Mr Puneet Monga's presentation from The Arm Clinic's educational event, 11th November 2016

1. Evidence Update-
Rotator Cuff Disorders
Mr Puneet Monga
Consultant Orthopaedic Shoulder Surgeon
Wrightington Hospital

2. The Rotator Cuff
Image Courtesy- www.patient.info

3. Understanding Cuff Function & Tears

4. Kinematics -Vectors
Supraspinatus
Subscap + Infra
Deltoid
Text
Denard PJ et al. 2012 Nov;28(11):1587-91.
Inman et l 1996

5. Equatorial Concept
Burkhart et al. Partial repair of irrepairable rotator cuff tears. Arthroscopy. 10; 363
Jost, Gerber et al. Long term outcome of structure after structural failure of rotator cuff repairs.
JBJS Am; 88: 472

6. Equatorial Concept
Burkhart et al. Partial repair of irrepairable rotator cuff tears. Arthroscopy. 10; 363
Jost, Gerber et al. Long term outcome of structure after structural failure of rotator cuff repairs.
JBJS Am; 88: 472

9. Transverse plane
couple

10. Restoring RC function is all about keeping
the ball under water !
(and not just “covering the Hole”)

11. The Pathology of RC
disease

12. Rotator Cuff
Disorders
• Impingement -
• Tendonitis / Tendinosis / Bursitis / Tendon
Entrapment
• Rotator Cuff Tears
• Calcific Tendonitis

13. Causation of Cuff Disease
• Mechanical (Extrinsic)
• Degenerative / Vascular (Intrinsic)

14. Progression
• Stage 1- Edema and Hemorrhage.
• Age <25 year
• Stage 2- Fibrosis and Tendinosis.
• Age 25-40 years
• Stage 3 - Bone spurs and Tendon rupture.
• Age>40 years

15. Cuff Disease Progression
Bursitis
Tendinosis
Impingement
Calcific Tendonosis
Oedema
Hemorrhag
e
Partial Tears Spurs
Full Thickness
Tears
Cuff tear
Arthritis

16. 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

17. Sub-acromial Wringer

18. Coronal Plane Patho-
anatomy
AbductionNeutral Position
Post- Decompression

19. Sagittal - oblique Plane Pathoanatomy
Sub-Acromial volume

20. Arch Decompression
Sub-Acromial volume

21. Intrinsic Theory
Extrinsic Theory doesn’t explain
• RCT- Bursectomy vs Bursectomy + acromioplasty- No
Difference
• Articular surface tendon damage more common
• No direct relation between acromial shape and impingement
symptoms
• Outcomes not proportional to extent of acromioplasty
Lewis J. Subacromial impingement syndrome: a musculoskeletal condition or a clinical illusion? Physical Therapy Reviews. 16(5):388-98. 2011
Hence Tendon degeneration likely to play important
role

22. Making a Diagnosis

23. Positive Special Test = Diagnosis!

24. Using a Cluster approach recommended
• History
• Look Feel Move + Special Tests
• Investigations
Making a Diagnosis

25. 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.

26. Cochrane Database Syst Rev. 2013 Apr 30;4:CD007427. doi: 10.1002/14651858.CD007427.pub2.
Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may
accompany impingement.
Hanchard NC, Lenza M, Handoll HH, Takwoingi Y.
Cochrane Database review
33 Studies - 4002 shoulders
170 Target Conditions / test combinations
!
Only 6 instances where the test was
performed and interpreted similarly
No Clear Evidence to support a test

27. Subscapularis
• Bear Hug Sensitivity 60% Specificity 100%
• Belly Press Sensitivity 40% Specificity 97.9%
• Napolean Sensitivity 25% Specificity 97.9%
• Lift off Sensitivity 17.6% Specificity 91.7%
• Internal Rotation Resistance test at
Maximal Abduction (IRRTM) 76.5% sensitivity
Bear Hug Test: A new and sensitive test for subscap tears.
Barth et al. Arthroscopy 2006
Lin Et al 2015 Internal rotation resistance test at abduction and external rotation: a new clinical test for diagnosing subscapularis lesions.

28. Supraspinatus
• Hug Up Test 94% sensitivity, 76% specificity
• Empty Can 84% sensitivity 74% specificity
• Full Can 74% sensitivity 81% specificity
• Lag Signs are not conclusive
The Hug-up Test: A New, Sensitive Diagnostic Test for Supraspinatus Tears. Chin Med J (Engl). 2016 20th Jan;129(2):147-153. doi:
10.4103/0366-6999.173461. Liu YL, Ao YF, Yan H, Cui GQ
Miller CA1, Forrester GA, Lewis JS The validity of the lag signs in diagnosing full-thickness tears of the rotator
cuff: a preliminary investigation. . Arch Phys Med Rehabil. 2008 Jun;89(6):1162-8.

29. Infraspinatus
• Ext Rotation Resistance
• Lag sign
Merolla, G., De Santis, E., Campi, F., Paladini, P., & Porcellini, G. (2010). Infraspinatus scapular retraction
test: a reliable and practical method to assess infraspinatus strength in overhead athletes with scapular
dyskinesis.Journal of Orthopaedics and Traumatology : Official Journal of the Italian Society of Orthopaedics
and Traumatology, 11(2), 105–110.

30. Teres Minor
• ER Lag sign >40’ 100% sensitivity 92% specificity
• ER Lag Sign >10’ 100% sensitivity 52% specificity
• Patte Sign (Hornblower) 93% Sensitivity 72%
specificity
• Drop Sign 87% sensitivity 88% specificity
Collin P1, Treseder T, Denard PJ, Neyton L, Walch G, Lädermann A. What is the Best Clinical Test for Assessment of the Teres Minor in Massive Rotator Cuff Tears? Clin
Orthop Relat Res. 2015 Sep;473(9):2959-66.

31. 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

32. Ultrasound Versus
MRI
Ultrasound
• One Stop clinic
• Operator dependent
• Post op assessment
• Interactive
• Dynamic
MRI
• Cross sectional anatomy
• Bone and Joint
• Partial Thickness & Interstitial
Tears
• Visual record
• Muscle wasting and Fatty
Atrophy

33. When to use Ultrasound
• “Go-to” Investigation for Impingement
and Rotator Cuff Syndrome.
• Check integrity of Cuff repair within 1
year of surgery
• Guided injections

34. When to use MRI
scan
• Pre-operatively to assess for Muscle
Wasting and Fatty atrophy
• Atypical symptoms
• Large patients

35. Management

36. First line
Management
• Rest
• Simple Analgesia
• NSAIDs
• Physiotherapy- Posture, motor
control, stretching, strengthening,
Manual therapy- 6 weeks
• Sub-acromial Steroid Injection- 1 only
BOA/ BESS commissioning guide

37. Indications for
Surgery
Failure of First line treatment

38. 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.

39. Factors affecting
Outcomes

40. Age
Age > 65 years associated with relatively
inferior outcomes
Cho NS, Lee BG, Rhee YG. Arthroscopic cuff repair using suture bridge technique: is the repair integrity actually
maintained? Am J Sports Med 2011; 39: 2108-16

41. Tendon Vascularity
Hypovascular Zone 10-15 mm prox to
insertion (Codman)
Vascularity at edge of torn tendon
normal...? artifact in earlier studies
(Goodmurphy et al)
Codman EA. The shoulder; rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa.
Boston, Mass.: T. Todd company; 1934: 123-37
Goodmurphy CW, Osborn J, Akesson EJ et al. An immunohistochemical analysis of torn rotator cuff tendon taken at the
time of repair. J Shoulder Elbow Surg 2003; 12:368-74.

42. Tear Size
Large / Massive tear have inferior healing /
poorer outcomes
Good function still possible in cases of non
healing repairs
D Factor and B Dale. Current concepts of rotator cuff tendinopathy. The International Journal of sports physical therapy
2014; 9(2): 274-82.
Chung SW et al. Arthroscopic repair of massive rotator cuff tears: outcome and analysis of factors associated with healing
failure or poor postoperative function. Am J Sports Med 2013; 41: 1674-83.
Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal
of Orthopaedics 2015; 6(2): 211-20.

43. Tendon Retraction
Initial retraction due to Muscle contraction
and secondarily involves tendon shortening
Increasing Gap associated with inferior
outcomes
Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of
Orthopaedics 2015; 6(2): 211-20.
Meyer DC, Wieser K, Farshad M, Gerber C. Retraction of supraspinatus muscle and tendon as predictors of success of
rotator cuff repair. Am J Sports Med 2012; 40:2242-2247

44. Fatty Atrophy /
Wasting

45. Fatty Atrophy, Muscle
Wasting
Both independent risk factors
Higher re-operation rates, poor outcomes
and poor tendon healing in presence of
fatty atrophy
Goutallier D, Postel JM, Gleyze P, Leguillox P, Van Driessche S. Influence of cuff muscle fatty degeneration on anatomic
and functional outcomes after simple suture of full thickness tears. J Shoulder Elbow Surg 2003; 12:550-554.
Gladstone JN, Bishop JY, Lo IK, Flatow EL. Fatty infiltration and atrophy of the rotator cuff do not improve after cuff repair
and correlate with poor functional outcome. Am J Sports Med 2007; 35: 719-728.
Liem D, Litchenberg S, Magosch P, Habermeyer P. Magnetic resonance imaging for arthroscopic supraspinatus repair. J
Bone Joint Surg 2007; 89:1770-76.

46. Reversibility of FA/
Wasting
Fatty Atrophy Irreversible but halts after successful
RC Healing
Muscle wasting potentially reversible but usually
halts after successful RC healing
Fatty Atrophy / Wasting worsen in cases where RC
does not heal.
Chung SW et al. Arthroscopic repair of massive rotator cuff tears: outcome and analysis of factors associated with healing
failure or poor postoperative function. Am J Sports Med 2013; 41: 1674-83.
Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of
Orthopaedics 2015; 6(2): 211-20.
Liem D, Litchenberg S, Magosch P, Habermeyer P. Magnetic resonance imaging for arthroscopic supraspinatus repair. J
Bone Joint Surg 2007; 89:1770-76.

47. Smoking
Higher Risk of Cuff Disease
Inferior Outcome
Baumgarten KM, Gerlach D, Galatz LM, et al. Cigarette smoking increases the risk for rotator cuff tears. Clinical
orthopaedics and related research. Jun 2010;468(6):1534-1541.
Mallon WJ, Misamore G, Snead DS, Denton P. The impact of preoperative smoking habits on the results of rotator cuff
repair. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.]. Mar-Apr
2004;13(2):129-132.

48. Acromial Shape
Related to Risk of RC tears
No difference in outcomes of
decompression with / out acromioplasty
Bigliani LU, Ticker JB, Flatow EL, Soslowsky LJ, Mow VC. The relationship of acromial architecture
to rotator cuff disease. Clinics in sports medicine. 1991;10(4):823-838
Henkus HE1, de Witte PB, Nelissen RG, Brand R, van Arkel ER. Bursectomy compared with acromioplasty in the management
of subacromial impingement syndrome: a prospective randomised study.J Bone Joint Surg Br. 2009 Apr;91(4):504-10.

49. Single vs Double Row
repair
Double Row has better biomechanical
characteristics- decreased gap formation
and higher load to failure
Improved outcomes in large / massive tears
No difference in clinical outcomes in small /
medium size tears
Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal
of Orthopaedics 2015; 6(2): 211-20.
Park JY, Lhee SH, Choi JH, Park HK, Yu JW, Seo JB. Comparison of the clinical outcomes of single- and double-row
repairs in rotator cuff tears. Am J Sports Med 2008; 36: 1310-1316

50. Repair configurations
Knotted / Knotless
Number of sutures
Different Suture configuations
No difference
Kim KC, Shin HD, Lee WY. Repair integrity and functional outcomes after arthroscopic suture-bridge rotator cuff repair. J
Bone Joint Surg Am 2012; 94: e48
Barber FA, Herbert MA, Schroeder FA, Aziz-Jacobo J, Mays MM, Rapley JH. Biomechanical advantages of triple-loaded
suture anchors compared with double-row rotator cuff repairs. Arthroscopy 2010; 26: 316-323

51. Post op Rehab
Early vs Delayed
No Difference
Better pain relief and ROM in short term
Slightly higher retear in early mobilization in large / massive tears
Abtahi A M, Granger E K and Tashjian R Z. Factors affecting healing after arthroscopic rotator cuff repair. World Journal of
Orthopaedics 2015; 6(2): 211-20.
Kim YS, Chung SW, Kim JY, Ok JH, Park I, Oh JH. Is early passive motion exercise necessary after arthroscopic rotator
cuff repair? Am J Sports Med 2012; 40: 815-821
Cuff DJ, Pupello DR. Prospective randomized study of arthroscopic rotator cuff repair using an early versus delayed
postoperative physical therapy protocol. J Shoulder Elbow Surg 2012; 21:1450-1455
Parsons BO, Gruson KI, Chen DD, Harrison AK, Gladstone J, Flatow EL. Does slower rehabilitation after arthroscopic
rotator cuff repair lead to long-term stiffness? J Shoulder Elbow Surg 2010; 19: 1034-1039.
Lee BG, Cho NS, Rhee YG. Effect of two rehabilitation protocols on range of motion and healing rates after arthroscopic
rotator cuff repair: aggressive versus limited early passive exercises. Arthroscopy 2012; 28: 34-42

52. Addition of Growth factors
BMP
PDGF - Promising
FGF
TGF-β - Promising
Gulotta LV, Kovacevic D, Packer JD, Ehteshami JR, Rodeo SA. Adenoviral mediated gene transfer of human bone
morphogenic protein -13 does not improve rotator cuff healing in rat model. Am J Sports Med 2011.; 39: 180-7
Rodeo SA, Potter HG, Kawamura S, Turner AS, Kim HJ, Atkinson BL Biologic augmentation of rotator cuff tendon-healing
with use of a mixture of osteoinductive growth factors. J Shoulder Elbow Surg 2007; 89:2485–2497
Uggen JC, Dines J, Uggen C.W et al.Tendon gene therapy modulates the local repair environment in the shoulder. The
Journal of the American Osteopathic Association 2005, 105: 20–21
M. Kobayashi, E. Itoi,H.Minagawa et al. Expression of growth factors in the early phase of supraspinatus tendon healing in
rabbits. Journal of Shoulder and Elbow Surgery 2006; 15: 371–377.
Thomopoulos S, Harwood FL, Silva MJ, Amiel D, Gelberman RH. Effect of several growth factors on canine flexor tendon
fibroblast proliferation and collagen synthesis in vitro. J Hand Surg Am 2005; 30: 441–7.
Gulotta LV, Rodeo SA. Growth factors for rotator cuff repair. Clin Sports Med 2009; 28:13–23
C. N. Manning, H. M. Kim, S. Sakiyama-Elbert, L. M. Galatz, N. Havlioglu, and S. Thomopoulos, Sustained delivery of
transforming growth factor beta three enhances tendon-to bone healing in a rat model. Journal of Orthopaedic Research
2011; 29: 1099–1105.
Kovacevic D, Fox A J, Bedi A et al. Calcium-phosphate matrix with or without TGF-𝛽3 improves tendon-bone healing after
rotator cuff repair. American Journal of Sports Medicine 2011; 39: 811–819

53. PRP
No difference (2) / improved outcomes (2)
Currently role unclear
Rodeo SA, Potter HG, Kawamura S, Turner AS, Kim HJ, Atkinson BL Biologic augmentation of rotator cuff tendon-healing
with use of a mixture of osteoinductive growth factors. J Shoulder Elbow Surg 2007; 89:2485–2497
Weber SC, Kauffman JI, Parise C, Weber SJ, Katz SD. Platelet rich fibrin matrix in the management of arthroscopic repair
of the rotator cuff: a prospective, randomized, double-blinded study. Am J Sports Med 2013; 41: 263-270
Barber FA, Hrnack SA, Snyder SJ, Hapa O. Rotator cuff repair healing influenced by platelet-rich plasma construct
augmentation. Arthroscopy 2011; 27: 1029-1035
Jo CH, Shin JS, Lee YG, Shin WH, Kim H, Lee SY, Yoon KS, Shin S. Platelet-rich plasma for arthroscopic repair of large
to massive rotator cuff tears: a randomized, single-blind, parallel-group trial. Am J Sports Med 2013; 41: 2240-2248

54. Mesenchymal stem
cells
Bone Marrow injection - promising
45 patients
10 year FU
Hernigou P, Flouzat Lachaniette CH, Delambre J, Zilber S, Duffiet P, Chevallier N, Rouard H. Biologic augmentation of
rotator cuff repair with mesenchymal stem cells during arthroscopy improves healing and prevents further tears: a case-
controlled study. Int Orthop 2014; 38: 1811-1818

55. Augmentation / scaffolds
• Biological (Type I Collagen) /Artificial
• Higher Resistance to Failure
• RCT - Better Scores and healing
when Graftjacket Augmentation used
along with Cuff repair
Barber FA, Burns JP, Deutsch A, et al. A prospective, randomized evaluation of acellular human dermal matrix augmentation for
arthroscopic rotator cuff repair. Arthroscopy. 2012; 28(1):8-15

56. Massive Cuff tears

57. Massive Cuff Tears
Biceps tenotomy/Tenodesis Boileau et al 2007 68 78%good Good for pain relief.
Tendon Transfer Tauber et al, 2010 42 10-27% poor results
Not applicable with
subscap / teres
minor tears
Dermal Subsitute Gupta et al, 2012 24 76% intact
All reported pain
relief. Costly.
InSpace Balloon Savarese et al 20 ?
Scores improved on
average. Under trial.
Suprascapular nerve ablation Nizian et al 2009 20 75% good to excellent
Indication intractable
shoulder pain
Superior Capsular
Reconstruction
Mihata et al 2013 24 83% healing. ? early days
Partial Repair Monga et al personal audit 19 82% reversal of psudoparalysis Practical
Reverse geometry Ek et al, 2013 46 37.5% had complications Salvage option

58. Over to Julia, Chrissy and
Tanya…
Credits- A Desai