149156.