Rotator cuff tears Acute or chronic? Mary Obele ANZSOM September 2012 Acknowledgement: ACC
Anatomy
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)
Epidemiology tears
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)
Tear progression
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 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
Extrinsic causes Primary impingement also: Coraco acromial ligament Greater tuberosity / coracoid Degenerative acromio-clavicular joint Os acromiale Postero-superior impingement in athletes
Extrinsic causes Secondary impingement Gleno-humeral instability Neurological pathology
Intrinsic causes Degenerative tendinopathy Muscle weakness Overuse Hypovascular area Genetics
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 20-25 was 1.00 Age-adjusted odd ratio for males with BMI > 35 was 3.13 (16)
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
Stage 2 Repeated episodes of inflammation leads to fibrosis and tendonitis of RC and bursa 25-40 year olds Aching pain after rigorous overhead activity, mild limitation of active/passive ROM Irreversible with activity modification Surgical management if conservative fails
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
Tendinosis
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
Impingement
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
Tears substantially due to trauma Acute symptoms: hear a tear or pop, severe pain (19) Early presentation (20)
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
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
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
Degenerative tears Reduced acromion-humeral interval <7mm
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
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)
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
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
Case 1
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
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
Case 2