Disease of the rotator cuff. Rotator cuff syndrome does not exist.
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Humans↗
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[Anatomy, biomechanics, and physiopathology of the rotator cuff].
Rotator cuff disease is the most common cause of shoulder pain and dysfunction in adults. Despite the significant amount of pain and disability related to rotator cuff pathology, there is insufficient information to guide the clinician in planning therapeutic interventions. In this article, we reviewed the anatomy, biomechanics, and pathophysiology of the rotator cuff in an attempt to cover recent literature thereof. A consensus is now emerging that the etiology of rotator cuff disease is multifactorial, including extrinsic and intrinsic factors. Further investigations are needed to clarify the mechanisms and the pathogenesis of rotator cuff disease, as well as the effectiveness of various treatment modalities.
Biomechanical Phenomena↗
Acromial structure and tears of the rotator cuff.
Rotator cuff lesions have been related to the structure of the acromion. We report a clinical review of 56 shoulders and the analysis of their acromial structure as seen on the radiographic arch (outlet) view and magnetic resonance imaging. The shoulders were classified as acromial type I (flat), type II (curved), or type III (hooked). On plain radiographs 89% of type III acromions had tearing of the rotator cuff (p < 0.001). The association between acromial type as determined on magnetic resonance imaging and the presence of rotator cuff tearing was less significant. Magnetic resonance imaging offered no additional benefit over plain radiographs for determining acromial type. In addition, a method of quantitating acromial structure (the "acromial angle") was devised. This angle showed a significant association with acromial types (p < 0.0001) seen on plain radiographs and had good interobserver reproducibility (coefficient of variation, 0.1). With this measurement system a type I acromion had an acromial angle of 0 degrees to 12 degrees; a type II acromion, 13 degrees to 27 degrees; and a type III acromion, greater than 27 degrees.
Acromion↗
[Methods for fixation of the rotator cuff].
Rotator cuff repair has gained increasing popularity in recent years. Fixation of the tendon to the bone presents challenging difficulties like those in many parts of the human body. There is ongoing research concerning clinical and biomechanical features of open and arthroscopic repair methods, though accumulated evidence in the past years suggests that the latter may provide a more secure fixation. Considering the general advantages of arthroscopy, we may propose that arthroscopic rotator cuff repair with anchor fixation will gain more acceptance. This article reviews the most recent literature on the subject.
Arthroscopy↗
Muscle cell-mediated gene delivery to the rotator cuff.
Rotator cuff lesions are one of the most common causes of upper extremity disability. Surgical therapy addresses mostly the extrinsic etiology, but not intrinsic factors such as aging, structural changes, low vascularity, and inflammatory processes. In this study, genetically engineered, highly purified muscle-derived cells (MDCs) were characterized and injected into the supraspinatus tendons of nude rats. The injected cells were monitored for 3 weeks. In vitro, the engineered, highly purified MDCs do not express vimentin; 98% of them are positive for the beta-galactosidase marker gene, and 99% hybridize with the specific pancentromeric mouse probe. beta-Galactosidase marker gene expression of the injected cells was detected up to 21 days. From day 7 after injection, the cell nuclei became spindle shaped, cells were integrated into the tendon collagen bundles, and the cells showed differentiation into vimentin-expressing fibroblastic cells. The results indicate that the rotator cuff tendon matrix and its original cellular components modulated the injected MDCs toward a fibroblastic phenotype. The compatibility and ability of MDCs to differentiate into other cell lineages, such as fibroblasts, might have high potential utility in tissue-engineering applications for tendon healing. This approach facilitates the application of muscle-derived progenitor cells and ex vivo gene therapy for the treatment of rotator cuff lesions.
Animals↗
Nonoperative management of full-thickness tears of the rotator cuff.
Rotator cuff tendonopathies are among the most common disorders encountered in the shoulder. There is an abundance of literature on the operative management of these lesions, but only a small amount devoted to nonoperative treatment of full-thickness tears of the rotator cuff. The purpose of this article is to review the literature pertaining to full-thickness tears as well as our results with expectant management.
Female↗
Tendon degeneration and chronic shoulder pain: changes in the collagen composition of the human rotator cuff tendons in rotator cuff tendinitis.
OBJECTIVES: To analyse the collagen composition of normal adult human supraspinatus tendon and to compare with: (1) a flexor tendon (the common biceps tendon) which is rarely involved in any degenerative pathology; (2) degenerate tendons from patients with chronic rotator cuff tendinitis. METHODS: Total collagen content, collagen solubility and collagen type were investigated by hydroxyproline analysis, acetic acid and pepsin digestion, cyanogen bromide peptide analysis, SDS-PAGE and Western blotting. RESULTS: The collagen content of the normal cadaver supraspinatus tendons (n = 60) was 96.3 micrograms HYPRO/mg dry weight (range 79.3-113.3) and there was no significant change across the age range 11 to 95 years. There was no significant difference from the common biceps tendon [93.3 (13.5) micrograms HYPRO/mg dry weight, n = 24]. Although extremely insoluble in both acetic acid and pepsin, much of the collagen was soluble after cyanogen bromide digestion [mean 47.9% (29.8)]. Seventeen per cent (10/60) of the 'normal' cadaver supraspinatus tendon sample contained more than 5% type III collagen, although none of the common biceps tendons had significant amounts. Degenerate supraspinatus and subscapularis tendons had a reduced collagen content [83.8 (13.9) micrograms/mg dry weight and 76.9 (16.8) micrograms/mg dry wt respectively) and were more soluble in acetic acid, pepsin and cyanogen bromide (p < 0.001). Eighty two per cent (14/17) of supraspinatus tendons and 100% (8/8) of subscapularis tendons from patients with tendinitis contained more than 5% type III collagen. CONCLUSIONS: The changes in collagen composition in rotator cuff tendinitis are consistent with new matrix synthesis, tissue remodelling and wound healing, in an attempt to repair the tendon defect, even in old and degenerate tendons. An increase in type III collagen in some 'normal' cadaver supraspinatus tendons is evidence that changes in collagen synthesis and turnover may precede tendon rupture. These changes may be the result of repeated minor injury and microscopic fibre damage or a consequence of local factors such as reduced vascular perfusion, tissue hypoxia, altered mechanical forces and the influence of cytokines. These collagenous changes may accumulate with age and substantially weaken the tendon structure, predisposing the tendon to rotator cuff tendinitis and eventual tendon rupture.
Adolescent↗
Arthroscopic insertion of a biologic rotator cuff tissue augmentation after rotator cuff repair.
Tissue augmentation has been used to reinforce repairs of massive chronic rotator cuff tears. This report describes a new technique for arthroscopic insertion of a biologic rotator cuff tissue augmentation. Double-loaded suture anchors are needed for the technique. One suture is used for the rotator cuff repair and 1 suture is used for the tissue augmentation. The sutures for the tissue augmentation are left exiting through accessory portals. Two free sutures are then passed through the repaired rotator cuff, 1 anteromedially and 1 posteromedially via the anterior and posterior cannulae, respectively. One limb from each of these 4 sutures is retrieved through the lateral portal. Each of the 4 limbs exiting through the lateral portal are then passed through the corresponding corner of the tissue augmentation and Mulberry knots are tied in each suture limb, on top of the tissue augmentation. The suture limbs of the 4 sutures exiting through the anterior and posterior cannulae and accessory portals are pulled simultaneously to reduce the tissue augmentation down onto the repaired rotator cuff. A trocar is used to help push the tissue augmentation through the lateral cannula. The Mulberry knots from each of the sutures are sequentially retrieved and tied arthroscopically to secure the tissue augmentation.
Arthroscopy↗
US of the shoulder: rotator cuff and non-rotator cuff disorders.
Ultrasonography (US) has been shown to be an effective imaging modality in the evaluation of both rotator cuff and non-rotator cuff disorders, usually serving in a complementary role to magnetic resonance imaging of the shoulder. US technique for shoulder examination depends on patient positioning, scanning protocol for every tendon and anatomic part, and dynamic imaging. The primary US signs for rotator cuff supraspinatus tendon tears are tendon nonvisualization for complete tears, focal tendon defect for full-thickness tears, a hypoechoic defect of the articular side of the tendon for an articular-side partial-thickness tear, and flattening of the bursal surface of the tendon for a bursal-side partial-thickness tear. Secondary US signs such as cortical irregularity of the greater tuberosity and joint and subacromial-subdeltoid bursal fluid are helpful when correlated with the primary signs. Tendon degeneration, tendinosis, and intrasubstance tear are demonstrated as internal heterogeneity. Long-head biceps tendon abnormalities include instability, acute or chronic tear, and tendinosis. The acromioclavicular joint is assessed for dislocation, fluid collection, cysts, and bone erosions. Other non-rotator cuff disorders include synovial disorders such as adhesive capsulitis and synovial osteochondromatosis; degenerative disorders such as osteoarthritis, amyloid arthropathy, hemarthrosis, and chondrocalcinosis; infectious disorders such as septic arthritis and bursitis; and space-occupying lesions.
Humans↗
Association of intramuscular cysts of the rotator cuff with tears of the rotator cuff: magnetic resonance imaging findings and clinical significance.
Cystic lesions that arise adjacent to the shoulder have been reported in association with labral tears or as an unusual manifestation of massive rotator cuff tears. The purpose of this study was to define the relationship between intramuscular cysts of the rotator cuff and tears of the rotator cuff. Thirteen cases of intramuscular cysts of the rotator cuff were identified on magnetic resonance imaging of the shoulder and analyzed retrospectively along with the clinical data. Surgical findings were retrospectively reviewed in 5 patients who underwent follow-up arthroscopy. This series shows that intramuscular cysts of the rotator cuff are associated with small, full-thickness tears or partial undersurface tears of the rotator cuff. These cysts are easily identified on T2-weighted sequences and, when present, should always prompt a thorough search for associated rotator cuff pathology.
Aged↗
The development and evaluation of a disease-specific quality-of-life questionnaire for disorders of the rotator cuff: The Western Ontario Rotator Cuff Index.
OBJECTIVE: The purpose of this study was to develop a valid and reliable disease-specific quality-of-life measurement tool for patients with rotator cuff disease. DESIGN: Health-related quality-of-life measurement tool development. METHODS: Methodology for the development and evaluation of the tool included the following: 1) identification of a specific patient population, 2) generation of potential items, 3) item reduction, 4) pretesting the prototype instrument, 5) determination of reliability, and 6) validation. RESULTS: The final instrument, the Western Ontario Rotator Cuff Index, double dagger has 21 items representing five domains, each with a Visual Analog Scale-type response option. Construct validation demonstrated that this instrument correlated predictably with other measurement tools (Disabilities of the Arm, Shoulder, and Hand outcome measure; American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form; University of California Los Angeles Shoulder Rating Scale; Constant Score; Rowe; Sickness Impact Profile; Short Form 36; and range of motion; 21 of 21 correlations within 0.19). Reliability was very high at 2 weeks, with an intraclass correlation coefficient of 0.96 and was more responsive (sensitive to change) than the other five shoulder measurement tools, global health instruments, and range of motion. CONCLUSIONS: This measurement tool can be used as the primary outcome in clinical trials evaluating treatments in this patient population, although its features are equally attractive for monitoring patients' progress in clinical practice.
Adult↗
Massive rotator cuff tears: the result of partial rotator cuff repair.
Massive rotator cuff tears often defy traditional repair techniques and have led to a variety of treatment recommendations. We reviewed retrospectively the results of partial repair of massive rotator cuff tears in 24 patients. Overall results were excellent in 11 patients (46%), good in 5 (21%), fair in 7 (29%), and poor in 1 (4%). Ninety-two percent of patients were satisfied with the result of surgery. Satisfactory pain relief was achieved in 83% (P<.001). Active elevation improved from 114 degrees to 154 degrees , and no patient lost strength after surgery. The ability to raise the arm to at least 135 degrees improved from 13 patients preoperatively to 21 patients postoperatively. This series serves as a basis of comparison to debridement, tendon transfers, and tendon augmentation procedures for the treatment of massive irreparable rotator cuff tears.
Adult↗
Prospective evaluation of the effect of rotator cuff integrity on the outcome of open rotator cuff repairs.
BACKGROUND: Open rotator cuff repairs have led to excellent clinical results; however, several studies have linked postoperative structural integrity to patient outcomes. The purpose of this study is to prospectively assess postoperative cuff integrity after open rotator cuff repair and assess its relationship to clinical outcome. HYPOTHESIS: Preoperative rotator cuff tear size and postoperative rotator cuff integrity are important factors in overall clinical outcomes. STUDY DESIGN: Prospective nonrandomized clinical outcomes study. METHODS: Forty-seven consecutive patients undergoing repair of full-thickness rotator cuff tears by a single surgeon were enrolled in this prospective study. A standardized evaluation was performed preoperatively and postoperatively at annual intervals. All patients underwent postoperative magnetic resonance imaging at least 1 year after surgery. Statistical evaluation was performed using paired and unpaired 2-tailed t tests for comparison. RESULTS: Thirty-two patients were available for evaluation. Overall, the patients experienced a significant (P < .05) improvement in their American Shoulder and Elbow Surgeons survey (40-85) and Constant (53-80) scores. The overall retear rate was 31%. Although patients with large tears preoperatively and retears postoperatively had lower overall outcomes scores, this was not significant. CONCLUSION: These data support open rotator cuff repair as an effective technique that restores excellent shoulder function. The authors did not find postoperative cuff integrity to have a significant effect on outcomes when compared with those with an intact cuff. In fact, those with a retear still had a significant improvement in all clinical areas assessed, including strength.
Adult↗
MR imaging of rotator cuff impingement: correlation with full-thickness rotator cuff tear.
BACKGROUND: Rotator cuff tears usually derive from shoulder impingement, and need surgical treatment. This study is to verify the Magnetic Resonance Image (MRI) findings of rotator cuff impingement which are related to full-thickness rotate cuff tear (FTRCT). METHODS: Totally 68 patients with shoulder impingement syndrome were studied, including 39 shoulders with surgically-proven FTRCT, and 29 shoulders without FTRCT. MRI findings of shoulder impingement were evaluated for peribursal fat plane, subacromial distance, acromion shape, subacromioclavicular space, irregularity of coracoacromial ligament and presence of subacromial spurs. The correlation with FTRCT was also determined. RESULTS: Peribursal fat plane obliteration (p = 0.0001), hook-shaped acromion (p = 0.0148), subacromioclavicular indentation (p = 0.0004), and decreased subacromial distance (p = 0.0005) showed significant correlation with FTRCT; however, subacromial spurs (p = 0.6238) and thickened irregular coracoacromial ligament (p = 0.1611) showed poor correlation. CONCLUSIONS: Specific MRI findings of rotator cuff impingement are fairly reliable and helpful for discrimination of FTRCT from non-FTRCT cases, and can be used preoperatively and noninvasively to determine the necessity of surgical repair of rotator cuff.
Adult↗
[Arthroscopic rotator cuff repair for the treatment of rotator cuff tear].
OBJECTIVE: To discuss and evaluate the surgical techniques of arthroscopic rotator cuff repair and its clinical results. METHODS: From March 2002 to May 2005, 44 out of 68 patients treated by arthroscopic rotator cuff repair had been reviewed with a mean post-operation time of 12 months. Of the 44 patients, 40 were available for follow-up, with a mean period of 20.6 (12 - 40) months. The mean age was 56 (30 - 81) years. According to Gerber classification, there were 8 partial tears, 27 small tears and 5 massive tears. No irreparable tear was included in this series. All tears were repaired under the scope, and metal suture anchor (Super-Revo, Linvatec) had been used in all patients. ASES score (American shoulder & elbow surgeons' score), Constant-Murley score and SST (simple shoulder test) questionnaire were adopted before operation and at the latest follow-up. RESULTS: The pre-operation and post-operation mean ASES score was 72.6 vs. 92.3 (P < 0.001), with the mean VAS score for pain 6.2 vs. 1.8 (P < 0.001), the mean forward flexion 74.5 degrees vs. 146.0 degrees (P < 0.001), and the mean external rotation 27.8 degrees vs. 38.3 degrees (P < 0.01). The excellent and good rate for post-operation ASES was 92.5%. The pre-operation and post-operation mean Constant-Murley score was 69.6 vs. 90.4 (P < 0.001), with an excellent and good rate of 90.0%. CONCLUSIONS: Arthroscopic rotator cuff repair is a successful treatment for rotator cuff tear. By the use of suture anchors, scope surgery shares the advantages of minimal morbidity, quick functional recovery and protection of deltoid muscle. With appropriate indication control, descent surgical skill and intense postoperative rehab, gratifying outcome can usually be anticipated.
Adult↗
Matrix molecule mRNA levels in the bursa and rotator cuff of patients with full-thickness rotator cuff tears.
PURPOSE: The purpose of this study was to evaluate at the mRNA level a subset of extracellular matrix molecules relevant during healing and remodeling of rotator cuff tears. TYPE OF STUDY: Controlled laboratory study. METHODS: Bursal and rotator cuff tissue from the margin of the rotator cuff tear were harvested from 10 patients (mean age, 57.5 +/- 7.3 years) undergoing surgical repair of full-thickness rotator cuff tears. There were six male and four female patients with a mean duration of symptoms of 14.6 months (range, 2 to 60 months). The mean tear size was 4.4 cm. In addition, tissue was obtained from 6 cadaveric specimens with no gross evidence of rotator cuff tearing. Reverse transcription polymerase chain reaction (RT-PCR) was performed for type I, II, and III collagen, biglycan, decorin, and aggrecan, and normalized to the housekeeping gene GAPDH. RESULTS: RT-PCR showed that both the bursa and rotator cuff margin had increased mRNA levels for type I and type III collagen in patients with full-thickness rotator cuff tears when compared with normal cadaveric controls. In addition, there was a significant decrease in decorin mRNA levels and an increase in aggrecan mRNA levels in the rotator cuff margin of torn rotator cuff tendons when compared with normal cadaveric controls. CONCLUSIONS: These results suggest that both the bursa and rotator cuff margin of patients with rotator cuff tears are actively remodeling after injury and that both tissues may potentially contribute to the healing process following repair. CLINICAL RELEVANCE: These findings may help clinicians determine what aspects of the repair process can be manipulated to affect optimal ruptured tendon repair.
Bursa, Synovial↗
Arthroscopic surgery for partial rotator cuff tears.
Rotator cuff pathology is one of the most common disorders of the shoulder. However, partial rotator cuff tears, treatment, and natural history are still in a state of flux. We believe that partial rotator cuff tears should be treated surgically when the rotator cuff is torn more than 50% of the thickness or when substantial thinning of the rotator cuff is identified arthroscopically. We believe that the technique described here addresses the need for increased blood supply in the rotator cuff and diminishes the chance for extension to a complete rotator cuff tear. The technique and postoperative rehabilitative regimen is described.
Arthroscopy↗
Arthroscopic treatment of rotator cuff disease.
Rotator cuff disease represents a spectrum of tendon lesions including inflammation of an intrinsically normal tendon, tendon fibrosis, partial-thickness tears, complete tears, and cuff tear arthropathy. An in-depth analysis of the entire subject is beyond the scope of this article. This article will focus on the arthroscopic management of the spectrum of rotator cuff disease in an attempt to provide a timely summary of the present state of knowledge. Five stages of rotator cuff disease will be reviewed: stage 2 impingement, partial-thickness cuff tears, complete-thickness rotator cuff tears, irreparable rotator cuff tears, and cuff tear arthropathy. In preparing this article I have assumed that the reader is familiar with the diagnosis of rotator cuff lesions through the use of appropriate patient history, physical examination, and radiologic studies.
Acromioclavicular Joint↗