Left
Right
Elevation/ABD supine
100 (active)
160 (passive)
150 (active)
160 (passive)
Elevation/ABD upright
80 (active)
130 (passive)
130 (active)
150 (passive)
External rotation
50 (active)
60 (passive)
60 (active)
75 (passive)
Internal rotation
L1
L1
When testing rotator cuff strength, the patient had significant weakness with resisted abduction at 90° (i.e., supraspinatus testing), with a positive drop-arm sign. She had 3/5 strength in resisted external rotation, and normal resisted internal rotation equal to the contralateral side. She was able to perform a belly-press and liftoff test, indicating a competent subscapularis muscle. Her deltoid and biceps strength were normal and equal to the contralateral side.
There was mild tenderness over the biceps tendon in the groove, with similar tenderness in the contralateral shoulder. Biceps testing (Speed and Yergason) was negative for pain or weakness. She had no tenderness over the acromioclavicular (AC) joint, and no significant pain with cross-body abduction. She had positive impingement signs (both Neer and Hawkins).
Radiographs included upright AP of the shoulder in internal and external rotation as well as axillary and scapular-Y views. These revealed that the humeral head was centered on the glenoid so there was no evidence of significant humeral head elevation, and preserved glenohumeral joint space. She had a type II acromion with minimal AC joint arthrosis.
A 1.5 T non-contrast MRI of the shoulder taken 2 months prior to our initial office evaluation was read by the radiologist as a full-thickness tear of the supraspinatus involving approximately 70% of the tendon footprint. There was significant tendinopathy throughout the remaining tendon as well as partial-thickness bursal-sided tearing (approximately 30%) of the infraspinatus tendon. The supraspinatus tendon was retracted to the glenoid. On T1-weighted sagittal views, there was approximately 40% atrophy of the supraspinatus muscle. The infraspinatus muscle was normal in appearance. There was a minimal amount of fluid within the AC joint. Degenerative fraying of the labrum was noted both anteriorly and posteriorly without a frank tear. The biceps tendon was located within the groove and was normal in appearance. The subscapularis was intact. A small amount of humeral head chondrosis was noted but the majority of the joint space appeared well preserved.
Diagnosis/Assessment
Based on imaging , the patient was diagnosed with a full-thickness rotator cuff tear with significant retraction. A number of surgical options were presented and the risks and benefits of each were explained. Ultimately, the surgeon’s recommendation was shoulder arthroscopy to address any chondrolabral pathology that may be encountered, capsular release if indicated, subacromial decompression, and attempted rotator cuff repair. Based on the degree of tendinopathy and atrophy seen on the MRI, the patient was cautioned that the quality and integrity of the remaining tendon may not be amenable to repair. If this were the case, then an arthroscopic debridement would be performed. The patient was made aware that with a debridement we would seek to diminish the pain, without significant improvements in strength and motion.
Management
In the weeks before surgery, the patient was weaned from her hydrocodone. No nerve block was used and once in the operating room, the patient was placed in the beach-chair position and underwent general anesthesia without paralysis. Examination of the shoulder under anesthesia showed minimal change in passive range of motion from her clinical encounter. The operative extremity was prepped and draped and preoperative antibiotics were given (Table 9.2).
Table 9.2
Pearls: pre-op
Patient selection | Imaging | Discussion |
|---|---|---|
Elderly (>65) | X-ray: elevation of humeral head, GH arthritis | Partial repair vs. debridement only |
Lower demand | MRI: amount of retraction, subscap tears, fatty atrophy | Pain relief realistic but gains in motion are not |
Pain > ROM loss |
A standard posterior-viewing portal was established after the joint was insufflated with 50 cc of normal saline utilizing an 18-guage spinal needle through the same path. A diagnostic arthroscopy was performed (Fig. 9.1).
Figure 9.1
The intra-articular portion of the diagnostic arthroscopy shows Grade III degenerative changes at the glenohumeral articulation (a). The biceps anchor is probed and a type I SLAP tear is noted (b). The rotator cuff tear is seen (c) with significant retraction
There was noted to be Grade III chondrosis of approximately 20% of the humeral head articular surface. A type I SLAP tear was encountered, with both the intra-articular and proximal-groove portion of the biceps tendon appearing normal. The rotator cuff was visibly torn with retraction to the level of the glenohumeral articulation. The axillary pouch was free of loose bodies. The subscapularis was covered in a thickened synovium but was intact. The middle and superior glenohumeral ligaments were contracted.
Under direct visualization, an anterior working portal was created between the biceps and subscapularis. A 5.5 mm cannula was introduced. A 4.0 mm shaver was used to lightly debride the degenerative anterior labrum and type I SLAP tear, as well as a small chondral flap on the humeral head. The anterior capsule was released using a combination of arthroscopic electrocautery and the shaver. Finally, a 0-PDS suture was introduced as a traction stitch through the rotator cuff using an 18-gauge spinal needle (Fig. 9.2).
