Treatment Options

The Ultimate Rotator Cuff Training Guide

Rotator Cuff Injury Exercises

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Nonoperative Management

Nonoperative treatment of rotator cuff disorders provides the possibility of avoiding the inherent risks of surgery. Failure of nonoperative treatment results in continued or recurrent symptoms and/or progression of pathology, leading to eventual surgical treatment, possibly after irreversible changes have occurred in the rotator cuff. When counseling patients regarding treatment options, it is helpful to characterize a cuff disorder with respect to the patient's age, the tear size, injury mechanism, chronicity, and muscle atrophy/fatty infiltration. Within this framework, the overall risk of irreversible changes to the cuff with continued nonoperative treatment is weighed against the potential for improvement with continued nonoperative treatment.

Tendonitis or partial-thickness tears are readily reversible conditions with surgical treatment and are unlikely to progress rapidly with nonoperative treatment. Therefore, a prolonged period of nonoperative treatment may be offered to a patient with little risk of progression of the pathology. In addition, non-

operative treatment of these conditions has been reported with success rates of 67%, with only 18% recurrence for an average of 2 years.34 Small- to medium-sized tears (2 to 3 cm), existing tears with a recent loss of function, or tears of any size in a young (younger than 60 years old) active population are at risk of progression if they fail early nonoperative therapy. In this group, prolonged nonoperative treatment has a low success rate and carries a risk of leading to irreversible changes that may complicate the eventual surgical repair. In this group, early surgical treatment after a short course of nonoperative treatment is preferable. Patients older than 70 years of age with large chronic tears have already experienced irreversible changes in their cuffs that lead to functional loss and pain. Because of these irreversible changes in the cuff there is little risk associated with attempting prolonged nonoperative treatment to control a patient's pain.

It is estimated that between 70% and 80% of rotator cuff tendonitis will be successfully treated nonoperatively. In one series of 616 patients, 78% of patients treated within 4 weeks of symptoms onset had a successful outcome versus 67% in patients who had symptoms for 6 months or more. In this study, acromial morphology played a role as well, with the highest rates (91%) of successful nonoperative treatment in patients with a type I (flat) acromion, compared to 68% with type II and 64% with type III.34 Nonoperative methods of treating rotator cuff tendonitis and impingement syndrome include corticosteroid injections, oral anti-inflammatory medication, activity modification, modalities of ultrasound and phonophoresis, and rehabilitation emphasizing stretching and strengthening the rotator cuff and scapular musculature. There are few controlled studies that provide objective data on these therapeutic options.

Corticosteroids have been shown to be effective in controlling symptoms associated with rotator cuff pathology, often eliminating the need for surgical treatment.35 Corticosteroid injections control pain and improve function better than lido-caine injections alone. However, these injections carry an inherent risk of causing necrosis and fragmentation of the tendon tissue, potentially making surgical repair more difficult.35 For this reason, corticosteroid injections into the subacromial space to treat rotator cuff tendonitis or symptomatic small tears should be used with discretion. We recommend a guideline of limiting a series of injections to three injections given at 3-month intervals.

Rehabilitation is a mainstay of nonoperative treatment of rotator cuff disorders. Following a brief (3-day) rest period to decrease acute inflammation and pain, the patient should engage in a stretching protocol to increase the range of motion, especially in patients who have lost internal rotation, as the tight posterior capsule can elevate the humeral head and cuff into the acromion. After improvement in range of motion is achieved, the patient may engage in regular light exercise to strengthen the muscles of the rotator cuff and scapular stabilizers in addition to deltoid and trapezius strengthening. Strengthening the rotator cuff and scapular stabilizers will improve shoulder kinematics, and a strong deltoid will improve abduction strength, providing a stable fulcrum is present. In order to benefit from a rehabilitation program, compliance with a regular program is essential. Insofar as supervised therapy improves compliance, there is benefit to supervised physical therapy. However, in one study of patients who had undergone arthroscopic subacromial decompression without rotator cuff repair, there was no difference in outcomes between the group in supervised therapy and the group in a self-directed program.36 It may be that being enrolled in the study heightened patients' awareness of the protocols and increased their compliance.

Supervised physical therapy often uses other modalities such as ultrasound, phonophoresis, or iontophoresis to treat subacro-mial bursitis, cuff tendonitis, or small symptomatic cuff tears. Ultrasound therapy is a common physical therapy modality that is often applied to the nonoperative treatment of rotator cuff tendonitis and subacromial impingement. High-frequency ultrasound (1 to 3 MHz) creates a thermal and possibly mechanical effect that can increase blood flow to a focal area, theoretically augmenting a tissue's capacity to heal. Although there are no studies that demonstrate its effectiveness in the treatment of rotator cuff tendonitis or subacromial impingement symptoms, ultrasound is used frequently. In a prospective, randomized, double-blind, placebo-controlled study, 20 patients with sub-acromial bursitis were randomized to receive either sham or real ultrasound 3 times per week for 4 weeks.37 There was no demonstrable benefit in the ultrasound group in terms of pain ratings, function, or time to recovery. In this small study with only 20 subjects, the authors concluded that there was no benefit to treatment of subacromial bursitis with ultrasound. It is possible that the therapeutic benefit was small and was not detected by low numbers of subjects in a short period of time. Phonophoresis is a technique that uses ultrasound to deliver medication directly into superficial tissues. It is postulated that the mechanical and thermal effects of ultrasound together increase tissue permeability and even cellular permeability. In a controlled study,38 47 patients were randomized to receive either corticosteroid phonophoresis or the identical ultrasound doses without corticosteroid. There were no differences found between the groups. Iontophoresis is another modality whereby physical properties of electric current is used to deliver medication directly to pathologic tissues, usually corticosteroids. Much recent work has been directed at determining the optimal physical parameters for maximal medication delivery. There is scant literature available regarding the clinical effectiveness of this treatment.

Surgical Treatment

Despite appropriate nonoperative care, patients often require surgical treatment. Surgical treatment of rotator cuff pathology requires a thorough understanding of the specific pathologic condition to be treated. Even with adequate imaging studies, an arthroscopic diagnostic evaluation of the glenohumeral joint and the subacromial space will help define the pathology, and provide an understanding of the involved anatomy. Arthroscopic findings will guide treatment, and intraoperative decisions often need to be made as anatomic details of the pathology are revealed.

Arthroscopic evaluation and treatment of subacromial bursi-tis and rotator cuff tears may be performed in the beach chair or lateral decubitus position. Use of the beach chair position prevents potential distortion of normal anatomy and allows the surgeon to frequently reposition and examine the arm during the procedure. The advantage of the lateral position is that the arm is distracted, which enlarges the subacromial space, potentially providing greater arthroscopic perspective to facilitate an accurate interpretation of the tear anatomy. As the lateral position holds the arm in a fixed abducted position, the arm should be removed from traction to allow for inspection in several positions. Care must be taken not to repair a cuff tear with the arm in excessive abduction, as this repair will be under additional tension when the arm is in a neutral position.

Diagnostic Arthroscopy

Surgical treatment of rotator cuff tendonitis or tears starts with a thorough diagnostic arthroscopy of the entire glenohumeral joint. With visualization of the glenohumeral joint from the posterior portal, a standard anterosuperior portal is placed within the rotator interval to allow outflow and instrumentation. The subscapularis insertion is evaluated in various degrees of arm rotation, with particular attention paid to its confluence with the glenohumeral ligament complex comprising the biceps sling. The biceps tendon is pulled into the joint and inspected for erythema or fraying, indicative of biceps tendonitis (Fig. 25-2A), or a torn biceps sling (Fig. 25-2B), which may suggest the need for a biceps tenodesis or tenotomy. The articular side of the supraspinatus is carefully inspected with the arm abducted, externally rotated, and forward elevated. The rotator cuff cable is identified (see Fig. 25-1), and an absorbable monofilament suture is passed through a spinal needle to mark focal irregularities or small tears in the articular side of the cuff tendon (Fig. 25-3A), which will facilitate bursal side inspection (Fig. 25-3B).

Subacromial Decompression

The subacromial space is entered posteriorly and a thorough bur-sectomy is performed. Visualization is maximized by maintaining hemostasis, through careful dissection using radiofrequency

Figure 25-2 A, Biceps tendonitis. B, Torn biceps sling.

coagulation and careful fluid management in the setting of effective intraoperative blood pressure control. Besides providing visualization, complete bursal debridement removes a pain-producing structure.39,40 If an acromioplasty is to be performed, the coracoacromial (CA) ligament insertion on the anterolateral corner of the acromion is identified and elevated with a radiofre-quency device introduced from the lateral portal. It is advisable to use coagulation in the region of the acromial branch of the tho-racoacromial artery, which runs in the substance of the CA liga-ment.11 We recommend that radiofrequency dissection continue cautiously beyond the anterior and lateral edges of the acromion to but not beyond the fibers of the deltoid muscle in order to identify bone irregularities including an anterior hook or bone excrescence. Maintaining deltoid fascia integrity will help prevent extravasation of fluid into the surrounding soft tissues. A bur is introduced from the lateral portal and starting with the lateral edge and anterolateral corner, the anterior portion of the acromion is decompressed to a flat surface. The acromioplasty is then completed, working through the posterior portal via a cutting block technique viewing from the lateral portal.

The decision to perform a routine acromioplasty is a source of controversy. Gartsman and O'Connor41 demonstrated no difference in outcomes in their series of 93 patients with primary rotator cuff tears and type II acromions who were prospectively randomized to undergo arthroscopic rotator cuff repair with or without acromioplasty. We often perform an acromioplasty when preparing an arthroscopic rotator cuff repair to maximize visualization, to ensure an absence of cuff impingement, and to reduce symptoms, as this has been a proven method for treating the pain associated with rotator cuff pathology.42

Arthroscopic Rotator Cuff Repair

If a repairable tear of the supraspinatus is identified, it is crucial to understand the anatomy of the tear and ensure the mobility of the tendon, remaining cognizant that large tears will be pulled medially and posteriorly. Dissection above the superior labrum, or through the rotator interval if necessary, will mobilize tendons and allow a low-tension reduction. Friable tendon edges are debrided carefully back to more intact tendon edge capable of holding suture. The footprint of the cuff is prepared by judicious use of a burr to expose fresh bone capable of evoking a healing response, taking care not to remove excessive (>1 mm) bone (Fig. 25-3C). To establish the working anterolateral accessory portal, dead man's43 angle is determined with a spinal needle, and a 6-mm threaded cannula is inserted at that angle directly over the footprint to allow anchor insertion at that angle as well (Fig. 25-3D).

The various techniques of arthroscopic rotator cuff repair are not thoroughly reviewed here. For large U-shaped tears that have retracted to the glenoid (Fig. 25-4A), dissecting the tendon off the glenoid neck (Fig. 25-4B) and coracoid will mobilize the tendon for repair. It is advisable to place side-to-side margin convergence sutures to reestablish force couples and to convert the tear to a smaller C-shaped tear (Fig. 25-4C),44,45 allowing for direct tendon to bone repair with anchors. With irregular L-shaped tears, it may be necessary to place and remove margin convergence sutures to determine that the location of the medial closure apex does not limit the ability to reduce the lateral tendon edge to bone. The location and total number of anchors should be planned before placing the first one, avoiding confluence of the anchor holes. Resorbable anchors have been shown to have adequate pull-out strength46 in good quality bone, but we will occasionally use metal anchors in poor-quality bone.

Figure 25-2 A, Biceps tendonitis. B, Torn biceps sling.

Frozen Shoulder Scar

Anchors loaded with multiple braided nonabsorbable sutures are our preference. Recent work has suggested that a double-row orientation of anchors and suture passage may improve healing by increasing the area of contact between the tendon and bone.47 Sutures are passed through tendon either directly or indirectly via a suture shuttle method using any number of commercially available devices. We routinely place anchors and pass sutures working posterior to anterior, as this provides the best visualization and the ability to reduce a posteriorly retracted cuff. Direct suture passage is performed by introducing a sharp-tipped grasping device via the posterior portal, penetrating the full thickness of the cuff 1 cm from the torn edge, taking care to avoid the articular surface of the humeral head that lies directly below the tendon edge. The desired suture can then be grasped and pulled directly through the tendon. Indirect suture passage uses an intermediary shuttle suture, which is passed through the cuff, retrieved through the working portal, tied to the desired suture, and then used to shuttle the suture through the cuff. If anchors are placed in a "stacked" or double-row configuration, the medial sutures should pass through the tendon in a mattress stitch close to the musculotendinous junction.

Regardless of the surgeon's knot and suture selection, arthro-scopic knot tying should follow principles of maintaining knot and loop security,48 tension-free tissue reduction, and proper placement of the suture loop and knot. Loop security describes the degree to which the tension applied to the knot is actually transmitted to the tissue-bone interface; without secure loops, even the tightest knot will not have the desired effect on the repair. The task of arthroscopic knot tying is greatly facilitated by ensuring that all extraneous soft tissue is debrided, which will not only maximize visualization, but also prevent soft-tissue interposition and subsequent knot loosening. Sliding knots are appropriate in most situations where suture freely passes through tendon and anchor eyelet, but excessive abrasion may weaken sutures or damage tendon. Nonsliding knots can be used in all situations, but careful attention must be paid to ensure

Figure 25-4 Massive tear. A, Retracted to glenoid. B, Release of adhesions between cuff and glenoid neck, above superior labrum. C, Side-to-side stitch closes U-shaped tear, allowing repair to greater tuberosity.

Figure 25-4 Massive tear. A, Retracted to glenoid. B, Release of adhesions between cuff and glenoid neck, above superior labrum. C, Side-to-side stitch closes U-shaped tear, allowing repair to greater tuberosity.

that the second and third throws seat the knot securely on tissue, preferably causing a slight indentation in the tendon tissue.

Partial-Thickness Tears

The treatment of partial-thickness tears is a controversial topic. Arthroscopic evaluation allows inspection of the cuff on both the articular and bursal sides, allowing accurate diagnosis of partial-thickness tears. This is especially true with respect to the articular-side tears, which cannot be fully appreciated without an arthroscopic evaluation of the glenohumeral joint. Early studies of arthroscopic debridement and acromioplasty alone as treatment of partial-thickness tears reported 76% to 89% good to excellent results.49,50

More recently, short-term pain relief has been reported following debridement and subacromial decompression of both articular- and bursal-side partial-thickness rotator cuff tears, with better results treating bursal-side tears.51 However, several authors52-54 recommend surgical repair of partial thickness tears, especially if they comprise 50% or more of the tendon thickness, with a lower threshold to repair bursal-side tears.54 For bursal-side tears, even a more invasive, mini-open repair resulted in better outcomes than simple arthroscopic debridement and subacromial decompression alone.55 Repair of articular-side partial-thickness rotator cuff tears can be performed arthroscopically by either completing the tear and using standard arthroscopic repair methods or by penetrating the intact portion with a suture anchor, pulling all sutures to the articular side, and passing sutures through the cuff by alternating between glenohumeral and subacromial visualization.53,54

Open/Mini-Open Rotator Cuff Repair

Prior to the advent of arthroscopic shoulder surgery, tears of the rotator cuff were identified and repaired with an open exposure of the subacromial space, requiring detachment of the anterior deltoid off the acromion, which required meticulous repair. Dehiscence of the deltoid from the acromion causes significant debilitation, and the value of minimizing deltoid intraoperative injury has since been recognized. In an effort to limit damage to the deltoid, mini-open techniques have been developed to allow open exposure to the subacromial space by splitting the deltoid without detachment from the acromion. We briefly describe the techniques of formal open exposure with deltoid repair and a less invasive mini-open deltoid-splitting technique.

Currently, the indications for considering formal open exposure include the inability to mobilize and repair a large retracted cuff tear arthroscopically or when performing a transfer of the latissimus or pectoralis as a salvage procedure. Even in the case of a formal open repair, a thorough arthroscopic evaluation of the shoulder is helpful to define the tear anatomy, mobilize the cuff, and identify other pathology. For open exposure of the supraspinatus tendon, every effort should be made to preserve the integrity of the deltoid attachment by using a mini-open approach that splits rather than detaches the deltoid. If necessary, the anterior 2 cm of the deltoid origin on the acromion may be elevated. Important anatomic features of the deltoid include its broad insertion on the periphery of the acromion. If detachment is necessary, it is critical to remove and maintain deep and superficial fascial planes of the deltoid to allow meticulous closure and full-thickness repair of both fascial layers directly to the acromion. Dehiscence of the anterior deltoid is a complication for which there is not a good solution, with predictably poor results following surgical repair.56 For an open exposure of a sub-scapularis tear, a standard anterior approach through the del-topectoral interval is used.

The most serious risk involved with the mini-open deltoid split is damage to the axillary nerve. Anatomic studies have identified an average distance of 5 cm,57 but a variable minimum between 4 and even 2 cm from the upper border of the deltoid muscle.58 The subdeltoid bursa remains cephalad to the axillary nerve, at an average distance of 0.8 cm (range, 0.0 to 1.4 cm).57 To minimize risk, the smallest exposure necessary to perform the repair should be used, and attempts should be made to limit that distance specifically to less than 4 cm. Furthermore, the split in the deltoid should remain above the boundry of the sub-deltoid bursa. To prevent inadvertent propagation of the split with retractors, a stitch is placed through the bottom of the deltoid split at the beginning of the surgical procedure.

Whether the deltoid is detached or split, open exposure allows direct visualization of the subacromial space. Even in the setting of an open exposure of the cuff, an acromioplasty can be performed arthroscopically prior to open exposure because arthroscopy allows better visualization of the anteromedial acromion. During this arthroscopic subacromial decompression, a complete bursectomy and cuff tear preparation may be performed, depending on the arthroscopic skill of the surgeon. Direct open visualization of the subacromial space will allow further debridement of the bursa and preparation of both the cuff tear and the tendon footprint. Depending on the size, location, and chronicity of the tear, adhesions to the coracoid and glenoid (through a large tear) may be released to mobilize the cuff, although this is often easier to perform accurately using an arthroscopic technique.

After debridement of the bursa, preparation of the tear includes mobilization of the tendon to allow a low-tension reduction and repair directly to the footprint of the tendon through bone tunnels or with suture anchors. Whether bone tunnels or suture anchors are used, an effort is made to preserve bone at the insertion site. Bone preparation should expose but not remove cancellous bone, thereby stimulating a healing response, without compromising anchor fixation or bone tunnel strength. The fixation strength of transosseous sutures can be maximized by orienting tunnel exits 1 cm distal to the tuberos-ity and creating a healthy bone bridge approximately 1 cm thick. As tendon is reduced and repaired, an appropriate amount of tension may be estimated by comparing the repaired tendon to the adjacent intact tendon insertion in whatever position the arm is in at the time of repair.

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