PartialThickness Rotator Cuff Tears - Andrew Wolff, MD...partialthickness rotator cuff tears are not...
Transcript of PartialThickness Rotator Cuff Tears - Andrew Wolff, MD...partialthickness rotator cuff tears are not...
PartialThickness Rotator Cuff Tears Andrew B. Wolff, MD
Abstract Paul Sethi, MD
Partialthickness rotator cuff tears are not a single entity; rather,
Karen M. Sutton, MD
they represent a spectrum of disease states. Although often
Aaron S. Covey, MD
asymptomatic, they can be significantly disabling. Overhead
David P. Magit, MD
Michael Medvecky, MD
throwing athletes with partialthickness rotator cuff tears differ with respect to etiology, goals, and treatment from older, nonathlete patients with degenerative tears. Pathogenesis of degenerative partialthickness tears is multifactorial, with evidence
Dr. Wolff is Resident, Department of
of intrinsic and extrinsic factors playing key roles. Diagnosis of
Orthopaedics and Rehabilitation, Yale
partialthickness rotator cuff tears should be based on the patient’s University School of Medicine, New Haven, CT. Dr. Sethi is Orthopaedic Surgeon, The Greenwich Sports and
symptoms together with magnetic resonance imaging studies. Conservative treatment is successful in most patients. Surgery
Shoulder Service, Orthopaedic and
generally is considered for patients with symptoms of sufficient Neurosurgical Specialists, Greenwich, CT. Dr. Sutton is Resident, Department of Orthopaedics and Rehabilitation, Yale
duration and intensity. The role of acromioplasty has not been clearly delineated, but it should be considered when there is
University School of Medicine. Dr. Covey
evidence of extrinsic causation for the partialthickness rotator is Resident, Department of
cuff tear. Orthopaedics and Rehabilitation, Yale University School of Medicine. Dr. Magit is Fellow, KerlanJobe Orthopaedic Clinic, Los Angeles, CA. Dr. Medvecky is Assistant Professor, Department of Orthopaedics and Rehabilitation, Yale University School of Medicine.
A dvances py, basic in science shoulder research, arthrosco and imaging modalities continue to in crease our understanding of and abil ity to treat rotator cuff disease. Com pared to studies on fullthickness rotator cuff tears, limited published data are available
regarding the opti mum treatment of partialthickness rotator cuff tears. In part, this is be cause of the emerging concept that
partialthickness rotator cuff tears are not a single entity with a single etiology. Similarly, treatment of symptomatic partialthickness rota tor cuff tears should be based on the patient’s goals, injury site, and cause of the tear.
Anatomy and Classification
The rotator cuff represents the coa lescence of the subscapularis, su
praspinatus, infraspinatus, and teres minor tendons. Clark and Harry man1 showed a significant amount of interdigitation of these tendons, as well as between the tendons, the None of the following authors or the
shoulder capsule, and the coraco departments with which they are
humeral ligament (Figure 1). Most affiliated has received anything of value
partialthickness rotator cuff tears in from or owns stock in a commercial
older patients occur on the articular company or institution related directly or
side of the supraspinatus tendon; indirectly to the subject of this article:
isolated involvement of the bursal Dr. Wolff, Dr. Sethi, Dr. Sutton, Dr.
side of the supraspinatus tendon or Covey, Dr. Magit, and Dr. Medvecky.
of the infraspinatus and subscapu
Reprint requests: Dr. Wolff, Department
laris tendons is less common. In con
of Orthopaedics and Rehabilitation, Yale
trast, tears in younger overhead
University School of Medicine, Yale
throwing athletes are articularsided, Physicians Building, First Floor, 800
partialthickness tears of the domi Howard Avenue, New Haven CT 06520.
nant arm at the supraspinatus
J Am Acad Orthop Surg 2006;14:715 725
infraspinatus interval.
Partialthickness tears of the rota tor cuff can be articularsided, Copyright 2006 by the American
bursalsided, intratendinous, or a Academy of Orthopaedic Surgeons.
combination thereof. Ellman2 de scribed a classification system that
Volume 14, Number 13, December 2006 715
PartialThickness Rotator Cuff Tears
716 Journal of the American Academy of Orthopaedic Surgeons
Figure 1
Transverse section of the rotator cuff with the orientations of the fascicles indicated by the lines on their upper surfaces. Layer 1 is composed of superficial fibers that overlie the cuff tendons and form an extension of the coracohumeral ligament (chl). Layers 2 and 3 contain the fibers of the supraspinatus (SP) and infraspinatus (IS) tendons. The fibers in layer 2 are oriented parallel to the axes of the supraspinatus and infraspinatus tendons; the fibers of layer 3 are smaller and obliquely oriented compared with the fibers of layer 2. The fibers of layer 4 make up the deep extension of the coracohumeral ligament. Layer 5 is the joint capsule. (Adapted with permission from Clark JM, Harryman DT II: Tendons, ligaments, and capsule of the rotator cuff: Gross and microscopic anatomy. J Bone Joint Surg Am 1992;74:713 725.)
A, Arthroscopic view through the midlateral port of a small bursalsided partial thickness tear (Ellman grade B2) after débridement, showing intact anterior and posterior attachments of the rotator cuff. B, Arthroscopic view through the midlateral portal of a nearly fullthickness tear of the bursal side of the rotator cuff (Ellman grade B3).
Table 1
Ellman’s Classification of PartialThickness Rotator Cuff Tears
Location Grade
A: Articular surface
differentiates between partial and fullthickness tears of the rotator cuff based on findings at the time of arthroscopy. Partialthickness tears are subdivided based on location and thickness of tear (Table 1) (Figures 2
1: <3 mm deep
and 3). Ruotolo et al3 showed the mean thickness of the supraspinatus tendon to be 11.6 mm anteriorly, B: Bursal surface 2: 36 mm deep
12.1 mm at midtendon, and 12 mm
C: Interstitial 3: >6 mm deep
posteriorly.
(Adapted with permission from
Incidence Ellman H: Diagnosis and treatment of incomplete rotator cuff tears. Clin Orthop Rel Res 1990;254:6474.)
Cadaveric and imaging studies have been performed in an attempt to de fine the incidence of rotator cuff
Figure 3
Figure 2
A, Arthroscopic view through the posterior portal of a small partialthickness tear of the articular side of the rotator cuff (Ellman grade A1). B, Arthroscopic view through the posterior portal of a deep partialthickness tear of the articular side of the rotator cuff (Ellman grade A3).
tears. In 1934, Codman4 noted a 32% prevalence of supraspinatus rupture. More recently, Fukuda et al5 reported a prevalence of 7% full thickness and 13% partialthick ness tears (of which 18% were bur salsided, 27% articularsided, and 55% intratendinous) in 249 cadav ers. However, Fukuda later cau tioned that “the statistics from ca daveric studies are skewed, because most of the specimens are from peo ple older than the patients in clini cal practice.”6
Data from imaging studies show an increasing incidence with age. In
Andrew B. Wolff, MD, et al
a 1995 magnetic resonance imaging
sible explanation for the increased (MRI) study of 96 asymptomatic
incidence of articularsided tears fol
Figure 4
shoulders, Sher et al7 reported no
lowing a traumatic event. fullthickness and 4% partial
The etiology of partialthickness thickness tears in subjects 19 to 39
rotator cuff tears can be broadly dif years of age. In contrast, among indi
ferentiated into intrinsic, extrinsic, viduals older than 60 years of age,
or traumatic causes. Evidence sug there was a 28% incidence of full
gests that the pathogenesis of bursal thickness and a 26% incidence of
sided and articularsided partial partialthickness tears. Similarly, ul
thickness tears may differ. In 1934, trasound studies of asymptomatic
Codman4 postulated that the origin volunteers has demonstrated a 5%
of rotator cuff tears was intrinsic and to 11% incidence of full or partial
degenerative. In 1972, Neer13 pro thickness tears in subjects in their
posed that the etiology of rotator fourth and fifth decades, increasing
cuff tears was primarily extrinsic to 80% in the eighth decade.8
and secondary to subacromial im Throughout the literature, clini
pingement. Although the pathogen cally noted articularsided tears are
esis of rotator cuff tears is still the approximately two to three times
subject of debate, evidence suggests more common than bursalsided
that both intrinsic and extrinsic fac
Typical stressstrain curve for the supraspinatus tendon. Bursal and articular sides of the rotator cuff tendon show nonlinear deformation initially, followed by elastic elongation. The bursal side is able to undergo a greater deformation
and has a greater tensile strength. (Adapted with permission from Nakajima T, Rokuuma N, Hamada tears.
tors play a role. The intrinsic tendi
K, Tomatsu T, Fukuda H: Histologic nopathy from degenerative changes
and biomechanical characteristics of
Pathogenesis
is most often thought to result in articularsided tears in older pa Bursal and articular surfaces of the
tients. Similarly, most partial
the supraspinatus tendon: Reference to rotator cuff tearing. J Shoulder Elbow Surg 1994;3:7987.) rotator cuff differ with respect to
thickness tears in young overhead their vascularity, biomechanical
throwing athletes are on the articu properties, and histologic composi
lar side. Bursalsided tears may have
Thus the differences in blood
sup tion. In 1965, Rothman and Parke9
a greater association with extrinsic
ply, biomechanical and histologic described the “critical zone” of hy
factors such as coracoacromial arch
properties, associated changes of the povascularity near the insertion of
narrowing or impingement from the
acromion, and association with trau the supraspinatus on the humerus.
distal clavicle.
ma suggest that the pathogenesis of Rathbun and Macnab10 histological
In a cadaveric study, Ozaki et al14
articular and bursalsided partial ly correlated areas of hypovasculari
found that all bursalsided tears were
thickness tears of the rotator cuff ty and degeneration of the rotator
associated with attritional lesions on
may differ. Evidence points to intrin cuff in this region. Lohr and
the coracoacromial ligament as well
sic factors such as hypovascularity Uhthoff11 found that the critical
as the anterior third of the undersur
and decreased tensile strength put zone hypovascularity predominated
face of the acromion; this was not
ting the articular side of the rotator on the articular side and extended
true of articularsided tears, in
cuff in greater jeopardy, while both from the musculotendinous junc
which the undersurface of the acro
intrinsic and extrinsic factors sub tion to within 5 mm of the inser
mion was almost always intact.
ject the bursal side of the rotator cuff tion.
Similarly, Burkhead et al15 reported
to greater wear. Nakajima et al12 reported differ
that iatrogenic impingement of the ences in biomechanical and histo
rotator cuff in rats caused exclusive logic properties in intact rotator
ly superior surface lesions on the
Clinical Presentation
cuffs taken from individuals at the
cuff. The impingement observed in
The most common reports by indi time of autopsy. They found that the
patients with bursalsided cuff inju
viduals with partialthickness rota bursal side was composed mostly of
ries still may be secondary to a pri
tor cuff tears are pain and stiffness. tendon bundles, whereas the articu
marily intrinsic cause that produces
Pain is the predominant symptom, lar side was a complex of tendon, lig
weakness of the rotator cuff. This
often most troubling at night and ament, and capsule. Furthermore,
weakness in turn may lead to supe
with overhead activities. Many pa they found that the bursal side was
rior migration of the humerus that
tients have a painful arc of motion able to undergo a greater deforma
causes increased impingement, initi
with impingement signs, with or tion and had a greater tensile
ating what Ozaki et al14 described as
without apparent or real muscle strength (Figure 4). This offers a pos
a “vicious cycle.”
weakness.
Volume 14, Number 13, December 2006 717
PartialThickness Rotator Cuff Tears
These partial tendon lesions are
fullthickness tears; the higher levels
imens have shown macrophages and often much more painful than full
of substance P correlated with the
multinucleated giant cells, which thickness tears.6 In contrast to full
significantly (P < 0.001) higher pain
exhibit strong immunoreactivity for thickness tears, partialthickness de
levels in the group of patients with
IL1β, cathepsin D, and matrix me fects of the cuff have been theorized
partialthickness tears. Gotoh et
talloprotease1; none was found in to give rise to stiffness and nonphys
al19 also found significantly higher
intact tendons.23 This led the au iologic tension on the remaining fi
levels of interleukin (IL)1β and IL1
thors to conclude that granulation bers. Halder et al16 found that de
receptor agonists (IL1ra), which are
tissue around the insertion of a torn tachment of one or two thirds of the
inflammatory cytokine mediators,
supraspinatus tendon contributes to supraspinatus tendon from the cres
in the subacromial bursae of patients
the progression of rotator cuff tears cent area had a negligible effect on
with rotator cuff pathology; the
by weakening the insertion of the re the force transmission of the rotator
amount of these mediators correlat
maining tendon. cuff. These authors disputed the idea
ed with patient pain levels. Further
Although relatively few direct that nonphysiologic tension plays a
more, they found that increased IL
data are available on the natural his role in symptomatology. They con
1β and IL1ra in the glenohumeral
tory of partialthickness rotator cuff cluded that neighboring fibers com
joint did not correlate with pain in
tears, there is a substantial body of posing the cables of the crescent
patients with rotator cuff patholo
circumstantial evidence to suggest andcable theory of rotator cuff
gy.20
that most partial tears do not heal on function were sufficient for force
their own. Patients may have wax transmission. However, Bey et al17 reported significantly increased
Natural History
ing and waning symptoms, but the clinical, biomechanical, epidemio strain on the remaining supraspina
Although the natural history of
logic, and biologic data suggest that tus tendon at arm abduction angles
partialthickness tears of the rotator
most of these tears progress to be of 30°, 45°, and 60° in a cadaveric
cuff is incompletely understood, ev
come larger rather than smaller with model after creation of a onethird
idence suggests that progression
time. thickness articularsided partial
may occur over time.7,14 Yamanaka thickness tear of a supraspinatus
and Matsumoto21 reported on 40 pa tendon. They concluded that
tients with articularsided tears diag
Diagnostic Imaging
articularsided tears predispose the
nosed by arthrography repeated at a
Various imaging modalities have remaining rotator cuff to further
mean of 412 days. They found an en
been used to assist in the diagnosis damage. Thus in vitro studies have
largement of tear size in 21 patients
of partialthickness rotator cuff shown that although mechanical
(53%), progression to fullthickness
tears. Arthrography and bursography strength may be preserved, strain on
tears in 11 patients (28%), reduction
have been described, but these are of neighboring fibers is increased. This
of tear size in 4 patients (10%), and
uncertain value given the wide rang increased strain likely plays a role in
disappearance of the tear in 4 pa
es of reported accuracy in the litera the symptoms experienced by those
tients (10%). This early study indi
ture—15% to 83% for arthrogra with partialthickness tears of the
cates that many articularsided tears
phy24,25 and 25% to 67% for rotator cuff.
can progress over relatively short pe
bursography.5,25 Sensitivity and spec Fukuda6 reported that 73.3% of
riods. It also suggests that although
ificity of preoperative ultrasound has patients with either subacromial
some patients become asymptomat
been reported to be as high as 94% bursitis or a partialthickness rotator
ic over time, few tears heal anatom
and 93% and as low as 41% and cuff tear reported “more than mod
ically.
91%, respectively, for arthroscopi erate” nocturnal pain, whereas only
The limited healing potential of
cally confirmed partialthickness 50% of patients with fullthickness
partialthickness cuff tears is sup
tears.26,27 tears reported this much pain. Fuku
ported by histologic studies that
Other authors have reported a da also found that bursalsided tears
have observed no active repair; prox
similarly variable accuracy level for produced notably more pain than did
imal stumps of the cuff were round
MRI in the evaluation of partial intratendinous or articularsided
ed, retracted, and avascular. At the
thickness tears, with sensitivity as partialthickness tears.6 Gotoh et
molecular level, cells at the tendi
low as 56%28 and falsenegative rates al18 reported significantly (P < 0.01)
nous margin of partialthickness
as high as 83%.24 However, with im higher levels of substance P, an affer
tears have been shown to contain α1
proved technology and the increas ent nerve pain mediator, in the sub
typeI procollagen mRNA, a precur
ing usage of MRI arthrography, the acromial bursae of patients with
sor of type I collagen, thereby dem
accuracy of MRI has improved. A re partialthickness rotator cuff tears
onstrating the potential for repair.22
cent study using magnetic resonance than in the bursae of patients with
However, other studies of tear spec
arthrograms with gadopentetate
718 Journal of the American Academy of Orthopaedic Surgeons
Andrew B. Wolff, MD, et al
dimeglumine contrast agent and
Initially, these tears should be man
In Neer’s original article describ coronal oblique T1weighted fat
aged with rest, activity modification,
ing open anterior acromioplasty,13 he suppression images yielded a sensi
and nonsteroidal antiinflammatory
noted that 15 of 16 patients with tivity of 84% and a specificity of
drugs. Physical therapy for range of
fraying of the bursal side of the su 96%.29
motion should then begin, with the
praspinatus who underwent anterior In comparing preoperative ultra sound to MRI in arthroscopically confirmed partialthickness rotator cuff tears, Teefey et al30 found that 13 of 19 tears were correctly identi fied by ultrasound, whereas 12 of 19 tears were correctly identified by MRI. Iannotti et al31 found the pre operative diagnostic accuracy of ul trasound and MRI to be 70% and 73%, respectively.
Although ultrasound and MRI can be of similar utility in the diag nosis of partialthickness tears, each has its limitations. Ultrasound can provide a less expensive and nonin vasive alternative for evaluation of these tears, but it is highly operator dependent and does not provide in formation regarding concomitant pathologies. In many patients with vague presenting signs and symp toms, MRI will offer a more com plete evaluation of the shoulder. MRI evaluation of partialthickness rotator cuff tears demonstrates alter ation of the morphology, without discontinuity of the rotator cuff, on T1weighted images in areas corre sponding to increased signal on T2 weighted images.
For most patients with suspected partialthickness cuff tears—espe cially young, overhead throwing ath letes—magnetic resonance arthrog raphy is the imaging modality of choice to best visualize these tears and assess for concomitant patholo gy. However, given the variable rates of accuracy and the high proportion of the population with asympto matic partialthickness tears, MRI should be considered in conjunction with clinical evaluation.
goal of regaining any motion lost be
acromioplasty had satisfactory re cause of capsular contractures. Al though recent reports have ques tioned the efficacy of corticosteroid injections,32 we have found them to be a useful adjunct. Strengthening of the rotator cuff and periscapular musculature should be initiated af ter range of motion has improved and inflammation has subsided. Al though there is a paucity of reliable reports on the clinical outcome of conservative treatment of partial tears, most patients will improve with conservative measures over 6 months; some continue to improve for up to 18 months.
Surgical intervention generally is considered for patients with symp toms of sufficient duration and in tensity. According to the literature, the timing of surgery has ranged from a few months to 1.5 years, but it should be based on the patient’s symptoms, improvement, and rate of improvement with nonsurgical therapy as well as on the goals of the patient. Many surgical procedures have been described to address the pathology and pathogenesis of partialthickness tears; these include acromioplasty alone, débridement of tears with or without acromioplasty, and both miniopen and arthroscop ic repair of tears, with or without acromioplasty.
OgilvieHarris and Wiley33 report ed that approximately half of 57 pa tients with partialthickness tears had successful results with arthro scopic débridement without acro mioplasty at a minimum of 1 year after surgery. Budoff et al34 reported 89% good and excellent results at 2 to 5year followup and 81% good and excellent results at >5year fol lowup; other authors
have reported success rates of 50% to 89% after ar throscopic débridement without acromioplasty.3335
Volume 14, Number 13, December 2006 719 sults at 9month to 5year followup. The articular side of the rotator cuff was not evaluated in these patients. Snyder et al35 reported 84% satisfac tory results with arthroscopic dé bridement of partialthickness rota tor cuff tears at 10 to 43 months. Bursoscopy was performed in 71% of these patients, with bursalsided partialthickness tears found in 82%; these patients underwent ar throscopic acromioplasty as well as débridement, resulting in an average postoperative University of Califor nia, Los Angeles (UCLA) score of 33 (range, 035). For patients found to have a normal bursal side of the ro tator cuff, acromioplasty was not performed, resulting in an average UCLA score of 30.
Conclusions based on these stud ies are difficult to draw because most are small retrospective studies with short followups and differing surgical techniques. Additionally, many studies combine data from pa tients with articularsided and bursalsided tears, traumatic and atraumatic tears, superficial fraying of the cuff and nearly fullthickness tears, and young overhead throwing athletes and older patients. From this group of reports it is difficult to define (1) the indications for surgery, (2) which aspects of the patients’ pa thologies were responsible for their symptoms, (3) why up to 50% of pa tients failed to achieve a satisfactory result, and (4) which aspect of the surgery (acromioplasty or débride ment) was responsible for improve ment after surgery.
In a 1999 study, Weber36 com pared the results at 2 to 7year
Treatment
followup of 65 patients with grade 3A or 3B partialthickness rotator Treatment of partialthickness rota
cuff tears treated either with acro tor cuff tears varies according to the
mioplasty with miniopen repair or cause and location of the pathology.
with acromioplasty and arthroscop
PartialThickness Rotator Cuff Tears
ic débridement. He reported a mean
Thus the lack of concordance with
Torpey et al39 demonstrated in a ca UCLA score of 31.6 for patients un
the study of Park et al37 cannot be
daveric model that a 4mm and a dergoing miniopen repair versus
explained by the longer followup in
6mm acromioplasty, respectively, 22.7 for those undergoing arthro
the work of Weber36 and Cordasco et
would be expected to release 43% scopic débridement. For the bursal
al.38 Based on these data, Cordasco et
and 72% of the anterior and lateral sided tear subgroup, he reported a
al38 stated that they have begun to
surfaces of the deltoid tendon origin mean UCLA score of 33.0 for those
repair grade 2B partialthickness
from the acromion; however, the treated with miniopen repair versus
tears.
clinical implications of this are un a UCLA score of 13.6 for those treat
The literature thus suggests that
known. Nevertheless, acromioplas ed with arthroscopic débridement.
repair of partialthickness tears of
ty, when done, should be performed Thus Weber concluded that débride
the rotator cuff should be considered
judiciously, with removal of no more ment and acromioplasty was not ad
in articularsided tears with a depth
bone than is necessary to achieve a equate treatment of most grade 3
>6 mm and in bursalsided tears with
flat acromion. tears, with bursalsided tears faring
a depth >3 mm. Completion of the
Snyder40 originally described an especially poorly.36
tear, followed by repair in the pre
arthroscopic transtendinous repair More recently, Park et al37 report
ferred manner (ie, allarthroscopic,
technique that does not involve ed 86% satisfactory results in 37 pa
miniopen, or open), should be con
completion of the tear. This tech tients with partialthickness cuff
sidered when the tear is near full
nique has the theoretic advantage of tears (24 articularsided, 13 bursal
thickness and the remaining tissue is
retaining the lateral portion of the sided) 2 years after arthroscopic acro
thin and tenuous, or when there is a
original footprint of the rotator cuff mioplasty and débridement of
concomitant tear on the opposite
insertion and minimizing the articular and bursalsided tears of
side of the rotator cuff. Alternatively,
lengthtension mismatch of the re <50% thickness. They noted that
arthroscopic repair of the tear with
paired rotator cuff. Excellent results bursalsided tears fared significantly
out creation of a fullthickness tear
were recently reported by Ide et al,41 better with respect to pain score and
can be performed when the opposite
who used this technique to repair function (P < 0.05 for both) at 6
side of the cuff is intact and tissue is
grade 3A partialthickness cuff tears. months, but that the groups were
of good quality.
Of 17 patients, 14 were rated as ex
not significantly different at 1year
The role of acromioplasty has not
cellent, 2 as good, and 1 as fair at an and 2year followups.
been clearly delineated. Multiple
average 39month followup (range, Cordasco et al38 reported results
studies demonstrate good results
25 to 57 months). Mean UCLA and of arthroscopic subacromial decom
with and without acromioplasty in
Japanese Orthopaedic Association pression and débridement of partial
the treatment of partialthickness
scores improved significantly (17.3 thickness tears that were in concor
rotator cuff tears.3438 We feel that, in
and 68.4 to 32.9 and 94.8, respective dance with those of Weber36 but
all patients undergoing shoulder ar
ly; P < 0.01). differed from those of Park et al.37
throscopy for a suspected partial
For articularsided tears >1.5 cm They demonstrated that patients
thickness tear, a comprehensive bur
in the anteriortoposterior direc with bursalsided tears have a much
sectomy should be performed to
tion, two bioabsorbable suture an higher rate of unsatisfactory out
visualize completely the bursal side
chors doubleloaded with no. 2 non comes than do patients with
of the rotator cuff, as well as to re
absorbable polyester are used. For articularsided tears at 2 to 10year
move any potential inflammatory
tears <1.5 cm, only one suture an followup (mean, 4.5 years). The au
mediators. Consideration should be
chor is used. For tears >1.5 cm, the thors reported a 5% failure rate (2/
given to performing an acromioplas
suture anchors are placed through 44) for grade 2A tears versus a 38%
ty when an extrinsic etiology of a
the rotator cuff at the lateral articu failure rate (3/8) for patients with
partialthickness tear is suspected,
lar margin at the medial extent of grade 2B tears (P = 0.02). When grade
as evidenced by damage to the bursal
the footprint after localization of the 1A and 1B tears were included, the
side of the rotator cuff and fraying of
angle with a spinal needle. The spi overall treatment failure rate for
the coracoacromial ligament and/or
nal needle and suture anchors are bursalsided tears was 29% (4/14),
anterior acromial osteophyte, or
passed just off the lateral aspect of whereas the failure rate in the
when there is evidence of impinge
the acromion to obtain an angle articularsided tears was 3% (2/63)
ment of the cuff on the undersurface
≤45°. From the subacromial space, (P = 0.008). The authors stated that
of the acromion under arthroscopic
one limb from each anchor is all of the patients in their study in
visualization.
grasped and pulled through the later whom the failure occurred garnered
The goal of acromioplasty is the
al portal, where it is tied over an in no benefits from surgery, and the
creation of a flat acromion that does
strument. Using the opposite ends of
failure was apparent immediately.38
not impinge on the rotator cuff.
these sutures, the knot is pulled into
720 Journal of the American Academy of Orthopaedic Surgeons
Andrew B. Wolff, MD, et al
Figure 5
1.5 cm anterior to posterior) A3B0 (Ellman grade A3) articularsided partialthickness rotator cuff tear, as seen through a standard posterior portal after arthroscopic transtendinous fixation using two suture anchors.
the subacromial space, cinching down the rotator cuff on top of the suture anchors, reestablishing the footprint. The opposite ends are then tied with static knots through a lat eral subacromial portal. This process is repeated with the remaining su ture limbs (Figure 5).
For articularsided tears <1.5 cm in the anteriortoposterior direc tion, the single doubleloaded suture
Volume 14, Number 13, December 2006 721
Arthroscopic repair of a partialthickness articularsided tear. A, A shuttle relay is passed through the spinal needle and retrieved through the anterior portal. B, One end of the suture is also retrieved through the anterior portal. C, One end of the suture is engaged in the eyelet of the shuttle relay and then pulled back out of the healthy portion of the partially torn tendon. D, A complete repair of an articularsided partialthickness rotator cuff tear. (Adapted with permission from Ide J, Maeda S, Takagi K: Arthroscopic transtendon repair of partialthickness articularside tears of the rotator cuff: Anatomical and clinical study. Am J Sports Med 2005;33: 1672 1679.)
anchor is placed in the same manner as described above. However, be cause the entire suture is passing through the same puncture of the ro tator cuff, a tissue bridge must be created. This is done either by a shuttle suture passed through a spi nal needle or with a suture passer, such as the Suture Lasso (Arthrex, Naples, FL) or BirdBeak (Arthrex). In either manner, one limb of each su
ture is passed posteromedially through different percutaneous por tals. Each suture is then retrieved and tied sequentially through the lateral subacromial portal (Figures 5 and 6).
For partialthickness bursalsided tears, bursectomy and acromioplas ty are performed. The frayed edges of the bursal flap are then gently débrided, and the tuberosity is exco riated to bleeding bone using a round burr. One or two bioabsorbable doubleloaded suture anchors are placed through the full thickness of the rotator cuff (one anterior, one posterior) using a percutaneous su ture lasso (Figures 7 and 8).
Based on the available literature, we propose the following treatment algorithm for patients with degener ative partialthickness rotator cuff tears who are not overhead throwing athletes (Figure 9). At presentation, nonsurgical management should be the mainstay of treatment in most cases. When progress is lacking with nonsurgical therapy, surgical inter vention can be considered as early as 3 months (but generally at 6 to 12 months) after initiation of nonsurgi cal management, depending on the patient’s desires and goals.
Figure 6
A large (
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PartialThickness Rotator Cuff Tears
Surgical treatment is based on lo cation and depth of tear. Depth of tear can be determined either by ex amining the tear with a probe of a known length or, for articularsided tears, by measuring the amount of bone lateral to the articular margin. A distance >7 mm represents a tear >50% (grade 3).3 Ellman grade 1 tears (<3 mm deep) of either the articular or bursal side, and grade 1 and 2 tears (3 to 6 mm deep) of the articular side, should be treated with débridement of the tear, with or without acro mioplasty. Although there is little ev idence to suggest that débridement of partialthickness tears stimulates a healing response or improves the bio mechanics of the rotator cuff, it is vi tal in the assessment of the depth of the tear. Débridement also may re lieve mechanical irritation in the subacromial space and the glenohu meral joint. In addition, débridement likely removes inflammatory cells and inflammatory mediators present in the torn rotator cuff tissue.23
Grade 2 tears of the bursal side (>3 mm deep) and grade 3 tears of the ar
722 Journal of the American Academy of Orthopaedic Surgeons
Figure 7
Placement of bioabsorbable doubleloaded suture anchors. A, The lasso is passed through the full thickness of the cuff through a percutaneous portal, which optimizes the angle required for repair. This is often accomplished through the Neviaser portal, the superior medial portal bordered by the clavicle, the acromioclavicular joint, and the spine of the scapula. The nitinol wire is shuttled out of a cannula, along with the more medial of the suture limbs, and then is pulled back out of the percutaneous portal along with the suture limb, passing the suture through the full thickness of the cuff. The procedure is repeated for the posterior limb of the suture after again passing a lasso through the full thickness of the rotator cuff in a more posterior position. B, After passing both the anterior and posterior sutures through the bursalsided tear, both sutures are tied securely over the bursal side of the rotator cuff, thereby restoring the bursal side of the cuff to its anatomic location.
ticular or bursal side (>6 mm deep) should be treated with repair, with or without acromioplasty. We prefer to complete articularsided tears and perform doublearrow arthroscopic repairs because we have found long er convalescence and stiffness to oc cur with intratendinous repairs. In contrast, we arthroscopically repair bursalsided tears without comple tion of the tear, using the articular footprint as an internal splint.
PartialThickness Rotator Cuff Tears in Overhead Throwing Athletes
Overhead throwing athletes repre sent a distinct population of individ uals in whom partialthickness tears of the rotator cuff develop. The etiol ogy and pathogenesis of these injuries often differ from those in the non– overhead throwing population. Ac cordingly, the treatment of this sub group can be very different as well, particularly when return to throwing is the goal. Partialthickness tears in
athletes are seen mostly in overhead throwing sports. Onset is usually in sidious, with symptoms of pain at rest, loss of velocity, and “popping” or “catching” while throwing.
Most partialthickness tears are articularsided tears of the dominant arm that begin at the supraspinatus infraspinatus interval, posterior to the location of tears commonly seen in the older population. Partial thickness tears are often associ ated with other shoulder pathology. Superior labral injury, including pos terosuperior labral injury and de tachment, posteroinferior capsular contracture, anterior capsular atten uation, and internal rotation deficit, are frequently associated with articularsided tears.42
The cause of partialthickness ro tator cuff tears in the overhead throwing athlete is a subject of con siderable debate. Andrews et al43 originally theorized that these articularsided tears resulted from repetitive trauma of the massive ec centric traction force to the su praspinatus and infraspinatus ten dons, which keep the humeral head in the correct position from the de celeration phase through the release phase of throwing. Davidson et al44 espoused a theory of internal im pingement from repetitive mi crotrauma of the rotator cuff result
Figure 8
1.5 A small (
<
cm anterior to posterior) bursalsided partialthickness rotator cuff tear after repair with a single suture
anchor.
Andrew B. Wolff, MD, et al
ing from anterior subluxation secondary to minor instability and
Figure 9
fatigue of the dynamic stabilizers, which results in a secondary im
Partialthickness rotator cuff tear pingement of the rotator cuff on the posterior edge of the glenoid. Citing the association with posterior type 2
Nonsurgical management superior labrum anteriorposterior
(minimum of 3 months) (SLAP) tears via a peelback mecha nism, Burkhart et al42 have theorized that a combination of repetitive ten sile loading of the cuff, and the sub
Symptom improvement No improvement
sequent partialthickness tear, may be caused by posterosuperior sublux ation of the humerus from posterior
Diagnostic arthroscopy
capsule contracture and by repeti tive torsional and shear overload generated by hyperexternal rotation
Bursalsided tear Articularsided tear
in throwing athletes.
Treatment of partialthickness cuff tears in the overhead throwing
<3 mm deep >3 mm deep athlete should begin with nonsurgi cal measures. All of the following may be used to effect resolution of
Débridement ± acromioplasty symptoms: stretching of the posteri or capsular tissues to address loss of internal rotation, rotator cuff strengthening programs (including eccentric and plyometric exercises), trunk and lower extremity strength ening exercises,
restoration of prop er throwing mechanics, nonsteroidal antiinflammatory drugs, and corti costeroid injections.
Surgical treatment is reserved for patients who fail to respond to non surgical management. Diagnostic ar throscopy often reveals concomitant pathology that may be the primary cause of the patient’s symptoms. Débridement of the articularsided tear and treatment of concomitant capsular or labral pathology should be the mainstay of surgical interven tion; repair of the partialthickness tear or acromioplasty is rarely indi cated.
Summary
Partialthickness rotator cuff tears are not a single entity but rather rep resent a spectrum of disease states affecting the rotator cuff. From asymptomatic to significantly dis
Volume 14, Number 13, December 2006 723
<6 mm deep >6 mm deep
Repair ±
Débridement;
Repair; acromioplasty
rarely acromioplasty
rarely acromioplasty
Proposed treatment algorithm for partialthickness rotator cuff tears.
Additional Resources
DVD/video: Surgical Techniques in Orthopaedics: “Arthroscopic Rota tor Cuff Repair”: http://www4.aaos.org/product/productpage.cfm?code =02640
Related clinical topics articles available on Orthopaedic Knowledge Online: “Glenohumeral Arthritis and the Rotator Cuff
Deficient Shoul der,” by Gregory P. Nicholson, MD, and Guido Marra, MD: http:// www5.aaos.org/oko/shoulder_elbow/ga_rcdeficient/pathophysiology/ pathophysiology.cfm
“Shoulder Arthroscopy,” by Stephen J. Snyder, MD, and Petra Waldherr, MD: http://www5.aaos.org/oko/shoulder_elbow/arthroscopy/anatomy/ anatomy.cfm
“Rotator Cuff Tears,” by Evan Flatow, MD, and Leesa Galatz, MD: http:// www5.aaos.org/oko/shoulder_elbow/rotator_cuff/pathophysiology/ pathophysiology.cfm
Patient information: Free information for your patients about rotator cuff tears and treatment is available on Your Orthopaedic Connection at http://www.orthoinfo.com
PartialThickness Rotator Cuff Tears
abling, partialthickness tears of the
1. Clark JM, Harryman DT II: Tendons,
Contemp Orthop 1995;31:262271. rotator cuff can affect patients in dif ferent ways. Young overhead athletes presenting with partialthickness tears differ with respect to etiology,
ligaments, and capsule of the rotator
16. Halder AM, O’Driscoll SW, Heers G, cuff: Gross and microscopic anatomy.
et al: Biomechanical comparison of ef J Bone Joint Surg Am 1992;74:713
fects of supraspinatus tendon detach 725.
ments, tendon defects, and muscle re 2. Ellman H: Diagnosis and treatment of
tractions. J Bone Joint Surg Am 2002; goals, and treatment from older pa
incomplete rotator cuff tears. Clin
84:780785. tients with degenerative tears.
Pathogenesis of degenerative tears is multifactorial. Articular sided tears are more likely caused by
Orthop Relat Res 1990;254:6474.
17. Bey MJ, Ramsey ML, Soslowsky LJ: 3. Ruotolo C, Fow JE, Nottage WM: The
Intratendinous strain fields of the su supraspinatus footprint: An anatomic
praspinatus tendon: Effect of a surgi study of the supraspinatus insertion.
cally created articularsurface rotator Arthroscopy 2004;20:246249.
cuff tear. J Shoulder Elbow Surg primarily intrinsic factors, while
4. Codman EA: The Shoulder: Rupture
2002;11:562569. both intrinsic and extrinsic factors
of the Supraspinatus Tendon and
18. Gotoh M, Hamada K, Yamakawa H, may play roles in the development of bursalsided tears. Diagnosis of clin ically significant partialthickness
Other Lesions in or About the Sub acromial Bursa. Boston, MA: Thomas Todd, 1934. 5. Fukuda H, Mikasa M, Yamanaka K:
Inoue A, Fukuda H: Increased sub stance P in subacromial bursa and shoulder pain in rotator cuff diseases. J Orthop Res 1998;16:618621. tears should be based on the pa
Incomplete thickness rotator cuff
19. Gotoh M, Hamada K, Yamakawa H, et tient’s symptoms and clinical find ings in conjunction with magnetic resonance arthrography.
tears diagnosed by subacromial bur sography. Clin Orthop Relat Res 1987;223:5158. 6. Fukuda H: Partialthickness rotator
al: Interleukin1induced subacromi al synovitis and shoulder pain in rota tor cuff diseases. Rheumatology (Oxford) 2001;40:9951001. Treatment should be based on the
cuff tears: A modern view on Cod
20. Gotoh M, Hamada K,
Yamakawa H, et patient’s goals, etiology, and depth of tear. Considerable thought should be given to differentiating between articular and bursalsided tears.
man’s classic. J Shoulder Elbow Surg
al: Interleukin1induced glenohu 2000;9:163168.
meral synovitis and shoulder pain in 7. Sher JS, Uribe JW, Posada A, Murphy
rotator cuff diseases. J Orthop Res BJ, Zlatkin MB: Abnormal findings on
2002;20:13651371. magnetic resonance images of asymp
21. Yamanaka K, Matsumoto T: The joint Nonsurgical treatment is successful
tomatic shoulders. J Bone Joint Surg
side tear of the rotator cuff: A fol in most patients. Surgical treatment, when necessary, should consist of tear débridement in articularsided tears <6 mm in depth and bursal
Am 1995;77:1015.
lowup study by arthrography. Clin 8. Milgrom C, Schaffler M, Gilbert S,
Orthop Relat Res 1994;304:6873. van Holsbeeck M: Rotatorcuff chang
22. Hamada K, Tomonaga A, Gotoh M, es in asymptomatic adults: The effect
Yamakawa H, Fukuda H: Intrinsic of age, hand dominance and gender.
healing capacity and tearing process sided tears <3 mm in depth. Consid
J Bone Joint Surg Br 1995;77:296298.
of torn supraspinatus tendons: In situ eration should be given to repairing
9. Rothman RH, Parke WW: The vascu
hybridization study of α1(I) procol tears >6 mm in depth on the articu lar side and >3 mm of depth on the bursal side. The role of acromioplas
lar anatomy of the rotator cuff. Clin
lagen mRNA. J Orthop Res 1997;15: Orthop Relat Res 1965;41:176186.
2432. 10. Rathbun JB, Macnab I: The microvas
23. Gotoh M, Hamada K, Yamakawa H, cular pattern of the rotator cuff.
Tomonaga A, Inoue A, Fukuda H: Sig ty has not been clearly delineated,
J Bone Joint Surg Br 1970;52:540553.
nificance of granulation tissue in torn but it should be considered when there is evidence of extrinsic causa tion of the tear. To optimize future treatment of patients with partial
11. Lohr JF, Uhthoff HK: The microvascu lar pattern of the supraspinatus ten don. Clin Orthop Relat Res 1990; 254:3538. 12. Nakajima T, Rokuuma N, Hamada K,
supraspinatus insertions: An immu nohistochemical study with antibod ies against interleukin1β, cathepsin D, and matrix metalloprotease1. J Orthop Res 1997;15:3339. thickness tears of the rotator cuff,
Tomatsu T, Fukuda H: Histologic and
24. Gartsman GM, Milne JC: Articular further research at the basic science
biomechanical characteristics of the
surface partialthickness rotator cuff and clinical levels is needed.
supraspinatus tendon: Reference to
tears. J Shoulder Elbow Surg 1995;4: rotator cuff tearing. J Shoulder Elbow
409415.
References
Surg 1994;3:7987.
25. Itoi E, Tabata S: Incomplete rotator 13. Neer CS II: Anterior acromioplasty for
cuff tears: Results of operative treat
Evidencebased Medicine: Level I/II prospective studies on partial
the chronic impingement syndrome
ment. Clin Orthop Relat Res 1992; in the shoulder: A preliminary report.
284:128135. J Bone Joint Surg Am 1972;54:4150.
26. Wiener SN, Seitz WH Jr: Sonography thickness rotator cuff tears: referenc
14. Ozaki J, Fujimoto S, Nakagawa Y,
of the shoulder in patients with tears es 32 and 36. The remaining refer ences are casecontrol case series or expert opinion studies.
Masuhara K, Tamai S: Tears of the ro
of the rotator cuff: Accuracy and value tator cuff of the shoulder associated
for selecting surgical options. AJR with pathological changes in the acro
Am J Roentgenol 1993;160:103107. mion: A study in cadavera. J Bone
27. Brenneke SL, Morgan CJ: Evaluation
Citation numbers printed in bold type indicate references published
Joint Surg Am 1988;70:12241230. 15. Burkhead WZ Jr, Burkhart SS, Gerber C, et al: Symposium: The rotator cuff.
of ultrasonography as a diagnostic technique in the assessment of rotator cuff tendon tears. Am J Sports Med within the past 5 years.
Debridement versus repair: Part I.
1992;20:287289.
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