ROTATOR CUFF TEARS - SHOULDER PATHOLOGY
SITS Muscles | Supraspinatus Most Common | Tear Size Predicts Outcome | Repair vs Reconstruction
COFIELD CLASSIFICATION BY SIZE
Critical Must-Knows
- SITS muscles: Supraspinatus, Infraspinatus, Teres minor, Subscapularis - rotator cuff components
- Force couple concept: RC depresses humeral head while deltoid elevates - loss disrupts mechanics
- Tear progression: Natural history shows increasing size and fatty infiltration over time
- Double-row repair: Improved footprint contact and biomechanical strength vs single-row
- Irreparable tears: Massive retracted tears with Goutallier Grade 3-4 fatty infiltration
Examiner's Pearls
- "Supraspinatus initiates abduction - tear causes painful arc 60-120 degrees
- "External rotation lag sign indicates infraspinatus/teres minor insufficiency
- "Subscapularis tear: belly-press test, lift-off test, bear-hug test positive
- "MRI shows tendon gap, retraction, muscle atrophy, fatty infiltration (Goutallier)
Clinical Imaging
Imaging Gallery
Critical Rotator Cuff Tear Exam Points
SITS Anatomy
Four muscles form the rotator cuff: Supraspinatus (superior), Infraspinatus (posterior-superior), Teres minor (posterior-inferior), Subscapularis (anterior). SITS mnemonic. Supraspinatus is the most commonly torn tendon - critical area at footprint 1cm medial to greater tuberosity.
Blood Supply Critical Zone
Hypovascular zone exists 1cm medial to supraspinatus insertion - watershed area between osseous and muscular blood supply. This critical zone is prone to degeneration and tears. Blood supply from suprascapular, anterior circumflex humeral, and posterior circumflex humeral arteries.
Force Couple Biomechanics
The rotator cuff creates a force couple with deltoid: RC compresses and depresses humeral head while deltoid elevates arm. Loss of this balance causes superior migration of humeral head and subacromial impingement. Subscapularis counterbalances posterior cuff.
Tear Progression and Irreparability
Natural history shows progression in size and quality. Goutallier grading (0-4) quantifies fatty infiltration - Grade 3-4 predicts poor repair outcomes. Patte staging (1-3) measures retraction. Tangent sign on MRI indicates advanced atrophy.
Quick Decision Guide - Tear Management
| Patient Profile | Tear Characteristics | Treatment | Key Pearl |
|---|---|---|---|
| Young active (less than 60), acute traumatic | Small-medium tear, minimal retraction | Arthroscopic single or double-row repair | Early repair prevents progression and muscle atrophy |
| Middle-aged (60-70), chronic symptoms | Large tear (3-5cm), moderate fatty change | Double-row repair with margin convergence | Repair still possible but rehabilitation longer |
| Elderly low demand (over 75), chronic | Massive tear, Goutallier 3-4 | Conservative management or reverse TSA | Repair likely to fail - focus on function |
| Young high demand, massive irreparable | Greater than 5cm, severe retraction, fatty change | Superior capsular reconstruction or graft augmentation | Bridging option before arthroplasty |
SITSSITS - Rotator Cuff Components
Memory Hook:The rotator cuff SITS on the humeral head - four muscles stabilizing the glenohumeral joint
EMPTYEMPTY CAN - Supraspinatus Testing
Memory Hook:EMPTY CAN test - like emptying a can with thumb down - isolates supraspinatus function
LAGERLAGER - External Rotation Lag Signs
Memory Hook:LAGER - like a lager falling when you let go - the arm lags in external rotation with posterior cuff tear
BEARBEAR - Subscapularis Testing
Memory Hook:BEAR HUG test - hugging like a bear tests the anterior cuff subscapularis muscle
Overview and Epidemiology
Rotator cuff tears are among the most common shoulder pathologies, representing a spectrum from partial-thickness tears to massive full-thickness defects involving multiple tendons. They result from a combination of intrinsic tendon degeneration and extrinsic mechanical factors.
Epidemiology:
- Prevalence increases dramatically with age - rare under 40, common over 60
- Many tears are asymptomatic (up to 50% of individuals over 60 have tears on imaging)
- Symptomatic tears often present with pain, weakness, and functional limitations
- Occupational and sports-related overhead activities increase risk
Asymptomatic Tears
Many rotator cuff tears are asymptomatic, particularly in older individuals. The decision to treat is based on symptoms, functional impairment, and patient goals - not just the presence of a tear on imaging. Asymptomatic tears may progress over time to become symptomatic.
Etiology - Multifactorial:
Intrinsic Factors
- Tendon degeneration: Age-related collagen breakdown, decreased vascularity
- Hypovascular zone: Critical zone 1cm medial to insertion
- Genetics: Family history increases risk
- Smoking: Impairs healing, increases tear size
Extrinsic Factors
- Subacromial impingement: Type I (flat), II (curved), III (hooked) acromion
- Os acromiale: Unfused acromial apophysis causing impingement
- Trauma: Acute on chronic, fall on outstretched hand
- Overuse: Repetitive overhead activity (swimmers, painters, throwers)
Natural History:
- Tear size tends to increase over time (approximately 40% enlarge within 2 years)
- Muscle atrophy and fatty infiltration progress (often irreversible)
- Pain may decrease over time even as tear enlarges (pseudoparalytic shoulder)
- Functional deficits worsen with tear progression
Pathophysiology and Mechanisms
The Rotator Cuff Complex:
The rotator cuff consists of four muscles and their tendons that originate from the scapula and insert on the humeral head, forming a circumferential cuff around the glenohumeral joint.
SITS Muscles - Origins, Insertions, Function, Innervation
| Muscle | Origin | Insertion | Function | Nerve |
|---|---|---|---|---|
| Supraspinatus | Supraspinous fossa scapula | Superior facet greater tuberosity | Initiates abduction 0-30 degrees | Suprascapular (C5-6) |
| Infraspinatus | Infraspinous fossa scapula | Middle facet greater tuberosity | External rotation, stabilization | Suprascapular (C5-6) |
| Teres minor | Lateral border scapula | Inferior facet greater tuberosity | External rotation, adduction | Axillary (C5-6) |
| Subscapularis | Subscapular fossa scapula | Lesser tuberosity | Internal rotation, anterior stability | Upper/lower subscapular (C5-7) |
Blood Supply - Critical Zone:
Hypovascular Critical Zone
The critical zone is a hypovascular area approximately 1cm medial to the supraspinatus insertion on the greater tuberosity. This represents a watershed zone between the osseous blood supply (from the humeral circumflex arteries) and the muscular blood supply (from the suprascapular and thoracoacromial arteries). This zone is particularly prone to degeneration and tear formation.
Arterial supply:
- Suprascapular artery - supplies supra/infraspinatus
- Anterior humeral circumflex artery - supplies anterior cuff and subscapularis
- Posterior humeral circumflex artery - supplies posterior cuff
- Thoracoacromial artery - contributes to anterior structures
Biomechanics - Force Couple Concept:
The rotator cuff creates force couples that stabilize the humeral head:
- Coronal plane: Deltoid (superior force) vs. infraspinatus/teres minor/subscapularis (inferior force)
- Transverse plane: Subscapularis (anterior force) vs. infraspinatus/teres minor (posterior force)
Force Couple Disruption
When the rotator cuff is torn, the force couple is disrupted. The deltoid pulls the humeral head superiorly without the opposing inferior force from the cuff. This causes superior migration of the humeral head, leading to subacromial impingement, acromioclavicular joint arthritis, and eventually rotator cuff arthropathy.
Functional Roles:
- Supraspinatus: Initiates abduction, provides superior compression
- Infraspinatus/Teres minor: External rotation, posterior stabilization
- Subscapularis: Internal rotation, anterior stabilization, resists posterior subluxation
Classification Systems
Cofield Classification by Tear Size
Based on maximum tear dimension in any plane:
| Size | Dimension | Typical Repair | Prognosis |
|---|---|---|---|
| Small | Less than 1cm | Single-row arthroscopic | Excellent healing |
| Medium | 1-3cm | Double-row arthroscopic | Good healing potential |
| Large | 3-5cm | Double-row with convergence | Guarded, longer rehab |
| Massive | Greater than 5cm or 2+ tendons | SCR or reverse TSA | Poor repair outcomes |
Massive Tear Definition
A massive tear is defined as either: (1) greater than 5cm in maximum dimension, OR (2) involvement of two or more complete tendons. These tears have poor healing potential with standard repair and may require alternative treatments like superior capsular reconstruction or reverse total shoulder arthroplasty.
Clinical Assessment
History:
Pain Characteristics
- Location: Anterolateral shoulder, often radiates to deltoid insertion
- Timing: Night pain common (lying on shoulder), difficulty sleeping
- Activity: Pain with overhead activities, reaching behind back
- Onset: Acute traumatic vs insidious degenerative
Functional Deficits
- Weakness: Difficulty with overhead activities, lifting
- Loss of motion: Active motion reduced more than passive
- Activities: Difficulty with hair combing, reaching for wallet
- Occupational: Impact on work, sports, daily living
Physical Examination:
Inspection and Range of Motion
- Inspect: Muscle atrophy (supraspinatus/infraspinatus fossae), asymmetry, scapular dyskinesis
- Active ROM: Often limited by pain and weakness (pseudoparalysis if massive tear)
- Passive ROM: Should be preserved (if limited, consider frozen shoulder, arthritis)
- Painful arc: Pain between 60-120 degrees abduction indicates impingement
Specific Tests for Individual Tendons
Rotator Cuff Physical Examination Tests
| Test | Tendon Tested | Technique | Positive Finding |
|---|---|---|---|
| Empty can (Jobe's) | Supraspinatus | Arm 90deg abducted, 30deg forward, thumb down, resist downward force | Pain or weakness |
| Full can | Supraspinatus | Arm 90deg abducted, 30deg forward, thumb up, resist downward force | Pain or weakness (more specific) |
| External rotation lag sign | Infraspinatus | Elbow 90deg flexed, arm at side, passively externally rotate, patient maintains | Arm drops greater than 10 degrees |
| Hornblower's sign | Teres minor | Arm 90deg abducted, elbow 90deg, externally rotate against resistance | Cannot maintain external rotation |
| Lift-off test | Subscapularis | Hand behind back, lift off from back against resistance | Cannot lift hand off back |
| Belly-press test | Subscapularis | Press hand against belly with elbow forward | Elbow moves posterior to trunk |
| Bear-hug test | Subscapularis | Hand on opposite shoulder, resist pull-off | Cannot resist or elbow drops |
External Rotation Lag Sign Importance
The external rotation lag sign is highly specific for a posterosuperior rotator cuff tear (infraspinatus/teres minor). A positive lag greater than 10 degrees indicates a large tear. The hornblower's sign (inability to externally rotate at 90 degrees abduction) suggests an even larger tear involving teres minor.
Impingement Tests
- Neer impingement sign: Passive forward flexion causes pain (subacromial impingement)
- Hawkins-Kennedy test: 90deg forward flexion, internal rotation causes pain
- These tests are sensitive but not specific for rotator cuff tears
Strength Testing
- Supraspinatus strength: Empty can or full can test
- External rotation strength: Resisted ER at side and at 90deg abduction
- Internal rotation strength: Resisted IR (belly press, lift-off)
- Pseudoparalysis: Inability to actively elevate arm despite full passive motion (massive tear)
Investigations
Imaging Protocol for Suspected Rotator Cuff Tear
Standard shoulder series: AP (3 views - neutral, internal rotation, external rotation), scapular Y, axillary lateral
What to assess:
- Acromiohumeral distance (normal greater than 7mm, less than 7mm suggests massive tear)
- Acromial morphology (Type I flat, II curved, III hooked - Bigliani)
- Os acromiale (unfused acromial apophysis)
- Greater tuberosity cysts, sclerosis, osteophytes
- Glenohumeral arthritis, acromioclavicular arthritis
- Superior migration of humeral head (chronic massive tear)
MRI is the gold standard for rotator cuff assessment
Sensitivity/Specificity: Greater than 90% for full-thickness tears
What MRI shows:
- Tear presence, size (anteroposterior and mediolateral), location
- Partial vs full-thickness, articular vs bursal side
- Tendon retraction (Patte staging 1-3)
- Muscle atrophy (tangent sign on sagittal view)
- Fatty infiltration (Goutallier grading 0-4)
- Associated pathology (labral tears, biceps pathology, bone marrow edema)
Operator-dependent but useful in experienced hands
- Dynamic assessment, lower cost than MRI
- Good for full-thickness tears (sensitivity 90%)
- Less accurate for partial tears, muscle quality
- Useful for guided injections
Less commonly used, but helpful in specific scenarios
- Cannot have MRI (pacemaker, metallic implants)
- Assessment of bone quality (revision surgery, arthroplasty planning)
- Goutallier grading of fatty infiltration possible
Imaging Examples
MRI Prognostic Factors
Key MRI findings that predict poor repair outcomes:
- Goutallier Grade 3-4 fatty infiltration (more fat than muscle)
- Patte Stage 3 retraction (medial to glenoid)
- Positive tangent sign (muscle belly below superior glenoid line)
- Massive tear size (greater than 5cm or 2 tendons)
- Acromiohumeral distance less than 7mm (chronic massive tear with superior migration)
MRI Grading Scheme
Management Algorithm
Non-Operative Treatment
Indications:
- Elderly, low-demand patients
- Asymptomatic or minimally symptomatic tears
- Massive tears with Goutallier 3-4 (poor repair prognosis)
- Medical comorbidities precluding surgery
- Patient preference
Conservative Treatment Steps
- Avoid painful overhead activities
- Modify work and sport activities
- Ergonomic adjustments
- Scapular stabilization: Strengthen periscapular muscles
- Deltoid strengthening: Compensate for cuff weakness
- Stretching: Maintain or improve passive range of motion
- Posterior capsule: Address tightness contributing to superior migration
- NSAIDs: Reduce inflammation and pain
- Analgesics: Paracetamol for pain control
- Subacromial corticosteroid injection: Reduce pain and inflammation
- Limit to 3 injections per year (tendon weakening risk)
- May provide temporary relief but does not heal tear
Tear Progression with Conservative Treatment
40% of rotator cuff tears increase in size within 2 years of conservative management. Muscle atrophy and fatty infiltration also progress and are largely irreversible. Delaying surgery may worsen repairability. In young, active patients with symptomatic tears, consider early surgery.
Management Algorithm
Surgical Technique
Single-Row Repair Technique
Indications: Small to medium tears (less than 3cm), good tissue quality
Pre-operative Planning:
Consent Points
- Re-tear: 10-30% depending on tear size and quality
- Stiffness: 5-10% risk, may require manipulation
- Infection: Less than 1% arthroscopic
- Nerve injury: Axillary nerve at risk (rare)
- Failure to heal: May require revision or alternative treatment
Equipment Checklist
- Arthroscope: 30-degree and 70-degree
- Anchors: Suture anchors (typically 2-4 for small-medium tear)
- Suture: High-strength non-absorbable (FiberWire, MaxBraid)
- Instruments: Graspers, suture retrievers, knot pushers
- Radiofrequency device: For debridement, hemostasis
Patient Positioning
Beach chair position (most common) or lateral decubitus:
Beach Chair Setup
Beach chair at 60-70 degrees upright
- Head secured in headrest with neutral position
- Arm free-draped to allow full range of motion
- Arm holder or assistant to position limb
- Bony prominences: Pad sacrum, heels, contralateral elbow
- Blood pressure: Monitor on contralateral arm
- Hypotensive anesthesia: Consider to reduce bleeding (MAP 55-65)
- Mark bony landmarks: acromion, clavicle, coracoid, AC joint
- Plan portal sites: posterior, lateral, anterior
Surgical Steps
Arthroscopic Repair Steps
Posterior portal (standard viewing portal)
- Glenohumeral joint: Assess cartilage, labrum, biceps, subscapularis
- Identify tear location, size, mobility
- Assess articular-side partial tears
Subacromial space visualization
- Lateral portal for instrument access
- Bursectomy to visualize cuff tear
- Acromioplasty if Type II or III acromion
- Avoid aggressive acromioplasty (weakens deltoid origin)
Prepare tendon for repair
- Release adhesions (interval slide for anterior-posterior mobility)
- Debride frayed edges (minimal debridement to preserve tissue)
- Prepare footprint on greater tuberosity (remove soft tissue, light decortication)
Single-row medial anchors
- Place anchors at articular margin (medial footprint)
- Spacing: 1-1.5cm apart, typically 2-4 anchors depending on tear size
- 45-degree deadman angle for optimal pull-out strength
Pass sutures through tendon
- Suture passer through tear, retrieve anchor suture
- Horizontal mattress configuration for strength
- Ensure adequate tissue bites (5-8mm from edge)
- Consider medial-lateral or side-to-side sutures if large gap
Secure repair
- Tie sliding or non-sliding knots (surgeon preference)
- Assess repair integrity, tension, footprint coverage
- Check range of motion (should achieve 140deg forward flexion without undue tension)
Single-Row Limitations
Single-row repair restores partial footprint contact but may have higher re-tear rates for larger tears compared to double-row. The tendon is fixed to the medial edge of the footprint only. For medium to large tears, double-row provides better biomechanical strength and footprint restoration.
Complications
Complications of Rotator Cuff Surgery
| Complication | Incidence | Risk Factors | Management |
|---|---|---|---|
| Re-tear | 10-30% (size-dependent) | Large tears, poor tissue quality, Goutallier 3-4, age over 65 | Revision repair, SCR, or arthroplasty |
| Stiffness/frozen shoulder | 5-10% | Pre-existing stiffness, diabetes, prolonged immobilization | Aggressive PT, manipulation under anesthesia |
| Infection | Less than 1% arthroscopic | Diabetes, immunosuppression, revision surgery | Antibiotics, irrigation/debridement, anchor removal |
| Deltoid dysfunction | 1-2% | Aggressive acromioplasty, nerve injury | Observation, nerve recovery, physio |
| Nerve injury (axillary, suprascapular) | Less than 1% | Traction, retractor placement, anchor misplacement | Observation (most recover), nerve exploration if no recovery |
| Anchor pull-out | 1-3% | Poor bone quality, osteoporosis, incorrect angle | Revision with larger anchors or different location |
Re-tear - Most Common Complication:
Re-tear Risk Factors
Factors predicting rotator cuff re-tear:
- Tear size: Small (10%), medium (15%), large (20%), massive (30-40%)
- Fatty infiltration: Goutallier 3-4 dramatically increases re-tear
- Age: Over 65 years higher risk
- Smoking: Impairs healing, doubles re-tear rate
- Diabetes: Poor tissue quality, delayed healing
- Repair technique: Single-row higher re-tear than double-row for medium-large tears
Despite re-tear, many patients remain clinically improved with reduced pain even if MRI shows persistent defect.
Stiffness Prevention:
- Early passive range of motion (start within first week)
- Progress to active-assisted motion at 6 weeks
- Avoid prolonged immobilization
- Diabetic patients at highest risk - aggressive PT protocol
Postoperative Care and Rehabilitation
Rehabilitation Protocol:
Standard Rehabilitation Timeline
Goals: Protect repair, prevent stiffness, minimize pain
- Sling: Wear at all times except for exercises and hygiene (4-6 weeks)
- Passive ROM: Start within first week, pendulums, table slides
- Forward flexion passive: Progress to 140 degrees by 6 weeks
- External rotation passive: Progress to 30-40 degrees by 6 weeks
- No active motion: Avoid activating repaired tendons
- Cryotherapy and pain control: Ice, analgesics, minimize NSAIDs (may impair healing)
Goals: Transition to active motion, gentle strengthening
- Discontinue sling at 6 weeks
- Active-assisted ROM: Pulley exercises, wand exercises
- Progress to active ROM: Deltoid-initiated elevation, avoid substitution patterns
- Begin gentle isometrics: Sub-maximal contractions, avoid pain
- Scapular stabilization: Periscapular muscle activation
Goals: Restore strength and function
- Progressive resistance exercises: Light weights progressing to heavier
- Rotator cuff strengthening: Resistance band exercises (IR, ER, abduction)
- Functional activities: Return to daily activities, work
- Sport-specific training: Gradual return to overhead sports (6 months minimum)
Goals: Full strength and function
- Most patients achieve maximal improvement by 12 months
- Continued home exercise program for maintenance
- Return to full sport/work as tolerated
Outcomes and Prognosis
Outcomes by Tear Size:
| Tear Size | Healing Rate | Functional Outcome | Notes |
|---|---|---|---|
| Small (less than 1cm) | 90-95% | Excellent | Most reliable results |
| Medium (1-3cm) | 80-90% | Good to excellent | Double-row improves healing |
| Large (3-5cm) | 60-80% | Good | Healing less predictable, longer rehab |
| Massive (greater than 5cm) | 30-60% | Fair to good | Even with re-tear, pain often improved |
Prognostic Factors for Success:
Favorable factors:
- Younger age (less than 60 years)
- Acute traumatic tear (as opposed to chronic degenerative)
- Small to medium tear size
- Good tissue quality (Goutallier 0-1)
- Minimal retraction (Patte 1-2)
- Non-smoker
- Compliant with rehabilitation
Unfavorable factors:
- Advanced age (over 70)
- Massive tear
- Chronic tear (greater than 6 months)
- Goutallier Grade 3-4 fatty infiltration
- Patte Stage 3 retraction
- Smoking, diabetes, worker's compensation
- Poor patient compliance
Clinical vs Structural Outcomes
Important distinction: Structural healing (tendon heals on MRI) does not always correlate with clinical outcome (pain and function). Many patients with re-tears on imaging have good clinical outcomes with improved pain and function compared to pre-operative state. The goal is a satisfactory clinical result, not necessarily perfect anatomic healing.
Evidence Base and Key Trials
Single-Row vs Double-Row Repair Meta-Analysis
- Meta-analysis of 14 RCTs comparing single-row vs double-row rotator cuff repair
- Double-row repair showed lower re-tear rates for medium-large tears (greater than 1-3cm)
- No significant difference in clinical outcomes (pain, function scores) between techniques
- Small tears (less than 1cm) showed no benefit from double-row over single-row
Rotator Cuff Tear Progression Without Surgery
- Prospective study of 53 patients with full-thickness RC tears treated non-operatively
- Follow-up MRI at mean 2.8 years showed tear size increased in 49% of patients
- Fatty infiltration progressed in 73% of patients
- Clinical outcomes (pain, function) did not correlate with tear progression on MRI
MOON Shoulder Group - RC Repair Outcomes by Age
- Prospective cohort of 452 patients undergoing arthroscopic rotator cuff repair
- Patients over 65 had higher re-tear rates but similar patient-reported outcomes
- Tear size and tissue quality more predictive of outcome than age alone
- Older patients with good tissue quality had outcomes comparable to younger patients
Superior Capsular Reconstruction for Irreparable Tears
- Case series of 23 patients with irreparable RC tears treated with SCR using fascia lata
- Significant improvement in pain, range of motion, and shoulder function scores
- Acromiohumeral distance restored (prevented superior migration)
- 85% of grafts intact at minimum 2-year follow-up
Reverse Total Shoulder for Rotator Cuff Arthropathy
- Prospective series of 80 reverse TSAs for cuff arthropathy with minimum 40-month follow-up
- Significant improvement in pain and function (Constant score 29 pre-op to 66 post-op)
- 91% good to excellent results
- Complications: 15% scapular notching, 4% instability
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Scenario 1: Chronic Rotator Cuff Tear Assessment (~2-3 min)
"A 62-year-old recreational golfer presents with 12 months of progressive right shoulder pain and weakness. He has failed physiotherapy and a subacromial steroid injection. On examination, he has full passive range of motion, painful arc 60-120 degrees, positive empty can test, and external rotation lag sign of 15 degrees. MRI shows a full-thickness supraspinatus tear measuring 2.5cm with minimal retraction and Goutallier Grade 1 fatty infiltration of supraspinatus and infraspinatus. What is your assessment and management?"
Scenario 2: Massive Irreparable Tear (~3-4 min)
"A 55-year-old manual laborer presents with severe right shoulder pain and inability to lift his arm. He fell off a ladder 6 months ago but delayed seeking treatment. Examination shows pseudoparalysis - he cannot actively elevate beyond 40 degrees but has full passive forward flexion. External rotation lag is 30 degrees. MRI shows a massive retracted tear of supraspinatus and infraspinatus (5.5cm), Patte Stage 3 retraction medial to the glenoid, Goutallier Grade 3 fatty infiltration, and positive tangent sign. Acromiohumeral distance is 4mm. How would you manage this patient?"
Scenario 3: Post-Operative Stiffness Complication (~2-3 min)
"A 68-year-old diabetic woman underwent arthroscopic rotator cuff repair for a medium-sized tear 3 months ago. She returns to clinic with severe stiffness - active forward flexion is 60 degrees and passive forward flexion is 90 degrees. She reports shoulder pain at rest and with movement. She has been compliant with physiotherapy. How do you assess and manage this complication?"
MCQ Practice Points
Anatomy Question
Q: Which rotator cuff muscle is NOT innervated by the suprascapular nerve? A: Teres minor (innervated by axillary nerve). Supraspinatus and infraspinatus are both innervated by the suprascapular nerve (C5-6). Subscapularis is innervated by upper and lower subscapular nerves (C5-7).
Blood Supply Question
Q: What is the critical zone of the rotator cuff and why is it significant? A: The critical zone is a hypovascular area approximately 1cm medial to the supraspinatus insertion. It represents a watershed zone between the osseous blood supply (humeral circumflex arteries) and muscular blood supply (suprascapular artery). This area is particularly prone to degeneration and tear formation.
Classification Question
Q: A rotator cuff tear measuring 4cm with Goutallier Grade 3 fatty infiltration and Patte Stage 3 retraction - what is the prognosis for repair? A: Poor prognosis. This is a large tear (3-5cm by Cofield) with unfavorable prognostic factors: Goutallier Grade 3 (more fat than muscle) predicts poor healing, and Patte Stage 3 retraction (medial to glenoid) makes repair technically difficult. This tear may be irreparable and alternative treatments (partial repair, SCR, reverse TSA) should be considered.
Examination Question
Q: What does a positive external rotation lag sign indicate? A: An external rotation lag sign (arm drops more than 10 degrees when released from passive external rotation) indicates a posterosuperior rotator cuff tear involving infraspinatus and possibly teres minor. It is highly specific for a significant tear and suggests the need for surgical intervention.
Surgical Technique Question
Q: What is the biomechanical advantage of double-row repair over single-row repair for medium to large rotator cuff tears? A: Double-row repair provides: (1) Increased footprint contact area - better anatomic restoration, (2) Higher ultimate load to failure - stronger construct, (3) Better pressure distribution across repair site, (4) Lower re-tear rates for medium-large tears compared to single-row. However, clinical outcome scores are similar between techniques.
Complication Question
Q: A patient has a confirmed rotator cuff re-tear on MRI at 1 year post-repair but reports good pain relief and improved function. What is your management? A: No further surgery. This demonstrates that structural healing (MRI) does not always correlate with clinical outcome. Many patients with re-tears have good clinical outcomes with improved pain and function. If the patient is satisfied and functional, no additional intervention is needed. Surgery would only be considered for symptomatic re-tear with significant pain or functional impairment.
Australian Context and Medicolegal Considerations
Australian Guidelines
- RACS Guidelines: Evidence-based approach to rotator cuff pathology
- Private health insurance: Rotator cuff repair covered, rehabilitation support
- Workers' compensation: Common work-related injury, requires documentation
Australian Epidemiology
- Prevalence similar to international data (30-40% over age 60)
- Occupational tears common: manual laborers, overhead workers
- Sports: Cricket, tennis, swimming high-risk activities
- Aging population increasing burden of degenerative tears
Medicolegal Considerations:
Documentation and Consent
Key medicolegal points for rotator cuff surgery:
-
Informed consent must include:
- Re-tear risk (10-30% depending on size)
- Stiffness risk (5-10%, higher in diabetics)
- Infection, nerve injury, anchor complications
- Prolonged recovery (6-12 months to maximal improvement)
- Possibility of failed repair requiring revision or arthroplasty
-
Documentation of conservative management:
- Trial of physiotherapy (typically 3-6 months)
- Medications (NSAIDs, analgesia)
- Injection therapy (if appropriate)
- Failure of conservative measures before proceeding to surgery
-
Preoperative imaging:
- MRI assessment of tear size, retraction, muscle quality (Goutallier)
- Document prognostic factors that may affect outcome
-
Operative notes:
- Detailed description of tear pattern, size, tissue quality
- Repair technique used (single-row, double-row, margin convergence)
- Any difficulties encountered, reasons for technique chosen
-
Postoperative care:
- Clear rehabilitation protocol provided to patient and physiotherapist
- Follow-up plan documented
Australian-Specific Considerations:
- Remote and rural areas: Access to arthroscopic expertise may be limited, open repairs may be more common
- Indigenous health: Consider cultural factors, access to rehabilitation services
- Workers' compensation: Occupational tears require clear documentation of mechanism, functional impact, return to work planning
ROTATOR CUFF TEARS
High-Yield Exam Summary
Key Anatomy - SITS
- •Supraspinatus: Superior cuff, initiates abduction, most commonly torn (suprascapular nerve C5-6)
- •Infraspinatus: Posterior cuff, external rotation (suprascapular nerve C5-6)
- •Teres minor: Posterior-inferior cuff, external rotation (axillary nerve C5-6)
- •Subscapularis: Anterior cuff, internal rotation (upper/lower subscapular nerves C5-7)
- •Critical zone: Hypovascular area 1cm medial to insertion - prone to degeneration
Classification Systems
- •Cofield by size: Small (less than 1cm), Medium (1-3cm), Large (3-5cm), Massive (greater than 5cm or 2 tendons)
- •Goutallier fatty infiltration: Grade 0 (normal) to Grade 4 (severe fat) - Grade 3-4 predicts poor repair
- •Patte retraction: Stage 1 (near tuberosity), Stage 2 (glenoid rim), Stage 3 (medial to glenoid)
- •Tangent sign: Muscle belly below superior glenoid line on sagittal MRI indicates severe atrophy
Clinical Assessment
- •Empty can test: Supraspinatus (arm 90deg abducted, 30deg forward, thumb down)
- •External rotation lag sign: Infraspinatus (drop greater than 10 degrees when released from ER)
- •Belly-press, lift-off, bear-hug tests: Subscapularis tears
- •Pseudoparalysis: Cannot actively elevate but full passive motion (massive tear)
Surgical Techniques
- •Single-row repair: Medial anchors only, suitable for small tears
- •Double-row repair: Medial and lateral rows, better for medium-large tears (improved footprint, lower re-tear)
- •Margin convergence: Side-to-side sutures for large U-shaped tears before bone fixation
- •Superior capsular reconstruction: Fascia lata graft for irreparable tears in young patients
- •Reverse TSA: Gold standard for cuff arthropathy with pseudoparalysis in elderly
Complications and Outcomes
- •Re-tear: 10-30% (size-dependent) - many asymptomatic, good clinical outcomes despite re-tear
- •Stiffness: 5-10%, higher in diabetics - early mobilization, aggressive PT, consider MUA
- •Prognostic factors: Tear size, Goutallier grade, Patte stage, age, smoking, diabetes
- •Rehabilitation: Passive immediate, active-assisted 6 weeks, strengthening 12 weeks, maximal improvement 12-24 months
Key Evidence and Pearls
- •Double-row reduces re-tear for medium-large tears but similar clinical outcomes to single-row
- •Tears progress in size (40% enlarge in 2 years) and fatty change (irreversible)
- •Goutallier 3-4 and Patte 3 indicate irreparable tear - consider SCR or reverse TSA
- •Force couple concept: RC compresses humeral head, deltoid elevates - disruption causes superior migration
- •Asymptomatic tears common (50% over age 60) - treat symptoms, not imaging