Standard sonography and arthrosonography in the study of rotator cuff tears

PURPOSE: The aim of this study was to evaluate the sensitivity of ultrasonography, integrating standard ultrasound and arthrosonography after injecting a saline solution into the glenohumeral cavity in cases of suspected rotator cuff tears. MATERIALS AND METHODS: We prospectively examined 40 patients awaiting shoulder arthroscopy for suspected or diagnosed tears of the rotator cuff. A radiologist, unaware of the pre-operative diagnosis, performed an ultrasound scan on all the patients before and after the injection of saline solution into the glenohumeral cavity. The parameters considered were presence or absence of a rotator cuff injury; type of injury according to Snyder and its extent along the longitudinal and transverse planes; presence or absence of effusion into the articular cavity; subacromial/subdeltoid bursal distension. All the patients underwent arthroscopy either the same day or the day after the ultrasound examination. RESULTS: Standard sonography showed 26 complete rotator cuff tears (type C according to Snyder), 2 partial tears (type B according to Snyder) and 12 intact rotator cuffs.Arthrosonography detected 31 complete rotator cuff tears (type C according to Snyder), 1 partial tear (type B according to Snyder) and 8 intact rotator cuffs.Arthroscopy identified 32 complete rotator cuff tears (type C according to Snyder), 1 partial tear (type B according to Snyder) and 8 intact rotator cuffs.Analysis of the results shows that, taking arthroscopy as the gold standard, the sensitivity of normal sonography is 81.2%, whereas that of arthrosonography is 96.8% (p < 0.05). CONCLUSIONS: On the basis of the data obtained in this study, standard sonography, integrated with the injection of a saline solution into the glenohumeral cavity, considerably increases the diagnostic sensitivity for rotator cuff tears. The authors suggest that arthrosonography can be used in the event of suspected rotator cuff tears, when MRI is contraindicated.     

Detection and measurement of rotator cuff tears with sonography: analysis of diagnostic errors

OBJECTIVE: The purpose of this study was to analyze the causes of errors in the detection and measurement of rotator cuff tears in our patient population. SUBJECTS AND METHODS: Seventy-one consecutive patients with shoulder pain who were prospectively studied with sonography had subsequent arthroscopy that showed a full-thickness or partial-thickness tear or intact cuff. For sonography and arthroscopy, the length or degree of retraction and width of a tear, when present, was recorded. When there were discrepant findings, representative images were jointly evaluated by the radiologist and orthopedic surgeon to determine the cause of the error. RESULTS: Fifteen detection errors were found, including five misses (three < 5-mm subscapularis and two small partial-thickness tears), four errors inherent with the test (distinguishing large bursal side or extensive partial-thickness from full-thickness tears and tendinopathy from partial-thickness tears), three errors of an unknown cause, two due to misinterpretation, and one error inherent with the patient. Seventeen measurement errors occurred with full-thickness tears, 15 of those in patients with large or massive tears. Bursal thickening (n = 4), non-visualization of the torn tendon end (n = 2), nonretracted tear (n = 2), and complex tear (n = 1) contributed to the errors. Eight measurement errors occurred with partial-thickness tears. Difficulty distinguishing tendinopathy from partial-thickness tears (n = 3) and complex tears (n = 3) accounted for six errors. CONCLUSION: Although infrequent, detection errors were due to limitations inherent with the test or misses. Limitations inherent with the patient and misinterpretation of the findings were rare. Most measurement errors occurred in patients with large or massive cuff tears.     

Arthroscopic rotator cuff repair

The use of the arthroscope to address shoulder pathology is continuously evolving. Many aspects of shoulder arthroscopy are readily accepted and used by orthopedic surgeons, but some procedures can be technically difficult. Arthroscopic rotator cuff repair has traditionally involved the use of cumbersome knot tying techniques, deterring many surgeons from using this technique. Although open and mini-open rotator cuff repair is commonly used with predictable results, there still remains inherent morbidity to any open technique. This article will outline a technique that avoids knot tying and suture management in arthroscopic rotator cuff repair. Although the indications are evolving, arthroscopic rotator cuff repair allows predictable results with excellent pain relief and return to function.     

Partial-thickness rotator cuff tears

Partial-thickness tears of the rotator cuff have been diagnosed with increased frequency because of a heightened awareness of the condition by clinicians and improved diagnostic methods. Research into the causes, natural history, and optimal treatment of this condition lags behind that of full-thickness tears. However, despite the limitations in the existing literature, there has emerged a consensus among shoulder experts that partial-thickness rotator cuff tears should be aggressively treated in the active athlete because of the unfavorable natural history of these lesions and success of accepted surgical algorithms. This review will provide an overview of the theories regarding the origins of partial-thickness rotator cuff tears, discuss the relative accuracy of accepted diagnostic techniques, and summarize the indications and methods of operative repair with an emphasis on the results of various treatment approaches.     

Ultrasonography of the rotator cuff

The authors suggest that sonography may be the best screening study for the diagnosis of rotator cuff tears.     

Imaging of the rotator cuff

The imaging evaluation of the rotator cuff augments the clinical evaluation. Radiography, computed tomography, and magnetic resonance imaging all have various roles in the assessment of the rotator cuff, which can be combined with arthrography for added detail. Furthermore, ultrasound is a very useful technique that provides functional information that is not offered by simple anatomic imaging.     

Rehabilitation of rotator cuff tendinopathy

Rehabilitation of the dysfunction that is associated with rotator cuff tendinopathy should be based on the evidence known about the pathoetiology of the tendinopathy, what is known about the extent of the local anatomic injury, the local and distant physiological and biomechanical alterations, and on the knowledge developed regarding progressive loading of the injured or altered structures. Prehabilitation, or prospective exercises to minimize future rotator cuff loading stresses, should be included at the end of rehabilitation as part of the return to function.     

Histopathology of rotator cuff tears

The pathogenesis of rotator cuff tears is multifactorial. Tendon abnormalities of the rotator cuff include alteration of collagen fiber structure, tenocytes, cellularity, and vascularity. Ruptured tendons show marked collagen degeneration and disordered arrangement of collagen fibers. Fibroblast population decreases as the size of the tear in the rotator cuff increases. The larger fibroblast population seen in the smaller tears is also actively proliferating and is part of an active reparative process. Inflammatory cell infiltrate correlates inversely to rotator cuff tear size in the torn supraspinatus tendon samples, with larger tears showing a marked reduction in all cell types. As tear size increase, there is also a progressive decrease in the number of blood vessels. Whether rotator cuff tear heals spontaneously is an important pathologic and clinical question. Histologic changes indicative of repair and inflammation lead to consider biological options in addition to biomechanical treatment of the rotator cuff tears.     

The rotator cuff functional index

BACKGROUND: Despite improvements in the clinical assessment of rotator cuff injuries, shortcomings exist in diagnosing rotator cuff tears. PURPOSE: To formulate a clinical rotator cuff functional index for predicting rotator cuff tears based on handheld dynamometer measurements for shoulder strength testing and to assess its ability to diagnose a rotator cuff tear. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Preoperative handheld dynamometer measurements, including supraspinatus, external rotation, internal rotation, adduction, and lift-off force, were compared in 100 patients with full-thickness rotator cuff tears (> 1.0 cm) and 100 patients with no rotator cuff injury (confirmed by arthroscopy). Using multiple logistic regression analysis, the rotator cuff functional index and index for rotator cuff tear size were formulated in which 100 represented excellent rotator cuff function and less than 0 indicated a full-thickness supraspinatus tear. Each patient's index was calculated to determine its clinical value in predicting a rotator cuff tear; the Pearson correlation coefficient was established for the rotator cuff functional index for rotator cuff size. RESULTS: Two handheld dynamometer measurements predicted a rotator cuff tear (P < .001, r = 0.53), with rotator cuff functional index = 1.27 * supraspinatus (N) - 0.72 * adduction (N) - 11.6, but not tear size (r = 0.38). In predicting a rotator cuff tear (rotator cuff functional index < 0 = rotator cuff tear; rotator cuff functional index > 0 = no tear), the rotator cuff functional index had 83% sensitivity, 79% specificity, 80% positive predictive value, 82% negative predictive value, likelihood ratio of 4.0 for a positive test result and 0.2 for a negative test result and an accuracy of 81%. CONCLUSION: The 2 most useful tests for determining a rotator cuff tear with a handheld dynamometer were supraspinatus force and adduction force (as negative control). A functional index based on these measurements was able to rule out a rotator cuff tear and predict the presence but not the size of the tear.     

All arthroscopic rotator cuff repairs

The arthroscopic operation for repair of full-thickness rotator cuff tears is successful and has the advantages ofglenohumeral joint inspection, treatment of intra-articular lesions, smaller incisions, no deltoid detachment, less soft tissue dissection, less pain, and more rapid rehabilitation. However, these advantages must be balanced against the technical difficulty of the method, which limits its application to surgeons skilled in both open and arthroscopic shoulder operations. This article contains many technical pearls to, as much as is possible, simplify and improve all arthroscopic cuff repair.     

Neoinnervation in rotator cuff tendinopathy

The aim of this study was to determine whether there are more nerves in tendinopathic human tendon, and if so, where are they located. Tendon biopsies were collected from normal, tendinopathic, and torn human rotator cuff tendons and then analyzed using immunohistochemistry and antibodies against a general nerve marker (protein gene product 9.5, PGP9.5), a nerve regeneration marker (growth-associated protein 43, GAP43), and an endothelial cell marker (CD34). Nerve fibers exhibiting PGP9.5 or GAP43 immunoreactivity were often observed intimately in association with tiny blood vessels in the endotendineum of tendinopathic tendons. The expression of PGP9.5 and GAP43 were significantly higher in tendinopathic tendon compared with control tendon and torn tendon. These data support the hypothesis that early tendinopathy is associated with increases of newly grown nerve fibers and blood vessels inside and around tendinopathic tendon, and these may be the source of pain in tendinopathy.     

MR imaging of the rotator cuff

MR imaging is the optimal method for evaluating suspected rotator cuff pathology.Current techniques of fast spin-echo imaging without and with fat suppression allow accurate identification and characterization of tendinous and myotendinous abnormalities of the rotator cuff. Impingement disorders, tendon degeneration, instability,and trauma comprise the multifactorial nature of rotator cuff disease. This article addresses the role of MR imaging in evaluating the rotator cuff and the importance of MR imaging in identifying other lesions that may mimic rotator cuff pathology. A rationale for protocol design, including MR arthrography and the use of specialized positioning, such as abduction and external rotation (ABER), are discussed.     

Conservative management of rotator cuff tear

Ranking among the most prevalent of shoulder disorders, lesions involving shoulder rotator cuff strike million of patients in the United States at different points in their lives. Despite the fact that rotator cuff disease is a very common cause of pain and disability of the upper arm, a high proportion of patients is asymptomatic and unaware of performing daily living activities despite of a shoulder lesion. Given these drawbacks, surgeons are trying exploring whether conservative treatment is a viable option for the management of these injuries. This study presents a rationale to consider nonoperative treatment an effective option when dealing with patients with rotator cuff tears.