Last updated: January 26 2005
It is often difficult to tell where concepts actually begin. It is certainly not obvious who first used the term rotator or musculotendinous cuff. Credit for first describing ruptures of this structure is often given to J. G. Smith who in 1834 described the occurrence of tendon rupture after shoulder injury in the London Medical Gazette. (Smith 1834)
Development of surgical technique
In 1924 Meyer published his attrition theory of cuff ruptures. (Meyer 1924) In his 1934 classic monograph Codman summarized his 25 years of observations on the musculotendinous cuff and its components and discussed ruptures of the supraspinatus tendon. (Codman 1934b) Beginning 10 years after the publication of Codman's book and for the next 20 years McLaughlin wrote on the etiology of cuff tears and their management. (McLaughlin 1944 McLaughlin and Asherman 1951) Arthrography was first carried out by Oberholtzer in 1933 using air as the contrast medium. (Oberholtzer 1933) Lindblom and Palmer (Lindblom and Palmer 1939) used radio-opaque contrast and described partial-thickness full-thickness and massive tears of the cuff.
Codman recommended early operative repair for complete cuff tears. He carried out what may have been the first cuff repair in 1909. (Codman 1934b) Current views of cuff tear pathogenesis diagnosis and treatment are quite similar to those that he proposed over 50 years ago.
Pettersson has provided an excellent summary of the early history of published observations on subacromial pathology. Because of its completeness his account is quoted here. (Pettersson 1942)
As already mentioned the tendon aponeurosis of the shoulder joint and the subacromial bursa are intimately connected with each other. An investigation on the pathological changes in one of these formations will necessarily concern the other one also. A historical review shows that there has been a good deal of confusion regarding the pathological and clinical observations on the two.
The first to observe morbid processes in the subacromial bursa was Jarjavay (Jarjavay 1867) who on the basis of a few cases gave a general description of subacromial bursitis. His views were modified and elaborated by Heineke (Heineke 1868) and Vogt. (Vogt 1881) Duplay (Duplay 1872) introduced the term "periarthritis humeroscapularis" to designate a disease picture characterized by stiffness and pain in the shoulder joint following a trauma. Duplay based his observations on cases of trauma to the shoulder joint and on other cases of stiffness in the shoulder following dislocation which he had studied at autopsy. The pathological foundation for the disease was believed by Duplay to lie in the subacromial and subdeltoid bursa. He thought that the cause was probably destruction or fusion of the bursa.
Duplay's views which were supported by his followers Tillaux (Tillaux 1888) and Deschª (Descheï 1892) were hotly disputed. His opponents Gosselin and his pupil Duronea (Duronea 1873) and Desplats (Desplats 1878) Pingaud and Charvot (Pinguad and Charvot 1879) tried to prove that the periarthritis should be regarded as a rheumatic affection neuritis etc.
In Germany Colley (Colley 1899) and Kuster (Kuster 1882) were of practically the same opinion regarding periarthritis humeroscapularis as Duplay. Roentgenography soon began to contribute to the problem of humeroscapular periarthritis. It was not long before calcium shadows began to be observed in the soft parts between the acromion and the greater tuberosity. (Painter 1907) The same finding was made by Stieda (Stieda 1908) who assumed that these calcium masses were situated in the wall and in the lumen of the subacromial bursa. These new findings were indiscriminately termed "bursitis calcarea subacromialis" or "subdeltoidea." The term "bursoliths" was even used by Haudek (Haudek 1911) and Holzknecht. (Holzknecht 1911) Later however as the condition showed a strong resemblance to humeroscapular periarthritis it became entirely identified with the latter.
In America Codman (Codman 1984) made a very important contribution to the question when he drew attention to the important role played by changes in the supraspinatus in the clinical picture of subacromial bursitis. Codman was the first to point out that many cases of inability to abduct the arm are due to incomplete or complete ruptures of the supraspinatus tendon.
With Codman's findings it was proved that humeroscapular periarthritis was not only a disease condition localized in the subacromial bursa but that pathological changes also occurred in the tendon aponeurosis of the shoulder joint. This theory was further supported by Wrede (Wrede 1912) who on the basis of one surgical case and several cases in which roentgenograms had revealed calcium shadows in the region of the greater tuberosity was able to show that the calcium deposits were localized in the supraspinatus tendon.
More and more disease conditions in the region of the shoulder joint have gradually been distinguished and separated from the general concept periarthritis humeroscapularis. For example Sievers (Sievers 1914) drew attention to the fact that arthritis deformans in the acromioclavicular joint may give a clinical picture reminiscent of periarthritis humeroscapularis. Bettman (Bettman 1926) and Meyer and Kessler (Meyer and Kessler 1926) pointed to the occurrence of deforming changes in the intertubercular sulcus the canal in which the biceps tendon glides. Payr (Payr 1931) attempted to isolate the clinical picture which appears when the shoulder joint without any previous trauma is immobilized too long in an unsuitable position. Julliard (Julliard 1933) demonstrated apophysitis in the coracoid process (coracoiditis) as forming a special subdivision of periarthritis. Wellisch (Wellisch 1934) described apophysitis at the insertion of the deltoid muscle on the humerus giving it the name of "deltoidalgia." Sch_r and Zweifel (Schar and Zweifel 1936) described deforming changes in connection with certain cases of os acromiale.
In addition to this excellent review Pettersson himself made a number of important contributions to the study of the rotator cuff as will be seen subsequently in this chapter.
The cuff story continues with the recognition of subacromial abrasion as an element in rotator cuff disease by a number of well-known surgeons including Codman (Codman 1984) Armstrong (Armstrong 1949) Hammond (Hammond 1962 Hammond 1971) McLaughlin (McLaughlin 1944) Moseley (Moseley 1969) Smith-Petersen and colleagues (Smith-Petersen Aufranc 1943) and Watson-Jones (Watson-Jones 1960). Some of these surgeons proposed complete acromionectomy (Armstrong 1949 Diamond 1964 Hammond 1962 Hammond 1971 Watson-Jones 1960) while others advocated lateral acromionectomy ( McLaughlin 1944 Smith-Petersen Aufranc 1943) for relief of these symptoms. The term "impingement syndrome" was popularized by Charles Neer in 1972. (Neer 1972) In 100 dissected scapulae Neer found eleven with a "characteristic ridge of proliferative spurs and excrescences on the undersurface of the anterior process (of the acromion) apparently caused by repeated impingement of the rotator cuff and the humeral head with traction of the coracoacromial ligament . . . Without exception it was the anterior lip and undersurface of the anterior third that was involved." Neer emphasized that the supraspinatus insertion to the greater tuberosity and the bicipital groove lie anterior to the coracoacromial arch with the shoulder in the neutral position and that with forward flexion of the shoulder these structures must pass beneath the arch providing the opportunity for abrasion. He suggested a continuum from chronic bursitis and partial tears to complete tears of the supraspinatus tendon which may extend to involve rupture of other parts of the cuff. He pointed out that the physical examination and plain radiographic findings were not reliable in differentiating chronic bursitis and partial tears from complete tears. Importantly he emphasized that patients with partial tears seemed more prone to increased shoulder stiffness and that surgery in this situation was inadvisable until the stiffness had resolved. He described the use of a subacromial lidocaine injection to help localize the clinical problem and before acromioplasty as a "useful guide of what the procedure would accomplish."
Neer described three different stages of the "impingement syndrome". In Stage 1 reversible edema and hemorrhage are present in a patient under 25 years of age. In Stage 2 fibrosis and tendinitis affect the rotator cuff of a patient typically in the 25- to 40-year age group. Pain often recurs with activity. In Stage 3 bone spurs and tendon ruptures are present in the individual over 40 years of age. He emphasized the importance of non operative management of cuff tendinitis. If surgery was performed Neer pointed out the importance of preserving a secure acromial origin of the deltoid a smooth resection of the undersurface of the anteroinferior acromion the careful inspection for other sources of abrasion (such as the undersurface of the acromioclavicular joint) and careful postoperative rehabilitation. (Neer 1972 Neer 1983 Neer Flatow 1988)
In 1972 Neer (Neer 1972) described the indications for acromioplasty as (1) long-term disability from chronic bursitis and partial tears of the supraspinatus tendon or (2) complete tears of the supraspinatus. He pointed out that the physical and roentgenographic findings in these two categories were indistinguishable including crepitus and tenderness over the supraspinatus with a painful arc of active elevation from 70 to 120 degrees and pain at the anterior edge of the acromion on forced elevation. Neer's 1983 report (Neer 1983) described candidates for acromioplasty as (1) patients with an arthrographically demonstrated cuff tear (2) patients older than 40 years with negative arthrograms but persistent disability for one year despite adequate conservative treatment (including efforts to eliminate stiffness) provided that the pain can be temporarily eliminated by the subacromial injection of lidocaine (3) certain patients under 40 with refractory Stage II impingement lesions and (4) patients undergoing other procedures for conditions in which impingement is likely (such as total shoulder replacement in patients with rheumatoid arthritis or old fracture). The proposed goal of acromioplasty was to relieve mechanical wear at the critical area of the rotator cuff. Surgery was not considered until any stiffness had resolved and until the disability had persisted for at least nine months. Even in patients who had had a previous lateral acromionectomy with continuing symptoms Neer considered anterior acromioplasty having found that many still had problems related to subacromial impingement. Neer also reported that the rare patient with an irreparable tear in the rotator cuff could be made more comfortable and could gain surprising function if impingement were relieved as long as the deltoid origin was preserved. (Neer 1983)
Neer (Neer 1983) recommended resection of small unfused acromial growth centers and internal fixation of larger unfused segments in a manner that tilted the acromion upwards to avoid impingement. His indications for resections of the lateral clavicle included (1) arthritis of the acromioclavicular joint (2) a need for greater exposure of the supraspinatus in a cuff repair and (3) nonarthritic enlargement of the acromioclavicular joint resulting in impingement on the supraspinatus (in this situation only the undersurface of the joint was resected). (Neer 1983)
Additional approaches to subacromial abrasion have been proposed including coracoacromial ligament section (Hawkins and Kennedy 1980 Jackson 1976 Kessel and Watson 1977 Penny and Welsh 1981) resection arthroplasty of the acromioclavicular joint (Kessel and Watson 1977) extensive acromionectomy (Armstrong 1949 Diamond 1964 Hammond 1962 Hammond 1971 McLaughlin 1944 Michelsson and Bakalim 1977 Moseley 1969 Smith-Petersen Aufranc 1943 Watson-Jones 1960) and combined procedures such as acromioplasty incision of the coracoacromial ligament acromioclavicular resection arthroplasty and excision of the intra-articular portion of the biceps tendon with tenodesis of the distal portion of the bicipital groove. (Ha'eri Orth 1982 Neviaser Neviaser 1982 Pujadas 1970)
Comparison of the results of these procedures is difficult owing to the heterogeneous patient groups and varying methods of evaluation. In 16 patients with chronic bursitis with fraying or partial tear of the supraspinatus Neer (Neer 1972) found that 15 attained satisfactory results (no significant pain less than 20 degrees of limitation of overhead extension and at least 75 per cent of normal strength). Thorling and coworkers (Thorling Bjerneld 1985) found good to excellent results in 33 of 51 patients following acromioplasty (in 11 resection of the acromioclavicular joint was performed as well).
Recently arthroscopic acromioplasty has been introduced. The frequency with which this procedure is performed has increased dramatically as the strictness of Neer's original indications for acromioplasty have been allowed to relax. Ellman (Ellman 1987) presented the initial results on 50 consecutive cases of arthroscopic acromioplasty for Stage II impingement without cuff tear (40 cases) and for full-thickness cuff tear (20 cases). Eighty-eight per cent of the patients had excellent or good results and the rest were unsatisfactory at a one- to three-year follow-up. He pointed out that the technique was technically demanding. Difficulties with arthroscopic acromioplasty range from inadequate subacromial smoothing on one hand to transection of the acromion or virtually total acromionectomy on the other. In his early series of 100 arthroscopic acromioplasties Gartsman (Gartsman 1988) found that at an average of 18.5 months' follow-up 85 shoulders were improved and 15 were failures of which 9 required subsequent open acromioplasty. The procedure took longer than open acromioplasty and did not speed the patient's return to work or sport. Morrison (Morrison 1988) reported a series of arthroscopic acromioplasties in which the quality of the result was closely correlated with the conversion of a curved or hooked acromion to a flat undersurface.
Even though the indications for its performance are still being defined arthroscopic acromioplasty is currently one of the commonest of all orthopedic procedures being applied to shoulder pain bursal hypertrophy partial thickness cuff tears calcific tendinitis as well as reparable and irreparable rotator cuff tears.