Rotator Cuff Treatment.

Last updated Wednesday, January 26, 2005

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Partial thickness cuff lesions

Signs and symptoms

Intrasubstance and articular surface

Judging from the cadaver studies reviewed earlier in this chapter, intrasubstance and articular surface partial thickness cuff tears represent the commonest forms of cuff involvement. These lesions usually involve the supraspinatus tendon near its anterior insertion, but may also involve the infraspinatus and subscapularis. Clinical observation of patients with documented partial thickness cuff lesions suggests that they produce symptoms analogous to other partial thickness tendon lesions, such as a partial Achilles tear, a partial tear of the patellar tendon, or a partial tear of the tendon of origin of the extensor carpi radialis brevis ("tennis elbow"). These partial tendon lesion symptoms include stiffness of the joint on passive motion in a direction that stretches the tendon and tendon signs, i.e. pain or weakness on isometric contraction of the tendon's muscle (see figure 32). These partial tendon lesions are often much more painful than full thickness tears. This is because, in contrast to full thickness tears, partial thickness defects of the cuff give rise to stiffness and unphysiologic tension on the remaining fibers.

In its less common form involving the bursal aspect of the cuff tendon, partial thickness cuff lesions may be associated with subacromial abrasion, yielding subacromial crepitance on passive joint motion.

There is not a lot of published information regarding the results of operative treatment for partial thickness cuff lesions. Fukuda and colleagues (Fukuda, Mikasa, 1983, Fukuda, Mikasa, 1987) described the management of six patients with partial-thickness bursal-side tears by acromioplasty and/or wedge resection with tendon repair to bone. They used an intraoperative "color test" in which dye was injected into the shoulder joint to indicate the extent of joint side tears. The results were satisfactory in 90 per cent of cases. Itoi and Tabata (Itoi and Tabata, 1992b) reported their results in managing 38 shoulders with partial thickness cuff lesions. The average follow-up period of 4.9 years and the average age at operation was 52.2 years. Three types of lesions were identified: superficial (12 shoulders), intratendinous (three), and deep surface tears (23). The authors performed full-thickness resection of the cuff including the lesion and repaired the defect with side-to-side suture (13 shoulders), side-to-bone suture (eight), fascial patch grafting (16), or side-to-bone suture with fascial patch grafting (one). The overall results were satisfactory in 31 shoulders (82%). The results were not affected by the tear types, operative methods, or follow-up period.

Arthroscopic treatment

Andrews et al (Andrews, Broussard, 1985) presented thirty-six patients with partial thickness tears of the supraspinatus portion of the cuff treated with arthroscopic debridement of the rotator cuff defect. No acromioplasty was performed. The average age was 22.5 and 64% of the patients were baseball pitchers. Of the 34 patients available for follow-up, 85% had an excellent (26 patients) or good (3 patients) result and were able to return to sports. The authors suggested that the debridement may initiate a healing response. Arthroscopy revealed a tear of some part of the glenoid labrum in all patients. Six had partial tears of the long head of the biceps tendon. These observations point to the difficult of deciding which surgical findings are responsible for the patient's symptoms.

Ogilvie-Harris and Wiley (Ogilvie-Harris and Wiley, 1986) reported on arthroscopic treatment of 57 incomplete tears of the rotator cuff with symptoms of impingement. These tears were debrided and no acromioplasty was performed. Half of the patients improved.

Wiley (Wiley, 1985) reported on thirty-three patients treated arthroscopically for partial tears of the rotator cuff. Only three patients achieved a satisfactory result.

Ellman reported good results from arthroscopic acromioplasty performed in conjunction with arthroscopic debridement of partial thickness tears of the rotator cuff. (Ellman and Kay, 1991)

Esch et al, (Esch, Ozerkis, 1988) in 1988, reported on thirty-four patients with stage II rotator cuff disease and partial thickness rotator cuff tears treated with arthroscopic acromioplasty and tear debridement. Twenty-eight patients were satisfied with their results; 16 patients were rated excellent, 10 were good, 6 were fair, and 2 were rated as poor.

Gartsman (Gartsman, 1990) presented forty patients with partial thickness rotator cuff tears in a group of 125 patients treated with arthroscopic acromioplasty. Of these partial thickness tears, thirty-two involved the articular surface of the supraspinatus tendon and four tears involved the bursal side. Four infraspinatus tears were identified, three of which involved the articular surface. Notably, in these forty patients, there were twenty-seven cases of labral fraying with six instances of biceps/labral complex detachment, again indicating the difficulty of relating symptoms to surgical findings. Of the forty patients, thirty-three (83% satisfactory results) had major improvement in their ratings for pain, activities of daily living, work and sports, at an average of 28.9 months post-arthroscopic debridement. Two patients, who had an unsatisfactory result, had a second operation: one, open acromioplasty and the other, repair of the rotator cuff with satisfactory results. Of the thirty patients in this group engaged in sports preoperatively, ten patients returned to those sports at the same level of performance as before the symptoms had started.

Altchek et al (Altchek, Warren, 1990) reported four of six good or excellent results in patients with partial thickness rotator cuff tears treated with arthroscopic acromioplasty and debridement of the rotator cuff defect.

Roye et al (Roye, Grana, 1995) presented thirty-eight patients with partial thickness rotator cuff tears (thirty-two involving the supraspinatus) treated with arthroscopic acromioplasty. A satisfactory result was achieved in 95%.

As part of a larger series, Ryu (Ryu, 1992), reported on thirty-five patients with partial thickness rotator cuff tears treated with arthroscopic acromioplasty. Thirty of thirty-five patients (86%) were rated with excellent or good results (5 fair, no poor) at a minimum follow-up of 12 months. Of the group with partial tears, four were found to involve only the articular surface. Three of these four were considered failures

In 1994, Olsewki and Depew (Olsewski and Depew, 1994) reported on their experience with 61 consecutive patients treated with arthroscopic acromioplasty and debridement of the rotator cuff defect (17 of 21 patients (81%) with a partial thickness rotator tear rated a satisfactory result (UCLA rating scale). This was identical to the result achieved in 27 patients treated with arthroscopic acromioplasty for rotator cuff "tendonitis" with an intact rotator cuff. As was the case with the series of Roye et al (Roye, Grana, 1995), the extent of the tear did not statistically affect the result.

From this group of reports it is difficult to define (1) the indications for surgery, (2) which aspects of the patients' pathologies were responsible for their symptoms, (3) why from 15-50% of patients failed to achieve a satisfactory result, and (4) which aspect of the surgery (acromioplasty or debridement) was responsible for improvement after surgery. It seems likely that those patients benefiting from this procedure were able to heal their tendon debridement in a way that stabilized the insertional mechanism, distributing the loads from muscle to bone in a way that prevented disproportionately large loads from being concentrated on the neighboring intact tendon fibers.

Authors' preferred method of treating partial thickness cuff lesions

Nonoperative treatment

The nonoperative management of partial thickness cuff tears is similar to that for subacromial abrasion described earlier in this chapter.Just as with partial lesions of the Achilles, patellar or extensor radialis brevis tendons, the program must emphasize stretching against all directions of tightness, including internal rotation (see figure 33), cross-body adduction (see figure 34), elevation (see figures 35 and 36) and occasionally external rotation (see figure 37). As in a tennis elbow rehabilitation program, when a comfortable normal range of passive motion is reestablished, gentle progressive muscle strengthening is instituted (see figures 38 and 39) An emphasis is always placed on gentle and comfortable progress of this rehabilitation program. The goal of this program is to assure that the scar collagen which forms in the defect will become as supple as normal tendon; otherwise scar contracture will tend to concentrate the loads of the cuff on the lesion leading to recurrence and propagation of injury.

Operative treatment - Open surgery

Just as is the case for partial Achilles, patellar and extensor carpi radialis brevis tendon lesions, there is no surgical treatment which reliably restores the tendon to its normal condition. Preoperatively, it is important to determine whether the patient's primary problem is due to stiffness or to difficulties upon active muscle contraction so that the procedure can be biased accordingly. On the one hand, sectioning of the fibers which remain intact (as in a tennis elbow release) may worsen the problem of weakness; although this may be the basis of the arthroscopic "debridement" advocated by some surgeons for this lesion. On the other hand, excision of the defect and repair would worsen the problem of stiffness. (Zuckerman, Leblanc, 1991) Furthermore, such surgical tightening of involved part of the cuff would cause the area of damage and repair to bear the majority of the load when the cuff muscles contract (reminiscent of the "quadregia" phenomenon in hand surgery). Thus excision and repair of partial thickness cuff lesions should include efforts to assure that the tendon load is distributed evenly at the insertion, by carrying out a repair that is isometric, allowing uniform load distribution and by carrying out a release of the capsule tightened in the repair. (Harryman, Matsen, 1996)

The surgical exposure to the partial thickness cuff lesion is identical to that described for the management of subacromial roughness (see figure 40). If symptoms are related to subacromial abrasion (i.e. symptomatic subacromial crepitance), subacromial smoothing is performed as described previously in this chapter.

The decision to convert a partial thickness cuff defect to a full thickness defect and then to repair it (see figure 41) is based on the patients preoperative evaluation and surgical findings. The thickness of the cuff can be determined at surgery by inspection, palpation and the Fukuda test described above. A depth gauge or calibrated nerve hook inserted in the area of the lesion may help determine the percentage of the tendon that remains intact. If the decision is made to perform an open repair, a tenotomy is performed in the most suspicious area along the line of the tendon fibers to explore the full thickness of the tissue. If, as is usually the case, the defect is within the substance of the tendon or on its deep surface near the anterior insertion of the supraspinatus, a longitudinal tenotomy and capsulotomy are performed along the anterior aspect of the supraspinatus near the rotator interval. This cut is then extended at right angles posteriorly through the partially detached cuff at its insertion to the greater tuberosity, turning back the flap of cuff until normal tendon of full thickness is encountered. Next an attempt is made to retrieve and consolidate any split laminations of cuff which may have retracted medially (see figure 41). These are usually on the deep articular surface where the cuff lesion begins and may have retracted up to 1 cm. Release of the coracohumeral ligament and the rotator interval capsule from the base of the coracoid (see figures 42 and 43) as well as release of the capsule from the glenoid lip (see figure 44) will minimize tension on the repair. Then the full thickness defect is repaired (see figures 45 and 46) with care to render the cuff insertion isometric with respect to all it fibers and smooth on its superior surface. Finally, with the anterior undersurface of the acromion in full view, the shoulder is put through a full range of motion to verify the elimination of any subacromial abrasion (see figure 47) and to assure that the repair has not restricted shoulder motion.

Postoperative management is the same as for the repair of full thickness defects with a particular emphasis on continuous passive motion (see figure 48) and on the early restitution of a full range of motion to prevent stiffness and adhesions (see figures 34, 35, 36, 37, 49, and 50).

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