The Hand and Upper Extremity Center of Northeast Wisconsin Shoulder Impingement and Rotator Cuff Tears Nathan L. Van Zeeland Hand & Upper Extremity Center of Northeast Wisconsin 2/24/12 Course Objectives Understand the relevant shoulder anatomy Gain an appreciation for the spectrum of rotator cuff pathology Learn a basic approach to rotator cuff injuries Understand clinical evaluation of rotator cuff injuries Understand imaging of rotator cuff injuries Course Objectives Understand non surgical management of rotator cuff pathology Understand surgical management of rotator cuff pathology Is it work related? Understand the natural history and apply to causation Introduction First, I Digress 1
Training Medical School at University of Wisconsin School of Medicine, 1999 2003 Training Orthopedic Surgery Residency at Vanderbilt University Medical Center, Nashville TN 2003 2008 Residency Mentors: Hand Residency Mentor: Shoulder Jeffry Watson, M.D. Doug Weikert, M.D. Don Lee, M.D. John Jed Kuhn, M.D. 2
Two Fellowships Mentors: Hand & Upper Extremity Hand & Upper Extremity, Washington University, St. Louis MO 2008 2009 Shoulder and Elbow, Washington University, St. Louis MO 2009 January 2010 Mentors: Shoulder & Elbow Ken Yamaguchi, M.D. Leesa Galatz, M.D. Jay Keener, M.D. Now.Happy to be back in Wisconsin Bony Anatomy: Humerus, Scapula, Clavicle, Thoracic Wall (rib cage) Joints: Glenohumeral Acromioclavicular Scapulothoracic Focus on Glenohumeral joint Shoulder Anatomy Shoulder Anatomy Static stabilizers: Minimal bony stability large humeral head and small flat glenoid (dinner plate) Ligaments and Labrum prevent dislocation yet allow significant motion 3
Glenoid bony socket Shallow Allows motion Differential cartilage thickness Labrum Cartilaginous Rim Increases Depth of Basic Anatomy glenoid fossa by 50% chock ADDS blocks 20% Stability in AP Plane Glenohumeral Ligaments Capsular thickenings SGHL: Thin, restrains inferior translation in adduction MGHL: Draped over subscapularis. Provides anterior stability in midabduction IGHL: Major stabilizer in 90 degrees of abduction Basic Anatomy Shoulder: Rotator Cuff Dynamic Stabilizers: Primarily the Rotator Cuff Four muscles that encircle the humeral head Supraspinatus Infraspinatus Teres Minor Subscapularis +/ Long head of Biceps Shoulder: Rotator Cuff Pulls the humeral head into the socket providing stability during motion Keeps the shoulder stable while moving through a very large range without allowing subluxation Assists with rotation, flexion, and abduction along with larger muscles Matsen et al., 1998 Dynamic Force Couple Rotary Cup Dynamic stabilizers create a balanced shoulder Net inferior and compressive vector from rotator cuff Net superior vector from deltoid Anterior stability provided by Subscapularis Balanced by posterior cuff: Infraspinatus and Teres Minor Allows for advanced range of motion 4
Rotary Club Rotator Cuff Dysfunction: What is happening? Rotator cuff dysfunction (impingement or tear) leads to some instability Superior migration of the humeral head with overhead activities Pinches the rotator cuff Vicious cycle Matsen et al., 1998 Rotator Cuff Pathology Spectrum of Disease Cuff Tendonitis Massive Cuff Tear Rotator Cuff: Injury Acute: Fall on the arm Dislocation in those over 40 Heavy lifting Eccentric contraction: Pop Generally fairly straight forward from a Worker s Compensation standpoint Immediate pain. Difficulty sleepy and motion very painful Rotator Cuff: Injury Chronic: Repetitive overhead activity Repetitive or heavy lifting especially overhead or abduction Reaching Repetitive reaching/rotating Acute on Chronic: Propagate an existing tear Rotator Cuff Disease: Risk Factors Age Dominant arm Trauma (acute or chronic) Heavy labor professions Less clear from a worker s compensation standpoint 5
Secondary Causes These factors can contribute to rotator cuff disease: Tuberosity fracture nonunion/malunion Mobile os acromiale Calcific tendonitis Adhesive capsulitis/frozen shoulder Biceps pathology Tight posterior capsule Rotator Cuff Tendonitis Multiple terms for the same malady Rotator Cuff Tendonitis Rotator Cuff Impingement Subacromial Impingement Subacromial Bursitis Rotator Cuff Tendinopathy Extrinsic Compression Theory Popularized by Neer (JBJS 1972) Source of pathologic impingement from the anterior/lateral acromion SPUR Extrinsic compression of the spur pinches cuff Coracoacromial ligament Acromioclavicular joint Acromial Morphology (Bigliani, et al 1986) Hooked Acromion correlated to higher incidence of rotator cuff degeneration Extrinsic Compression Theory cites mechanical compression and irritation as the source of the rotator cuff disease Intrinsic Degeneration Theory: Vascular Supply: Articular side of supraspinatus has relatively poor blood supply Lohr et al. CORR. 1990 6
Vascular and age related INTRINSIC tendon degeneration Leads to hypoxia, pain and dysfunction Weak supraspinatus leads to altered biomechanics Superior migration leads to further degeneration, etc. Osteophyte (spur) may occur secondarily Rotator Cuff Impingement May be an acute injury Often insidious onset, with escalating pain Worse with shoulder elevation or abduction Trouble handling objects away from body Anterolateral shoulder pain Trouble sleeping Rotator Cuff Impingement: Exam Inspection for atrophy or scapular winging Range of motion (active and passive) Restricted by pain or tight capsule? Rotator cuff strength Often weak and/or painful Provocative maneuvers Neer test Hawkins test Associated pathology Biceps signs AC joint pain Rotator Cuff Impingement: Exam Rotator Cuff Impingement: Imaging X rays initially Evaluate for arthritic disease at AC joint and glenohumeral articulation Evaluate for calcific tendonitis Rule out old fractures/malunion Evaluate os acromiale Hawkins Test Neer Test 7
Rotator Cuff Impingement: Imaging MRI study Arthrogram not always required Evaluate for tendinosis versus tear May detect partial tears Adhesive capsulitis (obliteration of axillary pouch) Evaluates biceps tendon Acromion morphology Loose bodies Rotator Cuff Impingement: Treatment Non operative modalities stressed NSAIDs Subacromial steroid injection Break the cycle Supervised therapy Home program Minimum 3 6 month trial Continue to reassess for additional structures involved Level 1 Study Subacromial Injection followed by 4 week PT program. Then home program. 74/94 (79%) patients did not require surgery at two year followup Significant improvement in validated outcome measures Rotator Cuff Impingement: Surgery After a 3 6 month trial of conservative management Arthroscopic bursectomy Subacromial decompression Evaluate for concomitant pathology that had been previously undetected Subacromial Impingement Surgery: Arthroscopic Bursectomy and Acromioplasty Subacromial Impingement Surgery: Arthroscopic Bursectomy and Acromioplasty Try to create a Type I Acromion 8
JBJS Br 2009 57 patients Trend toward better outcomes with acromioplasty Underpowered No statistical difference in outcomes Subacromial Decompression: Return to Work Belgian study Time to return to work full duty after arthroscopic subacromial decompression Mean time 11.1 weeks Self employed=1 week Workers comp=12 weeks Private insurance sick leave=8weeks Manual labor=12 weeks Acta Orthop Belg. 2011 Dec;77(6):737 42.Return to work after arthroscopic subacromial decompression. No Difference in Outcome Between Groups Surgery vs. Non Operative? Despite being exceedingly common, only 4 Randomized Control Trials in literature No difference in outcome in conservative versus surgical management Rotator Cuff Tears Rotator Cuff Repair Repair the torn tendon back to the bone Historically an open technique was used: now the vast majority are treated arthroscopically All Arthroscopic technique: Mini open technique: Burkhart, 2003 9
Rotator Cuff Repair Rotator Cuff Repair Rotator Cuff Dysfunction: Operative Postoperative course: Shoulder immobilizer and passive range of motion only for first 6 weeks followed by progressive increase in motion and strength: restrictions for 4 6 months Rotator Cuff Dysfunction: Operative Results: Results following large or massive tears are much more guarded and more commonly include permanent work restrictions, job change, and some functional loss Rotator Cuff Dysfunction: Treatment Rotator Cuff Tears: Nonrepairable Tears (chronic, massive tears with retraction and fatty infiltration of the muscle on MRI as well as superior migration of the humeral head under the acromion) Non operative measures Debride tear, bursectomy NO acromioplasty Partial repair Tendon transfers Rotator Cuff: Workplace Issues Return to modified duty as soon as feasible The longer the patient is out of work, the harder it is to get them back in the workplace Fairly long recovery time following repair makes the issue of modified duty very important Ideally varied tasks, rotating tasks, rest periods, and cross training decrease all types of repetitive workplace injury 10
Workers Compensation Status Int Orthop. 2009 Apr;33(2):315 20. Difference in outcome of shoulder surgery between workers' compensation and nonworkers' compensation populations. Meta analysis Workers Compensation status is independent predictor of poor outcome after any shoulder surgery 11