The rotator cuff is made up of tendons from the supraspinatous, infraspinatous, teres minor and subscapularis (‘SITS’) muscles, and plays an important role in the dynamic stability of the shoulder joint. These tendons may become damaged through an acute traumatic injury and/or through a chronic degenerative process of which multiple intrinsic and extrinsic risk factors have been described. A complete loss of continuity of one or multiple tendons is a full-thickness tear.
A full thickness cuff tear (RTC) can be classified by size (small, medium, large and massive i.e. >5cm), depth (partial or full thickness), degree of fatty infiltration (Goutallier classification, and tear pattern (ex. U-shaped, crescent, etc.).
Patients classically present with pain and/or weakness. A detailed history should fully elucidate the nature of the pain – location, any radiation or accompanying paresthesias, quality and quantity, duration, ameliorating and aggravating factors. Information regarding how the pain changes throughout the day as well as previous treatment modalities (i.e. medications, physical therapy, injections) should also be obtained. Finally, an assessment of functional limitations with regards to impact on activities of daily living, as well as recreational and occupational pursuits should also be identified.
Patients presenting with a full-thickness RTC tear typically complain of an achy-type pain that radiates laterally down the side of the shoulder, usually remaining above the elbow, often worse at night. They may or may not have had previous surgeries or interventions on the shoulder. Often, patients may also mention difficulty with reaching for objects on high shelves or pain with other overhead activities such as combing their hair or reaching for objects in their back pocket. Of note, the presence of pain and weakness for more than a year in the setting of a history consistent with full-thickness RTC tear, has also been reported to be associated with a worse prognosis.
Previous relevant surgical history, the presence of medical comorbidities, tobacco use and a general review of systems to assess candidacy for future surgical management should also be included.
Diagnostic workup begins with a history and physical examination. In the case of chronic tears, inspection may reveal muscle atrophy within the supraspinatus and infraspinatus fossae. For this reason, both shoulders should be inspected for comparison and symmetry. Concomitant degenerative processes may occur with findings of an enlarged acromioclavicular (AC) joint. On occasion, swelling due to an enlarged bursa can be identified. As with any general examination, previous surgical scars and the presence of any skin lesions should also be noted.
After inspection, palpating the bony prominences including the AC joint, greater tuberosity, acromion, and bicipital groove should be carried out in an attempt to elicit tenderness and potential sites of concomitant pathology. A systematic assessment of shoulder range of motion (ROM) is then performed. Both active and passive forward flexion, internal and external rotation of each shoulder is recorded.
Patients with pain and/or weakness secondary to supraspinatus muscle/tendon dysfunction may display a “painful arc” during shoulder abduction, as well as a “drop arm” sign in which the arm collapses to the side from a position of abduction. The presence of concomitant shoulder stiffness as marked by diminished active and passive ROM should be identified and treated prior to RTC surgery in order to minimize the chances for postoperative range of motion difficulty.
Several provocative tests and physical examination maneuvers have been described to evaluate the rotator cuff. The Jobe sign is performed by having the patient’s arm abducted 90 degrees in the scapular plane and fully internally rotated (thumbs down). The examiner then forces both of the patient’s arms downwards; the inability to resist the examiner’s push is a positive sign.
The lift-off test and belly press tests are both used to evaluate the subscapularis. The belly press test which is reportedly more specific for the superior fibers of the subscapularis, is positive if the patient is unable to maintain the elbow anterior to the plane of the body while pressing on the belly. The lift-off test, which is more specific for the inferior portion of the subscapularis is performed with the hand behind the back. A positive test is marked by the inability to lift the hand off the back and push the examiner’s hand away.
The teres minor is assessed with the hornblower’s sign. The patient’s arm is placed into 90 degrees of abduction and external rotation. An inability to maintain this position constitutes a positive sign and calls into question the integrity of the teres minor.
Finally, to test the infraspinatus the elbow is flexed to 90 degrees and the arm is adducted. The examiner fully externally rotates the arm while the elbow remains in a flexed position and if the patient’s arm lags back towards the chest wall rupture of the infraspinatus tendon should be suspected.
The presence of marked weakness marked by < 4/5 strength on manual muscle testing for any of the four RTC muscles generally carries a worse prognosis for successful repair.
The presence of external or outlet impingement is identified by positive impingement signs as described by Neer and/or Hawkins. Concomitant proximal biceps tendon pathology should also be evaluated by biceps tension signs using the Speeds and Yergason’s tests. The acromioclavicular joint should also be assessed as a potential source of pain by direct palpation or by performing provocative maneuvers (i.e. cross chest adduction or active compression test).
Finally, a neurovascular examination of all the peripheral nerves and pulses should be performed and fully documented, along with an examination of the elbow and cervical spine.
A complete set of plain radiographs including anteroposterior, outlet, ancillary and acromioclavicular joint views should be obtained when evaluating patients with suspected rotator cuff pathology. Findings associated with rotator cuff disease include a decreased acromiohumeral distance (i.e. <7mm) or proximal humeral head migration, subacromial spur formation, acromioclavicular joint arthritis with downward projecting osteophytes, an os acromiale, and cyst formation and sclerosis in the region of the greater tuberosity.
While ultrasound has proved to be an excellent screening tool for diagnosing patients with full-thickness rotator cuff tears its accuracy is operator-dependent and consequently MRI remains the imaging modality of choice. Typically, all the sequences are examined with particular emphasis on the T2 sequence, to identify the presence of a RTC tear. The approximate size, thickness of the tear, tendons involved and the amount of retraction are noted (Figure 1).
MRI also allows for the amount of fatty infiltration in the corresponding muscle bellies to be assessed. A classification system has been proposed by Goutallier: 1- some fat, 2-muscle > fat; 3-fat = muscle, 4-fat>muscle. The MRI should also be evaluated for other pathology involving the labrum, biceps, and articular surfaces to complete the imaging assessment of the shoulder joint.
A combination of physiotherapy, corticosteroid injections, and/or NSAIDs are often suggested as first line interventions for patients with a symptomatic RTC tear, although there may not be an abundance of level 1 studies to support the use of these interventions. Typically, physiotherapy is prescribed for restoration and preservation of shoulder range of motion, along with periscapular and RTC strengthening exercises. There is controversy regarding the use of corticosteroid injections in the setting of a full-thickness RTC tear. These injections can, however, provide short-term pain relief. Multiple injections should be avoided as tendon integrity can be compromised if surgery is being considered.
Duration of non-operative management varies. Decision-making on the duration of non-operative management is influenced by the chronicity of the tear, tear size, physical examination findings of marked weakness and radiographic findings of concomitant degenerative change or fatty infiltration of the muscle belly. Commonly, physiotherapy, NSAIDs and injections are used for at least 6-12 weeks prior to considering surgical intervention. Patient characteristics are also considered as those physiologically young with acute tears who present with marked weakness may benefit from operative interventions sooner.
Indications for Surgery
Pain refractory to non-operative care in the setting of a full-thickness RTC tear on MRI is the primary indication for surgical intervention.
Surgical options include:
Open RTC repair – open versus mini-open
Arthroscopic RTC repair
Latissimus dorsi and pectoralis major transfers for massive, irreparable RTC tears – please refer to the section on massive RTC tears
Reverse total shoulder arthroplasty in the setting of concomitant arthropathy (i.e. Rotator cuff arthropathy)
Rotator cuff repair is typically performed as an outpatient, ambulatory procedure. For both arthroscopic and open rotator cuff repair, patients may be administered a regional interscalene block and/or general anesthetic. Interscalene blocks offer the advantage of post-operative pain control lasting several hours, thus minimizing recovery room stay and the need for parenteral and oral narcotics during this time period. A systematic examination under anesthesia of the involved shoulder is then performed. Range of motion is assessed in all planes and compared to the contralateral shoulder. A careful manipulation is performed to release any capsular contracture as needed.
The procedure can be performed in either the beach-chair or lateral decubitus position according to surgeon preference. A careful, systematic diagnostic arthroscopy of the glenohumeral joint and subacromial space is performed initially. Concomitant pathology (i.e. biceps tendon lesions, labral tears, subacromial spurs, symptomatic acromioclavicular joint arthritis) is addressed at this time.
The basic principles of rotator cuff repair are the same regardless of technique and approach. These include tear identification, classification (i.e. morphology, size, degree of retraction, tissue quality), mobilization, footprint preparation, and secure fixation to bone. Rotator cuff tears are identified at the time of glenohumeral arthroscopy performed through a standard posterior viewing portal. Full-thickness tears will permit direct passage of the arthroscope into the subacromial space. Articular-sided tears should be debrided and tagged with a suture marker placed percutaneously along the lateral border of the acromion using an 18-gauge spinal needle, for later identification in the subacromial space. The arthroscope is re-directed into the subacromial space. A lateral portal is created approximately three fingerbreadths from the lateral border of the acromion. We prefer to place this portal using the spinal needle such that it is centered over the mid-portion of the tear. A bursectomy is performed as needed. An acromioplasty and and/or distal clavicle resection is typically carried out at this point if deemed appropriate based upon the pre-operative examination and imaging studies.
The rotator cuff tear should be assessed from both the posterior and lateral portals in order to gain a full appreciation of its size, shape, and degree of retraction and to formulate a plan for configuration of the repair (Figure 2).
A grasper is used to assess tear mobility and the need for releases. Arthroscopic elevators and radiofrequency or electrocautery devices are used to carefully release any bursal adhesions. An elevator can be directed towards the coracoid process while placing gentle traction on the rotator cuff with a grasper thereby releasing the coracoacromial ligament. If needed, a superior peri-labral release can be performed, however, instruments should not be directed too far medially (>1.5-cm) to avoid injury to the suprascapular nerve. If needed, anterior and/or posterior interval slides can be performed, but this is beyond the scope of this chapter. Once the tendon has been adequately mobilized and can be re-approximated to cover the footprint without excessive tension with the arm in adduction no additional releases are necessary.
Footprint preparation can be done using a motorized shaver or burr. A bleeding cancellous bed is created being careful to remove only the superficial cortical layer of bone so as not to compromise suture anchor fixation.
The surgeon can then proceed with either a mini-open or all arthroscopic repair according to preference and/or experience. Mini-Open RTC repair is performed through a small skin incision which is typically made in Langer’s lines by extending the lateral portal by a few centimeters. The incision is made and subcutaneous flaps are raised in all directions. A self-retaining retractor can be placed and a deltoid splitting incision is made from the acromion laterally for a distance of no more than 4-5-cm so as to avoid injury to the axillary nerve. A suture can be placed at the distal extent of the deltoid split to further protect the nerve. The retractor can be replaced at this time beneath the deltoid exposing the underling rotator cuff. The mayo scissors are then used to remove any residual overlying bursa, which may be identified with IR/ER of the humeral head. The cuff is then visualized and the tear identified and repaired.
A multitude of repair techniques and configurations have been described with the common principles of secure suture-tendon and tendon-bone fixation. In general, we prefer to use heavy number 2 non-absorbable braided solid-core suture material placed in a locking fashion (i.e. modified Mason-Allen) across the tendon edge to minimize the potential for suture cut-through. Fixation to bone can be accomplished either through transosseous tunnels or suture anchors. Transosseous tunnels are placed at the lateral extent of the footprint and exit lateral to the greater tuberosity. These are created by fashioning converging tunnels with either a drill, curved awl or in the case of “soft” bone by simply using a stout curved tapered needle. If suture anchors are chosen we typically prefer to use the “screw in” variety placed lateral to the tuberosity at 45 degrees with respect to the line of pull of the rotator cuff (“deadman’s” angle). Such placement has been shown to minimize the chances for anchor pull-out. Single, double or even triple loaded anchors can be used offering multiple options for repair configuration.
In an effort to mimic the biomechanical strength of a transosseous repair, double row techniques have been developed in which two rows of anchors are utilized. A medial row is placed just adjacent to the articular margin of the numeral head while a second row of anchors is inserted just lateral to the greater tuberosity. Medial row sutures are placed in a horizontal mattress fashion while lateral row sutures are placed in a simple or locking fashion to secure the tear edge. Alternatively, a “transosseous-equivalent” repair configuration can be chosen in which the limbs of the medial row sutures are “bridged” over the tendon edge and secured lateral to the tuberosity using knotless suture anchors. Medial row sutures are typically criss-crossed over the tendon in order to enhance footprint contact and re-approximation. The repair is then assessed and the wound closed in layers beginning with the deltoid split, followed by the subcutaneous tissue and skin (Figure 3).
The all-arthroscopic repair technique employs all of the same principles as the mini-open and open procedures. This technique, however, requires advanced arthroscopic skills and typically entails a rather steep learning curve to master.
An ancillary portal is placed just adjacent to the lateral edge of the acromion. This portal, which is first localized using a spinal needle, is used for anchor insertion. Several instruments have been developed to assist in suture passage. These can be categorized as either direct suture passing or suture shuttling devices. Additional anterior and posterolateral portals are created as necessary to assist with suture management and better access to the tear. Surgeons performing this technique must be proficient in arthroscopic knot-tying. Newer generation knotless anchors have been developed, however, to make these techniques somewhat simpler and more accessible to surgeons who may not perform a lot of repairs.
When choosing a technique it is worthwhile to keep in mind that well-performed open repair will typically yield a better outcome than a poorly performed arthroscopic repair. The technique chosen should therefore reflect the surgeon’s level of experience and training.
Pearls and Pitfalls of Technique
Mini-open RTC repair
Ensure the underlying cuff is protected prior to distal clavicle excision
Repair of deltotrapezial fascia is crucial to outcomes
Can be converted to latissimus dorsi transfer intra-operatively if tear assessed and too massive for repair
Larger incision cosmetically than arthroscopic procedure
Greater detachment of the deltoid and greater trauma to overlying soft tissues
Cannot address concomitant intra-articular pathology in single approach
Arthroscopic RTC repair
Pre-operative MRI allows assessment of degree of fatty infiltration of rotator cuff muscle bellies
Lateral decubitus may be preferable if suspected concomitant labral tear repair required
Arthroscopic technique allows for assessment of other glenohumeral pathology
Decreased cerebral perfusion and associated risks of beach-chair positioning
Cannot convert beach-chair positioned patient intra-operatively to tendon transfer for massive irreparable cuff tear
Complications pertaining to any surgery in beach-chair position including decreased cerebral perfusion and pressure sores on the face are present, as are complications associated with anesthesia and peri-operative resuscitation.
Other complications specific to this procedure include injury to the axially nerve, wound dehiscence, and repeat tears may occur although varying frequencies are cited, as well as the possibility of continued weakness and remnant pain despite the repair.
Post-operatively, depending on the size of the tear, rehabilitation protocols may vary. Generally, small repairs may be mobilized within 2 weeks. In the case of a larger tear, however, physical therapy may be delayed for up to 6 weeks following surgery. In either case, an arm sling is maintained for the first 6 weeks during which patients are instructed to perform active range of motion exercises for the elbow, wrist and hand. Active range of motion exercises are usually not initiated until 6 weeks after surgery and rotator cuff strengthening is not begun for 12 weeks. Constant surveillance is required during the early post-operative period to avoid shoulder stiffness. Patients should be encouraged to be an active participant in their rehabilitation through physical therapy attendance and daily home exercises. Full or near-full range of motion is generally desirable by 3-4 months while strength recovery can take considerably longer with strength restoration taking up to a year or more following repair.
Outcomes/Evidence in the Literature
Pedowitz, RA, Yamaguchi, K, Ahmad, CS, Burks, RT, Flatow, EL, Green, A, Ianotti, JP, Miller, BS, Tashjian, RZ, Watters, WC, Weber, K, Turkelson, CM, Wies, JL, Anderson, S, St Andre, J, Boyer, K, Raymond, L, Sluka, P, McGowan, R. “Optimizing the management of rotator cuff problems”. JAAOS. vol. 19. 2011. pp. 368-379. (Review of literature: Four practice recommendations with moderate evidence to support – include exercise, use of NSAIDs for rotator cuff symptoms; that routine acromioplasty is not indicated; and finally that porcine based patches not be used in RTC repairs.)
Bak, K, Sørensen, AK, Jørgensen, U, Nygaard, M, Krarup, AL, Thune, C, Sloth, C, Pedersen, ST. “The value of clinical tests in acute full-thickness tears of the supraspinatus tendon: does a subacromial lidocaine injection help in the clinical diagnosis? A prospective study”. Arthroscopy. vol. 26. 2010. pp. 734-42. (Level 1 study: subacromial lidocaine injection improves specificity but decreases sensitivity of a positive lag sign in predicting a full thickness supraspinatous tear.)
Castoldi, F, Blonna, D, Hertel, R. “External rotation lag sign revisited: accuracy for diagnosis of full thickness supraspinatus tear”. JSES. vol. 18. 2009. pp. 529-34. (Level 2 study: External rotation lag sign is highly sensitive and specific for the diagnosis of a full-thickness supraspinatous rotator cuff tear.)
Furcentese, SF, von Roll, AL, Pifrmann, CW, Gerber, C, Jost, B. “Evolution of nonoperatively treated symptomatic isolated full-thickness supraspinatous tears”. JBJS Am. vol. 94. 2012. pp. 801-8. (Natural history of non-operative management of small full-thickness cuff tears over an average of 3.5 years found variability in tears that remained versus those that increased in size. Despite conservative care for small cuff tears, patients had mean Constant score of 75 points over this time period.)
Kuhn, JE, Dunn, WR, Sanders, R, An, Q, Baumgarten, KM, Bishop, JY. “Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study”. JSES. 2013. (Level 1 study: Evidence that physical therapy is an effective treatment for atraumatic full-thickness RTC tears in 2 year follow-up.)
Koh, KH, Kang, KC, Lim, TK, Shon, MS, Yoo, JC. “Prospective randomized clinical trial of single- versus double-row suture anchor repair in 2- to 4-cm rotator cuff tears: clinical and magnetic resonance imaging results Arthroscopy”. vol. 27. 2011. pp. 453-62. (Level 1 study: No difference in retear rates of full-thickness RTC tears between single row and double row arthroscopic repairs.)
Zhang, Z, Gu, B, Zhu, W, Zhu, L, Li, Q. “Arthroscopic versus mini-open rotator cuff repair: a prospective, randomized study with 24-month follow-up”. European Journal of orthopaedic Surgery and traumatology. 2013. (Level 1 study: Arthroscopic repair of full thickness RTC tears has better post-operative strength but higher retear rate compared to mini-open repair.)
Van der Zwaal, P, Thomassen, BJ, Nieuwenhuijse, MJ, Lindenburg, R, Swen, JW, van Arkel, ER. “Clinical outcome in all-arthroscopic versus mini-open rotator cuff repair in small to medium-sized tears: a randomized controlled trial in 100 patients with 1-year follow-up”. vol. 29. 2013. pp. 266-73. (Level 2 RCT study: No difference was found in functional outcomes, pain, range of motion and complications at 1-year post-op between those patients treated with an all-arthroscopic technique versus those treated with a mini-open technique, although the arthroscopically treated group attained benefits from surgery at earlier time points in followup.)
Slabaugh, MA, Friel, NA, Karas, V, Romeo, AA, Verma, NN, Cole, BJ. “Interobserver and intraobserver reliability of the Goutallier classification using magnetic resonance imaging: proposal of a simplified classification system to increase reliability”. Arthroscopy. vol. 40. 2012. pp. 1728-34. (Good inter- and intra- observer reliability for looking at RTC on MRI and assessing degree of fatty infiltration.)
Cuff, DJ, Pupello, DR. “Prospective randomized study of arthroscopic rotator cuff repair using an early versus delayed postoperative physical therapy protocol”. JSES. vol. 21. 2012. pp. 1450-5. (Level 1 study: No difference in early (post-operative day 2) versus late (post-operative week 6) mobilization protocols after full-thickness rotator cuff repair.)
Full-thickness rotator cuff tears are diagnosed with the help of a thorough history and physical examination, as well as the use of imaging studies, most commonly, MRI. Symptomatic full thickness rotator cuff tears can be managed surgically. Surgical repair can often be performed arthroscopically. Post-operatively a graduated physiotherapy protocol is initiated, that may be adjusted depending on intra-operative findings.
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