Sports Medicine: Just the Facts

45 ROTATOR CUFF PATHOLOGY

Patrick St Pierre, MD

HISTORY

• John Gregory Smith published the first detailed series
  of rotator cuff ruptures, describing seven cases
  obtained by grave robbing, in a letter to the editor of
  the London Medical Gazette in 1834. Muller and
  Perthes were the first to perform repairs in the late
  1800s. Codman and later McLaughlin were pioneers
  in the early 1900s, describing their approach to the
  shoulder and detailing rotator cuff repair techniques
  that have been followed until today (Burkhead and
  Habermeyer, 1996).


• In 1972, Charles Neer II (Neer, 1972) first proposed
  the phrase “Impingement Syndrome” for pain involv-
  ing the subacromial bursa and superior rotator cuff.
  He described the clinical presentation of the painful
  shoulder and proposed a mechanism for how the
  pathology developed. He noted that many of these
  patients had a hooked acromion and his hypothesis
  was that the bursa and rotator cuff were impinged
  between the humeral head and acromion with eleva-
  tion of the arm. This would usually start as mild
  inflammation of the tendon, would progress to fibro-
  sis and tendonitis, and eventually could lead to full
  thickness rotator cuff tear.

IMPINGEMENT OR ROTATOR CUFF
SYNDROME (NEER, 1972;1983)

• Stage I, as described by Neer, included edema and
  hemorrhage in the tendon. Tendinosis of the
  supraspinatus and less frequently, the infraspinatus or
  subscapularis is involved.


• Stage II, consisted of fibrosis and tendonitis in the
  subacromial space. This is a secondary process result-
  ing from the underlying etiology.


• Stage III, resulted in the development of spurs and
  eventually tendon rupture.


• The long head of the biceps tendon may also be
  involved with pathology ranging from inflammation
  to rupture (Crenshaw and Kilgore, 1966). Dislocation
  of the biceps tendon from the bicipital groove is
  pathognomonic for a tear of the upper border of the
  subscapularis muscle from its humeral insertion
  (Gerber, Hersche, and Farron, 1996; Gerber and
  Krushell, 1991).

•Pain will often occur along the anterior–lateral

acromion, in the infraspinatus fossa, or distally at the

deltoid insertion on the humerus. This pain is likely to

be referred pain from the inflamed bursa, which irri-

tates the deep deltoid. Pain referring proximally to the

neck usually originates from the acromioclavicular

(AC) joint (Chen, Rokito, and Zuckerman, 2003;

Valadie et al, 2000; Warner et al, 2001; Yocum, 1983).

• There have been several other etiologies proposed for
  shoulder pain emanating from the subacromial space
  following Dr. Neer’s initial description (Jobe and
  Jobe, 1983; Jobe, Kvitne, and Giangarra, 1989; Walch
  et al, 1992). These different etiologies may or may not
  lead to actual impingement of the cuff by the
  acromion. Because multiple pathologies are often fac-
  tors in this condition, including tendinosis and bursi-
  tis, the best global term to describe this condition is
  Rotator Cuff Syndrome, reserving Impingement
  Syndrome for cases of true external impingement
  caused by AC arthritis or from the development of a
  coracoacromial(CA) ligament spur. Specific etiolo-
  gies, as discussed later, may also be used.

PATHOPHYSIOLOGY

• Rotator cuff syndrome
  •Historically, patients will occasionally remember a
  direct blow or some other form of trauma. There
  may be history of a traction injury or a fall directly
  on a patient’s shoulder.
  •Overuse injury is also a frequent cause of this syn-
  drome. Patients will often not recall a specific
  injury, but may have carried luggage all weekend,
  cleaned out their attic, or worked on their car. Often
  the patient will be a weekend athlete who plays a
  full day of tennis, softball or other activity that they
  are not sufficiently trained for.
  
  
  • These conditions occur primarily because of injury
    to the rotator cuff causing tendinosis and rotator cuff
    dysfunction. The subacromial impingement occurs
    chronically with the development of subacromial
    spurs and superior humeral head migration due to
    lower rotator cuff inhibition or fatigue.
  
  
  
  


• Secondary impingement: Subtle shoulder instability
  can lead to rotator cuff dysfunction and thus to rotator
  cuff syndrome. Jobe described this as secondary or
  internal impingement syndrome (Jobe and Jobe, 1983;
  Jobe, Kvitne, and Giangarra, 1989). This condition
  was originally noted in overhead throwing athletes, but
  should be suspected in all younger athletes who com-
  plain of impingement type pain. Treatment of this con-
  dition must address the underlying instability and not
  just the secondary pathology in the subacromial space.

268 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE