Rotator Cuff Historical Review.
Last updated Wednesday, January 26, 2005
Rotator cuff historical review
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 orthopaedic procedures, being applied to shoulder pain, bursal
hypertrophy, partial thickness cuff tears, calcific tendinitis, as well
as reparable and irreparable rotator cuff tears. Disclaimer
This resource has been provided by the University of Washington Department of Orthopaedics and Sports Medicine as general information only. This information may not apply to a specific patient. Additional information may be found at http://www.orthop.washington.edu or by contacting the UW Department of Orthopaedics and Sports Medicine.
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