rotator cuff tendinopathy

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  • Rotator Cuff Tendinopathy

    Mr Puneet MongaConsultant Orthopaedic Shoulder Surgeon

    Wrightington Hospital

  • Terminology

    Tendonitis / Tendinitis

    Tendinoses

    Tendinopathy

  • Whats the correct term to use ?

  • Terminology Tendonitis / Tendinitis - Inflammation of the

    tendon (rare)- Inappropriate terminology.

    Tendinoses- Degenerative condition- Tendon damage at cellular level.

    Tendinopathy - Disease of the tendon

  • Whats the function of the Rotator Cuff?

  • Function of a TendonForce Transmission from Muscle to bone

  • The Rotator Cuff

    Image Courtesy- www.patient.info

    http://www.patient.info

  • Function of the RC

    Rotation of the humerus w.r.t Scapula Compresses the head into the glenoid-

    dynamic stability

    Force coupling - Deltoid / Lattisimus / Pec Major

  • Whats the Aetiology of RC Tendinopathy

  • Causation of Rotator Cuff Tendinopathy

    Extrinsic factors Intrinsic factors

  • Acromial shapes

    Bigliani, L. U.; Morrison, D. S.; and April, E. W.: The morphology of the acromion and its relationship to

    rotator cuff tears. Orthop. Trans.,10: 228, 1986.10228 1986

    Higher proportion of RC tears seen in Curved and Hooked Acromions

    Image courtesy- Shoulderdoc.co.uk

  • Sub-acromial Wringer

  • Coronal Plane Patho-anatomy

    AbductionNeutral Position

    Repetitive Micro-trauma from external impingement

  • Sagittal - oblique Plane Pathoanatomy

    Sub-Acromial volume

  • Subacromial Decompression

    Sub-Acromial volume

  • Extrinsic Theory doesnt explain it all

    RCT- Bursectomy vs Bursectomy + acromioplasty- No Difference Articular surface tendon damage more common No direct relation between acromial shape and impingement

    symptoms

    Lewis J. Subacromial impingement syndrome: a musculoskeletal condition or a clinical illusion? Physical Therapy Reviews. 16(5):388-98. 2011

  • Lets understand the normal tendon structure and healing.

  • Normal Tendon

    Normal Cuff Tendon =

    Collagen (Type I predominantly)

    Elastin

    Glycosaminoglycan

    Proteoglycans

    Water

    Image Courtesy: www.ouhsc.edu

    http://www.ouhsc.edu

  • Injured tendon- Usual repair

    Total Collagen decreases

    Increased gene expression of Type I, VI, IX and III

    Decreased Type II expression.

    Repair and replacement of normal collagen

    Andrew Carr, Paul Harvie Chapter; Tendon Injuries pp 101-118 Rotator Cuff Tendinopathy.In Tendon Injuries. Maffulli et al Springer, 2005.

  • Normal HealingRepetitive loading

    Micro tears Healing

    Cellular Repair

  • Compensated OveruseExcessive loading

    Healing

    Cellular Repair

  • So, what goes wrong in tendinopathy?

  • Tendinopathy

    Excessive remodelling in response to tendon damage during tendon repair

    Aberrant quality Collagen

    Stiffer Extracellular matrix

  • Normal

    Tendinopathy-Disorganised matrix

    Cellular clumping

    Is Tendon Structure Associated with symptoms in Chronic Achilles TEndinopathy?An update on pain mechanisms Written by Robert-Jan de Vos, The Netherlands, Aspetar Sports Medicine Journal 2017

  • TendinopathyRepetitive loadingProne to

    damage

  • Can we blame our genes ?

  • Role of genetics

    Possible link with ank mutation

    (This is seen in association with Progressive form of arthritis)

    Gene codes for a protein which transports Pyrophosphate out of the cells..so a defective gene leads to high concentration of PPi.

    Increased Calcium deposition

    Andrew Carr, Paul Harvie Chapter; Tendon Injuries pp 101-118 Rotator Cuff Tendinopathy.In Tendon Injuries. Maffulli et al Springer, 2005.

  • Ok, what about the tendon blood supply?

  • Role of blood supplyCodmans Critical zone

    Debated- perhaps decreased blood supply a result rather than a cause

    Chicken or egg

    May explain the location along with external impingement

    Andrew Carr, Paul Harvie Chapter; Tendon Injuries pp 101-118 Rotator Cuff Tendinopathy.In Tendon Injuries. Maffulli et al Springer, 2005.

  • Whats the progression of Cuff tendinopathy ?

  • Unified Continuum Theory

  • Why do some partial tears progress to Full Why do some small tears progress to large Why do only 4% massive tears develop

    Cuff tear arthritis

    Presence of Cuff tear without impingement / vice versa

  • Discontinuous and multifactorial modelAndrew Carr, Paul Harvie Chapter; Tendon Injuries pp 101-118 Rotator Cuff Tendinopathy.

    In Tendon Injuries. Maffulli et al Springer, 2005.

  • Making a Diagnosis

  • Rotator Cuff Tendinopathy (and tears) may be asymptomatic

  • Using a Cluster approach recommended

    History Look Feel Move + Special Tests Investigations

    Making a Diagnosis

  • Positive Special Test = Diagnosis!

  • History and physical examination provide little guidance on diagnosis of rotator cuff tears.

    Jain NB, Yamaguchi K. Evid Based Med. 2014 Jun;19(3):108.

    http://www.ncbi.nlm.nih.gov/pubmed/?term=Jain%20NB%5BAuthor%5D&cauthor=true&cauthor_uid=24347201http://www.ncbi.nlm.nih.gov/pubmed/?term=Yamaguchi%20K%5BAuthor%5D&cauthor=true&cauthor_uid=24347201http://www.ncbi.nlm.nih.gov/pubmed/24347201#

  • Role of Investigations

    Ultrasound - Good for soft tissues & dynamic

    Xray- Good screening tool for Bone / joint

    CT- Good for bone

    MRI- Good for soft tissues and cross sectional

  • Management

  • First line Management

    Activity Modification Analgesia Physiotherapy- Posture, motor control,

    stretching, strengthening, Manual therapy- 6 weeks

  • Physiotherapy

    Principles

    Pain relief Maintaining Range of movement Progressive Strengthening

  • When would I expect physiotherapy to work?

  • Positive Predictors(1) Patient expectation of complete recovery compared to a slight improvement as a result of physiotherapy treatment,

    (2) Lower pain severity specifically at rest,

    (3) The absence of a previous major operation (shoulder surgery excluded),

    (4) The absence of pain in the opposite upper quadrant and

    (5) Change in pain or range of shoulder elevation with manual facilitation of the scapula during elevation of the arm.

  • Cortisone Injection in Cuff Tendinopathy

  • Is Tendinopathy inflammatory?

    No

    Biopsies- No inflammatory cells

    Degenerative changes

    Sports Med. 1999 Jun;27(6):393-408.Histopathology of common tendinopathies. Update and implications for clinical management. Khan KM1, Cook JL, Bonar F,

    Harcourt P, Astrom M.

  • 1. Pragmatic reason

    Neers Test - LA component Cross confirms the diagnosis

    So, Why inject?

  • And,. what about bursitis ?

  • Is Bursitis inflammatory?

    Yes

    Presence of Inflammatory mediators in Bursal biopsies

    Inflammatory mediators reduced following NSAIDs or cortisone injection

    Arch Orthop Trauma Surg. 1992;111(6):336-40. Inflammation of the subacromial bursa in chronic shoulder pain. Santavirta S1, Konttinen YT, Antti-Poika I, Nordstrm D

    J Shoulder Elbow Surg. 2005 Jan-Feb;14(1 Suppl S):84S-89S. The molecular pathophysiology of subacromial bursitis in rotator cuff disease. Blaine TA1, Kim YS, Voloshin I, Chen D, Murakami K, Chang SS, Winchester R, Lee FY, O'keefe RJ, Bigliani LU.

    J Orthop Res. 2006 Aug;24(8):1756-64. Stromal cell-derived factor 1 (SDF-1, CXCL12) is increased in subacromial bursitis and downregulated by steroid and nonsteroidal anti-inflammatory agents.Kim YS1, Bigliani LU, Fujisawa M, Murakami K, Chang SS, Lee HJ, Lee FY, Blaine TA.

  • Current Practice

    Sub-acromial Steroid Injection

    Usually 1

    BOA/ BESS commissioning guide

  • Indications for Surgery

    Failure of First line treatment

    Symptoms lasting more than 6 months

  • Notable Exception

    Acute Rotator Cuff Tears

    Early surgery has better outcomes

    Duncan NS, Booker SJ, Gooding BW, Geoghegan J, Wallace WA, Manning PA Surgery within 6 months of an acute rotator cuff tear significantly improves

    outcome. J Shoulder Elbow Surg. 2015 Dec;24(12):1876-80.

    http://www.ncbi.nlm.nih.gov/pubmed/?term=Duncan%20NS%5BAuthor%5D&cauthor=true&cauthor_uid=26163285http://www.ncbi.nlm.nih.gov/pubmed/?term=Booker%20SJ%5BAuthor%5D&cauthor=true&cauthor_uid=26163285http://www.ncbi.nlm.nih.gov/pubmed/?term=Gooding%20BW%5BAuthor%5D&cauthor=true&cauthor_uid=26163285http://www.ncbi.nlm.nih.gov/pubmed/?term=Geoghegan%20J%5BAuthor%5D&cauthor=true&cauthor_uid=26163285http://www.ncbi.nlm.nih.gov/pubmed/?term=Wallace%20WA%5BAuthor%5D&cauthor=true&cauthor_uid=26163285http://www.ncbi.nlm.nih.gov/pubmed/?term=Manning%20PA%5BAuthor%5D&cauthor=true&cauthor_uid=26163285http://www.ncbi.nlm.nih.gov/pubmed/26163285#

  • Setup Patient Position - Beach chair / lateral Arm holder - traction vs mechanical Kit- Coblation/ shaver/ pump

  • Portals

  • Outcomes

    20 year follow up 80% satisfied- 14% revision

    Arthroscopy. 2015 Oct 24. pii: S0749-8063(15)00704-5. doi: 10.1016/j.arthro.2015.08.026. [Epub ahead of print]

    Patients With Impingement Syndrome With and Without Rotator Cuff

    Tears Do Well 20 Years After Arthroscopic Subacromial Decompression. Jaeger M1, Berndt T2, Rhmann O2, Ler

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