Clinical management of lesions of the rotator cuff

Lesions of the rotator cuff are caused in most cases by degenerative changes in the critical area around the tuberosities of the humerus. Clinical examination reveals atrophy of the supra- and infraspinatus muscles, a painful arc of movement and, especially, pain at night. There are many clinical tests that can be helpful in the diagnosis. Both ultrasonography and arthrography have proved to be very sensitive methods for the detection of rotator cuff tears. Ultrasonography allows determination of the size and location in addition. Conservative treatment includes rest, physical therapy and anti-inflammatory medication. In many cases the symptoms are improved by many weeks of conservative treatment alone. Operative treatment becomes necessary when no pain relief and no satisfactory movement can be achieved. Complete correction of the tendon defect is important for postoperative care. Passive exercise must allow the tendon repair to remain intact without subjecting it to undue stress.     

Diagnosis and follow-up MRI evaluation of tennis leg:New understanding of the pathogenesis and imaging

ObjectivesTo evaluate the Magnetic resonance imaging (MRI) findings of patients with a clinical diagnosis of tennis leg and to explore the pathogenesis of tennis leg.MethodsA retrospective review of 58 (45 men, 13 women; age range, 7–81 years; mean age, 46.7 years) patients with a clinical diagnosis of tennis leg at our hospital during a 64-month period (May 2014 through Sep 2019) was conducted. All patients underwent MRI scan. Follow-up MRI was performed on 4 patients. Images findings, including integrity of the myotendinous junction and tendon of the gastrocnemius and soleus, and presence of fluid collection were analyzed.ResultsMRI revealed fluid collection between the medial head of the gastrocnemius and soleus in 44 cases (72.1%). In 25 cases (41.0%), the collected fluid spread to around the medial border of fascia cruris. Fifty-five cases (90.2%) had edema or disruption of the gastrocnemius, with most cases (n = 55) showing edema or disruption of the medial head of the gastrocnemius at the myotendinous junction. Twenty-two (36.1%) cases had edema or disruption of the soleus, with most cases (n = 17) showing edema or disruption of the soleus at the myotendinous junction. Plantaris tendon disruption was observed in 7 cases (11.5%). A thick area of reparative tissue at the distal myotendinous junction of the medial head of the gastrocnemius was observed in all 4 MRI patients followed up.ConclusionAbnormalities of the medial head of the gastrocnemius at the myotendinous junction and tendon appear to be more common than those of the plantaris tendon. Reparative tissue at the distal myotendinous junction of the medial head of the gastrocnemius may be an important specific indication of chronic tennis leg injury.     

Bildgebende Verfahren bei Rotatorenmanschettendefekten der Schulter

Diagnostic imaging in a patient with shoulder pain should be used only after a comprehensive clinical evaluation of the shoulder. X-ray and ultrasonography are the basic diagnostic tools; computed tomography and magnetic resonance imaging (MRI) should be used only with certain indications. Ultrasonography and MRI have comparable accuracy for identifying and measuring full-thickness rotator cuff tears, but the accuracy for identifying partial-thickness still needs to be improved. MR arthrography has significantly improved sensitivity and specificity for partial-thickness tears of the cuff. Only ultrasound provides a real-time examination tool during shoulder movements. Moreover, dynamic ultrasonography can assess the contraction patterns of the supraspinatus and infraspinatus muscles, which may improve decision making in the treatment of shoulder diseases. In depicting fatty atrophy of the supraspinatus and infraspinatus muscles, MRI remains the reference standard. MRI should not be used as a diagnostic screening tool in patients with chronic shoulder pain because it does not appear to significantly affect treatment or outcome.     

Glenoid cartilage mechanical properties decrease after rotator cuff tears in a rat model

Rotator cuff repairs are commonly performed to reduce pain and restore function. Tears are also treated successfully without surgical intervention; however, the effect that a torn tendon has on the glenohumeral cartilage remains unknown. Clinically, a correlation between massive rotator cuff tears and glenohumeral arthritis has often been observed. This may be due to a disruption in the balance of forces at the shoulder, resulting in migration of the humeral head and subsequently, abnormal loading of the glenoid. Our lab previously demonstrated changes in ambulation and intact tendon mechanical properties following supraspinatus and infraspinatus rotator cuff tendon tears in a rat model. Therefore, the purpose of this study was to investigate the effects of supraspinatus and infraspinatus rotator cuff tears on the glenoid cartilage. Nine rats underwent unilateral detachment of the supraspinatus and infraspinatus tendons and were sacrificed after 4 weeks. Cartilage thickness significantly decreased in the antero‐inferior region of injured shoulders. In addition, equilibrium elastic modulus significantly decreased in the center, antero‐superior, antero‐inferior, and superior regions. These results suggest that altered loading after rotator cuff injury may lead to damage to the joint with significant pain and dysfunction. Clinically, understanding the mechanical processes involved with joint damage will allow physicians to better advise patients. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 30:1435–1439, 2012     

Relationship of a low-lying muscle belly to tears of the peroneus brevis tendon

A lack of information exists regarding predisposing factors to peroneus brevis tendon (PBT) tears. In 30 human cadaveric specimens, the location of the musculotendinous junction (MTJ) with respect to the fibula tip and peroneal tubercle was measured, as well as the tendon width. Degenerative longitudinal tears were found in 4 cases. The MTJ was significantly more distal and the tendon was thicker in torn versus untorn specimens (P < 0.05). The data suggest that longitudinal location of the peroneus brevis MTJ may have an influence on the development of degenerative tears. This feature might be an important clinical risk factor for the development of PBT tears and warrants further clinical investigation.     

磁共振肩关节造影技术诊断肩关节损伤的临床应用

目的探讨磁共振(MR)肩关节造影诊断肩关节损伤的临床价值。方法回顾性分析20例肩关节损伤患者常规MRI和MR肩关节造影的影像表现,并与肩关节镜手术结果对照。结果关节镜诊断结果:肩袖部分撕裂17例,肩袖全层撕裂3例,肩袖撕裂并发盂唇损伤5例。MRI诊断结果:肩袖部分撕裂16例,肩袖全层撕裂3例,肩袖撕裂并发盂唇损伤1例。MR肩关节造影诊断结果:肩袖部分撕裂17例,肩袖全层撕裂3例,肩袖撕裂并发盂唇损伤5例。MR肩关节造影诊断结果与关节镜结果一致。结论MR肩关节造影较常规MRI检查能够提高肩关节损伤的诊断准确性。     

Accuracy of CT arthrography in the assessment of tears of the rotator cuff

CT arthrography and arthroscopy were used to assess tears of the rotator cuff in 259 shoulders. Tear size was determined in the frontal and sagittal planes according to the classification of the French Arthroscopy Society. CT arthrography had a sensitivity of 99% and a specificity of 100% for the diagnosis of tears of supraspinatus. For infraspinatus these figures were 97.44% and 99.52%, respectively and, for subscapularis, 64.71% and 98.17%. For lesions of the long head of the biceps, the sensitivity was 45.76% and the specificity was 99.57%. Our study showed an excellent correlation between CT arthrography and arthroscopy when assessing the extent of a rotator cuff tear. CT arthrography should, therefore, be an indispensable part of pre-operative assessment. It allows determination of whether a tear is reparable (retraction of the tendon and fatty degeneration of the corresponding muscle) and whether this is possible by arthroscopy (degree of tendon retraction and extension to subscapularis).     

Contribution of clinical tests to the diagnosis of rotator cuff disease: A systematic literature review

ObjectiveTo evaluate the diagnostic performance of clinical tests for degenerative rotator cuff disease, based on a systematic literature review.MethodsWe searched Medline, Embase, and Pascal Biomed until the first half of 2006 inclusive for articles that reported at least the sensitivity and specificity of clinical tests for rotator cuff disease. Predictive values and accuracy were recorded where available. The results were discussed and validated.ResultsWe selected nine studies, of which three investigated tests for subacromial impingement syndrome and seven tests for rotator cuff tendinopathy. The Neer and Hawkins tests had good sensitivity but low specificity for subacromial impingement syndrome. For diagnosing tears of the supraspinatus or infraspinatus, the Jobe sign and the full can test showed similar performance characteristics to the Patte test and resisted external rotation with the elbow at the side flexed at 90°. For diagnosing tendinopathies with or without tears, active unresisted external rotation for the infraspinatus and the lift off test for the subscapularis were specific but lacked sensitivity. In one study, limitation of the range of active unresisted internal rotation was sensitive and specific for subscapularis tendon disease. The palm up test performed poorly for diagnosing long head of biceps disease.ConclusionsData on the diagnostic performance of clinical tests for rotator cuff tendon disease are fragmentary. However objective data exist to support the usefulness of some of these tests. Further studies are needed.     

A comparative study of ultrasonography and arthrography in evaluation of the rotator cuff

Fifty patients with signs and symptoms of chronic impingement syndrome and/or rotator cuff tear were evaluated with shoulder arthrograms and ultrasonography. Ninety asymptomatic shoulders of a comparable age had ultrasonography to serve as a control group. All controls had normal ultrasonograms with no hypoechoic or sonolucent areas. The 50 symptomatic shoulder patients had the following: 28 had a normal arthrogram with either normal ultrasonograms or buckling of the supraspinatus tendon; eight had normal arthrograms, but ultrasonography indicated a thin (less than 4 mm) irregular supraspinatus tendon; 11 had complete rotator cuff tears visualized on both arthrography and ultrasonography (nine of these 11 patients had surgery confirming complete tears in all); two had a false-positive sonogram, and one had a false-negative sonogram. Thus, the ultrasonography's overall positive predictive value to detect a full-thickness rotator cuff tear was 85%, its negative predictive value was 97%, its sensitivity was 92%, and its specificity was 95%. Real-time ultrasonography is a diagnostically sensitive and specific noninvasive method to evaluate patients with shoulder impingement syndrome, leading to the recommendation that it be used as a primary imaging technique to obviate or supplement arthrography in evaluating rotator cuff disease. However, static ultrasonographic pictures, without real-time ultrasonography as a supplement, were not helpful.     

经皮超声造影对肩袖撕裂亚型的诊断价值

目的:探讨肩袖撕裂亚型的超声造影(contrast-enhanced ultrasound,CEUS)图像特征及其对肩袖撕裂亚型的诊断价值。方法:自2019年1月至2022年3月,采用经皮超声引导下肩峰下滑囊造影(percutaneous ultrasoundguided subacromial bursography,PUSB)联合经皮超声引导下肌腱造影(persutaneous ultrasound-guide tendon lesionography,PUTL)评估疑似肩袖损伤的患者114例,其中男54例,女60例;年龄35～75 (58.8±8.7)岁;右侧76例,左侧38例。采用美国GE LOGIQ E9彩色多普勒超声诊断仪线阵探头,探头频率6～12 MHz,对患者进行超声造影检查。以肩关节镜为金标准,采用受试者工作特征(receiver operating characteristic,ROC)曲线评估超声(ultrasound,US),MRI及CEUS对肩袖损伤的诊断效能,并计算敏感度、特异性、阳性预测值、阴性预测值和准确度,采用Kappa检验比较US、MRI及CEUS诊...     

Variation in external rotation moment arms among subregions of supraspinatus, infraspinatus, and teres minor muscles.

A rotator cuff tear causes morphologic changes in rotator cuff muscles and tendons and reduced shoulder strength. The mechanisms by which these changes affect joint strength are not understood. This study's purpose was to empirically determine rotation moment arms for subregions of supraspinatus, infraspinatus, and for teres minor, and to test the hypothesis that subregions of the cuff tendons increase their effective moment arms through connections to other subregions. Tendon excursions were measured for full ranges of rotation on 10 independent glenohumeral specimens with the humerus abducted in the scapular plane at 10 and 60 degrees . Supraspinatus and infraspinatus tendons were divided into equal width subregions. Two conditions were tested: tendon divided to the musculotendinous junction, and tendon divided to the insertion on the humerus. Moment arms were determined from tendon excursion via the principle of virtual work. Moment arms for the infraspinatus (p < 0.001) and supraspinatus (p < 0.001) were significantly greater when the tendon was only divided to the musculotendinous junction versus division to the humeral head. Moment arms across subregions of infraspinatus (p < 0.001) and supraspinatus (p < 0.001) were significantly different. A difference in teres minor moment arm was not found for the two cuff tendon conditions. Moment arm differences between muscle subregions and for tendon division conditions have clinical implications. Interaction between cuff regions could explain why some subjects retain strength after a small cuff tear. This finding helps explain why a partial cuff repair may be beneficial when a complete repair is not possible. Data presented here can help differentiate between cuff tear cases that would benefit from cuff repair and cases for which cuff repair might not be as favorable.     

Ultrasonographic evaluation of the rotator cuff and biceps tendon

Ultrasonography of the rotator cuff and biceps tendon was investigated in 106 patients who had been referred for arthrography of the shoulder. Both the sensitivity and the specificity of ultrasound in detecting a tear of the rotator cuff were 91 per cent. The predictive value of a negative sonogram was 95 per cent and the predictive value of a positive sonogram was 84 per cent. Ultrasonography proved to be superior to arthrography in the examination of the normal and abnormal biceps tendon. Sonographically detectable effusions from the tendon sheath of the biceps were present in 19 per cent of this population of patients. This finding was statistically highly associated (90 per cent) with rotator cuff tears and other soft-tissue abnormalities of the shoulder. Based on these results, it appears that ultrasonography can be used as the initial imaging test for many patients with suspected abnormalities of the rotator cuff or biceps tendon.     

The sensitivity and specificity of sonographic examination in detection of rotator cuff tear]

Sonographic examination was performed in 72 patients (74 shoulders) suffering from different shoulder diseases. The results were correlated with findings obtained during subsequent surgery in 57 patients (58 shoulders) and arthrography in 15 cases (16 shoulders). Rotator cuff tear was proved during surgical procedure in 37 patients (38 shoulders). The sensitivity and specificity of ultrasonography in detection of cuff tear was 98.2% and 90% respectively. In case of partial cuff tear ultrasonography had lower sensitivity--50% while specificity was 96.3%. In detection of supraspinatus tendon tear the ultrasound sensitivity was 100% and specificity 95.6%, in case of infraspinatus tear sensitivity was 66.7% and specificity 94% while for subscapularis tear these values were equal 75% and 98.1%. The size of sonographically estimated cuff defect correlated properly with intrasurgical measurement in 76.3% of all cases.     

Preoperative tendon retraction,not smoking,is a risk factor for failure with continuity after rotator cuff repair

BackgroundSmoking is a poor prognostic factor for healing after rotator cuff repair and is associated with inferior results. We hypothesized that smokers would have higher recurrent tear rates and more postoperative myotendinous junction (MTJ) retraction in healed repairs than nonsmokers three months postoperatively.MethodsRotator cuff repairs (RCRs) were retrospectively reviewed over a 2-year period. Patients underwent magnetic resonance imaging (MRI) within 6 months prior to surgery and again at 3 months postoperatively. Seventy-nine patients were included and stratified by smokers versus nonsmokers. Baseline patient demographics, tear characteristics, and surgical factors were collected. Preoperative and postoperative MRIs were assessed to quantify the MTJ position and to establish the recurrent tear rate.ResultsFor the total cohort (nonsmokers, n = 56; smokers, n = 23), significant differences in age, race, and traumatic onset of injury existed between groups. There were no significant differences in recurrent tear between smokers (26%) and nonsmokers (27%), but nonsmokers were more satisfied. For patients with healed RCRs (nonsmokers, n = 41; smokers, n = 17), there were significant differences in race. On univariate analysis, nonsmokers had a significantly more lateral MTJ postoperatively (P = 0.05). On multivariable regression analysis, medialized postoperative MTJ position in healed cuffs was driven only by greater preoperative rotator cuff retraction preoperatively. There were no significant differences in MTJ position based on smoking status for patients with healed RCRs.ConclusionSmoking does not appear to be an independent risk factor for postoperative MTJ retraction in healed RCRs, also known as failure in continuity. Preoperative tear size and retraction play the biggest roles in predicting postoperative MTJ position, regardless of smoking status. There are no significant differences in patient-reported outcomes for patients with healed RCRs, but nonsmokers had more satisfaction following RCR in the total cohort.Level of EvidenceLevel III; Retrospective cohort study; Diagnostic study     

Prevention of chronic entrapment of the ring finger flexor profundus muscle in ulnar shaft fractures in children – a case report

Background Diagnostic ultrasound examination of the shoulder is generally considered to require long experience. We examined the results of an orthopedic surgeon with little experience of ultrasound.

Patients and methods A relatively inexperienced examiner performed preoperative ultrasound scanning of 79 patients with symptoms from the rotator cuff and/or the long head of the biceps muscle. Tears of the rotator cuff and rupture or dislocation of the long head of the biceps muscle were the positive findings of interest. Results were compared to operative findings.

Results In 66 of 79 shoulders, ultrasonographic rotator cuff findings were confirmed at surgery (accuracy 84%). 20 of 26 full-thickness tears were diagnosed correctly. 6 of 7 partial-thickness tears were overlooked. Ultrasound was false positive in 1 case. For the long head of the biceps muscle, all 8 cases of dislocation or rupture of the tendon were diagnosed but differentiation between the two conditions was not possible in 2 cases.

Interpretation Our results may encourage orthopedic surgeons to start using ultrasound as a diagnostic technique for full-thickness tears of the rotator cuff and for pathology in the long head of the biceps muscle.     

The diagnostic value of arthrography and plain radiography in rotator cuff tears

In 26 patients with surgically verified rotator cuff tears, the findings at radiography and arthrography were analysed. Plain anteroposterior radiograms were of no value in diagnosis. In plain groove-films, the slope of the medial wall and the depth of the intertubercular groove correlated with dislocations of the biceps tendon. In arthrography, leakage of the contrast medium into the subacromial or subdeltoid bursa was a reliable sign of a full-thickness tear. There was no correlation between the size of the tear measured at arthrography and at surgery. In cases where the biceps tendon sheath was visualised, the appearance was in agreement with the surgical findings.     

Lesions of the rotator cuff footprint: diagnostic performance of MR arthrography compared with arthroscopy

Background

To evaluate the diagnostic performance of magnetic resonance arthrography (MR-A) of the shoulder in the diagnosis of rotator cuff tears involving the humeral insertion of the supraspinatus and infraspinatus tendon (footprint), using arthroscopy as the reference standard.

Materials and methods

The study population included 90 consecutive patients with history and clinical diagnosis of instability of the shoulder, rotator cuff tear or posterosuperior glenoid impingement. A total of 108 MR arthrograms were performed, since 18 patients had undergone a bilateral procedure. Arthroscopy, which was performed within 45 days after MR-A, was used as the reference standard. Sensitivity, specificity, accuracy, positive and negative predictive values were then calculated.

Results

Magnetic resonance arthrography showed a sensitivity of 92 % and a specificity of 78 % for the overall detection of tears involving the rotator cuff footprint. The diagnostic accuracy was 90 %, and the positive and negative predictive values were 95 and 64 %, respectively. Ten lesions were non-classifiable on surgery, of which eight were non-classifiable on MR-A also.

Conclusions

Magnetic resonance arthrography is extremely accurate for the detection and classification of rotator cuff footprint tears. Most of these lesions are articular-sided (partial articular-sided supraspinatus tendon avulsion lesions) with predominance in younger patients and concealed type of tear (concealed interstitial delamination lesions).

     

肩袖损伤诊断中肩关节造影和MRI的敏感性和特异性比较

目的 通过随访分析,比较肩关节造影和ＭＲＩ诊断户袖部分和完全撕裂的敏感性和特异性。方法 对５３例怀疑有肩袖损伤（包括部分撕裂和完全撕裂）患者的术前关节造影和ＭＲＩ检查结果与术中发现进行比较分析。结果 肩关节造影、ＭＲＩ诊断肩袖部分撕裂的敏感性分别为７０％和８０％,特异性均为７５％。诊断肩袖完全撕裂的敏感性分别为８７％和９０％,特异性分别为１００％和７５％。结论 关节造影与ＭＲＩ诊断肩袖损伤敏感性无     

Mechanical properties of the long‐head of the biceps tendon are altered in the presence of rotator cuff tears in a rat model

Rotator cuff tears are disabling conditions that result in changes in joint loading and functional deficiencies. Clinically, damage to the long‐head of the biceps tendon has been found in conjunction with rotator cuff tears, and this damage is thought to increase with increasing tear size. Despite its importance, controversy exists regarding the optimal treatment for the biceps. An animal model of this condition would allow for controlled studies to investigate the etiology of this problem and potential treatment strategies. We created rotator cuff tears in the rat model by detaching single (supraspinatus) and multiple (supraspinatus + infraspinatus or supraspinatus + subscapularis) rotator cuff tendons and measured the mechanical properties along the length of the long‐head of the biceps tendon 4 and 8 weeks following injury. Cross‐sectional area of the biceps was increased in the presence of a single rotator cuff tendon tear (by ～150%), with a greater increase in the presence of a multiple rotator cuff tendon tear (by up to 220%). Modulus values decreased as much as 43 and 56% with one and two tendon tears, respectively. Also, multiple tendon tear conditions involving the infraspinatus in addition to the supraspinatus affected the biceps tendon more than those involving the subscapularis and supraspinatus. Finally, biceps tendon mechanical properties worsened over time in multiple rotator cuff tendon tears. Therefore, the rat model correlates well with clinical findings of biceps tendon pathology in the presence of rotator cuff tears, and can be used to evaluate etiology and treatment modalities. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27:416–420, 2009