Rotator Cuff Tear

 
rotator cuffsmall.jpg
biceps.png

  • The rotator cuff is composed of 4 muscles: Subscapularis, Supraspinatous, Infraspinatous, Teres minor.

  • Although the biceps does not belong to the rotator cuff, but the long head of the biceps passes through the rotator cuff, and thus, tendinosis of the biceps can present as a rotator cuff pathology.

  • Prevalence

    • age >60: 28% have full-thickness tear

    • age >70: 65% have full-thickness tear

  • risk factors

    • age

    • smoking

    • hypercholesterolemia

    • family history

  • Associated conditions

    • AC joint pathology 

    • proximal biceps subluxation 

    • proximal biceps tendonitis

  • It is important to distinguish between degenerative and acute tears, since acute tears are more prone to surgical repair due to the better tendon quality.

People usually consulte for pain and weakness of the shoulders. an exhausted physical exam should be done to evaluate the lesions.

Rotator cuff tear can be complete or partial.

For complete (full tickness) tear, it is important to classify the lesion according to Patte and Goutallier classifications, since the more retracted the tendon is, and the more fatty muscle is present, the less chances to repair

Patte classification Clin Orthop Relat Res. 1990 May;(254):81-6

Patte classification

Clin Orthop Relat Res. 1990 May;(254):81-6

Goutallier classificationClin. Orthop. Relat. Res. 1994; (304): 78-83.

Goutallier classification

Clin. Orthop. Relat. Res. 1994; (304): 78-83.

For partial rotator cuff tears, we use the classification of Ellman to describe the lesion. the latter can be treated non-operatively, or can be a candidate for repair.

Ellman classificationClin Orthop Relat Res 1990:64-74.

Ellman classification

Clin Orthop Relat Res 1990:64-74.

Treatment considerations

arthroscopie.jpg
AO surgicalreference

AO surgicalreference

  • activity and age of patient

  • mechanism of tear (degenerative or traumatic avulsion)

  • characteristics of tear (size, depth, retraction, muscle atrophy)

    • partial thickness tears vs. complete tear

    • articular sided (PASTA lesion) vs. bursal sided  

      • bursal sided tears treated more aggressively

Medical treatment : NSAID’s, physical therapy, steroid’s injection, PRP ? shock wave ?

  • first line of treatment, especially if partial tears

  • Tears can increase in size…

Surgical treatment

rotator cuff repair.jpg

  • Arthroscopy is gold standard

    • rotator cuff repair + biceps tenodesis/tenotomy

    • debridement and tenotomy of biceps : massive rotator cuff.

  • Tendon trasnfert ( pectoralis major or latissimus dorsi transfers)

  • Reverse shoulder arthroplasty : massive cuff tears with (or without) glenohumeral arthritis with intact deltoid