Degenerative Rotator Cuff Tears Research Articles

Role of Critical Shoulder Angle in Degenerative Type Rotator Cuff Tears: A Turkish Cohort Study.

BACKGROUND This retrospective study investigated the association between the critical shoulder angle (CSA) and the development of full-thickness rotator cuff tears (FTRCTs) in the Turkish population. The CSA is an imaging parameter that quantifies the relationship between the inclination of the glenoid and the lateral extension of the acromion in the coronal plane. The CSA is an anatomical measurement, and higher CSA values have been associated with an increased incidence of FTRCTs. However, there is a lack of data on CSA regarding the Turkish population. MATERIAL AND METHODS In this study, CSA measurements were recorded in 2 groups: 50 patients with FTRCT who had arthroscopic repair (group 1) and 50 age- and sex-matched individuals with no FTRCT detected by magnetic resonance imaging (group 2). Sex, age, affected side, dominant side, and smoking status were recorded for each patient. The CSA measurements of the affected sides were performed on true anterior-posterior view radiographs. RESULTS The results showed a statistically significant difference between the mean CSA values of group 1 (37.48°) and group 2 (33.53°), P<0.001. CSA values of 36 and above had a sensitivity of 73.58%, specificity of 74.47%, positive predictive value of 75%, and negative predictive value of 74.47% for detecting FTRCT. CONCLUSIONS CSA measurement on radiographs is a useful diagnostic tool in the Turkish population, and an above-average CSA value is associated with a significantly increased incidence of degenerative-type FTRCT.

The Modified Ultrasound-Assisted Method: A Study of the Correlation between Magnetic Resonance Imaging and the Ultrasound-Assisted Evaluation of the Critical Shoulder Angle.

An increased or decreased critical shoulder angle (CSA) is a known risk factor for osteoarthritis, lesions, and re-ruptures in the rotator cuff. A CSA greater than 35° correlates with degenerative rotator cuff tears, while a CSA of less than 30° correlates with osteoarthritis in the glenohumeral joint. The diagnostic gold standard for its determination is X-ray or MRI. The primary objective of this research was to assess the viability of utilizing sonography imaging as a diagnostic tool to determine the modified critical shoulder angle (mCSA). This study aimed to investigate the feasibility and effectiveness of sonographic techniques in accurately diagnosing CSA compared to MRI. A cohort study was carried out (level of evidence 3). The CSA (MRI) and the mCSA (ultrasound) were assessed retrospectively by two independent board-certified investigators in 109 patients with shoulder pain by MRI and musculoskeletal sonography. The CSA in the MRI dataset was determined using routine protocols and then compared to the values assessed using the modified sonography-assisted method (mCSA). Both results were analyzed with linear regression to determine a possible correlation. All investigations were performed by a DEGUM (German Society for Medical Ultrasound)-certified specialist in musculoskeletal sonography. A total of 112 patients were included in this study, namely 40 female patients and 72 male patients with a mean age of 54.7 years at the time of the investigation. The mean CSA in MRI was 31.5° ± 3.899, and the mCSA in sonography was 30.1° ± 4.753. The inter- and intraobserver reliability for the CSA was factual with values of 0.993 and 0.967. The inter- and intraobserver reliability for mCSA was factual as well, with values of 0.989 and 0.948. The ANOVA analysis did not reveal a significant difference between the CSA and the mCSA values, and linear regression determined the R2 value to be 0.358 with p < 0.05. Diagnosing the mCSA using sonography is a safe and valid method. No statistically significant differences between the results in MRI and sonography could be seen. Although this is a retrospective, single-center study including only Caucasian mid-Europeans, and with the known limitations of ultrasound imaging, it nevertheless shows that sonography can be used as a simple, cheap, and fast technique to assess a modified CSA, which shows very good correlation with the standard CSA without losing the diagnostic quality.

[Effect of stump-preserving repair on rotator cuff healing and shoulder function for degenerative total rotator cuff tears].

To analyze the effect of stump-preserving repair on rotator cuff healing and shoulder function for degenerative total rotator cuff tears. A clinical data of 152 patients with degenerative total rotator cuff tears, who underwent arthroscopic repair between April 2019 and May 2022, was retrospectively analyzed. There were 76 males and 76 females with an average age of 55.4 years (range, 24-78 years). MRI was performed at 6 months postoperatively to evaluate the rotator cuff healing according to the Sugaya classification. Pre- and intra-operative related factors were included for univariate analysis, including age (≥60 years/<60 years), gender (male/female), passive activity disorder (yes/no), disease duration (≤3 months/>3 months), stump-preserving repair (yes/no), use of suture bridge technique (yes/no), shoulder joint abduction angle at knotting (<45°/≥45°), acromioplasty (yes/no), glucocorticoid injection (yes/no), time for patients to start postoperative passive exercise (≤2 weeks/>2 weeks), and time for patients to start postoperative active exercise (≤3 months/>3 months). The influencing factors of tendon healing were screened; further logistic regression was used to conduct multivariate analysis to screen for risk factors. Two sets of data were balanced by propensity score matching. The American Shoulder and Elbow Surgeons (ASES) score and Constant-Murley score of shoulder joint function at 6 and 12 months postoperatively, as well as rotator cuff healing rate at 6 months postoperatively, were compared between groups based on whether or not stump-preserving repair was used. All patients were followed up 12-33 months (mean, 23.8 months). MRI at 25-31 weeks postoperatively showed the 121 cases of rotator cuff healing and 31 cases of non healing. Univariate analysis showed that the disease duration, stump-preserving repair, shoulder joint abduction angle at knotting, and the time for patients to start postoperative active exercise were the influencing factors of rotator cuff healing ( P<0.05). Multivariate analysis showed that non-stump-preserving repair, shoulder abduction angle more than 45° at knotting, and the time to start active exercise within 3 months postoperatively were risk factors affecting rotator cuff healing ( P<0.05). A total of 51 pairs of cases were matched based on the grouping criteria of whether the disease duration exceeded 3 months, whether the shoulder abduction angle at knotting exceeded 45°, and whether the time to start postoperative active exercise exceeded 3 months. The rotator cuff healing rate, ASES score, and Constant-Murley score of the preserving repair group at 6 months postoperatively were superior to those of the non-preserving repair group, and the differences were significant ( P<0.05). There was no significant difference in ASES score and Constant-Murley score between the two groups at 12 months postoperatively ( P>0.05). For degenerative total rotator cuff tears, the stump-preserving repair can shorten the healing time and promote the shoulder function recovery, but has no significant effect on shoulder function at 1 year postoperatively.

Outcomes of initial nonoperative treatment of traumatic full-thickness rotator cuff tears

IntroductionNon-surgical management of chronic, degenerative rotator cuff tears (RCT) can be an effective treatment strategy, but there is limited evidence to support conservative treatment for acute, traumatic RCTs. The objective of this study is to assess clinical outcomes and predictors of treatment success for patients with traumatic RCTs who elected for initial non-operative treatment. MethodsPatients from a single institution were retrospectively identified using diagnostic codes for traumatic RCT followed by confirmed initial treatment with at least 2 months of physical therapy. Exclusion criteria included surgery within 2 months of injury and greater than grade I fatty infiltration on MRI. At minimum 2-year follow-up, patients were contacted by phone to collect interval surgical history and standardized patient reported outcomes. All those who had surgical treatment and those with satisfaction ratings of “moderately dissatisfied” and “very dissatisfied” were considered to have failed physical therapy. ResultsFollow-up outcomes were obtained in forty of 49 patients (82%) with an average follow-up time of 4.2 years. Nine RCTs (22%) were small (< 1cm), 22 (54%) were medium (>1 and < 3cm), and 9 (22%) were large (> 3 cm and < 5cm). Grade I fatty infiltration was seen on 25% (n=10) of MRIs. Eighteen patients (45%) underwent rotator cuff repair following an average 6 months (R: 3-12) of nonoperative treatment. In total, 23 of 40 patients (58%) were determined to have failed nonoperative treatment. Patients with multiple tendons torn were more likely to fail conservative management (p=0.014). Tear size and retraction were not significantly different between patents who had surgery and those who did not. Patients who underwent surgical management had 83% satisfaction rate at final follow-up compared to 55% satisfaction for patients who had no surgery (p=0.054). There was no statistical difference in the ASES (American Shoulder and Elbow Surgeons score) and VAS (Visual Analog Scale) between these groups. While patients who had surgery had a higher mean SANE (Single Alpha Numeric Evaluation) (86.3 vs. 75.1; p=0.041), this difference was below the previously established minimally clinically important difference. ConclusionNon-operative treatment remains a viable option for certain patients with traumatic RCTs; however, the results of our study demonstrate a considerable early failure rate. This study further supports historical literature demonstrating reliably successful outcomes with surgical treatment of acute, traumatic RCTs. Level of EvidenceLevel IV; Case Series; Treatment Study

Wearable Ultrasound Imaging Device for Dynamic Dual-Direction Shear Wave Elastography of Shoulder Muscle.

The shoulder is the most mobile joint in the human body, thus requiring intricate coordination of adjacent muscles. Patients suffered from rotator cuff muscle Injuries have several typical symptoms include shoulder pain and difficulty raising the arm, thus reducing work efficiency, and compromising the quality of life. Ultrasound has been used widely for shoulder soft tissue imaging as well as ultrasound elastography was introduced in shoulder examination for the dilemma of treating degenerative rotator cuff tears. However, most of ultrasound examination was performed under a static condition. Providing dynamic information from shoulder muscle are important in clinical applications because the pains sometime come from various positions of shoulder during moving. In this study, a customized wearable T-shaped ultrasound transducer (128+128 elements) was proposed for shoulder dual-direction shear wave elastography (DDSWE) which provides the SWE for both longitudinal (SW along the muscle fiber) and transverse (SW cross the muscle fiber) directions dynamically. An optical tracking system was synchronized with ultrasound imaging system to capture shoulder movements in 3-D space with their corresponding ultrasound images. The performance of DDSWE and the accuracy of optical tracking were verified by phantom experiments. Human studies were carried out from volunteers as they are moving their arms. Experimental results shows that the bias and precision for the proposed DDSWE in elastic phantom were about 6% and 1.2 % for both directions, respectively. A high accuracy of optical tracking was observed using 3-D motor stage experimental setup. Human experiments shows that the shear wave velocities (SWVs) were increased with the angles of shoulder abduction, the average transverse and longitudinal SWVs were increase from 2.24 m/s to 3.35 m/s and 2.95 m/s to 5.95 m/s with abduction angle from 0° to 60°, respectively, which they are anisotropic-dependent. All the experimental results indicates that the proposed wearable ultrasound DDSWE can quantify the mechanical properties of shoulder muscles dynamically, thereby may help surgeons and physical therapists determine whether the intensity of rehabilitation shoulder be tuned down or escalated in the future.

Associations of normal fasting glucose levels and of insulin resistance with degenerative rotator cuff tear

BackgroundThe upper normoglycemic range has been proposed as a risk factor for degenerative rotator cuff tendon tear (RCT), and insulin resistance has been suggested as a risk factor for tendinopathy. However, no research has established their association with degenerative RCT in the general population. This study aimed to determine whether fasting glucose levels and insulin resistance are risk factors for degenerative RCT in the normoglycemic population and identify the risk range for fasting glucose.MethodsThis study included 418 normoglycemic participants from a rural cohort. Participants completed questionnaires, physical exams, blood tests, and MRI evaluations of both shoulders. Insulin resistance was assessed using a triglyceride/high-density-lipoprotein (TG/HDL) ≥ 3.5. Logistic regression analysis was used to determine the association between fasting glucose level, TG/HDL ≥ 3.5, and other factors and degenerative RCT. The study calculated the areas under the receiver operating characteristic curve (AUC) to determine the more appropriate predicting value between the scale and categorical values of fasting glucose levels, and compared the AUCs using the DeLong method.ResultsIn the multivariable analyses, both scale and categorical values of fasting glucose levels, and TG/HDL ≥ 3.5 were significantly associated with degenerative RCT. Fasting glucose levels ≥ 90.5 mg/dL (OR: 3.87, 95% CI: 2.10–7.06) in scale value and 90–99 mg/dL (OR: 4.13, 95% CI: 2.87–8.12) in categorical value were significantly associated with degenerative RCT (P < .001). The AUC of the scale value of fasting glucose levels ≥ 90.5 mg/dL was 0.68. The AUC of the categorical value of fasting glucose levels of 90–99 mg/dL was 0.70. Because of the significantly larger AUC of the categorical value of fasting glucose levels of 90–99 mg/dL, those fasting glucose levels were determined to be independently associated with degenerative RCT (P < .001).ConclusionsHigh fasting glucose levels within the normal range may link to increase insulin resistance and risk of degenerative RCT. Normoglycemic levels of 90–99 mg/dL and insulin resistance may be risk factors for degenerative RCT.Level of evidenceLevel III, prognostic study.

The role of bone morphology of the greater tuberosity and lateral acromion on subacromial space during scaption: a three-dimensional dynamic simulation analysis

BackgroundThe bone morphology of the greater tuberosity and lateral acromion plays a central role in subacromial impingement syndrome. The critical shoulder angle (CSA) and greater tuberosity angle (GTA) are two-dimensional measurement parameters that have been validated to evaluate it radiologically. These markers are, however, static and don’t consider the dynamic effect of glenohumeral motion.ObjectivesThis study aimed to better understand the biomechanics in subacromial impingement with a dynamic simulation based on a validated 3D biomechanical model coupling joint kinematics and 3D reconstructed computed tomography.Study design & methodsSixty-one patients were included in this study: a case group of 44 patients with degenerative rotator cuff tears involving only the supraspinatus, and a control group of 17 without a rotator cuff tear. Patients with previous surgeries, traumatic cuff tears, and cuff tear arthropathy were excluded. CSA, GTA, and impingement-free range of motion (IF-ROM) of the glenohumeral joint in scaption were calculated. Correlation tests were used to determine the relationship between ROM and CSA, GTA, and combined CSA and GTA values.ResultsCSA and GTA were significantly higher in the rotator cuff tear group (p = 0.001 and < 0.001), while IF-ROM was significantly higher in the control group (p = 0.001). There was no overall correlation between CSA and GTA (R = 0.02, p = 0.8). Individual correlation between both angles with IF-ROM was negatively weak for CSA (R = -0.4, p < 0.001) and negatively moderate for GTA and IF-ROM (R = -0.5, p < 0.001). However, combining both angles resulted in a negatively high correlation with IF-ROM (R = -0.7, p < 0.001).ConclusionSubacromial space narrowing during scaption is highly correlated to the cumulative values of GTA and CSA. These findings suggest that the combined bony morphology of the lateral acromion and greater tuberosity plays an important role in subacromial impingement.Level of evidenceIII

Predictors of pain development for contralateral asymptomatic degenerative rotator cuff tears based on features of an ipsilateral painful cuff tear: a prospective longitudinal cohort study

Prior rotator cuff disease natural history studies have focused on tear-related factors that predict disease progression within a given shoulder. The purpose of this study is to examine both patient and tear-related characteristics of a painful rotator cuff tear that predict future pain development and functional impairment in a shoulder with a contralateral asymptomatic cuff tear. This is prospective longitudinal cohort study of subjects ≤65 years who underwent surgery for a painful degenerative rotator cuff tear and possessed an asymptomatic contralateral tear. Subjects were followed prospectively with shoulder ultrasound, physical examination and functional score assessment. Primary outcome was change in ASES score at 2 years. Secondary outcomes included WORC, PROMIS, HADS depression/anxiety, and VR-12 mental component scores. Sixty-five subjects were included with mean follow-up 37 (range 24-42) months. Seventeen (26%) developed contralateral shoulder pain at median 15.2(10.5) months. No difference in age, sex, CCI, occupational demand noted between subjects who did and did not develop pain. In the presenting painful shoulder there was no difference in baseline tear size, muscle degeneration, or biceps pathology between groups. The mean baseline tear length (8.6 vs. 3.8 mm, p=0.0008) and width (8.4 vs. 3.2 mm, p=0.0004) were larger in asymptomatic shoulders that subsequently developed pain compared to those that did not. However, there was no difference mean tear enlargement (length p=0.51, width p=0.90). There were no differences in baseline ASES, WORC, PROMIS scores or HADS depression/anxiety scores between shoulders that did and did not develop pain; however, subjects who developed pain reported lower baseline VR-12 MCS scores (53.3 vs 57.6, p=0.04). Shoulders that developed pain had higher VAS pain scores (2.9 [2.5] vs. 0.6 [1.0], p=0.016, lower ASES scores (7 [33] vs. 100[11.6], p=0.001) and significant changes in all WORC scales with pain onset compared to those that remained asymptomatic. There was no significant difference in changes of HADS anxiety/depression scores but a significant increase in VR-12 MCS scores in subjects who developed pain (7.1[12.6] vs. -1.9[8.7], p=0.036). A quarter of patients with painful cuff tear developed pain in a contralateral asymptomatic cuff tear that resulted in a measurable decline in function within 3 years. Analysis showed only baseline tear size of the asymptomatic shoulder was predictive of pain development. There were no tear-related features of the presenting painful rotator cuff tear or indices of mental health and physical function/occupational demand that were predictive of future pain development at short-term follow-up.

Can clinical tests show high diagnostic accuracy in the assessment of degenerative full-thickness rotator cuff tears?

Objectives: At present, the diagnosis of full-thickness rotator cuff tears (FTCTs) relies heavily on imaging. We suggest that clinical examination can reliably be used as a substitute for diagnostic imaging, particularly in relatively older patients who are undergoing conservative management. Our study evaluated the diagnostic value of five clinical tests in assessing FTCT in secondary care. Methods: One hundred and fifteen patients were examined by a consultant shoulder surgeon for suspected FTCT and underwent diagnostic imaging. Clinical examination included the empty-can test, resisted external rotation test, external rotation lag test, belly-press test, and lift-off test. Fifty two (45%) of these patients were referred for shoulder arthroscopy, while the rest were managed conservatively. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of these tests were calculated, comparing clinical results with arthroscopic findings. Results: Our results showed that, in combination, these five special tests have high diagnostic values for FTCT, with an overall accuracy of 90%. Both the empty-can test and the resisted external rotation test had a sensitivity of 97%. While the external rotation lag test had poor accuracy, it was 100% successful at ruling in tears. The belly-press and lift-off tests were 100% sensitive and specific for full-thickness tears of the subscapularis. Conclusion: Clinical tests for diagnosing FTCT have high diagnostic value, comparable to imaging modalities explored in the literature. Overreliance on magnetic resonance imaging and ultrasonography may not be justified, particularly in a relatively older population when a rotator cuff tear repair is not scheduled.

Evaluation of Survivorship of Asymptomatic Degenerative Rotator Cuff Tears in Patients 65 Years and Younger: A Prospective Analysis with Long-Term Follow Up.

The purpose of this prospective study is to describe the mid to long-term natural history of untreated asymptomatic degenerative rotator cuff tears in patients 65 years and younger. Subjects with an asymptomatic rotator cuff tear in one shoulder and a contralateral painful cuff tear age 65 years or younger were enrolled in a previously described prospective longitudinal study. Annual physical and ultrasonographic evaluations and surveillance for pain development were performed utilizing independent examiners for the asymptomatic shoulder. Two hundred twenty-nine subjects (mean age 57.1 years) were followed for a median of 7.1 (range 0.3-13.1) years. Tear enlargement occurred in 138 (60%) shoulders. Full-thickness tears were at greater risk for enlargement compared to partial-thickness (HR=2.93, 95%CI 1.71-5.03, p<0.0001) and control shoulders (HR=18.8, 95%CI 4.63-76.1, p<0.0001). Mean survival rates from Kaplan-Meier analyses indicate that full-thickness tears enlarged earlier (mean 4.7, 95%CI 4.1-5.2 years) than partial-thickness (mean 7.4, 95%CI 6.2-8.5 years) and control shoulders (mean 9.7, 95%CI 9.0-10.4 years). Tear presence in the dominant shoulder was associated with a greater enlargement risk (HR=1.70, 95%CI 1.21-1.39, p=0.002). Patient age (p=0.37) and gender (p=0.74) were not associated with tear enlargement. The 2,5 and 8-year survivorship free of tear enlargement for full-thickness tears was 74%, 42% and 20%, respectively. Shoulder pain developed in 131 (57%) shoulders. Pain development was associated with tear enlargement (HR=1.79, 95%CI 1.24-2.58, p=0.002) and was more common in full-thickness tears compared to controls (p=0.0003) and partial tears (p=0.01). An analysis of progression of muscle degeneration was performed 138 shoulders with full-thickness tears. Tear enlargement was seen in 104 of 138 (75%) of these shoulders during follow-up (median 7.7 [6.0] years). Progression of muscle fatty degeneration was seen in the supraspinatus in 46 (33%) and the infraspinatus in 40 (29%) shoulders. Adjusting for age, both the presence of fatty muscle degeneration and the progression of muscle changes for both the supraspinatus (p<0.0001) and infraspinatus (p<0.0001) muscles were associated with tear size. For both the supraspinatus (p=0.03) and infraspinatus (p=0.03) muscles, tear enlargement was significantly associated with progression of muscle fatty degeneration. Anterior cable integrity was significantly associated with the risk of muscle degeneration progression for both the supraspinatus (p<0.0001) and the infraspinatus (p=0.005) muscles. Asymptomatic degenerative rotator cuff tears progress in patient 65 years and younger. Full-thickness rotator cuff tears have a higher risk of continued tear enlargement, progression of fatty muscle degeneration and pain development than partial-thickness tears.

Poster 168: Notching of the Greater Tuberosity Revisited: A Radiographic Indicator of Degenerative Rotator Cuff Tears

Objectives: The greater tuberosity notch (GTN) is an uncommonly reported radiographic finding which has been associated with articular sided partial rotator cuff tears (RCTs) in throwing athletes. This finding has yet to be evaluated in patients with degenerative tears. The purpose of this study is to assess the GTN measurement along with five other previously described radiographic indicators for degenerative RTCs. Methods: After obtaining IRB approval, we prospectively collected and compared 80 standard shoulder radiograph series with an additional “notch view”, a lateral oblique radiograph showing the greater tuberosity in profile. Thirty-four patients had confirmed rotator cuff tears confirmed via arthroscopy and 46 control patients did not have suspected rotator cuff pathology. Two musculoskeletal radiologists independently reviewed radiographs for GTN size and five previously described radiographic indicators of RCTs including: greater tuberosity cyst (GTC), acromiohumeral interval (AHI), critical shoulder angle (CSA), inferior acromial sclerosis (IAS), and lateral acromial spurring (LAS). A receiver operator characteristic (ROC) curve was performed to compare the individual performance of each of the six radiographic markers. Nearest neighbor analysis based on Euclidean distances followed by clustering described the pattern of radiographic variables occurring together in the setting of a RCT. Results: A total of 320 radiographs were reviewed and 1920 measurements were made. RCTs were independently associated with IAS, LAS, GTCs, decreased AHI and large GTNs (P &lt; 0.01), but not the CSA or smaller notch sizes. Overall, the GTN size predicted a RCT with moderate accuracy (AUC=0.676). Cluster analysis suggested the AHI has the strongest correlation with RCTs and is the most closely related to the GTN size (P &lt; 0.003) compared to other indicators based on Euclidean distances. Conclusions: The presence of a medium-sized greater tuberosity notch alone is moderately sensitive for detecting a degenerative RCT. Additionally, the presence of at least one other indicator on radiographs dramatically increases the likelihood of finding a RCT during surgery. The size and presence of these radiographic markers in combination may represent a continuum of increasing severity of cuff pathology.

Risk Factors for Early Failure of Non-operative Management of Degenerative Rotator Cuff Tears

Risk Factors for Early Failure of Non-operative Management of Degenerative Rotator Cuff Tears

Evaluation of the prognostic value of the anatomical characteristics of the bony structures in the shoulder in bursal-sided partial-thickness rotator cuff tears.

In recent studies, individual scapular anatomy has been found to be related to degenerative full-thickness rotator cuff tears. However, research on the relationship between the anatomical characteristics of shoulder radiographs and bursal-sided partial-thickness rotator cuff tears (PTRCTs) is limited, and the risk factors for this pathology still need to be determined. The bursal-sided PTRCTs group included 102 patients without a history of shoulder trauma who underwent arthroscopy between January 2021 and October 2022. A total of 102 demographically matched outpatients with intact rotator cuffs were selected as the control group. Radiographs were used to measure the lateral acromial angle (LAA), critical shoulder angle (CSA), greater tuberosity angle (GTA), β-angle, acromion index (AI), acromiohumeral distance (AHD), acromial tilt (AT), acromial slope (AS), acromial type, and acromial spur by two independent observers. Multivariate analyses of these data were used to identify potential risk factors for bursal-sided PTRCTs. Receiver operating characteristic (ROC) analysis was performed to assess the sensitivity and specificity of CSA, GTA, and AI for this type of pathology. The β-angle, AHD, AS and acromion type showed no difference between bursal-sided PTRCTs and controls (p = 0.009, 0.200, 0.747 and 0.078, respectively). CSA, GTA and AI were significantly higher in bursal-sided PTRCTs (p < 0.001). LAA, β-angle and AT were significantly lower in bursal-sided PTRCTs. Multivariate logistic regression analysis demonstrated significant correlations between the acromial spur (p = 0.024), GTA (p = 0.004), CSA (p = 0.003) and AI (p = 0.048) and bursal-sided PTRCTs. The areas under the ROC curves for AI, CSA, and GTA were 0.655 (95% CI 0.580-0.729), 0.714 (95% CI 0.644-0.784), and 0.695 (95% CI 0.622-0.767), respectively. Acromial spur, GTA, CSA, and AI were independent risk factors for bursal-sided PTRCTs. Furthermore, CSA was the most powerful predictor of bursal-sided PTRCTs compared to GTA and AI.

MRI findings of traumatic and degenerative rotator cuff tears and introduction of the “cobra sign”

A rotator cuff tear (RCT) is a common shoulder diagnosis and its etiology may be acute, traumatic, or chronic degenerative. Differentiation between the 2 etiologies may be important for multiple reasons, but remains difficult based on imaging. Further knowledge about radiographic and magnetic resonance findings to distinguish traumatic from degenerative RCT is needed. We analyzed magnetic resonance arthrograms (MRAs) of 96 patients with traumatic or degenerative superior RCT, which were matched according their age and the affected rotator cuff muscle into the 2 groups. Patients older than 66 years of age were excluded from the study to avoid including cases with pre-existing degeneration. In the case of traumatic RCT, the time between the trauma and MRA had to be less than 3 months. Various parameters of the supraspinatus (SSP) muscle-tendon unit were assessed (tendon thickness, presence of a remaining tendon stump at the greater tubercle, magnitude of retraction, layer appearance). The retraction of the 2 SSP layers were individually measured to determine the difference of retraction. Additionally, edema of the tendon and muscle, the tangent- and kinking-sign as well as the newly introduced Cobra-sign (bulging of the distal part of the ruptured tendon with slim configuration of the medial part of the tendon) were analyzed. Edema within the SSP muscle (sensitivity 13%, specificity 100%, P=.011) or the tendon (sensitivity 86%, specificity 36%, P=.014) are more frequent in traumatic RCT. The same association was found for the kinking-sign (sensitivity 53%, specificity 71%, P=.018) and the Cobra sign (sensitivity 47%, specificity 84%, P=.001). Even though not statistically significant, tendencies were observed toward thicker tendon stumps in traumatic RCT, and greater difference in retraction between the 2 SSP layers in the degenerative group. The cohorts had no difference in the presence of a tendon stump at the greater tuberosity. Muscle and tendon edema, as well as tendon kinking appearance and the newly introduced cobra-sign are suitable MRA parameters to distinguish between traumatic and degenerative etiology of a superior RTC.

Clinical Tests show High Diagnostic Accuracy in the Assessment of Degenerative Full-Thickness Rotator Cuff Tears

Introduction Currently, the diagnosis of full-thickness rotator cuff tears (FTCT) relies heavily on imaging. We suggest that clinical examination can reliably be used as a substitute for diagnostic imaging, particularly in relatively older patients who are undergoing conservative management. Our study evaluates the diagnostic value of 5 clinical tests in the assessment of FTCT in secondary care. Methods 115 patients were examined by a consultant shoulder surgeon for suspected FTCT and underwent diagnostic imaging. Clinical examination included the Empty Can test, Resisted External Rotation test, External Rotation Lag test, Belly-press test and Lift-off test. 52 of these patients were referred for shoulder arthroscopy, while the rest were managed conservatively. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of these tests were calculated, comparing clinical results with arthroscopic findings. Results We show that in combination these 5 special tests have high diagnostic value for FTCT, with an overall accuracy of 90%. Both the Empty Can test and the Resisted External Rotation test had a sensitivity of 97%. While the External Rotation Lag test had poor accuracy, it was 100% successful at ruling-in tears. The Belly-press and Lift-off tests were 100% sensitive and specific for full-thickness tears of the subscapularis. Discussion and Conclusion Clinical tests for the diagnosis of full-thickness rotator cuff tears have high diagnostic value, comparable to imaging modalities explored in the literature. Overreliance on MRI and ultrasonography may not be justified, particularly in a relatively older population when a rotator cuff tear repair is not scheduled.

Functional outcome following arthroscopic single row repair in degenerative rotator cuff tear

Background: Rotator cuff disease encompasses a wide range of pathology from minimal bursal or articular side irritation and tendonitis to severe degenerative rotator cuff arthropathy. Rotator cuff pathology affects adults of all ages and other shoulder afflictions must be ruled out by careful history and physical examination. Arthroscopic surgery allows for a shorter recovery time and predictably less pain following procedure than any open surgery.Materials and methods: We did a prospective study on 32 patients of age more than 40 years of age with degenerative rotator cuff tear, who met the inclusion criteria and were operated using single row technique of arthroscopic rotator cuff repair and were followed up at 1 month, 3 months and 6 months and pain, function, muscle power and range of movements were assessed by ASES and UCLA scoring system.Results: The mean age of the patients was found to be 54.94 years. The Male: Female ratio in our study was found to be 3:1. The average ASES score in the pre-operative and post-operative period was found to be 22.66 and 89.53 respectively. The average UCLA score in the pre-operative and post-operative period was found to be 8.97 and29.13 respectively.Conclusion:Arthroscopic rotator cuff repair with single row repair provides early pain relief and improves mobility, strength as well as patient satisfaction post operatively. Key words: Single row repair, Arthroscopic rotator cuff repair, UCLA scoring, ASES shoulder score index.

Hyaluronic acid as an alternative treatment option for degenerative rotator cuff tears

Rotator cuff tears have a high prevalence in older people. This research examines the clinical outcome of the non-operative treatment of symptomatic degenerative rotator cuff tears with hyaluronic acid (HA) injections. 72 patients (43 females/29 males), with an average age of 66 years with symptomatic degenerative full- thickness rotator cuff tear, confirmed with arthro-CT, were treated with three intra-articular hyaluronic acid injections and followed on multiple observational moments during a 5-year follow-up using the SF- 36 (Short-Form Health Survey), DASH (Disabilities of the Arm, Shoulder, and Hand), CMS (Constant Murley Score), and OSS (Oxford Shoulder Scale. 54 patients completed the 5-year follow-up questionnaire. 77% of the patients did not require additional treatment for their shoulder pathology, and 89% were treated conservatively. Only 11% of the patients included in this study needed surgery. Between subjects, the analysis revealed a significant difference in response in the DASH (p=0.015) and CMS (p=0.033) when the subscapularis muscle was involved. Intra-articular infiltrations with hyaluronic acid improve pain and shoulder function, especially if the subscapularis muscle is not involved.

Hyaluronic acid as an alternative treatment option for degenerative rotator cuff tears

Rotator cuff tears have a high prevalence in older people. This research examines the clinical outcome of the non-operative treatment of symptomatic degenerative rotator cuff tears with hyaluronic acid (HA) injections. 72 patients (43 females/29 males), with an average age of 66 years with symptomatic degenerative full- thickness rotator cuff tear, confirmed with arthro-CT, were treated with three intra-articular hyaluronic acid injections and followed on multiple observational moments during a 5-year follow-up using the SF- 36 (Short-Form Health Survey), DASH (Disabilities of the Arm, Shoulder, and Hand), CMS (Constant Murley Score), and OSS (Oxford Shoulder Scale. 54 patients completed the 5-year follow-up questionnaire. 77% of the patients did not require additional treatment for their shoulder pathology, and 89% were treated conservatively. Only 11% of the patients included in this study needed surgery. Between subjects, the analysis revealed a significant difference in response in the DASH (p=0.015) and CMS (p=0.033) when the subscapularis muscle was involved. Intra-articular infiltrations with hyaluronic acid improve pain and shoulder function, especially if the subscapularis muscle is not involved.

Hyaluronic acid as an alternative treatment option for degenerative rotator cuff tears.

Rotator cuff tears have a high prevalence in older people. This research examines the clinical outcome of the non-operative treatment of symptomatic degenerative rotator cuff tears with hyaluronic acid (HA) injections. 72 patients (43 females/29 males), with an average age of 66 years with symptomatic degenerative full- thickness rotator cuff tear, confirmed with arthro-CT, were treated with three intra-articular hyaluronic acid injections and followed on multiple observational moments during a 5-year follow-up using the SF- 36 (Short-Form Health Survey), DASH (Disabilities of the Arm, Shoulder, and Hand), CMS (Constant Murley Score), and OSS (Oxford Shoulder Scale. 54 patients completed the 5-year follow-up questionnaire. 77% of the patients did not require additional treatment for their shoulder pathology, and 89% were treated conservatively. Only 11% of the patients included in this study needed surgery. Between subjects, the analysis revealed a significant difference in response in the DASH (p=0.015) and CMS (p=0.033) when the subscapularis muscle was involved. Intra-articular infiltrations with hyaluronic acid improve pain and shoulder function, especially if the subscapularis muscle is not involved.

Acute, Traumatic Rotator Cuff Tears Have Smaller Critical Shoulder Angles Than Degenerative Tears

To determine whether the critical shoulder angle (CSA) in acute, traumatic rotator cuff tears (RCTs) is consistent with the previously described CSA in chronic degenerative RCTs. We performed a multicenter retrospective analysis of 134 patients presenting to 5 surgeons fellowship trained in shoulder and elbow or sports. Preoperative imaging was used to measure the CSA and tear characteristics. Patients were included if they had acute, traumatic full-thickness RCTs documented on advanced imaging and had preoperative Grashey radiographs. Patients were excluded if they had any history of shoulder pain, injury, surgery, or treatment prior to the current episode; were overhead athletes; or had fatty infiltration greater than Goutallier grade 1 on imaging. The mean CSA was 33.5° (standard deviation, 4.1°), and 60% of tears had a CSA of less than 35°, much below the mean of 38.0° and the threshold of greater than 35° in degenerative RCTs. The mean age was 58 years, and 70% of patients were men. Overall, 60% of tears involved the subscapularis, 49% of tears occurred in patients aged 60 years or older, and 18% of patients sustained a dislocation. Older age (β= 0.316, P= .003) and male sex (β= 5.532, P= .025) were predictive of tear size, and older age (β= 0.229, P= .011) and biceps avulsion (β= 8.822, P= .012) were predictive of tear retraction. Acute, traumatic RCTs have CSAs that are 5° smaller than those of degenerative tears, and the majority (60%) have CSAs that are below the threshold consistent with degenerative RCTs. The majority of traumatic tears (60%) involve the subscapularis. The study findings suggest that a traumatic tear is not simply the acute failure of a degenerative tendon and that it represents a distinct pathologic entity. These findings support current practice of treating traumatic RCTs differently than degenerative RCTs.