Rotator cuff contusions of the shoulder in professional football players: epidemiology and magnetic resonance imaging findings

BACKGROUND: No published reports have studied the epidemiology and magnetic resonance imaging findings associated with rotator cuff contusions of the shoulder in professional football players. PURPOSE: To determine a single professional football team's incidence, treatment, and magnetic resonance imaging appearance of players sustaining rotator cuff contusions of the shoulder. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: From 1999 to 2005, a North American professional football team's injury records were retrospectively reviewed for athletes who had sustained a rotator cuff contusion of the shoulder during in-season participation. Those patients who had magnetic resonance imaging of the shoulder with a 1.5-Tesla magnet were reviewed by a musculoskeletal radiologist and graded according to the appearance and severity of clinical injury. RESULTS: Twenty-six players had a rotator cuff contusion. There was an average of 5.5 rotator cuff contusions per season (47% of all shoulder injuries). The predominant mechanism of injury was a direct blow in 70.3%. Magnetic resonance imaging findings included peritendon edema at the myotendinous junction, critical zone tendon edema, and subentheseal bone bruises. Treatment consisted of a protocol involving modalities and cuff rehabilitation in all patients. Six patients had persistent pain and weakness for a minimum of 3 days and were given a subacromial corticosteroid injection. Overall, 3 patients (11.4%) required later surgical treatment on the shoulder. CONCLUSION: Rotator cuff contusions accounted for nearly half of all shoulder injuries in the football players in this study. Magnetic resonance imaging is an extremely useful tool in determining severity of injury and integrity of the rotator cuff. The majority of athletes are able to return to sports with conservative treatment; a minority of shoulders might progress to more severe injuries such as rotator cuff tears.     

Imaging of degenerative and posttraumatic disease in the shoulder joint with ultrasound

This article reviews the examination technique of shoulder ultrasound, normal and abnormal ultrasound findings in acute (posttraumatic) and chronic (degenerative) lesions. Moreover, it reviews the effectiveness of ultrasound in relation to magnetic resonance (MR) imaging. Most authors report that full-thickness tears of the supraspinatus can reliably be diagnosed by ultrasound. However, the simple diagnosis of a full-thickness rotator cuff tear is no longer sufficient for surgical management. The precise localization and size of rotator cuff tears as well as the extent of muscle degeneration is important for surgical planning. For this aspect and for partial-thickness tears of the supraspinatus, for subscapularis lesions as well as for lesions of the long biceps tendons there is no consensus regarding the diagnostic value of ultrasound. To the present, ultrasound (contrary to MR imaging) has failed to demonstrate that it consistently influences the clinician's degree of confidence in the clinical diagnosis or the treatment plan. Therefore, some orthopedic surgeons prefer MR imaging to ultrasound in the evaluation of rotator cuff tears and other abnormalities of the glenohumeral joint. Moreover, MR imaging, especially when combined with arthrography, represents a one-step investigation, which not only allows for assessment of rotator cuff lesion but also of lesions of the labrum (Bankart lesions, SLAP lesions), the joint capsule and the biceps tendon. It also demonstrates muscle atrophy, which represents an important predictor of surgical outcome in rotator cuff repair.     

Diagnosis of tears in rotator-cuff-injuries

Pathology of the rotator cuff is the cause of most common problems at the shoulder joint. Acute injuries are not as frequent as chronic cuff disease, but often they aggravate inflammatory or degenerative tendon alterations, even if they are of minor severity. Traumatic rotator cuff tears predominantly affect the supraspinatus tendon or the rotator interval. The subscapularis tendon is involved in anterior dislocations of the glenohumeral joint or in direct trauma. Plain film radiography still remains the base of all further imaging studies. If only full-thickness tears must be ruled out, double-contrast arthrography and ultrasound are acceptable imaging modalities. However, the former has a drawback in being invasive and does not detect partial tears at the bursal site of the cuff or rotator cuff tendinopathy, whereas the latter heavily depends on the experience of the radiologist and is restricted to the rotator cuff. Nowadays the most comprehensive imaging method is magnetic resonance (MR) imaging. MR imaging enables the detection or exclusion of complete rotator cuff tears with a reasonable accuracy and is also suitable to diagnose further pathologies of the shoulder joint. MR arthrography is valuable in the detection of subtle anatomic details and further improves the differentiation of rotator cuff diseases. Although in comparison MR imaging is still the most expensive imaging method, its high negative predictive value for the diagnosis of complete rotator cuff tears and its reliability evaluating different shoulder joint pathologies make it the preferred imaging modality.     

MRI and sonography of the shoulder

We prospectively evaluated the diagnostic value of sonography and magnetic resonance imaging (MRI) in 24 shoulders in 23 patients with suspected rotator cuff tears using arthrography as gold standard. Sonography demonstrated 14 of 15, MRI 10 of 15 rotator cuff tears, respectively. Sonography diagnosed seven of nine intact rotator cuffs correctly, MRI eight of nine. In a retrospective study we reviewed the diagnostic value of sonography and MRI in other pathologies of the shoulder including intra-articular pathology, humeral head and acromioclavicular joint pathology, and calcification. We conclude that with regard to cost and patient compliance, sonography should be the first radiologic examination in suspected rotator cuff tears if performed by an experienced sonographer. MRI is superior in depicting additional pathology and is less operator dependent. It may thus become the method of choice for the evaluation of the rotator cuff and related pathology in the future.     

Evaluation and treatment of rotator cuff tears

Rotator cuff injuries are common problems and a frequent reason for patients to present to primary care physicians. These injuries are seen more frequently now with the aging population. These muscles allow for movement of the arm in overhead activities and controlled movements through space. A thorough physical examination can lead to the diagnosis of rotator cuff pathology. Radiographic imaging may offer some insight into the underlying pathology, and magnetic resonance imaging provides for excellent visualization of the rotator cuff. Many rotator cuff tears, especially partial tears, will symptomatically improve with conservative management. Surgical treatment may offer improved pain relief and function in those patients for whom nonoperative care is insufficient. In cases in which rotator cuff repair is not possible, the reverse total shoulder arthroplasty is a possibility. New technologies are also under investigation that allow for biological augmentation of rotator cuff tears.     

Mechanical properties of the rotator cuff: response to cyclic loading at varying abduction angles

The rotator cuff is loaded under static as well as dynamic conditions. Whilst the static properties of the rotator cuff muscle-tendon junctions have been reported, the dynamic mechanical behaviour has not. This study reports the dynamic mechanical properties with varying abduction angles in a human cadaver rotator cuff. No significant effect was found with varying the angle of testing or in the presence of a tear in the tendon. The supraspinatus was found to be the stiffest of the rotator cuff tendons followed by the subscapularis and infraspinatus.     

MRI of the shoulder

Magnetic resonance imaging of the shoulder is routinely used, especially in the evaluation of rotator cuff disease and glenohumeral instability. More recent studies have provided a more sophisticated understanding of what represents a pathologic rotator cuff. Similarly, there has been an increased focus on the role of the glenohumeral ligaments and their labral attachment sites in maintaining glenohumeral stability. There have been technical advances as well, including the increased use of magnetic resonance arthrography. In addition, newer studies have shed light on the pathophysiology of the long bicipital tendon and compression neuropathies involving the suprascapular and axillary nerves.     

"Uncoverage" of the humeral head by the anterolateral acromion and its relationship to full-thickness rotator cuff tears

The relationship between the humeral head and the anterolateral acromion was compared for subjects with and without full-thickness rotator cuff tears, as indicated by magnetic resonance imaging, using a case-control design. "Uncoverage" of the humeral head by the anterolateral acromion was defined as the percentage of the humeral head width not covered superiorly by the anterolateral acromion, as measured digitally on magnetic resonance imaging scans of the shoulder in the oblique coronal plane. The uncoverage of the humeral head by the anterolateral acromion was 32.0% for men > or = 40 years of age with normal rotator cuffs (n = 39) and 38.2% for men > or = 40 years of age with full-thickness rotator cuff tears (n = 43). The difference in uncoverage of 6.2% was statistically significant (p < 0.001). The uncoverage of the humeral head by the anterolateral acromion was 36.1% for women > or = 40 years of age with normal rotator cuffs (n = 10) and 41.8% for women > or = 40 years of age with full-thickness rotator cuff tears (n = 17). The difference in uncoverage of 5.72% was not statistically significant with the number of subjects available (p = 0.108). We concluded that increased uncoverage of the humeral head by the anterolateral acromion may be a factor in the pathogenesis of full-thickness rotator cuff tears.     

Imaging of the rotator cuff and biceps tendon

Several different imaging techniques are available for evaluating the rotator cuff and biceps tendon. The common disorders of impingement, rotator cuff tears and biceps tendonitis are discussed along with the role which the various imaging modalities can play in establishing their diagnosis. Plain radiographs can be helpful particularly with a history of trauma but give limited information on the soft tissues. Ultrasound is a useful and inexpensive means of assessing the rotator cuff and biceps tendon but has a number of limitations and varying reports on its accuracy. Computed tomography (CT) is most helpful in the evaluation of shoulder trauma but gives limited information on the soft tissues. Magnetic resonance imaging (MRI) is an accurate imaging modality for evaluating the rotator cuff and biceps tendon, allowing visualisation of the soft tissues and the adjacent bony structures.     

Magnetic resonance imaging of sports-related injuries to the shoulder: impingement and rotator cuff

MR imaging provides clinically useful information in detecting and characterizing sports-related pathology of the rotator cuff and other shoulder disorders in a non-invasive fashion. Complete and partial tears of the rotator cuff, as well as factors contributing to impingement, can be detected and characterized with MR imaging. The size and location of complete tears of the rotator cuff can be accurately determined with MR imaging.     

Evaluation and Treatment of Rotator Cuff Tears

Abstract

Rotator cuff injuries are common problems and a frequent reason for patients to present to primary care physicians. These injuries are seen more frequently now with the aging population. These muscles allow for movement of the arm in overhead activities and controlled movements through space. A thorough physical examination can lead to the diagnosis of rotator cuff pathology. Radiographic imaging may offer some insight into the underlying pathology, and magnetic resonance imaging provides for excellent visualization of the rotator cuff. Many rotator cuff tears, especially partial tears, will symptomatically improve with conservative management. Surgical treatment may offer improved pain relief and function in those patients for whom nonoperative care is insufficient. In cases in which rotator cuff repair is not possible, the reverse total shoulder arthroplasty is a possibility. New technologies are also under investigation that allow for biological augmentation of rotator cuff tears.     

Evaluation of post-exercise magnetic resonance images of the rotator cuff

 Objective. To examine the effect of strenuous exercise on the magnetic resonance imaging (MRI) characteristics of the rotator cuff tendon. A second objective was to define an optimal time to image the rotator cuff and possibly eliminate exercise-induced false positives. Design and patients. Five male subjects from 24 to 38 years old with normal rotator cuffs by history, physical examination, and screening MRI underwent a rotator cuff exercise session on the Biodex System 2 (Biodex, Shirley, New York). The exercise sessions were followed by sequential MRI scans of the exercised shoulder. These were performed immediately and at 8 h and 24 h after exercise. Results and conclusions. The rotator cuff tendon and subacromial-subdeltoid bursal signal remained unchanged from the pre-exercise through the 24-h post-exercise scans. The rotator cuff muscle signal was increased in five of five subjects on the immediate post-exercise fat-suppressed T2-weighted images. This signal returned to baseline by the 8-h scan. Positive findings of rotator cuff pathology on MRI after strenuous athletic activity should not be discounted as normal exercise-induced changes. Also, diagnostic MRI scanning may take place after a practice session without an increased risk of false positives.     

Ultrasound of the rotator cuff with MRI and anatomic correlation

Magnetic resonance imaging and high-resolution ultrasound (US) are frequently used for the detection of rotator cuff tears. The diagnostic yield of US is influenced by several factors as technique, knowledge of the imaging characteristics of anatomic and pathologic findings and of pitfalls. The purpose of this article is to illustrates that the standardized high-resolution US examination of the shoulder covers the entire rotator cuff and correlates with MR imaging and anatomic sections.     

Cystic changes at supraspinatus and infraspinatus tendon insertion sites: association with age and rotator cuff disorders in 238 patients

PURPOSE: To retrospectively determine the frequency of posterior and anterior cystic abnormalities at rotator cuff insertion site on the greater tuberosity and to determine their relationship to patient age and rotator cuff disorders. MATERIALS AND METHODS: Institutional review board approval was given; informed consent was waived. The study was HIPAA compliant. In 238 patients with rotator cuff diagnoses at surgery, preoperative magnetic resonance (MR) imaging studies were reviewed to localize osseous cystic changes as anterior (supraspinatus insertion site) or posterior (infraspinatus insertion site) on the greater tuberosity. If rotator cuff tear was present, tendon retraction and location of partial tear (articular or bursal surface) were recorded. Two radiologists reached conclusions by consensus. Locations of cysts were correlated to surgical cuff diagnoses: no tear, tendinopathy, partial-thickness tear, and complete tear. Prospective interpretations from original MR reports were compared with surgical results. Statistical analyses included one-way analysis of variance, chi(2), Fisher exact, and Student t tests, as well as logistic regression and receiver operating characteristic curve comparison. RESULTS: There were 238 consecutive patients (150 men, 88 women; mean age, 43 years). Cysts were located at or near footprint of cuff tendon and demonstrated fluid or soft-tissue signal intensities. Posterior cysts occurred in 56.7% of shoulders and showed no statistical correlation to age or cuff diagnosis. Anterior cysts occurred in 22.7% of shoulders and were strongly associated with cuff disorders (P<.001). Controlling for cuff disorders, there was no relationship between anterior cysts and age (P>.50). Anterior cysts were more common in partial-thickness articular (48%) than in bursal (13%) tears (P<.001). CONCLUSION: Posterior cysts were more common than anterior cysts and showed nearly random distribution among patients, regardless of age and cuff diagnosis. Anterior cysts were closely associated with cuff disorders.     

Current imaging of the rotator cuff

Rotator cuff pathology is a common cause of shoulder pain, and imaging plays a major role in the management of shoulder problems. General radiography may be useful as an initial screening test particularly in trauma and arthritis. Musculoskeletal ultrasound and magnetic resonance imaging are the most suitable modalities for the investigation of the rotator cuff, having high sensitivities and specificities for full-thickness tears. Musculoskeletal ultrasound and magnetic resonance imaging are less accurate in the detection of partial-thickness tears with greater observer variability. This article reviews the normal and pathologic imaging features of the rotator cuff and highlights the potential usefulness and limitations of various imaging modalities in the assessment of the tendon and the potential impact of imaging findings on clinical patient care.     

Equivalent clinical results of arthroscopic single-row and double-row suture anchor repair for rotator cuff tears: a randomized controlled trial

BACKGROUND: Restoring the anatomical footprint may improve the healing and mechanical strength of repaired tendons. A double row of suture anchors increases the tendon-bone contact area, reconstituting a more anatomical configuration of the rotator cuff footprint. HYPOTHESIS: There is no difference in clinical and imaging outcome between single-row and double-row suture anchor technique repairs of rotator cuff tears. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: The authors recruited 60 patients. In 30 patients, rotator cuff repair was performed with a single-row suture anchor technique (group 1). In the other 30 patients, rotator cuff repair was performed with a double-row suture anchor technique (group 2). RESULTS: Eight patients (4 in the single-row anchor repair group and 4 in the double-row anchor repair group) did not return at the final follow-up. At the 2-year follow-up, no statistically significant differences were seen with respect to the University of California, Los Angeles score and range of motion values. At 2-year follow-up, postoperative magnetic resonance arthrography in group 1 showed intact tendons in 14 patients, partial-thickness defects in 10 patients, and full-thickness defects in 2 patients. In group 2, magnetic resonance arthrography showed an intact rotator cuff in 18 patients, partial-thickness defects in 7 patients, and full-thickness defects in 1 patient. CONCLUSION: Single- and double-row techniques provide comparable clinical outcome at 2 years. A double-row technique produces a mechanically superior construct compared with the single-row method in restoring the anatomical footprint of the rotator cuff, but these mechanical advantages do not translate into superior clinical performance.     

Prospective evaluation of the effect of rotator cuff integrity on the outcome of open rotator cuff repairs

BACKGROUND: Open rotator cuff repairs have led to excellent clinical results; however, several studies have linked postoperative structural integrity to patient outcomes. The purpose of this study is to prospectively assess postoperative cuff integrity after open rotator cuff repair and assess its relationship to clinical outcome. HYPOTHESIS: Preoperative rotator cuff tear size and postoperative rotator cuff integrity are important factors in overall clinical outcomes. STUDY DESIGN: Prospective nonrandomized clinical outcomes study. METHODS: Forty-seven consecutive patients undergoing repair of full-thickness rotator cuff tears by a single surgeon were enrolled in this prospective study. A standardized evaluation was performed preoperatively and postoperatively at annual intervals. All patients underwent postoperative magnetic resonance imaging at least 1 year after surgery. Statistical evaluation was performed using paired and unpaired 2-tailed t tests for comparison. RESULTS: Thirty-two patients were available for evaluation. Overall, the patients experienced a significant (P < .05) improvement in their American Shoulder and Elbow Surgeons survey (40-85) and Constant (53-80) scores. The overall retear rate was 31%. Although patients with large tears preoperatively and retears postoperatively had lower overall outcomes scores, this was not significant. CONCLUSION: These data support open rotator cuff repair as an effective technique that restores excellent shoulder function. The authors did not find postoperative cuff integrity to have a significant effect on outcomes when compared with those with an intact cuff. In fact, those with a retear still had a significant improvement in all clinical areas assessed, including strength.     

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.     

Gadolinium MR Arthrography of the Rotator Cuff

Conventional magnetic resonance imaging (MRI) of the rotator cuff has not done well in distinguishing partial-thickness tears from tendonitis or small, full-thickness tears. However, these are important distinctions for orthopedic surgeons who are deciding whether to operate and what type of surgery to perform on a patient with suspect rotator cuff pathology. Gadolinium magnetic resonance arthrography (MRA) involves injecting dilute gadolinium into the shoulder under fluoroscopy. Subsequent multiplanar T1-weighted fat-suppressed fast spin echo combined with T2-weighted fast spin echo and short tau inversion recovery (STIR) produces images that can accurately differentiate absence of tear from partial-thickness tear and from small, full-thickness tear; as a fringe benefit, this combination of sequences can identify the inflammation associated with tendonitis. Furthermore, the technique differentiates articular from bursal surface partial-thickness tears, and it accurately quantitates the size of full-thickness tears to help surgeons choose between arthroscopic versus open surgery.     

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.