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.     

Trabecular microstructure and surface changes in the greater tuberosity in rotator cuff tears

OBJECTIVE: When planning surgery in patients with rotator cuff tear, strength of bone at the tendon insertion and trabecular bone structure in the greater tuberosity are usually taken into consideration. We investigated radiographic changes in bone structure of the greater tuberosity in rotator cuff tears. DESIGN: Twenty-two human cadaveric shoulders from subjects ranging from 55 to 75 years of age were obtained. The integrity of the rotator cuff was examined by sonography to determine if it is intact without any tear, or torn partially or completely. The humeral head was sectioned in 3 mm thick coronal slab sections and microradiographed. After digitization of the microradiographs and imaging processing with in-house semi-automated image processing software tools developed using software interfaces on a Sun workstation, the trabecular histomorphometrical structural parameters and connectivity in the greater tuberosity were quantified. The degenerative changes on the surface of the greater tuberosity were interpreted blindly by 2 independent readers. RESULTS: Among the 22 shoulder specimens, the rotator cuff was found intact in 10 shoulders, partially in 7 and fully torn in 5. Statistically significant loss in apparent trabecular bone volume fraction, number of trabecular nodes, and number of trabecular branches, and a statistically significant increase in apparent trabecular separation and number of trabecular free ends were found in the greater tuberosity of the shoulders with tears. The loss was greater in association with full tear than in partial tear. Thickening of the cortical margin of the enthesis, irregularity of its surface, and calcification beyond the tidemark were observed in 2 (20%) shoulders with intact rotator cuff, in 6 (86%) shoulders with partial tear, and in 5 (100%) shoulders with full tear. CONCLUSIONS: Rotator cuff tears are associated with degenerative changes on the bone surface and with disuse osteopenia of the greater tuberosity. Aging, degenerative enthesopathy of the supraspinatus tendon, and rotator cuff tears appear closely related.     

Greater tuberosity notch: an important indicator of articular-side partial rotator cuff tears in the shoulders of throwing athletes.

We examined the location of rotator cuff tears, associated labral injuries, and notches on the greater tuberosity of the humeral head in shoulders of throwing athletes. Arthroscopic findings (rotator cuff tear, labral condition, and greater tuberosity notch) as well as other factors (duration of playing baseball, range of motion, and joint laxity) of 61 baseball players were retrospectively studied. The presence of a greater tuberosity notch was also evaluated for by plain radiographs. Forty patients had articular-side partial rotator cuff tears, most of which occurred in the interval between the supraspinatus and infraspinatus tendons. The existence of a rotator cuff tear was not related to the range of motion, joint laxity, the detachment of the superior glenoid labrum, or posterosuperior labral injury. Greater tuberosity notches were recognized in 38 shoulders by arthroscopy and most were detected on plain radiographs. The presence of a notch was significantly related to the existence of a rotator cuff tear, while the size of the notch was significantly related to the depth and width of the tear. The greater tuberosity notch seems to be one of the most important diagnostic indicators for a rotator cuff tear in throwing athletes.     

肱骨大结节囊性变发生率与肩袖撕裂的关系

目的:探讨肱骨大结节囊性变发生率与肩袖撕裂之间的关系。方法:回顾性总结了2006年至2008年于北京大学第三医院运动医学研究所接受肩关节镜治疗的肩袖撕裂患者74名和复发性脱位患者71名,分别为肩袖撕裂组和复发性脱位组。测量患者MRI及X线片上显示的囊性变的最大直径,并且使用X线片评估大结节及肩峰的硬化、增生情况及形态。结果:所有患者中,39.3%患者的MRI中发现有囊性变。肩袖撕裂组,60.8%患者的MRI显示有囊性变,44.6%患者的MRI及X线片同时显示有囊性变。复发性脱位组,16.9%患者的MRI显示有囊性变,8.5%患者的MRI及X线片同时可见囊性变。肩袖撕裂患者中,有囊性变的患者平均病史23个月(7天-20年),未发现囊性变的患者平均病史26.8个月(1-120个月)。X线片显示,肱骨大结节囊性变及局限性密度减低,同时伴有III型肩峰及大结节增生硬化的患者均为肩袖撕裂患者。结论:肩袖撕裂患者出现肱骨大结节囊性变的比例明显高于无肩袖损伤患者,囊性变发生率与病史无明显相关。     

Greater tuberosity sclerosis: Does it correlate with tear size?

Introduction

Radiographic findings of the shoulder joint have been reported in patients with rotator cuff tear, greater tuberosity changes are among the most reported.The aim of this work is to assess the greater tuberosity sclerosis as a radiographic sign of rotator cuff tear and its relation to the tear size.

Coexistence of calcific tendinitis and rotator cuff tear: an arthrographic study

A prospective evaluation of the coexistence of calcific tendinitis and tear of the rotator cuff demonstrated by arthrography was made in patients presenting with shoulder pain. Patients were X-rayed using conventional views and impingement views. Eighty-one patients (mean age 61.2 years) with calcific tendinitis underwent arthrography. Arthrography showed 22 partial or complete tears of the rotator cuff. A small rather than a large amount of calcification was more likely to be associated with a rotator cuff tear (p = 0.005). The coexistence of calcific tendinitis with rotator cuff tear is not uncommon, especially in older age groups.     

Cysts within and adjacent to the lesser tuberosity: correlation with shoulder arthroscopy

Objective

The purpose of our study was to determine if cysts in and adjacent to the lesser tuberosity are associated with rotator cuff pathology found at arthroscopy.

Materials and methods

A retrospective review was undertaken of the magnetic resonance (MR) imaging of 286 consecutive arthroscopic procedures performed by a single orthopedic shoulder surgeon from February 2001 to June 2009. Images of the shoulders were reviewed by an experienced fellowship-trained musculoskeletal radiologist, reader 1, and a musculoskeletal fellow, reader 2, for the presence and location of lesser tuberosity cysts. Cysts were grouped by their location into those within the lesser tuberosity and those adjacent to the lesser tuberosity. Interreader agreement was calculated using kappa values.

Results

A total of 26 patients (17 men, 9 women; age range 14–84?years; mean of 61?years) had cysts in or adjacent to the lesser tuberosity. For reader 1, patients with cysts located in the lesser tuberosity were found to be significantly older (p?=?0.03) and more likely to have subscapularis tendon tears (p?=?0.02) than patients with cysts located adjacent to the tuberosity. No significant difference in any category between patients with a cyst located in the lesser tuberosity and those adjacent to the tuberosity was identified for reader 2. Interreader agreement of imaging findings ranged from fair to near perfect agreement.

Conclusion

Cysts located in the lesser tuberosity at the insertion of the subscapularis tendon are suggestive of subscapularis tendon pathology and may occur in older individuals.     

Rupture of the rotator cuff. Quantification of indirect signs in standard radiology and the Leclercq maneuver

The roentgenograms and the "Leclercq's manoeuvre" of 105 patients who had a shoulder arthrography were reviewed. We differentiated two groups: One with a rotator cuff tear. The other without a rotator cuff tear. The space between the acromion and the head of the humerus was measured on rotation zero degree and external rotational roentgenograms. When the acromio-humeral space was less than 8 mm, it was always correlated with a rotator cuff tear (specificity = 1). If at least tow of the following signs were present, there was in most cases a rotator cuff tear (specificity = 0.96): Sclerosed acromion. Spur of the acromion. Cystic changes around the greater tuberosity. Rounded tuberosities. Inferior gleno-humeral spur. The "Leclercq's manoeuvre" was considered positive either when there was an acromio-humeral space narrowing compared with the other side, or when there was an upward subluxation of the head of the humerus. When positive there was always a rotator cuff tear (sensibility = 0.7; specificity = 1).     

Isolated greater tuberosity fractures of the proximal humerus: anatomy,injury patterns,multimodality imaging,and approach to management

The greater tuberosity is an important anatomic structure and its integrity is important for shoulder abduction and external rotation. Isolated fractures of the greater tuberosity are often subtle and may not be detected on initial radiographs. Clinically, these patients display symptoms which mimic a full thickness rotator cuff tear. It is important to differentiate these two entities, as their treatment is different (typically nonsurgical management for minimally displaced fractures versus rotator cuff repair for acute full thickness rotator cuff tears). When greater tuberosity fractures are significantly displaced and allowed to heal without anatomic reduction, they can lead to impingement. This article will review greater tuberosity anatomy and function, as well as the clinical presentation and multimodality imaging findings of greater tuberosity fractures. Imaging optimization, pitfalls, and clinical management of these fractures will also be discussed.     

Intramuscular rotator cuff cysts: association with tendon tears on MRI and arthroscopy

OBJECTIVE: This study was designed to explore the relationship between intramuscular cysts and rotator cuff tendon tears. CONCLUSION: Intramuscular cysts are strongly associated with rotator cuff tendon tears. Identification of such a cyst should prompt a search for a rotator cuff tear. Findings on MR arthrography and surgery suggest that a delaminating component of the rotator cuff tear may lead to the development of these cysts and may explain the occasional discrepancy between location of tears and location of cysts.     

合并肩袖损伤的肩关节盂唇损伤的临床特征

目的 分析合并肩袖损伤的肩关节盂唇损伤患者的临床特征,提出其发病规律与病变特点,为临床微创手术治疗提供参考. 方法 本组50例,其中男28例,女22例;年龄30～58岁,平均45岁.记录患者的损伤机制、损伤时间、临床症状、体征,摄X线片和MRI.根据临床诊断,采用肩关节镜微创手术修复盂唇和肩袖损伤,记录损伤部位、范围及程度并进行分析.本组表现前盂唇损伤37例,上盂唇撕裂8例,后盂唇损伤5例;肩袖损伤轻度36例,中度10例,重度3例,特大裂口1例.其中肩袖前侧(冈上肌前侧)损伤21例,中部损伤(冈上肌与冈下肌部)16例,后部损伤(冈下肌部、小圆肌)13例.盂唇损伤的MRI表现为:三角外形消失,前关节囊扩大.肩袖损伤表现为:损伤部位高信号,连续性丧失. 结果 本组患者平均随访36个月(6～72个月),临床效果满意.美国加州洛杉矶大学关节功能评分标准(UCLA)评分:术前(15±3)分,术后(32±3)分(P＜0.01). 结论 创伤性肩关节盂唇损伤患者常同时合并肩袖损伤,临床上应予重视,避免遗漏诊断或耽误治疗.盂唇损伤范围与肩袖损伤部位存在对应关系,盂唇损伤范围越大,肩袖损伤越接近后侧.     

Anterior versus posterior, and rim-rent rotator cuff tears: prevalence and MR sensitivity

Purpose. To determine the relative distribution of the locations of rotator cuff tears, and the sensitivity of anterior versus posterior tears on MR images. Patients and methods. We identified 110 consecutive patients who had a shoulder MR and either a partial-thickness or a small full-thickness rotator cuff tear diagnosed at arthroscopy. From the arthroscopy videotapes, we classified the tears as centered in the anterior or posterior half of the cuff, and as either in the critical zone or adjacent to the bony insertion. The original MR interpretation was compared with the arthroscopic findings. MR sensitivity and patient age were compared between patients with tears in the anterior and posterior halves of the cuff. In addition, in patients with partial tears less than 2 cm in diameter, an age comparison between those with tears in the critical zone and those with articular surface tears adjacent to the bony insertion (rim-rent tear) was performed. Results. The tear was centered in the anterior half of the rotator cuff in 79% of the patients younger than 36 years old, and in 89% of the patients 36 years old and over. The average age of the patients with tears in the anterior half (44 years) was not significantly different from the average age of those with posterior tears (40 years)(P=0.23). The sensitivity of MR for anterior tears was 0.69, and for posterior tears it was 0.56 (P=0.17). The average age of the 9 patients with rim-rent tears was 31 years, while that of the 28 patients with similarly-sized partial tears not involving the insertion was 40 years old (P=0.048). Five of the nine rim-rent tears (0.56) were interpreted correctly on the original MR report; two of the other tears were misinterpreted as intratendinous fluid but were diagnosable in retrospect. Conclusion. Even in patients less than 36 years old, most partial and small full-thickness rotator cuff tears are centered in the anterior half of the supraspinatus. Although our figure for MR sensitivity for these tears is lower than in recent articles, we found no significant difference between the sensitivity of MR for diagnosing posterior tears versus tears in the anterior half of the supraspinatus tendon. Rim-rent tears can be mistaken for intratendinous signal, and should be carefully looked for in younger patients with shoulder pain.     

MR imaging of shoulder injuries in professional baseball players.

Magnetic resonance (MR) imaging was used to evaluate the shoulders of 10 symptomatic professional baseball players and one asymptomatic player, with surgical correlation in six cases and arthrographic correlation in two cases. Seven small rotator cuff tears measuring 0.5-1 cm were identified on MR images, with arthrographic and surgical confirmation of these findings in two patients and surgical confirmation only in three patients. Cortical irregularity and/or subchondral cyst formation at the posterior aspect of the greater tuberosity near the insertion site of the infraspinatus tendon was found in five of the seven players with rotator cuff tears. Similar findings were noted in the asymptomatic volunteer and in one of the three players without cuff tear, who also had irregular thickening of the posterior capsule. These findings are believed to represent chronic avulsive changes resulting from the deceleration stresses of the follow-through motion.     

Muscle atrophy as a consequence of rotator cuff tears: should we compare the muscles of the rotator cuff with those of the deltoid?

Purpose The quantitative assessment of muscle atrophy has a degree of importance in prognosticating rotator cuff treatment. However, it has been conjectured that muscle fat increases with aging. Therefore, we thought that the quantitative assessment of the supraspinatous would be better if made in comparison with a standard of reference such as the deltoid. Consequently, we performed a two-part study, first evaluating supraspinatous changes compared with the deltoid in “normals” with aging, and second, determining if in patients with cuff tears the supraspinatous fat exceeds that of the deltoid. Materials and methods In part 1, we studied 50 patients stratified by decade. In the first sitting, two blinded independent observers quantitatively graded the deltoid (with the supraspinatous obscured) and in the second sitting the same two observers quantitatively graded the supraspinatous (with the deltoid obscured). In part 2 of the study, we evaluated patients with moderate rotator cuff tears (>2 cm) and performed the same blinded, two-sitting, quantitative assessment (with the comparison muscle obscured). Results We found that muscle atrophy increases with age in patients without tears (0.011/0.028 U/year), although to a greater degree in the deltoid (p = 0.032). Also, in similarly aged patients, quantitative scores of the deltoid closely matched those of the supraspinatous (p = 0.071). Notably, however, in patients with large tears, the supraspinatous showed significant changes disproportionate to those of the deltoid, regardless of patient age (p = 0.044). Conclusion In the presence of a normal rotator cuff, fatty infiltration increases with age. Age-related changes occur more frequently in the deltoid, verifying this muscle’s potential as a standard of reference. With cuff tears, supraspinatous atrophy was disproportionate to that of the deltoid. Therefore, systematic assessment of supraspinatous muscle atrophy may be more reliable using the deltoid as a control for comparison than assessing it in isolation.     

Greater tuberosity changes as revealed by radiography: lack of clinical usefulness in patients with rotator cuff disease

OBJECTIVE: Studies linking greater tuberosity findings on radiographs with rotator cuff disease have largely been uncontrolled and biased toward more severe disease. We correlated greater tuberosity changes seen on radiography with rotator cuff disease seen on MR images in a broadly symptomatic patient population. MATERIALS AND METHODS: Both radiography and MR imaging were performed in 108 shoulders. Unaware of the MR imaging findings, three radiologists independently reviewed the radiographs for cortical thickening, subcortical sclerosis, and cystlike lesions in the humeral greater tuberosity. Interobserver agreement was analyzed using kappa statistics. We correlated the radiographic findings with MR imaging evidence of rotator cuff tears and tendonopathy. The positive predictive value of each finding for rotator cuff disease was also calculated. RESULTS: Interobserver agreement for the three radiographic findings was poor to fair: Kappa values ranged from .06 to .41. Cortical thickening and subcortical sclerosis were not seen more frequently in shoulders with rotator cuff disease than in normal shoulders. Cystlike lesions were more prevalent in shoulders with rotator cuff disease, but the association reached statistical significance (p < .05) for one observer only. Positive predictive values for each finding were low (14-48% for predicting full-thickness rotator cuff tears). CONCLUSION: Cortical thickening of the greater tuberosity and subcortical sclerosis are not associated with rotator cuff disease. For some observers, identifying cystlike lesions is associated with rotator cuff disease, but the clinical usefulness of the observation is limited by high interobserver variability and poor positive predictive value.     

Clinical Y-view versus 3-dimensional assessments of intramuscular fat in patients with full-thickness rotator cuff tears

Rationale and Objectives.Recent evidence suggests an inhomogeneous distribution of intramuscular rotator cuff fat infiltration (FI) in a small sample of individuals with rotator cuff tears, yet clinically just a few slices at the scapular Y-view are used to evaluate FI in patients with rotator cuff tears. The purpose of this study was to determine if assessment of FI using the scapular Y-view is representative of the entire muscle in patients with full-thickness rotator cuff tears, and whether this varies by tear size.Materials and methodsPatients (N = 25) diagnosed with full-thickness rotator cuff tear and confirmed with magnetic resonance imaging (MRI) were included. Fat-water sequences were used to objectively quantify mean FI (%) in the entire 3D muscle and the mean from 3 slices at the Y-view. Mixed-model 2 × 2 ANOVAs were used to assess for differences between methods, and if results vary by tear-size.ResultsThere were no statistically significant differences between mean amount of FI of the entire 3D muscle and mean Y-view in the supraspinatus or infraspinatus muscles (p > 0.05). Additionally, this did not differ across tear size groups (p > 0.05).ConclusionResults of this study suggest FI assessed in the Y-view is not different (mean difference < 1.0%) from FI of the entire 3D muscle in patients with full-thickness rotator cuff tears. Therefore, the clinical utility of evaluating rotator cuff intramuscular fat infiltration with the Y-view is further supported in patients with full-thickness rotator cuff tears across tear sizes.     

Creatinine and nonprotein nitrogen plasma levels: possible etiopathogenetic factors in rotator cuff tears

Objective: To determine the plasma levels of nonprotein nitrogen (NPN) and creatinine in healthy patients with rotator cuff tears. Methods: The study included 400 subjects. The study group included 200 patients (93 men and 107 women; mean age, 56.8 years; range, 23-81 years) who underwent arthroscopic repair of a rotator cuff tear from 2004 to 2007. The control group included 200 patients (93 men and 107 women; mean age, 53.9 years; range, 20-81 years) who underwent arthroscopy for management of a meniscal tear, with or without articular cartilage damage, in the same period. The 2 groups were frequency-matched by age and sex. Measurement of plasma levels of NPN and creatinine were performed in all patients. Results: Patients with rotator cuff tears showed higher plasma NPN levels within the normal range (P = 0.035) than patients with knee disorders (control group). Creatinine levels were comparable (P = 0.66) in both groups. Conclusion: There appears to be an association between plasma NPN levels and rotator cuff tears. On the basis of our findings, plasma NPN could be involved in the pathogenesis of rotator cuff tears, although we advocate further research to draw more definitive conclusions.     

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.     

MR assessment of the repaired rotator cuff: prevalence, size, location, and clinical relevance of tendon rerupture

The objectives of this study were to use magnetic resonance (MR) imaging to evaluate the prevalence, size, location, and clinical relevance of tendon rerupture following complete repair of full-thickness rotator cuff tear (RCT). A total of 78 surgically proven full-thickness rotator cuff tears in 74 patients were retrospectively included in the study. Clinical assessment was performed using the University of California at Los Angeles score. Postoperative MR imaging was evaluated to determine prevalence, size, and location of tendon rerupture. At a mean 48.4 months’ follow-up, 62 shoulders (79.5%) had favorable outcomes and 45 shoulders (57.6%) showed rerupture on MR imaging studies. Reruptures were significantly more prevalent among patients with intermediate-to-bad outcomes (81.3%), with surgically demonstrated two-tendon tears (78.9%) or three-tendon tears (100%), and with preoperative fatty degeneration of the supraspinatus muscle greater than 1 (91.6%). Reruptures were also significantly larger in those subgroups. Complete repair of RCT of all sizes may have favorable outcomes in a significant proportion of patients in spite of a high prevalence of reruptures. Preoperative tear size and degree of muscle fatty degeneration influence the prevalence and rerupture size. After repair of supraspinatus tears, reruptures tend to invade the posterior aspect of the tendon.     

Arthroscopic hybrid double-row rotator cuff repair

A Beath pin is drilled on the greater tuberosity under arthroscopy using an anterior cruciate ligament guide. The suture anchor is inserted in the lateral aspect of the footprint. Sutures are then passed through the margins of the rotator cuff tear and tied with sliding knot. One strand of tied suture anchor is passed into the bony trough. One passed strand and the other strand are then tied with a non-sliding knot on the greater tuberosity. The strength of cuff fixation does not only rely on the quality of the bone, it restores the footprint contact area of rotator cuff, and reduces the use of suture anchors to the minimum in this method.