Download - Rotator Cuff Tendinopathy
Rotator Cuff Tendinopathy
Mr Puneet MongaConsultant Orthopaedic Shoulder Surgeon
Wrightington Hospital
Terminology• Tendonitis / Tendinitis - Inflammation of the
tendon (rare)- Inappropriate terminology.
• Tendinoses- Degenerative condition- Tendon damage at cellular level.
• Tendinopathy - Disease of the tendon
Function of the RC
• Rotation of the humerus w.r.t Scapula
• Compresses the head into the glenoid- dynamic stability
• Force coupling - Deltoid / Lattisimus / Pec Major
Acromial shapes
Bigliani, L. U.; Morrison, D. S.; and April, E. W.: The morphology of the acromion and its relationship to
rotator cuff tears. Orthop. Trans.,10: 228, 1986.10228 1986
Higher proportion of RC tears seen in Curved and Hooked Acromions
Image courtesy- Shoulderdoc.co.uk
Coronal Plane Patho-anatomy
AbductionNeutral Position
Repetitive Micro-trauma from external impingement
Extrinsic Theory doesn’t explain it all
• RCT- Bursectomy vs Bursectomy + acromioplasty- No Difference
• Articular surface tendon damage more common
• No direct relation between acromial shape and impingement symptoms
Lewis J. Subacromial impingement syndrome: a musculoskeletal condition or a clinical illusion? Physical Therapy Reviews. 16(5):388-98. 2011
Normal Tendon
Normal Cuff Tendon =
Collagen (Type I predominantly)
Elastin
Glycosaminoglycan
Proteoglycans
Water
Image Courtesy: www.ouhsc.edu
Injured tendon- Usual repair
Total Collagen decreases
Increased gene expression of Type I, VI, IX and III
Decreased Type II expression.
Repair and replacement of normal collagen
Andrew Carr, Paul Harvie Chapter; Tendon Injuries pp 101-118 Rotator Cuff Tendinopathy.In Tendon Injuries. Maffulli et al Springer, 2005.
Tendinopathy
• Excessive remodelling in response to tendon damage during tendon repair
• Aberrant “quality” Collagen
“Stiffer Extracellular matrix”
Normal
Tendinopathy-Disorganised matrix
Cellular clumping
Is Tendon Structure Associated with symptoms in Chronic Achilles TEndinopathy?An update on pain mechanisms– Written by Robert-Jan de Vos, The Netherlands, Aspetar Sports Medicine Journal 2017
Role of genetics
Possible link with “ank” mutation
(This is seen in association with Progressive form of arthritis)
Gene codes for a protein which transports Pyrophosphate out of the cells…..so a defective gene leads to high concentration of PPi.
Increased Calcium deposition
Andrew Carr, Paul Harvie Chapter; Tendon Injuries pp 101-118 Rotator Cuff Tendinopathy.In Tendon Injuries. Maffulli et al Springer, 2005.
Role of blood supplyCodman’s Critical zone
Debated- perhaps decreased blood supply a result rather than a cause
“Chicken or egg”
May explain the location along with external impingement
Andrew Carr, Paul Harvie Chapter; Tendon Injuries pp 101-118 Rotator Cuff Tendinopathy.In Tendon Injuries. Maffulli et al Springer, 2005.
• Why do some partial tears progress to Full
• Why do some small tears progress to large
• Why do only 4% massive tears develop Cuff tear arthritis
• Presence of Cuff tear without impingement / vice versa
Discontinuous and multifactorial modelAndrew Carr, Paul Harvie Chapter; Tendon Injuries pp 101-118 Rotator Cuff Tendinopathy.
In Tendon Injuries. Maffulli et al Springer, 2005.
Using a Cluster approach recommended
• History
• Look Feel Move + Special Tests
• Investigations
Making a Diagnosis
History and physical examination provide little guidance on diagnosis of rotator cuff tears.
Jain NB, Yamaguchi K. Evid Based Med. 2014 Jun;19(3):108.
Role of Investigations
• Ultrasound - Good for soft tissues & dynamic
• Xray- Good screening tool for Bone / joint
• CT- Good for bone
• MRI- Good for soft tissues and cross sectional
First line Management
• Activity Modification
• Analgesia
• Physiotherapy- Posture, motor control, stretching, strengthening, Manual therapy- 6 weeks
Positive Predictors(1) Patient expectation of ‘complete recovery’ compared to a ‘slight improvement’ as ‘a result of physiotherapy treatment’,
(2) Lower pain severity specifically at rest,
(3) The absence of a previous major operation (shoulder surgery excluded),
(4) The absence of pain in the opposite upper quadrant and
(5) Change in pain or range of shoulder elevation with manual facilitation of the scapula during elevation of the arm.
Is Tendinopathy inflammatory?
• No
• Biopsies- No inflammatory cells
• Degenerative changes
Sports Med. 1999 Jun;27(6):393-408.Histopathology of common tendinopathies. Update and implications for clinical management. Khan KM1, Cook JL, Bonar F,
Harcourt P, Astrom M.
Is Bursitis inflammatory?
• Yes
• Presence of Inflammatory mediators in Bursal biopsies
• Inflammatory mediators reduced following NSAIDs or cortisone injection
Arch Orthop Trauma Surg. 1992;111(6):336-40. Inflammation of the subacromial bursa in chronic shoulder pain. Santavirta S1, Konttinen YT, Antti-Poika I, Nordström D
J Shoulder Elbow Surg. 2005 Jan-Feb;14(1 Suppl S):84S-89S. The molecular pathophysiology of subacromial bursitis in rotator cuff disease. Blaine TA1, Kim YS, Voloshin I, Chen D, Murakami K, Chang SS, Winchester R, Lee FY, O'keefe RJ, Bigliani LU.
J Orthop Res. 2006 Aug;24(8):1756-64. Stromal cell-derived factor 1 (SDF-1, CXCL12) is increased in subacromial bursitis and downregulated by steroid and nonsteroidal anti-inflammatory agents.Kim YS1, Bigliani LU, Fujisawa M, Murakami K, Chang SS, Lee HJ, Lee FY, Blaine TA.
Notable Exception
Acute Rotator Cuff Tears
Early surgery has better outcomes
Duncan NS, Booker SJ, Gooding BW, Geoghegan J, Wallace WA, Manning PA Surgery within 6 months of an acute rotator cuff tear significantly improves
outcome. J Shoulder Elbow Surg. 2015 Dec;24(12):1876-80.
Setup• Patient Position - Beach chair / lateral
• Arm holder - traction vs mechanical
• Kit- Coblation/ shaver/ pump
Outcomes
20 year follow up 80% satisfied- 14% revision
Arthroscopy. 2015 Oct 24. pii: S0749-8063(15)00704-5. doi: 10.1016/j.arthro.2015.08.026. [Epub ahead of print]
Patients With Impingement Syndrome With and Without Rotator Cuff
Tears Do Well 20 Years After Arthroscopic Subacromial Decompression. Jaeger M1, Berndt T2, Rühmann O2, Lerch S2.
Key Points
• Both Extrinsic and Intrinsic factors play a role
• Tendinopathy is degenerative not inflammatory
• ASD when first line treatment fails
• Reliable outcomes in carefully selected patients