History

Determining the pathologic origin of shoulder pain can be challenging for even the most astute diagnostician. Rotator cuff tears are commonly associated with impingement signs such as lateral deltoid pain, night pain, and pain with overhead activity. The symptoms can progress to pain at rest. Rotator cuff tears are often multifactorial in origin. There are extrinsic factors, such as patient anatomy with acromial morphology, patient activity levels, repetitive trauma, acute one-time trauma, and associated pathology, that contribute to tendon failure. There are intrinsic factors, such as patient age, tendon biology, and comorbid conditions such as diabetes and smoking, that are associated with cuff tears. A careful history can help sort out acute, acute on chronic, and chronic aspects of the condition.

Physical Examination

Examination of the shoulder girdle is important to observe for any muscular atrophy that might be visually perceptible in the supraspinatus and infraspinatus fossae. Palpation of the shoulder for areas of pain is important. Range of motion of the shoulder is critical to assess. Assess passive versus active range of motion in all planes. Compare the affected side with the unaffected side. Patients with tears can demonstrate good passive motion but can lack active reproduction of motion. This can be particularly evident with loss or weakness of external rotation or internal rotation. Manual muscle strength testing can identify areas of weakness or pain. Other specific maneuvers including impingement sign, response to a subacromial injection (the impingement test), pain at the AC joint, pain of the biceps groove, and the external rotation lag sign and Hornblower’s signs can be helpful in the diagnosis of rotator cuff pathology. The cervical spine should be evaluated, and a neurologic examination should be performed also.

Imaging

Imaging should include plain radiography with three standard views of the shoulder: a true anteroposterior (AP) view of the glenohumeral joint (a Grashey view), an outlet view, and an axillary view. Acromial morphology on the outlet and AP views can reveal encroaching morphology, acromial bone spurs, and outlet narrowing resulting from shape and tilt of the bony anatomy. Arthritic changes may be apparent, as well as calcific tendinosis on plain radiographs. Cystic changes at the rotator cuff insertion should also be assessed. An os acromiale usually will be evident on the axillary lateral view. It will also be important to evaluate the acromioclavicular joint for changes. Measurement of the acromiohumeral interval is also important to determine if a rotator cuff defect is allowing superior migration of the humeral head. A measurement of less than 7 mm is indicative of significant superior migration of the humeral head.

Magnetic resonance imaging (MRI) without contrast is useful in working up rotator cuff tears. Tears are best assessed on the coronal T2-weighted images, but T1-images are also helpful. Important information to collect includes (1) whether tears are full or partial thickness, (2) amount of retraction, (3) whether muscle atrophy is present, and (4) presence of fatty infiltration. Associated pathology is also important to note, including biceps pathology.

Ultrasound has proved to be a useful modality to assess rotator cuff tears as well. Multiple studies have demonstrated its efficacy in not only diagnosing rotator cuff tears, but also evaluating the healing of tears postoperatively. More investigation will continue to define the usefulness in expanding the indications for its use.

Indications

Rotator cuff repair may be indicated for patients who have symptoms (pain and altered function) and in whom conservative management has failed. The symptoms are continuing to affect their occupation, recreation, sleep, and activities of daily living and have not resolved with appropriate therapy, medical management, time, and activity modification. Also, the rotator cuff tear is thought to be reparable on MRI evaluation. Indications for rotator cuff surgery have been challenged in recent literature. In December 2010 the American Academy of Orthopaedic Surgeons (AAOS) released its guidelines on optimizing the management of rotator cuff problems.¹ These guidelines were created by a panel of experts who performed a systematic review of the literature in an effort to delineate appropriate recommendations based on a review of articles. The guidelines state that there is weak evidence for repair of acute tears and that surgical intervention is an option for those with chronic, symptomatic, full-thickness repairs. These recommendations were the result of what was described as a paucity of high-level randomized controlled trials in the literature.

There are some generally accepted principles that have come from the literature. Acute tears, in which an event happens with a resultant decrease in function, are generally treated earlier than chronic tears. Chronic tears were found in 39% of cadavers by DePalma and colleagues² and on MRI in 54% of 60-year-old individuals.³ Thus, asymptomatic tears are not to be addressed surgically. Tears thought to be ideal for clinical success are smaller tears with minimal retraction, no atrophy, and no fatty infiltration and heal postoperatively.

All-arthroscopic techniques have continued to improve, gain in popularity, and achieve results similar to those of other techniques. Nho and colleagues⁴ performed a systematic review of the literature regarding all-arthroscopic techniques versus mini-open repair. Based on included studies they determined that results were equivalent between arthroscopic and mini-open techniques in terms of shoulder function and clinical outcome. There was a trend toward higher complication rates in the mini-open repair group. Their final statement was that both techniques are effective, and one should choose the technique that is most reproducible in his or her hands.

There are certain situations in which it has been argued that a mini-open procedure would be more advantageous than an all-arthroscopic surgery. These include retracted cuffs, larger tears, and tears involving the subscapularis and biceps dislocation as well as revision cuff surgery. However, these issues are difficult to address through any surgical technique.