Rotator Cuff Tendinopathy
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- Geoffrey Bruce
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1 Differential Diagnosis of Rotator Cuff Disease Director of Clinical Outcomes and Research Director University of Southern California; Los Angeles, CA Rotator Cuff Tendinopathy Tendinopathy Partial thickness RC tear Full Thickness RC tear Tendinopathy Partial thickness RC tear Articular, bursal, mid-substance Full-thickness RC tear Complete rupture superior to inferior Not necessarily side to side Hole in the sock 1
2 Rotator Cuff Tendinopathy Full-thickness RC tear Partial thickness RC tear Tendon pathology without tear Subacromial impingement Single clinical diagnostic category: Subacromial pain syndrome Tendon USC What s in a name. subacromial impingement Limited support for compression mechanism Perpetuates flawed reasoning & treatment Subacromial Pain Syndrome (SPS) Allows for uncertainty of the pain generator: tendons, bursae, biceps, CNS, other Allows for mechanisms other than impingement Other names ex: RC Related Shoulder USC 2
3 Subacromial Impingement Syndrome RCT 2 predominant theories Supraspinatus Tendon Tendon overload & Degeneration Mechanical Compression in SA Space If mechanical compression is the predominant mechanism, then. ALL would benefit from an acromioplasty Acromioplasty + rehab was not clinically more beneficial than rehab alone in multiple trials (Brox et al; 1993, 1999; Haahr, 2005, 2006; Ketola S, 2009, 2013) Bony pathology is not the only mechanism Impingement May not be an appropriate label (Cools AM and Michener LA, BJSM, USC 3
4 Mechanisms of RC (Tendon) Disease Mechanisms: Overload and Compression Factors contributing to the mechanisms: Intrinsic factors within the tendon Extrinsic factors external to the tendon Other factors Personal and Environmental factors LabUSC Intrinsic factors: Within the tendon Vascularity Morphology Mechanical Aging Genetics Extrinsic factors: Strength/ m. control Tightness & Laxity Posture: spine, sh Bony abnormalities Scap & GH kinematics Neurophysiological Brain / CNS Load SA space- impingement?? RCD USC 4
5 Tendon overload Neovascularization? Conflicting evidence (Lewis J, 2009; Kardouni JR, 2013) Is the tendon painful? Tendon Degeneration with Overload Inflammation present (Dean BJ, BJSM; 2015) Abnormal collagen laydown Tendon thickens initially then thins Thicker in SPS (Michener LA, 2015; Joensen J, 2009; Leong HT, 2012) Thins with progressive tendon disease *Thickens response to use Overhead athletes, Spinal Cord Injuires (SCI) (Belley AF, 2016; Maenhout A, 2012; Wang HK, 2005) 5
6 Is compression in the SA Outlet causing tendon changes? Compression or impingement of RC tendons - Subacromial (SA) space SA space measured Scapular al, 2012) AHD AHD= acromiohumeral distance mm in healthy Tendon compression is it possible? SA space and shoulder pain: Space is smaller: AHD in impingement (Hekimoglu B, 2013; Leong H-T, 2012; Seitz AL, 2011, Hebert LJ, 2003, Graichen H, 1999) Tendon is thicker: initially with disease & overuse Occupation ratio > : supraspinatus tendon: AHD Impingement : tendon occupies > amount of AHD (Michener LA, 2013) Overhead athletes & Spinal Cord Injury (SCI) (Belley AF, 2016; Maenhout A, 2012; Wang HK, USC 6
7 Tendon compression is it possible? Compression observed cadaveric (Hughes PC, et al, 2012) Compression risk: Smallest AHD: supraspinatus tendon 0-60 Smallest AHD: tendon footprint (Lawrence R, JOR, 2017) Tendon is not available for compression (under the acromion) above ~ 70 elevation (Giphart JE, 2012; Thompson MD, 2011; Bey MJ, 2007) Tendon compression may < USC Glenohumeral impingement Posterior / Internal Compression between the posterior glenoid and the humeral head Described in overhead athletes Recent evidence maybe in non-overhead athletes (Lawence R, Ludewig P, et al; CSM, 2017) 7
8 European Society of MSK Radiology: Shoulder MSK Technical Guidelines 8
9 So is it compression or is it degeneration? Both compression AND degeneration are causes Less support for compression LabUSC Rotator Cuff Tendinopathy: What s the Evidence for Diagnosis? Subacromial Pain Syndrome (SPS) SPS Partial- thickness RC tears Full-thickness Rotator Cuff Tear USC 9
10 Key Metrics for Dx Accuracy Diagnostic Accuracy values: Sensitivity Specificity PPV: Predictive value of a positive test NPV: Predictive value of a negative test LR+: Positive likelihood ratio LR- Negative likelihood ratio 10
11 Sensitivity and Specificity Sensitivity SnNOut = When Sn is high, a Negative test rules Out the disease Specificity (SpPIn) SpPIn = When Sp is high, a Positive test rules In the disease. Interpretation: Indicates if a test s or s disease probability BUT: No set cut-off to quantify shift in probability Likelihood Ratios More helpful for Dx Indicate by how much a given diagnostic test result will or the probability of the disease. Quantify shifts in probability of the diagnosis Ex: +LR= 5: a patient with a + test is 5x more likely in a patient with the disease as compared to a patient without the disease Minimal affect of prevalence 11
12 Likelihood Ratio + Interpretation >10 <0.1 Large & often conclusive changes from pre-test to post-test probability Moderate shifts in pre-test to post-test probability Small but sometimes important changes in probability Small and rarely important changes in probability Pre-test Prob = 1% +LR = 5 Post-test Prob = 85% Pre-test Prob = 50% +LR = 5 Post-test Prob = 5% 12
13 Recommendations for Diagnostic Values Interpretation Screen (Rule/ Out) Sensitivity: SnNOut * Sn > 80% Confirm (Rule/ IN) Specificity: SpPIn * Sp > 80% Likelihood ratio ( LR) * LR < 0.5 +Likelihood ratio (+LR) * +LR > 2.0 LabUSC BLUF Dx SA pain - Systematic Reviews 1. Hermans J, JAMA, 2013; 2. Hanchard NCA, Cochrane, 2013; 3. Hegedus EJ, BMJ, 2012; 4. Alqunaee M, APMR, 2012 Confirm SA pain (R/In) single tests 1- Painful arc 2- Resisted ER (ERRT) pain or weak 3- Full Can 4- Drop Arm * Combo of tests too! * Screen Out SA pain (R/Out) single tests 1- Painful arc 2- Resisted ER (ERRT) pain or weakness 3- Hawkins 4- Neer 5- Full Can 6- Empty/ Jobe Can 13
14 BLUF Combo of Tests: SA Pain 3/3 tests: (Park HB, JBJS; 2005) Hawkins, Painful arc, ER resistance (Pain/Weak) - All 3+: +LR of All 3-: LR of /5 tests: (Michener LA, APMR, 2009) Hawkins, Neer, Painful arc, Empty can, ER resistance - If > 3+ / 5 : +LR of If < 3+/ 5: LR of 0.34 Posterior Internal Impingement Impingement of the internal/deep aspect of RC tendons on posterior superior edge of the glenoid + for POSTERIOR or Post/ Superior should pain May be associated with anterior instability 14
15 Diagnosis FT-RCT- Systematic Reviews 1. Hermans J, JAMA, 2013; 2. Hanchard NCA, Cochrane, 2013; 3. Hegedus EJ, BMJ, 2012; 4. Alqunaee M, APMR, 2012 Confirm FT-RCT (R/In) single tests 1- Painful arc 2- Resist ER- marked weak 3- Drop Arm 4- ER lag - massive tears 5- Atrophy infraspinatus 6- IR lag & lift off 7- Belly off- subscap Screen Out FT-RCT (R/Out) single tests 1- Resisted ER marked weak 2- IR lag and lift off 3- Full Can 4- Empty/ Jobe Can History: Age > 60/ 65yo and c/o night pain BLUF Dx FT-RCT - Syst Reviews 1. Hermans J, JAMA, 2013; 2. Hanchard NCA, Cochrane, 2013; 3. Hegedus EJ, BMJ, 2012; 4. Alqunaee M, APMR, 2012 Confirm FT-RCT (R/In) single tests 1- Painful arc 2- Resisted ER pain or weak 3- ER lag test supraspinatus infraspinatus 4- IR lag & Lift off subscapularis 5- Drop arm 6- Atrophy of infraspinatus 7- Belly off Subscapularis **Combo of tests** Screen Out FT-RCT (R/Out) single tests 1- Resisted ER (ERRT) pain or weakness 2- IR lag & Lift-off subscapularis 3- Empty Can 4- Full Can History: Age > 60/ 65yo and c/o night pain 15
16 BLUF Combination of Tests: FT- RCT Test Combo (Litaker D, et al; J Am Geriatr Soc, 2000) >65yo, ER weak (ERRT), night pain All 3 +: R/In +LR: 9.84 All 3 -: R/Out - LR: 0.54 Test Combo (Park HB, et al; JBJS, 2005) 3 Tests: Drop arm, Painful arc, ERRT All 3 tests + R/In +LR: All 3 tests - R/Out -LR: tests & >60yo: All 3 tests & >60yo + R/In +LR: 28.0 All 3 tests & >60yo - R/Out -LR: 0.09 Thank USC 16
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