-
Natural History of Rotator CuImplications on Management
monrogrehistomptolargeor dinvolvral hlihooal indriskdegepriate
initial treatments and rening surgical
c. Al
Introducti
Rotator cuff disis the most coconsiderable controptimal
managemhave signicant vClinical practice gof Orthopaedic Sulack of
high-qualitof patients with cconstructing the clto better
understanatural history ofhistory, we can be
er understanding
Cuff
ies7-15 have beenisease. Because ofistics and designsin the
general
ss studies is thewith increased
,12,13 Yamaguchi
nilateral cuff tears, andalmost perfect 10-year7.8 years,
respectively.tomatic side, therewas a66 years of age or older.
Amore recent population-based studysupported this nding13a quarter
of patients older than 60
2 http://dx.doi.org/10.1053/j.oto.2014.11.0061048-6666//&
2015 Elsevier Inc. All rights reserved.
AR051026.Address reprint requests to Jay Keener, MD, CB 8233,
660 S Euclid Ave, St.
Louis, MO 63110. E-mail: [email protected]% chance of having a
cuff tear on the asymptomatic side atdisease progression can be
identied, allowing for furtherincremental increase in cuff
tearingwithpatients with bilaterally intact cuffs, ubilateral cuff
tears demonstrated andistribution and was 48.7, 58.7, and 6In
patientswith a cuff tear on the sympSome studies cited in this
articles were publications by the author (Keener),
which were funded by a grant from the NIH, USA Grant no. R01
Department of Orthopaedic Surgery, University of Washington,
Seattle, WA.oration and the progression of irreversiblemuscle
changeswithtime. Through natural history studies, tears with higher
risk of
et al performed bilateral shoulder ultrasounds on
patientspresenting with unilateral shoulder pain, demonstrating
an
age. The average age ofonease is prevalent in the aging
population andmmon cause of shoulder disability. There isoversy
among orthopaedic surgeons on theent of rotator cuff disease, and
cliniciansariation in the management of cuff tears.1
uidelines set out by the American Academyrgeons on rotator cuff
disease demonstrate ay evidence available to help guide
treatmentuff pathology. The work group involved ininical practice
guidelines suggested the neednd the epidemiology and demographics
ofrotator cuff disease. By studying the naturaltter understand risk
factors for tear deteri-
renement of surgical indications and a bettof the risks of
nonoperative treatment.
Epidemiology of RotatorDiseaseBoth cadaveric2-6 and in vivo
imaging studused to dene the prevalence of rotator cuff dsignicant
difference in population characterof these studies, the reported
prevalencepopulation varies widely. Consistent acronding that
increasing age is associatedprevalence of rotator cuff
pathology.5,6,10
12KEYWORDS Rotator cuff tear, natural history, surgical
indicationsJason Hsu, MD, and Jay D Keener, MD
Degenerative rotator cuff disease is comasymptomatic. The
factors related to tear pbeing dened through longitudinal
naturalservatively treated painful cuff tears or asyintervals show
slow progression of tear enThese studies have highlighted greater
risks fas the presence of a full-thickness tear and itendon.
Coupling the knowledge of the natuwith variables associated with
greater likesurgery will allow better renement of surgicnatural
history studies may better dene thearticle reviews pertinent
literature regardingon variables important to dening
approindications.Oper Tech Orthop 25:2-9 C 2015 Elsevier In l
rights reserved.ff Disease and
ly associated with ageing and is oftenssion and pain development
are just nowry studies. Most studies that follow con-matic tears
that are monitored at regularment and muscle degeneration over
time.seaseprogression for certain variables, suchement of the
anterior aspect supraspinatusistory of degenerative cuff tear
progressiond of successful tendon healing followingications for
rotator cuff disease. In addition,s of nonoperative treatment over
time. Thisnerative rotator cuff disease with emphasis
-
multifactorial and includes biological and mechanical inuen-
recommended to perform an early repair for acute, traumatic
inuence the disease progression. Painful tears are often
treatedwith physiotherapy, injections, or surgery, any of which
maydisrupt the true natural history of disease progression. An
idealcohort for dening the risks of tear enlargement and
pro-gression of muscle degeneration comprises patients
withasymptomatic degenerative cuff tears that can be identiedearly
and followed longitudinally. As cuff disease if oftenbilateral,
screening subjects with unilateral painful cuff diseaseon
presentation can identify a large number of asymptomatictears.12
Additionally, patients with unilateral symptomaticrotator cuff
tears have been shown to be at risk for paindevelopment and tear
progression on the asymptomaticside.20,26
Tear Initiation and LocationUnderstanding the common locations
and site of initiation of
3rotator cuff tears, particularly in young individuals, to
optimizethe tissue quality and healing environment, aswell as to
preventtear retraction and fatty degeneration of the involved
muscle.Bassett and Coeld22 studied 37 patients who had rotator
cuffrepair within 3 months of injury and divided them into
groupsthat had surgery within 3 weeks, between 3 and 6 weeks,
andbetween 6 and12weeks. Thosewhounderwent repairwithin 3weeks had
the best functional results. The threshold of thetiming for optimal
results of acute cuff tears ranged anywherefrom 3 weeks22-24 to 4
months.25
Treatment of atraumatic degenerative rotator cuff tears
thatoccur with advancing age is more controversial. Many
factorsincluding patient age, tear size, tendon retraction,
muscledegeneration, and overall healing capacity must be taken
intoaccount. Study of the natural history of degenerative tears
canelucidate the risk factors for tear progression and
irreversiblechanges and canhelp cliniciansmake evidence-based
decisionsregarding management of these tears.
Study of the Natural History ofRotator Cuff Disease
ThroughAsymptomatic Tearsces, recent studies have also suggested a
strong genetic inuenceon disease development.16-18 Tashjian et al17
used the UtahPopulation Database to analyze potential heritable
predisposi-tion to rotator cuff disease and found signicantly
elevated risksin rst- and second-degree relatives of patients with
rotator cuffdisease. Harvie et al16 performed ultrasounds in
siblings ofmore than 200 patients with full-thickness cuff tears.
Using thesubjects spouse as a control group, there was a
signicantlyincreased risk for rotator cuff tears in siblings of
patients. Asubsequent study by the same group implied that
geneticfactors may have a role in the progression of tears as
well.18
Another consistent nding throughout the literature is
therelatively high prevalence of asymptomatic
tears.7,10-12,14,19-21
Because these patients have no pain, have acceptable
shoulderfunction, and do not require any treatment for their
tears,prospective evaluation of these shoulders has provided us
witha wealth of information regarding the natural history of
rotatorcuff disease.
Traumatic vs DegenerativeRotator Cuff Tears.Evaluation of a
patient should attempt to differentiate traumaticfrom degenerative,
attritional rotator cuff tears. Although thesupporting literature
is limited to case series,22-25 it is generallyyears and one-half
of patients older than 80 years were foundto have a rotator cuff
tear. These and other studies14,15 suggestthat tendon degeneration
occurs with aging.Although most would agree that rotator cuff
disease is
Rotator cuff diseaseAttempting to dene the natural history of
rotator cuff diseaseof painful cuff tears is not ideal, as
treatment may interrupt ordegenerative rotator cuff tears is
essential to describe thepathogenesis of the disease. Early
theories on tear initiationreported that the common location of
degenerative tears wasthe articular aspect of the anterior
supraspinatus adjacent to thebiceps tendon.2,27,28 Tears were felt
to then propagate poste-riorly into the supraspinatus and
infraspinatus tendons. Thisconventional theory has been challenged
with recent research.Kim et al29mapped the common locations of
degenerative cufftears with ultrasound by measuring the distance
from theanterior tear edge to the biceps tendon and then factoring
inthe size (sagittal planewidth) of the tear (Fig. 1). Analyzing
datafrom 272 patients, histograms were generated plotting
thefrequency of tear involvement within the cuff footprint at
eachmillimeter distance posterior from the biceps tendon.
Whenanalyzing full-thickness tears, the area approximately13-17 mm
posterior to the biceps tendon was most frequentlyinvolved, with
only 30% of tears involving the most anterioraspect of the
supraspinatus. In addition, when looking at onlysmall
full-thickness tears, a similar distribution was foundwiththe
highest frequency located 15 mm posterior to the biceps.Figure 1
Ultrasound can be used to measure the distance from theposterior
biceps to the anterior border of the rotator cuff tear.
-
The similarity in tear location of full-thickness tears of
varioussizes suggest the common location of tear initiation
fordegenerative cuff tears to lie within the rotator crescent,
usuallysparing the anterior cable attachment of the
supraspinatustendon.This nding had a number of implications based
on the
anatomy of the rotator cuff. First, the area 15 mm posterior
tothe biceps tendon lies either at the junction of the
supra-spinatus and the infraspinatus or predominantly within
theanterior infraspinatus, depending on which anatomical de-nition
is used.30,31 Second, this area correlates to the middle ofthe
rotator crescent tissue as described by Burkhart et al32
(Fig. 2). As opposed to the rotator cable, which is a
thickerband of rotator cuff tissue spanning from the anterior
supra-spinatus to the posterior infraspinatus, the crescent tissue
isthinner, more avascular tissue lateral to the cable. This
crescenttissue is typically shielded from stress owing to the
suspensionbridge conguration of the cable. These data would
suggestthat rotator cuff tears initiate toward themiddle of this
crescenttissue and likely propagate anteriorly and posteriorly
fromthat point.
importance of the anterior supraspinatus tissue. Ultrasound
nonoperatively.
previous basic science research.
4TearCharacteristics andMuscleDegenerationMuscle degeneration
has important prognostic considerationfor patients undergoing
rotator cuff repair surgery asadvanced degeneration has been linked
to lower rates oftendon healing.33,34 Based on the suspension
bridge con-cept, the anterior portion of the supraspinatus is a
criticalarea of tissue for distribution of forces along the
cable.Disruption of the anterior cable may lead to
acceleratedretraction and muscle degeneration. Kim et al35 used
similarmethods to the study on tear initiation to quantify
theFigure 2 Rotator cuff tears initiate approximately 15 mm
posterior tobiceps tendon within the rotator crescent tissue.Tear
Enlargement and Pain Development ofAsymptomatic TearsPerhaps the
most valuable aspect of studying asymptomaticrotator cuff tears
longitudinally is dening the risks of tearprogression and pain
development over time. Characterizingthe risks of pain development,
tear enlargement, and muscledegeneration can help us rene surgical
indications andcounsel patients regarding the risk of nonoperative
treatment.This requires long-term prospective studies following
theseasymptomatic tears.14,20,26
Moosmayer et al20 followed 50 patients with asymptomatictears
over 3-year period. Of 50 tears, 18 (36%) developedsymptoms, and
tear progression was signicantly larger in thesymptomatic than the
asymptomatic group. Progression ofmuscle atrophy and fatty
degeneration was also higher in thesymptomatic group than the
asymptomatic group. This studydemonstrated an association between
symptom developmentTear Size and Glenohumeral KinematicsAs rotator
cuff tears increase in size, disruption of normalglenohumeral
kinematics can occur. This may manifest asproximal humeral
migration. The effect of rotator cuff size onglenohumeral
kinematics and proximal humeral migrationwas investigated by Keener
et al36 using a computer-basedcalculation of the humeral head
center in relation to the glenoidcenter. A cohort of 98
asymptomatic and 62 symptomatic full-thickness tears was examined.
Symptomatic tears and largertears involving the infraspinatus
hadmoremigration than tearsin asymptomatic patients and smaller
tears isolated to thesupraspinatus. A critical tear area of 175 mm2
was associatedwith proximal humeral migration correlating with a
tear size ofapproximately 15 mm with retraction of 12-15 mm.
Thesendings highlight the importance of the infraspinatus
inmaintaining normal coronal plane kinematics as noted by
37-39was used to measure tear location referenced to the
bicepstendon and tear size compared with the degree of
fattydegeneration of the cuff muscles. Both tear size and
tearlocation were associated with patterns of fatty
muscledegeneration. Tears with disruption of the anterior
supra-spinatus tendon demonstrated more advanced degenerationof the
supraspinatus tendon. Infraspinatus degeneration wasmore closely
linked to the sagittal plane size of the tear.Larger tears with
propagation into the infraspinatus footprintwere more likely to
have both supraspinatus and infra-spinatus muscle degeneration,
especially when the anteriorsupraspinatus tendon was compromised
(Fig. 3). These datastress the importance of anterior supraspinatus
tissue integ-rity. Patientswith cuff tears close to the
anteriormargin of thesupraspinatus should be counseled regarding
possessing ahigher risk of tendon retraction and muscle atrophy.
Closersurveillance of these tears may be warranted when treated
J. Hsu, J.D Keenerand increasing tear size. These results are
consistent with thendings of Mall et al26 who investigated
variables associated
-
romwith pain development in asymptomatic tears, also noting
thatpain development in patients with asymptomatic tears
wasassociated with tear progression.A subsequent report of this
cohort has better dened the
risks of tear progression and pain development for a period of5
years after identication of an asymptomatic degenerativetear.40 A
total of 224 patients with 118 full-thickness tears,
56partial-thickness tears, and 50 controls were followed
longi-tudinally for a median of 5.1 years. Tear enlargement
occurredin a time-dependent manner with greater risks of
enlargementseen in more severe tear types. Tear progression or
enlarge-ment was seen in 49% of shoulders, with a median time
toenlargement of 2.8 years. Full-thickness tears were 1.5 and4
times more likely to enlarge compared with partial-thicknesstears
and control shoulders. Likewise, muscle degenerationwas more
frequent in full-thickness tears and those tears thatprogressed in
size. Overall, 46% of shoulders developed newpain, and the median
time to pain development was 2.6 years.Tear enlargement was a
signicant risk factor for pain develop-ment. Thirtyeight percent of
shoulders that remained asymp-tomatic enlarged compared to 63% of
shoulders thatdeveloped pain. More severe tear types (full vs
partial) also
Figure 3 Association between location of tear (distance
fdegeneration.Rotator cuff diseasehad a greater risk for future
pain development. The ndingsfrom this study support the progressive
nature of degenerativerotator cuff disease and highlight
full-thickness tears to be ahigher risk group for future tear
enlargement, progression ofmuscle degeneration, and pain
development.
Natural History of SymptomaticRotator Cuff TearsCurrently, few
studies have evaluated the natural history ofsymptomatic rotator
cuff tears.41-43 Maman et al43 retrospec-tively studied 59
shoulders with full- and partial-thicknessrotator cuff tears
treated nonoperatively. Each shoulder had abaseline magnetic
resonance imaging and a repeat imagingperformed a minimum of 6
months later. Progression of tearsize was found in 48% of the tears
that were followed for atleast 18months vs only 19% of those
followed for less than 18months. Full-thickness tears were more
likely to progress thanpartial-thickness tears (52% vs 8%). Age was
an importantpredictor of tear deterioration, with 54% of tears in
patientsolder than 60 years progressing vs only 17% of tears in
thoseyounger than 60 years. Safran et al42 specically investigated
acohort of patients younger than 60 years who were
treatednonoperatively for full-thickness rotator cuff tears and
found ahigher rate of tear progression in these younger patients.
Of the61 tears, 49% of tears increased in size by ultrasound.
Therewas a signicant correlation between pain and increase intear
size.Fucentese et al41 reported seemingly contradictory ndings
in their report of 24 patients refusing operative treatment
forfull-thickness supraspinatus tears. They used magnetic
reso-nance (MR) arthrography as their initial imaging modality
andMR without arthrography for their follow-up imaging andreported
no increase in the mean size of the rotator cuff tears3.5 years
after the initial MR arthrogram. Although the meantear size did not
increase, 8 of the 24 patients (33%) had anincrease in tear size,
and 4 (17%) had no change in size. Theydo report a high level of
satisfaction in this group of patientstreated nonoperatively.The
Multicenter Orthopaedic Outcomes Network Shoulder
biceps to anterior margin of tear) and rotator cuff fatty
5Group has also provided valuable information in the
non-operative treatment of symptomatic rotator cuff tears.44-47
Thisgroup has done multiple observational and
cross-sectionalstudies on more than 400 patients with atraumatic,
full-thickness rotator cuff tears. They have found that pain
andduration of symptoms are not strongly associated with
theseverity of rotator cuff tears45,48 and that
nonoperativemanage-ment with physical therapy is effective in
treating 75% ofpatients up to 2 years.46 Interestingly, the most
importantfactor for predicting a successful response to
conservativetreatment from this study was the patients perception
thatphysical therapy would be benecial.The association of pain with
full-thickness rotator cuff tears
is controversial. Studies by the Multicenter Orthopaedic
Out-comes Network Shoulder Group suggest that pain andduration of
symptoms do not correlate with the severity ofrotator cuff
tears45,48; however, other studies have shownstronger correlations
between enlargement of tears and devel-opment of pain.20,26 These
differences are likely attributed to
-
consideration. Prior treatments such as physical
therapy,injections, and surgery should be documented.Physical
examination is performed with the shoulder
exposed. Atrophy of the spinati fossa can be visually distinctin
chronic cuff tears (Fig. 4). The examiner will often
notesubacromial crepitus with rotation. Both passive and
activerange of motion should be documented to rule out
restrictionsin motion due to arthritic conditions or adhesive
capsulitis.Internal rotation behind the backmay be limited due to
pain inpatients with active cuff inammation. Signs of
subacromialimpingement can identify patients with cuff-based pain.
Acareful examination for signs of cervical radiculopathy shouldbe
performed especially in patients withmedial scapula pain orsymptoms
radiating below the elbow.Strength testing can isolate eachof the 4
rotator cuffmuscles.
Resistance to abduction with the thumb down can test
thesupraspinatus. External rotation with the arm at the side
cantest infraspinatus strength, whereas an external rotation
lagsign and the Hornblowers sign can indicate posterior
tearextension into the teres minor. The abdominal compressiontest
can test subscapularis function. The lift-off test can also
testsubscapularis function but is often restricted by pain in
patients
J. Hsu, J.D Keener6differences in study design (cross sectional
vs prospectiveobservational). More data, other than tear size
progression,may identify factors causally related to the onset of
pain.
Important Clinical andRadiographic VariablesWhen evaluating a
patient with a suspected degenerativerotator cuff tear, a
comprehensive history is the rst andarguably the most important
aspect of a complex decision-making process. The patients age is
thought to be a strongpredictor of rotator cuff healing if
operative intervention isconsideredolder patients are less likely
to have a durablerepair. Time since initiation of symptoms is
important toestimate the chronicity of the tear. While inuencing
otherfactors, such as tear size and location, chronicity likely has
anundened effect on healing potential. Activity expectationsmust be
taken into considerationa patient without highfunctional demands
may retain good function with a full-thickness rotator cuff tear.
On the contrary, a small full-thickness rotator cuff tear may
present difculties to a younglaborer who requires overhead motion
and strength. Geneticpredisposition, hand dominance, smoking,
medical comor-bidities, and social factors affecting postoperative
rehabilitationpotential are other variables that should also be
taken into
Figure 4 Atrophy of the supraspinatus and infraspinatus fossas
can bevisible in chronic tears.with tears of the superior cuff.
External rotation weakness withor without abduction weakness out of
proportion to theseverity of a cuff tear may be secondary to pain
but also maysignal a suprascapular nerve injury. Consideration for
electro-myographic or nerve conduction studies should be
entertainedin these select cases.Imaging should begin with plain
radiographs including AP,
true AP (Grashey view) in 301 of abduction, scapular Y,
andaxillary views. The Grashey view activates the deltoid
muscleallowing proximal humeral migration in chronic, larger
tears(Fig. 5). The scapular Y view can assess acromial spursFigure
5 Proximal humeral migration is best viewed on a true APradiograph
with the arm in 301 of abduction. AP, anteroposterior.
-
associated with cuff tears that may need to be addressed at
thetime of surgery.49 The axillary view demonstrates joint
spacenarrowing as well as potential anterior or posterior
humeralsubluxation.Advanced imaging modalities including ultrasound
and
MRI should be used when a rotator cuff disease is suspectedby
history and examination. These modalities can be used tofurther
characterize the size, location, and retraction of rotatorcuff
tears. The presence or absence of muscle atrophy shouldbe
documented in full-thickness tears (Fig. 6) and gradedaccording to
the Goutallier classication.50 Concomitantpathology to other
structures such as the long head of thebiceps, labrum, and early
glenoid and humeral chondrosisshould be assessed.
Clinical Decision MakingOur understanding of the natural history
of rotator cuff diseasecontinues to improve, and it assists
clinicians in an oftencomplex decision-making process. As we
continue to learnmore, our indications for operative repair will
continue to be
associated with muscle degeneration, early surgical
intervention
Rotator cuff diseaseFigure 6 Fatty muscle degeneration of the
rotator cuff muscle bellies isrened. Surgical indications may be
simplied by dividing cufftears into 3 categories where the risks
for nonoperativetreatment may vary signicantly and the potential
benets ofsurgery may be maximized.Group IEarly operative repair.
Early surgery should be
considered in patients presenting with a rotator cuff
tearstemming from a distinct, acute event with imaging
thatcorroborates an acute injury. Pain or weakness before injuryand
signs ofmuscle degeneration on imagingmay be signs of
anacute-on-chronic tear. In these situations, an injury resulting
in asignicant increase in shoulder weakness likely represents
asignicant acute component to the tear. Consideration for earlybest
visualized on MRI with T1 oblique sagittal cuts. MRI,
magneticresonance imaging.or close surveillance should be employed
in patients who havefull-thickness tears involving the anterior
supraspinatus tendon.Group IITrial of conservative treatment.
Initial nonoper-
ative treatment is reasonable in any patient with a
painfulpartial-thickness tear or a potentially reparable
full-thicknesstear that is not acute in onset. In these cases,
conservativetreatment has been shown to produce reliable results in
theshort term, and some signs of tear chronicity are often
alreadyevident. Although risks for tear enlargement and
muscleatrophy progression are present, the natural history
studiessuggest that these changes occur slowly allowing for
adequatetime to attempt conservative treatment. Surgery can
beconsidered if conservative treatment fails.Group IIIMaximize
conservative treatment. Conservative
treatment should be maximized in patients in situations
wheresuccessful tendon healing is unlikely. These include
olderpatients (465-70 years), patients with chronic
full-thicknesstears (retracted tears of any size with advanced
muscledegeneration), and tears associated with xed proximalhumeral
migration (signs of chronic mechanical contact ofthe greater
tuberosity and acromion).
ConclusionsOur understanding of the natural history of rotator
cuff diseasecontinues to expand. Following asymptomatic rotator
cufftears found in patients with symptomatic contralateral
should-ers is a good model for studying the natural history. Using
thismodel, important information regarding tear initiation,
loca-tion, size, progression, and survivorship has been
gathered.Degenerative tears initiate approximately 15 mm posterior
tothe biceps tendon, with less than one-third of tears involvingthe
anterior edge of the supraspinatus tendon. Loss of integrityof the
anterior supraspinatus tissue is associated with supra-spinatus
muscle degeneration. A critical tear size of approx-imately 175 mm2
is associated with early disruption of normalkinematics of the
shoulder. Approximately 50% of degener-ative tears will progress in
size by 5 years, and full-thicknesssurgery should be given in these
scenarios if the imaging tests donot suggest severe muscle atrophy.
Early repair should beperformed in acute subscapularis tears or
more chronicsubscapularis tears with biceps tendon instability.
Acute,retracted subscapularis tears are considered more urgent
owingto the potential forxed retraction andmuscle degeneration
thatcan accompany these injuries. Early operative repair should
alsobe considered in small- to medium-sized full-thickness
degen-erative tears in patients younger than 62-65 years with
minimalor no muscle atrophy; however, specic patient
characteristicsshould be used to rene which patients should be
indicated forrepair. The reason to consider early surgery in these
scenariosrelates to the established risks for the potential for
tear enlarge-ment and progression of muscle atrophy in patients who
stillpossess a reasonable potential to heal a surgical repair.
Owing tothe fact that loss of anterior supraspinatus tissue
integrity is
7tears are more likely to enlarge and develop muscle
degener-ation than partial-thickness tears. Aswe continue to
learnmore
-
about the natural history of cuff disease through this
model,clinicians will be able to further rene indications for
rotatorcuff repair.
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Rotator cuff disease 9
Natural History of Rotator Cuff Disease and Implications on
ManagementIntroductionEpidemiology of Rotator Cuff DiseaseTraumatic
vs Degenerative Rotator Cuff TearsStudy of the Natural History of
Rotator Cuff Disease Through Asymptomatic TearsTear Initiation and
LocationTear Characteristics and Muscle DegenerationTear Size and
Glenohumeral KinematicsTear Enlargement and Pain Development of
Asymptomatic Tears
Natural History of Symptomatic Rotator Cuff TearsImportant
Clinical and Radiographic VariablesClinical Decision
MakingConclusionsReferences