Rotator cuff repair - is acromioplasty a good thing?

In his 1972 article , Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report, Charles Neer pointed out that "a characteristic ridge of proliferative spurs and excrescences on the undersurface of the anterior process [of the acromion] was seen frequently, apparently caused by repeated impingement of the rotator cuff and humeral head, with traction on the coracoacromial ligament" as shown in his figure





and his x-ray showing the traction spur in the coracoacromial ligament, but - notably - not encroaching on the rotator cuff space



Since this publication, numerous authors have tried to understand if these acromial changes are an effect or a cause of degenerative cuff disease.

The authors of Published Evidence Relevant to the Diagnosis of Impingement Syndrome of the Shoulder pointed out that acromioplasty for impingement syndrome of the shoulder is one of the most common orthopaedic surgical procedures. They sought high levels of evidence in the published literature related to five hypotheses pertinent to the concept of the impingement syndrome and the rationale supporting acromioplasty in its treatment:
(1) clinical signs and tests can reliably differentiate the so-called impingement syndrome from other conditions,
(2) clinically common forms of rotator cuff abnormality are caused by contact with the coracoacromial arch,
(3) contact between the coracoacromial arch and the rotator cuff does not occur in normal shoulders,
(4) spurs seen on the anterior aspect of the acromion extend beyond the coracoacromial ligament and encroach on the underlying rotator cuff, and
(5) successful treatment of the impingement syndrome requires surgical alteration of the acromion and/or coracoacromial arch.

 
They found that these hypotheses were not supported by high levels of evidence.


Recently, the authors of Arthroscopic Rotator Cuff Repair with and without Acromioplasty in the Treatment of Full-Thickness Rotator Cuff Tears Long-Term Outcomes of a Multicenter, Randomized Controlled Trial provided a longer term followup of their original study: Arthroscopic rotator cuff repair with and without acromioplasty in the treatment of full-thickness rotator cuff tears: a multicenter, randomized controlled trial with the goal of determining the long-term efficacy of subacromial decompression in patients with full-thickness rotator cuff tears.

Eighty-six patients were randomized in the original trial, with 31 of 45 from the group without acromioplasty and 25 of 41 from the acromioplasty group returning for long-term follow-up (mean: 11 years).

There was no significant difference in WORC scores between the groups with and without acromioplasty at the time of the long-term follow-up (p = 0.30).

Seven (16%) of the 45 patients in the group without acromioplasty and one (2%) of the initial 41 patients allocated to acromioplasty underwent or were recommended to have reoperation.





Comment: Two experienced surgeons performed all the surgeries. The distribution of primary cases and the distribution of revision cases between these two surgeons is not presented.

The authors stated, "Tears of ≤4 in size of one or more tendons were included," however the tear sizes in the acromioplasty and non acromioplasty groups are not presented. Furthermore, the initial tear sizes in the revised and unrevised shoulders are not presented. Thus is not clear whether the cuff pathology was worse in the shoulders with type 2 or type 3 acromions.

The integrity of the cuff / retears in the two groups were not routinely evaluated by MRI or ultrasound. The operative findings - particularly the integrity of the cuff and the degree of subacromial scarring- in the revised cases are not presented. Thus the cause of symptoms leading to repeat surgery is not clarified. This study does not provide robust evidence to support the concept that acromioplasty has "a protective effect on the rotator cuff repair in patients with an amorphous acromion."


A few additional thoughts in closing.

We need to continue to think about the observation of Codman (The Shoulder 1934, p24), that the articulation between the cuff and the coracoacromial arch is an "auxillilary joint" (see his drawing below), providing stability of the humeral head against upward directed loads...

....as well as his admonition (p 13), that "the coracoacromial ligament has an important duty [restraining the humeral head] and should not be thoughtlessly divided at any operation."

The articulation between the coracoacromial arch needs - as is the case for any articulation - to be smooth and to provide a broad contact area. As Neer pointed out, acromial spurs arise within the coracoacromial ligament. As such these spurs rarely encroach on the cuff. If there is a prominence to palpation of the curvature of the CA arch (which is uncommon), it can be conservatively smoothed with a bur without transection of the ligament or a major acromial resection.

Finally, some techniques of rotator cuff repair can disrupt the smoothness of the subacromial articulation by adding "top knots" that protrude from the surface of the repaired cuff.









In performing cuff repair, it may be best to position knots so that they do not rub against the CA arch.

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Acromioplasty - is it benign?

The effect of coracoacromial ligament excision and acromioplasty on the amount of rotator cuff force production necessary to restore intact glenohumeral biomechanics.


These authors point out that coracoacromial ligament (CAL) excision and acromioplasty increase superior and anterosuperior glenohumeral translation. They used a cadaver model to estimate how much of an increase in rotator cuff force is required to re-establish intact glenohumeral biomechanics after acromioplasty.

Nine cadaveric shoulders were subjected to loading in the superior and anterosuperior directions in the intact state after CAL excision, acromioplasty, and recording of the translations. The rotator cuff force was then increased to normalize glenohumeral biomechanics.

At 150 and 200 N of superior and anterosuperior loading, an increase in the rotator cuff force of 25% was required to eliminate the increased translation resulting from CAL excision.

At 150 and 200 N of superior and anterosuperior loading, an increase in the rotator cuff force of 25% and 30%, respectively, was required to eliminate the increased translation resulting from acromioplasty and CAL excision.

The authors concluded that after subacromial decompression, the rotator cuff has to increase  its force production to maintain baseline glenohumeral mechanics. Under many circumstances, in vivo force requirements may be even greater after surgical attenuation of the coracoacromial arch.

Comment: As Codman pointed out in 1934 "The coracoacromial ligament has an important duty and should not be thoughtlessly divided at any operation." 

He recognized then, as we should today, that the coracoacromial arch provides an important stabilizing function resisting the superiorly directed force applied by the deltoid or when pushing up from a chair, bed, floor or bar. He pointed to the normal articulation between the superior aspect of the cuff and the undersurface of the coracoacromial arch. 

The center of curvature of the arch is the same as the center of curvature of the humeral head.

The stabilizing effect of the arch remains the same if there is ossification of part of the coracoacromial ligament.

We have previously demonstrated that the acromion is loaded when superiorly directed force is applied through the humeral head (whether or not the cuff is intact).

 When the superior cuff tissue is absent, superiorly directed loads applied to the humeral head produce superior translation of the head until it is stopped by the coracoacromial arch.

Sacrifice of the coracoacromial arch in the cuff deficient shoulder is a common cause of anterosuperior escape and pseudoparalysis.

Where does that leave the concept of 'impingement'? See this link.

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"Impingement syndrome" (also known as an unspecified disorder of the shoulder tendons and bursae) in the military.

Shoulder impingement in the United States military.

These authors queried the Defense Medical Epidemiology Database was queried for all shoulder impingement injuries using International Classification of Disease, Ninth Addition, Clinical Modification code 726.10 within a 10-year period from 1999 through 2008.

In an at-risk population of 13,768,534 person-years, they identified 106,940 cases of shoulder impingement resulting in an incidence of 7.77/1000 person-years in the U.S. military. 

The incidence of shoulder impingement increased with age, male sex, in service members branches of the service other than the Navy (Air Force, Army, and Marine Corps).

Comment: These authors attributed the diagnosis of "impingement syndrome" to those shoulders in the database with ICD-9-CM code 726.10. which is the code for "unspecified disorders of shoulder tendons and bursae. The code book lists the below as 'disease synonyms'. 

Biceps tendinitis
Bilat rotator cuff syndrome
Bilat shoulder bursa disorder
Bilateral rotator cuff syndrome
Bilateral shoulder bursa disorder
Bilateral supraspinatus tendinitis
Bursitis of bilat shoulders
Bursitis of bilateral shoulders
Bursitis of L shoulder
Bursitis of left shoulder
Bursitis of R shoulder
Bursitis of right shoulder
Bursitis of shoulder
Bursitis of shoulder region
Contracture of tendon of shoulder region
Disorder of bursa of shoulder region
Disorder of rotator cuff
Disorder of shoulder bursa
Disorder of tendon of left shoulder
Disorder of tendon of right shoulder
Disorder of tendon of shoulder region
Enthesopathy of bilat shoulders
Enthesopathy of bilateral shoulders
Enthesopathy of left shoulder
Enthesopathy of right shoulder
Enthesopathy of shoulder
Enthesopathy of shoulder region
Infraspinatus tendinitis
Injury of tendon of the rotator cuff of shoulder
L rotator cuff syndrome
Left rotator cuff syndrome
Left shoulder bursa disorder
Left supraspinatus tendinitis
R rotator cuff syndrome
Right rotator cuff syndrome
Right shoulder bursa disorder
Right supraspinatus tendinitis
Rotator cuff impingement syndrome
Rotator cuff syndrome
Shoulder bursa disorder
Shoulder tendinitis
Supraspinatus syndrome
Supraspinatus syndrome (shoulder condition)
Supraspinatus tendinitis
Supraspinitus tear
Tendinitis AND/OR tenosynovitis of the shoulder region
Tendinitis of bilat shoulders
Tendinitis of bilat supraspinatus tendons
Tendinitis of bilateral shoulders
Tendinitis of bilateral supraspinatus tendons
Tendinitis of left shoulder
Tendinitis of left supraspinatus tendon
Tendinitis of right shoulder
Tendinitis of right supraspinatus tendon
Tendinitis of shoulder
Tendonitis of shoulder
Tendonitis of supraspinatus
Unspecified tendon disorder of L shoulder
Unspecified tendon disorder of left shoulder
Unspecified tendon disorder of R shoulder
Unspecified tendon disorder of right shoulder
Unspecified tendon disorder of shoulder
Applies To

Rotator cuff syndrome NOS
Supraspinatus syndrome NOS

As we've pointed out here and here, it is no longer practical to use the term 'impingement syndrome' as a diagnosis in that it does not tell us what is going on with the shoulder.

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Subacromial 'impingement' - it's the way the shoulder normally works!

Which shoulder motions cause subacromial impingement? Evaluating the vertical displacement and peak strain of the coracoacromial ligament by ultrasound speckle tracking imaging

These authors studied 16 normal male shoulders (average age 28.6 years). They measured the vertical displacement and peak strain of the coracoacromial ligament by a motion tracing program during these active motions: (1) forward flexion in the scapular plane, (2) horizontal abduction in the axial plane, (3) external rotation with the arm at 0° abduction (ER0), (4) internal rotation with the arm at 0° abduction (IR0), (5) internal rotation with the arm at 90° abduction (IR90), and (6) internal rotation at the back (IRB).

An experienced sonographer examined the shoulders using 2-dimensional speckle tracking echocardiography (2D STE). Dynamic ultrasonography with the motion tracking program was used to evaluate the vertical displacement and peak strain of the coracoacromial ligament during the active motions. The coracoacromial ligament was identified with the ultrasonographic transducer placed perpendicular to the skin between the coracoid process and the acromial tip. The coracoacromial ligament was traced throughout each shoulder motion. The vertical displacement of the coracoacromial ligament with various degrees of superior bulging away from the surface of the rotator cuff could be seen, and degree of vertical displacement was measured from the vertex of the coracoacromial ligament convexity to a line connecting the acromion and coracoid process. The longitudinal peak strain of the coracoacromial ligament was calculated by the horizontal fractional change. 

The mean vertical displacement of the coracoacromial ligament during forward flexion (2.2 mm), horizontal abduction (2.2 mm), and IR90 (2.4 mm) was significantly greater than that during the other motions (ER0, −0.7 mm; IR0, 0.5 mm; IRB, 1.0 mm; P < .003). The mean peak strain was significantly higher in forward flexion (6.88%), horizontal abduction (6.58%), and IR90 (4.88%) than with the other motions (ER0, 1.42%; IR0, 1.78%; IRB, 2.61%; P < .003).

The authors concluded that normal shoulders without any pathologic change could result in physiologic contact beneath the coracoacromial ligament. The coracoacromial ligament was vertically displaced during some shoulder motions in all subjects. These findings indicate that there is physiologic contact between the coracoacromial ligament and the rotator cuff in normal shoulders.

Comment: This is a very interesting and important study. It demonstrates that loading of the coracoacromial ligament by the subjacent rotator cuff occurs in normal movements of the normal shoulder. Nature's design is marvelous in that rather than having a rigid unyielding bony bridge between the coracoid and the acromion, the coracoacromial ligament provides a conforming 'spring' ligament between these two structures that can accommodate loading by the cuff and minor variations in the shape of the proximal humeral convexity.

 In previous studies, we have demonstrated the loading of the coracoacromial arch by the rotator cuff in vivo and in vitro. Superiorly directed forces are applied to the coracoacromial arch by the subjacent rotator cuff (for example when pushing down on the arms of a chair to stand).

Loss of the coracoacromial ligament by surgery to 'decompress' the rotator cuff can result in anteriorsuperior escape.

Contact between the cuff and the ligament, "impingement", is normal!

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Atraumatic cuff tears: an intrinsic age-related degenerative process

The authors of Research Zeroes in on Pathogenesis of Rotator Cuff Disease received the 2014 Ann Doner Vaughan Kappa Delta Award.

These authors observed that non-traumatic rotator cuff tears result from degenerative changes in the tendon that progress in size over time in association with fatty degeneration of the attached muscle. At a certain stage, these changes become irreversible.

They conducted a longitudinal, prospective follow-up study of a cohort of 262 patients with asymptomatic full or partial thickness rotator cuff tears that were incidentally discovered contralateral to a symptomatic cuff tear by routine ultrasound examination.

The findings indicated that rotator cuff disease develops in an age-related, bilateral, degenerative way; approximately 40 percent of rotator cuff tears increase in size over as few as three years due to an intrinsic, degenerative process, rather than the previously held belief that tears develop due to acromial “impingement”.

In this study, tears commonly started about 1.5 cm posterior to the biceps tendon—and then propagated in both posterior and anterior directions. Loss of the anterior supraspinatus tendon attachment correlated with fatty degeneration. Proximal migration of the humeral head was much more likely to occur once the tear reached a specific threshold: tears wider than 1.5 cm at the humeral insertion were more likely to have superior migration, tears that extended to the bicipital groove and through the anterior supraspinatus tendon were more likely to have altered kinematics.

The authors recommend that patients younger than 60 years with small or medium-sized tears that are significantly painful should be given strong consideration for early surgical intervention in hopes of preventing progression in tear size and development of fatty degeneration. They noted that rotator cuff repair is much less likely to lead to tendon healing in patients who are 63 years and older; early surgical intervention does not provide much clinical advantage in these patients for which there is concern for healing.

Comment: The recognition that cuff tearing is an intrinsic progressive degenerative process, rather than related to subacromial ‘impingement’ is important. This recognition is consistent with the lack of evidence that acromioplasty is an important part of treatment of rotator cuff disease. Furthermore the recognition that cuff failure is a degenerative process suggests that at some point the tendon and associated muscle will degenerate to the point that attempting surgical reattachment of the degenerated tendon to bone is unlikely to result in a durable repair.

What remains to be established is whether reattachment of a tendon early in the process of degeneration will reverse the degenerative process.
As H.L.McLaughlin stated in 1962, "the wise surgeon, realizing that he may find little but rotten cloth to sew, will operate only by necessity and make a carefully guarded prognosis."
It has yet to be demonstrated that suturing degenerated tendon results in improvement in the quality of the tendon.
Bottom line: it matters if the cuff fails because of tear or wear

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Measuring internal rotation in abduction - the key to diagnosing posterior capsular tightness

Accuracy and reliability testing of two methods to measure internal rotation of the glenohumeral joint

The authors compared the accuracy and reliability of a traditional method of measurement (most cephalad vertebral spinous process that can be reached by a patient with the extended thumb) to estimates made with the shoulder in abduction to determine if there were differences between the two methods.

Internal rotation estimates made with the shoulder abducted demonstrated interobserver reliability superior to that of spinous process estimates, and reproducibility was high.

Comment: We use this method as well. Here's a nice illustration from a website:

It nicely shows how to examine the shoulder for loss of internal rotation with the arm abducted.

Interestingly, pain on this test used to be called a positive 'impingement sign'.

Such an internal rotation deficit can often be resolved by the sleeper stretch.

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"Impingement" or posterior capsular tightness?

One of our colleagues sent this question from a recent 'in training' examination.

It demonstrates the recognition that what used to be called 'impingement' is in many cases tightness of the posterior capsule which can be treated by stretching.

See more of the Rotator Cuff Book here.

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"Impingement syndrome" - why are we still using this term?

Is radiofrequency treatment effective for shoulder impingement syndrome? A prospective randomized controlled study.

It is now recognized that the diagnosis of 'impingement syndrome' is but a catchall term for a host of non-arthritic shoulder pathologies that can be distinguished using clinical and imaging tests. Cases of what used to be called 'impingement syndrome' are now recognized to be cuff tendinosis, partial cuff tear, full thickness cuff tear or tightness of the posterior capsule (GIRD).

Yet some articles persist in using the old terminology. 

This paper reports on 384 consecutive patients with "shoulder impingement syndrome".

The authors report that of these patients, 202 were diagnosed with full-thickness tears, and 93 patients were diagnosed with partial-thickness rotator cuff tears. Are they saying that cuff tear = impingement syndrome?

They further report that the remaining 89 patients were diagnosed with "impingement syndrome".  Didn't they say that all 384 had "impingement syndrome"?

They report that all 89 patients without evident cuff tears presented with supraspinatus tendinosis on the preoperative MRI with physical signs of pain on stretching the posterior capsule (pain when the arm was brought into full elevation in the scapular plane with the arm internally rotated by the examiner or  pain when the arm was forcibly internally rotated with the shoulder placed in 90 of forward flexion and the elbow was bent 90 by the examiner) or clinical evidence of tendon involvement (pain or weakness presented when the patient resists a downward force applied by the examiner to the wrist with the arm at 90 of elevation in the scapular plane with an internal rotation with the thumb pointing down).

One should ask, why not in this series of patients and for others, scrap the term 'impingement syndrome' and simply report that of the 384 cases with non-arthritic shoulder symptoms, 202 had full thickness cuff tears, 93 had partial thickness cuff tears and 89 had cuff tendinosis and tight posterior capsule? With that degree of clarity, we can better understand the pathology that is being treated.

In the old days we used the term "internal derangement of the knee" to refer to non-arthritic problems of the knee: "Internal derangement of the knee (IDK) is a chronic disorder of the knee due to a torn, ruptured or deranged meniscus of the knee, or a partial or complete cruciate rupture, with or without injury to the capsular ligament of the knee, resulting in ongoing or intermittent signs and symptoms such as pain, instability, or abnormal mobility of that knee." We now joke that IDK means "I don't know"; current diagnostic methods enable us to differentiate a meniscus tear from a cruciate tear.

It seems that "impingement syndrome" is the IDK of the shoulder.

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Impingement, acromioplasty and sick leave

Arthroscopic subacromial decompression and predictors of long-term sick leave benefit and permanent benefits

While the authors state in their introduction that "Shoulder impingement syndrome is a common musculoskeletal complaint leading to reduced work ability", we have previously pointed out that we no longer should use the term "impingement" in that it lacks specificity.  While the authors do not state the criteria they used to make this diagnosis, we know that it is problematic to assign this term to non-specific shoulder pain, especially in those with work related claims. As shown in this article, acromioplasty has not been shown to be superior to non-operative measures in treating what has been referred to as 'impingment syndrome'

This study included 615 individuals undergoing arthroscopic acromioplasty.  At 1 year after surgery 16.6% of the patients were receiving sick leave benefit. . At 5 years after surgery 22.6% were receiving permanent benefit. The strongest predictor of long-term sick leave benefit and permanent benefit was opioid use during the first year after the procedure.

Work-related shoulder issues are complex, as we've noted in the past. It is important to avoid non-specific diagnoses in those with job related claims.

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Steroid vs NSAID injection for shoulder pain

A double-blind randomized controlled trial comparing the effects of subacromial injection with corticosteroid versus NSAID in patients with shoulder impingement syndrome.

The inclusion criteria included shoulder pain with passive and/or active abduction, diagnosis of subacromial bursitis based on tenderness to palpation about the acromion, positive Neer’s sign, positive Hawkin’s sign, and pain exacerbated with the shoulder held in internal rotation. It is not clear how many of these had to be present for inclusion. As is pointed out recently, the diagnosis of 'impingement syndrome' can in most cases be replaced with a more specific anatomical diagnosis, because many of the 'classical' signs have been shown to be non-specific. While MRI imaging was not used in all patients, a number of patients meeting the inclusion criteria were found to have cuff tears.

Nevertheless, this study is of interest because it was a double-blinded randomized controlled clinical trial comparing the subacromial injection of either 40 mg triamcinolone or 60 mg of ketorolac.

While both group were improved, the authors noted that an injection of ketorolac resulted in greater improvements in the UCLA scale than an injection of triamcinolone at 4 weeks follow-up. They suggest that ketorolac may have fewer potential side effects that steroid injection.

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Relationship of radiographic acromial characteristics and rotator cuff disease: a prospective investigation of clinical, radiographic, and sonographic findings. JSES

JSES recently published: Relationship of radiographic acromial characteristics and rotator cuff disease: a prospective investigation of clinical, radiographic, and sonographic findings.

This article considered the relationship of acromial morphology (Bigliani Classification), acromial spurring, and acromial index to the presence of a full-thickness rotator cuff tear. Assessement of acromial morphology had poor inter observer reliability. The acromial index was not associated with the presence of a cuff tear (the same finding as previously reported). The association between acromial spurring and the presence of a full thickness cuff tear was significant, but as shown below 22% of shoulders with a spur did not have a full thickness cuff tear, and 51% of the shoulders of the shoulders without a spur had a full thickness tear - thus spur presence or absence is not a reliable indicator of the status of the cuff.

Importantly, the authors point out that these results cannot be used to infer a causal relationship between acromial spurring and rotator cuff disease. As pointed out in the recent article "Published evidence relevant to the diagnosis of impingement syndrome of the shoulder.", changes in the acromion may result from, rather than cause cuff pathology.

As has been suggested in a previous post and by the results of this study, it may be time to stop attributing cuff pathology to acromial factors.

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