Rotator cuff tears Acute or chronic? Mary Obele ANZSOM September 2012 Acknowledgement: ACC

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Harvey Lucas
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1 Rotator cuff tears Acute or chronic? Mary Obele ANZSOM September 2012 Acknowledgement: ACC

2 Anatomy

3 Epidemiology Asymptomatic rotator cuff tears: prevalence is 35% (5) 15% full thickness and 20% partial thickness (5, 7) Symptomatic rotator cuff tears: prevalence is 40% (5, 7) In patients with a full thickness symptomatic tear, 35% had a full thickness tear on the contra lateral side (7)

tears: prevalence is 40% (5, 7) In patients with a full thickness

4 Epidemiology tears

5 Epidemiology tears In those with partial thickness tears, over an average time of 412 days 10% became smaller 53% enlarged 28% became full thickness tears (21)

6 Tear progression

7 Aetiology The aetiology of rotator cuff tendonitis is classified into: Extrinsic primary causes and extrinsic secondary causes. Extrinsic direct compression beneath the subacromial arch Intrinsic causes. Intrinsic tendons. Bursal thickening SST tendinopathy

Extrinsic direct compression beneath the subacromial arch

8 Extrinsic causes Primary impingement From supraspinatus outlet stenosis Neer : most cuff tears due to impingement from narrowing of outlet due to variation in shape and slope of acromion, and osteophytes on its antero-inferior surface Bigliami > I straight, II curved, III hooked

outlet due to variation in shape and slope of acromion, and

9 Extrinsic causes Primary impingement also: Coraco acromial ligament Greater tuberosity / coracoid Degenerative acromio-clavicular joint Os acromiale Postero-superior impingement in athletes

10 Extrinsic causes Secondary impingement Gleno-humeral instability Neurological pathology

11 Intrinsic causes Degenerative tendinopathy Muscle weakness Overuse Hypovascular area Genetics

12 Other factors A significant dose response between body mass index and shoulder repair surgery reported in men and women between 53 and 77 years Age-adjusted odd ratio for males with BMI was 1.00 Age-adjusted odd ratio for males with BMI > 35 was 3.13 (16)

and 77 years Age-adjusted odd ratio for males with BMI 20-25 was

13 Stage 1 Oedema and haemorrhage of RC and subacromial bursa <25 year olds Painful arc (60-120), tender over greater tuberosity, anterior acromion Reversible, good prognosis, conservative management

14 Stage 2 Repeated episodes of inflammation leads to fibrosis and tendonitis of RC and bursa year olds Aching pain after rigorous overhead activity, mild limitation of active/passive ROM Irreversible with activity modification Surgical management if conservative fails

rigorous overhead activity, mild limitation of active/passive ROM

15 Stage 3 Prolonged history of refractory tendonitis and tendon degeneration including partial/full tears of RC +/- biceps lesion, bony changes >40 year olds Significant night pain, limited ROM, weakness Injection of subacromial space doesn t improve weakness or ROM

lesion, bony changes >40 year olds Significant night pain,

16 Tendinosis

17 Age-related degenerative changes in the SST (9) Decreased fibrocartilage at the cuff insertion Decreased vascularity Loss of cellularity Collagen changes Disruption of attachment to bone

18 Impingement

19 Impingement In general it is almost universally accepted that the subacromial bursa is a contributor to pain of rotator cuff tendinopathy Called subacromial bursitis but no neutrophils, lymphocytes, plasma cells

to pain of rotator cuff tendinopathy Called

20 Tears substantially due to trauma Acute symptoms: hear a tear or pop, severe pain (19) Early presentation (20)

21 Tears substantially due to trauma Adequate trauma mechanism Forced external/internal rotation with ab/adduction of arm eg holding onto railing when falling down stairs Passive traction force eg unplanned catching of falling tumbling object Axial compression eg fall onto posteriorly extended arm Traumatic shoulder dislocation

22 Tears substantially due to trauma Loss of strength or active range of motion (ROM) at assessment, inability to abduct the arm > 90 degrees (20) Haematoma Dislocation Excessive bursal fluid, blood or debris Mid substance tears (tissue on tuberosity) MRI oedema on the greater tuberosity Unilateral tears if bilateral USS available

23 Degenerative tears Pre-existing shoulder symptoms (10) Inadequate trauma mechanism (29) Controlled lifting of holding of loads Direct impact injury Simple fall onto front or side of arm without twisting or forced abduction

24 Degenerative tears Reduced acromion-humeral interval <7mm

25 Degenerative tears Retraction beyond rim or >35 mm Muscle fatty atrophy No fluid (joint or bursa) Medium spurs (5-10mm) Inferior AC joint osteophyte Anterior greater tuberosity cysts

26 Degenerative tears Greater tuberosity irregularity on USS imaging (X-ray changes not clear evidence) Generalised tendinosis in multiple tendons Symptoms and pathology in the contralateral shoulder (7)

27 Case 1 William 40 year old male Fit and well Date of injury = date of lodgement No previous shoulder problems Slipped on snow, fell heavily onto left shoulder and somehow wrenched shoulder backwards Instant severe pain Can t work overhead activities

28 Case 1 GP notes Distressed Right shoulder normal Left shoulder anterior tenderness, limited abduction and forwards flexion Neurovascularly intact X-ray no fracture or dislocation, no calcification, otherwise normal

29 Case 1

30 Case 2 Herbert 70 year old male Diabetes Long standing shoulder problems since 2000 s Had a fall in 2005, fell on backwards onto bottom, thinks he must have injured right shoulder as well because it was sore a week later Settled with conservative treatment

31 Case 2 Now presents with sore right shoulder Remembers injury 6 months ago when he pulled vigorously on a tree branch Sore right shoulder, can t roll on it, can t sleep Can t work overhead activities GP exam: Limited ROM right and left shoulder Lodged ACC form for the injury 6 months ago X-rays: unremarkable

32 Case 2

Ms. Ruth Delaney ROTATOR CUFF DISEASE Orthopaedic Surgeon, Shoulder Specialist

Ms. Ruth Delaney ROTATOR CUFF DISEASE Orthopaedic Surgeon, Shoulder Specialist WHAT DOES THE ROTATOR CUFF DO? WHAT DOES THE ROTATOR CUFF DO? WHO GETS ROTATOR CUFF TEARS? HOW DO I CLINICALLY DIAGNOSE A CUFF TEAR? WHO NEEDS AN MRI? DOES EVERY CUFF TEAR NEED TO BE FIXED? WHAT DOES ROTATOR