CHAPTER 45 • ROTATOR CUFF PATHOLOGY 271ROM is restored and lower cuff strength is sufficient
to allow overhead motion without pain.- Most patients’ symptoms resolve with this program.
Injections are usually limited to three, but each
patient treatment is individualized. Many practition-
ers are concerned about the effects of corticos-
teroids on the damaged tendon and either forego this
step or limit the number of injections. Patients who
have developed subacromial spurs and AC arthritis
are less likely to improve due to fixed impingement
and may require surgery. On the other hand, a younger
patient with normal radiographs may get more
injections and physical therapy prior to surgical
intervention.
SURGICAL INTERVENTION
- Subacromial decompression
- Originally described by Neer as an open operation
to remove anterior and lateral spurs on the
acromion, remove the inflamed bursa, and resection
or release of the CA ligament (Neer, 1972). - Nirschl has proposed that the development of spurs
is a secondary process and is not causative in nature
as once thought by Neer (Nirschl, 1989). The spurs
are usually anterior and medial and due to calcifica-
tion of the CA ligament. He advocates inspection of
the acromion and CA ligament, with the removal of
bone only if abnormal ossification has occurred. He
maintains that frequently an acromioplasty and CA
ligament resection is not necessary. This is espe-
cially true for articular sided tears cause by intrinsic
pathology. - Arthroscopy has led to a less invasive approach to
decompression and the operative goal is usually to
convert the acromion to a so-called type I acromion.
A bursectomy and inspection of the cuff is included.
•Pathology of the long head of the biceps tendon is
often a part of this syndrome. A thorough inspection
of the biceps tendon intra-articularly and into the
bicipital groove is necessary. Treatment of these
conditions is described in chapter 47.
- Originally described by Neer as an open operation
- AC joint surgery (Also discussed in chapter 46)
- Originally described as an open operation by
Mumford (Blevins et al, 1996), 1.5–2.0 cm of the
distal clavicle is removal for treatment of AC joint
arthritis (Chen, Rokito, and Zuckerman, 2003). - This surgery relies on the coracoclavicular liga-
ments providing stabilization of the clavicle. The
acromioclavicular ligaments are repaired at closure. - Arthroscopic surgeons have found that resection of
8–10 mm is all that is necessary for adequate
decompression and pain relief.- Often neglected is medial spurring on the acromion
at the AC joint. This should also be resected with
either an open or arthroscopic procedure.
- Often neglected is medial spurring on the acromion
- Originally described as an open operation by
- Rotator cuff repair
- The indications and necessity of rotator cuff repair
remains controversial. The fact that many patients—
with a full thickness rotator cuff tear—are asympto-
matic indicates that the mere presence of a hole in the
supraspinatus tendon does not necessitate surgical
repair. Many patients also do well with a simple lower
rotator cuff rehabilitation program to strengthen and
balance the anterior and posterior forces providing
humeral head depression (Burkhart, Esch, and Jolson,
1993). Some surgeons advocate subacromial decom-
pression alone without repair of the rotator cuff
(Burkhart, 1993). - On the other hand, Yamaguchi has shown us that
many tears will progress (Yamaguchi et al, 2001),
leading to a dysfunctional shoulder. Once these tears
are large, the muscles will atrophy and undergo fatty
degeneration, making a functional repair impossible. - Therefore, most shoulder surgeons will repair rotator
cuff tears whenever possible. Burkhart has shown us
that balancing the forces of the infraspinatus and sub-
scapularis, without necessarily a water tight closure
is often sufficient for a successful repair (Burkhart,
1997; 2000; 2001; Burkhart et al, 1994); however, for
large, massive tears, many advocate decompression
alone or tendon transfers to restore some function of
the lower rotator cuff (Gartsman, 1997). The use and
technique of tendon transfer for rotator cuff defi-
ciency is beyond the scope of this book.
1.Open rotator cuff repair: Open repair of the rotator
cuff to the tuberosities of the humerus has been the
gold standard for many years (Cordasco and
Bigliani, 1997; McLaughlin, 1944). This requires
detachment of a portion of the deltoid off of the
acromion. The risk of postoperative deltoid detach-
ment leads some surgeons to take off a sliver of
bone to enhance healing. The fear of deltoid failure
or detachment has led surgeons to develop less
invasive techniques.
2.Mini-open repair (Blevins et al, 1996): Develo-
pment of shoulder arthroscopy methods has
allowed surgeons to perform subacromial decom-
pression by burscoscopy. This allows visualization
of the rotator cuff, and the ability to address sub-
acromial bursitis, AC joint pathology, and acro-
mial changes such as the development of spurs or
ossification of the CA ligament. The mini-open
repair takes advantage of this preparation and uti-
lizes a deltoid split to access the rotator cuff tear
and perform an open repair (Blevins et al, 1996).
The advantage is that the deltoid is preserved