Female 60 Years Old with Chronic Shoulder Pain, for a period of six months, came in my office.
She was treated with all these drugs! Does the correct treatment option include so many drugs???
Chronic shoulder pain is very common, and the Orthopaedic surgeon must recognize its causes before starting any treatment.
The most common etiology of chronic shoulder pain can be:
• Cuff Disease including Impingement Syndrome
• Anterior or Posterior Instability
• Multidirectional Instability
• Biceps Tendon Pathology including SLAP Lesion
• Acromio-clavicular Arthritis, and
• Glenohumeral Arthritis
From all these, I would like to emphasize that chronic biceps tendinitis, rarely is the only lesion. Usually, this is a condition which results from Cuff Disease or a SLAP Lesion.
For many years, we believed that impingement syndrome was a different condition from rotator cuff tear, and there was a debate if the impingement does the tear, or the tear does the impingement. Now, it has become clear, that the pathology is the same, and the term rotator cuff disease describes it best.
Rotator cuff disease, is a condition for which we could write a book. However, within the next minutes, I will try to explain the most important topics of the pathology.
The (Neer’s) CLASSIFICATION OF IMPINGEMENT syndrome is as follows:
• TYPE I: PRIMARY IMPINGEMENT
• TYPE II: SECONDARY IMPINGEMENT
• TYPE III: SUBCORACOID IMPINGEMENT / STENOSIS
• TYPE IV: INTERNAL GLENOID IMPINGEMENT
The stages of rotator cuff disease as described by Neer are:
• Stage I: CUFF TENDINITIS with EDEMA and HEMORRHAGE
• Stage II: FIBROSIS AND TENDINOSIS
• Stage III: CALCIFIC TENDONITIS
• Stage IV: PARTIAL / FULL THICKNESS ROTATOR CUFF TEARS
The pathogenesis of rotator cuff disease is due to:
• Traumatic factors which lead to a traumatic cuff tear or a fracture of humeral tuberosities or the acromion and impingement from malunion,
• Degenerative factors especially of the Acromion, the acromio- clavicular joint, the coraco- acromio ligament and of course the Rotator cuff itself
• Capsuloligamentous factors such as instability or capsular contracture, which alter cuff mechanics.
Other causes which lead to rotator cuff disease are:
• Infamatory disease such as Calcific tendonitis or Bursitis, and Rheumatoid Arthritis,
• Iatrogenic disorders such a hardware misplacement or multiple steroid injections which lead to tendinopathy, and
• Developmental factors (OS Acromiale, hooked Acromion, Coracoid process)
The coraco – acromial arch includes the acromion, the coracoacromial ligament, the subacromial spurs, the AC joint, the coracoid process and all can lead to impingement.
On this slide, we can see a schematic way of the inflamed bursa and tendon, the hooked acromion and the stenosis of the subacromial space.
Calcifying tendinitis is a condition where there is intra-tendinous calcium deposition due to tendon degeneration or injury. Can be:
• Small (up to 0.5 mm)
• Medium (0.5 to 1.5 mm), or
• Large ( >1.5 mm).
More than 30%, of insulin- dependent diabetics have tendon calcification.
The classification of Calcifying Tendinitis is:
• Type I: The Calcific Nodule Has Sharply Defined Edges
• Type II: It is Mixture of Cloudy and Sharp Edges
• Type III: Has Cloudy Edges
The type of acromion was believed for many years to be a pathogenetic factor for impingement syndrome and rotator cuff tears.
Bigliani has described 3 types of acromion.
• TYPE I: Flat Acromion, and Low Incidence of Impingement
• TYPE II: Curved Acromion and Higher Incidence of Impingement, and
• TYPE III: Beaked Acromion and Very High Incidence of Impingement
However, over the last years, the importance of the acromion type as a cause for impingement syndrome and cuff tear is rather criticized in the recent literature.
We can see on the slide a schematic representation of the shoulder and the impingement signs which lead to cuff tear. On the right slide we can see a serious tuberosity erosion due to chronic impingement. In those pictures on the anatomical model, we can see the stenosis of the subacromial space, during the humeral head motion.
The incidence of rotator cuff tear has been described by a lot of authors. Looks to be up to 6% in cadavers younger than 60 years, and up to 30% in cadavers older than 60 years.
Diagnosis of Rotator Cuff disease is confirmed by history, physical examination and diagnostic imaging. The most common symptom is pain. Pain in the anterior, lateral and superior aspects of the shoulder which often refer to the arm, to the level of the deltoid insertion. Rarely, extented down to the elbow. The pain is activity related and becomes worse at night. Weakness is secondary due to pain. In complete cuff tears, weakness is significantly worse.
Limitation of motion is also caused by pain. Then, muscle weakness and capsular contracture results in further loss of motion. Crepitus is more common in complete cuff tears due to block of the tendon in the subacromial space.
There are a lot of clinical diagnostic tests to determine the rotator cuff disease. From all these, I would like to describe the following:
In the classic Neer test, full forward flexion, reproduces anterior shoulder pain, in patients with subcromial impingement. In the Hawkins – Kennedy test, the patient’s shoulder is placed in 90 degrees of forward flexion.
During the internal rotation of the arm the patient has pain to the great tuberosity, due to impingement. Positive O’ BRIEN TEST (with resistance against downward pressure with the arm in 90 degrees of flexion, 15 degrees of adduction, and full internal rotation), indicates biceps pathology. Other specific tests are the INFRASPINATUS & TERES MINOR test, the SUPRASPINATUS and the SUBSCAPULARIS tests. A positive SPEED test indicates biceps pathology and finally, the cross body adduction test, which indicate acromio-clavicular joint pathology.
Diagnostic imaging may include Plain Radiographs, Arthrogram, Subacromial Bursography, Ultrasound, CT-scan or CT- Arthrogram and MRI or MRI- Arthrogram. Concerning plain radiographs, I would like to emphasize the Anterposterior View, the Axillary Lateral View, the Thirty-Degree Caudal Tilt View and the Scapular Outlet View. The Anteroposterior View reveals associated calcific tendinitis, the superior migration of the humeral head under the acromion, cystic sclerotic changes in the greater tuberosity, degenerative changes in the AC joint, and sclerotic changes of the acromion, and narrowing of the acromiohumeral interval). The Axillary Lateral View is ideal to investigate the presence of glenohumeral arthritis. On Thirty-Degree Caudal Tilt View, we can note sub-acromial spurs. Finally, the Scapular Outlet View offers a good view of the outlet of the supra-spinatus-tendon unit and the coracoacromial arch. Arthrogram and Subcromial Bursography have been used in the past, but today they are routinely used only by a few physicians. Ultrasound is an effective diagnostic technique, but if surgical treatment is necessary, MRI is more sensitive. CT- SCAN is effective for cases with bone malformations, as a humeral head fracture, and the CT- Arthrogram is ideal for cases in which MRI is forbitten such in patient with pacemaker. The shoulder MRI has High Sensitivity for Full-Thickness Tears of Rotator Cuff, but it is Insufficient for Partial-Thickness Tears and Instability. On the other hand, MRI – Arthrogram is Effective for Both Full and Partial-Thickness Tears of the Rotator Cuff, Glenohumerus Instability, and SLAP Lesion, and it must be therefore preferred.
The differential diagnosis of rotator cuff disease includes: nerve entrapment syndromes such as Cervical spine disease, suprascapular nerve compression, or thoracic outlet syndrome, Brachial plexus neuritis, Arthritis of the glenohumeral or acromio-clavicular joint, Snapping scapula, and Frozen shoulder. On the other hand we must always look for fractures, as is a skier’ fracture, or a tumor of the humeral head primary or metastatic. On the picture we can see the most common tumors of the humeral head, and the position that they occur.
The treatment of rotator cuff disease can be conservative or surgical. Conservative treatment includes Non steroidal anti-inflammatory drugs, steroid injection, Physical Therapy and rarely modification of activities. We prefer to perform the steroid Injection behind, as Dean Sotereanos taught us. Its major advantage is the painless insertion in the subcromial space. The hands of the physician that are shown on the picture are Dean’s hands. We made together a video with injections techniques in the upper extremity for the Academy, when I was fellow in the UPMC.
Calcifying Tendinitis symptoms can resolve after 7-10 days. For this period non steroid antiinflamatory drugs and physical therapy may be the treatment of choice. On the other hand, steroid injection, needling, or fluoroscopic aspiration are alternative methods of conservative treatment. Conservative treatment includes also a home exercise program with strengthening of Rotator Cuff muscles, Heat Application and Stretching for Posterior Capsular Tightness.
When conservative treatment fails, after at least a 6 months period, surgical treatment must be selected. The indications for surgical treatment first described by Neer in 1972 are long term disability from chronic bursitis and partial tear of the Supraspinatus tendon, and complete tear of the Supraspinatus tendon. Ten years later the same great shoulder surgeon extended the indications as follows: Cuff Tears (Arthroscopically confirmed), patients older than 40yrs old with more than 1yr disability, patients younger than 40yrs old with Stage II Impingement, previous operations which could lead to impingement (as shoulder Fx, or a Total Shoulder Replacement), and a previous failed acromioplasty.
Surgical treatment includes decompression, simple cuff debridement and cuff repair. For the subacromial decompression we can perform acromioplasty, coracoacromial ligament resection and AC joint osteophytes resection. For the cuff tear we must recognize the type of the lesion. For partial tears, treatment depends on the lesion site. Partial Subcromial surface tear needs repair. Intratendinous tear needs Acromioplasty. For partial articular surface tear we can perform debridement or repair. Finally, for full thickness Rotator Cuff tears we have to select between simple decompression, repair or, when needed, mobilization and repair. The surgical techniques are open, mini open or arthroscopic.
Open techniques described first by Neer are now rarely used, mainly from less inexperienced surgeons.
I would like, however, to describe the technique, because, I believe that before you perform an arthroscopic procedure, you must first know how to do this open:
Beach chair position
The Acromion and the Acromioplasty
The sites of acromion, which we must resect for adequate decompression.
The cuff repair, here is a longitudinal tear, before and after suturing.
Another case of large full thickness supraspinatus tear, where you can see the biceps tendon.
Finally, the deltoid reconstruction with the use of drill holes is necessary to avoid deltoid retraction and functional limitation.
The mini – open techniques cause minimum trauma on the deltoid and have been used for many years. You can use the beach chair or the lateral decubitus position if you also want to do shoulder arthroscopy. The incision is over the acromion, and must be less than 2.5 cm.
Over the last years, arthroscopic techniques have become the gold standard for the treatment of the rotator cuff tears. Both beach chair and lateral decubitus positions are acceptable depending on surgeon’s experience.
In the following pictures, we can see the acromion before and after debridement, the acromioplasty and the cuff tear before the repair.
In my practice, I’m using routinely arthroscopically assisted real mini open technique, with an incision of only 1 to 1.5 cm. After arthroscopic evaluation and debridement of the lesion, one can identify exactly the acromion with the use of 2 or 3 needles, and the incision is just over this. Please note that in patient oldier than 50 years old, I perform always acromioplasty. After acromioplasty, you have a good view of the subcromial space. A small retractor is used, and with the arm in abduction and external or internal rotation, you can see the supraspinatus and infraspinatus tendons and you can repair them when needed. I’m using, most of the times, double row technique.
The anterior incision is the portal for the arthroscopic evaluation of the shoulder,
and the posterior incision is for the subucromial decompression and cuff repair. The final result is similar to the real arthroscopic technique. I prefer this technique as it is faster and cheaper.
However, for patients younger than 50 years old I perform only all – arthroscopic techniques. Whenever surgery for cuff tear or chronic impingement is performed, removal of Calcium Deposits must also be done, either by Open or Arthroscopic Techniques.
The term “massive rotator cuff tear” can have two definitions. In North America, massive rotator tear is in size greater than 5 cm. In Europe, massive tear is rupture of two or more tendons.
Treatment of massive rotator cuff tear includes:
• SIMPLE DECOMPRESSION
• MOBILIZATION AND REPAIR
• TENDON GRAFTS
• FASCIA LATA
• GRAFT JACKET
• TENDON TRANSFER
• REVERSE PROSTHESIS
Simple decompression is a minimal procedure, and it offers pain relief, but the results are short term. Functional improvement is also limited.
Mobilization and repair is the gold standard for massive rotator cuff treatment.
This is a case with massive tear, and the method of repair, after adequate mobilization.
The use of fascia latta is an alternative technique for massive rotator cuff tear with tendon retraction. Although, there is little evidence in the literature, in this case of a 76 year old patient with a neglected massive tear, with good appearance on MRI, we used fascia lata graft for the repair and the results were excellent. You can see on the pictures the full range of motion.
Graft jacket is a Human tissue product and can be applied using, open or arthroscopic techniques. No major complications have been reported, and the results are encouraging. In our practice, however, we have limited experience with the use of those material.
Goutallier, in 1994, first reported the correlation of shoulder function with the degree of fatty degeneration and muscle atrophy. In these cases tendon transfers are indicated.
The muscles than we can transfer are: the LATISSIMUS DORSI, SPLIT PECTORALIS MAJOR, TRAPEZIUS, and the DELTOID flap
The indication for latissimus Dorsi transfer is massive POSTEROSUPERIOR DEFECT, with
• CHRONIC SUPRASPINATUS, INFRASPINATUS and/or TERES MINOR tears
• NO POSTERIOR SUBLUXATION, and
• FATTY muscle DEGENERATION
SPLIT PECTORALIS MAJOR transfer has as indication in anterior-superior defects, such as a chronic Subscapularis tear or failed repair.
We must have:
• NO ANTERIOR SUBLUXATION, and, of course,
• FATTY DEGENERATION
This is case of a 60 year old patient with massive tear, which had fatty degeneration in the MRI. We performed pectoralis major transfer, with excellent results.
In cases with chronic irreparable Rotator Cuff tears, muscle fatty degeneration and anterior-superior or posterior-superior subluxation, Reverse Shoulder Replacement must be performed.
Postoperative Management, after rotator cuff repair, includes passive mobilization for 1 to 3 Weeks. Active Motion is allowed after 1-6 Weeks, depending on the size and type of cuff tear. Muscle Strengthening starting at 8 weeks post – operatively for a period of at least 3 months.
Return to sports is allowed at 5 months post-op. Patients Older than 60yrs Need Additional Physical Therapy for a Longer Time Period. They may experience Loss of Motion after 2-3 Years, due to muscle fatigue. Here is a custom made passive mobilization device, which a patient of mine made for his home exercises.
The results of operative treatment of cuff disease are described by many authors as successful in a rate of 80% to 96%, with open techniques. Arthroscopic treatment has 88% – 96% successful results. There are a lot of comparison studies between open and arthroscopic procedures for rotator cuff treatment and they all agree that with arthroscopy one has better evaluation of the shoulder joint pathology and has shorter recovery time, but there is no significant functional difference in long term Follow – Up. Nowadays, arthroscopic procedures are steadily becoming the treatment of choice for these disorders.
Since 2001, I perform mini open technique for the decompression of the subacromial space and the treatment of partial or full – thickness tears of the rotator cuff, out of 40 patients. The results were 84% (percent) excellent or good, and 16% fair or poor. Arthroscopy was not a standard procedure in the first patients. From the 7 patients with fair and poor results we then performed MRI-arthrogram in 4, and the findings were: SLAP Lesion in 2 patients, Anterior Instability in 1, and Articular Surface Supraspinatus Tendon Tear in 1. We then Performed Shoulder Arthroscopy in those 4 Patients and the Intra-operative Findings were Identical with our MRI-Arthrogram Diagnosis.
Therefore, the knowledge of the associated rotator cuff lesions can help improving our results in cuff disease treatment. Cuff tear associated disorders can be biceps tendon pathology, superior labral anterior and posterior lesions, acromioclavicular joint arthritis, sternoclavicular joint arthritis, glenohumeral joint arthritis and frozen shoulder.
Biceps tendinitis first described by Neer, is secondary to cuff disease for the majority of cases in clinical practice. The close relationship between the biceps tendon, the glenohumeral joint and the rotator cuff has direct impact of one structure on the other. Biceps tendon pathology includes primary bicipital tendinitis, biceps tendinitis with cuff disease, long head instability, and slap lesion. Long head instability, includes subluxation, dislocation, or complete displacement, as we can see on the picture. The indications for treatment are instability, partial tear more than 25%, tendon atrophy more than 25%, and when there is risk of autotenodesis. Other indications are the presence of biceps pathology associated with failed acromioplasty, and biceps pathology associated with SLAP tear. There are three options of surgical treatment: Debridement, tenodesis or tenotomy, and reduction and reconstruction of the dislocation. Debridement must be performed in simple cases with slight pathology. Tenodesis can be performed in patients less than 60 years old, with moderate to high demands, and for cosmetic concerns. Tenodesis can be: Bony tenodesis in high demand patients which is indicated in patients younger than 50 years, and soft tissue tenodesis, in lower demand patients which is indicated in patients older than 50 to 60 years. Here is a case with bone tenodesis with a use of a bone anchor. Tenotomy is ideal for patients older than 60 years, who have low demands, have minimal cosmetic concern and who have a massive rotator cuff tear. On the left picture a Popeye deformity is shown due to biceps long head tenotomy. We can see on the slide a serious degenerative biceps lesion which was treated by tenotomy, before cuff repair. Arthroscopic Reduction of the displaced biceps tendon and Reconstruction of the transverse humeral ligament must be performed in young active patients and especially in athletes, although the technique is difficult and needs a lot of experience.
The superior labrum anterior to posterior lesions, known as SLAP lesion, is another special condition often associated with cuff tear. ANDREWS, SNYDER and others have described the types of the pathology, and when indicated, the treatment is necessary. Treatment includes debridement for types I and III lesions, and repair for types II and IV, as we can see on the following pictures, where a type II lesion was reconstructed arthroscopically with the use of two bone anchors. And this is the final result.
One other condition associated with cuff disease is shoulder instability. In these cases it is important to repair the labrum in addition to the rotator cuff repair, especially in young patients, as showed on the next slide. The anterior labrum tear before and after the repair. In patients older than 60 or 70 years with mild or moderate glenohumeral arthritis, we must be very careful with the labrum repair, because the arthritic joint, has some type of balance, the disruption of which may lead to pain.
The ACROMIO – CLAVICULAR joint arthritis except from the pain can also cause impingement syndrome and cuff disease. Treatment can be osteophytes or joint resection. The indications for AC joint resection are tenderness Over AC Joint, Positive Injection Test and AC Joint Arthritis, radiologically confirmed. However, it is necessary to have the Superior and Posterior Capsule Intact. We can see a significant AC joint arthritis and the excision of the distal clavicular part, through a separate small incision.
The STERNO – CLAVICULAR joint arthritis is rare, usually after trauma. The steroid injection is most of the times effective. If not, excision arthroplasty must be performed, as it is shown on the slide. In this patient with a well documented cuff tear, careful evaluation showed additional sternoclavicular joint arthritis, which was also addressed using a small separate incision.
In cases of slight or moderate glenohumeral arthritis it is important to debride the joint first, in addition to the cuff repair, well before the any total replacement.
Rotator cuff arthropathy is a special pathology of the shoulder resulting from a chronic massive rotator cuff tear, which includes humeral head collapse and erosion of the acromion, the AC joint and the distal part of the clavicle. The pathogenesis can be due to deposit of Calcium Phosphate Crystals as described by McCARTY, or due to glenohumeral instability as suggested by NEER.
The classification (by Seebauer) includes:
Type IA, with good centralization of the humeral head,
Type IB, with centered medialized humeral head,
Type IIA, with decentered and limited stable humeral head, and
Type IIB, with decentered and unstable humeral head.
The treatment is tendon transfer or reverse shoulder arthroplasty. The philosophy of the reverse arthroplasty is to move the axis of rotation medially and downwards, so the deltoid can have better mechanical function. Here is a case with a 67 years old lady with rotator cuff arthropathy stage IB, and the procedure that we performed.
Frozen shoulder or adhesive capsulitis is one of the most common, poorly understood, disorders, that in the clinical practice it is very often associated with cuff disease. The etiology can be primary , called as idiopathic, and secondary associated either with known disorders, or after a surgical procedure or a fracture, when it is commonly called as “shoulder stiffness”.
The secondary frozen shoulder can result by intrinsic causes such as rotator cuff tendinitis or tears, biceps tendinitis, and ac arthritis. The extrinsic causes are humerus fx, cardio-pulmonary disease, parkinson’s disease, and systemic diseases like diabetes melittus. The symptoms are pain (minor to severe, especially at night), swelling and global stiffness and there are similar to rotator cuff pathology.
The treatment must first address the primary disorder if known. In the other cases non operative treatment is effective, including physical therapy and closed manipulation under anesthesia. On the other hand. arthroscopic or open decompression and capsular release is most of the times very helpful. on the slide we can the hemorrhagic synovitis.
Secondary impingement is a special condition of a shoulder with an Unstable Humeral Head resulting in Rotator Cuff Tendinitis. It can result from weakness of the Rotator cuff muscles (Functional Instability), or from Glenohumeral capsule and ligament laxity (Micro-Instability). The treatment is conservative, with muscle strengthening.
Subcoracoid impingement and stenosis result to Subscapularis tear. The treatment includes debridement or repair of the Subscapularis tear, and Coracoplasty. On the left picture, we can see the repair of the subscapularis tear, with the use of bone anchors,
Internal impingement involves abnormal contact between the posterior rotator cuff and the posterior and superior glenoid rim. It can lead to superior labral tears and partial articular surface rotator cuff tears. Treatment of Internal Impingement is first Conservative as follows: Rest (the patient must stop sports!), Rehabilitation which includes Posterior Capsular Stretching and Muscular Strengthening). Improvement of throwing technique is critical! Surgical Treatment includes debridement / decompression of subacromial space, Posterior Capsular Release and Anterior Laxity Reconstruction.
What can cause a cuff repair and acromioplasty to fail? The first and more common reason is Incorrect Technique! This includes failure of tendon fixation, failure of adequate decompression, excessive acromial resection, deltoid retraction and nerve injury.
It is reported in the literature that 5% to 90% of the Tendon Fixations fail to heal!
This depends from the size, the chronicity, the muscle atrophy, the fibrous degeneration, and the method of repair. On the pictures, we can see an excessive acromial and AC joint resection, with a limited functional result. Other reasons for Failed Cuff Repair and Acromioplasty are Postoperative Complications, such as Infection, Excessive Scar Formation, Acromial Stress Fracture and RSD or frozen shoulder. Failure of Rehabilitation is very important, too. And, of course, Pathology Other than Cuff Disease is a real and common factor for an unacceptable result. Therefore, good evaluation and correct surgical technique can have this excellent functional result.
We must evaluate the shoulder for Cuff pathology, first!
Conservative treatment must be our first choice, except the cases with large cuff tear!
Marteen Van De List, from Amsterdam, says that he can treat 60% of his patients with cuff disease non-operatively.
In cases where surgical treatment is needed, we must perform
• Arthroscopic Evaluation of the Shoulder, and Intra- Articular and Associated Lesions Repair
• Arthroscopically Assisted Real Mini Open (?) or Arthroscopic Repair of Cuff Tears, and Acromioplasty when needed.
• Massive Tears repair Need Special Management, and you must also
• Repair of the Associated Lesions.
In the following pictures we can see Dean Sotereanos 15 years before, the Upper Extremity fellows in 1994, and of course the Pittsburgh!
Finally a picture from Greece. Santorini island!
Thank you for your kind Attention!
PANAGIOTIS N. GIANNAKOPOULOS MD