Adam Norfolk
Lock Haven University
Physician Assistant Program
A rotator cuff tear pertains to the “disease or injury to one or
more of the four muscle tendon units that help secure the
shoulder girdle.”
The “SITS” muscles include:
-Supraspinatus (most commonly injured)
-Infraspinatus
-Teres Minor
-Subscapularis
Codman reportedly performed the first open rotator cuff repair in
1911
Severity
•Partial-thickness tear: Partial fraying or tearing of an
intact RC tendon.
•Full-thickness tear: tear through the entire tendon. Can
be small pin-point tears or larger button hole tears that
involve the majority of the tendon. (Maintains
functionality)
•Full-thickness tear with detachment of tendon: (Nonfunctioning)
Full thickness rotator cuff tear
•U-Shaped
•Crescent-shaped
•L-shaped
•Large chronic rotator cuff tear
•Reattaching supraspinatus and infraspinatus to greater
tuberosity of the proximal humerus
•Extrinsic: Subacromial bone spurring, which rubs on
the tendon during arm elevation (Shoulder
Impingement Syndrome), compromising the integrity
of the tendon.
•Overhead activities, weight training, sports
•Intrinsic: Age-related factors, such as decreased
blood supply to the tendon contributing to tendon
degeneration and complete tearing
•Trauma, such as direct falls, are most often
associated with degenerative-type tears
•5-10% of the population will suffer from a rotator
cuff tear at some point in their lives
•4% < 40 years of age
•50% > 60 years of age
•Average age: 57.6 years
•> 40 years of age
•Smokers
•Multiple steroid injections
•Men
•Inspection: Chronic RCT may reveal muscle
atrophy/asymmetry
•Pain: anterolateral aspect of shoulder  distal humerus
•Studies reveal patients being diagnosed with RTC via MRI
whom never complained of pain prior to exam
•Decreased strength: *Drop arm sign*
•Decreased ROM:
•IR, ER, Abduction, Adduction, elevation
•Adhesive capsulitis (Frozen Shoulder
•Biceps Tendinitis
•Glenohumeral instability
•Acromioclavicular degenerationthe joint.
•Glenohumeral joint arthritis
•Referred pain: MI, cervical radiculopathy, Gallbladder
disease
Supraspinatus testing: external rotation and abduction
•Jobe’s Test/Empty Can
Placing the arm in 90 degrees of abduction in the scapular
plane with the thumbs down and asking the patient to
resist downward pressure. + Test = Pain and decr strength
Subscapularis testing:
•Lift-off test and Abdominal Compression Test:
•Lift-off test: Testing the superior portion of subscap
•Abdominal compression test: Inferior subscapularis
Posterosuperior Rotator cuff tear
•Lag Sign: placing the arm in maximal external rotation.
A large massive tear will not be able to maintain this
position and will swing forward in neutral position.
Teres Minor tear:
•Hornblower’s Sign: unable to externally rotate to 90
degrees with the arm in abduction
•History
•Physical exam
•Imaging:
•MRI: Reveals retraction of the muscle, atrophy of the muscle
belly and proximal migration of the humeral head in relation to
the glenoid, and fatty infiltration of the around the cuff .
•X-Ray:
•AP
view showing < 7mm from proximal humeral head to
subacromial surface due to anterior and superior migrating
of the humeral head from RCT.
•May also see degenerative changes and subacromial
spurring.
Magnetic
resonance image
shows a tear
within the
supraspinatus
tendon.
Plain radiograph
of the shoulder
(AP view) showing
reduced
subacromial space
(black arrow) and
acromioclavicular
joint osteoarthritis
(white arrow).
•Conservative (Nonsurgical)
•Physical Therapy and behavior modification
•Downfalls of conservative therapy:
idecreased strength
•tears increasing in size
•muscle retraction
•
•Surgical
•Open repair:
•Mini-open repair (Gold Standard): 3-5cm incision
•All-arthroscopic : ~1cm incisions
•No tear can be considered irreparable until a repair is
attempted
1. Arthroscopically assisted open repair, which consists of
arthroscopic subacromial decompression followed by
open repair of the rotator cuff through a lateral deltoidsplitting approach.
2. Mini-open arthroscopically assisted repair, which
includes arthroscopic subacromial decompression, release
of adhesions, placement of tagging sutures, and
debridement of the tendon edges followed by a mini-open
deltoid-splitting approach to obtain suture management
and bone-tendon fixation.
3. Complete arthroscopic repair, in which subacromial
decompression, release of adhesions, and bone-tendon
fixation are all carried out in an arthroscopic fashion.
•Patient's expectations
•The pathoanatomy of the cuff
•Surgical experience of the surgeon
Intraoperative
photograph of an
open rotator cuff
repair illustrating
the typical size of
a surgical incision.
In this intraoperative
photograph, the typical
incision size for a miniopen rotator cuff repair
is shown in black on a
patient's left shoulder.
The yellow arrow
indicates the incision
used to perform the
arthroscopy.
Arthroscopic
photographs of a
rotator cuff tear and
the Sutures (green)
used to reattach the
tendon back to bone.
•Preservation of the deltoid origin
•Adequate decompression of the subacromial
space by resection of anteroinferior osteophytes
•Surgical releases to obtain mobile muscletendon units
•Secure fixation of the tendon to the greater
tuberosity
•Early rehabilitation including passive motion
with a protected range
Do patients, aged 20-60 who undergo rotator cuff
repair surgery, experience less morbidity from
rotator cuff tears when treated Arthroscopically
versus using Open and Mini-Open techniques, such
as less hospital stay, decreased pain, improved
cosmesis, and quicker time returning to activity or
sport?
The true incidence of rotator cuff tears in the
general population is difficult to determine
because 5% to 40% of people without shoulder
pain may have a torn rotator cuff. This reveals
that it is possible to manage RCT without
surgical intervention.
Meta-analysis of the surgical repair of rotator cuff tears: A comparison of arthroscopic and open techniques
Open repair results:
Metcalf 2003
Author
Satisfied Patients
Range of Motion Improved
Strength Improved
Lefy et al
96%
Yes
Yes
Paulos et al
94%
Yes
Yes
Blevins et al
89%
Yes
Yes
Mini-open repair results:
Author
Satisfied Patients Range of Motion Improved
Strength Improved
Ellman
98%
Yes
Yes
Hawkins et al 94%
Yes
Yes
Cofield
Yes
Yes
77%
All-arthroscopic repair results:
Author
Satisfied Patients
Range of Motion Improved
Strength Improved
Tauro
92%
Yes
Yes
Gartsman
90%
Yes
Yes
•If one does decide to have their rotator cuff surgically
repaired, it is important to know that 80-90% of
patients will have successful outcomes.
•Adequate pain relief
•Restoration or improvement of function
•Improved ROM
•Patient satisfaction with the procedure
•Downfalls to using arthroscopy:
•Decreased comfort level due to an increase in technical skill
•Higher rate of tendon re-tear with all-arthroscopic repair versus using
an open procedure (6%)
•Downfalls to using open:
•Deltoid detachment is an operative disaster (< 1%)
•Open and Min-Open rotator cuff repair requires the
dissection and manipulation of the deltoid muscle
compromising its integrity.
•Increased risk of infection
•Axillary Nerve injury ( 1-2%)
(Harryman: Repairs of the rotator cuff: Correlation of functional results with integrity of the cuff)
•Re-tear rate is 41% with individuals who have had more than
two rotator cuff tendons repaired arthroscopically.
•Overall re-tear rates begin to rise when patients reach > 65 years
of age
Galatz, L.M., Craig, M., Teefey, S., Middleton, W.D., Yamaguchi, K. (2004). The Outcome and Repair
Integrity of Completely Arthroscopically Repaired Large and Massive Rotator Cuff Tears, The Journal of
Bone and Joint Surgery, 86:219-224.
Fig. 5 The prevalence of tendon healing according to age.
Arthroscopic repair of full-thickness supraspinatus tears achieves
a rate of complete tendon healing equivalent to those reported in
the literature with open or mini-open techniques.
•Results of arthroscopic repairs of isolated supraspinatus tears are
equal to those reported following open repair
•25% re-tear rate with patients associated with muscular atrophy
and fatty infiltration preoperatively
•Early diagnosis and treatment of RCT prevents problems associated
with chronic tears, such as atrophy and fat infiltration
Dennis Liem, MD1, Sven Lichtenberg, MD2, Petra Magosch, MD2 and Peter Habermeyer, MD2 (2007). Magnetic
Resonance Imaging of Arthroscopic Supraspinatus Tendon Repair, The Journal of Bone and Joint Surgery
(American). 89:1771-1776.
•Comparison of patient populations with small (<1-cm),
medium (1 to 3-cm), and large (>3 cm) tears revealed no
differences in University of California at Los Angeles or
American Shoulder and Elbow Surgeons (ASES) scores.
Also, no difference in outcome was noted among patients
of different ages, suggesting that the arthroscopic repair
is equally effective in all age groups, regardless of tear
size.
Stollsteimer GT, Savoie FH 3rd. Arthroscopic rotator cuff repair: current indications, limitations, techniques,
and results. Instr Course Lect, 1998;47: 59-65.
Gartsman GM, Khan M, Hammerman SM. Arthroscopic repair of full-thickness tears of the rotator cuff. J
Bone Joint Surg Am, 1998;80: 832-40.
Nottage W, Severud E. A comparison of all arthroscopic vs. mini-open rotator cuff repair: results at 45
months. Read at the Summer Institute Meeting of the American Academy of Orthopaedic Surgeons; 2001
Sept 6-9; San Diego, CA.
•Patients seeking pain relief may pursue arthroscopic
repair
•Open or mini-open repair for patients who are concerned
about loss of strength that require a more solid repair.
•Open and mini-open can be structurally more sound due
to direct visualization of suture placement and knot tying.
Ken Yamaguchi, MD, William N. Levine, MD, Guido Marra, MD, Leesa M. Galatz, MD,
Steven Klepps, MD and Evan Flatow, MD (2003). Transitioning to Arthroscopic Rotator
Cuff Repair: The Pros and Cons, The Journal of Bone and Joint Surgery (American) 85:144155
•A patient with a repairable tear and little muscle atrophy
who is seeking strength more than pain relief may wish
the most mechanically secure repair, such as the miniopen or open procedure.
•An elderly patient with a very large defect and muscle
atrophy, where deltoid preservation and reduced
morbidity are of paramount importance, may benefit
more from the less invasive arthroscopic repair.
Ken Yamaguchi, MD, William N. Levine, MD, Guido Marra, MD, Leesa M. Galatz, MD,
Steven Klepps, MD and Evan Flatow, MD (2003). Transitioning to Arthroscopic Rotator
Cuff Repair: The Pros and Cons, The Journal of Bone and Joint Surgery (American) 85:144155
Pros for Open technique:
•Direct visualization of rotator cuff (detached deltoid)
•Quicker OR time
•Increase in knot security
Mini-Open Advantages
•“Best of both worlds approach”
•Better visualization
•Decreased OR time
•Less post-operative pain versus Open technique
•Increased security while placing your knots
•Open and mini-open can be structurally more sound due
to direct visualization of suture placement and knot tying.
•Less scaring versus Open
•Less trauma to deltoid
Pros of Arthroscopy:
•Improved cosmesis
•Less invasive
•Decreased surgical insult to the deltoid
•Decreased immediate postoperative Pain and better
rehabilitation
•Decreased postoperative stiffness
•Any size of tear can be repaired arthroscopically without
compromising the result
Multiple factors affect the outcomes of treatment of
rotator cuff disease:
•Understanding tear patterns
•Restoring normal anatomy
•Decreasing tension at the repair site
•Currently there is a lack of High-Quality Randomized
Controlled trials explaining which technique is preferred, a
common theme regarding surgical intervention studies.
•There is clinically no long-term difference in outcome
when comparing the three techniques mentioned
•Less invasive techniques show improvements within the
first 3 months post-operation, unlike open techniques
•Any of the three repair techniques for rotator cuff tear
can be beneficial and increase patient satisfaction
outcomes
•It is important to decrease one’s pain, improve strength,
and return to ADL
•With certain factors included in an arthroscopic case, retear rates and defect may be encountered
•Further research is require
•Treatment of rotator cuff tears is dependent more on the
individual expertise of the surgeon, than the technique
chosen to accomplish the repair.
•Morse, K., Davis, A.D., Afra, R., Kaye, E.K., Schepsis, A., Voloshin, I. (2008). Arthroscopic Versus Mini-open
Rotator Cuff Repair. The American Journal of Sports Medicine, vol. 36 no. 9 1824-1828.
•Mohtadi, N.G., MD, Hollinshead, R.M., MD, Sasyniuk, T.M., MD, Fletcher, J.A., MD, Chan, D.S., MBT, Li, F.X.,
MD (2008). A Randomized Clinical Trial Comparing Open to Arthroscopic Acromioplasty With Mini-Open
Rotator Cuff Repair for Full-Thickness Rotator Cuff Tears. The American Journal of Sports Medicine, vol. 36
no. 6 1043-1051.
•Vaccaro, A.R., MD, FACS (2005). Orthopaedic Knowledge Update. Rosemont, IL: American Academy of
Orthopaedic Surgeons.
•“Rotator Cuff Tendinitis and Tear” UpToDate.
http://www.uptodate.com/online/content/topic.do?topicKey=bone_joi/11463&selectedTitle=14~150&sour
ce=search_result#27: Archived on January 27th, 2009. “Rotator Cuff Tears and Treatment Options”
•American Academy of Orthopaedic Surgeons.
http://orthoinfo.aaos.org/topic.cfm?topic=A00406: Archived January 27, 2009.
•Coghlan JA, Buchbinder R, Green S, Johnston RV, Bell SN. Surgery for rotator cuff disease. Cochrane
Database of Systematic Reviews 2008, Issue 1. Art. No.: CD005619. DOI:
10.1002/14651858.CD005619.pub2.
• Burns, J.P., Snyder, S.J., Albritton, M., Arthoscopic Rotator Cuff Repair Using Triple-Loaded Anchors, Suture
Shuttles, and Suture Savers, Journal of the American Academy of Orthopaedic Surgeons 2007, Vol 15, No 7,
432-444.
•Green, A., Chronic Massive Rotator Cuff Tear: Evaluation and Management, Journal of the American
Academy of Orthpaedic Surgeons 2003, Vol 11, No 5
•Metcalf M, Savoie FS, Smith KA, Matsen FA: Meta-analysis of the surgical repair of rotator cuff tears:
Comparison of open and arthroscopic techniques, in Proceedings from the AAOS 2003 Annual Meeting.
Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, paper 266.
•Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB: Abnormal findings on magnetic resonance of
asymptomatic shoulders. J Bone Joint Surg Am 1995;77:10-15. 7822341
•Ianotti JP, Naranja J, Gartsman G: Surgical treatment of the intact cuff and repairable cuff defect:
Arthroscopic and open techniques, in Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and
Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 151-155.
•Ken Yamaguchi, MD, William N. Levine, MD, Guido Marra, MD, Leesa M. Galatz, MD, Steven Klepps,
MD and Evan Flatow, MD (2003). Transitioning to Arthroscopic Rotator Cuff Repair: The Pros and
Cons, The Journal of Bone and Joint Surgery (American) 85:144-155
•Gartsman GM, Khan M, Hammerman SM. Arthroscopic repair of full-thickness tears of the rotator
cuff. J Bone Joint Surg Am, 1998;80: 832-40.
•Weber S. Comparison of all arthroscopic and mini-open rotator cuff repairs. Read at the Annual
Meeting of the Arthroscopic Association of North America; 2001 Apr 19-22; Seattle, WA.
•Nottage W, Severud E. A comparison of all arthroscopic vs. mini-open rotator cuff repair: results at
45 months. Read at the Summer Institute Meeting of the American Academy of Orthopaedic
Surgeons; 2001 Sept 6-9; San Diego, CA.
•Stollsteimer GT, Savoie FH 3rd. Arthroscopic rotator cuff repair: current indications, limitations,
techniques, and results. Instr Course Lect, 1998;47: 59-65.
•Harryman DT 2nd, Mack LA, Wang KY, Jackins SE, Richardson ML, Matsen FA 3rd. Repairs of the
rotator cuff. Correlation of functional results with integrity of the cuff. J Bone Joint Surg Am, 1991;73:
982-9.
•Dennis Liem, MD1, Sven Lichtenberg, MD2, Petra Magosch, MD2 and Peter Habermeyer, MD2 (2007).
Magnetic Resonance Imaging of Arthroscopic Supraspinatus Tendon Repair, The Journal of Bone and
Joint Surgery (American). 89:1771-1776.
•Gartsman GM, Khan M, Hammerman SM. Arthroscopic repair of full-thickness tears of the rotator
cuff. J Bone Joint Surg Am, 1998;80: 832-40.
•Andrew C. Gerdeman, MD1, MaCalus V. Hogan, MD1 and Mark D. Miller, MD (2009). What’s New
in Sports Medicine, The Journal of Bone and Joint Surgery (American), 91:241256.