Shoulder Ultrasonography as a Diagnostic Tool for Rotator Cuff Disease Jay D Keener, MD Associate Professor Shoulder and Elbow Service Washington University
Disclosure No relevant financial disclosures NIH funding Natural history of rotator cuff disease
Rotator Cuff Disease Clinical significance #1 cause of shoulder pain/injury Major cause of MSK morbidity and time lost from work Second to back pain as cause of musculoskeletal disability and occupational injury 250,000 rotator cuff repair surgeries/year in the U.S.
What is the Rotator Cuff? Group of 4 muscles Originate from the shoulder blade Insert into the humerus through a sheet of thick tendons
Function of the Rotator Cuff? Mobility Strength for elevation and rotation of the shoulder Stability Helps to keep the humeral head located Centering Centers the humeral head from forces of other muscles
Force Couple
Rotator Cuff Disease Pathology wide spectrum of problems Tendonitis, partial and full-thickness tears The tendons are the problem Inflammation and degenerative tears develop: Normal ageing Overuse esp overhead lifting Changes in activity Injuries
Risk Factors Age #1, incidence increases after 55-60 yrs Hand dominance HIGH DEMAND jobs manual labor, repetitive overhead activities Anatomic risk factors large acromial spurs Family history Smoking?
Age Why does age play a role? Decreased blood supply of the tendons with increased age Cumulative trauma Diminished ability to heal after minor injury with increased age
Preexisting shoulder pain or treatment! Injury mechanism Pain Location Aggravating activities Night pain Occupational Demands History
Physical Examination Accurate for detecting rotator cuff pain Inaccurate for distinguishing pain/inflammation from small tears in the rotator cuff Rely on advanced imaging: MRI CT arthrogram Ultrasound
Radiographs Standard Xrays primarily to r/o other problems Can give clues supporting rotator cuff dz
Bone Spurs? Are they important? Yes and No! Large spurs associated with rotator cuff tears Hamid, JSES 2012 Overemphasized as the common cause of cuff tears Majority of tears have no spur Acromial morphology inconsistently linked to tears
Proximal Migration Only seen with larger tears also involving the infraspinatus tendon Often a sign of chronic injury Poorer prognosis with attempted cuff repair
MRI Gold standard for imaging soft tissues of shoulder Reliable Presence of a tear Health of cuff muscle bellies Less reliable Partial tears Post surgical setting
MRI Limitations Post surgical accuracy Distinguishing scar from tendon Metal artifact issues Patient comfort Cost Zumstein et al, JBJS, 2008
Ultrasonography *Accepted method of assessing cuff disease Increasingly popular in recent years Diagnostic tool Image guided injections
Shoulder Ultrasonography Why consider it? Very accurate for cuff disease Patient comfort/tolerance Cost typically 10-15% of MRI
US Accuracy 100 cases US vs operative findings 96% accurate for detecting cuff tear Correct size predicted in 86% full-thickness tears Teefey et al, JBJS 2000
US Accuracy - 71 cases comparison of US and MRI to operative findings - US and MRI comparable in accuracy 87-90% accurate - Both studies less reliable for partial-thickness tears Teefey et al, JBJS 2004
US Accuracy Other institutions = similar results Iannotti et al, JBJS 2005 99 shoulders MRI vs US vs operative findings Similar accuracy between US (85%) and MRI (93%) Milosavjevic, Acta Radiol 2005 190 shoulders operative vs US findings 95% accuracy
US as a Diagnostic Tool Experience counts need 50-100 exams for learning curve Murphy et al, JBJS 2013 Gaining popularity Limitations Accurate for cuff and biceps cannot image labrum and articular cartilage Not readily available
US Assessment of Muscle Degeneration Comparison of US and MRI for assessing muscle degeneration - US 93% accurate for SS and IS muscles - Similar interobserver reliability as MRI Wall et al, JBJS 2012
Information Gained Mapping study of rotator cuff tears based on: - Tear size - Tear location Kim et al, JBJS 2010
Distance from Bicep Tendon
Full-thickness Tear Distribution Mode = 16 239 of 272 tears Tear commonly located 13-17 mm posterior to biceps tendon Less than 1/3 of tears involve the front edge of the supraspinatus 2 nd most common = 15 237 of 272 tears
Common Location Rotator Cable Rotator Crescent BT 15 mm Anterior Posterior
Superior Supraspinatus Infraspinatus Biceps tendon Anterior Posterior Subscapularis Humeral Head Teres Minor Inferior
Superior Supraspinatus Infraspinatus Biceps tendon Anterior Posterior Subscapularis Humeral Head Teres Minor Inferior
US and Surgical Indications Similar to MRI, US provides info regarding: Tear size Tear location Health/status of rotator cuff muscle bellies 3 most important factors affecting tendon healing: Patient age, tear size, severity of muscle degeneration
US PostSurgical Setting 44 subjects with pain following surgery 34/44 patients with prior cuff repair US 89% accurate for correctly diagnosing cuff status compared to intraoperative findings
US Post Surgical Setting Codsi et al, JSES 2014 US had good concordance with MRI for assessing cuff integrity following cuff repair surgery (n=113 cases) Similar concordance noted between radiologists and community orthopaedic surgeons
US Following Cuff Repair Why consider? Better distinguish SA scarring from truly healed repair (dynamic study) Less susceptible to post surgical artifact Metal debris and anchors Diffuse scarring Can use in office setting as a screening tool
Acute Injury? Preexisting painless tears are common Do you have to prove the injury is acute? Evidence of acute injury Injury with sudden weakness Full-thickness tear without muscle atrophy Stump of tendon left on tuberosity
Treatment Options Will depend on severity of injury Workman s compensation cases Often require more aggressive treatment Higher demand patients Finality to problem
Partial-Thickness Tears Very controversial Conservative treatment initially Successful early pain relief for most Tendon will not heal Surgery should be considered when >50% of footprint is torn
Full-thickness Tears Determine if acute/subacute or chronic (>6 months) Surgery indicated: Acute/subacute ruptures Reasonable tendon Min/mod muscle atrophy Age under 65 Certain acute on chronic injuries - grey area
When is a Cuff Repair a Bad Idea? Large tears with advanced muscle atrophy Large tear with GH jt arthritis Revision cuff repair with poor quality tissue Unrealistic expectations Factors affecting healing Age of patient Size of tear
Post-operative Recovery MMI typically 6 months, can be longer for larger tears Rehab 3 phases 0-6 weeks Passive motion and sling 6-12 weeks AAROM/AROM 12 weeks and beyond - strengthening
Rehabilitation Pearls No such thing as accelerated rehabilitation Not safe to strengthen the cuff until 3 months, probably 4 months for larger tears Early stiffness is common and can be good = higher rate of tendon healing Supervised PT is helpful but will vary for each patient
Work Status Most cuff repairs are eligible for RTW at 2 weeks with no use of arm Full-duty return depends on work demands, usu b/w 4 to 6 months Work conditioning and work hardening can be useful for higher demand jobs usu starts at 4 to 5 months
FCE When? At MMI When unsure about ability to return to work When pain or limited function persist to objectify limitations
Outcomes 85-90% successful in general population Less successful in WC cases! Why: WC patients more dependent on healing Higher functional demands Secondary gain issues
Options for Failed Surgery Do you have the right diagnosis! Age, tendon quality and work demands must all be considered Surgical options Revision repair Tendon transfers Reverse TSA Job retraining, live with it
Revision Repairs Select cases only Reasonable tendon quality Light/moderate work demands Age less than 60-65 Reasonable expectations Healing is less predictable
Tendon Transfers Less common Needs good deltoid and subscapularis, no OA Can provide pain relief and ER control, will not provide overhead strength Needs 9 to 12 months Not great for heavy laborer
When: Cuff is not repairable severe weakness Arthritis older patients > 65 Very reliable for pain relief and improved function Avoid in young or heavy laborers Reverse TSA
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