Rotator Cuff Disease Update

2015
Mark Lembach MD
Orthopaedic Surgery and Sports Medicine
 Disclosures

I have no financial or other disclosures related to

this talk.
 Overview
Scope of the problem
Review rotator cuff anatomy
Review rotator cuff function
Current treatment strategies for rotator cuff
problems
Current research and potential future
advancements
 Rotator Cuff Disease

Shoulder pain is 3rd most common musculoskeletal

complaint.
20% incidence of rotator cuff tear in the general
population.
200,000 Rotator cuff repairs are done annually in the
United States. Additional 400,000 surgeries for tendinitis,
impingement, partial tears
 Rotator Cuff Tears and Aging
Patients with no shoulder pain and full
thickness rotator cuff tears.
40-60 yo: 4-13% incidence
60-70 yo: 20% incidence
70-80 to: 31-50% incidence
80 years and older: 50-80% incidence

So many rotator cuff tears dont cause pain

or significant dysfunction!
Rotator Cuff Anatomy
Rotator Cuff Anatomy
 Rotator Cuff Function
Helps coordinate
and balance
movement of the
shoulder in
concert with the
large muscles of
the shoulder
deltoid, pec
major, lat dorsi,
trapezius,
parascapular
muscles.
 Rotator Cuff Function
Dynamic stabilization of the gleno-humeral
joint throughout range of motion.
Long head biceps
Gleno-humeral ligaments (static)
 Rotator Cuff Disease
Tendinitis indicates inflammation from overuse,
irritation, strain, poor mechanics
Tendinosis degenerated and disorganized
collagen without obvious inflammation
Tendinopathy overuse condition characterized
by pain in and around tendons with a failure of
regenerative healing
Tendon Tear discontinuity of the myotendinous
attachment
Myopathy muscle atrophy and fatty infiltration
 Rotator cuff disease

Tendinitis Partial tears Complete tears

Where does the patient fall?

 Impingement - Tendinitis
Neer Codman
Impingement hypovascularity
Rotator Cuff Tear - Partial
 Partial rotator cuff tears
Partial thickness tears
Articular sided:
 Partial rotator cuff tears
Partial thickness tears
Articular sided

Bursal sided
 Partial rotator cuff tears
Partial thickness tears
Articular sided

Bursal sided

Interstitial
Full Thickness Rotator Cuff Tear
 Rotator Cuff Tear - Full

*In many situations, these tears should be treated

surgically
 Massive Rotator Cuff Tear
Tear larger than 5
cm and involving 2
tendons,
frequently involves
supraspinatus and
infraspinatus and
often extends into
the subscapularis
or teres minor
 Irreparable Rotator Cuff Tear
Not repairable or
perhaps should not be
repaired because of no
healing potential
Retracted medial to the
glenoid
>50% atrophy/fatty
replacement of the
muscle
Humeral head riding
high on x-rays
Chronic irreversible
changes
 Rotator Cuff Disease and
Overhead Athletes
GIRD, internal impingement, partial articular
sided RC tear, SLAP tears
The demarcation of adaptive versus
pathologic is not always clear
 Overhead Athletes
Mainstay of treatment is non-operative
Posterior capsular stretching
Dynamic strengthening Throwers 10
Appropriate mechanics
 Overhead Athletes
Repairs see
same extreme
forces that
caused
pathology in the
first place
Return to
previous level
guarded
 Treatment
Nonsurgical Indicated for tendinitis,
impingement, many partial thickness tears,
some full thickness tears
Activity modification, NSAIDS, cryotherapy
PT/exercises/modalities
Corticosteroid Injection
? Platelet Rich Plasma (PRP) injection
 Physical Therapy
Restoration of ROM capsular stretching
Strengthening of the rotator cuff and
parascapular muscles
Normalizing scapulo-throracic and gleno-
humeral rhythm
 PT for the Irreparable Tear
Flexibility, postural re-education, adaptive
muscle recruitment, anterior deltoid
strengthening, proprioception
Jackins exercises
MOON protocol
 Treatment
Surgical
Repair indicated for younger patients with full
thickness tears with adequate tendon and
muscle quality for a low tension repair.
Arthroscopic Repair
Arthroscopic Repair
Arthroscopic Repair
 Results of Rotator Cuff Repair
~90% success rates in pain relief and
satisfaction
Open, mini-open, arthroscopic
Healing rates of ~25-90%
Functional restoration related to healing
 Treatment
Other surgical options for irreparable tears:
Debridement, partial repair, biceps tenotomy
Tendon transfers- Lattissimus Dorsi, Pec major salvage
Reverse total shoulder prosthesis salvage
 Expanding Reparability
Tissue augmentation - grafts
 Expanding Reparability - The Future?
Biologic Enhancement
PRP platelet rich plasma
Growth factors
Tissue engineering
Grafts with growth factors and cells
Mesenchymal Stem cells
 Myths - 2015
1. All rotator cuff tears are symptomatic.
2. All rotator cuff tears can be repaired.
3. All rotator cuff tears should be repaired.
4. All rotator cuff repairs heal well and do well.
5. There cannot be good shoulder function
without an intact rotator cuff.
How can we make surgery more reliable, better
address irreparable tears?
Questions and Comments?
References