Shoulder:Rotator Cuff Pathology/Thickness Rotator Cuff Tears/Traumatic versus degenerative tears

Bullet points • Accidental lesion and lesion assimilated to an accidental lesion are two legal concepts. • They require expert medical knowledge to determine whether the lesion is of degenerative or traumatic nature. • Minor degenerative disorders, symptomatic or asymptomatic depending on the individual, are frequent over age 30 and should no longer be taken into account in deciding whether the origin of a lesion was traumatic or degenerative. • The prevalence of full-thickness degenerative lesions has significantly decreased over the last 15 years. • Full-thickness and anterior lesions are often accidental in younger subjects. • Demographic, anamnestic, clinical, radiographic and intraoperative data should be used to distinguish between degenerative and traumatic lesions. 1. INTRODUCTION The present chapter updates the criteria for full-thickness rotator-cuff lesion being probably traumatic, in the light of the present state of knowledge. Traumatic lesion and lesion assimilated to a traumatic lesion are in some countries two legal concepts. The criteria allowing differentiation between degenerative lesions and lesions probably due to an accident sometimes lead to interminable legal quarrels between patients, the insured and insurance companies. Legal disputes are thus legion and risk delaying treatment, to the detriment of both patient and employer. The issue is medically critical, as rapid treatment of traumatic rotator-cuff lesions is the key to good functional outcome.(Bassett and Cofield 1983, Lahteenmaki, Virolainen et al. 2006, Krishnan, Harkins et al. 2008, Petersen and Murphy 2011, Mall, Lee et al. 2013, Duncan, Booker et al. 2015, Tan, Lam et al. 2016) Definition/framework Full or partial thickness tears or avulsions suggestive of an accident are to be distinguished from defects, which consist rather in tendon thinning or tendon stump shortening.(Meyer, Lajtai et al. 2006, Meyer, Farshad et al. 2012) These tendinopathy-associated defects, as well as occupational diseases, will not be dealt with here (please refer to https://wiki.beemed.com/view/Shoulder:Rotator_Cuff_Pathology/Rotator_Cuff_Tendinopathy), being degenerative rather than accidental in nature. Partial thickness lesions may be as well of traumatic origin,(Kim and Ha 2000) even in very young subjects (Figure),(Zbojniewicz, Maeder et al. 2014) but will not be dealt with for the sake of simplification. The present chapter focuses exclusively on full-thickness rotator-cuff tear or avulsion.

Figure: Magnetic resonance imaging of a 14-year-old patient after a ski fall. Observe the 10 mm long interstitial tear. Greg j’ai l’image mais pas encore de bonne qualité. Te la fais suivre dès que je la recois. Car boris Study Factors The main difficulty is to distinguish between a traumatic rotator-cuff lesion, acute exacerbation of a pre-existing degenerative lesion, and simple painful or functional decompensation of a pre-existing degenerative lesion.(Lahteenmaki, Virolainen et al. 2006) The present chapter collates and distinguishes objective and indisputable demographic, anamnestic, clinical and radiographic rotator-cuff lesion data (e.g., fatty infiltration) as a basis to decide whether in a given case the tear was traumatic (or assimilated) or more likely of degenerative or disease-specific nature. It is thus a question of defining the clinical and paraclinical data that formally confirm or exclude accidental status. A single risk factor, such as smoking (Bishop, Santiago-Torres et al. 2015), hypercholesterolemia (Chung, Park et al. 2016), alcohol abuse (Passaretti, Candela et al. 2016) high blood pressure (Gumina, Arceri et al. 2013), hyperthyroidism (Oliva, Osti et al. 2014), or critical shoulder angle (Balke, Schmidt et al. 2013, Moor, Wieser et al. 2014),…) is not necessarily a criterion. (Greg est ce que tu veux rajouter ici ton angle ?)

Natural phenomena Minor degenerative disorders, which may be symptomatic or asymptomatic depending on the individual, are frequent over 30 years old(Girish, Lobo et al. 2011, Teunis, Lubberts et al. 2014) and should probably no longer be taken into account in deciding whether a given lesion is degenerative or accidental. An ultrasound study of 51 asymptomatic patients aged 40 to 70 years reported abnormalities such as tendinosis (65%), acromioclavicular osteoarthritis (65%), labral pathology (14%) and partial tear of the bursa side of the supraspinatus tendon (22%).(Girish, Lobo et al. 2011) The supraspinatus tendon insertion on the greater tuberosity may show degeneration that is probably multifactorial: vascular,(Adler, Fealy et al. 2008) mechanical (Neer 1972), morphologic (Moor, Bouaicha et al. 2013, Moor, Rothlisberger et al. 2014), and genetic (Gwilym, Watkins et al. 2009),…). The prevalence of full-thickness rotator-cuff tear in the population under age 70 who has never shown symptoms is at most 15%.(Yamamoto, Takagishi et al. 2010, Girish, Lobo et al. 2011)

4.2 Demographic criteria The age criteria in the first guidelines are out of date.(Milgrom) Several studies have since demonstrated that the prevalence of degenerative full-thickness tear is clearly lower (Table).

Table: Prevalence of degenerative full-thickness tear 20-30 ans 30-40 ans 40-50 ans 50-60 ans 60-70 ans 70-80 Ans >80 ans Tempelhof et al. 13% 20% 31% 51% Abate et al.(Abate, Schiavone et al. 2010) 10.9% 10.9% Fehringer et al.(Fehringer, Sun et al. 2008) 22% 22% Moosmayer et al.(Moosmayer, Smith et al. 2009)

2.1% 5.7% 15% Yamamoto et al.(Yamamoto, Takagishi et al. 2010) 0% 10.7% 15.2% 26.5% 36.8% Liem et al. (Liem, Buschmann et al. 2014) 0% 20-30 ans 30-40 ans 40-50 ans 50-60 ans 60-70 ans 70-80 Ans >80 ans Abate et al.(Abate, Schiavone et al. 2010) 10.9% 10.9% Fehringer et al.(Fehringer, Sun et al. 2008) 22% 22% Moosmayer et al.(Moosmayer, Smith et al. 2009)

2.1% 5.7% 15% Yamamoto et al.(Yamamoto, Takagishi et al. 2010) 0% 10.7% 15.2% 26.5% 36.8% Liem et al. (Liem, Buschmann et al. 2014) 0%

In an ultrasound study of asymptomatic subjects over 65 years old, Abate et al. reported the prevalence of rotator-cuff lesions:(Abate, Schiavone et al. 2010) only 3.1% of non-diabetic patients had partial or full thickness tears of less than 1 cm, and 7.8% had tears greater than 1 cm. In a study of 200 shoulders in 100 patients with a mean age of 71.4 years (range, 65-87 years), Fehringer et al. found 22% prevalence of full-thickness rotator-cuff lesions in patients consulting for lower-limb issues, whether the shoulder was symptomatic or not.(Fehringer, Sun et al. 2008) Another ultrasound and magnetic resonance imaging (MRI) assessment of 420 asymptomatic volunteers found a prevalence of full-thickness rotator cuff tear of 2%, 6% and 15% in the 50-59, 60-69 and 70-79 year-old age-groups respectively,(Moosmayer, Smith et al. 2009) with location in the supraspinatus tendon in 78% of cases. In a similar study of 664 volunteers in a single village, prevalence of full-thickness tear was 22.1%:(Yamamoto, Takagishi et al. 2010) 0% between 20 and 49 years of age, 10.7% for subjects in their 50s, 15.2% in the 60s, 26.5% in the 70s and 36.6% in over-79 year-olds; only 34.7% of these lesions were symptomatic. Liem et al. reported no rotator-cuff lesions in a control group of 55 under 60 years old.(Liem, Buschmann et al. 2014) In summary, lesions are rarely full-thickness before the age of 60 (in fewer than 10% of cases even in the elderly), and involve the supraspinatus tendon in 85% of cases. Between 70 and 79 years of age, 74-89% of subjects have a functional rotator cuff. Traumatic tears concern younger subjects, with a mean age of 54 years.(Mall, Lee et al. 2013) A traumatic event was recorded in 79.2% of cases (57/72 shoulders) in a study of full-thickness cuff tear in subjects under 50 years old .(Lin, Huang et al. 2012)

4.3 Clinical criteria Immediate impairment of active flexion or external rotation or onset of pseudoparalytic shoulder (loss of active anterior forward flexion) due to rotator-cuff tear are typical consequences of a trauma.(Loew 2000, Loew, Habermeyer et al. 2000, Lahteenmaki, Virolainen et al. 2006, Berhouet, Collin et al. 2009, Denard, Lädermann et al. 2015) Berhouet et al. reported on 112 patients under 65 year old patients with rotator-cuff lesions. More than half had clearly been involved in an accident,(Berhouet, Collin et al. 2009) and all these patients showed loss of forward flexion or external rotation. Denard et al. prospectively studied 58 patients with pseudoparetic shoulder and rotator cuff tear;(Denard, Lädermann et al. 2015) 78% of the cases (45 out of 58) involved a trauma. There is thus a high rate of traumatic events associated with acute loss of function. Loew reported severe pain after traumatic rotator-cuff injury, subsiding after 3 days, which may account for delayed consultation and treatment.(Loew 2000, Loew, Habermeyer et al. 2000)

4.4 Factorial criteria Only 5 studies reported the mechanism of traumatic rotator cuff lesions.(Bassett and Cofield 1983, Gerber, Hersche et al. 1996, Ide, Tokiyoshi et al. 2007, Namdari, Henn et al. 2008, Bjornsson, Norlin et al. 2010) This mainly involves falling onto the arm in extension.(Mall, Lee et al. 2013) Other associated actions causing injury comprise external rotation against resistance, violent traction while trying to avoid a fall or lifting a heavy weight, or shoulder dislocation. However, the mechanism is usually unclear, especially in road accidents. The following actions should be considered:(Loew 2000, Loew, Habermeyer et al. 2000)  Appropriate injurious action Significant trauma with violent passive backward and inward movement of the arm, or arm stabilized by muscle action: for example, trying to avoid a fall from scaffolding or on stairs.  Shoulder dislocation causes full-thickness cuff tear in 41% of cases in 40-to-55 year-olds, in 71% in 56-to-70 year-olds, and systematically in older subjects.(Simank, Dauer et al. 2006)  Suddenly hanging with the arm in suspension bearing full body-weight.  Violent passive traction in adduction, antepulsion or abduction, as in wrenching the arm or trying to avoid a fall with arms outstretched.  Axial impact during a fall on the elbow or hand.  Direct shock to the shoulder without necessarily involving the arm in extension can also cause full-thickness tear.

4.5 Radiologic criteria Correct analysis of assessment comprising conventional X-ray, ultrasound and magnetic resonance imaging (MRI) or computed tomography (CT) is often decisive and, in the light of present knowledge, can distinguish between degenerative and accidental lesions.

4.5.1 Conventional radiologic criteria Acromion morphology and acromioclavicular osteoarthritis Whether acromion morphology is a risk factor for rotator-cuff lesion is controversial. Acromion morphology according to Bigliani,(Bigliani, Ticker et al. 1991) acromial slope in the frontal and parasagittal planes, lateral protrusion (Nyffeler, Werner et al. 2006) and critical shoulder angle are debated factors.(Balke, Schmidt et al. 2013, Moor, Wieser et al. 2014) Anterior coraco-acromial ligament spur,(Gill, McIrvin et al. 2002) presence of an os acromiale (Ouellette, Thomas et al. 2007) and acromioclavicular arthropathy (Needell, Zlatkin et al. 1996) do not correlate with rotator-cuff lesion; the only clear association is with acromial acetabulization.

Proximal humeral remodeling Subchondral sclerosis and greater tuberosity subchondral cysts do not seem to be signs of chronic rotator-cuff lesion, having wide interobserver variability and poor predictive value.(Huang, Rubin et al. 1999, Williams, Lambert et al. 2006) (attention il y a une public récente qui dit le contraire) They are thus not reliable signs of chronic or degenerative lesion, an seem to be related to age. Chronic partial or retracted cuff lesions are associated with major remodeling of the greater tuberosity in the form of “femoralization” and osteopenia.(Neer 1972, Neer, Craig et al. 1983, Jiang, Zhao et al. 2002, Meyer, Fucentese et al. 2004) Localized greater tuberosity osteopenia on AP X-ray is the bone response to lack of mechanical stress (Wolff’s law).(Wolff 1892)

Acromio-humeral distance Acromio-humeral distance <7 mm on anteroposterior shoulder view is a sign of chronic rotator-cuff tear.(Nove-Josserand, Edwards et al. 2005, Saupe, Pfirrmann et al. 2006) Saupe et al. correlated this 7 mm threshold with computed tomography (CT)-arthrography evidence of lesion, and found full-thickness supraspinatus tear in 90% of cases, infraspinatus tear in 67% and subscapularis tear in 47%.(Saupe, Pfirrmann et al. 2006) Distance <7 mm generally corresponds to a massive tear of several months’ progression, associated with altered muscle trophicity.(Nove-Josserand, Edwards et al. 2005, Saupe, Pfirrmann et al.)

4.5.2 Magnetic resonance imaging (MRI) and computed tomography (CT) criteria The only irrefutable signs of accidental lesion are fractures and stigmata of glenohumeral or acromioclavicular dislocation.(Loew, Magosch et al. 2015) Magnetic resonance imaging (MRI) and, to a lesser extent, CT are now contributive to confirming or ruling out accidental etiology. Above all, they can rule out occult fracture, notably of the greater tuberosity.

Rotator-cuff muscle atrophy and fatty infiltration Supraspinatus atrophy is assessed via the tangent sign (Zanetti, Weishaupt et al. 1998). Magnetic resonance imaging (MRI)(Fuchs, Weishaupt et al. 1999) and computed tomography (CT)(Goutallier, Postel et al. 1994) quantify fatty infiltration in the rotator-cuff muscles. This quantification is essential, as initial fatty infiltration exceeding grade 2 generally contraindicates repair surgery, because of a very high risk of healing failure. It is thus a decisive prognostic factor for clinical and radiological outcome.(Zumstein, Jost et al. 2008) For the supraspinatus muscle, it is more reliably assessed in the axial plane.(Williams, Lädermann et al. 2009)

The fishbone sign also indicates a chronic lesion (Figure).(Williams, Lädermann et al. 2009) Figure: Fishbone sign. The supraspinatus with grade 3 fatty infiltration resembles a fishbone. Je t’envoie une image si tu n’en as pas

These changes seem to appear quickly, as soon as 3 weeks in animal models.(Mallon, Wilson et al. 2006, Liu, Manzano et al. 2011) In humans, they are observed only after 6 months or if there is no traumatic etiology.(Berhouet, Collin et al. 2009) In both traumatic and non-traumatic cases, grade 2 fatty infiltration sets in at 3, 2.5 and 2.5 years after symptom onset in the supraspinatus, infraspinatus and subscapularis muscles, respectively; progression to grades 3 and 4 takes respectively 5, 4 and 3 years.(Mélis, A. et al. 2008, Melis, DeFranco et al. 2010) Isolated supraspinatus lesions showed no significant fatty infiltration at 4 years’ follow-up.(Fucentese, von Roll et al. 2012) In contrast, massive lesions become irreparable after the same period of time.(Zingg, Jost et al. 2007) Time to onset of fatty infiltration differs between traumatic and progressive cases, being shorter in the first case and after a massive lesion (≥ 2 whole tendons) (Table).(Mélis, A. et al. 2008)

Table: Average time to onset of different fatty infiltration stages assessed in overall series and traumatic versus progressive onset Time to onset (months) Supraspinatus fatty infiltration Infraspinatus fatty infiltration Subsacapularis fatty infiltration

Minimal Intermediate Severe Minimal Intermediate Severe Minimal Intermediate Severe

Overall series 24 46 70 26 44 67 24 34 46 Traumatic onset 19 35 58 19 31 46 17 31 39 Progressive onset 29 54 84 33 56 84 33 36 55

According to Goutallier,(Goutallier, Postel et al. 1994) significant fatty infiltration (grade 3 or 4, generally contraindicating repair) at the time of the accident probably involves decompensation or acute extension of a pre-existing lesion. Severe fatty infiltration may however develop within months of accidental massive lesion, particularly if the anterior rotator cuff is involved (Figure). Figure jointe IG developped in months

Figure: T1-weighted sagittal slices without fat-sat: pseudoparalytic left shoulder 4 months (A) and 7 months (B) post-trauma. Infiltration became severe by 3 months, contraindicating repair.

Bone and muscle edema Greater tuberosity edema used to be thought of as being associated with full-thickness rotator-cuff tear,(McCauley, Disler et al. 2000) but this was not confirmed in a more recent study.(Loew, Magosch et al. 2015) Screening for muscle edema, on the other hand, is crucial. Except in real involvement of the muscle-tendon junction,(Lädermann, Christophe et al. 2012) rare denervation phenomena as found in suprascapular nerve compression (<2%)(Collin, Treseder et al. 2014) or Parsonage-Turner syndrome and other infrequent entities,(May, Disler et al. 2000) muscle edema is associated with acute retraction and indicates accidental etiology (Figure).(Loew, Magosch et al. 2015) Onset is within days, unlike neurologic edema, where onset is a matter of weeks.

Figure: Posterosuperior rotator-cuff edema in traumatic tear Figure: Examples of acute posterosuperior rotator-cuff edema in traumatic tear with chronic anterior cuff lesion. A: Posterosuperior rotator-cuff edema on frontal T1 slices. The persistence of a tendon remnant on the greater tuberosity is also indicative of traumatic etiology.(Loew, Porschke et al. 2014) B: T1-weighted sagittal slice, showing significant fatty infiltration only in the subscapularis.

Changes in subacromial and subdeltoid bursa Fluid or hematoma in the bursa is more frequently found in acute than chronic lesions, and is generally associated with lesions of the tendon rather than of the tendon-bone junction (mid-substance tear). Blood signal following an accident is a sign of traumatic rotator-cuff lesion.(Teefey, Middleton et al. 2000)

Location and type of tendon lesion Location of the lesion is also an important factor. In the frontal plane, traumatic lesions generally involve the tendon itself.(Teefey, Middleton et al. 2000) Medial tendon retraction according to Patte(Patte 1990) (Table) then develops,(McCauley, Disler et al. 2000) generally with slow progression. Braune et al. found no retracted tendons in the glenoid or beyond 12 weeks after trauma.(Braune, Gramlich et al. 2000) However, some cases of grade 3 retraction at the glenoid without fatty infiltration may be found during the weeks following a trauma, suggesting acute massive lesions with severe muscle and tendon retraction. In the sagittal plane, subscapularis tendon lesions are typical of accidents.(Gerber, Hersche et al. 1996, Krishnan, Harkins et al. 2008, Bjornsson, Norlin et al. 2011) Moreover, 80% of asymptomatic lesions involve the supraspinatus tendon.(Moosmayer, Smith et al. 2009) Anterior or posterior extension in a previously asymptomatic patient suggests a traumatic etiology.

4.6 Intraoperative criteria Lesion type alone may not be a sufficient criteria to determine a traumatic or non-traumatic etiology.(Braune, Gramlich et al. 2000) The most significant criteria for traumatic origin are hemarthrosis, tendon remnant on the greater tuberosity, frayed and bleeding tendon edge, and subscapularis involvement.(Braune, Gramlich et al. 2000, Loew, Porschke et al. 2014)

CONCLUSION Rotator-cuff tears are most often degenerative but some may nevertheless be caused or aggravated by a traumatic event. It is not recommended to apply just a single criterion, such as age, to determine whether a causal relation is above or below the threshold of likelihood. The field of application of the concept of causality (no accident, no injury) is deliberately wide; ruling it out requires an exhaustive argumentation using all of the criteria defined above. 8. REFERENCES

Abate, M., et al. (2010). "Sonographic evaluation of the shoulder in asymptomatic elderly subjects with diabetes." BMC Musculoskelet Disord 11: 278. BACKGROUND: The prevalence of rotator cuff tears increases with age and several studies have shown that diabetes is associated with symptomatic shoulder pathologies. Aim of our research was to evaluate the prevalence of shoulder lesions in a population of asymptomatic elderly subjects, normal and with non insulin - dependent diabetes mellitus. METHODS: The study was performed on 48 subjects with diabetes and 32 controls (mean age: 71.5 +/- 4.8 and 70.7 +/- 4.5, respectively), who did not complain shoulder pain or dysfunction. An ultrasound examination was performed on both shoulders according to a standard protocol, utilizing multiplanar scans. RESULTS: Tendons thickness was greater in diabetics than in controls (Supraspinatus Tendon: 6.2 +/- 0.09 mm vs 5.2 +/- 0.7 mm, p < 0.001; Biceps Tendon: 4 +/- 0.8 mm vs 3.2 +/- 0.4 mm, p < 0.001). Sonographic appearances of degenerative features in the rotator cuff and biceps were more frequently observed in diabetics (Supraspinatus Tendon: 42.7% vs 20.3%, p < 0.003; Biceps Tendon: 27% vs 7.8%, p < 0.002).Subjects with diabetes exhibited more tears in the Supraspinatus Tendon (Minor tears: 15 (15.8%) vs 2 (3.1%), p < 0.03; Major tears: 15 (15.8%) vs 5 (7.8%), p = ns), but not in the long head of Biceps. More effusions in subacromial bursa were observed in diabetics (23.9% vs 10.9%, p < 0.03) as well as tenosynovitis in biceps tendon (33.3% vs 10.9%, p < 0.001).In both groups, pathological findings were prevalent on the dominant side, but no difference related to duration of diabetes was found. CONCLUSIONS: Our results suggest that age - related rotator cuff tendon degenerative changes are more common in diabetics.Ultrasound is an useful tool for discovering in pre - symptomatic stages the subjects that may undergo shoulder symptomatic pathologies.

Adler, R. S., et al. (2008). "Rotator cuff in asymptomatic volunteers: contrast-enhanced US depiction of intratendinous and peritendinous vascularity." Radiology 248(3): 954-961. PURPOSE: To test the hypothesis that regional variations in supraspinatus tendon vascularity exist and can be imaged and quantified in asymptomatic individuals by using contrast material-enhanced ultrasonography (US). MATERIALS AND METHODS: After institutional review board approval and informed consent were obtained, 31 volunteers aged 22-65 years (mean age, 41.5 years) underwent lipid microsphere contrast-enhanced shoulder US performed with an L8-4 transducer operating in contrast harmonic mode and a mechanical index of 0.07 in a HIPAA-compliant protocol. Images were obtained in the volunteers at rest and after exercise. Quantitative analysis was performed by using the time-enhancement postcontrast data derived from four regions of interest (ROIs): bursal medial, articular medial, bursal lateral, and articular lateral. Two 2-minute acquisitions were performed after each contrast material bolus. Baseline enhancement and peak enhancement for each ROI were estimated from these acquisitions. Baseline gray-scale and power Doppler US images of the supraspinatus tendon were obtained by using an L12-5 transducer. The Mann-Whitney nonparametric test was used to test for significant differences between ROIs in all volunteers. RESULTS: In the volunteers at rest before exercise, significant variations in regional enhancement between the articular medial zone and both the bursal medial zone (P = .002) and the bursal lateral zone (P = .003) were observed. Differences in enhancement between the articular medial and articular lateral zones approached significance. Greater differentiation (P < .001) was observed after exercise, with a significant increase in apparent enhancement in each ROI in all volunteers. CONCLUSION: This study revealed the spatial distribution of the blood supply to the supraspinatus tendon in asymptomatic individuals. The addition of exercise to the protocol resulted in a significantly increased level of enhancement compared with that at rest and enabled more sensitive assessment of intratendinous and peritendinous vascularity. SUPPLEMENTAL MATERIAL: http://radiology.rsnajnls.org/cgi/content/full/2483071400/DC1.

Balke, M., et al. (2013). "Correlation of acromial morphology with impingement syndrome and rotator cuff tears." Acta Orthop 84(2): 178-183. Background and purpose Indications for acromioplasty are based on clinical symptoms and are generally supported by typical changes in acromial morphology on standard radiographs. We evaluated 5 commonly used radiographic parameters of acromial morphology and assessed the association between different radiographic characteristics on the one hand and subacromial impingement or rotator cuff tears on the other. Patients and methods We measured acromial type (Bigliani), acromial slope (AS), acromial tilt (AT), lateral acromial angle (LAA), and acromion index (AI) on standard radiographs from 50 patients with full-thickness supraspinatus tendon tears, 50 patients with subacromial impingement, and 50 controls without subacromial pathology. Results The acromial type according to Bigliani was not associated with any particular cuff lesion. A statistically significant difference between controls and impingement patients was found for AS. AT of controls was significantly smaller than that of impingement patients and cuff-tear patients. LAA of cuff-tear patients differed significantly from that of controls and impingement patients, but LAA of controls was not significantly different from that of impingement patients. Differences between impingement patients and cuff-tear patients were also significant. AI of controls was significantly lower than of impingement patients and of cuff-tear patients. A good correlation was found between acromial type and AS. Interpretation A low lateral acromial angle and a large lateral extension of the acromion were associated with a higher prevalence of impingement and rotator cuff tears. An extremely hooked anterior acromion with a slope of more than 43 degrees and an LAA of less than 70 degrees only occurred in patients with rotator cuff tears.

Bassett, R. W. and R. H. Cofield (1983). "Acute tears of the rotator cuff. The timing of surgical repair." Clin Orthop Relat Res(175): 18-24. Thirty-seven patients had surgical repair within three months after significant ruptures of the shoulder rotator cuff. Twelve were repaired within three weeks (Group 1), six within three to six weeks (Group 2), and 19 within six to 12 weeks after injury (Group 3). Follow-up periods averaged 7.0 years (range, 1.25-21.00 years). Pain relief was generally satisfactory; however, active postoperative abduction averaged 168 degrees for Group 1, 126 degrees for Group 2, and only 129 degrees for Group 3. At open operation, the tear size was graded as small, medium, or large. The correlation of average values of postoperative abduction (148 degrees, 152 degrees, and 133 degrees) with tear size was not statistically significant. Roentgenograms showed that rotator cuff disease is associated with glenohumeral arthritis. With evidence of an acute and complete disruption of the rotator cuff if one must consider surgery, early surgical repair (with 3 weeks of injury) affords the best opportunity for maximal recovery of shoulder function.

Berhouet, J., et al. (2009). "Massive rotator cuff tears in patients younger than 65 years. Epidemiology and characteristics." Orthop Traumatol Surg Res 95(4 Suppl 1): S13-18. Currently, there is little information on the clinical, radiographic and electric profile of patients younger than 65 years of age with large rotator cuff tear. According to our hypothesis, massive rotator cuff tear, when discovered after recent traumatism, do not provide typical radiographic findings and suprascapular nerve impairment in large rotator cuff tears is uncommon. This is a prospective, descriptive, multicenter study of a series of 112 patients younger than 65 years, including 66 males and 46 females with extensive or massive cuff tear. Duration of symptoms was less than 6 months in 28 cases and secondary to trauma in 57 cases. Patients had loss of elevation or external rotation or both in 57 cases. An electromyogram (EMG) of suprascapular nerve was performed in 50 cases. A higher incidence of advanced fatty infiltration of the infraspinatus muscle (>stage 2 according to Goutallier) was observed in case of long-term symptomatology or in the absence of known trauma. Traumatic status was commonly found in patients with functional deficit in shoulder elevation, thus reporting a significantly lower Constant score (p<0.0001). Patients with both loss of shoulder elevation and external rotation had a significantly narrower subacromial space (5 mm versus 7.2 mm). No significant relationship could be established between electric impairment and massive cuff tear. According to the present study, in case of traumatic context and recent symptomatology, subacromial height and fatty infiltration of the infraspinatus muscle are better prognostic factors despite a pseudoparalytic shoulder. Repair should thus be considered. Moreover, the interest of a preoperative suprascapular nerve EMG is questionable.

Bigliani, L. U., et al. (1991). "[Relationship of acromial architecture and diseases of the rotator cuff]." Orthopade 20(5): 302-309. Variations in the architecture of the coraco-acromial arch can lead to a clinically symptomatic rotator cuff lesion. Differences in the shape and slope of the acromion, anterior acromial spurs and inferior protruding acromio-clavicular osteophytes decrease the volume of the subacromial space, leading to impingement. Recent anatomic, radiographic, biomechanic and stereophotogrammetric studies have confirmed these architectural variations and their effect on the contents of the subacromial space. Abnormal contact between the acromion and these soft tissues can result in pathological lesions. Surgical procedures should be aimed at increasing the space beneath the coraco-acromial arch to reduce wear on the rotator cuff.

Bishop, J. Y., et al. (2015). "Smoking Predisposes to Rotator Cuff Pathology and Shoulder Dysfunction: A Systematic Review." Arthroscopy 31(8): 1598-1605. PURPOSE: To investigate the association of smoking with rotator cuff (RTC) disease and shoulder dysfunction, defined as poor scores on shoulder rating scales. METHODS: A systematic review was performed using a search strategy based on "shoulder AND [smoke OR smoking OR nicotine OR tobacco]." English-language clinical or basic science studies testing the association of smoking and shoulder dysfunction on shoulder rating scales or disease of the soft tissue of the shoulder were included. Level V evidence studies and articles reporting only on surgery outcomes, subjective symptoms, adhesive capsulitis, or presence of fracture or oncologic mass were excluded. RESULTS: Thirteen studies were included, comprising a total of 16,172 patients, of whom 6,081 were smokers. All 4 clinical studies addressing the association between smoking and patient-reported shoulder symptoms and dysfunction in terms of poor scores on shoulder rating scales (i.e., Simple Shoulder Test; University of California, Los Angeles shoulder scale; and self-reported surveys) confirmed this correlation with 6,678 patients, of whom 1,723 were smokers. Two of four studies documenting provider-reported RTC disease comprised 8,461 patients, of whom 4,082 were smokers, and found a time- and dose-dependent relation of smoking with RTC tears and a correlation of smoking with impingement syndrome. Smoking was also reported in 4 other articles to be associated with the prevalence of larger RTC tears or tears with pronounced degenerative changes in 1,033 patients, of whom 276 were smokers, and may accelerate RTC degeneration, which could result in tears at a younger age. In addition, 1 basic science study showed that nicotine increased stiffness of the supraspinatus tendon in a rat model. CONCLUSIONS: Smoking is associated with RTC tears, shoulder dysfunction, and shoulder symptoms. Smoking may also accelerate RTC degeneration and increase the prevalence of larger RTC tears. These correlations suggest that smoking may increase the risk of symptomatic RTC disease, which could consequently increase the need for surgical interventions. LEVEL OF EVIDENCE: Level IV, systematic review of Level II through IV studies.

Bjornsson, H., et al. (2010). "Fewer rotator cuff tears fifteen years after arthroscopic subacromial decompression." J Shoulder Elbow Surg 19(1): 111-115. BACKGROUND: A successful clinical result is reported in 75% to 85% of impingement patients after arthroscopic subacromial decompression. The result is maintained over time, but few studies have investigated the integrity of the rotator cuff in these patients. MATERIALS AND METHODS: Using ultrasonography, we examined the integrity of the rotator cuff in 70 patients 15 years after arthroscopic subacromial decompression. All patients had an intact rotator cuff at the index procedure. RESULTS: Tendons were still intact in 57 patients (82%), 10 (14%) had partial-thickness tears, and 3 (4%) had full-thickness tears. DISCUSSION: The total number of 18% tears (partial and full thickness) in this study, including patients clinically diagnosed with subacromial impingement at a mean age of 60 years, is unexpectedly low compared with 40% degenerative tears reported in asymptomatic adults of the same age. CONCLUSION: Arthroscopic subacromial decompression seems to reduce the prevalence of rotator cuff tears in impingement patients. This appears attributable to elimination of extrinsic factors such as mechanical wear and bursitis. The potential effect of surgery on intrinsic cuff degeneration is unknown, but intrinsic factors may explain tears still developing despite decompression. LEVEL OF EVIDENCE: Level III, therapeutic study.

Bjornsson, H. C., et al. (2011). "The influence of age, delay of repair, and tendon involvement in acute rotator cuff tears: structural and clinical outcomes after repair of 42 shoulders." Acta Orthop 82(2): 187-192. BACKGROUND AND PURPOSE: Few authors have considered the outcome after acute traumatic rotator cuff tears in previously asymptomatic patients. We investigated whether delay of surgery, age at repair, and the number of cuff tendons involved affect the structural and clinical outcome. PATIENTS AND METHODS: 42 patients with pseudoparalysis after trauma and no previous history of shoulder symptoms were included. A full-thickness tear in at least 1 of the rotator cuff tendons was diagnosed in all patients. Mean time to surgery was 38 (6-91) days. Follow-up at a mean of 39 (12-108) months after surgery included ultrasound, plain radiographs, Constant-Murley score, DASH score, and western Ontario rotator cuff (WORC) score. RESULTS: At follow-up, 4 patients had a full-thickness tear and 9 had a partial-thickness tear in the repaired shoulder. No correlation between the structural or clinical outcome and the time to repair within 3 months was found. The patients with a tendon defect at follow-up had a statistically significantly lower Constant-Murley score and WORC index in the injured shoulder and were significantly older than those with intact tendons. The outcomes were similar irrespective of the number of tendons repaired. INTERPRETATION: A delay of 3 months to repair had no effect on outcome. The patients with cuff defects at follow-up were older and they had a worse clinical outcome. Multi-tendon injury did not generate worse outcomes than single-tendon tears at follow-up.

Braune, C., et al. (2000). "Intraoperative shape of rotator cuff tears in traumatic and non traumatic cases." Unfallchirurg 103(6): 462-467. The decision whether a rotator cuff tear has a traumatic or degenerative origin still causes some controversy. Especially in medical expert appraisements the etiology of the rotator cuff tear plays an important role refering to insurance services for the patient. The purpose of this paper is to compare the intraoperative pathomorphologic shape of the cuff tear in traumatic and degenerative cases. This study reports of 56 patients with rotator cuff tears which were devided in primarily acute, subacute traumatic and degenerative study groups refering to their history of present illness. We considered the location of the tear,the shape and the size. Furthermore the grade of retraction of the supraspinatus tendon, its quality and the shape of the long head of biceps were examined. The results showed that in general the shape of the tear gives only in some cases significant information whether the etiology is traumatic or not. The isolated rupture of the subscapularis muscle and the hematoma at the edge of the tendon is significant for the trauma. In comparison with the degenerative study group the tenosynovitis and the dislocation of the long head of biceps is in our study sigificant for traumatic tears.

Chung, S. W., et al. (2016). "Effect of Hypercholesterolemia on Fatty Infiltration and Quality of Tendon-to-Bone Healing in a Rabbit Model of a Chronic Rotator Cuff Tear: Electrophysiological, Biomechanical, and Histological Analyses." Am J Sports Med 44(5): 1153-1164. BACKGROUND: The incidence of healing failure after rotator cuff repair is high, and fatty infiltration is a crucial factor in healing failure. PURPOSE: To verify the effect of hypercholesterolemia on fatty infiltration and the quality of tendon-to-bone healing and its reversibility by lowering the cholesterol level in a chronic tear model using the rabbit supraspinatus. STUDY DESIGN: Controlled laboratory study. METHODS: Forty-eight rabbits were randomly allocated into 4 groups (n = 12 each). After 4 weeks of a high-cholesterol diet (groups A and B) and a regular diet (groups C and D), the supraspinatus tendon was detached and left alone for 6 weeks and then was repaired in a transosseous manner (groups A, B, and C). Group D served as a control. Group A continued to receive the high-cholesterol diet until the final evaluation (6 weeks after repair); however, at the time of repair, group B was changed to a general diet with administration of a cholesterol-lowering agent (simvastatin). Histological evaluation of the fat-to-muscle proportion was performed twice, at the time of repair and the final evaluation, and an electromyographic (EMG) test, mechanical test, and histological test of tendon-to-bone healing were performed at the final evaluation. RESULTS: For the EMG test, group A showed a significantly smaller area of compound muscle action potential compared with groups C and D (all P <.01), and group B showed a larger area than group A, almost up to the level of group C (P = .312). Similarly, group A showed significantly lower mechanical properties both in load-to-failure and stiffness compared with groups C and D (all P <.05). In addition, although not significantly different, the mechanical properties of group B were higher than those of group A (mean load-to-failure: group A = 42.01 N, group B = 58.23 N [P = .103]; mean stiffness: group A = 36.32 N/mm, group B = 47.22 N/mm [P = .153]). For the histological test, groups A and B showed a significantly higher fat-to-muscle proportion than did groups C and D at 6 weeks after detachment (all P <.05), but at the final evaluation, group B showed a decreased fat-to-muscle proportion (mean +/- SD: from 64.02% +/- 11.87% to 54.68% +/- 10.47%; P = .146) compared with group A, which showed increased fat-to-muscle proportion (from 59.26% +/- 17.80% to 78.23% +/- 10.87%; P = .015). Groups B and C showed better tendon-to-bone interface structures than did group A, which showed coarse and poorly organized collagen fibers with fat interposition. CONCLUSION: Hypercholesterolemia had a deleterious effect on fatty infiltration and the quality of tendon-to-bone repair site, and lowering hypercholesterolemia seemed to halt or reverse these harmful effects in this experimental model. CLINICAL RELEVANCE: Systemic diseases such as hypercholesterolemia should be tightly controlled during the perioperative period of rotator cuff repair.

Collin, P., et al. (2014). "Neuropathy of the suprascapular nerve and massive rotator cuff tears: a prospective electromyographic study." J Shoulder Elbow Surg 23(1): 28-34. BACKGROUND: An association between massive rotator cuff tear (RCT) and suprascapular nerve neuropathy has previously been suggested. The anatomic course of the suprascapular nerve is relatively fixed along its passage. Thus, injury to the nerve by trauma, compression, and iatrogenic reasons is well documented. However, the association between retraction of the RCT and development of neuropathy of the suprascapular nerve remains unclear. We aimed to prospectively evaluate the suprascapular nerve for preoperative neurodiagnostic abnormalities in shoulders with massive RCT. METHODS AND MATERIALS: A prospective study was performed in 2 centers. Fifty patients with retracted tears of both supraspinatus and infraspinatus were evaluated. This was confirmed with preoperative computed tomography arthrography, and the fatty infiltration of the affected muscles was graded. Forty-nine preoperative electromyograms were performed in a standardized fashion and the results analyzed twice. RESULTS: Of 49 shoulders, 6 (12%) had neurologic lesions noted on electromyography: 1 suprascapular nerve neuropathy, 1 radicular lesion of the C5 root, 1 affected electromyogram in the context of a previous stroke, and 3 cases of partial axillary nerve palsy with a history of shoulder dislocation. No difference or diminution of the latency or amplitude of the electromyographic curve was found in the cases that presented significant fatty infiltration. CONCLUSION: This study did not detect a suprascapular lesion in the majority of cases of massive RCT. With a low association of neuropathy with massive RCT, we find no evidence to support the routine practice of suprascapular nerve release when RCT repair is performed.

Denard, P. J., et al. (2015). "Pseudoparalysis From a Massive Rotator Cuff Tear Is Reliably Reversed With an Arthroscopic Rotator Cuff Repair in Patients Without Preoperative Glenohumeral Arthritis." Am J Sports Med 43(10): 2373-2378. BACKGROUND: Pseudoparalysis is defined as active forward flexion less than 90 degrees with full passive motion. There is controversy about the ideal surgical management of a massive rotator cuff tear with pseudoparalysis. PURPOSE/HYPOTHESIS: The purpose of this study was to prospectively analyze the ability to reverse pseudoparalysis with an arthroscopic rotator cuff repair (ARCR). The hypothesis was that in the absence of substantial glenohumeral arthritis, preoperative fatty infiltration of grade 3 or higher and an acromiohumeral interval (AHI) of less than 7 mm would not prevent reversal of pseudoparalysis with an ARCR. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A prospective multicenter study of ARCR performed for preoperative pseudoparalysis was conducted. The minimum follow-up was 1 year. The mean patient age was 63 years, and pseudoparalysis was present for a mean of 4.2 months preoperatively. Preoperative radiographic evaluation included plain film evaluation of the AHI and Hamada classification and MRI evaluation of fatty degeneration and rotator cuff retraction. Functional outcome was determined by the Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) Shoulder Score, visual analog scale (VAS), and subjective shoulder value (SSV). RESULTS: Of the 58 patients enrolled, 56 had at least 1 year of follow-up. Mean active forward flexion improved from 47 degrees preoperatively to 159 degrees postoperatively (P < .001). Statistically significant improvements were seen in the SST (from 2.8 preoperatively to 10.1 postoperatively), SSV (from 28 to 83), ASES Shoulder Score (from 37 to 88), and VAS (from 5.7 to 1.1) (P < .001). Pseudoparalysis was reversed in 53 of 56 patients (95%). There was no difference in the rate of reversal of pseudoparalysis between those patients with an AHI of less than 7 mm (88.2%) and those with an AHI of 7 mm or more (96.9%) (P =.289). Pseudoparalysis was reversed in all 8 of the patients with fatty degeneration of grade 3 or higher in 1 or more of the rotator cuff muscles. CONCLUSION: ARCR can lead to reversal of preoperative pseudoparalysis in patients with minimal preoperative glenohumeral arthritis. ARCR is a viable first line of treatment for patients with pseudoparalysis in the absence of advanced glenohumeral arthritis.

Duncan, N. S., et al. (2015). "Surgery within 6 months of an acute rotator cuff tear significantly improves outcome." J Shoulder Elbow Surg 24(12): 1876-1880. BACKGROUND: To determine the effect of time to repair on the outcome after an acute rotator cuff tear. METHODS: We performed a retrospective analysis of prospectively collected data on patients presenting with acute rotator cuff tear to our shoulder clinic. Patient-reported outcomes were assessed using the Oxford Shoulder Score, and symptomatic retears were diagnosed by clinical assessment plus imaging. RESULTS: Twenty patients underwent rotator cuff repair within 6 months of injury via initial referral through the Acute Shoulder Injury Clinic (early repair group; mean age, 60 years; age range, 39-77 years). Twenty age- and sex-matched patients were identified who had undergone delayed repair (6-18 months after injury; mean age, 60 years; age range, 40-78 years). The mean follow-up period was 10 months for the early repair group versus 11 months for the delayed repair group. Both groups had clinically significant improvements in their Oxford scores, although the early repair group had an improvement that was nearly double that of the delayed repair group (20.3 for early vs 10.4 for delayed, P = .0014). Postoperative Oxford scores were significantly higher in the early repair group (mean of 43.8 for early vs 35.8 for delayed, P = .0057). There were 2 symptomatic retears in the early repair group versus 5 in the delayed repair group. CONCLUSION: Our results show improved outcomes with early repair (within 6 months) of acute rotator cuff tears and support the provision of an acute shoulder injury referral clinic.

Fehringer, E. V., et al. (2008). "Full-thickness rotator cuff tear prevalence and correlation with function and co-morbidities in patients sixty-five years and older." J Shoulder Elbow Surg 17(6): 881-885. The purpose of this study was to determine full-thickness rotator cuff tear prevalence in patients 65 and older and to correlate tears with comfort, function, and co-morbidities. Two-hundred shoulders without prior surgery were evaluated with a Simple Shoulder Test, a Constant Score, and ultrasound. Full thickness tear prevalence was 22%. Adjusting for age and gender, those with tears had lower scores than those without (P < .001 for each). Adjusting for many potential confounders, with a 10-year age increase, the odds of a tear increased 2.69-fold (P = .005). For those with tears, scores were no different for those who had seen a physician for their shoulder compared to those who had not. Full-thickness cuff tear prevalence was 22% in those 65 and older. Tear prevalence increased with increasing age. Shoulder scores were poorer for those with tears.

Fucentese, S. F., et al. (2012). "Evolution of nonoperatively treated symptomatic isolated full-thickness supraspinatus tears." J Bone Joint Surg Am 94(9): 801-808. BACKGROUND: The natural history of small, symptomatic rotator cuff tears is currently unclear. The purpose of the present study was to assess the clinical and structural outcomes for a consecutive series of patients with symptomatic, isolated full-thickness supraspinatus tears who had been offered rotator cuff repair but declined operative treatment. METHODS: In the study period, twenty-four patients with isolated full-thickness supraspinatus tears that had been diagnosed by means of magnetic resonance arthrography were offered rotator cuff repair and elected nonoperative treatment. The twenty men and four women had an average age of fifty-two years at the time of diagnosis. At a median of forty-two months after the diagnosis, all patients were reexamined clinically according to the Constant and Murley scoring system and all shoulders underwent standard magnetic resonance imaging. RESULTS: At the time of follow-up, the mean subjective shoulder score was 74% of that for a normal shoulder and the mean Constant score was 75 points (relative Constant score, 86%). The mean rotator cuff tear size did not change significantly over time (95% confidence interval, 0.51 to 1.12). In two shoulders, the tear was no longer detectable on magnetic resonance imaging, in nine shoulders the tear was smaller than it had been at the time of the initial diagnosis, in nine patients the tear had not changed, and in six patients the tear had increased in size. There was a slight but significant progression of fatty muscle infiltration of the supraspinatus, but no patient had fatty infiltration beyond stage 2 at the time of the latest follow-up (95% confidence interval, 0% to 14%). CONCLUSIONS: In a consecutive series of patients who had been offered repair of an isolated, symptomatic supraspinatus tear, the refusal of operative treatment resulted in surprisingly high clinical patient satisfaction and no increase of the average size of the rotator cuff tear 3.5 years after the recommendation of operative repair. This study confirms that the size of small rotator cuff tears does not invariably increase over a limited period of time. Distinguishing tears that will increase in size from those that will not needs further study.

Fuchs, B., et al. (1999). "Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging." J Shoulder Elbow Surg 8(6): 599-605. Forty-one patients scheduled for shoulder surgery underwent computed tomography (CT) and magnetic resonance imaging (MRI) examination of their affected shoulder to verify whether fatty degeneration of the rotator cuff muscles could reproducibly be assessed by CT or by MRI and whether the grading with the 2 methods was comparable. In addition, rotator cuff muscle cross-sectional areas were measured on parasagittal MRI scans to establish a possible correlation between rotator cuff muscle atrophy and fatty degeneration. Interobserver reproducibility for grading fatty degeneration was good to excellent for CT and for MRI. The correlation between MRI and CT was fair to moderate and remained unsatisfactory, even if the classification system was simplified with only a 3- rather than a 5-grade scale as originally proposed. The degree of fatty degeneration was significantly related to the amount of atrophy of the respective muscles.

Gerber, C., et al. (1996). "Isolated rupture of the subscapularis tendon." J Bone Joint Surg Am 78(7): 1015-1023. Sixteen consecutive patients were managed operatively for repair of an isolated traumatic rupture of the subscapularis tendon in the absence of avulsion of the lesser tuberosity. All of the patients were men. The diagnosis was made for each patient on the basis of the clinical examination and was confirmed by imaging studies and operative exploration. The operative treatment consisted of mobilization of the subscapularis after exploration and protection of the axillary nerve, transosseous reinsertion of the tendon to a trough created at the lesser tuberosity, closure of the rotator interval, and protection of the shoulder for six weeks postoperatively. The average duration of follow-up was forty-three months (range, twenty-four to eighty-four months). Thirteen patients subjectively rated the result as excellent or good. The average functional score of the shoulder, as assessed according to the system of Constant, was 82 per cent of the average age and gender-matched normal value. Active flexion was normal in twelve patients, was decreased by 15 degrees or less in three, and was severely limited in one patient. The capacity of the patients to work in their original occupations had increased from an average of 59 per cent of full capacity preoperatively to an average of 95 per cent postoperatively (p = 0.006). Operative treatment proved to be economically sound within the Swiss National Accident Insurance system. The quality of the result did not depend on the capacity for work at the time of the operation, on the type of work in which the patient was engaged, on the state of the biceps, or on the duration of follow-up. Conversely, the results were less successful when there was an increased delay from the time of the injury to the time of the operative repair.

Gill, T. J., et al. (2002). "The relative importance of acromial morphology and age with respect to rotator cuff pathology." J Shoulder Elbow Surg 11(4): 327-330. The purpose of this study was to examine the relationship between patient age, acromial morphology, and rotator cuff pathology. Data on 523 patients who had arthroscopic and/or open shoulder surgery were reviewed. Acromial morphology was classified by the system of Bigliani. All patients were categorized by postoperative diagnosis as having tendinitis of the rotator cuff, partial rotator cuff tear, complete rotator cuff tear, and non-rotator cuff-related pathology. Univariate analysis results for acromial morphology (P <.001), age (P <.001), and gender (P =.019) showed a significant association with rotator cuff pathology. Fifty percent of patients with rotator cuff tendinitis had type I acromions, and 58% of patients with full-thickness rotator cuff tears had type III acromions. Stratified univariate analysis revealed no significant association between acromial morphology and rotator cuff pathology in patients who were over 50 years old. Patients with full-thickness rotator cuff tears were significantly older than those with partial-thickness tears or tendinitis. A larger proportion of male patients than female patients had full-thickness rotator cuff tears. Multivariable logistic regression analysis identified acromial morphology, age, and gender as independent multivariate predictors of rotator cuff pathology. Age, acromial morphology, and gender all have an independent association with rotator cuff pathology.

Girish, G., et al. (2011). "Ultrasound of the shoulder: asymptomatic findings in men." AJR Am J Roentgenol 197(4): W713-719. OBJECTIVE: The purpose of this study was to examine the range and prevalence of asymp tomatic findings at sonography of the shoulder. MATERIALS AND METHODS: The study sample comprised 51 consecutively enrolled subjects who had no symptoms in either shoulder. Ultrasound of one shoulder per patient was performed by a musculoskeletal sonographer according to a defined protocol that included imaging of the rotator cuff, tendon of the long head of the biceps brachii muscle, subacromial-subdeltoid bursa, acromioclavicular joint, and posterior labrum. The shoulder imaged was determined at random. The 51 scans were retrospectively analyzed by three fellowship-trained musculoskeletal radiologists in consensus, and pathologic findings were recorded. Subtle or questionable findings of mild tendinosis, bursal prominence, and mild osteoarthritis were not recorded. RESULTS: Twenty-five right and 26 left shoulders were imaged. The subject age range was 40-70 years. Ultrasound showed subacromial-subdeltoid bursal thickening in 78% (40/51) of the subjects, acromioclavicular joint osteoarthritis in 65% (33/51), supraspinatus tendinosis in 39% (20/51), subscapularis tendinosis in 25% (13/51), partial-thickness tear of the bursal side of the supraspinatus tendon in 22% (11/51), and posterior glenoid labral abnormality in 14% (7/51). All other findings had a prevalence of 10% or less. CONCLUSION: Asymptomatic shoulder abnormalities were found in 96% of the subjects. The most common were subacromial-subdeltoid bursal thickening, acromioclavicular joint osteoarthritis, and supraspinatus tendinosis. Ultrasound findings should be interpreted closely with clinical findings to determine the cause of symptoms.

Goutallier, D., et al. (1994). "Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan." Clin Orthop Relat Res(304): 78-83. A preoperative computed tomography (CT) scan grading muscular fatty degeneration in five stages was done in 63 patients scheduled for repair of a torn rotator cuff. The results were compared with postoperative evaluation done after a mean of 17.7 months in 57 patients. Postoperative arthrographies were also performed in 56 patients. Preoperative CT scans demonstrated that infraspinatus fatty degeneration can occur in the presence of large anterosuperior tears even when the infraspinatus tendon is not torn; it worsens with time. The subscapularis rarely degenerates, and when it does it degenerates moderately, even when its tendon is not torn. After an effective surgical repair, moderate supraspinatus degeneration regressed in six of 14 patients; that of the infraspinatus never regressed but rather, increased, in three patients. One of these deteriorations, involving both supra- and infraspinatus, could probably be attributed to a partial subscapular nerve injury. Infraspinatus degeneration was correlated with functional pre- and postoperative impairment of active external rotation. Recurrence of infraspinatus tear was never observed, but recurrence occurred in 25% of supraspinatus repairs. Infraspinatus degeneration had a highly negative influence on the outcome of supraspinatus repairs. It seems preferable to operate on wide tears before irreversible muscular damage takes place.

Gumina, S., et al. (2013). "The association between arterial hypertension and rotator cuff tear: the influence on rotator cuff tear sizes." J Shoulder Elbow Surg 22(2): 229-232. BACKGROUND: This study was conducted to establish whether hypertension increases the risk of occurrence of rotator cuff tear and influences its size. MATERIALS AND METHODS: A case-control design was used. We studied 408 consecutive patients (228 men, 180 women) who underwent arthroscopic rotator cuff repair. Tear size was determined during surgery. The control group included 201 individuals. For the study purpose, participants were divided into 2 groups by presence or absence of hypertension. We applied a logistic regression model to investigate if hypertension affects the risk of cuff tear. A multinomial logistic regression model was applied to explore the association between hypertension and tear size. We used the analysis of covariance method to determine if the duration of hypertension influences the severity of the tear; finally, we compared mean duration of antihypertensive therapy in patients with small, large, and massive tears. All analyses were adjusted for age and sex. RESULTS: Hypertension was associated with a 2-fold higher risk of tear occurrence (odds ratio [OR], 2.05; 95% confidence interval [CI], 41-2.98). No association was detected between hypertension and the probability of a small tear (OR, 0.63, 95% CI, 0.33-1.19). Hypertensive individuals were 2 times more likely to experience large tear (OR, 02.09; 95% CI, 1.39-3.16) and 4 times more likely to experience massive tear (OR, 04.30; 95% CI, 2.44-7.58) than normotensive individuals. Mean duration of antihypertensive therapy significantly increased from small tear (1.08 years) to large tear (3.20 years) to massive tear (6.34 years) patients (analysis of covariance: F((2,403)) = 16.357, P = 1.48 x 10(-7)). CONCLUSIONS: Our data provide evidence that hypertension is a significant risk factor for the occurrence and severity of rotator cuff tears.

Gwilym, S. E., et al. (2009). "Genetic influences in the progression of tears of the rotator cuff." J Bone Joint Surg Br 91(7): 915-917. The aim of this study was to investigate genetic influences on the development and progression of tears of the rotator cuff. From a group of siblings of patients with a tear of the rotator cuff and of controls studied five years earlier, we determined the prevalence of tears of the rotator cuff with and without associated symptoms using ultrasound and the Oxford Shoulder Score. In the five years since the previous assessment, three of 62 (4.8%) of the sibling group and one of the 68 (1.5%) controls had undergone shoulder surgery. These subjects were excluded from the follow-up. Full-thickness tears were found in 39 of 62 (62.9%) siblings and in 15 of 68 (22.1%) controls (p = 0.0001). The relative risk of full-thickness tears in siblings as opposed to controls was 2.85 (95% confidence interval (CI) 1.75 to 4.64), compared to 2.42 (95% CI 1.77 to 3.31) five years earlier. Full-thickness tears associated with pain were found in 30 of 39 (76.9%) tears in the siblings and in eight of 15 (53.3%) tears in the controls (p = 0.045). The relative risk of pain associated with a full-thickness tear in the siblings as opposed to the controls was 1.44 (95% CI 2.04 to 8.28) (p = 0.045). In the siblings group ten of 62 (16.1%) had progressed in terms of tear size or development compared to one of 68 (1.5%) in the control group which had increased in size. Full-thickness rotator cuff tears in siblings are significantly more likely to progress over a period of five years than in a control population. This implies that genetic factors have a role, not only in the development but also in the progression of full-thickness tears of the rotator cuff.

Huang, L. F., et al. (1999). "Greater tuberosity changes as revealed by radiography: lack of clinical usefulness in patients with rotator cuff disease." AJR Am J Roentgenol 172(5): 1381-1388. OBJECTIVE: Studies linking greater tuberosity findings on radiographs with rotator cuff disease have largely been uncontrolled and biased toward more severe disease. We correlated greater tuberosity changes seen on radiography with rotator cuff disease seen on MR images in a broadly symptomatic patient population. MATERIALS AND METHODS: Both radiography and MR imaging were performed in 108 shoulders. Unaware of the MR imaging findings, three radiologists independently reviewed the radiographs for cortical thickening, subcortical sclerosis, and cystlike lesions in the humeral greater tuberosity. Interobserver agreement was analyzed using kappa statistics. We correlated the radiographic findings with MR imaging evidence of rotator cuff tears and tendonopathy. The positive predictive value of each finding for rotator cuff disease was also calculated. RESULTS: Interobserver agreement for the three radiographic findings was poor to fair: Kappa values ranged from .06 to .41. Cortical thickening and subcortical sclerosis were not seen more frequently in shoulders with rotator cuff disease than in normal shoulders. Cystlike lesions were more prevalent in shoulders with rotator cuff disease, but the association reached statistical significance (p < .05) for one observer only. Positive predictive values for each finding were low (14-48% for predicting full-thickness rotator cuff tears). CONCLUSION: Cortical thickening of the greater tuberosity and subcortical sclerosis are not associated with rotator cuff disease. For some observers, identifying cystlike lesions is associated with rotator cuff disease, but the clinical usefulness of the observation is limited by high interobserver variability and poor positive predictive value.

Ide, J., et al. (2007). "Arthroscopic repair of traumatic combined rotator cuff tears involving the subscapularis tendon." J Bone Joint Surg Am 89(11): 2378-2388. BACKGROUND: Although the use of arthroscopic repair to treat rotator cuff tears involving the subscapularis has increased, there are few studies on treatment outcomes and repair integrity. We hypothesized that arthroscopic repair of combined rotator cuff tears that include the subscapularis yields successful functional and structural outcomes. METHODS: Our study population consisted of seventeen men and three women (twenty shoulders) whose mean age was 61.7 years. The mean duration of follow-up was 36.1 months, and all patients were followed for at least two years. All had traumatic full-thickness tears of the subscapularis and supraspinatus, and seven had a concomitant infraspinatus tear. The mean time from the injury to the surgery was 2.7 months. An arthroscopic suture-anchor technique was used for the repair. The shoulders were evaluated before and after the procedure with use of the University of California at Los Angeles (UCLA) score, the Japanese Orthopaedic Association (JOA) score, plain radiographs, and magnetic resonance imaging scans. RESULTS: After arthroscopic repair, the mean UCLA and JOA scores significantly improved from 14.9 and 55.7 points to 31.1 and 91.0 points, respectively (p < 0.0001). According to the JOA rating scale, the outcome was excellent for thirteen patients (65%), good for five (25%), fair for one (5%), and poor for one (5%). Of the twenty patients, seven (35%) had recurrent tears after the surgery; four of them had originally had a three-tendon tear and the other three had had a two-tendon tear. Of these seven patients, one had an excellent outcome; five, a good outcome; and one, a fair outcome. The postoperative mean JOA score was significantly lower for the patients with a failed repair than it was for those with an intact repair (p = 0.0034). The patients with a failed repair also had a significantly higher mean age (68.4 years compared with 58.1 years for those with an intact repair; p = 0.014), and the prevalence of recurrent tears was significantly higher in the patients with severe tendon retraction compared with those with minimal or moderate tendon retraction (p = 0.0191). CONCLUSIONS: Arthroscopic repair with use of the suture anchor technique is a safe and effective procedure for the treatment of combined rotator cuff tears involving the subscapularis tendon; it can alleviate shoulder pain and improve function and the range of motion. The postoperative integrity of the repair correlates with the clinical results. Patient age and the degree of tendon retraction can affect the integrity of the repair.

Jiang, Y., et al. (2002). "Trabecular microstructure and surface changes in the greater tuberosity in rotator cuff tears." Skeletal Radiol 31(9): 522-528. OBJECTIVE: When planning surgery in patients with rotator cuff tear, strength of bone at the tendon insertion and trabecular bone structure in the greater tuberosity are usually taken into consideration. We investigated radiographic changes in bone structure of the greater tuberosity in rotator cuff tears. DESIGN: Twenty-two human cadaveric shoulders from subjects ranging from 55 to 75 years of age were obtained. The integrity of the rotator cuff was examined by sonography to determine if it is intact without any tear, or torn partially or completely. The humeral head was sectioned in 3 mm thick coronal slab sections and microradiographed. After digitization of the microradiographs and imaging processing with in-house semi-automated image processing software tools developed using software interfaces on a Sun workstation, the trabecular histomorphometrical structural parameters and connectivity in the greater tuberosity were quantified. The degenerative changes on the surface of the greater tuberosity were interpreted blindly by 2 independent readers. RESULTS: Among the 22 shoulder specimens, the rotator cuff was found intact in 10 shoulders, partially in 7 and fully torn in 5. Statistically significant loss in apparent trabecular bone volume fraction, number of trabecular nodes, and number of trabecular branches, and a statistically significant increase in apparent trabecular separation and number of trabecular free ends were found in the greater tuberosity of the shoulders with tears. The loss was greater in association with full tear than in partial tear. Thickening of the cortical margin of the enthesis, irregularity of its surface, and calcification beyond the tidemark were observed in 2 (20%) shoulders with intact rotator cuff, in 6 (86%) shoulders with partial tear, and in 5 (100%) shoulders with full tear. CONCLUSIONS: Rotator cuff tears are associated with degenerative changes on the bone surface and with disuse osteopenia of the greater tuberosity. Aging, degenerative enthesopathy of the supraspinatus tendon, and rotator cuff tears appear closely related.

Kim, S. H. and K. I. Ha (2000). "Arthroscopic treatment of symptomatic shoulders with minimally displaced greater tuberosity fracture." Arthroscopy 16(7): 695-700. PURPOSE: The purpose of this study is to describe arthroscopic findings and the results of arthroscopic treatment of patients with chronic shoulder pain caused by a minimally displaced fracture of the greater tuberosity. TYPE OF STUDY: This is a retrospective case series in a consecutive sample of 23 patients with a minimally displaced or nondisplaced fracture of the greater tuberosity who underwent outcome analysis after arthroscopic treatment. MATERIALS AND METHODS: Twenty-three patients with chronic shoulder pain beyond 6 months after fracture of the greater tuberosity underwent arthroscopic treatment and were retrospectively assessed after an average of 29 months (range, 22 to 40 months). There were 18 men and 5 women with the average age of 39 years (range, 24 to 61 years). Fourteen fractures were isolated and 9 were related to acute anterior instability episode. The average displacement of the fracture was 2.3 mm (range, 0 to 4 mm) as shown on anteroposterior view plain radiographs. RESULTS: At the time of arthroscopy, all patients had partial-thickness rotator cuff tears on the articular surface. The cuff tears were located on the tuberosity fracture area and were an Ellman grade I to II in depth. After arthroscopic debridement or repair of the tear, depending on the condition of the tear itself, as well as subacromial decompression, the UCLA score results were good to excellent in 20 and fair in 3 patients. Nineteen of the patients had returned to the previous level of activities. However, the patients engaged in overhead sports activity had a lower level of return to activity (P =.034). CONCLUSIONS: A partial-thickness rotator cuff tear on the articular surface should be considered in patients with chronic shoulder pain after a minimally displaced fracture of the greater tuberosity. Arthroscopic debridement or repair is an appropriate procedure.

Krishnan, S. G., et al. (2008). "Arthroscopic repair of full-thickness tears of the rotator cuff in patients younger than 40 years." Arthroscopy 24(3): 324-328. PURPOSE: Recent reports document excellent outcomes with arthroscopic repair of rotator cuff tears (RCT). However, full-thickness RCT are uncommon in patients younger than 40 years, and few reports document results after repair in this population. The purpose of this study is to retrospectively report results of arthroscopic repair of full-thickness RCT in patients younger than 40 years. METHODS: Twenty-three consecutive patients younger than 40 years with full-thickness RCT underwent arthroscopic repair with suture anchors. Mean age was 37 years (range, 21 to 39). The mean size of RCT was 2.4 cm in the largest dimension (range, 1 to 4 cm). The mean number of anchors used was 2.5 (range, 1 to 4). Concomitant procedures included subacromial decompression (22), distal clavicle resection (13), SLAP repair (2), biceps tenodesis (2), anterior capsulorraphy (1), and capsular releases (1), and were performed at the discretion of the surgeon. Twenty-two patients (95%) recalled a single incipient trauma; two patients sustained a dislocation. Ten patients (43%) claimed Workers' Compensation (WC). Minimum follow-up was 24 months, and mean follow-up was 26 months (range, 24 to 29). RESULTS: Mean preoperative American Shoulder and Elbow Surgeon's (ASES) self-report score was 42 (range, 22 to 60); the mean postoperative score was 92 (range, 65 to 100; P < .01). Twenty-one patients (90%) returned to their previous level of activity and employment, including 9 (90%) with WC claims. All patients (100%) reported diminished pain, and 22 (95%) reported improvement with activities of daily living. Complications included superficial wound infection (1) and axillary nerve palsy after initial dislocation (1). Given the choice, 22 patients (95%) would have same procedure again. CONCLUSIONS: Excellent outcomes were observed following arthroscopic rotator cuff repair both with and without concomitant procedures in patients younger than 40 years. Full-thickness RCT in patients younger than 40 years appeared to be traumatic in etiology. Successful repair returns patients to their pre-injury level of function. These results support arthroscopic rotator cuff repair in young, active patients. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Lädermann, A., et al. (2012). "Supraspinatus rupture at the musclotendinous junction: an uncommonly recognized phenomenon." J Shoulder Elbow Surg 21(1): 72-76. BACKGROUND: The majority of rotator cuff lesions involving the supraspinatus occur at or near the level of bone-tendon interface. We present a series of supraspinatus injuries at the musculotendinous junction. METHODS: Between October 2002 and December 2009, we prospectively evaluated all patients presenting with an injury of the supraspinatus at the musculotendinous junction. RESULTS: Five patients (1 female and 4 males) were identified. Three patients had a clear history of trauma. All patients presented acutely with pain and muscular edema on T2 magnetic resonance imaging (MRI) sequences. Lesions were characterized as stretch injuries in 2 cases and complete rupture at the level of the musculotendinous junction in 3 cases. Electrodiagnostic studies were normal in all cases. All patients were treated nonoperatively. On clinical and radiological examination at an average of 24 +/- 10 months (range, 10-38), 1 patient had complete clinical and radiological resolution, 1 improved, and 3 who complained of loss of function demonstrated severe fatty infiltration on MRI. CONCLUSION: Musculotendinous rupture of the supraspinatus is an unusual lesion of the rotator cuff. With incomplete injuries, recovery can be anticipated with nonsurgical management. However, in the case of a complete rupture with muscle retraction, nonoperative management leads to unsatisfactory outcomes.

Lahteenmaki, H. E., et al. (2006). "Results of early operative treatment of rotator cuff tears with acute symptoms." J Shoulder Elbow Surg 15(2): 148-153. The distinction among an acute tear, acute symptoms of a chronic tear, or the acute extension of an existing chronic tear is very difficult, if not impossible, to make. In general, operative treatment of lesions with a sudden onset has yielded favorable results in many studies. However, the timing of the operation for tears with an acute onset of symptoms is still a very controversial issue, as are the treatment options for chronic tears with acute symptoms. This study analyzes the follow-up results of early operative treatment of rotator cuff tears with an acute onset of symptoms, regardless of tear type. Twenty-nine patients with a sudden onset of symptoms and significant impairment of shoulder function had a full-thickness rotator cuff tear. The patients were operated on within 3 weeks from the beginning of the symptoms. Twenty-six patients underwent follow-up. The results were evaluated by use of the UCLA shoulder rating scale. At follow-up, 22 patients (85%) had no pain and 21 (81%) had returned to normal activities and had normal shoulder function. Active forward flexion averaged 51 degrees preoperatively and 167 degrees at follow-up. After repair of the tear, shoulder strength was normal in 22 of 26 shoulders (85%); 3 patients had fair strength, all after repair of a massive tear. Of the patients, 25 (96%) were satisfied with the result. The overall result was excellent in 20 patients (77%), good in 4 (15%), fair in 1 (4%), and poor in 1 (4%). Early operative treatment appears to be better for rotator cuff tears with a sudden onset of symptoms and poor function to achieve maximal return of shoulder function. With time, the tear may enlarge, and the cuff may lose its elasticity, thus making the late surgical repair more difficult or even impossible.

Liem, D., et al. (2014). "The prevalence of rotator cuff tears: is the contralateral shoulder at risk?" Am J Sports Med 42(4): 826-830. BACKGROUND: Rotator cuff tears are a common cause of pain and disability of the shoulder. Information on the prevalence and identification of potential risk factors could help in early detection of rotator cuff tears and improve treatment outcome. HYPOTHESIS: Patients treated for a symptomatic rotator cuff tear on one side have a higher prevalence of rotator cuff tears and decreased shoulder function on the contralateral side compared with an age- and sex-matched group of healthy individuals. STUDY DESIGN: Case control study; Level of evidence, 3. METHODS: One group consisted of 55 patients who had been arthroscopically treated on one shoulder for rotator cuff tear (tear group). In this group, the nonoperated contralateral shoulder was examined. For comparison, the matching shoulder in a control group consisting of 55 subjectively healthy individuals matched by age (+/-1 year) and sex to the tear group was included. Diagnosis of a rotator cuff tear was made by ultrasound. Outcomes were measured using the Constant score. RESULTS: The prevalence of supraspinatus tears was significantly higher (P < .0001) in the tear group (67.3%) compared with the control group (11.0%). The Constant score for the activities of daily living subscale, however, was significantly lower (18.4) in the tear group compared with the control group (19.9; P = .012). No other subcategory score nor the overall score showed a significant difference. There was a significantly higher tear prevalence in the tear group of patients aged between 50 and 59 years (P < .001) and 60 and 69 years (P = .004). No tear was diagnosed in the control group in individuals younger than 60 years. CONCLUSION: Patients treated for partial and full-thickness rotator cuff tears have a significantly higher risk of having a tear on the contralateral side and have noticeable deficits in their shoulder function regarding activities of daily living even if the tear is otherwise asymptomatic.

Lin, Y. P., et al. (2012). "Rotator cuff tears in patients younger than 50 years of age." Acta Orthop Belg 78(5): 592-596. The purpose of this study was to investigate the characteristics of rotator cuff tears and the clinical outcome of rotator cuff repair in patients under 50 years of age. Sixty-eight patients (72 shoulders) aged < 50 years, who underwent repair of rotator cuff tears were evaluated. We analyzed the cause of injury, tear size, time from symptom onset to surgery, and rate that patients returned to previous jobs and sports. Postoperative results were assessed by pain, strength, range of motion, and UCLA scoring system. Most of the injuries were caused by an unambiguous traumatic event. The tear size generally was medium or large, while the time from symptom onset to surgery was shorter than that seen in a mixed population. The postoperative outcomes generally were good to excellent, and the rate that patients returned to previous jobs and sports was high. The findings suggest that a good outcome after early repair in younger patients with traumatic rotator cuff tears can be expected.

Liu, X., et al. (2011). "A rat model of massive rotator cuff tears." J Orthop Res 29(4): 588-595. Rotator cuff tears (RCTs) are the most common tendon injury seen in orthopedic patients. Massive RCT does not heal spontaneously and results in poor clinical outcomes. Muscle atrophy and fatty infiltration in rotator cuff muscles are major complications of chronic massive RCT and are thought to be the key factors responsible for the failure of attempted massive RCT repair. However, the pathophysiology of rotator cuff muscle atrophy and fat infiltration remains largely unknown, and no small animal model has been shown to reproduce the histologic and molecular changes seen in massive RCT. In this article, we report a novel rat massive RCT model, in which significant and consistent muscle atrophy and fat infiltration were observed in the rotator cuff muscles after rotator cuff tendon transection and denervation. The supraspinatus and infraspinatus muscle lost 25.4% and 28.9% of their wet weight 2 weeks after complete tendon transection, respectively. Six weeks after surgery, the average wet weight of supraspinatus and infraspinatus muscles decreased 13.2% and 28.3%, respectively. Significant fat infiltration was only observed in infraspinatus 6 weeks after tendon transection.

Loew, M. (2000). "[Traumatic development of rotator cuff lesion. Scientific principles and consequences for expert assessment]." Orthopade 29(10): 881-887. The traumatic etiology of rotator cuff lesions is a matter of controversial discussed in legal assessments. Because of the relatively high prevalence of degenerative changes with increasing age, including partial and complete rotator cuff tears, it may be difficult to demonstrate the cause of an acute traumatic rotator cuff tear. This article presents a review of the literature concerning current knowledge of the anatomy, biomechanics and pathogenesis of rotator cuff pathology. According to this, a catalogue of potentially adequate and inadequate trauma mechanisms is proposed. Another focus of this work is in the post-traumatic diagnostic steps following persistent rotator cuff-deficient shoulder function. X-ray, ultrasound, MRI and operative findings in rotator cuff tears underline the criteria for distinguishing between traumatic and degenerative lesions. From a legal point of view (e.g., private accident insurance, workers compensation claims), various minor and major arguments are defined, which could help the expert in judging the cause of post-traumatic rotator cuff deficiency.

Loew, M., et al. (2000). "Recommendations for diagnosis and legal assessment of traumatic rotator cuff tears." Unfallchirurg 103(5): 417-426. Traumatic rotator cuff lesions are a very rare condition. However,this article represents a comprehensive survey according to current knowledge on anatomy, biomechanics,and pathogenesis of rotator cuff pathology. Because of the relatively high prevalence of degenerative changes with increasing age, including partial and complete relator cuff tears, it may be difficult to demonstrate the causality of an acute traumatic rotator cuff tear. Therefore, a catalogue of potential adequate and inadequate trauma mechanisms is proposed. Emphasis is also placed on posttraumatic diagnostic steps following persistent rotator cuff deficient shoulder function (e.g., ultrasound, MRI). From a legal aspect (e.g., private accident insurance,workers compensation claim),different minor and major criteria are defined, which could help experts to judge the causality of posttraumatic rotator cuff deficiency. These criteria mainly refer to distinct details concerning patients' history, trauma mechanism, primary clinical appearance, and diagnostic findings.

Loew, M., et al. (2015). "How to discriminate between acute traumatic and chronic degenerative rotator cuff lesions: an analysis of specific criteria on radiography and magnetic resonance imaging." J Shoulder Elbow Surg 24(11): 1685-1693. BACKGROUND: Discrimination between acute traumatic and chronic degenerative rotator cuff lesions (RCLs) is an important aid to decision making in therapeutic management. To date, no clinical signs or radiologic findings that enable confident differentiation between these distinct etiologic entities have been identified. The purpose of this investigation was to perform a systematic analysis of known radiographic and magnetic resonance imaging (MRI) features of RCLs and of further, not yet accurately described parameters. The hypothesis was that there are specific radiologic features that allow reliable discrimination between traumatic and nontraumatic RCLs. METHODS: Fifty consecutive patients with RCLs confirmed by MRI were enrolled in this study. Group A was made up of 25 patients with a history of trauma within the previous 6 weeks and no pre-existing shoulder pain, whereas group B comprised 25 patients with shoulder pain for not more than 12 months and no history of relevant trauma. Radiographs and magnetic resonance images were analyzed in a standardized protocol. RESULTS: No radiographic features were found to differ significantly between the 2 groups. On MRI, edema in the injured muscle was more common in group A (37.5% vs 4%, P = .04). A characteristic feature in traumatic RCLs was a wavelike appearance (kinking) of the central tendon (64% vs 32%, P = .03). In group B, more muscular atrophy was found (29.2% vs 60%, P = .02). Thinning and retraction did not differ between the groups. CONCLUSION: MRI, but not radiography, can be used to help discriminate between traumatic and nontraumatic RCLs. Although no absolute distinguishing feature was found, edema, kinking, and muscular atrophy are positive criteria for differentiation.

Loew, M., et al. (2014). "Zur Unterscheidung zwischen traumatischer und degenerativer Rotatorenmanschettenruptur –eine klinische und radiologische Untersuchung." Obere Extremität 9: 209–214.

Mall, N. A., et al. (2013). "An Evidenced-Based Examination of the Epidemiology and Outcomes of Traumatic Rotator Cuff Tears." Arthroscopy-the Journal of Arthroscopic and Related Surgery 29(2): 366-376. Purpose: The purpose of this study was to systematically review the literature to better define the epidemiology, mechanism of injury, tear characteristics, outcomes, and healing of traumatic rotator cuff tears. A secondary goal was to determine if sufficient evidence exists to recommend early surgical repair in traumatic rotator cuff tears. Methods: An independent systematic review was conducted of evidence Levels I to IV. A literature search of PubMed, Medline, Embase, and Cochrane Collaboration of Systematic Reviews was conducted, with 3 reviewers assessing studies for inclusion, methodology of individual study, and extracted data. Results: Nine studies met the inclusion and exclusion criteria. Average patient age was 54.7 (34 to 61) years, and reported mean time to surgical intervention, 66 days (3 to 48 weeks) from the time of injury. The most common mechanism of injury was fall onto an outstretched arm. Supraspinatus was involved in 84% of tears, and infraspinatus was torn in 39% of shoulders. Subscapularis tears were present in 78% of injuries. Tear size was <3 cm in 22%, 3 to >5 cm in 36%, and >5 cm in 42%. Average active forward elevation improved from 81 degrees to 150 degrees postoperatively. The weighted mean postoperative UCLA score was 30, and the Constant score was 77. Conclusions: Traumatic rotator cuff tears are more likely to occur in relatively young (age 54.7), largely male patients who suffer a fall or trauma to an abducted, externally rotated arm. These tears are typically large and involve the subscapularis, and repair results in acceptable results. However, insufficient data prevent a firm recommendation for early surgical repair. Level of Evidence: Level IV, systematic review Levels III and IV studies.

Mallon, W. J., et al. (2006). "The association of suprascapular neuropathy with massive rotator cuff tears: a preliminary report." J Shoulder Elbow Surg 15(4): 395-398. We studied a prospective, consecutive series of 8 patients presenting with massive rotator cuff tears (>5 cm. in maximum dimension), all associated with severe retraction and fatty infiltration of the supraspinatus muscle on magnetic resonance imaging studies. All 8 patients had suprascapular neuropathy shown by electromyography (EMG) findings of denervation in the supraspinatus and/or infraspinatus muscles. Clinically, all patients had severe limitation of active motion, with no patient able to elevate their affected arm actively >40 degrees . Four patients elected debridement and partial surgical repair using margin convergence principles via a mini-open approach. Follow-up of these patients averaged 24 months. All 4 patients regained the ability to elevate their affected arm to >90 degrees , and to place their hand actively behind their head without assistance. Two of the 4 surgical patients consented to follow-up EMG studies that demonstrated, in both cases, that the suprascapular nerve had significant renervation potentials, with almost complete recovery of the nerve in 1 case. We conclude that suprascapular neuropathy may be associated with massive rotator cuff tears, and that partial rotator cuff repair may allow recovery of the nerve and improvement of function.

May, D. A., et al. (2000). "Abnormal signal intensity in skeletal muscle at MR imaging: patterns, pearls, and pitfalls." Radiographics 20 Spec No: S295-315. Abnormal signal intensity within skeletal muscle is frequently encountered at magnetic resonance (MR) imaging. Potential causes are diverse, including traumatic, infectious, autoimmune, inflammatory, neoplastic, neurologic, and iatrogenic conditions. Alterations in muscle signal intensity seen in pathologic conditions usually fall into one of three recognizable patterns: muscle edema, fatty infiltration, and mass lesion. Muscle edema may be seen in polymyositis and dermatomyositis, mild injuries, infectious myositis, radiation therapy, subacute denervation, compartment syndrome, early myositis ossificans, rhabdomyolysis, and sickle cell crisis. Fatty infiltration may be seen in chronic denervation, in chronic disuse, as a late finding after a severe muscle injury or chronic tendon tear, and in corticosteroid use. The mass lesion pattern may be seen in neoplasms, intramuscular abscess, myonecrosis, traumatic injury, myositis ossificans, muscular sarcoidosis, and parasitic infection. Some of these conditions require prompt medical or surgical management, whereas others do not benefit from medical intervention. The ability to accurately diagnose these conditions is therefore necessary, and biopsy may be required to establish the correct diagnosis. Clues to the correct diagnosis and whether biopsy is necessary or appropriate are often present on the MR images, especially when they are correlated with clinical features and the findings from other imaging modalities.

McCauley, T. R., et al. (2000). "Bone marrow edema in the greater tuberosity of the humerus at MR imaging: association with rotator cuff tears and traumatic injury." Magnetic Resonance Imaging 18(8): 979-984. The purpose of this study was to determine the prevalence of bone marrow edema in the greater tuberosity of the humerus on MR imaging, the association with other findings at MR imaging and the injury mechanism which can lead to this finding. SUBJECTS AND METHODS: MR reports from 863 patients referred for shoulder MRI over 74 months were reviewed to identify patients with marrow edema in the greater tuberosity. The MR images from patients with greater tuberosity marrow edema were reviewed by consensus of two radiologists for the extent of marrow edema and for associated injuries. Marrow edema in the greater tuberosity was seen in 11 of 863 patients (1.3%). Nine patients (82%) had associated rotator cuff tear by MR imaging (four full thickness and five partial thickness), one patient had avulsion of the greater tuberosity from the humerus, and one had no rotator cuff abnormality. History of trauma was reported by eight patients including fall without direct blow to the shoulder (6), car accident (1) and direct blow to the top of the shoulder (1). Marrow edema in the greater tuberosity is an infrequent finding. Marrow edema most often is associated with a history of trauma and with rotator cuff abnormalities including full thickness tears. The history of trauma without direct blow to the shoulder and the location of the edema indicates that marrow edema often results from avulsion injury by the supraspinatus tendon.

Mélis, B., et al. (2008). "Histoire naturelle de l'infiltration graisseuse musculaire dans les ruptures de la coiffe des rotateurs." Rev Chir Orthop 94: 231S.

Melis, B., et al. (2010). "Natural history of fatty infiltration and atrophy of the supraspinatus muscle in rotator cuff tears." Clin Orthop Relat Res 468(6): 1498-1505. BACKGROUND: In some patients nonoperative treatment of a rotator cuff tear is sufficient, while in others it is only the first stage of treatment prior to surgery. Fatty infiltration progresses throughout the nonoperative treatment although it is not known at what point fatty infiltration contributes to poor functional outcomes, absence of healing, or increased rerupture rates. QUESTIONS/PURPOSES: We therefore identified factors related to the appearance of supraspinatus muscle fatty infiltration, determined the speed of appearance and progression of this phenomenon, and correlated fatty infiltration with muscular atrophy. METHODS: We retrospectively reviewed 1688 patients with rotator cuff tears and recorded the following: number of tendons torn, etiology of the tear, time between onset of shoulder symptoms and diagnosis of rotator cuff tear. Fatty infiltration of the supraspinatus was graded using either CT or MRI classification. Muscular atrophy was measured indirectly using the tangent sign. RESULTS: Moderate supraspinatus fatty infiltration appeared an average of 3 years after onset of symptoms and severe fatty infiltration at an average of 5 years after the onset of symptoms. A positive tangent sign appeared at an average of 4.5 years after the onset of symptoms. CONCLUSIONS: Our results suggest that rotator cuff repair should be performed before the appearance of fatty infiltration (Stage 2) and atrophy (positive tangent sign)-especially when the tear involves multiple tendons. LEVEL OF EVIDENCE: Level IV, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Meyer, D. C., et al. (2012). "Quantitative analysis of muscle and tendon retraction in chronic rotator cuff tears." Am J Sports Med 40(3): 606-610. BACKGROUND: Musculotendinous retraction is a limiting factor for repair of long-standing rotator cuff tears. However, it is currently unknown to what extent the muscle and tendon contribute to the degree of total retraction. Further understanding of this may possibly influence the strategy of musculotendinous reconstruction. PURPOSE: To analyze the contribution of muscle and tendon to the process of myotendinous retraction. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Magnetic resonance imaging of 130 shoulders with intact (n = 20) or completely torn supraspinatus tendons was analyzed. Fatty infiltration of the supraspinatus muscle was graded according to Goutallier stages. The degree of retraction of the tendon stump and of the musculotendinous junction was assessed. RESULTS: There were 30 shoulders without evidence of supraspinatus fatty infiltration, 25 with stage 1, 23 with stage 2, 25 with stage 3, and 15 with stage 4 changes. The corresponding tear sizes (distance of tendon end from greater tuberosity) were 4, 21, 27, 37, and 41 mm; the distance of the myotendinous junction from the greater tuberosity was 22, 33, 39, 48, and 48 mm; and the length of the tendons (distance of tendon end to myotendinous junction) was 19, 13, 12, 11, and 8 mm, respectively. In Goutallier stage 3 and above, and in case of a positive tangent sign, the musculotendinous junction was, in 90% of the cases, retracted to or beyond the glenoid. CONCLUSION: Musculotendinous retraction in chronic rotator cuff tears results mainly from shortening of the muscle fibers but in advanced stages results also from shortening of the tendon tissue itself. The present data demonstrate, for the first time, that the residual tendon stump in a tendon tear does not have the length of the original tendon and is further shortened over time. Therefore, direct anatomic tendon reinsertion will result in lengthening of the supraspinatus muscle greater than what it would have been before the tear.

Meyer, D. C., et al. (2004). "Association of osteopenia of the humeral head with full-thickness rotator cuff tears." J Shoulder Elbow Surg 13(3): 333-337. Rotator cuff tendon repair may fail for various reasons. Although the role of repair techniques and of the musculotendinous unit has been studied, there is little information on the quality of the bone to which the tendon is to be repaired. Therefore, 14 cadaveric humeral heads, 7 specimens without and 7 with a full-thickness rotator cuff tendon tear, were quantitatively assessed by use of high-resolution micro-computed tomography. Bone density is higher below the articular surface than in the greater tuberosity (40% vs 10%-20%), and tendon tears are associated with a reduction in cancellous bone density of greater than 50%, leading to a virtually hollow greater tuberosity, with intact cortical bone. The results found suggest that in long-standing rotator cuff tears, creating a deep trough should be avoided to achieve reliable tendon-to-bone contact. For optimal suture fixation to bone, sutures or anchors should be positioned subcortically or medially under the articular surface.

Meyer, D. C., et al. (2006). "Tendon retracts more than muscle in experimental chronic tears of the rotator cuff." J Bone Joint Surg Br 88(11): 1533-1538. We released the infraspinatus tendons of six sheep, allowed retraction of the musculotendinous unit over a period of 40 weeks and then performed a repair. We studied retraction of the musculotendinous unit 35 weeks later using CT, MRI and macroscopic dissection. The tendon was retracted by a mean of 4.7 cm (3.8 to 5.1) 40 weeks after release and remained at a mean of 4.2 cm (3.3 to 4.7) 35 weeks after the repair. Retraction of the muscle was only a mean of 2.7 cm (2.0 to 3.3) and 1.7 cm (1.1 to 2.2) respectively at these two points. Thus, the musculotendinous junction had shifted distally by a mean of 2.5 cm (2.0 to 2.8) relative to the tendon. Sheep muscle showed an ability to compensate for approximately 60% of the tendon retraction in a hitherto unknown fashion. Such retraction may not be a quantitatively reliable indicator of retraction of the muscle and may overestimate the need for elongation of the musculotendinous unit during repair.

Moor, B. K., et al. (2013). "Is there an association between the individual anatomy of the scapula and the development of rotator cuff tears or osteoarthritis of the glenohumeral joint?: A radiological study of the critical shoulder angle." Bone Joint J 95-B(7): 935-941. We hypothesised that a large acromial cover with an upwardly tilted glenoid fossa would be associated with degenerative rotator cuff tears (RCTs), and conversely, that a short acromion with an inferiorly inclined glenoid would be associated with glenohumeral osteoarthritis (OA). This hypothesis was tested using a new radiological parameter, the critical shoulder angle (CSA), which combines the measurements of inclination of the glenoid and the lateral extension of the acromion (the acromion index). The CSA was measured on standardised radiographs of three groups: 1) a control group of 94 asymptomatic shoulders with normal rotator cuffs and no OA; 2) a group of 102 shoulders with MRI-documented full-thickness RCTs without OA; and 3) a group of 102 shoulders with primary OA and no RCTs noted during total shoulder replacement. The mean CSA was 33.1 degrees (26.8 degrees to 38.6 degrees ) in the control group, 38.0 degrees (29.5 degrees to 43.5 degrees ) in the RCT group and 28.1 degrees (18.6 degrees to 35.8 degrees ) in the OA group. Of patients with a CSA > 35 degrees , 84% were in the RCT group and of those with a CSA < 30 degrees , 93% were in the OA group. We therefore concluded that primary glenohumeral OA is associated with significantly smaller degenerative RCTs with significantly larger CSAs than asymptomatic shoulders without these pathologies. These findings suggest that individual quantitative anatomy may imply biomechanics that are likely to induce specific types of degenerative joint disorders.

Moor, B. K., et al. (2014). "Age, trauma and the critical shoulder angle accurately predict supraspinatus tendon tears." Orthop Traumatol Surg Res 100(5): 489-494. BACKGROUND: The pathogenesis of full-thickness tears of the rotator cuff remains unclear. Apart from age and trauma, distinct scapular morphologies have been found to be associated with rotator cuff disease. The purpose of the present study was to evaluate whether a score formed using these established risk factors was able to predict the presence of a rotator cuff tear reliably. METHODS: We retrospectively assessed a consecutive series of patients with a minimal age of 40 years old, who had true antero-posterior (AP) radiographs of their shoulders, as well as a magnetic resonance (MR) gadolinium-arthrography, between January and December 2011. In all of these patients, the critical shoulder angle (CSA) was determined, and MR images were assessed for the presence of rotator cuff tears. Additionally, the patients' charts were reviewed to obtain details of symptom onset. Based on these factors, the so-called rotator cuff tear (RCT) score was calculated. RESULTS: Patients with full-thickness RCTs were significantly older and had significantly larger CSAs than patients with intact rotator cuffs. Multiple logistic regression, using trauma, age and CSA as independent variables, revealed areas under the curve (AUCs) for trauma of 0.55, for age of 0.65 and for CSA of 0.86. The combination of all three factors was the most powerful predictor, with an AUC of 0.92. CONCLUSION: Age, trauma and the CSA can accurately predict the presence of a posterosuperior RCT. LEVEL OF EVIDENCE: Level IV. Case series with no comparison groups.

Moor, B. K., et al. (2014). "Relationship of individual scapular anatomy and degenerative rotator cuff tears." J Shoulder Elbow Surg 23(4): 536-541. BACKGROUND: The etiology of rotator cuff disease is age related, as documented by prevalence data. Despite conflicting results, growing evidence suggests that distinct scapular morphologies may accelerate the underlying degenerative process. The purpose of the present study was to evaluate the predictive power of 5 commonly used radiologic parameters of scapular morphology to discriminate between patients with intact rotator cuff tendons and those with torn rotator cuff tendons. METHODS: A pre hoc power analysis was performed to determine the sample size. Two independent readers measured the acromion index, lateral acromion angle, and critical shoulder angle on standardized anteroposterior radiographs. In addition, the acromial morphology according to Bigliani and the acromial slope were determined on true outlet views. Measurements were performed in 51 consecutive patients with documented degenerative rotator cuff tears and in an age- and sex-matched control group of 51 patients with intact rotator cuff tendons. Receiver operating characteristic analyses were performed to determine cutoff values and to assess the sensitivity and specificity of each parameter. RESULTS: Patients with degenerative rotator cuff tears demonstrated significantly higher acromion indices, smaller lateral acromion angles, and larger critical shoulder angles than patients with intact rotator cuffs. However, no difference was found between the acromial morphology according to Bigliani and the acromial slope. With an area under the receiver operating characteristic curve of 0.855 and an odds ratio of 10.8, the critical shoulder angle represented the strongest predictor for the presence of a rotator cuff tear. CONCLUSION: The acromion index, lateral acromion angle, and critical shoulder angle accurately predict the presence of degenerative rotator cuff tears.

Moosmayer, S., et al. (2009). "Prevalence and characteristics of asymptomatic tears of the rotator cuff: an ultrasonographic and clinical study." J Bone Joint Surg Br 91(2): 196-200. We undertook clinical and ultrasonographic examination of the shoulders of 420 asymptomatic volunteers aged between 50 and 79 years. MRI was performed in selected cases. Full-thickness tears of the rotator cuff were detected in 32 subjects (7.6%). The prevalence increased with age as follows: 50 to 59 years, 2.1%; 60 to 69 years, 5.7%; and 70 to 79 years, 15%. The mean size of the tear was less than 3 cm and tear localisation was limited to the supraspinatus tendon in most cases (78%). The strength of flexion was reduced significantly in the group with tears (p = 0.01). Asymptomatic tears of the rotator cuff should be regarded as part of the normal ageing process in the elderly but may be less common than hitherto believed.

Namdari, S., et al. (2008). "Traumatic anterosuperior rotator cuff tears: The outcome of open surgical repair." Journal of Bone and Joint Surgery-American Volume 90A(9): 1906-1913. Background: Anterosuperior rotator cuff tears involving the subscapularis and supraspinatus tendons are less common than posterosuperior tears and are rarely discussed in the literature. The purpose of this study was to identify the unique features of this injury and to assess the outcome of operative treatment. Methods: Thirty consecutive patients, with a mean age of fifty-seven years (range, forty-three to seventy-three years), had an open repair of a traumatic anterosuperior rotator cuff tear. Twenty-four patients (80%) were male. Sixteen patients (53%) had involvement of the dominant shoulder, twenty-three (77%) had a biceps tendon disorder, and sixteen (53%) had a positive liftoff maneuver prior to surgery. Surgical approaches included an isolated superior deltoid-splitting approach in twenty patients, an isolated deltopectoral approach in five patients, and a combined approach in five patients. Open repair was performed at a mean of 4.5 months after the injury or the onset of symptoms. The final outcomes were determined with a physical examination and patient self-assessed outcome tools. Results: At a mean follow-up of fifty-six months, twenty-one of the thirty patients were satisfied with their symptoms, and twenty-nine would have the surgery again. The mean pain score on the visual analog scale improved from 6.2 to 1.2 (p < 0.001). The mean score on the Disabilities of the Arm, Shoulder and Hand questionnaire improved from 41.7 to 12.2 (p < 0.001). The mean percentage of functions that patients were able to perform on the Simple Shoulder Test improved from 36.4% to 82.8% (p < 0.001). The mean age and sex-adjusted Constant score was 93.4 postoperatively. The mean elevation, external rotation, and internal rotation of the involved shoulders were 97%, 109%, and 97%, respectively, of those of the contralateral side. The mean strength of elevation, external rotation, and internal rotation were 85%, 93%, and 101%, respectively, of those of the contralateral side. Infraspinatus involvement (p = 0.04), the extent of the supraspinatus tear (p = 0.03), and a Workers' Compensation claim (p = 0.03) were associated with worse outcomes and decreased satisfaction. Conclusions: Patients with a traumatic anterosuperior rotator cuff tear present with internal rotation weakness, and they usually have a biceps tendon disorder. While larger tears involving greater portions of the supraspinatus and extending into the infraspinatus are associated with poorer outcomes, early recognition of this injury and open repair can reliably restore shoulder function to near normal levels.

Needell, S. D., et al. (1996). "MR imaging of the rotator cuff: peritendinous and bone abnormalities in an asymptomatic population." AJR Am J Roentgenol 166(4): 863-867. OBJECTIVE: MR imaging of the shoulder was performed in an asymptomatic population to determine the prevalence of MR-evident peritendinous and bone abnormalities. Findings were correlated with subject age and rotator cuff abnormalities. SUBJECTS AND METHODS: Dual-echo T2-weighted oblique coronal MR images of the shoulder were evaluated for 100 asymptomatic volunteers who were 19-88 years old. Twenty symptomatic patients with arthroscopic correlation were included as controls. Images were assessed independently by two reviewers with no knowledge of subject history or symptomatology. Bursal, peribursal, and bone findings were correlated with subject age and the appearance of the rotator cuff tendon. RESULTS: Changes characteristic of acromioclavicular joint osteoarthrosis were present in three fourths of the shoulders. One third had subacromial spurs. Changes in the peribursal fat plane and the presence of fluid in the subacromial-subdeltoid bursa paralleled the degree of MR-evident rotator cuff abnormalities. Joint fluid was observed in nearly all subjects. CONCLUSION: Our findings reveal a high prevalence of MR-evident bone and peritendinous shoulder abnormalities among asymptomatic individuals. The prevalence of subacromial spurs and humeral head cysts correlated closely with the severity of MR-evident rotator cuff abnormalities, as did changes in the bursa and peribursal fat. Acromioclavicular joint osteoarthrosis is seen in many shoulders independently of rotator cuff disease; therefore, its presence alone does not appear to be a reliable indicator of pain or tendon disease.

Neer, C. S., 2nd (1972). "Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report." J Bone Joint Surg Am 54(1): 41-50.

Neer, C. S., 2nd, et al. (1983). "Cuff-tear arthropathy." J Bone Joint Surg Am 65(9): 1232-1244. In this report we describe the clinical and pathological findings of cuff-tear arthropathy in twenty-six patients and discuss the differential diagnosis and a hypothesis on the pathomechanics that lead to its development. This lesion is thought to be peculiar to the glenohumeral joint because of the unique anatomy of the rotator cuff. Following a massive tear of the rotator cuff there is inactivity and disuse of the shoulder, leaking of the synovial fluid, and instability of the humeral head. These events in turn result in both nutritional and mechanical factors that cause atrophy of the glenohumeral articular cartilage and osteoporosis of the subchondral bone of the humeral head. A massive tear also allows the humeral head to be displaced upward, causing subacromial impingement that in time erodes the anterior portion of the acromion and the acromioclavicular joint. Eventually the soft, atrophic head collapses, producing the complete syndrome of cuff-tear arthropathy. The incongruous head may eventually erode the glenoid so deeply that the coracoid becomes eroded as well. Although treatment of cuff-tear arthropathy is extremely difficult, the preferred method appears to be a resurfacing total shoulder replacement with rotator-cuff reconstruction and special rehabilitation. We think that it is important to recognize cuff-tear arthropathy as a distinct pathological entity, as such recognition enhances our understanding of the more common impingement lesions. Cuff-tear arthropathy is especially difficult to treat, and although many tears of the rotator cuff do not enlarge sufficiently to allow this condition to develop, it is a factor to consider when deciding whether or not a documented tear of the rotator cuff should be surgically repaired.

Nove-Josserand, L., et al. (2005). "The acromiohumeral and coracohumeral intervals are abnormal in rotator cuff tears with muscular fatty degeneration." Clin Orthop Relat Res(433): 90-96. We sought to determine how various types of full-thickness rotator cuff tears, fatty degeneration of the rotator cuff muscles, duration of symptoms, and mechanism of injury affect the sizes of the acromiohumeral and coracohumeral intervals. We studied 206 shoulders with rotator cuff tears that had surgical treatment. The acromiohumeral interval (anteroposterior radiograph) and the coracohumeral interval (computed tomogram) were measured on preoperative imaging studies. An abnormal acromiohumeral interval was associated with multiple-tendon rotator cuff tears involving the infraspinatus, fatty degeneration of the supraspinatus or infraspinatus, and duration of symptoms longer than 5 years. An abnormal coracohumeral interval was associated with a combined tear of the supraspinatus and subscapularis and fatty degeneration of the infraspinatus or subscapularis. Fatty degeneration of the infraspinatus therefore was associated with an abnormal acromiohumeral interval and an abnormal coracohumeral interval. Evaluation of a patient who has a diminished acromiohumeral or coracohumeral interval should involve examination with computed tomography or magnetic resonance imaging of the rotator cuff tendons to determine the type of tear and of the rotator cuff muscles to determine the degree of fatty degeneration. LEVEL OF EVIDENCE: Diagnostic study, Level II-1 (development of diagnostic criteria on basis of consecutive patients--with universally applied reference "gold" standard). See the Guidelines for Authors for a complete description of levels of evidence.

Nyffeler, R. W., et al. (2006). "Association of a large lateral extension of the acromion with rotator cuff tears." J Bone Joint Surg Am 88(4): 800-805. BACKGROUND: Factors predisposing to tearing of the rotator cuff are poorly understood. We have observed that the acromion of patients with a rotator cuff tear very often appears large on anteroposterior radiographs or during surgery. The purpose of this study was to quantify the lateral extension of the acromion in patients with a full-thickness rotator cuff tear and in patients with an intact rotator cuff. METHODS: The lateral extension of the acromion was assessed on true anteroposterior radiographs made with the arm in neutral rotation. The distance from the glenoid plane to the lateral border of the acromion was divided by the distance from the glenoid plane to the lateral aspect of the humeral head to calculate the acromion index. This index was determined in a group of 102 patients (average age, 65.0 years) with a proven full-thickness rotator cuff tear, in an age and gender-matched group of forty-seven patients (average age, 63.7 years) with osteoarthritis of the shoulder and an intact rotator cuff, and in an age and gender-matched control group of seventy volunteers (average age, 64.4 years) with an intact rotator cuff as demonstrated by ultrasonography. RESULTS: The average acromion index (and standard deviation) was 0.73 +/- 0.06 in the shoulders with a full-thickness tear, 0.60 +/- 0.08 in those with osteoarthritis and an intact rotator cuff, and 0.64 +/- 0.06 in the asymptomatic, normal shoulders with an intact rotator cuff. The difference between the index in the shoulders with a full-thickness supraspinatus tear and the index in those with an intact rotator cuff was highly significant (p < 0.0001). CONCLUSIONS: A large lateral extension of the acromion appears to be associated with full-thickness tearing of the rotator cuff.

Oliva, F., et al. (2014). "Epidemiology of the rotator cuff tears: a new incidence related to thyroid disease." Muscles Ligaments Tendons J 4(3): 309-314. BACKGROUND: in the last years the incidence of rotator cuff tears increased and one main cause still waiting to be clarified. Receptors for thyroid hormones in rotator cuff tendons suggest possible effects on tendons metabolism and status. We undertook a retrospective, observational cohort study of 441 patients who underwent arthroscopic and mini-open repair for non traumatic degenerative rotator cuff tears. METHODS: all the patients, predominantly females (63%), were interview to assess the relationship (frequency for class age "20 yrs" and factor analysis) between lesions of the rotator cuff with the following variables: gender, thyroid disease, smoker, taking medications for diabetes, hypertension or high cholesterol; presence of associated conditions (diabetes, hypertension, hypercholesterolemia). RESULTS: thyroid disease is highly frequently (until 63% for 60<80 yrs) in females group independent to the age. Conversely, males showed a high frequency for smoker 37<62% until 80 yrs and 50% hypercholesterolemia over 80 yrs for the clinical variable studied. CONCLUSIONS: this is the first clinical report that shown a relationship between thyroid pathologies and non-traumatic rotator cuff tear as increased risk factors.

Ouellette, H., et al. (2007). "Re-examining the association of os acromiale with supraspinatus and infraspinatus tears." Skeletal Radiol 36(9): 835-839. PURPOSE: To re-evaluate the relationship between os acromiale and rotator cuff tears. METHODS: We retrospectively analyzed 84 magnetic resonance imaging studies of the shoulder. Forty-two subjects with os acromiale (n = 42; 32 men and ten women, age 25-81 years, mean 47.6 years) were compared with age- and gender-matched subjects with no evidence of os acromiale (controls). Arthroscopy data were available in 19 os acromiale and 12 control subjects. Statistical analyses were performed to determine differences between groups regarding rotator cuff tears affecting the supraspinatus and infraspinatus tendons detected by magnetic resonance imaging and arthroscopy. Analysis of os acromiale type, ossicle synchondrosis edema, acromioclavicular joint degenerative changes and step-off deformity at the synchondrosis were tabulated. RESULTS: No statistically significant difference between the os acromiale and control groups was noted, either on magnetic resonance imaging or arthroscopy, with regard to tears of the supraspinatus (P = 1.000 and 0.981, respectively) and infraspinatus (P = 1.000 and 0.667, respectively) tendons. There was a statistically significant increased number of supraspinatus (P = 0.007) and infraspinatus (P = 0.03) tears in a comparison of subjects with os acromiale and step-off deformity (10/42) vs os acromiale without step-off deformity (32/42). CONCLUSION: The presence of os acromiale may not significantly predispose to supraspinatus and infraspinatus tendon tears. However, subjects with step-off deformity of an os acromiale are at greater risk of rotator cuff tears than are similar subjects without such deformity.

Passaretti, D., et al. (2016). "Association between alcohol consumption and rotator cuff tear." Acta Orthop 87(2): 165-168. BACKGROUND AND PURPOSE: Long-term alcohol intake is associated with various negative effects on capillary microcirculation and tissue perfusion. We hypothesized that alcohol consumption might be a risk factor for both the occurrence and the severity of rotator cuff tears (RCTs). PATIENTS AND METHODS: A case-control study was performed. We studied 249 consecutive patients (139 men and 110 women; mean age 64 (54-78) years) who underwent arthroscopic rotator cuff repair. Tear size was determined intraoperatively. The control group had 356 subjects (186 men and 170 women; mean age 66 (58-82) years) with no RCT. All participants were questioned about their alcohol intake. Participants were divided into: (1) non-drinkers if they consumed less than 0.01 g of ethanol per day, and (2) moderate drinkers and (3) excessive drinkers if women (men) consumed > 24 g (36 g) per day for at least 2 years. RESULTS: Total alcohol consumption, wine consumption, and duration of alcohol intake were higher in both men and women with RCT than in both men and women in the control group. Excessive alcohol consumption was found to be a risk factor for the occurrence of RCT in both sexes (men: OR = 1.7, 95% CI: 1.2-3.9; women: OR = 1.9, 95% CI: 0.94-4.1). Massive tears were associated with a higher intake of alcohol (especially wine) than smaller lesions. INTERPRETATION: Long-term alcohol intake is a significant risk factor for the occurrence and severity of rotator cuff tear in both sexes.

Patte, D. (1990). "Classification of rotator cuff lesions." Clin Orthop Relat Res(254): 81-86. Among various studies reporting the outcome of surgical repairs of rotator cuff tears, comparisons are very difficult because of the absence of a classification system. A proposed classification system takes into account the extent of the tear, its topography in the sagittal and frontal planes, the trophic quality of the muscle, and the integrity of the long head of the biceps. The new classification system exploits the advances in diagnostic imaging and is useful in the assessment of nonoperatively treated patients.

Petersen, S. A. and T. P. Murphy (2011). "The timing of rotator cuff repair for the restoration of function." J Shoulder Elbow Surg 20(1): 62-68. INTRODUCTION: This study was developed to test the hypothesis that there is a period in which a painful, traumatic rotator cuff tear, with associated weakness and the inability to abduct above shoulder level, should be repaired to allow for improvement in function. METHODS: Forty-two consecutive, prospectively followed patients met the criteria for entrance into this study. Of those, 36 patients were available for a minimum 9 months follow-up (average, 31 months; range, 9-71) by office visit. Patient outcomes were measured using the UCLA End-Result and ASES scoring systems. Patient variables, including time from injury to repair, tear size, degree of preoperative fat infiltration, patient satisfaction, and improvement in pain, were evaluated for their association with surgical outcome using independent t testing. Time to repair was evaluated at 0-2 months, 2-4 months, and greater than 4 months. RESULTS: Pain scores improved from 7 to 1.4 (P < .01) and active elevation improved from 55 degrees to 133 degrees (P < .01). UCLA/ASES scores improved from 8/30 to 26/79, respectively (P < .01, P < .01). All but 2 of the 36 patients were satisfied with their result. Preoperative fatty atrophy did not correlate with postoperative function. Rotator cuff tear size had no influence on patient outcome if repaired before 4 months. Massive tears repaired after 4 months had the worst outcome. CONCLUSION: Our results emphasize that the treatment outcome for traumatic rotator cuff tears of all sizes, with associated weakness, is not compromised up to 4 months after their injury.

Saupe, N., et al. (2006). "Association between rotator cuff abnormalities and reduced acromiohumeral distance." AJR Am J Roentgenol 187(2): 376-382. OBJECTIVE: The purpose of this study was to evaluate the association between rotator cuff abnormalities and reduced acromiohumeral distance. MATERIALS AND METHODS: Acromiohumeral distance was measured on conventional radiographs and on MR images. Three age- and sex-matched patient groups each including 21 patients were stratified according to acromiohumeral distance on conventional radiographs (group 1, <or= 7 mm; group 2, 8-10 mm; group 3, > 10 mm). Acromiohumeral distance was related to the presence, location, and size of a rotator cuff tear and the degree of fatty degeneration of the muscle assessed on MR arthrography. The relative influence on acromiohumeral distance of the various MR arthrographic findings was assessed. Spearman's rank correlation and stepwise regression were used for statistical analysis. RESULTS: In group 1 (acromiohumeral distance <or= 7 mm) full-thickness supraspinatus tendon tears were present in 90% (19/21) of the patients, infraspinatus tendon tears in 67% (14/21) of the patients, and subscapularis tendon tears in 43% (9/21) of the patients. The size of rotator cuff tendon tears and the degree of fatty degeneration in all rotator cuff muscles showed a significant negative correlation with acromiohumeral distance (p < 0.05). After stepwise regression, a significant relative influence on acromiohumeral distance remained for size of rotator cuff tear (p < 0.0001) and for degree of fatty degeneration of the infraspinatus muscle (p = 0.013). CONCLUSION: Tendon tears and fatty muscle degeneration in the rotator cuff correlate with reduced acromiohumeral distance. Size of rotator cuff tear and degree of fatty degeneration of the infraspinatus muscle have the most pronounced influence on acromiohumeral distance.

Simank, H. G., et al. (2006). "Incidence of rotator cuff tears in shoulder dislocations and results of therapy in older patients." Arch Orthop Trauma Surg 126(4): 235-240. INTRODUCTION: In older patients we documented the incidence of additional injuries in shoulder dislocations in a non-randomised, prospective study and compared the results of conservative and of operative therapy of rotator cuff tears. MATERIAL AND METHODS: Between 1993 and 1999 a total of 87 patients were prospectively enrolled. In the case of documented tears of the rotator cuff in combination with symptoms persisting after conservative therapy patients were free to decide between surgical and conservative treatment. Patients were monitored for function, subjective stability, and satisfaction over a minimum follow-up period of 1 year. RESULTS: In 54% of the patients enrolled a cuff tear was documented; the frequency increased with advancing age to 100% in patients over the age of 70. Surgical treatment of the cuff tears resulted in better function and satisfaction. There were three recurrences in the conservative treatment group, while no recurrences were documented in surgically treated patients. The significant benefit of cuff repair was confirmed by regression analysis. CONCLUSION: In this selected patient group, we believe surgical repair of the symptomatic rotator cuff tear should be discussed with the patient.

Tan, M., et al. (2016). "Trauma versus no trauma: an analysis of the effect of tear mechanism on tendon healing in 1300 consecutive patients after arthroscopic rotator cuff repair." J Shoulder Elbow Surg 25(1): 12-21. BACKGROUND: Patients with rotator cuff tears often recall a specific initiating event (traumatic), whereas many cannot (nontraumatic). It is unclear how important a history of trauma is to the outcomes of rotator cuff repair. METHODS: This question was addressed in a study cohort of 1300 consecutive patients who completed a preoperative questionnaire regarding their shoulder injury and had a systematic evaluation of shoulder range of motion and strength, a primary arthroscopic rotator cuff repair performed by a single surgeon, an ultrasound scan, and the same subjective and objective measurements made of their shoulder 6 months after surgery. Post hoc, this cohort was separated into 2 groups: those who reported no history of trauma on presentation (n = 489) and those with a history of traumatic injury (n = 811). RESULTS: The retear rate in the group with no history of trauma was 12%, whereas that of the group with a history of trauma was 14% (P = .36). Those patients with a history of shoulder trauma who waited longer than 24 months had higher retear rates (20%) than those who had their surgery earlier (13%) (P = .040). CONCLUSION: Recollection of a traumatic initiating event had little effect on the outcome of arthroscopic rotator cuff repair. Duration of symptoms was important in predicting retears if patients recalled a specific initiating event but not in patients who did not recall any specific initiating event. Patients with a history of trauma should be encouraged to have their rotator cuff tear repaired within 2 years.

Teefey, S. A., et al. (2000). "Sonographic differences in the appearance of acute and chronic full-thickness rotator cuff tears." J Ultrasound Med 19(6): 377-378; quiz 383. This study was undertaken to identify differences in the sonographic appearance of acute and chronic full-thickness rotator cuff tears. The ultrasonograms of 24 patients with an acute rotator cuff tear and 20 with a chronic tear were reviewed for tear size (width), location, and the presence and distribution of fluid. Among these 24 patients, 75% with a midsubstance tear location had an acute tear; 64% of patients with joint or bursal fluid had an acute tear; 80% of patients with a nonvisualized rotator cuff due to a massive tear had a chronic tear; and 73% of patients with no sonographic evidence of bursal or joint fluid had a chronic tear. In conclusion, a midsubstance location and the presence of joint or bursal fluid were more commonly associated with an acute tear. A nonvisualized cuff and the absence of joint and bursal fluid were more commonly observed with a chronic tear.

Teunis, T., et al. (2014). "A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age." J Shoulder Elbow Surg 23(12): 1913-1921. UNLABELLED: Hypothesis and background: Abnormalities of the rotator cuff are more common with age, but the exact prevalence of abnormalities and the extent to which the presence of an abnormality is associated with symptoms are topics of debate. Our aim was to review the published literature to establish the prevalence of abnormalities of the rotator cuff and to determine if the prevalence of abnormalities increases with older age in 10-year intervals. In addition, we assessed prevalence in 4 separate groups: (1) asymptomatic patients, (2) general population, (3) symptomatic patients, and (4) patients after shoulder dislocation. METHODS: We searched PubMed, EMBASE, and the Cochrane Library up to February 24, 2014, and included studies reporting rotator cuff abnormalities by age. Thirty studies including 6112 shoulders met our criteria. We pooled the individual patient data and calculated proportions of patients with and without abnormalities per decade (range, younger than 20 years to 80 years and older). RESULTS: Overall prevalence of abnormalities increased with age, from 9.7% (29 of 299) in patients aged 20 years and younger to 62% (166 of 268) in patients aged 80 years and older (P < .001) (odds ratio, 15; 95% confidence interval, 9.6-24; P < .001). There was a similar increasing prevalence of abnormalities regardless of symptoms or shoulder dislocation. DISCUSSION AND CONCLUSION: The prevalence of rotator cuff abnormalities in asymptomatic people is high enough for degeneration of the rotator cuff to be considered a common aspect of normal human aging and to make it difficult to determine when an abnormality is new (e.g., after a dislocation) or is the cause of symptoms.

Williams, M., et al. (2006). "Humeral head cysts and rotator cuff tears: an MR arthrographic study." Skeletal Radiol 35(12): 909-914. OBJECTIVE: Humeral tuberosity cysts are a common finding, with previous reports suggesting they are related to rotator cuff tear or aging. The aim of this study was to investigate the characteristics of cysts in the tuberosities of the humeral head and their relationship with rotator cuff tear and age. DESIGN AND PATIENTS: Shoulder MR arthrograms were reviewed in 120 consecutive patients-83 males (mean age 38.0, range 19-59 years) and 37 females (mean age 41.2, range 15-59 years). Patients were referred for investigation of a variety of conditions, and instability was suspected in only a minority of cases. MR was performed before and after direct arthrography with 0.01% solution of gadolinium. Cysts were defined as well-demarcated circular/ovoid foci in two planes that demonstrated high signal on pre-arthrographic T2W sequences. Location, size and numbers of cysts and post-arthrographic enhancement were documented, along with the location of rotator cuff tears, if present. RESULTS: Cysts in the tuberosities of the humerus were identified in 84 patients (70%), and were seen seven times more frequently in the posterior aspect of the greater tuberosity than anteriorly. Most cysts (94%) demonstrated communication with the joint post-arthrogram. Rotator cuff tears were present in 36 patients, and 79% of all tears occurred in supraspinatus tendon. There was no significant difference in the occurrence of cysts between patients older or younger than age 40 or between genders, but rotator cuff tears were seen significantly more often in the older age group (p<0.01). Tuberosity cysts and rotator cuff tears did not appear to be related (p=0.55). However, whilst this lack of association was quite obvious posteriorly (p=0.84), the trend in the anterior aspect of the greater tuberosity is not as clear (p=0.14). CONCLUSIONS: Humeral cysts are most often located in the posterior aspect of the greater tuberosity, communicate with the joint space and, in this location, are not related to aging or rotator cuff tear.

Williams, M. D., et al. (2009). "Fatty infiltration of the supraspinatus: a reliability study." J Shoulder Elbow Surg 18(4): 581-587. BACKGROUND: The Goutallier classification of rotator cuff fatty infiltration is an accepted standard, yet no recommendations exist for which computed tomography plane is best to identify fatty infiltration of the supraspinatus. Our purpose was to determine the most reliable plane to evaluate supraspinatus fatty infiltration, assess reliability of the tangent sign, and to correlate fatty infiltration and muscle atrophy. METHODS: Fatty infiltration in 87 computed tomography scans was reviewed by 3 shoulder surgeons using the 5-tiered Goutallier classification and a separate 3-grade scale. The supraspinatus muscle was evaluated in the axial, coronal, and sagittal plane. The tangent sign was used to assess muscle atrophy. RESULTS: The axial plane produced the highest agreement for both the 5-tiered and 3-tiered systems. An objective radiographic marker was described to reliably determine grade 3 fatty infiltration. The tangent sign produced excellent agreement for the presence of muscle atrophy. A significant relationship between the tangent sign and fatty infiltration was discovered (P < .0001); grades 3 and 4 fatty infiltration correlated statistically with supraspinatus atrophy. CONCLUSION: The tangent sign is acceptable for determining the presence of muscle atrophy and clinical decision making. A positive tangent sign is an indicator of advanced fatty infiltration. The axial computed tomography plane should be used when evaluating fatty infiltration. LEVEL OF EVIDENCE: Level 3; Diagnostic study.

Wolff, J. (1892). Das Gesetz der Transformation der Knochen. Berlin, Hirschwald Verlag.

Yamamoto, A., et al. (2010). "Prevalence and risk factors of a rotator cuff tear in the general population." J Shoulder Elbow Surg 19(1): 116-120. BACKGROUND: Little information is available about the epidemiology of rotator cuff tears in a population-based study. The purpose of this study was to elucidate the true prevalence of rotator cuff tears regardless of the presence or absence of symptoms in the general population and to assess the relationship between tears and their backgrounds. MATERIAL AND METHODS: A medical check-up was conducted for residents of a mountain village in Japan. The subjects consisted of 683 people (total of 1,366 shoulders), including 229 males and 454 females with a mean age of 57.9 years (range, 22-87). We examined their background factors, physical examinations and ultrasonographic examinations on both shoulders. RESULTS: Rotator cuff tears were present in 20.7% and the prevalence increased with age. Thirty-six percent of the subjects with current symptoms had rotator cuff tears, while 16.9% of the subjects without symptoms also had rotator cuff tears. Rotator cuff tears in the general population were most commonly associated with elderly patients, males, affected the dominant arm, engaged in heavy labor, having a history of trauma, positive for impingement sign, showed lesser active forward elevation and weaker muscle strength in abduction and external rotation. A logistic regression analysis revealed the risk factors for a rotator cuff tear to be a history of trauma, dominant arm and age. CONCLUSION: 20.7% of 1,366 shoulders had full-thickness rotator cuff tears in the general population. The risk factors for rotator cuff tear included a history of trauma, dominant arm and age. LEVEL OF EVIDENCE: Level 3.

Zanetti, M., et al. (1998). "MR abnormalities in patients suspected of having acute traumatic rotator cuff tears: Greater tuberosity fractures and subscapularis tendon tears are common." Radiology 209P: 343-343.

Zbojniewicz, A. M., et al. (2014). "Rotator cuff tears in children and adolescents: experience at a large pediatric hospital." Pediatr Radiol 44(6): 729-737. BACKGROUND: Prior literature, limited to small case series and case reports, suggests that rotator cuff tears are rare in adolescents. However, we have identified rotator cuff tears in numerous children and adolescents who have undergone shoulder MRI evaluation. OBJECTIVE: The purpose of this study is to describe the prevalence and characteristics of rotator cuff tears in children and adolescents referred for MRI evaluation of the shoulder at a large pediatric hospital and to correlate the presence of rotator cuff tears with concurrent labral pathology, skeletal maturity and patient activity and outcomes. MATERIALS AND METHODS: We reviewed reports from 455 consecutive non-contrast MRI and magnetic resonance arthrogram examinations of the shoulder performed during a 2-year period, and following exclusions we yielded 205 examinations in 201 patients (ages 8-18 years; 75 girls, 126 boys). Rotator cuff tears were classified by tendon involved, tear thickness (partial or full), surface and location of tear (when partial) and presence of delamination. We recorded concurrent labral pathology when present. Physeal patency of the proximal humerus was considered open, closing or closed. Statistical analysis was performed to evaluate for a relationship between rotator cuff tears and degree of physeal patency. We obtained patient activity at the time of injury, surgical reports and outcomes from clinical records when available. RESULTS: Twenty-five (12.2%) rotator cuff tears were identified in 17 boys and 7 girls (ages 10-18 years; one patient had bilateral tears). The supraspinatus tendon was most frequently involved (56%). There were 2 full-thickness and 23 partial-thickness tears with articular-side partial-thickness tears most frequent (78%). Insertional partial-thickness tears were more common (78%) than critical zone tears (22%) and 10 (43%) partial-thickness tears were delamination tears. Nine (36%) patients with rotator cuff tears had concurrent labral pathology. There was no statistically significant relationship between rotator cuff tears and physeal patency (P > 0.05). Most patients were athletes (76%). Five tears were confirmed at surgery. Poor clinical follow-up limited evaluation of patient outcomes. CONCLUSION: Rotator cuff tears can be identified during MRI examination of symptomatic child and adolescent shoulders and often consist of tear patterns associated with repetitive microtrauma in overhead athletic activities or with single traumatic events. Rotator cuff tears are seen throughout the range of skeletal maturity, often coexist with labral tears and typically are found in athletes.

Zingg, P. O., et al. (2007). "Clinical and structural outcomes of nonoperative management of massive rotator cuff tears." J Bone Joint Surg Am 89(9): 1928-1934. BACKGROUND: The natural history of massive rotator cuff tears is not well known. The purpose of this study was to determine the clinical and structural mid-term outcomes in a series of nonoperatively managed massive rotator cuff tears. METHODS: Nineteen consecutive patients (twelve men and seven women; average age, sixty-four years) with a massive rotator cuff tear, documented by magnetic resonance imaging, were identified retrospectively. There were six complete tears of two rotator cuff tendons and thirteen complete tears of three rotator cuff tendons. All patients were managed exclusively with nonoperative means. Nonoperative management was chosen when a patient had low functional demands and relatively few symptoms and/or if he or she refused to have surgery. For the purpose of this study, patients were examined clinically and with standard radiographs and magnetic resonance imaging. RESULTS: After a mean duration of follow-up of forty-eight months, the mean relative Constant score was 83% and the mean subjective shoulder value was 68%. The score for pain averaged 11.5 points on a 0 to 15-point visual analogue scale in which 15 points represented no pain. The active range of motion did not change over time. Forward flexion and abduction averaged 136 degrees; external rotation, 39 degrees; and internal rotation, 66 degrees. Glenohumeral osteoarthritis progressed (p = 0.014), the acromiohumeral distance decreased (p = 0.005), the size of the tendon tear increased (p = 0.003), and fatty infiltration increased by approximately one stage in all three muscles (p = 0.001). Patients with a three-tendon tear showed more progression of osteoarthritis (p = 0.01) than did patients with a two-tendon tear. Four of the eight rotator cuff tears that were graded as reparable at the time of the diagnosis became irreparable at the time of final follow-up. CONCLUSIONS: Patients with a nonoperatively managed, moderately symptomatic massive rotator cuff tear can maintain satisfactory shoulder function for at least four years despite significant progression of degenerative structural joint changes. There is a risk of a reparable tear progressing to an irreparable tear within four years.

Zumstein, M. A., et al. (2008). "The clinical and structural long-term results of open repair of massive tears of the rotator cuff." J Bone Joint Surg Am 90(11): 2423-2431. BACKGROUND: At a mean follow-up of 3.1 years, twenty-seven consecutive repairs of massive rotator cuff tears yielded good and excellent clinical results despite a retear rate of 37%. Patients with a retear had improvement over the preoperative state, but those with a structurally intact repair had a substantially better result. The purpose of this study was to reassess the same patients to determine the long-term functional and structural results. METHODS: At a mean follow-up interval of 9.9 years, twenty-three of the twenty-seven patients returned for a review and were examined clinically, radiographically, and with magnetic resonance imaging with use of a methodology identical to that used at 3.1 years. RESULTS: Twenty-two of the twenty-three patients remained very satisfied or satisfied with the result. The mean subjective shoulder value was 82% (compared with 80% at 3.1 years). The mean relative Constant score was 85% (compared with 83% at 3.1 years). The retear rate was 57% at 9.9 years (compared with 37% at 3.1 years; p = 0.168). Patients with an intact repair had a better result than those with a failed reconstruction with respect to the mean absolute Constant score (81 compared with 64 points, respectively; p = 0.015), mean relative Constant score (95% and 77%; p = 0.002), and mean strength of abduction (5.5 and 2.6 kg; p = 0.007). The mean retear size had increased from 882 to 1164 mm(2) (p = 0.016). Supraspinatus and infraspinatus muscle fatty infiltration had increased (p = 0.004 and 0.008, respectively). Muscles with torn tendons preoperatively showed more fatty infiltration than muscles with intact tendons preoperatively, regardless of repair integrity. Shoulders with a retear had a significantly higher mean acromion index than those without retear (0.75 and 0.65, respectively; p = 0.004). CONCLUSIONS: Open repair of massive rotator cuff tears yielded clinically durable, excellent results with high patient satisfaction at a mean of almost ten years postoperatively. Conversely, fatty muscle infiltration of the supraspinatus and infraspinatus progressed, and the retear size increased over time. The preoperative integrity of the tendon appeared to be protective against muscle deterioration. A wide lateral extension of the acromion was identified as a previously unknown risk factor for retearing.

Shoulder:Rotator Cuff Pathology/Thickness Rotator Cuff Tears/Traumatic versus degenerative tears

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