It is difficult to pinpoint where the concept of “rotator cuff” began, but it has been around for at least a hundred years.
What causes rotator cuff injuries?
Subacromial abrasion has been recognized as a possible cause of rotator cuff injury, and this idea has been supported by many prominent surgical experts.
Neer describes three distinct phases of “impingement syndrome,” the first of which is seen in patients younger than 25 years of age with reversible edema and hemorrhagic spots. In the second stage, the patient is between 25 and 40 years old and presents with fibrosis and tendonitis of the rotator cuff and recurrence of pain with activity. In the third stage, bone spurs and tendon tears are present and the patient is older than 40 years of age.
The rotator cuff is composed of four muscles that originate from the scapula. It is commonly believed that the rotator cuff muscles have the following three functions.
(1) To rotate the humerus corresponding to the scapula.
(2) compressing the humeral head into the articular glenoid
(3) maintaining muscle balance.
I. Incidence of rotator cuff injury
The incidence of rotator cuff injury varies from 7% reported by Yamannala et al. to 26, 5% reported by Wilson. Age is important in the incidence of injury, which is only 6% in those under 60 years of age and may reach 30% in those over 60 years of age.
The incidence of partial tears is twice as high as that of full tears. 30% of tears occur over 40 years of age, 0.3% occur on the bursal side, 3% on the articular side, 7% on the through tendon, and the bursal side is the most symptomatic. The study concluded that “rotator cuff injuries occur naturally with age and are mostly asymptomatic”.
This was confirmed by Sher et al. using MRI, who concluded that.
(1) MRI confirms the high incidence of rotator cuff tears in the asymptomatic population.
(2) the incidence of tears increased significantly with age.
(3) these injuries were not associated with pain or functional impairment.
II. Clinical presentation
To summarize the clinical manifestations of various types of rotator cuff injuries mostly include
stiffness of the shoulder joint.
Difficulty in movement.
weakness.
joint instability
Astringency of the joint.
Clinical problems related to rotator cuff
There are eight main areas.
1. Asymptomatic shoulder injury – the shoulder joint itself is asymptomatic, but imaging may show a total tear of the rotator cuff tendon.
2. Posterior capsular tension – limited motion of the shoulder joint in all directions, including abduction and internal rotation. Anterior lap shoulder, posterior extension, and anterior flexion.
3, Subacromial wear (no obvious rotator cuff defect) – humerus rotation under the acromion can be palpated with obvious twisting of the shoulder, no pain or weak force on rotator cuff muscle strength isotonic examination.
4, partial rotator cuff injury – isotonic contraction impedance examination of rotator cuff related muscles triggers pain or weak force; often combined with posterior joint capsule tension. Imaging suggests thinning of the rotator cuff tendon, but the injury does not pass through the whole layer of the tendon.
5.Total rotator cuff tear – pain or weakness on isotonic contraction impedance examination of rotator cuff related muscles; complete rupture of more than one tendon can be confirmed by ultrasonography, arthroscopy, MRI, and incisional surgery.
6, Rotator cuff tear arthropathy – isotonic contraction impedance examination of rotator cuff muscles reveals weakness; intertrochanteric and intertrochanteric motion of the rotator cuff triggers twisting pronation.
7, Failed acromioplasty – The patient is dissatisfied with the results of previous arthroscopic or incisional acromioplasty and seeks further surgical exploration.
8, Failed rotator cuff repair – the patient is dissatisfied with the results of a previous arthroscopic or incisional rotator cuff repair and seeks further surgical exploration.
IV. Imaging
Radiographs
For evaluating rotator cuff injuries, radiographs provide only limited assistance. In younger patients, rotator cuff injury may be accompanied by avulsion of small bone fragments from the greater tuberosity
Arthrography
For many years, contrast arthrography alone has been the standard test to diagnose rotator cuff injuries. Contrast contrast material is injected into the glenohumeral cavity; the contrast material may penetrate into the rotator cuff and outward through the rotator cuff into the subacromial and subdeltoid bursae.
Intraoperative contrast (bursography) is used to evaluate the subacromial region and the superior surface of the rotator cuff; Fukuda compared plain x-rays with bursography films in 6 patients, and the intraoperative findings confirmed the accuracy of bursography at 67%. Although this test can detect injury, the accuracy cannot be determined.
MRI
MRI can show tendons and muscles. MRI has a sensitivity of 89% and a specificity of 100% for unoperated rotator cuff tears, and the missed cases are all partial tears. Recurrent tears that have been surgically repaired have an MRI accuracy of 91%.
MRI can also show muscle tissue. Atrophy and fat filling suggest a poor prognosis for rotator cuff function.
Ultrasonography
With ultrasound, an experienced examiner can determine the thickness of the muscles in each portion of the rotator cuff integrity. Studies report that the specificity of ultrasonography is 98% and the sensitivity is 91% when confirmed by surgery. False-negative findings are mostly tears of less than 1 cm.
The advantages of ultrasonography are safety and speed. It is also easy to perform bilateral comparisons (other tests such as MRI, arthrography, arthroscopy, etc. are difficult to do due to cost, time and safety considerations). Ultrasound can also provide dynamic, real-time images of the shoulder. And the cost of ultrasound is lower.
V. Differential diagnosis
Traditionally, rotator cuff tears should be differentiated from rotator cuff tendinitis and bursitis; however, sometimes the symptoms judged to be tendinitis and bursitis may actually be the result of an acute fiber injury that is not clinically detected.
Patients with frozen shoulder present with limited passive motion and normal plain radiographs. Some patients with rotator cuff tears present with similar limitation of motion. Patients with total laminar tears usually have normal passive range of motion and present with decreased muscle strength and limited active range of motion.
Scapular popping, which produces pain and strangulation during shoulder supination, would be similar to the subacromial popping of rotator cuff tears. The latter may be elicited during rotation in the forward flexion or posterior extension position of the shoulder. Shoulder popping from the superior medial angle of the scapula and with local discomfort is elicited when the scapula is moved while the shoulder is immobilized.
Glenohumeral arthritis, too, can produce pain, weakness, and locking sensations. Differentiation from rotator cuff disorders is based on history, physical examination, and x-ray.
In acromioclavicular arthritis, the features are similar to those of rotator cuff disease. Shoulder pain is worse when the upper extremity is hiked toward the opposite shoulder, and pressure pain is limited to the acromioclavicular joint. Local injections of lidocaine may temporarily relieve the pain, and cephalometric radiographs may help confirm the diagnosis.
Suprascapular neuropathy and cervical neuropathy, similar to rotator cuff disease. The suprascapular nerve is composed of C5 and C6 nerve roots and innervates two important muscles DD supraspinatus and infraspinatus. Therefore the above disorders may present with shoulder pain and decreased supination and abduction muscle strength.
If weakness is manifested, neurological examination should include C5 to T1 dermatomes. The biceps tendon reflex and triceps tendon reflex correspond to C5-C6 and C7-C8, respectively. further examination should note the movement of the joint in all directions: shoulder abduction C5; shoulder adduction C6C5 and C8; shoulder external rotation C5; internal rotation C6C7 and C8; elbow flexion C5C6; elbow extension C7C8; wrist extension and flexion C6C7; finger extension and flexion C7C8; finger abduction and adduction C7C8.
Associated disorders to be identified include (1) cervical spondylosis (C5C6 segment); (2) brachial plexus neuropathy (suprascapular nerve); (3) strain injury (e.g., Erb palsy mechanism); (4) suprascapular nerve entrapment (suprascapular fossa); (5) trauma resulting in nerve rupture; (6) compression of the inferior branch of the suprascapular nerve; and (7) injury of medical origin.
VI. Treatment
Treatment of the rotator cuff can be discussed in the eight aforementioned areas: asymptomatic rotator cuff injury, posterior capsular tension, subacromial wear, failed acromioplasty, partially torn rotator cuff injury, fully torn rotator cuff injury, failed rotator cuff repair, and rotator cuff tear arthropathy.
l. Asymptomatic rotator cuff injury
In this case, the patient does not feel any effect on himself, but the imaging data shows a total rotator cuff tear. Full tears have some incidence in the general population and may be asymptomatic but may lead to an aggravation of the underlying problem, and the recommended treatment is surgical exposure and complete repair. However, exposing asymptomatic patients to surgery to prevent unknown future problems is quite difficult and should be explained to the patient so that he or she understands that surgical treatment is valuable.
l. Posterior joint capsule tension
In this case, the signs and symptoms present as a “mild frozen shoulder”, similar to what used to be thought of as “impingement syndrome”. This is a common condition caused by mild rotator cuff injuries and is usually treated non-surgically. The most effective method is for the patient to perform gentle extension exercises on his or her own. Stretching is performed for one minute at a time until the patient feels a pulling sensation at the back of the shoulder but does not feel pain. The patient exercises for half an hour daily. Progress is generally rapid in the first month, but complete resolution of symptoms takes up to 3 months. In rare cases, arthroscopic release of the capsule is recommended.
l. Subacromial wear (no obvious defect in the rotator cuff)
In this case, rotation of the humerus under the acromion can be palpated with a pronounced twist of the shoulder, and there is no pain or weak force on isotonic examination of the rotator cuff musculature. The examiner’s action of pressing the tendon toward the rostral shoulder arch is commonly used for diagnosis. Arthroscopy confirms a positive rate of 75% and 92% for Neer’s palpation test and Hawkins’ impingement test, respectively.
(I) Non-surgical treatment of subacromial wear
Patients complaining of subacromial twisting pronation can usually be relieved by gentle extension exercises and plyometric exercises. A variety of functional training methods for the rotator cuff are used in general patients and athletes (including throwing athletes). Shoulder acromioplasty must be performed after the symptoms of shoulder stiffness have resolved and functional limitations have been present for at least 9 months.
The low success rate of return to play for athletes who undergo acromioplasty demonstrates the importance of conservative treatment for this professional population. The same treatment principles apply to workers whose shoulders are frequently in an aggravated subacromial wear body position.
Subacromial injections of corticosteroids have been used for symptomatic relief. Berry et al. compared acupuncture, physical therapy, steroid injections, and anti-inflammatory medications and found no difference between these therapies.
Steroid injections in and around the rotator cuff and biceps tendon may lead to tendon atrophy or impair the ability of the injured tendon to repair itself.
Kennedy and Willis’ study noted that physiologic doses of steroid injections into normal tendon tissue resulted in significant weakness over a two-week period. wotson reviewed what was seen in 89 patients with major rotator cuff tears who underwent surgery and found that all patients who were not injected with steroid drugs had very strong residual tendons. Of the 62 patients who received one to four injections, 13 had weak residual tendons that were difficult to suture. Of the 20 patients who received more than 4 injections, 17 had very weak tendon tissue and poor surgical results.
Thus, the diagnosis of “tendinitis” or “bursitis” and the use of repeated steroid injections often results in inevitable degeneration of the rotator cuff tendon and a negative response to treatment.
Patients with subacromial wear can often be treated non-surgically to obtain normal motion, strength, coordination and comfort.
Sarah Jackins has devised a comprehensive treatment program similar to that used for tennis elbow and Achilles tendinitis that includes (1) avoidance of repetitive injury, (2) restoration of normal flexibility, (3) restoration of normal strength, (4) aerobic exercise, and (5) improvement of work and sports activities. (5) improving the way you work and exercise. A good exercise method should be simple and easy to master, and the patient can do it independently. (2) Smooth subacromial treatment
The roughness and irregularity of the subacromial surface are almost exclusively on the humeral side rather than on the rostral arch side. Therefore, the goal of surgery is to reconstruct a smooth surface of the proximal humerus while maintaining the integrity of the rostro-capital arch and deltoid muscle.
In the experience of Rockwood et al. good results in reconstructing a smooth subacromial surface depend on (1) patients over 40 years of age with good range of motion of the joint, (2) no posterior capsular tension, (3) persistent subacromial twist pronation, (Figure 12-21) (4) no tendon signs present or other pathologic changes in the shoulder joint, and (5) symptoms unrelated to occupational injury is not relevant. Possible factors for poor surgical outcome are (1) patient age less than 40 years; (2) joint stiffness; (3) absence of subacromial twist pronation; (4) positive tendon sign or other shoulder pathology; (5) symptoms related to the patient’s occupational characteristics; (6) concomitant glenohumeral instability; and (7) neuropathic rotator cuff weakness.
(C) Management of failed acromioplasty
In this case, the patient is not satisfied with the result of the acromioplasty and requests further surgical treatment. The incidence of this condition is between 3% and 11%, and it occurs with all types of capsuloplasty. Patients are left with weakness, pain, and limited joint movement. It is difficult to regain a high level of motion and to perform the previous work.
Reasons for failure to achieve satisfactory results include: (1) symptoms not originating from pathological changes in the rotator cuff; (2) failure to achieve subacromial smoothing; (3) failure of deltoid resurfacing; (4) excessive resection of the acromion; (5) postoperative complications such as formation of dense scarring; (6) improper postoperative rehabilitation; and (7) glenohumeral instability. Many of these problems result in patients with more symptoms than before surgery.
Surgical approach.
Patients who have undergone capsuloplasty with poor postoperative results should be evaluated in detail for the presence of joint stiffness, weakness, instability, or roughness of the articular surface.
Jackins non-surgical treatment is preferred, even if the patient has already experienced “physical therapy”. Since surgery has already failed once, it is worthwhile to be conservative and observe the patient for a longer period of time.
Patients with a positive tendonsign should be considered for rotator cuff imaging. Vocational rehabilitation is fundamental, but if one course of treatment fails to work, the results of the next course are unlikely to be effective.
The indication for reoperation is good range of motion of the joint, with residual subacromial roughness and stiffness due to postoperative scarring of the glenohumeral joint interface of motion (Figure 12-3). As opposed to the initial acromioplasty, reoperation is indicated for recalcitrant joint stiffness, as this condition mostly stems from dense scarring that forms between the rotator cuff and the acromion and is difficult to treat nonoperatively. The revision surgery is basically the same as the aforementioned subacromial smoothing procedure.
(iv) Treatment of partial rotator cuff injury
In this case, partial rotator cuff injury is characterized by a weak or painful isotonic impedance examination of the injured rotator cuff muscles. This is usually accompanied by posterior joint capsule tension. Imaging shows thinning or partial defect of the tendon, rather than a full tendon rupture.
Arthroscopic treatment of this disease remains difficult to define, including (1) the indications for surgery, (2) which part of the injury causes the onset of symptoms, (3) why surgery is not effective in 15% to 50% of patients, and (4) which part of the surgery (acromioplasty or ruptured tendon removal) is useful for symptom relief. One view is that the efficacy of such treatments may be due to their alteration of the position of the rotator cuff stops, thus distributing the load they bear equally and avoiding excessive local tendon tension.
1. Non-surgical treatment
Non-surgical treatments are basically the same as the aforementioned treatments for subacromial wear. This group of therapies emphasizes antagonistic extension in all directions of tension to release adhesions, including internal rotation, internal retraction, supination, and sometimes external rotation. Similar to the rehabilitation of tennis elbow, gentle plyometric exercises are performed after the passive and painless range of motion of the joint is normalized. The rehabilitation process emphasizes gentleness and comfort. The goal of treatment is to make the gelatinous scar formed by the injury repair as soft as a normal tendon; otherwise the scar tissue will cause the stress concentration on the tendon and cause the injury to recur and spread.
2.Surgical method
Before surgery, it is important to first clarify whether the cause is stiffness or muscle contracture resulting in difficulty in movement. Misjudgment may lead to deviation in the direction of treatment; on the one hand, cutting off the intact fibers can lead to increased weakness, although this routine practice of arthroscopic surgery to some doctors’ esteem. On the other hand, excision of the defect and repair can exacerbate symptoms of stiffness. Moreover, this treatment of tension in the damaged rotator cuff can lead to a major load on the area of injury and repair, thus, when excising and repairing a partially injured rotator cuff, it is important to ensure that the tendon load is evenly distributed to each tendon stop, which is achieved by equalizing the tension of each tendon and releasing the tense joint capsule.
(E) Management of total rotator cuff injuries
The characteristic sign of a total rotator cuff tear is a positive isotonic impedance test of the rotator cuff muscles. Age over 65 years, pain at night, and weakness in supination are more suggestive of a rotator cuff tear. There are three specific tests to help diagnose a rotator cuff tear: decreased supraspinatus strength, decreased external rotation strength, and impingement signs. If the patient is positive on all three tests, or on two of them and is over 60 years of age, there is a 98% chance of a rotator cuff tear. The sensitivity of palpation for a total tear is 95,7%, while the specificity is 96,8%. The sensitivity and specificity of the corresponding MRI were 90,9% and 89,5%, respectively.
One or more tendon defects can be confirmed by ultrasound, arthrography, MRI, arthroscopy, and incisional surgery. The diagnosis of the disease is not difficult, but there are a number of factors that influence the choice of the appropriate treatment. Some rotator cuff defects cannot be repaired, as Mclaughlin describes, and are like “fixing a bad mop”. Other rotator cuff tears may have no clinical symptoms, indicating that the presence of a rotator cuff defect does not necessarily require treatment.
1. Non-surgical treatment
Non-surgical treatment usually includes physical therapy, non-steroidal anti-inflammatory drugs, rest, avoidance of activities that aggravate the injury, and hormonal drug injections.
The physiological characteristics of a repaired rotator cuff injury will not be effectively restored. A 12-week delay in repair of supraspinatus tendon rupture does not reverse muscle atrophy in the rabbit model. Compared to unrepaired tendon ruptures, repaired ruptured tendons have more fat deposits.
The clinical effectiveness of non-surgical treatment ranges from 33% to 90%. The use of local hormone injections as the primary method of non-surgical treatment appears to be questioned by comparison with sodium hyaluronate injections and with local anesthesia. Hormone therapy is somewhat effective in providing short-term pain relief, but does not help promote functional recovery of the joint.
2.Surgical treatment
The aim of rotator cuff surgery is to improve the function and comfort of the shoulder. The indications for surgery are.
(1) Significant acute rotator cuff tears
(2) Chronic rotator cuff injury with significant clinical symptoms, where systematic conservative treatment has been ineffective for more than 3 months.
In acute rotator cuff tears in the normal shoulder joint, the quantity and quality of repairable tendons are guaranteed, so surgery should be performed promptly to avoid defective, retracted, or atrophied tissue.
For chronic injuries that are more than 6 months old, there is no need to rush to surgical repair. Non-surgical treatment can be attempted first, including routine shoulder distraction and strength training. Non-surgical treatment is indicated in patients with chronic weakness or in patients who are not candidates for surgical treatment. Therefore, once the diagnosis is made, rehabilitation should be preferred and the patient should be warned that timely and effective treatment can lead to recurrent tendon rupture if subjected to large loads.
(F) Treatment of rotator cuff tear arthropathy
1. The treatment of rotator cuff tears is to “femoralize” the proximal humerus and “acetabularize” the glenoid-rostral shoulder ligament socket. The most effective and safe way to reconstruct this suitable “ball and socket joint” is to replace the humeral head with an artificial prosthesis. The goals of the procedure are to.
1) Ensure a smooth rostral shoulder arch. To avoid acromioplasty and removal of the rostral shoulder ligament, which could destabilize the overlying humeral head.
2) remove useless rotator cuff and bursal fragments.
3) Reconstruct the damaged articular surface of the humeral head and form a new joint with the rostroscopic shoulder arch. Make every effort to preserve the deltoid muscle.
4) Maintain moderate tension in the joint capsule to allow for 60° of internal rotation of the abducted upper extremity. No rotator cuff repair is required, and care is taken not to use a double-cup or oversized humeral head prosthesis.
Passive movement of the joint is started immediately after surgery and the patient is allowed to actively move the joint within a comfortable range.
2. Depuy’s specialized humeral head prosthesis for rotator cuff tear arthropathy (CuffTearArthropathyCTA) provides a humeral head articular surface that extends to the greater tuberosity, allowing a new joint to be formed with the articular glenoid and subacromial surface. This procedure provides smooth motion of the shoulder joint without the need for a glenoid prosthesis and avoids causing joint stiffness.