Patient self-assessed shoulder comfort and function and active motion are not closely related to surgically documented rotator cuff tear integrity
These authors sought to determine the relationship between rotator cuff integrity and the shoulder's comfort, function and active motion in 55 patients having surgery for cuff-related symptoms.
These authors sought to determine the relationship between rotator cuff integrity and the shoulder's comfort, function and active motion in 55 patients having surgery for cuff-related symptoms.
The average Simple Shoulder Test scores, range of active abduction and active flexion were
3.7 ± 3.3, 111° ± 38° and 115° ± 36° for the 16 shoulders with tendinosis or partial-thickness tears
3.6 ± 2.8, 94° ± 47°, and 94° ± 52° for the 22 full-thickness supraspinatus tears and
3.9 ± 2.7, 89° ± 39°, and 100° ± 39° for the 17 supraspinatus and infraspinatus tears.
These authors concluded that the patients' self assessed shoulder comfort and function was not associated with the surgically observed integrity of the rotator cuff. They suggest that whereas surgeons often seek to improve the integrity of the rotator cuff, the management of patients with rotator cuff disorders needs to be informed by a better understanding of the factors other than cuff integrity that influence the comfort and functioning of shoulders with cuff disease.
These authors concluded that the patients' self assessed shoulder comfort and function was not associated with the surgically observed integrity of the rotator cuff. They suggest that whereas surgeons often seek to improve the integrity of the rotator cuff, the management of patients with rotator cuff disorders needs to be informed by a better understanding of the factors other than cuff integrity that influence the comfort and functioning of shoulders with cuff disease.
Comment: The thought that the comfort and function of shoulders with chronic cuff tears is in large part unrelated to rotator cuff integrity is supported by the functional improvement experienced by patients having non-repair surgery for their cuff-related symptoms. See the post below:
Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty
These authors sought to determine whether shoulders with irreparable rotator cuff tears and retained active elevation (>100 degrees) can be durably improved using a conservative surgical procedure that smoothes the interface between the proximal humeral convexity and the concave undersurface of the coracoacromial arch followed by immediate range of motion exercises.
The typical pathology in these cases is shown in the figure below.
In 77 shoulders with previously unrepaired irreparable tears, Simple Shoulder Test (SST) scores improved from an average of 4.6 (range 0–12) to 8.5 (range 1–12) (p < 0.001). Fifty-four patients (70%) improved by at least the minimally clinically important difference (MCID) of 2 SST points.
The surgical approach is through a deltoid splitting incision that preserves the deltoid origin, the acromion and the coracoacromial ligament.
The coracoacromial arch is preserved to avoid the complication of anterosuperior escape that is commonly encountered when acromioplasty is performed in the presence of a large cuff tear.
The surgery includes smoothing of the prominence of the greater tuberosity that is exposed in cuff tears along with resection of adhesions in the humeroscapular motion interface and a gentle manipulation under anesthesia to resolve the stiffness that is commonly associated with chronic cuff tears. Immediate active assisted and active motion are encouraged immediately after surgery. Because no repair or reconstruction has been performed, activities, including deltoid strengthening can be resumed as soon as they are comfortable.
They reviewed 151 patients with a mean age of 63.4 (range 40–90) years at a mean of 7.3 (range 2–19) years after this surgery. The patient data are shown below, contrasting the patients that did and did not improve by the MCID of 2 in the Simple Shoulder Test
For 74 shoulders with irreparable failed prior repairs, SST scores improved from 4.0 (range 0–11) to 7.5 (range 0–12) (p < 0.001). Fifty-four patients (73%) improved by the MCID of 2 SST points.
They provided this case example. A rancher in his mid 60s had a right rotator cuff reconstruction with freeze-dried acellular human dermal collagen tissue matrix that subsequently became infected. He presented to us with a painful stiff right shoulder. At surgery there was extensive scar throughout the humeral scapular motion interface. The subscapularis was detached but was reconstructible. The supraspinatus was absent. The upper 2/3 of the infraspinatus was absent as well. The tuberosities were prominent. He had a smooth and move procedure at which time the abundant scar in the humeral scapular motion interface was debrided. The previous sutures and Graft Jacket were excised. The bursa was removed. The prominent tuberosities were resected using a rongeur and a burr. A manipulation under anesthesia was performed to assure a full passive range of motion. Passive and active range of motion exercises were started immediately after surgery. Three years later he reported excellent shoulder comfort and function and sent us this photo of his return to one of his favorite activities
They concluded that smoothing of the humeroscapular interface can durably improve symptomatic shoulders with irreparable cuff tears and retained active elevation > 100 degrees. They point out that this conservative procedure offers an alternative to more complex procedures in the management of irreparable rotator cuff tears.
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