Rotator cuff disease is a highly prevalent phenomenon in patients >40 years old. It is a continuum of disease, where acute trauma or chronic damage can lead to rotator cuff tears and eventual arthropathy. This chapter outlines the epidemiology, pathophysiology, clinical presentation, and treatment options of rotator cuff tears.
8 Rotator Cuff Disease
Continuum of disease: Subacromial or subcoracoid impingement, calcific tendonitis, partial- or full-thickness rotator cuff (RTC) tears, massive tears, and cuff tear arthropathy.
Prevalence: 7–40% in cadaveric studies
Age >60: 28% have full-thickness tear
Age >70: 65% have full-thickness tear
In those with unilateral painful full-thickness tears, there is 56% chance of having an asymptomatic contralateral full- or partial-thickness tear
Of all asymptomatic tears, 50% will get symptoms in 3 years. Of these, 40% will have progression of tear.
Chronic degenerative tear:
Seen in older patients
Most commonly involves the supraspinatus and infraspinatus
Can extend to subscapularis and teres minor
Attributed to age-related intrinsic degeneration of the tendon
Disoriented collagen fibers, myxoid, and hyaline degeneration.
Typically starts at bursal surface of supraspinatus and infraspinatus
Os acromiale or bony acromial spur causes direct pressure and attritional injury to the bursal tendon
Deteriorated scapular motion most common cause of extrinsic RTC tearing
Also seen in internal impingement in overhead throwing athletes:
Partial articular supraspinatus tendon avulsion (PASTA) tears seen from impingement of posterosuperior glenoid and articular RTC.
Acute traumatic avulsions:
Seen with shoulder dislocations in age >40 years
Subscapularis avulsions seen in younger patients from hyperabduction/external rotation injuries
Acute avulsion may have better prognosis than chronic degenerative tear, if repaired in the acute phase.
Subscapularis failure seen after open anterior shoulder surgery from failure of repair.
Layer I: Most superficial thin layer, composed of fibers from coracohumeral ligament
Layer II: Dense collage fibers parallel to long axis of tendon (3–5 mm thick)
Layer III: Smaller loose bundles of collagen at 45 degrees angle to Layer II (3 mm thick)
Layer IV: Loose connective tissue continuous with coracohumeral ligament
Layer V: Shoulder capsule (2 mm thick).
Articular-side fibers have only half the strength of bursal side
Located in between supraspinatus and subscapularis
Comprises superior glenohumeral ligament (SGHL), coracohumeral ligament, long head of biceps tendon, and capsule.
Runs perpendicularly along the insertions of supraspinatus and infraspinatus
Thick fibers at the avascular zone of the coracohumeral ligament.
Cuff tear size (DeOrio and Cofield):
Small: Less than 1 cm
Medium: 1–3 cm
Large: 3–5 cm
Massive: lLrger than 5 cm (multiple tendons).
Partial-thickness RTC tears (Ellman):
Grade I (<3 mm, <25% thickness), Grade II (3–6 mm, 25–50%), Grade III (>6 mm, >50%)
A – Articular sided, B – Bursal sided, C – Intratendinous.
Cuff atrophy (Goutallier grade)
1–Some fatty streaks
2–More muscle than fat
3–Equal amounts of fat and muscle
4–More fat than muscle.
Cuff tear shape (▶ Fig. 8.1 )—Site Burkhart: Crescent, U-shape, L-shape, massive and immobile.