Rotator cuff tears - muscle degeneration to the point of no return

Histological Evidence of Muscle Degeneration in Advanced Human Rotator Cuff Disease

To study the effects of chronic cuff tears on the cuff musculature, these authors took biopsy samples were taken from the scapular fossae from 23 consecutive patients undergoing reverse total shoulder arthroplasty.

The samples primarily consisted of dense, organized connective tissue and disorganized, loose connective tissue, with substantially smaller fractions of muscle and fat. Only one quarter of the biopsy pool contained any muscle fibers at all. Increased inflammatory cell counts and increased vascularization were observed across biopsies.

Muscle fiber degeneration was observed in most of the observable muscle fascicles, and the percentage of centrally nucleated muscle fibers was pathologically elevated. Fat accumulation was noted in both perifascicular and intrafascicular spaces, with evidence that lipid may replace contractile elements without altering muscle organization.

They concluded that dramatic degeneration and inflammation of the rotator cuff muscles are characteristics of the mostchronic and severe rotator cuff disease states, suggesting that muscle loss is more complicated than, and distinct from the simple atrophy found in less severe cases.
In a large majority of the samples, muscle tissue was completely replaced by a disorganized, vascular connective-tissue network with high macrophage density. It is possible that such tissue appears similar to muscle in clinical imaging, leading to gross underestimation of muscle degeneration.

Comment: While there is enthusiasm in some parts for attempting repair of chronic massive cuff tears, these results indicate that severe forms of degeneration may not respond well to muscle reloading.

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You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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Chronic rotator cuff tears - how should they be treated?

The Rotator Cuff Quality-of-Life Index Predicts the Outcome of Nonoperative Treatment of Patients with a Chronic Rotator Cuff Tear.

These authors studied ninety-three patients with a documented chronic (defined as symptomatic for 3 or more months) full-thickness rotator cuff tears. These patients averaged 60 years of age and 42% were female. The tears averaged 1.6 cm (in the 60 with imaging) and half had a traumatic onset. Forward elevation averaged 154 degrees and symptoms averaged 28 months in duration.

Patients underwent a three-month supervised program of nonoperative treatment consisting of stretching exercises followed by strengthening exercises when pain and stiffness had subsided.

Treatment was defined as successful if surgical treatment was no longer deemed appropriate by both patient and surgeon because the patient had improved considerably and was predominantly asymptomatic. Treatment was defined as a failure if the patient elected to have surgery after failing to improve and remaining symptomatic.

Rehabilitation was successful in seventy (75%) of the patients. Eighty-nine percent of patients maintained their three-month outcome at two years of follow-up. It is not known if the tear size progressed over the two year time frame.

The preoperative Rotator Cuff Quality-of-Life Index (RC-QOL) score was a significant predictor of outcome.

The results are shown graphically below.

Comment: This is an important article in that it indicates (1) non-operative treatment can be durably successful in the management of small chronic cuff tears and (2) that patients that succeeded with rehabilitative treatment had higher pre-treatment Rotator Cuff Quality-of-Life Index (RC-QOL) scores. In that the cuff tears in this study were chronic, there seems little harm in giving such patients a trial of non-operative management and avoiding surgery in the majority of them that succeed with this program.

While it is sometimes stated that failure of non-operative management is an indication for surgery, it is not obvious that individuals that fail non-operative treatment are good candidates for surgery. Thus it would be most informative if the authors could do a similar study with surgical treatment; it seems likely that patients with low Rotator Cuff Quality-of-Life Index (RC-QOL) scores before surgery will do less well with operative treatment. 

Readers may be interested in a recent post that compares operative and non-operative treatment of atraumatic rotator cuff tears.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Rotator Cuff 10 - Surgery for rotator cuff tears - repair

The decision to repair a rotator cuff tear requires consideration of a number of factors.

Is the tear acute and the result of a definite injury? In such a case, surgery deserves strong consideration in that repair is often most successful if performed soon after the tear occurs (say within a few weeks on months).

If the tear is chronic (long standing), are the symptoms related to weakness, to stiffness, or to catching and grinding? Has the shoulder had a good attempt at non-operative management to resolve these symptoms? (there is no rush for surgery when the tear is chronic).

Is it likely that the tear is reparable?

Is the patient prepared to avoid active use of the shoulder of the shoulder for three or so months while the tendon repair heals and remodels? Note that any active use of the arm with the elbow away from the side puts a load on the repair and many challenge its successful healing.

Should the repair be done with a mini open approach or using arthroscopic techniques? Here it is important to recall that the goal of repair is the secure reattachment of the torn tendon back to the bone from which it became separated, not the size of the skin incision. Here's the skin incision I use.

It almost always heals with a barely visible scar, even when appearance is very important, as in this man (can you see the scar?)

The surgeon should use the method that in that surgeon's hands yields the most secure repair. My personal preference now and for the last 40 years is for a mini-open approach that does not in any way compromise the deltoid muscle and that enables complete mobilization and secure repair of the tendon - to a groove in bone if necessary. Doing it securely the first time is the key for us. I also avoid shaving the acromion in that in my view there is no evidence that this improves the results on one hand and in that it adds unnecessarily to the procedure on the other.


So, in my hands the priorities in treating disorders of the rotator cuff are:
(1) to preserve the deltoid – our mini-open surgical approach is conducted through the superior ‘deltoid-on’ approach (which I will describe in more detail later).

(2) to assure smoothness of the humeroscapular motion interface – thus the upper aspect of the humerus and cuff must present a smooth convexity to articulate with the concave undersurface of the coracoacromial arch. All hypertrophic bursa and excrescences of the tuberosities are removed leaving a smooth proximal humeral convexity.

Sutures are placed so that the knots do not lie on the superior aspect of the cuff or tuberosity. "Top knots" (such as those shown below) are avoided. 

 (3) to maintain the normal mobility of the glenohumeral joint – thus limiting scar must be resolved and the cuff tendons must be released from the glenoid and coracoid if necessary before reattachment. 

(4) to assure an even distribution of tension on the cuff insertion spreading the load among multiple sutures – thus differential tightness at the area of cuff repair is avoided.

(5) to assure that if cuff tendon reattachment is performed, that it is sufficiently robust to heal and to allow early motion after surgery – thus multiple sutures securing the tendon edge into a bony trough are preferred. The trough excludes joint fluid from the repair site and allows for the possibility of some slip of the tendon while maintaining tendon to bone contact.

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How you can support research in shoulder surgery Click on this link.

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).