Diagnosis and treatment of anterosuperior rotator cuff tears.

Over the last decade, significant advances have been made in the study and understanding of shoulder mechanics. Much of this may be attributed to the use of more sophisticated technology to improve our ability to assess the shoulder in real-time athletics. As a consequence of these advances, our understanding of the pathophysiology of injury has also increased. Our manual examination skills have improved and our noninvasive diagnostic techniques have advanced greatly. New insight into forces at play during actions as complex as the throwing motion has allowed us to develop better protocols for the prevention and treatment of the most common injuries. Additionally, paralleling improvements in the understanding of shoulder kinematics and the pathophysiology of injury, advances in surgical techniques, particularly arthroscopy, have aided in the diagnosis of and the development of less invasive surgical treatments for injuries that do not respond to nonoperative measures. Undoubtedly, an up-to-date understanding of the developments in shoulder biomechanics, pathophysiology of injury, diagnostic techniques, and surgical management is necessary for the clinician who wishes to continue to apply proper skills in the sports medicine setting.

Injuries to the Shoulder in the Throwing Athlete: Part One: Biomechanics/Pathophysiology/Classification of Injury

Purpose: The purpose of this study was to document the incidence of lesions of the rotator interval, illustrate the arthroscopic appearance of subtle differences in these lesions, and discuss how various lesions may affect biceps tendon stability in the bicipital groove Type of Study: A Data Registry has been used in my office since 1995 (Microsoft Office Access) This study reports on the results of a retrospective database "query" of the prospectively entered data from 1995 to 1998 Thus, by default, the format of this study is a consecutive sample Only patients with a disruption of rotator cuff tendons, labrum and/or gleno-coracohumeral ligaments are included by study design Methods: This study has identified and reports on 46 arthroscopically identified subscapularis tears, 25 "hidden" rotator interval lesions (SGHL/MCHL complex) and 6 SGHL/CHL complex plastic deformation lesions in 165 patients undergoing shoulder arthroscopy for conditions ranging from anterior instability to rotator cuff tears Arthroscopically identified lesions include partial or complete disruptions of the subscapularis tendon, disruptions of the superior glenohumeral/medial head coracohumeral ligament complex (SGHL/MCHL), disruptions of the lateral head coracohumeral ligament (LCHL), and various combinations of the above Results: The incidence rate of subscapularis tendon involvement in 165 arthroscopically treated shoulder patients was 27% The incidence rate of subscapularis tendon disruptions with rotator cuff pathology was 35% The incidence rate of SGHL/MCHL lesions (tear or stretch) in 165 arthroscopically treated shoulder patients was 18% The incidence rate of SGHL/MCHL tears in 165 arthroscopically treated shoulder patients was 15% Forty-seven percent of all subscapularis tears involved the SGHL/CHL complex Ten percent of all rotator cuff tears involving the supraspinatus tendon involved the LCHL Conclusions: This study has recorded the incidence of lesions of the subscapularis, SGHL/MCHL complex and/or the LCHL, and combinations thereof in degenerative cuff and instability patients Primary lesions of the rotator interval can occur and regardless of the associated pathology, and if these lesions are not repaired, biceps tendon subluxation may exist Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 2 (February), 2001: pp 173–180

Subscapularis, medial, and lateral head coracohumeral ligament insertion anatomy. Arthroscopic appearance and incidence of "hidden" rotator interval lesions.

Tendinopathy of the long head of the biceps brachii encompasses a spectrum of pathology ranging from inflammatory tendinitis to degenerative tendinosis. Disorders of the long head of the biceps often occur in conjunction with other shoulder pathology. A thorough patient history, physical examination, and radiographic evaluation are necessary for diagnosis. Nonsurgical management, including rest, nonsteroidal anti-inflammatory drugs, physical therapy, and injections, is attempted first in patients with mild disease. Surgical management is indicated for refractory or severe disease. In addition to simple biceps tenotomy, a variety of tenodesis techniques has been described. Open biceps tenodesis has been used historically. However, promising results have recently been reported with arthroscopic tenodesis.

/pdf/long-head-of-the-biceps-tendinopathy-diagnosis-and-59yani63hk.pdf

Long Head of the Biceps Tendinopathy: Diagnosis and Management

Partial-thickness tears of the rotator cuff have been diagnosed with increased frequency because of a heightened awareness of the condition by clinicians and improved diagnostic methods. Research into the causes, natural history, and optimal treatment of this condition lags behind that of full-thickness tears. However, despite the limitations in the existing literature, there has emerged a consensus among shoulder experts that partial-thickness rotator cuff tears should be aggressively treated in the active athlete because of the unfavorable natural history of these lesions and success of accepted surgical algorithms. This review will provide an overview of the theories regarding the origins of partial-thickness rotator cuff tears, discuss the relative accuracy of accepted diagnostic techniques, and summarize the indications and methods of operative repair with an emphasis on the results of various treatment approaches.

Partial-thickness rotator cuff tears.

Tears of the supraspinatus tendon associated with “hidden” lesions of the rotator interval

We identified 20 throwing athletes who continued to have pain after articular debridement for posterosuperior impingement syndrome. These patients were unable to resume sports, and we subsequently performed a derotational humeral osteotomy with a myorraphy of the subscapularis muscle. Patients were observed for an average of 46 months (range, 12 to 69). Eleven patients were able to resume the same sport at the same level, five resumed the same sport at a lower level, three changed sport secondary to persistent pain, and the last patient did not resume any sport and was worse after surgery. Patients returned to sports at an average of 6 months postoperatively (range, 4 to 44) and to their previous level of sports at an average of 12 months (range, 8 to 18). The mean increase in humeral retroversion was 29 degrees (range, 18 degrees to 44 degrees) Three women with preoperative multidirectional hyperlaxity were considered to have failed results. Derotational humeral osteotomy can be considered in the throwing athlete with posterosuperior impingement after failure of all other means of treatment. Careful patient selection and preoperative evaluation of humeral retroversion is important. Best results can be achieved in a motivated patient with low retroversion (< 10 degrees). If retroversion is normal (20 degrees to 30 degrees), the surgical indication is unclear. We do not recommend this surgery for patients with hyperlaxity.

Results of derotational humeral osteotomy in posterosuperior glenoid impingement

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Tears of the supraspinatus tendon associated with “hidden” lesions of the rotator interval

Results of derotational humeral osteotomy in posterosuperior glenoid impingement