Rotator Cuff Disorders Research Articles

Glenoid inclination is associated with full-thickness rotator cuff tears.

Anatomic factors, such as a hooked acromion, have been associated with rotator cuff disorders. Orientation of the glenoid relative to the scapula has been implicated in shoulder instability, but it has not been linked to rotator cuff disorders. The purpose of the current study was to test the hypothesis that superior inclination of the glenoid is associated with full-thickness rotator cuff tears. Glenoid inclination angles were measured from 16 shoulder radiographs of a convenience sample of eight cadavers in which one shoulder had an intact rotator cuff and the other shoulder had a full-thickness rotator cuff tear. Glenoid inclination angles for shoulders with rotator cuff tears were compared with contralateral normal shoulders using nonparametric statistical analysis. The glenoid inclination angle was greater in cadaver shoulders having full-thickness rotator cuff tears (98.6 degrees ) than in shoulders without tears (91.0 degrees ). A second experiment was done to assess the reliability of using 34 Grashey view radiographs from a clinical population to measure glenoid inclination angle. A method to measure the glenoid inclination on Grashey views was tested and was found to correlate with the inclination angles measured on cadaveric scapulae. Intrarater reliability of measurements from clinical Grashey views was 0.93, and interrater reliability was at least 0.88.

A Method for Measuring Euler Rotation Angles and Helical Axis of Upper Arm Motion

Clinical observation suggests that shoulder pathologies such as rotator cuff disorders and shoulder instability may alter the normal shoulder rhythm or relative motions of the structures comprising the shoulder girdle. The purpose of this study was to assess the accuracy of using a skin-mounted humeral cuff that could be used in vivo to determine Euler rotation angles and the helical axis of motion (HAM) during upper extremity movements. An in vitro model was used to compare the kinematics determined from the externally applied humeral cuff to the kinematics measured directly from the humerus. The upper extremities of five cadavers were moved through several humerus and forearm motion trials. Measurements from the humeral cuff were compared directly to the bone measurements for all trials to determine the accuracy of the Euler rotation angles. In evaluating the HAM, the orientation, location, and magnitude of rotation were compared either to the bone measurements or to the known rotational axis of the testing fixture. Euler rotation angles and the helical axis of motion determined by the measurements taken from the skin-mounted humeral cuff were very similar to those using the measurements from the bone-mounted sensor. The humeral cuff was shown to provide a viable, noninvasive method for determining the Euler rotation angles and helical axis of motion during 3-D humeral movements. The validation makes the humeral cuff a valuable tool for examining the effect of shoulder pathologies on the kinematics of the upper extremity.

Apoptosis in rotator cuff tendonopathy

The aim of this study was to investigate the involvement of apoptosis (programmed cell death) in the pathogenesis of rotator cuff disorders. The edges of torn supraspinatus rotator cuff tendons were collected from patients with rotator cuff tear ( n=25). Samples of the intra-articular portion of subscapularis tendons were collected from patients without rotator cuff tear as control ( n=6). To minimize individual variance, we also collected six pairs of supraspinatus tendon and subscapularis tendon from six patients with rotator cuff tears. Apoptosis was detected by in situ DNA end labelling assay and DNA laddering assay. Immunohistochemical staining was performed to identify cells undergoing apoptosis. Control subscapularis tendon had normal morphology. Tendon from torn supraspinatus rotator cuff showed significant mucoid degeneration. Within the areas of degeneration, there were large numbers of apoptotic cells. The percentage of apoptotic cells in the degenerative rotator cuff (34%) was significantly higher than that in controls (13%) ( p<0.001). The excessive apoptosis detected in degenerative rotator cuff tissue was confirmed by DNA laddering assays. This is the first report of excessive apoptosis in degenerating rotator cuff tendon. Cells undergoing apoptosis in rotator cuff were mainly fibroblast-like cells. These finding indicate that apoptosis may play an important role in the pathogenesis of rotator cuff degeneration.

Extracorporeal shock wave therapy for lateral epicondylitis––a double blind randomised controlled trial

Extracorporeal shock wave therapy (ESWT) is an increasingly popular therapeutic approach to the treatment of a number of soft tissue complaints. Whilst benefit has been demonstrated in calcific tendinitis, evidence is lacking for benefit in the management of non-calcific rotator cuff disorders. Aims: To perform a double-blind placebo controlled trial of moderate dose ESWT in chronic lateral epicondylitis. Methods: Adults with lateral epicondylitis were randomised to receive either active treatment (1500 pulses ESWT at 0.12 mJ/mm 2) or sham therapy, monthly for three months. All were assessed before each treatment and one month after completion of therapy. Outcome measures consisted of visual analogue scores for pain in the day and at night. Results: Seventy-five subjects participated and there were no significant differences between the two groups at baseline. The mean duration of symptoms was 15.9 and 12 months in the ESWT and sham groups, respectively. Both groups showed significant improvements from two months. No significant difference existed between the groups with respect to the degrees of change in pain scores over the study period. In the ESWT group the mean (SD, range) pain score was 73.4 (14.5, 38–99) at baseline and 47.9 (31.4, 3–100) at three months. In the sham group the mean (SD, range) pain score was 67.2 (21.7, 12–100) at baseline and 51.5 (32.5, 3–100) at three months. At three months, 50% improvement from baseline was noted in 35% of the ESWT group and 34% of the sham group with respect to pain. Conclusions: There appears to be a significant placebo effect of moderate dose ESWT in subjects with lateral epicondylitis but there is no evidence of added benefit of treatment when compared to sham therapy.

Rope pulley isokinetic system in shoulder rehabilitation--initial results

Of this study was to evaluate the results of a shoulder rehabilitation program of different shoulder diseases, based on an isokinetie pulley system ("Moflex", Recotec/Bernina, Swiss). In this prospective study 70 patients participated in a standardized rehabilitation program (instability: n = 19; rotator cuff disorders: n = 23; impingement syndrome without lesion: n = 16; others: n = 12; operative therapy: n = 47). The major aspect of the program was an isokinetic pulley system. Isokinetic training with the used device affords strict monitor-feedback to avoid critical torque values. Strength which was attained without relevant pain was almost linearly increased by a mean of 31% until the 20th day of rehabilitation, workload by 79%. At the end of the rehabilitation program the strength of the affected (mostly dominant) shoulder was 15% higher than in the unaffected shoulder; the respective workload values were almost equal. These first results demonstrate the value of the isokinetic pulley system in the rehabilitation of the investigated shoulder diseases. The equipment may be used already in an early postoperative state. First results of strength increases using an isokinetic pulley system in shoulder rehabilitation are presented.

Factors associated with thoracic spinal cord injury, lesion level and rotator cuff disorders.

The study was concerned with the secondary functional compromise persons with long-term paraplegia contend with, that has been shown to be associated with wheelchair use. Of particular interest was the relationship between the level of thoracic spinal cord injury (SCI) and factors predisposing to rotator cuff disorders (RCD), one of the most common upper extremity musculoskeletal complications linked with long-term SCI. Disorders of these peri-articular structures have previously been associated with impaired trunk postural control and abnormal muscle strength ratios in both able-bodied groups and in paraplegic athletes. Despite their neurologically intact shoulder joint musculature, high-level and low-level paraplegics have different degrees of trunk and pelvic stability available to them during activities of daily living (ADL). This fundamental functional anatomical difference between high-level and low-level paraplegics had not previously been related to the diagnosis of RCD in a non-athletic long-term paraplegic population. A descriptive cross sectional study was undertaken to demonstrate the differences in the prevalence of clinically diagnosed RCD in a high-level (n=22) and a low-level (n=20) group of persons with long-term paraplegia. Any perceived differences were then related to the functional anatomical variations between the two groups. Inferences were made based on factors predisposing to RCD known to exist among both able-bodied and paraplegic athletes. The 42 subjects completed the Wheelchair User's Shoulder Pain Index (WUSPI) to establish the presence or absence of shoulder pain and the Musculoskeletal Function Assessment (MFA) instrument to determine differences in functional ability and perceived degree of difficulty within five categories of ADL. Each participant underwent a clinical examination using validated provocative clinical tests and isometric muscle strength ratio testing. There was a higher prevalence of RCD in the high-level group (P=0.009) which correlated with decreased trunk control (P=0.009). Differences in ability to perform functional tasks were not shown to be greater in the high-level group, although there was a higher degree of perceived difficulty in ADL. Muscle strength imbalances between the shoulder adductors and abductors were shown to be greater in the high-level group. The results of this study suggest that the functional anatomical differences that exist within paraplegia contribute to the propensity of high-level paraplegic persons to suffer from RCD. These findings send a clear message to service-providers that greater acknowledgement of the differences in trunk postural control specific to the level of thoracic SCI is required. This may have implications for the prescription of wheelchairs, assistive devices and instruction for alternative ADL techniques to this specific population.

Rotator Cuff Pathology and Subacromial Impingement

Musculoskeletal complaints are one of the most common reasons for primary care office visits, and rotator cuff disorders are the most common source of shoulder pain. Subacromial impingement with subsequent tendinitis and bursitis is frequently found in young adult patients. Rotator cuff tears are a common cause of shoulder pain in patients over age 40. The majority of subacromial impingement and incomplete rotator cuff tears may be successfully managed with conservative treatment. This article discusses anatomic function of the glenohumeral joint and subacromial space, etiology of subacromial impingement and rotator cuff disorders, examination of the shoulder, diagnostic testing, and treatment of subacromial impingement and rotator cuff disorders in the primary care setting.

SHOULDER IMPINGEMENT

Understanding the pathophysiology and treatment of rotator cuff disorders is the key to understanding all other aspects of shoulder rehabilitation. Impingement rehabilitation focuses on strengthening the humeral head depressors, while ignoring the deltoid and supraspinatus muscles. Later treatment includes specific retraining of scapular balancing muscles. The final phase of treatment includes strengthening the prime humeral movers in positions that avoid further stress to the injured rotator cuff tendons and, last of all, specifically strengthening the supraspinatus muscle.

38 The effect of physiotherapy for the rotator cuff disorders

38 The effect of physiotherapy for the rotator cuff disorders

MR IMAGING OF IMPINGEMENT AND ROTATOR CUFF DISORDERS: A Surgical Perspective

The role of MR imaging in the diagnosis of impingement and rotator cuff disorders is expanding greatly. This article discusses the clinically pertinent history, physical examination, and surgical treatment of rotator cuff problems. A rationale for consideration of open, "mini-open," and arthroscopic surgical intervention is proposed. The utilization of MR imaging by the orthopedic surgeon for nonoperative, preoperative, and postoperative decision-making are presented. A close working relationship between the radiologist and the orthopedist is emphasized.

MR IMAGING OF THE ROTATOR CUFF

MR imaging provides clinically useful information in detecting and characterizing pathology of the rotator cuff and other shoulder disorders in a noninvasive 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.

Rotator Cuff Disorders

Rotator Cuff Disorders Wayne Z. Burkhead, Jr. (Ed.) “Everything you wanted to know about the rotator cuff- and then some!” is the way the foreword introduces Rotator Cuff Disorders edited by Dr. Burkhead. Although the 47 contributors are predominantly distinguished orthopaedic surgeons, there are specific contributions by other specialists in fields such as anatomy, pathology, and radiology. Laid out in the format of traditional surgical texts, the book begins with an historical review of the rotator cuff. Section Two covers the basic science of the rotator cuff under the headings anatomy, pathophysiology, and biomechanics at a level adequate for a surgical text. Perhaps in a book purporting to report “everything you wanted to know” on such a precise area, an attempt could have been made to report more recent knowledge on the cellular and molecular mechanisms being examined in cuff disease. Section Three covers the evaluation and classification of cuff lesions, including clinical assessment and imaging in some detail. The next section is organized by chapter as a comprehensive list of clinical disorders, with thorough coverage of basic science, clinical features, and treatment of each diagnosis. This duplicates information elsewhere; however, it is extremely useful when looking for specific information in a clinical setting. The next two sections briefly cover conservative and arthroscopic aspects of treatment for rotator cuff disease. The final section provides extensive coverage of surgical management of massive cuff tears and degeneration. Some balance is provided by an excellent chapter arguing for unified biomechanical rationale behind the treatment of rotator cuff tears. The book concludes with two valuable chapters on the results and assessment of surgical treatment and the management of failed rotator cuff repairs. For readers of a journal such as Medicine and Science in Sports and Exercise, the limited coverage of the sporting shoulder, with only a short 14-page chapter devoted to the throwing athlete, is disappointing. The section on conservative management is also brief. This book provides comprehensive coverage of most aspects of rotator cuff disease especially relevant to orthopaedic surgeons in community practice. The sections on specific clinical disorders are useful for reference for most practitioners. Those with a specific interest in the athlete's shoulder would be better served by one of several recently published texts on the subject.

Arthroscopic Treatment of Rotator Cuff Disorders

The past 2 decades have seen rapid advancement in the field of shoulder arthroscopy in general and of rotator cuff disorders in particular. Arthroscopy allows superior visualization of pathologic conditions with less soft-tissue trauma than open exposures. Arthroscopic surgical techniques also are being applied to the actual treatment of many forms of rotator cuff disorders with clinical results similar to more traditional, open procedures. Although these techniques and their indications continue to evolve, it remains clear that, in carefully selected patients, arthroscopy has become a highly useful and effective tool in the diagnosis, evaluation, and surgical management of common disorders of the rotator cuff.

Rotator Cuff Disorders of the Shoulder

Rotator Cuff Disorders of the Shoulder

The conservative management of rotator cuff disorders.

A process of progressive tendon failure leads to rotator cuff rupture in a significant percentage of the ageing population but many individuals remain asymptomatic. Aetiological factors are varied and not completely understood but greater knowledge of shoulder function and mechanics allows for improved non-operative and operative management. There is a definite role for comprehensive conservative treatment of rotator cuff disorders in those cases where surgery is not clearly indicated. Successful rehabilitation depends largely on proper clinical assessment and individualized treatment. This requires a good understanding of the biomechanics of shoulder, and especially rotator cuff, function. Few recent studies have properly evaluated the results of such non-operative treatment.

The Relationship of Acromial Architecture to Rotator Cuff Disease

Variations in the architecture of the coracoacromial arch can lead to a clinically symptomatic rotator cuff lesion. Differences in the development and morphology of the acromion, and the presence of anterior acromial spurs and inferior acromioclavicular osteophytes decrease the volume of the subacromial space, leading to impingement. Recent anatomic, radiographic, biomechanical, and SPG studies have confirmed these architectural variations and their effects on the contents of the subacromial space. Abnormal contact between the acromion and these soft tissues can lead to pathologic lesions. Surgical procedures should be directed at increasing the space beneath the coracoacromial arch to reduce wear on the rotator cuff.

Normal rotator cuff: MR imaging with conventional and fat-suppression techniques.

The signal intensity and morphologic characteristics of the rotator cuff and surrounding structures at magnetic resonance (MR) imaging were investigated with five pulse sequences in 15 asymptomatic subjects. In all subjects, a focal region of relative increased signal intensity corresponding to the critical zone was observed in the supraspinatus tendon just proximal to its insertion. Soft-tissue signal intensity (isointense with muscle) was also located between the supraspinatus tendon and underlying joint capsule, interposed between the conjoined leaves of the supraspinatus and infraspinatus tendons, and superolateral to the conjoined cuff tendon, near its insertion. These regions were most conspicuous and most clearly defined with fat-suppression imaging. Small amounts of fluid were observed within the joint space and its recesses, the bicipital tendon sheath, and the subacromial-subdeltoid bursa. These and other MR imaging findings of this study previously have been regarded as indicative of rotator cuff abnormalities. These results will help refine the criteria for diagnosis of rotator cuff disorders with MR imaging.

High-resolution MR imaging of the normal rotator cuff.

The shoulders of six normal volunteers were imaged with high-resolution MR in the axial, sagittal, and coronal planes. An angled pair of counter-rotating current loop-gap resonators designed specifically for the shoulder was used as a local coil. All images were compared with corresponding cryomicrotome sections from cadaver shoulders. The rotator cuff was analyzed in detail. It appeared as a complex, heterogeneous band to tissue superficial to the humeral head. The areas of low signal intensity corresponded to the central tendons of the four rotator cuff muscles. These tendons could be distinguished from each other as well as from the intervening components of the cuff, which have a moderate intensity. We concluded that MR is capable of imaging the normal rotator cuff and of separating the various components. This may allow for improved precision in the diagnosis of rotator cuff disorders.

Soft Tissue Rheumatic Pain: Recognition, Management, Prevention

This timely book discusses a number of rheumatic afflictions that are responsible for much of the disability that puts rheumatic diseases in first place among potential causes. Not all the disorders are caused by soft-tissue lesions; some derive from joint and bone disease, but their major manifestations are in the soft tissues, and they figure among the important differential diagnoses. Even the introduction alone could teach worthwhile lessons in clinical diagnosis and therapy. However, the first 11 chapters address themselves to various regions, beginning with the head and neck and including the thoracic outlet, shoulder girdle, elbow, wrist, hand, thoracic cage, dorsal spine, lower back, pelvis, thigh, knee, foreleg, and, finally, the ankle and foot. Peritendinitis, bursitis, ganglia, tendinitis, and psychologically induced syndromes are discussed in detail. Vascular and joint dysfunctions also come under scrutiny, and the medical approach to rotator cuff disorders is carefully detailed. Appropriate illustrations make difficult