rotator cuff tendinopathy - physiotherapy alberta · rotator cuff tendinopathy tendinopathy partial...

Rotator Cuff Disease: Rehab and Surgery Lori Michener, PhD, PT, ATC, SCS, FAPTA

2/12/2018

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Lori Michener, PhD, PT, ATC, SCS, FAPTADirector of Clinical Outcomes and Research

Director – COOR LabUniversity of Southern California; Los Angeles, CA

[email protected]://pt.usc.edu/COOR/

Differential Diagnosis ofRotator Cuff Disease

COOR Lab

@LoriM_PT

Rotator Cuff Tendinopathy

Tendinopathy Partial thickness RC tear Full Thickness RC tear

• Tendinopathy

• Partial thickness RC tear– Articular, bursal, mid-substance

• Full-thickness RC tear– Complete rupture superior to inferior

– Not necessarily side to side

– “Hole’ in the sock


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Rotator Cuff Tendinopathy

• Full-thickness RC tear

• Partial thickness RC tear

• Tendon pathology without tear

• Subacromial impingement

Single clinical diagnosticcategory:

Subacromial pain syndrome

COOR Lab @ USC@LoriM_PT

Tendon Pathology

What’s in a name….• ‘subacromial impingement’

– Limited support for compression mechanism

– Perpetuates flawed reasoning & treatment

• Subacromial Pain Syndrome (SPS)– Allows for uncertainty of the pain generator:

tendons, bursae, biceps, CNS, other…

– Allows for mechanisms other than impingement

• Other names – ex: RC Related Shoulder Pain

COOR LabCOOR Lab @ USC@LoriM_PT


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SupraspinatusTendon

Tendon overload &Degeneration

Mechanical Compression in

SA Space

Subacromial Impingement Syndrome RCT 2 predominant theories

If mechanical compression is the predominant mechanism, then….

… ALL would benefit from an acromioplasty

• Acromioplasty + rehab was not clinically more beneficial than rehab alone in multiple trials (Brox et al; 1993, 1999; Haahr, 2005, 2006; Ketola S, 2009, 2013)

• Bony pathology is not the only mechanism

• ‘Impingement’ – May not be an appropriate label (Cools AM and Michener LA, BJSM, 2017)



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Mechanisms of RC (Tendon) Disease

• Mechanisms:– Overload and Compression

• Factors contributing to the mechanisms:– Intrinsic factors – within the tendon

– Extrinsic factors – external to the tendon

– Other factors –• Personal and Environmental factors


Intrinsic factors:Within the tendon

VascularityMorphologyMechanical

AgingGenetics

SA space- impingement??

RCD

Extrinsic factors:Strength/ m. control Tightness & LaxityPosture: spine, shBony abnormalities

Scap & GH kinematicsNeurophysiological

Brain / CNS

Load Load

COOR Lab @ USC


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Tendon overload• Neovascularization?

• Conflicting evidence (Lewis J, 2009; Kardouni JR, 2013)

• Is the tendon painful?

Tendon Degeneration with Overload• Inflammation present (Dean BJ, BJSM; 2015)

• Abnormal collagen laydown

• Tendon thickens initially then thins

• Thicker in SPS (Michener LA, 2015; Joensen J, 2009; Leong HT, 2012)

• Thins with progressive tendon disease

• *Thickens response to use Overhead athletes, Spinal Cord Injuires (SCI) (Belley AF, 2016; Maenhout A, 2012; Wang HK, 2005)


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Is compression in the SA Outlet causing tendon changes?

Compression or ‘impingement’ of RC tendons

- Subacromial (SA) space

SA space measured

Scapular al, 2012)

AHD= acromiohumeral distance10 – 15 mm in healthy

AHD

Tendon compression – is it possible?

SA space and shoulder pain:

– Space is smaller: AHD in ‘impingement’ (Hekimoglu B, 2013; Leong H-T, 2012; Seitz AL, 2011, Hebert LJ, 2003, Graichen H, 1999)

– Tendon is thicker: initially with disease & ‘overuse’

– Occupation ratio > : supraspinatus tendon: AHD • ‘Impingement’: tendon occupies > amount of AHD

(Michener LA, 2013)

• Overhead athletes & Spinal Cord Injury (SCI) (Belley AF, 2016; Maenhout A, 2012; Wang HK, 2005)



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Tendon compression – is it possible?

• Compression observed– cadaveric (Hughes PC, et al, 2012)

• Compression risk:– Smallest AHD: supraspinatus tendon 0 - 60°

Smallest AHD: tendon footprint 30 - 90°(Lawrence R, JOR, 2017)

– Tendon is not ‘available’ for compression (under the acromion) above ~ 70 elevation (Giphart JE, 2012; Thompson MD, 2011; Bey MJ, 2007)

Tendon compression may occur @ < 70°


Glenohumeral impingement

• Posterior / Internal– Compression between the

posterior glenoid and the humeral head

– Described in overhead athletes

– Recent evidence –maybe in non-overhead athletes (Lawence R, Ludewig P, et

al; CSM, 2017)


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European Society of MSK Radiology: Shoulder MSK Technical Guidelines


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So is it compression or is it degeneration?

• Both compression AND degeneration are causes– Less support for compression


Rotator Cuff Tendinopathy:What’s the Evidence for Diagnosis?

• Subacromial Pain Syndrome (SPS)– SPS

– Partial- thickness RC tears

• Full-thickness Rotator Cuff Tear (FT-RCT)



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Key Metrics for Dx Accuracy

• Diagnostic Accuracy values:– Sensitivity

– Specificity

– PPV: Predictive value of a positive test

– NPV: Predictive value of a negative test

– LR+: Positive likelihood ratio

– LR- Negative likelihood ratio

COOR Lab


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Sensitivity and Specificity

• Sensitivity • SnNOut = When Sn is high, a Negative test rules Out the

disease

• Specificity (SpPIn) • SpPIn = When Sp is high, a Positive test rules In the

disease.

• Interpretation:• Indicates if a test s or s disease probability

• BUT: No set cut-off to quantify shift in probability

COOR Lab

Likelihood Ratios

• More helpful for Dx• Indicate by how much a given diagnostic test

result will or the probability of the disease.• Quantify shifts in probability of the diagnosis

• Ex: +LR= 5: a patient with a + test is 5x more likely in a patient with the disease as compared to a patient without the disease

• Minimal affect of prevalence

COOR Lab


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Likelihood Ratio“+” “—”

Interpretation

>10 <0.1 Large & often conclusive changes from pre-test to post-test probability

5 – 10 0.1 – 0.2 Moderate shifts in pre-test to post-test probability

2 – 5 0.5 – 0.2 Small but sometimes important changes in probability

1 – 2 0.5 – 1 Small and rarely important changes in probability

Pre-test Prob = 1%+LR = 5

Pre-test Prob = 50%+LR = 5

Post-test Prob= 85%

Post-test Prob= 5%


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Recommendations for Diagnostic Values Interpretation

Screen (Rule/ Out)

– Sensitivity: SnNOut

* Sn > 80%

– Likelihood ratio (– LR)

* – LR < 0.5

Confirm (Rule/ IN)

– Specificity: SpPIn* Sp > 80%

– +Likelihood ratio (+LR)

* +LR > 2.0


Dx SA pain - Systematic Reviews1. Hermans J, JAMA, 2013; 2. Hanchard NCA, Cochrane, 2013;

3. Hegedus EJ, BMJ, 2012; 4. Alqunaee M, APMR, 2012

Confirm SA pain(R/In) – single tests

1- Painful arc2- Resisted ER

(ERRT)– pain or weak3- Full Can4- Drop Arm

* Combo of tests too! *

Screen Out SA pain(R/Out) – single tests

1- Painful arc2- Resisted ER (ERRT)

– pain or weakness3- Hawkins4- Neer5- Full Can6- Empty/ Jobe Can

BLUF


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Combo of Tests: SA Pain3/3 tests: (Park HB, JBJS; 2005)

Hawkins, Painful arc, ER resistance (Pain/Weak)

- All 3+: +LR of 10.56- All 3-: –LR of 0.17

3/5 tests: (Michener LA, APMR, 2009)

– Hawkins, Neer, Painful arc, Empty can, ER resistance

- If > 3+ / 5 : +LR of 2.93- If < 3+/ 5: –LR of 0.34

BLUF

Posterior Internal Impingement

• Impingement of the internal/deep aspect of RC tendons on posterior superior edge of the glenoid

• + for POSTERIOR or Post/ Superior should pain

• May be associated with anterior instability

COOR Lab


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Diagnosis FT-RCT- Systematic Reviews1. Hermans J, JAMA, 2013; 2. Hanchard NCA, Cochrane, 2013;


Confirm FT-RCT(R/In) – single tests

1- Painful arc2- Resist ER- marked weak

3- Drop Arm4- ER lag - massive tears

5- Atrophy infraspinatus

6- IR lag & lift off7- Belly off- subscap

Screen Out FT-RCT(R/Out) – single tests

1- Resisted ER marked weak

2- IR lag and lift off3- Full Can4- Empty/ Jobe Can

History: Age > 60/ 65yo and c/o night pain

Dx FT-RCT - Syst Reviews1. Hermans J, JAMA, 2013; 2. Hanchard NCA, Cochrane, 2013;


Confirm FT-RCT(R/In) – single tests1- Painful arc2- Resisted ER – pain or weak3- ER lag test – supraspinatus

infraspinatus4- IR lag & Lift off

subscapularis5- Drop arm6- Atrophy of infraspinatus7- Belly off – Subscapularis**Combo of tests**

Screen Out FT-RCT(R/Out) – single tests1- Resisted ER (ERRT)

– pain or weakness2- IR lag & Lift-off

subscapularis3- Empty Can4- Full Can

COOR Lab

History: Age > 60/ 65yo and c/o night pain

BLUF


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Combination of Tests: FT- RCT

• Test Combo (Litaker D, et al; J Am Geriatr Soc, 2000)

>65yo, ER weak (ERRT), night pain All 3 +: R/In +LR: 9.84All 3 -: R/Out - LR: 0.54

• Test Combo (Park HB, et al; JBJS, 2005)

3 Tests: Drop arm, Painful arc, ERRT All 3 tests + R/In +LR: 15.57 All 3 tests - R/Out -LR: 0.16

3 tests & >60yo:All 3 tests & >60yo + R/In +LR: 28.0 All 3 tests & >60yo - R/Out -LR: 0.09

COOR Lab

BLUF

Thank you!


rotator cuff tendinopathy - physiotherapy alberta · rotator cuff tendinopathy tendinopathy partial...

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