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PubMed2006

Decreasing glenoid inclination improves function in shoulders with simulated massive rotator cuff tears.

BACKGROUND: A massive rotator cuff tear leads to poor shoulder function as evidenced by diminished glenohumeral abduction and superior translation of the humeral head compared to its normal position. The inclination angle of the glenoid has been associated with rotator cuff tears. The objective of this study was to quantify the effect of a decreased glenoid inclination angle on glenohumeral kinematics during active abduction in shoulders with a simulated, massive rotator cuff tear. METHODS: Eight fresh-frozen full upper extremities were tested using a dynamic shoulder testing apparatus. After recording the kinematics of the intact shoulder, a massive rotator cuff tear was surgically simulated. An osteotomy of the glenoid was then performed and the inclination angle was decreased by 30 degrees . The translation of the humeral head during abduction and the maximum abduction angle were recorded. FINDINGS: With an intact rotator cuff minimal humeral head translation on the glenoid occurred and the maximum abduction angle was mean 85.5 degrees (SD 7.4 degrees ). A massive rotator cuff tear resulted in superior translation of the humeral head with impingement on the acromion. The maximum abduction angle was mean 15.5 degrees (SD 9.4 degrees ). Decreasing the inclination angle of the glenoid resulted in a significant reduction of superior humeral head translation during abduction and there was no impingement on the acromion. The maximum abduction achieved was mean 28.5 degrees (SD 17.0 degrees ). INTERPRETATION: From a clinical perspective the reduced superior translation may decrease shoulder pain since the humeral head no longer impinges on the acromion. Further investigations are necessary to assess if the improvement in abduction is clinically significant.

Cadaver↗
PubMed1994

Changes in the moment arms of the rotator cuff and deltoid muscles with abduction and rotation.

The behavior of the moment arms of the rotator cuff and deltoid muscles was studied during simple and combine movements of abduction and rotation about the glenohumeral joint. This was done by experimental measurement of excursions of the muscles in an in vitro cadaver model and by use of a multiple-regression analysis to delineate the changes in the moment arms as a function of abduction and rotation. The results demonstrated the potential of some rotator cuff muscles to contribute to both abduction and rotation, the sensitivity of the abductor moment-arm lengths to internal and external rotation and of the rotator moment-arm lengths to the degree of abduction, and the capacity of the abductor moment-arm lengths of the deltoid to increase with increasing abduction. Characterization of this behavior resulted in an increased understanding of the complex role of the rotator cuff and deltoid muscles about the gleno-humeral joint and provided quantitative descriptions of functional relationships. This study demonstrates the capacity of the infraspinatus and subscapularis muscles to contribute not only to external and internal rotation, respectively, but also to elevation of the arm in the plane of the scapula, a role for which these muscles have been given little or no consideration. Furthermore, it demonstrates that the contribution of the infraspinatus to abduction is enhanced with internal rotation while that of the subscapularis is enhanced with external rotation. Thus, dysfunction of the supraspinatus muscle need not preclude good elevation of the arm, and rehabilitation to reprogram and strengthen the remaining muscles becomes an important consideration.

Aged↗
PubMed2006

The rotator cuff functional index.

BACKGROUND: Despite improvements in the clinical assessment of rotator cuff injuries, shortcomings exist in diagnosing rotator cuff tears. PURPOSE: To formulate a clinical rotator cuff functional index for predicting rotator cuff tears based on handheld dynamometer measurements for shoulder strength testing and to assess its ability to diagnose a rotator cuff tear. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Preoperative handheld dynamometer measurements, including supraspinatus, external rotation, internal rotation, adduction, and lift-off force, were compared in 100 patients with full-thickness rotator cuff tears (> 1.0 cm) and 100 patients with no rotator cuff injury (confirmed by arthroscopy). Using multiple logistic regression analysis, the rotator cuff functional index and index for rotator cuff tear size were formulated in which 100 represented excellent rotator cuff function and less than 0 indicated a full-thickness supraspinatus tear. Each patient's index was calculated to determine its clinical value in predicting a rotator cuff tear; the Pearson correlation coefficient was established for the rotator cuff functional index for rotator cuff size. RESULTS: Two handheld dynamometer measurements predicted a rotator cuff tear (P < .001, r = 0.53), with rotator cuff functional index = 1.27 * supraspinatus (N) - 0.72 * adduction (N) - 11.6, but not tear size (r = 0.38). In predicting a rotator cuff tear (rotator cuff functional index < 0 = rotator cuff tear; rotator cuff functional index > 0 = no tear), the rotator cuff functional index had 83% sensitivity, 79% specificity, 80% positive predictive value, 82% negative predictive value, likelihood ratio of 4.0 for a positive test result and 0.2 for a negative test result and an accuracy of 81%. CONCLUSION: The 2 most useful tests for determining a rotator cuff tear with a handheld dynamometer were supraspinatus force and adduction force (as negative control). A functional index based on these measurements was able to rule out a rotator cuff tear and predict the presence but not the size of the tear.

Adult↗
PubMed1997

Rotator cuff pathology in athletes.

The rotator cuff is the primary dynamic stabiliser of the glenohumeral joint and is placed under significant stress during overhead and contact sports. Mechanisms of injury include repetitive microtrauma, usually seen in the athlete involved in overhand sports, and macrotrauma associated with contact sports. Rotator cuff injury and dysfunction in the overhand athlete may be classified based on aetiology as primary impingement, primary tensile overload, and secondary impingement and tensile overload resulting from glenohumeral instability. A thorough history and physical examination are paramount in the evaluation, classification and treatment planning of the athlete with rotator cuff pathology. Imaging studies are a helpful adjunct to the history and physical. Athletes with primary impingement are usually middle aged or older and often have chronic shoulder pain and sometimes weakness associated with overhand sporting activities. Night pain is typical of full thickness rotator cuff tears. Impingement signs are positive and strength of elevation and external rotation are often limited. They usually respond to a nonoperative rehabilitation programme centred on decreasing inflammation, restoring range of motion and strengthening the rotator cuff and scapular stabilisers. Depending on the degree of cuff pathology, acromioplasty, debridement of partial cuff tears, and repair of full thickness tears are usually successful in those who fail a rehabilitation programme. Overhand athletes with cuff pathology secondary to subtle anterior instability are usually young and complain of pain and decreased throwing velocity. Instability may be so subtle that it is only detectable through a positive relocation test on examination. The majority of these athletes do not have a Bankart lesion on magnetic resonance imaging or arthroscopic examination. Arthroscopic examination usually demonstrates anterior capsular laxity (positive 'drive-through' sign), as well as superior-posterior labral and cuff injury typical of internal impingement. If rehabilitation alone is not successful, a capsulolabral repair followed by rehabilitation may allow the athlete to return to their previous level of competition. The athlete with an acute episode of macrotrauma to the shoulder resulting in cuff pathology usually presents with pain, limited active elevation and a positive 'shrug sign'. Arthroscopy and debridement of thickened, inflamed or scarred subacromial bursa with cuff repair or debridement as indicated is usually successful in those who do not respond to a rehabilitation programme.

Arthroscopy↗
PubMedDate not supplied

Cuff integrity after arthroscopic versus open rotator cuff repair: a prospective study.

Arthroscopic rotator cuff repair (RCR) has been reported to have good clinical results but high retear rates by ultrasound. We prospectively assessed postoperative cuff integrity and outcome after arthroscopic RCR (40 patients) and compared these results with open RCR (32 patients). Evaluation preoperatively and at 1 year included a physical examination and magnetic resonance imaging. American Shoulder and Elbow Surgeons and Constant scores improved significantly in both groups (P < .0001). Overall, 69% of repairs in the open group and 53% in the arthroscopic group were intact by magnetic resonance imaging. Of tears less than 3 cm in size, 74% in the open group and 84% in the arthroscopic group were intact. Of tears greater than 3 cm in size, 62% in the open group and 24% in the arthroscopic group were intact (P < .036). In the arthroscopic group, patients with an intact cuff had significantly greater strength of elevation (P = .01) and external rotation (P = .02). We conclude that open and arthroscopic RCRs have similar clinical outcomes. Cuff integrity is comparable for small tears, but large tears have twice the retear rate after arthroscopic repair.

Aged↗
PubMed2003

Bipolar hemiarthroplasty for chronic rotator cuff tear arthropathy.

Massive rotator cuff tears associated with glenohumeral arthritis are currently an unsolvable clinical entity. We review our series of 14 patients with rotator cuff tear arthropathy (RCTA) who underwent a bipolar prosthesis of the shoulder. The average follow up was 27.8 months (range, 24-48 months), and the average age was 71 years (range, 57-84 years). Of these 14 patients, 9 were men and 5 women. None of these patients had undergone previous shoulder surgery, and all patients underwent conservative treatment that failed to improve their symptoms or range of motion. Preoperatively, the average active forward flexion was 30 degrees, active external rotation was 10 degrees, and the American Shoulder and Elbow Society (ASES) score was 25 points. Postoperatively, the average active forward flexion improved to 88 degrees, active external rotation increased to 37 degrees, and the ASES score improved to 80 points. Of the 14 patients, 12 stated that they had no pain with activities of daily living. Two patients continued to have moderate pain in everyday activity.

Aged↗
PubMed1993

Rehabilitation of the shoulder following rotator cuff injury or surgery.

Rotator cuff problems are encountered frequently and must be rehabilitated precisely. The pace and intensity of the program are regulated by the degree of pathology and the patient's activity requirements. As our ability to understand the biomechanics of shoulder motion improves, we realize that many rotator cuff problems are secondary to instability. This instability can be subtle. The following article details a rehabilitative program for patients with rotator cuff pathology and includes both conservative and postoperative programs for pathology secondary to instability as well as primary impingement.

Adult↗
PubMed1983

Serious rotator cuff injuries.

Usually, serious rotator cuff injuries can be operated upon and a high level of performance can be achieved afer surgery. This is not so for the substantial tears seen in baseball pitchers. However, a damaged rotator cuff can be rehabilitated and can recover from the threatened tear without surgery if detected early enough and given the proper treatment.

Adolescent↗
PubMed2005

Determinants of patient satisfaction with outcome after rotator cuff surgery.

BACKGROUND: The outcome after rotator cuff surgery has been reported frequently with use of condition-specific measures, but patient satisfaction has not been well studied. The purpose of this study was to identify the determinants of patient satisfaction with the outcome after rotator cuff surgery. METHODS: A cohort of 311 patients undergoing rotator cuff surgery was studied prospectively. Two hundred and fifty-four patients had subjective follow-up for a minimum of one year, and fifty-seven patients had subjective and objective follow-up for a minimum of one year. Diagnoses included tendinitis or impingement (eighty patients), a partial-thickness rotator cuff tear (fifty-five patients), and a full-thickness rotator cuff tear (176 patients). The dependent variable was patient satisfaction with the outcome, graded ordinally on a scale of 1 to 10. Independent variables included demographic, surgical, objective follow-up, and subjective follow-up parameters. Univariate and multivariate analyses were performed to identify the determinants of satisfaction. RESULTS: Univariate analysis of demographic variables demonstrated no significant differences (p > 0.05) with respect to patient satisfaction. Analysis of the surgical variables showed significantly decreased satisfaction (p < 0.05) for patients who had debridement for a massive, irreparable cuff tear; those who had subscapularis tears; and those with larger supraspinatus and infraspinatus tears. Analysis of the objective variables at follow-up demonstrated significantly decreased satisfaction (p < 0.05) for patients with diminished and weakened forward elevation, impingement signs, and acromioclavicular joint pain and tenderness. Univariate analysis of subjective variables at follow-up showed significantly decreased satisfaction (p < 0.001) for patients with pain, functional difficulty, and work disability. Multivariate analysis demonstrated significantly decreased satisfaction associated with pain (p < 0.001) and dysfunction (p < 0.05). A significant relationship (p < 0.05) was detected between satisfaction and a willingness to recommend the surgery to another. A significant relationship (p < 0.05) was also found between satisfaction and the American Shoulder and Elbow Surgeons score. CONCLUSIONS: Subjective variables of symptoms and function have the most robust associations with patient satisfaction following rotator cuff surgery. Thus, in assessing the outcome of rotator cuff surgery from the perspective of patient satisfaction with outcome, we emphasize the importance of patient-derived subjective assessment of symptoms and function.

Arthralgia↗
PubMed2006

Physiotherapy rehabilitation in patients with massive, irreparable rotator cuff tears.

BACKGROUND: Massive rotator cuff tears provide a challenge for effective rehabilitation. Work has been ongoing at Torbay Hospital, Devon since 2000 to develop an exercise programme for the management of this patient group. This programme has been evaluated in a pilot study and a further randomised controlled trial is currently taking place which will enable us to estimate the treatment effect. This paper discusses the background to the development of the rehabilitation programme, the programme itself and the results of the pilot study. The pilot study was an evaluation of the rehabilitation programme. OBJECTIVES: This study examined the effectiveness of a physiotherapy regime for the treatment of patients with massive rotator cuff tears. METHODS: Patients identified through primary and secondary care referrals to physiotherapy with a clinical diagnosis of a massive rotator cuff tear underwent an ultrasound scan to confirm the diagnosis. A massive cuff tear was one where the leading edge of the tear had retracted past the glenoid margin. The clinical diagnosis was based on the presence of some or all of the following signs: positive humeral thrust on elevation, gross weakness and wasting of supraspinatus and infraspinatus, infraspinatus lag and rupture of the long head of biceps. Eligible patients were invited to take part in the study and informed consent was obtained. The baseline assessment was carried out and then the patient undertook the treatment programme. Outcome measures were reassessed 12 weeks from the baseline assessment. DESIGN: A cohort study of 10 patients evaluating the change from baseline to twelve weeks in the shoulder function of patients undergoing a programme of anterior deltoid strengthening and functional rehabilitation. The outcome measures used were the Oxford Shoulder Disability Questionnaire (OSDQ) and SF36. The OSDQ is validated for use with the UK population and has 12 questions with 5 point responses. The lowest (best) score is 12 and the highest (worse) score is 60. RESULTS: Scores on the OSDQ improved with all patients. The mean improvement was 9 (range 3 to 16, standard deviation 10.3). The SF36 showed an improvement in the pain scores for all patients (mean 22 points) and an overall improvement of 10 points for the sections on role limitation due to physical health. There was an overall decline in perceived general health (9 points) and in role limitation due to emotional health (23 points). CONCLUSIONS: As all 10 patients showed improved scores on the OSDQ, in spite of the long-standing nature of many of their shoulder problems, this rehabilitation programme was shown to improve shoulder function in this group of patients. The variation shown in the quality of life scores reflects the age group of this cohort who had a mean age of 75.5 years. All patients deemed their pain and function to have improved over the three-month period.

Aged↗
PubMed2003

Magnetic resonance imaging in quantitative analysis of rotator cuff muscle volume.

Tears of the rotator cuff are accompanied by muscle atrophy, which has direct implications on patient outcome after rotator cuff surgery. However, no reliable method exists to determine muscle volumes in situ. The current authors evaluated the reliability of magnetic resonance imaging in assessing rotator cuff muscle volumes. Muscle volumes were determined in 10 shoulders from cadavers using two methods: (1). oblique sagittal shoulder scans were obtained, the contours of the supraspinatus, infraspinatus and teres minor, and subscapularis muscles were traced, and muscle volumes were calculated using image analysis software; and (2). rotator cuff muscles were dissected and muscle volumes were measured by water displacement. The average magnetic resonance imaging volume of the supraspinatus, infraspinatus and teres minor, and subscapularis muscles were 36 +/- 12, 96 +/- 41, and 99 +/- 33 mL, respectively. There was a significant correlation between magnetic resonance imaging and water displacement measurements. The intraobserver and interobserver variabilities were less than 4%. The results indicate the magnetic resonance imaging is a reliable method to determine rotator cuff muscle volumes with good intraobserver and interobserver variability. This method may prove valuable preoperative assessment of rotator cuff muscles and prediction of outcome after rotator cuff repair.

Aged↗
PubMed2006

Partial-thickness rotator cuff tears.

Partial-thickness rotator cuff tears are not a single entity; rather, they represent a spectrum of disease states. Although often asymptomatic, they can be significantly disabling. Overhead throwing athletes with partial-thickness rotator cuff tears differ with respect to etiology, goals, and treatment from older, nonathlete patients with degenerative tears. Pathogenesis of degenerative partial-thickness tears is multifactorial, with evidence of intrinsic and extrinsic factors playing key roles. Diagnosis of partial-thickness rotator cuff tears should be based on the patient's symptoms together with magnetic resonance imaging studies. Conservative treatment is successful in most patients. Surgery generally is considered for patients with symptoms of sufficient duration and intensity. The role of acromioplasty has not been clearly delineated, but it should be considered when there is evidence of extrinsic causation for the partial-thickness rotator cuff tear.

Acromion↗
PubMed2006

Conservative treatment of rotator cuff injuries.

Across all ages and activity levels, rotator cuff injuries are one of the most common causes of shoulder pain. The anatomy and biomechanics of the shoulder guide the history and physical exam toward the appropriate treatment of rotator cuff injuries. Rotator cuff tears are rare under the age of 40 unless accompanied by acute trauma. Throwing athletes are prone to rotator cuff injury from various causes of impingement (subacromial, internal, or secondary) and flexibility deficits, strength deficits, or both along the kinetic chain. Most rotator cuff injuries may be treated conservatively by using regimens of nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, and functional rehabilitation therapy. Injury prevention programs are essential for the long-term care of patients with rotator cuff disease, for primary prevention, and for prevention of recurrent injuries, unless a traumatically torn rotator cuff is present. Surgical management is reserved for refractory cases that have exhausted conservative measures.

Adrenal Cortex Hormones↗
PubMed1991

Superior humeral dislocation. A complication following decompression and debridement for rotator cuff tears.

Very large rotator cuff tears may be surgically irreparable and under such circumstances debridement of the edges of the cuff and bursal decompression may relieve pain. In this paper, four cases are described of the development of superior migration of the humeral head following a debridement and bural decompression. In all four patients attempts were made to repair the rotator cuff. In each case the repair failed and the humeral head migrated. Two of the patients had the humeral head replaced because of a fracture; in these patients the prosthesis displaced upwards. This serious complication may follow debridement and release of the subacromial bursa when rotator cuff repair cannot be achieved. In the correction of superior humeral migration, reestablishment of the roof of the bursa was carried out in two cases. This procedure appears effective and may be considered in the future for such cases.

Aged↗
PubMed2000

Coracoacromial arch decompression in rotator cuff surgery.

In rotator cuff surgery it is important to obtain adequate decompression of the coracoacromial arch. However, it is difficult to localize the impingement site preoperatively. Based on histological and morphological studies and the clinical findings in 45 patients and 15 cadavers, we have tried to determine the impingement site. In addition, as a part of these investigations, we assessed the clinical outcome for 100 patients. Soft tissue decompression was indicated in 12 shoulders, anterior acromioplasty in 67 and anterior acromioplasty with coracoplasty in 21. According to Neer's criteria there were 92 satisfactory and 8 unsatisfactory results. The mean postoperative UCLA score was 33.4 points and the results were rated excellent in 78, good in 18 and fair in 4.

Acromion↗
PubMed1993

Classification and treatment of rotator cuff injuries in the overhand athlete.

Rotator cuff injury in athletes results from accumulation of microtrauma to both the static and dynamic stabilizers of the shoulder. Our classification of these injuries and treatment protocol is based on knowledge of the pathophysiology of events leading to rotator cuff failure. Rotator cuff disease is attributed to one of five different modes of failure: primary compressive disease, secondary compressive disease, primary tensile overload, secondary tensile overload, and macrotraumatic injuries. Although disease is categorized based on a single failure mode, there is often significant overlap between the mechanisms of injury leading to the disease. Categorization and, consequently, treatment of the injury rely upon proper identification of the primary pathology and an understanding of the causative factors leading to rotator cuff failure. In most cases conservative management is successful, but, in the refractory cases, minimally invasive surgical techniques have also been successful in returning most athletes to a premorbid level of function.

Adult↗
PubMedDate not supplied

Postoperative subcoracoid impingement syndrome in patients with rotator cuff tear.

Impingement of the tendinous rotator cuff on the coracoid process (subcoracoid impingement syndrome) has rarely been reported as a cause of pain after surgery for rotator cuff tear. We evaluated clinical features, surgical results, and histopathology findings of resected coracoid processes in patients with subcoracoid impingement syndrome after anterior acromioplasty and management of rotator cuff tear. Pain at the anterior aspect of the shoulder, localized tenderness of the coracoid process, anterior shoulder pain on horizontal adduction testing, and positive subcoracoid block suggest subcoracoid impingement syndrome. Postoperative subcoracoid impingement syndrome was investigated in 11 of 216 cases with rotator cuff surgery. The average patient age at the time of surgery was 61.2 y (range, 28-78 y). Coracoplasty (partial resection of the posterolateral side of the coracoid process) was performed in 9 shoulders that had not responded to a 6-month regimen of conservative treatment. Complete pain relief was achieved in all cases. Histopathologic findings revealed hypertrophic changes of the fibrocartilage layer at the posterior aspect of the resected coracoid process. We concluded that subcoracoid impingement syndrome was an important factor in unsuccessful rotator cuff surgery and recommend that coracoplasty be performed on patients with symptoms of subcoracoid impingement syndrome after management of the rotator cuff tear.

Adult↗
PubMed2001

Biochemical markers in the synovial fluid of glenohumeral joints from patients with rotator cuff tear.

It is known that rotator cuff tears are sometimes accompanied by joint destruction. Our purpose was to elucidate the pathology with this condition. Thirty-two synovial fluid (SF) samples aspirated from the glenohumeral joints of patients with rotator cuff tears, including 7 with partial-thickness and 25 with full-thickness tears of the rotator cuff (10 massive and 15 isolated supraspinatus tendon (SSp) tears), were examined. Collagenase (MMP-1), stromelysin 1 (MMP-3), tissue inhibitor of metalloproteinases-1 (TIMP-1) and carboxy-terminal type II procollagen peptide (pCOL Il-C) were measured in the SF using the respective sandwich enzyme immunoassays. Glycosaminoglycan (GAG) was also quantified with a cationic dye binding method using 1,9-dimethylmethylene blue. Levels of any molecules except pCOL II-C in the SF appeared to be higher in full-thickness tears than those in partial-thickness tears. Moreover, levels of MMP-1, MMP-3 and GAG in the SF were significantly higher in massive tears of the rotator cuff in comparison with those in isolated SSp tears. Such significance was not observed in the levels of TIMP-1 or pCOL II C in the SF. We examined the relation of those levels with operative findings or clinical parameters from full-thickness tears, and observed significant correlations of the tear size with the levels of MMP-1, MMP-3 and GAG in the SF. Although these marker molecules in SF do not always originate from cartilage, our results may indicate the potential for accelerated cartilage-degrading activity in the glenohumeral joint in massive tears of the rotator cuff.

Adult↗