Rotator cuff tear
Encyclopedia
Rotator cuff tears are tears of one or more of the four tendon
s of the rotator cuff
muscles. A rotator cuff injury can include any type of irritation or damage to the rotator cuff muscles or tendons.
Rotator cuff tears are among the most common conditions affecting the shoulder.
The tendons of the rotator cuff, not the muscles, are most commonly torn. Of the four tendons, the supraspinatus is most frequently torn as it passes below the acromion; the tear usually occurs at its point of insertion onto the humeral head at the greater tubercule.
s, joint
s, muscle
s, and tendon
s:
, the humerus
, and the scapula
that features the glenoid fossa
, acromion and coracoid processes. These three bones create a ball-and-socket joint, also known as the glenohumeral joint
, that give the shoulder its wide range of motion encompassing three different planes. In order for this joint to be operational ligament
s, muscle
s, and tendon
s help support the bone; keeping it in place.
Ligament
s and joint
s are formed from the connection between two bones that are adjacent. Examples of both ligament
s and joint
s are represented by the glenohumeral, acromiclavicular, and sternoclavicular regions.
and rotates the humerus
outward. The cuff centers the humeral head in the glenoid cavity
via passive effects and, more importantly, via active multidirectional effects. In other words, the cuff prevents upward migration of the humeral head caused by the pull of the deltoid
muscle at the beginning of arm elevation. Furthermore, two cuff muscles, the infraspinatus and the teres minor, are the only muscles that ensure external rotation of the arm.
s of these muscles converge to form the rotator cuff tendon. The tendinous insertions of the rotator cuff muscles along with the articular capsule, the coracohumeral ligament
, and the glenohumeral ligament complex blend into a confluent sheet before insertion into the humeral tuberosities. The insertion site of the rotator cuff tendon at the greater tuberosity is often referred to as the footprint. The infraspinatus and teres minor fuse near their musculotendinous junctions, while the supraspinatus and subscapularis tendons join as a sheath that surrounds the biceps tendon at the entrance of the bicipital groove. The supraspinatus is the most common muscle tendon torn in a rotator cuff tear.
The insertions sites of the supraspinatus and infraspinatus tendon
s have been further described as a five-layer structure:
This layered anatomy of the rotator cuff tendons provides a glimpse into the various types of tears that could form given the different fiber characteristics of each layer.
. In a study of 306 cadaveric shoulders, noted a 32% incidence of partial-thickness tears and a 19% incidence of full-thickness tears within the supraspinatus tendon. Cadaveric studies have noted intratendinous tears to actually be more frequent than bursal-sided or articular-sided tears. Partial-thickness tears were further grouped as bursal-sided (2.4%), intratendinous (7.2%), and articular-sided (3.6%). However, clinically, articular-sided tears are found to be 2 to 3 times more common than bursal-sided tears. In fact, among a population of young athletes, found that articular-sided tears comprised 91% of all partial-thickness tears. Partial-thickness tears of the subscapularis that were seen with concomitant lesions of the long head of the biceps in 30.4% of these tears have also merited attention. Therefore, lesions within the biceps tendon mandate close evaluation for related injury within the subscapularis tendon.
or trauma
. Partial and full thickness tears have been found on post mortem studies and on MRI
studies, in people who do not have a history of shoulder pain or symptoms.
Rotator cuff disease may be initiated, or proliferated, by factors that are both extrinsic and intrinsic in nature:
Extrinsic factors are grouped into anatomical and environmental. One of the most acclaimed anatomical factors is the morphologic characteristics of the acromion. Hooked, curved, and laterally sloping acromions are strongly associated with cuff tears and may contribute by causing tractional damage to the tendon. On the other hand, flat acromions may have a insignificant involvement in cuff disease and consequently are often best treated conservatively. The development of these different acromial shapes is likely both genetically inherited and acquired from other causes. With acquired causes, only age has been positively correlated to progression from a flat to a curved or hooked acromion. The nature of mechanical activities, such as sports involving the shoulder, along with frequency and intensity of such a sport may be responsible for the adverse development. Sports such as bowling in cricket, swimming, tennis, baseball, and kayaking are primarily responsible. Moreover, a progression to a hooked acromion may simply be an adaptation to an already damaged, poorly balanced rotator cuff that is creating increasing stress on the coracoacromial arch. Other anatomical factors that may have significance include os acromiale and acromial spurs. Environmental factors implicated include increasing age, shoulder overuse, smoking, and any medical condition that impairs the inflammatory and healing response such as diabetes mellitus.
Intrinsic factors encompass the range of injury mechanisms that occur within the rotator cuff itself. Chief among these is a degenerative-microtrauma model, which supposes that age-related tendon damage compounded by chronic microtrauma results in partial tendon tears that then develop into full rotator cuff tears. As a result of repetitive microtrauma in the setting of a degenerative rotator cuff tendon, inflammatory mediators alter the local environment, and oxidative stress induces tenocyte apoptosis
causing further rotator cuff tendon degeneration. A neural theory also exists that suggests neural overstimulation leads to the recruitment of inflammatory cells and may also contribute to tendon degeneration.
Shoulder pain is variable and does not always correspond to the size of the tear.
For surgical purposes classifying the tendon
further is needed in order to determine the correct repair strategy. Neer generalized the concept of rotator cuff disease in 3 stages. Stage I occurs in those younger than 25 years and involves edema
and hemorrhage of the tendon
and bursa. Stage II involves tendinitis and fibrosis of the rotator cuff in 25- to 40-year-olds. Stage III involves tearing of the rotator cuff (partial or full-thickness) and occurs in those older than 40 years. Before surgery every aspect of the shoulder needs to be taken into account. Therefore, it has further been described depending on the tear location (articular, bursal, complete), size or area (in mm2), and depth (grade 1, <3 mm deep; grade 2, 3–6 mm deep; grade 3, >6 mm deep). And still further measurements are taken to classify the acromiohumeral distance, acromial shape, fatty infiltration or degeneration of muscle
s, muscle atrophy
, tendon retraction, vascular proliferation, chondroid metaplasia, and calcification
. Age-related degeneration of thinning and disorientation of the collagen
fibers, myxoid degeneration, and hyaline degeneration also need to be taken into consideration before a surgery plan is implemented.
Tears are also sometimes classified as acute, subacute, and chronic based on the trauma that caused the injury:
Epidemiological studies strongly support a relationship between age and cuff tear prevalence. In a recent study the frequency of such tears increased from 13% in the youngest group (aged 50–59 y) to 20% (aged 60–69 y), 31% (aged 70–79 y), and 51% in the oldest group (aged 80–89 y). This high rate of tear prevalence in asymptomatic individuals suggests that rotator cuff tears could be considered a "normal" process of aging rather than a result of an apparent pathological process.
Common medical studies used in diagnosing a rotator cuff tear include X-ray, MRI, double-contrast arthrography, and ultrasound techniques. A normal rotator cuff tear usually goes undetected with an X-ray, although bone spurs, which can pinch the rotator cuff tendons and result in a tear, can be captured. Moreover, if bone spurs are present, it suggests chronic severe rotator cuff disease. Double-contrast arthrography involves injecting contrast dye into the shoulder joint to detect leakage out of the injured rotator cuff. Arthrography and ultrasound are used, but depend heavily on the experience of a radiologist. The most effective and common diagnosis tool is magnetic resonance imaging (MRI), which can sometimes tell how large the tear is, as well as its location within the tendon. Furthermore, MRI enables the detection or exclusion of complete rotator cuff tears with a reasonable accuracy and is also suitable to diagnose further pathologies of the shoulder joint.
Acute injuries are not as frequent as chronic rotator cuff disease. Acute tears occur following bouts of forcefully raising the arm against resistance, which are evident during weight lifting. In addition, falling forcefully on the shoulder can elicit acute symptoms. Traumatic rotator cuff tears predominantly affect the supraspinatus tendon
or the rotator interval. These acute symptoms include severe pain that radiates through the arm, tenderness at the site of injury, and limited range of motion, specifically during abduction motions of the shoulder.
Chronic tears occur among individuals that constantly participate in overhead activities, such as pitching or swimming. Also, these tears can develop from shoulder tendinitis or rotator cuff disease. This disease comprises a wide range of pathology of the rotator cuff tendons. Symptoms that persist as a result of a chronic rotator cuff tears are sporadic worsening of pain, debilitation and atrophy of the muscle
s, noticeable pain during rest, crackling sensations when moving the shoulder, and inability to move or lift the arm sufficiently, especially during abduction and flexion motions.
Pain in the anterolateral aspect of the shoulder can be due to many causes, symptoms may reflect pathology outside of the shoulder which cause referred pain to the shoulder from sites such as the neck, heart or gut.
Patient history will often include pain or ache over the front and outer aspect of the shoulder, pain aggravated by leaning on the elbow and pushing upwards on the shoulder (such as leaning on the armrest of a reclining chair), intolerance to overhead activity, pain at night when lying directly on the affected shoulder, pain when reaching forward (e.g. unable to lift a gallon of milk from the refrigerator). Weakness may be reported, but is often masked by pain and is usually found only through examination. With longer standing pain, the shoulder is favored and gradually loss of motion and weakness may develop which, due to pain and guarding are often missed by the patient and are only brought out during the examination.
Primary shoulder problems may cause pain over the deltoid
muscle
that is made worse by abduction against resistance, called the impingement sign. Impingement reflects pain arising from the rotator cuff but cannot distinguish between inflammation, strain, or tear. Patients may report their experience with the impingement sign when they report that they are unable to reach upwards to brush their hair or to reach in front to lift a can of beans up from an overhead shelf.
Some areas of the rotator cuff tendons have poor blood supply.
studies have also been reported as a means of identifying rotator cuff tears. Unlike x-rays which require exposure to radiation and MRI studies which are costly, ultrasound studies have been advocated as an alternative, when read by experienced clinicians. When ultrasonography and magnetic resonance imaging studies have been read by investigators with comparable experience, they have been shown to have comparable accuracy for identifying and measuring the size of full-thickness and partial-thickness rotator cuff tears. Ultrasound can also reveal the presence of other conditions that may mimic rotator cuff tear at clinical examination, including tendinosis, calcific tendinitis, subacromial subdeltoid bursitis, greater tuberosity fracture, and adhesive capsulitis. The MRI provides more information about adjacent structures in the shoulder such as the capsule, glenoid labrum muscles and bone. These are factors to be considered in each case when selecting the appropriate study.
Clinicians and patients are advised to use clinical judgement and not rely on MRI images or x-rays to determine the cause of shoulder pain or treatment, since rotator cuff tears are found in people without any pain or symptoms. The role of x-rays, MRI and ultrasound, are part of the entire clinical picture and serve to confirm the diagnosis, which is provisionally made by a thorough history and physical examination. Over reliance on x-rays or MRI imaging may lead to over treatment or distraction from the true underlying problem.
It is thought that the cortisone helps diminish inflammation of the bursa that directly over lies the rotator cuff (sub-acromial bursitis). The test, if pain is relieved, is considered positive for rotator cuff impingement, of which tendinitis and bursitis are a part. However, partial rotator cuff tears may also have good pain relief and a good response cannot rule out a partial rotator cuff tear. In the face of good function and no pain, even with a partial rotator cuff tear, treatment would not change and the impingement test is useful in relief of pain and avoiding over testing or unnecessary surgery.
Formal and structural changes are presumed to be rotator cuff damages. Changes in the echogenicity as there can be detected areas with a higher, respectively, lower echo intensity. Or dynamic alterations like floating retractions or bulges at the tendon surface. An enlargement of the bursa subacromialis of more than 2mm is an unspecific change which can also appear with a fully intact rotator cuff for example at a subacromial syndrome.
Formal changes
Changes in structure or echogenicity
Hyperechogenicity: Represents an area of damage. Important to allude is that the surrounding rotator cuff area has to show normal echogenicity. Higher echos can be artificially caused through the physiologically curved surface and tilting of the ultrasonographic transducer.
Hypoechogenicity: Seems to represent the disordered fiber texture at the border area of the damages. If combined with acoustic shadow, calcific deposits or osseous fragments are contemplable.
Healthy rotator cuff tendons have in almost all sequences a low signal intensity. At T1-weighted spin echo images the signal weak rotator cuff is well visibly separated from the shoulder top through the subacromial fat stripe. Because water has no strong signal too in this adjustment it is despite to the good image resolution hard to circumscribe inflammative tendon changes, especially for joint fluid at the damaged area. Therefore at the T1-weighted image small defects can be missed out or result in false-positive findings.
A moderately higher signal at the T1-weighted image and with it a clearly higher intensity at the T2-weighted image are regarded to be a sign for partial or full rotator cuff tears. T2-weighted images can imitate the arthrographic effect of showing a very high signal at the damaged area and a communication between the joint and bursa space.
T2-weighted spin echo images create contrast due to the differences of bonded and loose water at the tissue and thus are more sensitive for inflammative changes and joint fluid at the tendon course as a sign for damage.
Analog to the inhomogeneities of the tendon structure at the ultrasonography are the inhomogeneities at the T1- and proton-weighted images correlated with histopathological signs of degeneration. Because they have been found in a very high percentage in asymptomatic shoulders their meaning in the daily clinic remains unclear and secondary.
Injured, but not aparted tendons have an elevated water affinity due to their changed collagen structure. These areas have a slightly higher signal intensity at T1-weighted images.
To achieve an extreme distinct fat-water-contrast, T2-weighted spin echo images have to be executed with a very long TE time and have to own a fat suppression. Thereby damage diagnosis can be enhanced via MRA. An alternative to fat suppressed T2-weighted sequences are modified STIR sequences. Gradient echo sequences are like T2-weighted images quickly available. However, disadvantageous are the susceptibility to artifacts, for example the so-called magic angle artifact or after surgical abrasive intervention.
The T1-weighted images are well qualified for the assessment of medial tendon retraction and secondary muscle atrophy causing fatty degeneration. The degree of the atrophy and fatty degeneration determines the prognosis after a rotator cuff reconstruction.
The MRI classifications are similar to Goutallier’s CT classifications. They relate fat to muscle tissue and are best seen on T1-weighted images.
In summary, regarded to be rotator cuff damages are alterations of the subacromial fat stripe, fluidity in the bursa subacromialis / subdeltoidea with visible communication to the joint space, elevated signal of the tendon at T1-weighted images which even augments at T2-weighted images and discontinuity of the tendon signal.
Lesions at the rotator cuff interval between supraspinatus and infraspinatus are hardly diagnosable at the native MRI. On the contrary good with the MR Arthrography.
One must say that literature inclusively an extensive meta analysis have shown that ultrasonography can achieve similar reliability as MRI in detecting full and partial tears of the rotator cuff.
Kenn et al. see significant advantage and important indication for MRI in detecting intratendinous ruptures. Those particular ruptures do not show intervention claiming pathological changes at arthroscopic subacromial bursoscopy, at open / endoscopic subacromial decompression or at ultrasonography. However, concerned patients would benefit from early surgical intervention. The MRI shows an extensive softening and intralaminar fraying.
Since many patients with partial tears and some even with complete tears can respond to non-operative management, generally conservative care is offered first. If a significant trauma such as a shoulder dislocation
, or fracture
, or high energy force is known to have been followed by complete to near complete loss of rotator cuff- mediated motion and strength, then an operative work-up is initiated with plans to proceed to surgery for repair, if confirmatory.
pain thought to be related to the rotator cuff, or a tear of the rotator cuff, includes oral medications that provide pain relief such as anti-inflammatory medications, topical pain relievers such as cold packs and if warranted a subacromial cortisone/local anesthetic injection to block the pain and start direct instillation of anti-inflammatory treatment. An alternative to needle injection is iontophoresis
, a battery powered patch which phoresis the medication to the target tissue. A sling may be offered for comfort for a day or two, with the awareness that the shoulder can become stiff with prolonged immobilization, which is to be avoided. Early physical therapy
may afford pain relief with modalities (ex. iontophoresis) and help to maintain motion. Ultrasound
treatment is not efficacious. As pain decreases, strength deficiencies and biomechanical errors can be corrected. Home exercises may be obtained from the clinician's office or physical therapist.
A non-operative or conservative physical therapy
treatment program begins with preliminary rest and restriction from engaging in the event which caused the injury itself. Frequently the duration of rest is too short. Under normal situations, inflammation can usually be controlled within 1 to 2 weeks, using NSAIDs
and subacromial steroid injections to decrease inflammation, to the point that pain has been significantly decreased to make stretching tolerable. After this short period of 1 to 2 weeks rapid stiffening and an increase in pain can result if sufficient stretching has not been implemented.
A gentle, passive range-of-motion program should be started to help prevent stiffness and maintain range of motion during this resting period by a licensed physical therapist. Exercises, for the anterior, inferior, and posterior shoulder, should be performed by the patient as a part of the motion program that has been specifically designed by a physical therapist. Codman exercises are renowned sources of motion using the pendulum to "permit the patient to abduct the arm by gravity, the supraspinatus remains relaxed, and no fulcrum is required," which is widely practiced in clinics. The use of NSAIDs; hot and cold packs; and physical therapy modalities, such as ultrasound, phonophoresis, or iontophoresis, can be instituted during this stretching period, if effective. Injections are recommended 2 to 3 months apart with a maximum of three injections. Multiple steroid injections (four or more) have been shown to compromise the results of rotator cuff surgery which result in weakening the tendon in . Before any rotator cuff strengthening can be started, the shoulder must have a full range of motion.
After a full, painless range of motion is achieved, the patient may advance to a gentle strengthening program that is specifically designed by a physical therapist. Rockwood coined the term orthotherapy to describe this program, which is an interactive exchange between the patient, the treating orthopedic surgeon, and physical therapist aimed at creating an exercise regimen that initially gently improves motion, then gradually improves strength in the shoulder girdle. Each patient is personally instructed in the exercise program by a physical therapist. Each patient is given a home therapy kit, which includes elastic bands of six different colors and strengths; a pulley set; and a three-piece, 1-m-long stick. The program is customized to each individual patient, fitting the needs of the patient and altering when necessary. Patients are asked to do all their home exercise program on their own whether that be at home, at work, or when traveling.
There are several instances in which nonoperative treatment would not be suggested. The first is the 20- to 30-year-old active patient with an acute tear and severe functional deficit from a specific event. The second is the 30- to 50-year-old patient with an acute rotator cuff tear secondary to a specific event. The third instance is the highly competitive athlete who is primarily involved in overhead or throwing sports. These patients need to be treated operatively because rotator cuff repair is necessary for restoration of the normal strength required to return these athletes to the same competitive preoperative level of function. Patients who do not respond or are unsatisfied with conservative treatment should seek operative management.
Autologous tenocyte implantation treatment management (ATITM) is a tendon regeneration therapy designed to assist and improve the regeneration of damaged/injured tendons. A biopsy harvests a small piece of tendon from a healthy tendon (typically the tendon below the kneecap). The biopsied tissue is taken to laboratory where the building blocks of the tendon, the tenocyte cells, are isolated and grown over a period of approximately 4-5 weeks. The cells are then implanted via injection into the affected tissue with ultrasound guidance. Evidence supports ATITM therapy as successful in treatment of common tendinopathy. See the Journal of Tissue Engineering, 2007 J. M. Chen MD MMS, C. Willers, J. Xu MD, A. Wang MD, M.H. Zheng MD PhD*.Department of Orthopaedics Surgery, School of Surgery and Pathology, University of Western Australia.
s. Surgery is designated in patients under 60 years of age, full thickness tear demonstrated clinically, failure to improve after 6–8 weeks of physical therapy
, and activity levels requiring use of the shoulder.
There are several surgical options for treatment of a rotator cuff tear. The exact type of surgery may depend on factors including the degree of tendon
disruption, location of the tear, patients preferred activities, and presence or absence of bone spur
s that may be contributing to the tear (ehealthmd.com). The three general approaches of surgical repairs are arthroscopic repair, mini-open repair, and open surgical repair. In the recent past small tears were treated arthroscopically, while larger tears would usually require an open procedure. Advances in the procedure now allow Arthroscopic repair of even the largest tears, and arthroscopic techniques are now required to mobilize many of the retracted tears. Arthroscopic results now match open surgical techniques, and allow for a more thorough evaluation of the shoulder at the time of surgery, increasing the diagnostic value of the procedure, as several other conditions may simultaneously cause shoulder pain. Arthroscopic surgery allows for a shorter recovery time and predictably less pain in the first few days following the procedure than does open surgery.
If there is a bone spur
that instigated the rotator cuff tear, arthroscopic repair, open repair (6–10 cm incision), or mini-open repair (3–5 cm incision) will often include an acromioplasty, a subacromial decompression, as part of the procedures. Subacromial decompression consists of removal of a small portion of the bone
(acromion) that overlies the rotator cuff, hoping to relieve pressure on the rotator cuff in certain conditions and promote healing and recovery. Although subacromial decompression may be beneficial to partial and full thickness tears, this procedure does not consists of physically repairing the tears. Arthroscopic decompression has more recently been combined with "mini-open" repair of the rotator cuff, which allows for the repair of the cuff without disruption of the deltoid origin. A sole decompression approach tends to degrade with time, but combining repairing of the tear with decompression produces better results.
A complete full-thickness rotator cuff tear, the most severe, involves mending the torn rotator cuff by suturing the tissues
back together. The usual method that is currently in use, is to place an anchor in the bone of the natural attachment site, and suture the torn tendon end back down to the bone from which it originally tore away. If the tissue quality is poor the surgeon might use a mesh (collagen
, Artelon
or other degradable material) to reinforce the repair. The repair can be performed through an open incision, again requiring detachment of a portion of the deltoid. The mini-open technique approaches the tear through a deltoid
splitting approach. This seemingly causes less damage to the deltoid
muscle and may produce better results. Modern techniques now use an all arthroscopic approach.
Surgical recovery can take as long as 3–6 months, with a sling being worn for the first 1–6 weeks. Furthermore, in some severe cases where arthritis
has developed, one option is to replace the shoulder
joint, but these represent a small minority of cases.
Surgical outcomes for severe tears of the rotator cuff have been shown to be positive on a 10 year follow-up. However, the same study demonstrated ongoing and progressive fatty atrophy and re-tears of the rotator cuff. Shen has shown that MRI evidence of fatty atrophy in the rotator cuff prior to surgery is predicative of a poor surgical outcome. To address this issue of failure of surgical repair and poor conservative care outcomes caused by muscular atrophy, bioengineering may be the answer. Mesenchymal stem cells have been shown to differentiate into skeletal muscle. Rotator cuff tears can be hereditary. Regardless of the method used, recent studies have shown that stable repairs of the rotator cuff give a more functional shoulder. Rotator cuff tears of the impingement type usually begin in patients in their 40's, and progress with time.
constitutes a group of four muscles: the infraspinatus, supraspinatus, subscapularis, and teres minor. The cuff adheres to the glenohumeral capsule and attaches to the humeral head. The main functions of the cuff are to stabilizes the glenohumeral joint
and rotate the humerus
outward. When shoulder trauma occurs, these functions can be attenuated, therefore suggesting a rotator cuff tear. Since individuals are highly dependent on the shoulder for many activities, overuse and overbearing of the muscles can lead to tears, with the vast majority of these tears occurring in the supraspinatus tendon
. Additionally, environmental factors such as increase in age, smoking, and diabetes mellitus
can enhance the probability of a tear. Acute tears may occur after falling on the shoulder or while exerting too much force during an overhead motion. These types of traumas elicit sharp, throbbing pain, as well as limited range of motion. Overuse of the muscles is subject to chronic shoulder conditions, such as arthritis
and bone spur
s, which can eventually lead to a tear. Once a tear happens in the rotator cuff, it is much more likely to recur. To avoid this, proper strengthening exercises can be performed. Partial tears can be treated with rest, anti-inflammatory drugs, and eventually physical therapy. A complete tear usually requires surgical procedures such as arthroscopic repair, open repair, or mini-open repair. These procedures are used in the rotator cuff
area to remove bone spur
s (subacromial decompression), repair the tear by suturing the tendons, transfer tendons, and even replace the shoulder
joint when arthritis has developed.
Tendon
A tendon is a tough band of fibrous connective tissue that usually connects muscle to bone and is capable of withstanding tension. Tendons are similar to ligaments and fasciae as they are all made of collagen except that ligaments join one bone to another bone, and fasciae connect muscles to other...
s of the rotator cuff
Rotator cuff
In anatomy, the rotator cuff is the group of muscles and their tendons that act to stabilize the shoulder. The four muscles of the rotator cuff, along with the teres major muscle, the coracobrachialis muscle and the deltoid, make up the seven scapulohumeral muscles of the human body.-Function:The...
muscles. A rotator cuff injury can include any type of irritation or damage to the rotator cuff muscles or tendons.
Rotator cuff tears are among the most common conditions affecting the shoulder.
The tendons of the rotator cuff, not the muscles, are most commonly torn. Of the four tendons, the supraspinatus is most frequently torn as it passes below the acromion; the tear usually occurs at its point of insertion onto the humeral head at the greater tubercule.
Anatomy
The shoulder is a complex mechanism of intertwining bones, ligamentLigament
In anatomy, the term ligament is used to denote any of three types of structures. Most commonly, it refers to fibrous tissue that connects bones to other bones and is also known as articular ligament, articular larua, fibrous ligament, or true ligament.Ligament can also refer to:* Peritoneal...
s, joint
Joint
A joint is the location at which two or more bones make contact. They are constructed to allow movement and provide mechanical support, and are classified structurally and functionally.-Classification:...
s, muscle
Muscle
Muscle is a contractile tissue of animals and is derived from the mesodermal layer of embryonic germ cells. Muscle cells contain contractile filaments that move past each other and change the size of the cell. They are classified as skeletal, cardiac, or smooth muscles. Their function is to...
s, and tendon
Tendon
A tendon is a tough band of fibrous connective tissue that usually connects muscle to bone and is capable of withstanding tension. Tendons are similar to ligaments and fasciae as they are all made of collagen except that ligaments join one bone to another bone, and fasciae connect muscles to other...
s:
Bones of rotator cuff
Bone is living tissue that makes up the body's skeleton providing shape and support. The bones that form the shoulder are the clavicleClavicle
In human anatomy, the clavicle or collar bone is a long bone of short length that serves as a strut between the scapula and the sternum. It is the only long bone in body that lies horizontally...
, the humerus
Humerus
The humerus is a long bone in the arm or forelimb that runs from the shoulder to the elbow....
, and the scapula
Scapula
In anatomy, the scapula , omo, or shoulder blade, is the bone that connects the humerus with the clavicle ....
that features the glenoid fossa
Glenoid fossa
Glenoid fossa can refer to:* Glenoid cavity * Mandibular fossa...
, acromion and coracoid processes. These three bones create a ball-and-socket joint, also known as the glenohumeral joint
Glenohumeral joint
The glenohumeral joint, or shoulder joint, is a multiaxial synovial ball and socket joint and involves articulation between the glenoid fossa of the scapula and the head of the humerus...
, that give the shoulder its wide range of motion encompassing three different planes. In order for this joint to be operational ligament
Ligament
In anatomy, the term ligament is used to denote any of three types of structures. Most commonly, it refers to fibrous tissue that connects bones to other bones and is also known as articular ligament, articular larua, fibrous ligament, or true ligament.Ligament can also refer to:* Peritoneal...
s, muscle
Muscle
Muscle is a contractile tissue of animals and is derived from the mesodermal layer of embryonic germ cells. Muscle cells contain contractile filaments that move past each other and change the size of the cell. They are classified as skeletal, cardiac, or smooth muscles. Their function is to...
s, and tendon
Tendon
A tendon is a tough band of fibrous connective tissue that usually connects muscle to bone and is capable of withstanding tension. Tendons are similar to ligaments and fasciae as they are all made of collagen except that ligaments join one bone to another bone, and fasciae connect muscles to other...
s help support the bone; keeping it in place.
Ligament
Ligament
In anatomy, the term ligament is used to denote any of three types of structures. Most commonly, it refers to fibrous tissue that connects bones to other bones and is also known as articular ligament, articular larua, fibrous ligament, or true ligament.Ligament can also refer to:* Peritoneal...
s and joint
Joint
A joint is the location at which two or more bones make contact. They are constructed to allow movement and provide mechanical support, and are classified structurally and functionally.-Classification:...
s are formed from the connection between two bones that are adjacent. Examples of both ligament
Ligament
In anatomy, the term ligament is used to denote any of three types of structures. Most commonly, it refers to fibrous tissue that connects bones to other bones and is also known as articular ligament, articular larua, fibrous ligament, or true ligament.Ligament can also refer to:* Peritoneal...
s and joint
Joint
A joint is the location at which two or more bones make contact. They are constructed to allow movement and provide mechanical support, and are classified structurally and functionally.-Classification:...
s are represented by the glenohumeral, acromiclavicular, and sternoclavicular regions.
Muscles of rotator cuff
The major muscle groups of the rotator cuff are the supraspinatus, subscapularis, infraspinatus, and teres minor that contribute to the stability of the shoulder. The cuff adheres to the glenohumeral capsule and attaches to the humeral head. The only individualized structures at the humeral head are the upper edge of the subscapularis tendon and anterior edge of the supraspinatus muscle, which delineate a triangular space called the rotator interval. The cuff plays two main roles: it stabilizes the glenohumeral jointGlenohumeral joint
The glenohumeral joint, or shoulder joint, is a multiaxial synovial ball and socket joint and involves articulation between the glenoid fossa of the scapula and the head of the humerus...
and rotates the humerus
Humerus
The humerus is a long bone in the arm or forelimb that runs from the shoulder to the elbow....
outward. The cuff centers the humeral head in the glenoid cavity
Glenoid cavity
The glenoid cavity is a shallow pyriform, articular surface, which is located on the lateral angle of the scapula. It is directed laterally and forward and articulates with the head of the humerus; it is broader below than above and its vertical diameter is the longest.This cavity forms the...
via passive effects and, more importantly, via active multidirectional effects. In other words, the cuff prevents upward migration of the humeral head caused by the pull of the deltoid
Deltoid
Deltoid can refer to:* The deltoid muscle, a muscle in the shoulder* Kite , also known as a deltoid, a type of quadrilateral* A deltoid curve, a three-sided hypocycloid* A leaf shape* The deltoid tuberosity, a part of the humerus...
muscle at the beginning of arm elevation. Furthermore, two cuff muscles, the infraspinatus and the teres minor, are the only muscles that ensure external rotation of the arm.
Major tendons of rotator cuff
The four tendonTendon
A tendon is a tough band of fibrous connective tissue that usually connects muscle to bone and is capable of withstanding tension. Tendons are similar to ligaments and fasciae as they are all made of collagen except that ligaments join one bone to another bone, and fasciae connect muscles to other...
s of these muscles converge to form the rotator cuff tendon. The tendinous insertions of the rotator cuff muscles along with the articular capsule, the coracohumeral ligament
Coracohumeral ligament
The coracohumeral ligament is a broad ligament which strengthens the upper part of the capsule of the shoulder joint.It arises from the lateral border of the coracoid process, and passes obliquely downward and lateralward to the front of the greater tubercle of the humerus, blending with the tendon...
, and the glenohumeral ligament complex blend into a confluent sheet before insertion into the humeral tuberosities. The insertion site of the rotator cuff tendon at the greater tuberosity is often referred to as the footprint. The infraspinatus and teres minor fuse near their musculotendinous junctions, while the supraspinatus and subscapularis tendons join as a sheath that surrounds the biceps tendon at the entrance of the bicipital groove. The supraspinatus is the most common muscle tendon torn in a rotator cuff tear.
The insertions sites of the supraspinatus and infraspinatus tendon
Tendon
A tendon is a tough band of fibrous connective tissue that usually connects muscle to bone and is capable of withstanding tension. Tendons are similar to ligaments and fasciae as they are all made of collagen except that ligaments join one bone to another bone, and fasciae connect muscles to other...
s have been further described as a five-layer structure:
- Layer 1: contains large arterioles and comprises fibers from the coracohumeral ligamentCoracohumeral ligamentThe coracohumeral ligament is a broad ligament which strengthens the upper part of the capsule of the shoulder joint.It arises from the lateral border of the coracoid process, and passes obliquely downward and lateralward to the front of the greater tubercle of the humerus, blending with the tendon...
. This layer is 1 mm thick and contains fibers that are oriented obliquely to the long axis of the muscle bellies. - Layer 2: is the main portion of the cuff tendons being 3 to 5 mm thick; is seen as closely packed parallel tendon fibers grouped in large bundles extending directly from the muscle bellies to the insertion on the humerus.
- Layer 3: is approximately 3 mm thick and comprises smaller bundles of collagenCollagenCollagen is a group of naturally occurring proteins found in animals, especially in the flesh and connective tissues of mammals. It is the main component of connective tissue, and is the most abundant protein in mammals, making up about 25% to 35% of the whole-body protein content...
with less uniform orientation than in layer 2. Fibers within this layer travel at 45 degree angles to one another to form an interdigitating meshwork that contributes to the fusion of the cuff tendon insertion. - Layer 4: comprises loose connective tissue and thick collagenCollagenCollagen is a group of naturally occurring proteins found in animals, especially in the flesh and connective tissues of mammals. It is the main component of connective tissue, and is the most abundant protein in mammals, making up about 25% to 35% of the whole-body protein content...
bands that merge with the coracohumeral ligamentCoracohumeral ligamentThe coracohumeral ligament is a broad ligament which strengthens the upper part of the capsule of the shoulder joint.It arises from the lateral border of the coracoid process, and passes obliquely downward and lateralward to the front of the greater tubercle of the humerus, blending with the tendon...
at the most anterior border of the supraspinatus. - Layer 5: is 2 mm thick and represents the shoulder capsule and comprises a sheet of interwoven collagenCollagenCollagen is a group of naturally occurring proteins found in animals, especially in the flesh and connective tissues of mammals. It is the main component of connective tissue, and is the most abundant protein in mammals, making up about 25% to 35% of the whole-body protein content...
extending from the glenoid labrum to the humerusHumerusThe humerus is a long bone in the arm or forelimb that runs from the shoulder to the elbow....
.
This layered anatomy of the rotator cuff tendons provides a glimpse into the various types of tears that could form given the different fiber characteristics of each layer.
Incidence
The vast majority of these tears seem to occur in the supraspinatus tendonTendon
A tendon is a tough band of fibrous connective tissue that usually connects muscle to bone and is capable of withstanding tension. Tendons are similar to ligaments and fasciae as they are all made of collagen except that ligaments join one bone to another bone, and fasciae connect muscles to other...
. In a study of 306 cadaveric shoulders, noted a 32% incidence of partial-thickness tears and a 19% incidence of full-thickness tears within the supraspinatus tendon. Cadaveric studies have noted intratendinous tears to actually be more frequent than bursal-sided or articular-sided tears. Partial-thickness tears were further grouped as bursal-sided (2.4%), intratendinous (7.2%), and articular-sided (3.6%). However, clinically, articular-sided tears are found to be 2 to 3 times more common than bursal-sided tears. In fact, among a population of young athletes, found that articular-sided tears comprised 91% of all partial-thickness tears. Partial-thickness tears of the subscapularis that were seen with concomitant lesions of the long head of the biceps in 30.4% of these tears have also merited attention. Therefore, lesions within the biceps tendon mandate close evaluation for related injury within the subscapularis tendon.
Presentation
Many rotator cuff tears cause no pain nor produce any symptoms, tears are known to have an increasing incidence with increasing age. The most frequent cause of rotator cuff damage is age related degeneration and less frequently by sports injuriesSports injuries
Sports injuries are injuries that occur in athletic activities. In many cases, these types of injuries are often due to overuse or acute trauma of a part of the body when participating in a certain activity. For example, runner's knee is a painful condition generally associated with running, while...
or trauma
Physical trauma
Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...
. Partial and full thickness tears have been found on post mortem studies and on MRI
Magnetic resonance imaging
Magnetic resonance imaging , nuclear magnetic resonance imaging , or magnetic resonance tomography is a medical imaging technique used in radiology to visualize detailed internal structures...
studies, in people who do not have a history of shoulder pain or symptoms.
Rotator cuff disease may be initiated, or proliferated, by factors that are both extrinsic and intrinsic in nature:
Extrinsic factors are grouped into anatomical and environmental. One of the most acclaimed anatomical factors is the morphologic characteristics of the acromion. Hooked, curved, and laterally sloping acromions are strongly associated with cuff tears and may contribute by causing tractional damage to the tendon. On the other hand, flat acromions may have a insignificant involvement in cuff disease and consequently are often best treated conservatively. The development of these different acromial shapes is likely both genetically inherited and acquired from other causes. With acquired causes, only age has been positively correlated to progression from a flat to a curved or hooked acromion. The nature of mechanical activities, such as sports involving the shoulder, along with frequency and intensity of such a sport may be responsible for the adverse development. Sports such as bowling in cricket, swimming, tennis, baseball, and kayaking are primarily responsible. Moreover, a progression to a hooked acromion may simply be an adaptation to an already damaged, poorly balanced rotator cuff that is creating increasing stress on the coracoacromial arch. Other anatomical factors that may have significance include os acromiale and acromial spurs. Environmental factors implicated include increasing age, shoulder overuse, smoking, and any medical condition that impairs the inflammatory and healing response such as diabetes mellitus.
Intrinsic factors encompass the range of injury mechanisms that occur within the rotator cuff itself. Chief among these is a degenerative-microtrauma model, which supposes that age-related tendon damage compounded by chronic microtrauma results in partial tendon tears that then develop into full rotator cuff tears. As a result of repetitive microtrauma in the setting of a degenerative rotator cuff tendon, inflammatory mediators alter the local environment, and oxidative stress induces tenocyte apoptosis
Apoptosis
Apoptosis is the process of programmed cell death that may occur in multicellular organisms. Biochemical events lead to characteristic cell changes and death. These changes include blebbing, cell shrinkage, nuclear fragmentation, chromatin condensation, and chromosomal DNA fragmentation...
causing further rotator cuff tendon degeneration. A neural theory also exists that suggests neural overstimulation leads to the recruitment of inflammatory cells and may also contribute to tendon degeneration.
Classification
Tears of the rotator cuff tendon are described as partial thickness tears, full thickness tears and full thickness tears with complete detachment of the tendons from bone.- Partial thickness tears often appear as fraying of an intact tendonTendonA tendon is a tough band of fibrous connective tissue that usually connects muscle to bone and is capable of withstanding tension. Tendons are similar to ligaments and fasciae as they are all made of collagen except that ligaments join one bone to another bone, and fasciae connect muscles to other...
.
- Full thickness tears are through-and-through tears. These can be small pin-point tears or larger button hole tears or tears involving the majority of the tendonTendonA tendon is a tough band of fibrous connective tissue that usually connects muscle to bone and is capable of withstanding tension. Tendons are similar to ligaments and fasciae as they are all made of collagen except that ligaments join one bone to another bone, and fasciae connect muscles to other...
where the tendonTendonA tendon is a tough band of fibrous connective tissue that usually connects muscle to bone and is capable of withstanding tension. Tendons are similar to ligaments and fasciae as they are all made of collagen except that ligaments join one bone to another bone, and fasciae connect muscles to other...
still remains substantially attached to the humeral head and thus maintains function.
- Full thickness tears may also involve complete detachment of the tendonTendonA tendon is a tough band of fibrous connective tissue that usually connects muscle to bone and is capable of withstanding tension. Tendons are similar to ligaments and fasciae as they are all made of collagen except that ligaments join one bone to another bone, and fasciae connect muscles to other...
(s) from the humeral head and may result in impaired shoulder motion and function may be significantly affected.
Shoulder pain is variable and does not always correspond to the size of the tear.
For surgical purposes classifying the tendon
Tendon
A tendon is a tough band of fibrous connective tissue that usually connects muscle to bone and is capable of withstanding tension. Tendons are similar to ligaments and fasciae as they are all made of collagen except that ligaments join one bone to another bone, and fasciae connect muscles to other...
further is needed in order to determine the correct repair strategy. Neer generalized the concept of rotator cuff disease in 3 stages. Stage I occurs in those younger than 25 years and involves edema
Edema
Edema or oedema ; both words from the Greek , oídēma "swelling"), formerly known as dropsy or hydropsy, is an abnormal accumulation of fluid beneath the skin or in one or more cavities of the body that produces swelling...
and hemorrhage of the tendon
Tendon
A tendon is a tough band of fibrous connective tissue that usually connects muscle to bone and is capable of withstanding tension. Tendons are similar to ligaments and fasciae as they are all made of collagen except that ligaments join one bone to another bone, and fasciae connect muscles to other...
and bursa. Stage II involves tendinitis and fibrosis of the rotator cuff in 25- to 40-year-olds. Stage III involves tearing of the rotator cuff (partial or full-thickness) and occurs in those older than 40 years. Before surgery every aspect of the shoulder needs to be taken into account. Therefore, it has further been described depending on the tear location (articular, bursal, complete), size or area (in mm2), and depth (grade 1, <3 mm deep; grade 2, 3–6 mm deep; grade 3, >6 mm deep). And still further measurements are taken to classify the acromiohumeral distance, acromial shape, fatty infiltration or degeneration of muscle
Muscle
Muscle is a contractile tissue of animals and is derived from the mesodermal layer of embryonic germ cells. Muscle cells contain contractile filaments that move past each other and change the size of the cell. They are classified as skeletal, cardiac, or smooth muscles. Their function is to...
s, muscle atrophy
Atrophy
Atrophy is the partial or complete wasting away of a part of the body. Causes of atrophy include mutations , poor nourishment, poor circulation, loss of hormonal support, loss of nerve supply to the target organ, disuse or lack of exercise or disease intrinsic to the tissue itself...
, tendon retraction, vascular proliferation, chondroid metaplasia, and calcification
Calcification
Calcification is the process in which calcium salts build up in soft tissue, causing it to harden. Calcifications may be classified on whether there is mineral balance or not, and the location of the calcification.-Causes:...
. Age-related degeneration of thinning and disorientation of the collagen
Collagen
Collagen is a group of naturally occurring proteins found in animals, especially in the flesh and connective tissues of mammals. It is the main component of connective tissue, and is the most abundant protein in mammals, making up about 25% to 35% of the whole-body protein content...
fibers, myxoid degeneration, and hyaline degeneration also need to be taken into consideration before a surgery plan is implemented.
Tears are also sometimes classified as acute, subacute, and chronic based on the trauma that caused the injury:
- Acute tends to happen as a result of a sudden, powerful movement. This might include falling over onto an outstretched hand at speed, making a sudden thrust with the paddle in kayaking, or following a powerful pitch/throw.
- Subacute arises in similar situations to acute; however it tends to happen in one of the 5 layers of the shoulder anatomy.
- Chronic develops over a period of time, usual occurs at or near the tendonTendonA tendon is a tough band of fibrous connective tissue that usually connects muscle to bone and is capable of withstanding tension. Tendons are similar to ligaments and fasciae as they are all made of collagen except that ligaments join one bone to another bone, and fasciae connect muscles to other...
(as a result of the tendon rubbing against the overlying bone), and is usually associated with an impingement syndrome.
Prognosis
While people with rotator cuff tears may not have any noticeable symptoms, studies have shown that over time 40% will have enlargement of the tear over a 5-year period. Of those whose tears enlarge, 20% have no symptoms while 80% eventually develop symptoms.Epidemiological studies strongly support a relationship between age and cuff tear prevalence. In a recent study the frequency of such tears increased from 13% in the youngest group (aged 50–59 y) to 20% (aged 60–69 y), 31% (aged 70–79 y), and 51% in the oldest group (aged 80–89 y). This high rate of tear prevalence in asymptomatic individuals suggests that rotator cuff tears could be considered a "normal" process of aging rather than a result of an apparent pathological process.
Diagnosis
Diagnosis is based upon a physical assessment and a detailed history of the patient, including descriptions of previously participated activities and acute or chronic symptoms experienced. The physical examination of a shoulder deals with a systematic approach constituting inspection, palpation, range of motion, strength testing, and neurological testing. The shoulder will be examined to see whether it is tender in any area or whether there is a deformity. Since most cervical pain is commonly mistaken for shoulder pain, the physical examination should include a thorough assessment of the cervical spine in order to eliminate other contradictions such as a "pinched nerve", osteoarthritis or rheumatoid arthritis.Common medical studies used in diagnosing a rotator cuff tear include X-ray, MRI, double-contrast arthrography, and ultrasound techniques. A normal rotator cuff tear usually goes undetected with an X-ray, although bone spurs, which can pinch the rotator cuff tendons and result in a tear, can be captured. Moreover, if bone spurs are present, it suggests chronic severe rotator cuff disease. Double-contrast arthrography involves injecting contrast dye into the shoulder joint to detect leakage out of the injured rotator cuff. Arthrography and ultrasound are used, but depend heavily on the experience of a radiologist. The most effective and common diagnosis tool is magnetic resonance imaging (MRI), which can sometimes tell how large the tear is, as well as its location within the tendon. Furthermore, MRI enables the detection or exclusion of complete rotator cuff tears with a reasonable accuracy and is also suitable to diagnose further pathologies of the shoulder joint.
Symptoms
Symptoms of a rotator cuff tear may advance instantly after a trauma (acute) or develop gradually, yet persistently over time (chronic).Acute injuries are not as frequent as chronic rotator cuff disease. Acute tears occur following bouts of forcefully raising the arm against resistance, which are evident during weight lifting. In addition, falling forcefully on the shoulder can elicit acute symptoms. Traumatic rotator cuff tears predominantly affect the supraspinatus tendon
Tendon
A tendon is a tough band of fibrous connective tissue that usually connects muscle to bone and is capable of withstanding tension. Tendons are similar to ligaments and fasciae as they are all made of collagen except that ligaments join one bone to another bone, and fasciae connect muscles to other...
or the rotator interval. These acute symptoms include severe pain that radiates through the arm, tenderness at the site of injury, and limited range of motion, specifically during abduction motions of the shoulder.
Chronic tears occur among individuals that constantly participate in overhead activities, such as pitching or swimming. Also, these tears can develop from shoulder tendinitis or rotator cuff disease. This disease comprises a wide range of pathology of the rotator cuff tendons. Symptoms that persist as a result of a chronic rotator cuff tears are sporadic worsening of pain, debilitation and atrophy of the muscle
Muscle
Muscle is a contractile tissue of animals and is derived from the mesodermal layer of embryonic germ cells. Muscle cells contain contractile filaments that move past each other and change the size of the cell. They are classified as skeletal, cardiac, or smooth muscles. Their function is to...
s, noticeable pain during rest, crackling sensations when moving the shoulder, and inability to move or lift the arm sufficiently, especially during abduction and flexion motions.
Pain in the anterolateral aspect of the shoulder can be due to many causes, symptoms may reflect pathology outside of the shoulder which cause referred pain to the shoulder from sites such as the neck, heart or gut.
Patient history will often include pain or ache over the front and outer aspect of the shoulder, pain aggravated by leaning on the elbow and pushing upwards on the shoulder (such as leaning on the armrest of a reclining chair), intolerance to overhead activity, pain at night when lying directly on the affected shoulder, pain when reaching forward (e.g. unable to lift a gallon of milk from the refrigerator). Weakness may be reported, but is often masked by pain and is usually found only through examination. With longer standing pain, the shoulder is favored and gradually loss of motion and weakness may develop which, due to pain and guarding are often missed by the patient and are only brought out during the examination.
Primary shoulder problems may cause pain over the deltoid
Deltoid
Deltoid can refer to:* The deltoid muscle, a muscle in the shoulder* Kite , also known as a deltoid, a type of quadrilateral* A deltoid curve, a three-sided hypocycloid* A leaf shape* The deltoid tuberosity, a part of the humerus...
muscle
Muscle
Muscle is a contractile tissue of animals and is derived from the mesodermal layer of embryonic germ cells. Muscle cells contain contractile filaments that move past each other and change the size of the cell. They are classified as skeletal, cardiac, or smooth muscles. Their function is to...
that is made worse by abduction against resistance, called the impingement sign. Impingement reflects pain arising from the rotator cuff but cannot distinguish between inflammation, strain, or tear. Patients may report their experience with the impingement sign when they report that they are unable to reach upwards to brush their hair or to reach in front to lift a can of beans up from an overhead shelf.
Some areas of the rotator cuff tendons have poor blood supply.
Signs
Park et al. evaluated eight well known physical examination tests to determine their diagnostic values to help distinguish between bursitis, partial-thickness rotator cuff tears, and full-thickness rotator cuff tears. The study concluded that "the best test" was a combination of tests. For the diagnosis of impingement disease the best combination of tests were a positive: Hawkins-Kennedy impingement sign, a positive painful arc sign, and weakness in external rotation with the arm at the side. To diagnose a full-thickness rotator cuff tear, the best combination of tests, when all three are positive: were the painful arc, the drop-arm sign, and weakness in external rotation.Diagnostic tests
The correct use of diagnostic tests is an important component of effective medical practice. X-rays cannot directly reveal tears of the rotator cuff as the tendon is made of soft tissue and not bone. Normal x-rays cannot rule out a torn or damaged rotator cuff. Indirect evidence of rotator cuff pathology can be seen on x-ray in instances where one or more of the tendons have undergone degenerative calcification ( calcific tendinitis). Large tears of the rotator cuff may allow the humeral head to migrate upwards ( high riding humeral head) and this can be seen on x-ray. Prolonged contact between a high riding humeral head and the acromion above it, may lead to x-rays findings of wear on the humeral head and the acromion and secondary degenerative arthritis of the glenohumeral joint(the ball and socket joint of the shoulder) may ensue called cuff arthropathy. Incidental x-ray findings of bone spurs at the adjacent acromio-clavicular joint (A-C joint) may show a bone spur growing from the outer edge of the clavicle downwards towards the rotator cuff. Bone spurs may also be seen on the underside of the acromion. These types of bone spurs were thought to cause direct fraying of the rotator cuff from contact friction, a concept currently in controversy.MRI
Magnetic resonance imaging (MRI) or ultrasound are comparable to examine the rotator cuff. The MRI can reliably detect most full thickness tears, although very small pin point tears can be missed. If a small pin point tear is suspected, an MRI combined with an injection of contrast material, called an MR-arthrogram may help to confirm the diagnosis. With larger tears, a false positive, is less likely. However, a normal MRI cannot fully rule out a small tear (a false negative). Partial thickness tears are not as reliably detected on MRI. The MRI is sensitive in identifying tendon degeneration (tendinopathy), however, the MRI may not be able to reliably distinguish between a degenerative tendon and a partially torn tendon. Magnetic resonance arthrography can improve the differentiation of rotator cuff degeneration from partial or complete rotator cuff tears. Stetson et al., in 2005 showed a false-negative rate of 9% and sensitivity at 91%, the authors concluded that magnetic resonance arthrography was a very reliable test in the detection of partial-thickness rotator cuff tears. The routine use of magnetic resonance arthrography was not advised and the test was reserved in cases where the diagnosis was unclear.Ultrasound
UltrasoundUltrasound
Ultrasound is cyclic sound pressure with a frequency greater than the upper limit of human hearing. Ultrasound is thus not separated from "normal" sound based on differences in physical properties, only the fact that humans cannot hear it. Although this limit varies from person to person, it is...
studies have also been reported as a means of identifying rotator cuff tears. Unlike x-rays which require exposure to radiation and MRI studies which are costly, ultrasound studies have been advocated as an alternative, when read by experienced clinicians. When ultrasonography and magnetic resonance imaging studies have been read by investigators with comparable experience, they have been shown to have comparable accuracy for identifying and measuring the size of full-thickness and partial-thickness rotator cuff tears. Ultrasound can also reveal the presence of other conditions that may mimic rotator cuff tear at clinical examination, including tendinosis, calcific tendinitis, subacromial subdeltoid bursitis, greater tuberosity fracture, and adhesive capsulitis. The MRI provides more information about adjacent structures in the shoulder such as the capsule, glenoid labrum muscles and bone. These are factors to be considered in each case when selecting the appropriate study.
Clinicians and patients are advised to use clinical judgement and not rely on MRI images or x-rays to determine the cause of shoulder pain or treatment, since rotator cuff tears are found in people without any pain or symptoms. The role of x-rays, MRI and ultrasound, are part of the entire clinical picture and serve to confirm the diagnosis, which is provisionally made by a thorough history and physical examination. Over reliance on x-rays or MRI imaging may lead to over treatment or distraction from the true underlying problem.
In-office Testing
As part of clinical decision making, a simple minimally invasive in-office procedure may be performed, called the rotator cuff impingement test. A few cc's of a local anesthetic and an injectable cortisone preparation are injected into the subacromial space to block pain and to provide anti-inflammatory relief. If the pain disappears and function remains good no further treatment or testing are pursued. The test helps to confirm that the pain arises from the shoulder primarily and is not referred pain from the neck, heart or gut.It is thought that the cortisone helps diminish inflammation of the bursa that directly over lies the rotator cuff (sub-acromial bursitis). The test, if pain is relieved, is considered positive for rotator cuff impingement, of which tendinitis and bursitis are a part. However, partial rotator cuff tears may also have good pain relief and a good response cannot rule out a partial rotator cuff tear. In the face of good function and no pain, even with a partial rotator cuff tear, treatment would not change and the impingement test is useful in relief of pain and avoiding over testing or unnecessary surgery.
Conventional Radiography
The degeneration of the rotator cuff often causes articular-sided partial damage and leads to typical changes at the so-called rotator cuff footprint. Located at the region of the capsule tendon insertion of the tuberculum majus and the collum anatomicum. Cotton et al. has dissected rotator cuff damages and put them in correlation with x-ray findings at the humerus and acromion, i.e. cystic, subcortical changes at the upper parts of the collum anatomicum, sclerosis, erosion and unsteady corticalis delineation at the tuberculum majus, plus a sulcus deepening between the tuberculum majus and the cartilaginous joint face. These abnormal changes, and sometimes as well the sclerosis at the acromion undersurface up to a neoarthrose accumulation and appositional acromial osseous extension is illustratable at a simple a.p. projection. At the latest through an Y-projection possible pathologies get unveiled. The 30° lowered a.p. projection after Rockwood is specific for illustrating anterior spores at the acromion.Ultrasonography
Already with the techniques in the second half of the 80ies it was possible to achieve useful diagnostic results of full or partial defects. The ultrasonography of the rotator cuff tears predominantly serves as instrument to a diagnosis by exclusion. The sensitivity is lower than the specificity. The clinic has specific questions to the diagnostic medical sonographers. Those few questions can deliver a global insight into the rotator cuff and shoulder status.- Is the rotator cuff continuity conserved?
- Are there references for a partial or full cuff damage?
- How far is the stub retracted after a full cuff tear?
- Has the bursa subacromialis / subdeltoidea evidence for inflammation?
- How is the actual condition of the muscle?
Formal and structural changes are presumed to be rotator cuff damages. Changes in the echogenicity as there can be detected areas with a higher, respectively, lower echo intensity. Or dynamic alterations like floating retractions or bulges at the tendon surface. An enlargement of the bursa subacromialis of more than 2mm is an unspecific change which can also appear with a fully intact rotator cuff for example at a subacromial syndrome.
Formal changes
- Reversal contour, for example the usually convex cranial contour of the rotator cuff is flattened or even concave.
- Discontinuance at the well contoured border lamella of the bursa subacromialis.
- Narrowed rotator cuff.
- A level at the border layer.
- Absent delineation of the rotator cuff.
Changes in structure or echogenicity
Hyperechogenicity: Represents an area of damage. Important to allude is that the surrounding rotator cuff area has to show normal echogenicity. Higher echos can be artificially caused through the physiologically curved surface and tilting of the ultrasonographic transducer.
Hypoechogenicity: Seems to represent the disordered fiber texture at the border area of the damages. If combined with acoustic shadow, calcific deposits or osseous fragments are contemplable.
MRI
Rotator cuff diseases and or injuries are the number one indication for a MR image of the shoulder. The clinically relevant questions are similar to the ultrasonography. It is due to its high costs inadvisable to use MR as a screening method. At unclear clinical status or unspecific question like shoulder pain, the MR results are in general disillusioning.Healthy rotator cuff tendons have in almost all sequences a low signal intensity. At T1-weighted spin echo images the signal weak rotator cuff is well visibly separated from the shoulder top through the subacromial fat stripe. Because water has no strong signal too in this adjustment it is despite to the good image resolution hard to circumscribe inflammative tendon changes, especially for joint fluid at the damaged area. Therefore at the T1-weighted image small defects can be missed out or result in false-positive findings.
A moderately higher signal at the T1-weighted image and with it a clearly higher intensity at the T2-weighted image are regarded to be a sign for partial or full rotator cuff tears. T2-weighted images can imitate the arthrographic effect of showing a very high signal at the damaged area and a communication between the joint and bursa space.
T2-weighted spin echo images create contrast due to the differences of bonded and loose water at the tissue and thus are more sensitive for inflammative changes and joint fluid at the tendon course as a sign for damage.
Analog to the inhomogeneities of the tendon structure at the ultrasonography are the inhomogeneities at the T1- and proton-weighted images correlated with histopathological signs of degeneration. Because they have been found in a very high percentage in asymptomatic shoulders their meaning in the daily clinic remains unclear and secondary.
Injured, but not aparted tendons have an elevated water affinity due to their changed collagen structure. These areas have a slightly higher signal intensity at T1-weighted images.
To achieve an extreme distinct fat-water-contrast, T2-weighted spin echo images have to be executed with a very long TE time and have to own a fat suppression. Thereby damage diagnosis can be enhanced via MRA. An alternative to fat suppressed T2-weighted sequences are modified STIR sequences. Gradient echo sequences are like T2-weighted images quickly available. However, disadvantageous are the susceptibility to artifacts, for example the so-called magic angle artifact or after surgical abrasive intervention.
The T1-weighted images are well qualified for the assessment of medial tendon retraction and secondary muscle atrophy causing fatty degeneration. The degree of the atrophy and fatty degeneration determines the prognosis after a rotator cuff reconstruction.
The MRI classifications are similar to Goutallier’s CT classifications. They relate fat to muscle tissue and are best seen on T1-weighted images.
In summary, regarded to be rotator cuff damages are alterations of the subacromial fat stripe, fluidity in the bursa subacromialis / subdeltoidea with visible communication to the joint space, elevated signal of the tendon at T1-weighted images which even augments at T2-weighted images and discontinuity of the tendon signal.
Lesions at the rotator cuff interval between supraspinatus and infraspinatus are hardly diagnosable at the native MRI. On the contrary good with the MR Arthrography.
One must say that literature inclusively an extensive meta analysis have shown that ultrasonography can achieve similar reliability as MRI in detecting full and partial tears of the rotator cuff.
Kenn et al. see significant advantage and important indication for MRI in detecting intratendinous ruptures. Those particular ruptures do not show intervention claiming pathological changes at arthroscopic subacromial bursoscopy, at open / endoscopic subacromial decompression or at ultrasonography. However, concerned patients would benefit from early surgical intervention. The MRI shows an extensive softening and intralaminar fraying.
Treatment
Patients suspected of having a rotator cuff tear are divided into two treatment groups initially: Each patient is initially a candidate for either operative or non-operative treatment, however patients are re-evaluated throughout the course of treatment and may move from one group to the other based on their clinical response and findings on repeated examination.Since many patients with partial tears and some even with complete tears can respond to non-operative management, generally conservative care is offered first. If a significant trauma such as a shoulder dislocation
Dislocation
In materials science, a dislocation is a crystallographic defect, or irregularity, within a crystal structure. The presence of dislocations strongly influences many of the properties of materials...
, or fracture
Fracture
A fracture is the separation of an object or material into two, or more, pieces under the action of stress.The word fracture is often applied to bones of living creatures , or to crystals or crystalline materials, such as gemstones or metal...
, or high energy force is known to have been followed by complete to near complete loss of rotator cuff- mediated motion and strength, then an operative work-up is initiated with plans to proceed to surgery for repair, if confirmatory.
Non-operative treatment
Patients with pain and maintenance of reasonable function are generally treated for pain relief at first. Non-operative treatment of shoulderShoulder
The human shoulder is made up of three bones: the clavicle , the scapula , and the humerus as well as associated muscles, ligaments and tendons. The articulations between the bones of the shoulder make up the shoulder joints. The major joint of the shoulder is the glenohumeral joint, which...
pain thought to be related to the rotator cuff, or a tear of the rotator cuff, includes oral medications that provide pain relief such as anti-inflammatory medications, topical pain relievers such as cold packs and if warranted a subacromial cortisone/local anesthetic injection to block the pain and start direct instillation of anti-inflammatory treatment. An alternative to needle injection is iontophoresis
Iontophoresis
Iontophoresis is a technique using a small electric charge to deliver a medicine or other chemical through the skin. It is basically an injection without the needle...
, a battery powered patch which phoresis the medication to the target tissue. A sling may be offered for comfort for a day or two, with the awareness that the shoulder can become stiff with prolonged immobilization, which is to be avoided. Early physical therapy
Physical therapy
Physical therapy , often abbreviated PT, is a health care profession. Physical therapy is concerned with identifying and maximizing quality of life and movement potential within the spheres of promotion, prevention, diagnosis, treatment/intervention,and rehabilitation...
may afford pain relief with modalities (ex. iontophoresis) and help to maintain motion. Ultrasound
Ultrasound
Ultrasound is cyclic sound pressure with a frequency greater than the upper limit of human hearing. Ultrasound is thus not separated from "normal" sound based on differences in physical properties, only the fact that humans cannot hear it. Although this limit varies from person to person, it is...
treatment is not efficacious. As pain decreases, strength deficiencies and biomechanical errors can be corrected. Home exercises may be obtained from the clinician's office or physical therapist.
A non-operative or conservative physical therapy
Physical therapy
Physical therapy , often abbreviated PT, is a health care profession. Physical therapy is concerned with identifying and maximizing quality of life and movement potential within the spheres of promotion, prevention, diagnosis, treatment/intervention,and rehabilitation...
treatment program begins with preliminary rest and restriction from engaging in the event which caused the injury itself. Frequently the duration of rest is too short. Under normal situations, inflammation can usually be controlled within 1 to 2 weeks, using NSAIDs
Non-steroidal anti-inflammatory drug
Nonsteroidal anti-inflammatory drugs, usually abbreviated to NSAIDs or NAIDs, but also referred to as nonsteroidal anti-inflammatory agents/analgesics or nonsteroidal Anti-inflammatory medicines , are drugs with analgesic and antipyretic effects and which have, in higher doses, anti-inflammatory...
and subacromial steroid injections to decrease inflammation, to the point that pain has been significantly decreased to make stretching tolerable. After this short period of 1 to 2 weeks rapid stiffening and an increase in pain can result if sufficient stretching has not been implemented.
A gentle, passive range-of-motion program should be started to help prevent stiffness and maintain range of motion during this resting period by a licensed physical therapist. Exercises, for the anterior, inferior, and posterior shoulder, should be performed by the patient as a part of the motion program that has been specifically designed by a physical therapist. Codman exercises are renowned sources of motion using the pendulum to "permit the patient to abduct the arm by gravity, the supraspinatus remains relaxed, and no fulcrum is required," which is widely practiced in clinics. The use of NSAIDs; hot and cold packs; and physical therapy modalities, such as ultrasound, phonophoresis, or iontophoresis, can be instituted during this stretching period, if effective. Injections are recommended 2 to 3 months apart with a maximum of three injections. Multiple steroid injections (four or more) have been shown to compromise the results of rotator cuff surgery which result in weakening the tendon in . Before any rotator cuff strengthening can be started, the shoulder must have a full range of motion.
After a full, painless range of motion is achieved, the patient may advance to a gentle strengthening program that is specifically designed by a physical therapist. Rockwood coined the term orthotherapy to describe this program, which is an interactive exchange between the patient, the treating orthopedic surgeon, and physical therapist aimed at creating an exercise regimen that initially gently improves motion, then gradually improves strength in the shoulder girdle. Each patient is personally instructed in the exercise program by a physical therapist. Each patient is given a home therapy kit, which includes elastic bands of six different colors and strengths; a pulley set; and a three-piece, 1-m-long stick. The program is customized to each individual patient, fitting the needs of the patient and altering when necessary. Patients are asked to do all their home exercise program on their own whether that be at home, at work, or when traveling.
There are several instances in which nonoperative treatment would not be suggested. The first is the 20- to 30-year-old active patient with an acute tear and severe functional deficit from a specific event. The second is the 30- to 50-year-old patient with an acute rotator cuff tear secondary to a specific event. The third instance is the highly competitive athlete who is primarily involved in overhead or throwing sports. These patients need to be treated operatively because rotator cuff repair is necessary for restoration of the normal strength required to return these athletes to the same competitive preoperative level of function. Patients who do not respond or are unsatisfied with conservative treatment should seek operative management.
Autologous tenocyte implantation treatment management (ATITM) is a tendon regeneration therapy designed to assist and improve the regeneration of damaged/injured tendons. A biopsy harvests a small piece of tendon from a healthy tendon (typically the tendon below the kneecap). The biopsied tissue is taken to laboratory where the building blocks of the tendon, the tenocyte cells, are isolated and grown over a period of approximately 4-5 weeks. The cells are then implanted via injection into the affected tissue with ultrasound guidance. Evidence supports ATITM therapy as successful in treatment of common tendinopathy. See the Journal of Tissue Engineering, 2007 J. M. Chen MD MMS, C. Willers, J. Xu MD, A. Wang MD, M.H. Zheng MD PhD*.Department of Orthopaedics Surgery, School of Surgery and Pathology, University of Western Australia.
Invasive treatment
If conservative treatments have yielded poor results, surgery is considered to repair the torn tendonTendon
A tendon is a tough band of fibrous connective tissue that usually connects muscle to bone and is capable of withstanding tension. Tendons are similar to ligaments and fasciae as they are all made of collagen except that ligaments join one bone to another bone, and fasciae connect muscles to other...
s. Surgery is designated in patients under 60 years of age, full thickness tear demonstrated clinically, failure to improve after 6–8 weeks of physical therapy
Physical therapy
Physical therapy , often abbreviated PT, is a health care profession. Physical therapy is concerned with identifying and maximizing quality of life and movement potential within the spheres of promotion, prevention, diagnosis, treatment/intervention,and rehabilitation...
, and activity levels requiring use of the shoulder.
There are several surgical options for treatment of a rotator cuff tear. The exact type of surgery may depend on factors including the degree of tendon
Tendon
A tendon is a tough band of fibrous connective tissue that usually connects muscle to bone and is capable of withstanding tension. Tendons are similar to ligaments and fasciae as they are all made of collagen except that ligaments join one bone to another bone, and fasciae connect muscles to other...
disruption, location of the tear, patients preferred activities, and presence or absence of bone spur
Bone spur
Osteophytes, commonly referred to as bone spurs, are bony projections that form along joint margins. They should not be confused with enthesophytes, which are bony projections which form at the attachment of a tendon or ligament.-Pathophysiology:...
s that may be contributing to the tear (ehealthmd.com). The three general approaches of surgical repairs are arthroscopic repair, mini-open repair, and open surgical repair. In the recent past small tears were treated arthroscopically, while larger tears would usually require an open procedure. Advances in the procedure now allow Arthroscopic repair of even the largest tears, and arthroscopic techniques are now required to mobilize many of the retracted tears. Arthroscopic results now match open surgical techniques, and allow for a more thorough evaluation of the shoulder at the time of surgery, increasing the diagnostic value of the procedure, as several other conditions may simultaneously cause shoulder pain. Arthroscopic surgery allows for a shorter recovery time and predictably less pain in the first few days following the procedure than does open surgery.
If there is a bone spur
Bone spur
Osteophytes, commonly referred to as bone spurs, are bony projections that form along joint margins. They should not be confused with enthesophytes, which are bony projections which form at the attachment of a tendon or ligament.-Pathophysiology:...
that instigated the rotator cuff tear, arthroscopic repair, open repair (6–10 cm incision), or mini-open repair (3–5 cm incision) will often include an acromioplasty, a subacromial decompression, as part of the procedures. Subacromial decompression consists of removal of a small portion of the bone
Bone
Bones are rigid organs that constitute part of the endoskeleton of vertebrates. They support, and protect the various organs of the body, produce red and white blood cells and store minerals. Bone tissue is a type of dense connective tissue...
(acromion) that overlies the rotator cuff, hoping to relieve pressure on the rotator cuff in certain conditions and promote healing and recovery. Although subacromial decompression may be beneficial to partial and full thickness tears, this procedure does not consists of physically repairing the tears. Arthroscopic decompression has more recently been combined with "mini-open" repair of the rotator cuff, which allows for the repair of the cuff without disruption of the deltoid origin. A sole decompression approach tends to degrade with time, but combining repairing of the tear with decompression produces better results.
A complete full-thickness rotator cuff tear, the most severe, involves mending the torn rotator cuff by suturing the tissues
Tissue (biology)
Tissue is a cellular organizational level intermediate between cells and a complete organism. A tissue is an ensemble of cells, not necessarily identical, but from the same origin, that together carry out a specific function. These are called tissues because of their identical functioning...
back together. The usual method that is currently in use, is to place an anchor in the bone of the natural attachment site, and suture the torn tendon end back down to the bone from which it originally tore away. If the tissue quality is poor the surgeon might use a mesh (collagen
Collagen
Collagen is a group of naturally occurring proteins found in animals, especially in the flesh and connective tissues of mammals. It is the main component of connective tissue, and is the most abundant protein in mammals, making up about 25% to 35% of the whole-body protein content...
, Artelon
Artelon
Artelon is a biomaterial developed and sold by the Swedish company Artimplant. Artelon is a porous polyurethaneurea and acts as a scaffold which promotes ingrowth of native human tissue. Artelon degrades over a period of around 5–7 years during which time most of the material is replaced by native...
or other degradable material) to reinforce the repair. The repair can be performed through an open incision, again requiring detachment of a portion of the deltoid. The mini-open technique approaches the tear through a deltoid
Deltoid
Deltoid can refer to:* The deltoid muscle, a muscle in the shoulder* Kite , also known as a deltoid, a type of quadrilateral* A deltoid curve, a three-sided hypocycloid* A leaf shape* The deltoid tuberosity, a part of the humerus...
splitting approach. This seemingly causes less damage to the deltoid
Deltoid
Deltoid can refer to:* The deltoid muscle, a muscle in the shoulder* Kite , also known as a deltoid, a type of quadrilateral* A deltoid curve, a three-sided hypocycloid* A leaf shape* The deltoid tuberosity, a part of the humerus...
muscle and may produce better results. Modern techniques now use an all arthroscopic approach.
Surgical recovery can take as long as 3–6 months, with a sling being worn for the first 1–6 weeks. Furthermore, in some severe cases where arthritis
Arthritis
Arthritis is a form of joint disorder that involves inflammation of one or more joints....
has developed, one option is to replace the shoulder
Shoulder
The human shoulder is made up of three bones: the clavicle , the scapula , and the humerus as well as associated muscles, ligaments and tendons. The articulations between the bones of the shoulder make up the shoulder joints. The major joint of the shoulder is the glenohumeral joint, which...
joint, but these represent a small minority of cases.
Surgical outcomes for severe tears of the rotator cuff have been shown to be positive on a 10 year follow-up. However, the same study demonstrated ongoing and progressive fatty atrophy and re-tears of the rotator cuff. Shen has shown that MRI evidence of fatty atrophy in the rotator cuff prior to surgery is predicative of a poor surgical outcome. To address this issue of failure of surgical repair and poor conservative care outcomes caused by muscular atrophy, bioengineering may be the answer. Mesenchymal stem cells have been shown to differentiate into skeletal muscle. Rotator cuff tears can be hereditary. Regardless of the method used, recent studies have shown that stable repairs of the rotator cuff give a more functional shoulder. Rotator cuff tears of the impingement type usually begin in patients in their 40's, and progress with time.
Summary
The rotator cuffRotator cuff
In anatomy, the rotator cuff is the group of muscles and their tendons that act to stabilize the shoulder. The four muscles of the rotator cuff, along with the teres major muscle, the coracobrachialis muscle and the deltoid, make up the seven scapulohumeral muscles of the human body.-Function:The...
constitutes a group of four muscles: the infraspinatus, supraspinatus, subscapularis, and teres minor. The cuff adheres to the glenohumeral capsule and attaches to the humeral head. The main functions of the cuff are to stabilizes the glenohumeral joint
Glenohumeral joint
The glenohumeral joint, or shoulder joint, is a multiaxial synovial ball and socket joint and involves articulation between the glenoid fossa of the scapula and the head of the humerus...
and rotate the humerus
Humerus
The humerus is a long bone in the arm or forelimb that runs from the shoulder to the elbow....
outward. When shoulder trauma occurs, these functions can be attenuated, therefore suggesting a rotator cuff tear. Since individuals are highly dependent on the shoulder for many activities, overuse and overbearing of the muscles can lead to tears, with the vast majority of these tears occurring in the supraspinatus tendon
Tendon
A tendon is a tough band of fibrous connective tissue that usually connects muscle to bone and is capable of withstanding tension. Tendons are similar to ligaments and fasciae as they are all made of collagen except that ligaments join one bone to another bone, and fasciae connect muscles to other...
. Additionally, environmental factors such as increase in age, smoking, and diabetes mellitus
Diabetes mellitus
Diabetes mellitus, often simply referred to as diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced...
can enhance the probability of a tear. Acute tears may occur after falling on the shoulder or while exerting too much force during an overhead motion. These types of traumas elicit sharp, throbbing pain, as well as limited range of motion. Overuse of the muscles is subject to chronic shoulder conditions, such as arthritis
Arthritis
Arthritis is a form of joint disorder that involves inflammation of one or more joints....
and bone spur
Bone spur
Osteophytes, commonly referred to as bone spurs, are bony projections that form along joint margins. They should not be confused with enthesophytes, which are bony projections which form at the attachment of a tendon or ligament.-Pathophysiology:...
s, which can eventually lead to a tear. Once a tear happens in the rotator cuff, it is much more likely to recur. To avoid this, proper strengthening exercises can be performed. Partial tears can be treated with rest, anti-inflammatory drugs, and eventually physical therapy. A complete tear usually requires surgical procedures such as arthroscopic repair, open repair, or mini-open repair. These procedures are used in the rotator cuff
Rotator cuff
In anatomy, the rotator cuff is the group of muscles and their tendons that act to stabilize the shoulder. The four muscles of the rotator cuff, along with the teres major muscle, the coracobrachialis muscle and the deltoid, make up the seven scapulohumeral muscles of the human body.-Function:The...
area to remove bone spur
Bone spur
Osteophytes, commonly referred to as bone spurs, are bony projections that form along joint margins. They should not be confused with enthesophytes, which are bony projections which form at the attachment of a tendon or ligament.-Pathophysiology:...
s (subacromial decompression), repair the tear by suturing the tendons, transfer tendons, and even replace the shoulder
Shoulder
The human shoulder is made up of three bones: the clavicle , the scapula , and the humerus as well as associated muscles, ligaments and tendons. The articulations between the bones of the shoulder make up the shoulder joints. The major joint of the shoulder is the glenohumeral joint, which...
joint when arthritis has developed.
External links
- Rotator Cuff Tears. Wheeless' Textbook of Orthopedics. A description of rotator cuff tears from Wheeless'