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PubMedDate not supplied

The use of in-office, orthopaedist-performed ultrasound of the shoulder to evaluate and manage rotator cuff disorders.

This study presents the use of in-office ultrasound, performed by an attending orthopaedic surgeon, as a means of evaluating the integrity of the rotator cuff. The results of 282 shoulder sonograms in patients ultimately treated surgically were included. Findings at surgery were recorded and compared with those documented during the ultrasound examination. Ultrasound findings included 118 full-thickness and 143 partial-thickness rotator cuff tears and 6 intact cuffs confirmed at surgery. One patient with a partial supraspinatus tear on ultrasound was intact at surgery, nine with complete supraspinatus tears had partial-thickness tears at surgery, one with an intact supraspinatus had a full-thickness tear at surgery, and four with partial-thickness supraspinatus tears had full-thickness tears at surgery. The sensitivity, specificity, positive predictive value, and negative predictive value were 94.1%, 96.1%, 96.6%, and 93.2%, respectively, for partial-thickness tears; 95.9%, 94.3%, 92.9%, and 96.8%, respectively, for full-thickness tears; and 99.6%, 85.7%, 99.6%, and 85.7%, respectively, when the rotator cuff was evaluated for damage (either partial- or full-thickness tears). This series documents the ability of an orthopaedic surgeon to image the rotator cuff effectively using portable ultrasound in the clinic setting, allowing for a more efficient implementation of the management plan.

Adolescent↗
PubMed1994

Determinants of outcome in the treatment of rotator cuff disease.

One hundred thirty-six patients with impingement syndrome and rotator cuff disease who were treated nonoperatively from 1987 to 1991 were reviewed to identify findings at initial presentation that correlated with final outcome. Mean followup was 20 months (range, 6-41 months). All patients received initial conservative treatment. The results were analyzed in 2 groups. Group I consisted of the entire 136 patients with a minimum 6-month followup. Group II consisted of a subgroup of 68 patients with at least an 18-month followup. The overall results in Group I were 66% excellent and good and 34% fair and poor. For Group II, the overall results were 76% excellent and good and 24% fair and poor. For the Group II patients, a distribution of clinical findings at the 6-month followup demonstrated only 46% excellent and good results, indicating that the clinical result improves significantly as followup duration increased. Patient characteristics and prognostic factors that were associated with an unfavorable clinical outcome included a rotator cuff tear > 1 cm2, a history of pretreatment clinical symptoms for > 1-year duration, and significant functional impairment at initial presentation. Factors not associated with clinical outcome included patient age, occupation, gender, associated instability, dominance, chronicity of onset, active range of motion, or specific treatment modalities. Early operative intervention is recommended for patients with poor prognostic factors to avoid a protracted clinical course.

Adult↗
PubMedDate not supplied

[Complete rotator cuff rupture--differential surgical techniques and intermediate-term results].

QUESTIONS: What is the mid term result of open rotator cuff repair? What are the criteria for a good surgical result? METHODS: Between February 1988 and December 1993 130 patients (135 shoulders) underwent surgery for rotator cuff repair. All surgical techniques were combined with a acromioplasty--transosseous refixation, transtendinous suture, isolated or combined transfers of tendons. The retrospective analysis consisted of clinical examination including the Constant score, X-rays and sonograms of the shoulder before and after surgery. RESULTS: 95 patients (98 shoulders) were controlled 4 years and 8 months after surgery by clinical, radiological and sonographical examination. 80% of all cases showed good or very good long term results by chiefly transosseous refixation alone or in combination with tendon transfer. Analysis of all data made it possible to create simple prognostic criteria. These criteria can help preoperatively to give an idea of the expected outcome. CONCLUSION: The best preoperative criteria for a prognostic good surgical result were an acromion-humeral head distance in the native true a.p.-X-ray of more than 7 mm, a rotator cuff defect of less than 2 x 3 cm and a passive free range of motion.

Adult↗
PubMedDate not supplied

Magnetic resonance imaging evaluation of the rotator cuff tendons in the asymptomatic shoulder.

Thirty shoulders in 20 volunteers (average age, 29 years; range, 17 to 49) with no shoulder symptoms or known abnormalities were scanned using magnetic resonance imaging. All scans were interpreted by one radiologist who was blinded to clinical data. Appearance of rotator cuff tendons on the images was graded. Grade 0 was normal, homogeneous low signal intensity structure. Grade 1 lesion was focal, linear, or diffuse intermediate signal through the tendon. Grade 2 lesion was high signal intensity within the tendon and less than full thickness. Grade 3 was high signal intensity through full thickness of the tendon. No supraspinatus or infraspinatus tendons were grade 0 (normal); all supraspinatus and infraspinatus tendons had grade 1 changes through the tendons; and 7 of 30 (23%) of the tendons had grade 2 changes. None of the 30 shoulders had grade 3 changes in the rotator cuff tendons. There is a wide array of abnormal magnetic resonance imaging signals in shoulders of young asymptomatic individuals, but they do not have full-thickness rotator cuff tears (grade 3 lesion). Nonenhanced magnetic resonance imaging may be of limited value in defining rotator cuff injury in a patient with shoulder pain unless a full-thickness rotator cuff tear is suspected clinically.

Adolescent↗
PubMed1994

Partial repair of irreparable rotator cuff tears.

This study analyzes the results of a previously unreported technique of reconstruction for the massive irreparable rotator cuff tear. The technique involves repair of the margins of the tear to restore the force couples and "suspension bridge" system of force transmission in the shoulder. Complete coverage of the defect was not considered to be essential as long as the normal mechanics of the shoulder were restored and the rotator cuff tear was converted to a "functional cuff tear." This procedure was performed on 14 patients. Improvement in function was dramatic. Active elevation (elevation denotes the plane of motion midway between the planes of shoulder abduction and shoulder flexion; elevation is reported because it is the most functional plane in which to raise the arm) improved by 90.8 degrees: from a preoperative average of 59.6 degrees to a postoperative average of 150.4 degrees. Strength improved an average of 2.3 grades on a 0-to-5-point scale. The average score on the UCLA Shoulder Rating Scale improved from a preoperative value of 9.8 to a postoperative value of 27.6. All but one patient was very satisfied with his or her result. The authors are of the opinion that this technique is preferable to other reconstructive techniques, such as tendon transposition, that emphasize coverage of the defect at the expense of destroying the normal mechanics of the shoulder. The authors suggest that partial repair of massive irreparable rotator cuff tears should supplant tendon transposition as the procedure of choice for this condition.

Adult↗
PubMed2005

Arthroscopic rotator cuff repair: the learning curve.

PURPOSE: The purpose of this study was to answer the question: How many cases are required for a surgeon to become proficient in performing arthroscopic rotator cuff repair? We hypothesize that as surgical experienced is gained, learning can be quantitatively shown by a significant decrease in operative time. TYPE OF STUDY: Prospective case series. METHODS: Rotator cuff repair time (RCRT) in minutes (as well as other time components comprising total surgical time) was recorded for 100 consecutive patients having arthroscopic rotator cuff repair performed by a single surgeon beginning with his first case in private practice. Mean RCRTs for consecutive blocks of 10 cases were compared. Learning is graphically represented by plotting the RCRT by case number and generating a logarithmic trend curve. A best-fit linear equation (y = mx + b) allows comparison of the initial 10 cases with the subsequent 90 cases, where m , the slope, represents the rate of decrease in RCRT (learning). RESULTS: Mean RCRT decreased significantly (P < .05) from the first block of 10 cases to the second block of 10 cases. There were no significant changes in mean RCRT when comparing other consecutive blocks of 10 cases. The slope of the line fitting the first block of 10 cases is -8.75; the slope (m) of the line fitting the subsequent 90 cases is -0.23. There is no significant difference in mean RCRT when cases are stratified by tear size. CONCLUSIONS: Graphic representation of RCRT by case number generates a learning curve whereby learning is quantitatively shown as a significant decrease in operative time as surgical experience is gained. CLINICAL RELEVANCE: Qualification of the learning curve for arthroscopic rotator cuff repair provides a guide for orthopaedic surgeons contemplating the expected time line for acquiring proficiency in this technique.

Arthroscopy↗
PubMed1995

Acute traumatic tears of the rotator cuff: value of sonography.

PURPOSE: To determine the value of sonography in the evaluation of acute traumatic tears of the rotator cuff. MATERIALS AND METHODS: Preoperative sonography was performed within 3 weeks of trauma in 184 patients, 98 of whom underwent surgery. The rotator cuff tears were preoperatively classified as partial-thickness tears or as small, large, or massive full-thickness tears. Sonographic findings were correlated with surgical findings (n = 70) and arthroscopic inspection (n = 28). RESULTS: Adequate examination was possible in 163 (88%) of 184 patients. Sonography demonstrated 42 (91%) of 46 full-thickness tears and seven (78%) of nine partial-thickness tears. Sonography showed more extensive tears than were found at surgery in four (4%) of 98 patients and less extensive tears in seven (7%) of 98 patients. Sonographic patterns were a defect (31 [63%] of 49 tears), focal thinning (10 [21%] of 49 tears), and nonvisualization (eight [16%] of 49 tears). CONCLUSION: Sonography is useful in the evaluation of acute shoulder trauma when a rotator cuff tear is suspected and findings at plain radiography are negative.

Adult↗
PubMed2001

In-vitro reconstruction of massive rotator cuff ruptures with triceps tendon or coracoacromial ligament.

The possibility of reconstructing a massive rotator cuff rupture with a free graft of the triceps tendon or the coracoacromial ligament was tested experimentally in an anatomical and biophysical cadaver investigation. After dissection of the rotator cuff, a section of the supraspinatus tendon was removed to simulate a defect in the cuff. In dissection of the grafts, a bony squama was incorporated by osteotomy. The rotator cuff was reconstructed by suturing the free grafts into the defect. In addition, the bony squama was refixed in a prepared bone groove in the greater tuberosity of the humerus. The tensile strength and the elasticity of the grafts were compared with that of the supraspinatus tendon in rupture tests. The mean value of the maximum load determined (FRm) was greatest for the triceps tendon (706.451 N), while very much lower values were found for the coracoacromial ligament (395.836 N) and the supraspinatus tendon (496.792 N). The mean value of the maximum elasticity (LAm) was lowest for the coracoacromial ligament (4.701%); the supraspinatus tendon (7.047%) and the triceps tendon (8.250%) showed very much greater elasticity.

Humans↗
PubMed1994

The entire rotator cuff contributes to elevation of the arm.

The function of the infraspinatus, teres minor, and subscapularis during elevation of the arm remains poorly defined. These muscles may generate moments that contribute to abduction of the arm, although they frequently are classified as humeral depressors. The purposes of this study were to measure the contributions to abduction made by the more inferiorly positioned rotator cuff muscles relative to the contributions of the supraspinatus and to determine the range of motion at which the muscles are most effective. Five fresh cadaveric shoulder girdles were mounted in an apparatus designed to simulate contraction of the deltoid and rotator cuff while maintaining the normal relationship between glenohumeral and scapulothoracic motions. The deltoid force required for elevation was measured without simulated contraction of the rotator cuff and with simulated contraction of the entire rotator cuff, of the supraspinatus only, and of the infraspinatus-teres minor and subscapularis only. A significant reduction in deltoid force when other muscle activity was added indicated that the additions contributed significantly to abduction. The deltoid force required with concurrent contraction of the entire rotator cuff averaged 41% less than with the deltoid alone but was not significantly different than with the deltoid and supraspinatus or with the deltoid, infraspinatus-teres minor, and subscapularis. Concurrent application of forces to the supraspinatus or the infraspinatus-teres minor and subscapularis significantly reduced the required deltoid force over the range of motion studied by an average of 28 and 36%, respectively. The contributions of the rotator cuff muscles to abduction of the arm were greatest at low abduction angles (30 and 60 degrees) and were insignificant by 120 degrees. The infraspinatus-teres minor and subscapularis contribute significantly to abduction: their contribution was equal to that of the supraspinatus and, like the supraspinatus, they are most effective during the first 90 degrees of abduction.

Aged↗
PubMedDate not supplied

Strength after surgical repair of the rotator cuff.

Forty-two consecutive patients (20 men and 22 women, age range 39 to 78 years) with full-thickness rotator cuff tears underwent a comprehensive isokinetic strength assessment before and at 3-month intervals for 1 year after surgery. All patients underwent acromioplasty and rotator cuff repair and were treated with a standardized postoperative rehabilitation program. Isokinetic strength testing was performed in flexion/extension, abduction/adduction, and external/internal rotation at 60 degrees/sec. The unaffected contralateral shoulder was tested for comparison. Clinical outcomes were assessed with the University of California Los Angeles Shoulder Rating Scale (maximum = 35 points). The average University of California Los Angeles score was 31.2 by 1 year after operation. Patients with small and medium tears had an average rating of 33.5, whereas those with large and massive tears had an average score of 28.3. Strength increased gradually during the first postoperative year. The preoperative mean peak torque was 54%, 45%, and 64% of the uninvolved shoulder in flexion, abduction, and external rotation, respectively; after operation it increased to 78%, 80%, and 79% by 6 months and 84%, 90%, and 91% by 12 months. The greatest improvement in strength consistently occurred during the first 6 months after surgery. Patients also showed marked increases in both work and power. By 12 months after operation mean work had increased to 70% in flexion and abduction and 90% in external rotation of the uninvolved shoulder. Similarly, mean power had increased to 68%, 79%, and 90% of the uninvolved shoulder in flexion, abduction, and external rotation, respectively, by 12 months after operation. Recovery of strength correlated primarily with the size of the tear: for small and medium tears recovery of strength was almost complete during the first year, and for large and massive tears it was much slower and less consistent. By using isokinetic strength evaluation we found that recovery of strength after rotator cuff repair requires at least 1 year of rehabilitation.

Adult↗
PubMed1996

Arthroscopic treatment of rotator cuff disorders.

The past 2 decades have seen rapid advancement in the field of shoulder arthroscopy in general and of rotator cuff disorders in particular. Arthroscopy allows superior visualization of pathologic conditions with less soft-tissue trauma than open exposures. Arthroscopic surgical techniques also are being applied to the actual treatment of many forms of rotator cuff disorders with clinical results similar to more traditional, open procedures. Although these techniques and their indications continue to evolve, it remains clear that, in carefully selected patients, arthroscopy has become a highly useful and effective tool in the diagnosis, evaluation, and surgical management of common disorders of the rotator cuff.

Arthroscopy↗
PubMedDate not supplied

The rotator cuff opposes superior translation of the humeral head.

To determine the influence of rotator cuff muscle activity on humeral head migration relative to the glenoid during active arm elevation we studied five fresh cadaveric shoulders. The shoulder girdles were mounted in an apparatus that simulated contraction of the deltoid and rotator cuff muscles while maintaining the normal scapulothoracic relationship. The arms were abducted using four different configurations of simulated muscle activity: deltoid alone; deltoid and supraspinatus; deltoid, infraspinatus, teres minor, and subscapularis; and deltoid, supraspinatus, infraspinatus, teres minor, and subscapularis. For each simulated muscle configuration the vertical position of the humeral head in relation to the glenoid was determined at 30 degrees, 60 degrees, 90 degrees, and 120 degrees of abduction using digitized anteroposterior radiographs. Both muscle activity and abduction angle significantly influenced the glenohumeral relationship. With simulated activity of the entire rotator cuff, the geometric center of the humeral head was centered in the glenoid at 30 degrees but had moved 1.5 mm superiorly by 120 degrees. Abduction without the subscapularis, infraspinatus, and teres minor muscles caused significant superiorly directed shifts in humeral head position as did abduction using only the deltoid muscle. These results support the possible use of selective strengthening exercises for the infraspinatus, teres minor, and subscapularis muscles in treatment of the impingement syndrome.

Aged↗
PubMed1998

The 'dropping' and 'hornblower's' signs in evaluation of rotator-cuff tears.

We studied 54 patients operated on for combined supraspinatus and infraspinatus rotator-cuff tears. The presence or absence of the dropping and hornblower's clinical signs of impaired external rotation were correlated with Goutallier stage-3 or stage-4 fatty degeneration of infraspinatus and teres minor. These grades of fatty degeneration have previously been correlated with a poorer outcome from reconstructive surgery. We found that hornblower's sign had 100% sensitivity and 93% specificity for irreparable degeneration of teres minor and the dropping sign 100% sensitivity and 100% specificity for similar degeneration of infraspinatus. In seven patients, teres minor showed hypertrophy. This muscle can give useful function for the activities of daily living in patients with rotator-cuff tears in whom it is intact.

Activities of Daily Living↗
PubMedDate not supplied

Rotator cuff repairs in individuals with paraplegia.

Shoulder pain and dysfunction are common problems among those individuals with a spinal cord injury (SCI). Among individuals with SCI who have shoulder pain, the prevalence of rotator cuff tears is 65 TO 71%. To date, there has been little discussion as to the efficacy of various treatments for shoulder pain used in the SCI population. The purpose of this retrospective study was to evaluate the outcome of rotator cuff repairs at the Spinal Cord Injury Center (Veterans Administration Puget Sound Health Care System). Five patients (six shoulders) were identified who had undergone shoulder surgery for rotator cuff tear since 1987. Four individuals (five shoulders) had large rotator cuff tears, and following surgery, none of these repairs resulted in improvement of shoulder function or improvement in active range of motion. The one patient with a smaller tear limited to the supraspinatus had a successful surgical outcome in that he had decreased pain, increased strength, and increased range of motion. There is a general lack of epidemiologic information about shoulder pain in individuals with paraplegia. There is also a remarkable lack of research as to the functional impact of shoulder pain and the outcome of nonsurgical and surgical treatments. This case series, drawn from a population of 511 individuals with spinal cord injury, demonstrates that poor outcome was more likely in those with supraspinatus atrophy, those with upward displacement of the humeral head on x-ray, and in those with tears involving more than one muscle. There is a need for further study of conservative treatment and development of selection criteria for those individuals who are being considered for surgery.

Aged↗
PubMed2000

The effect of strength training and reduced training on rotator cuff musculature.

OBJECTIVE: Elucidate the training frequency required to maintain strength gains acquired via short-term resistance training on the rotator cuff. DESIGN: Twenty-one participants performed 12 wk resistance training followed by 12 wk reduced training. Following the training phase (three rotator-cuff-specific exercises; three sessions/wk), participants were randomly assigned to one of three reduced training groups (2, 1 or 0 session(s)/wk). METHODS: Isokinetic testing was done at 0, 6, 12, 18 and 24 wk to obtain mean and peak torque (N m). Testing involved concentric and eccentric actions of internal and external rotation for both shoulders at 60 and 120 degrees /s. RESULTS: Training produced increases in mean and peak torque for all tests but the four of concentric external rotation. A control group performed no training, showing no changes in strength at 0, 6 and 12 wk. Reduced training (2 or 1 session(s)/wk) produced no decreases in peak or mean torque. Detraining (0 session/wk) produced mean torque decreases in four tests, with eccentric strength showing greater losses. CONCLUSIONS: A training frequency of 1 session/wk maintains rotator cuff strength gains in previously untrained subjects. Further, eccentric strength may be more susceptible to detraining. RelevanceThese findings have direct relevance to functional rehabilitation practices for the rotator cuff. They may aid in resistance training programming for athletes during the off-season or returning from injury, particularly those in overhand sports.

Arm↗
PubMed2000

The effect of negative intraarticular pressure and rotator cuff force on glenohumeral translation during simulated active elevation.

OBJECTIVE: The objective of this study was to determine the effect of negative pressure in the intraarticular space and subacromial bursa, as well as rotator cuff force, on glenohumeral translation during active elevation. DESIGN: Glenohumeral translation during elevation in the scapular plane was measured under greater than, less than, and equal to physiologic rotator cuff muscle force, as well as with and without the subacromial bursa and intraarticular space vented. BACKGROUND: Negative intraarticular pressure has been shown to help stabilize the glenohumeral joint in passive motion, although the effect on translation during active motion has not been investigated. METHODS: Eight cadaverous human shoulder specimens were tested in a dynamic shoulder simulator. Forces in the muscles of the rotator as well as the middle deltoid muscle were simulated using servohydraulic cylinders. Joint motion was measured using an ultrasonic motion analysis system. RESULTS: Superior translation of the humerus increased 1.2 mm (SD, 0.4) upon venting of the bursa, and 2.1 mm (SD, 1.7) upon venting of the joint capsule at 25 degrees of glenohumeral elevation in the scapular plane. At 90 degrees elevation, venting the bursa did not change superior translation but increased anterior translation 1.04 mm (SD, 1.0). Venting of the joint capsule increased superior translation by 2.8 mm (SD, 2.5). Decreasing rotator cuff force increased superior translation, while reducing it did not. CONCLUSION: The muscles of the rotator cuff and the negative pressure of the intraarticular space and the subacromial bursa stabilize the glenohumeral joint since they restrict translation in the superior and anterior directions. RelevanceIncreased glenohumeral translation and the resulting asymmetric loading may lead to arthrosis and ultimately rotator cuff arthropathy.

Adult↗
PubMed2006

Shoulder instability and related rotator cuff tears: arthroscopic findings and treatment in patients aged 40 to 60 years.

PURPOSE: To report our experience with the arthroscopic treatment of patients aged 40 to 60 years with rotator cuff lesions, shoulder instability, or both, and to seek a relationship among capsular-labral complex lesions, cuff tears, number of dislocations, and patient age. TYPE OF STUDY: Case series. METHODS: From January 2000, all patients aged between 40 and 60 years undergoing an arthroscopic procedure for rotator cuff lesions, shoulder instability, or both were divided into 3 cohorts: shoulder instability (group I), complete cuff tear (group C), and instability and complete cuff tear (group IC). In May 2002 there were 50 patients per group. Arthroscopic findings were analyzed using the Pearson correlation coefficient and the chi2 test to seek correlations between the lesions. The Student t test was used to highlight significant differences between preoperative and postoperative scores. RESULTS: There was a strong correlation between the rising number of dislocations and associated lesions of the supraspinatus and infraspinatus (P < .001); this correlation became stronger after 7 episodes of dislocation (P < .0001). There was no correlation between capsular or Bankart lesion and presence or absence of rotator cuff tears (P > .5). Two cases of recurrence of instability were recorded in group IC. Postoperatively, the Constant and Rowe scores rose significantly and consistently in all patients (P < .001). CONCLUSIONS: Rotator cuff tears and glenohumeral instability appear to be closely related. Patient age and number of dislocations do not appear to correlate with Bankart or capsular lesions, whereas posterosuperior cuff tears seem to be influenced by number of dislocations. Although data do not permit us to conclude whether repair of the sole cuff tear can achieve shoulder stability nor whether shoulder stabilization alone can resolve the instability, treatment of both lesions should be performed arthroscopically. LEVEL OF EVIDENCE: Level IV, case series.

Adult↗
PubMed2006

Cross-sectional and longitudinal construct validity of two rotator cuff disease-specific outcome measures.

BACKGROUND: Disease-specific Quality Of Life (QOL) measures are devised to assess the impact of a specific disease across a spectrum of important domains of life. The purpose of this study was to examine the cross-sectional and longitudinal construct validity (sensitivity to change) of two rotator cuff disease-specific measures, the Rotator Cuff-Quality Of Life (RC-QOL) and the Western Ontario Rotator Cuff (WORC) index, in relation to one another and to other joint and limb specific measures in the same population of the patients suffering from rotator cuff pathology. METHODS: Participants enrolled were consecutive patients who received physical therapy for management of impingement syndrome or received treatment following rotator cuff repair, acromioplasty or decompression surgeries. All subjects received physical therapy treatment and completed four outcome measures at 3 single points (initial, interim, and final). Cross-sectional convergent validity was assessed at each of the 3 time-points by correlating the WORC and RC-QOL's scores to each other and to two alternative scales; a joint-specific scale, the American Shoulder and Elbow Surgeons (ASES) standardized shoulder assessment form and a limb-specific measure, the Upper Extremity Functional Index (UEFI). Non-parametric statistics (Spearman's rho and Wilcoxon-Mann-Whitney tests) examined the construct validity. The standardized response mean (SRM) was used to examine sensitivity to change. RESULTS: Forty-one participants entered the study and their scores were compared at 3 cross sectional single points. The correlation coefficients among the 4 measures varied from 0.60 to 0.91. Correlation between corresponding domains of the WORC and RC-QOL varied from 0.45 to 0.85. The known group validity was not significantly different among individual sub-scores and total scores. The final SRMs were (1.42), (1.43), (1.44), and (1.54) for the ASES, RCQOL, WORC, and UEFI respectively. CONCLUSION: The WORC and RC-QOL exhibit similar cross-sectional convergent validity in patients suffering from rotator cuff pathology. The sensitivity to change was very close among all scores, with the UEFI having the highest sensitivity. Further research is needed to examine the extent to which each physical or emotional domain contributes to prognostic or therapeutic decision-making.

Adult↗