The Rotator Cuff

This session included presentations on: How accurate is imaging of the rotator cuff?; Non-operative management of rotator cuff; Rehabilitation of the elite upper limb athlete; Management of partial thickness cuff tears; Picking the winner: when to operate on a full-thickness tear; and The role of allograft reconstructions.

The tendons of four muscles, the supraspinatus, infraspinatus, subscapularis and teres minor join together to form the rotator cuff tendon attaches to the head the humerus. There is a high prevalence of asymptomatic cuff tears in those over 50 years old. The clinical tests for rotator cuff integrity are often unreliable, and although an experienced clinician can exclude a full-thickness tear imaging is needed to confirm a tear. There is very little difference in results from use of US compared to MRI, so the choice of which imaging modality to use depends on ‘local factors’. Shoulder pain is very common and is usually due to impingement syndromes or rotator cuff disease and is, therefore, usually managed conservatively. Rehab is best with an MDT and revolves around managing the pain, treating the cuff (stability, normal ROM, strength, functional rehab and RTP) treating the patient through a holistic and thorough picture of the athlete and their environment and with carefully graded exposure to workload. The acute/chronic workload is of major importance, as is the need to maintain fitness levels in all other areas. Partial thickness tears are classified according to the depth of tear and the side of the injury (articular or bursal surface). A key point is whether the tear is less than or greater than 50%. Debridement is more likely to be the treatment for small tears and older patients, whereas repair is more likely to be performed for younger patients with larger tears. Rehab has to be tailored to the individual, i.e. player specific, a guide rather than a prescription and needs good communication between all the stakeholders. Rehab should only progress as the patient is able to perform all the exercises at the previous level without pain or apprehension. Surgery has the best outcomes for healthy active patients who comply with rehab, have a short history, minimal wasting/weakness, no pseudoparalysis, a mobile well-centred joint and a smaller tear. However, the re-tear rate may still be 15–20%. The high rate of recurrent tear following repair has led to the development extracellular matrix (ECM) augmentation, creating a tissue bridge between the shortened tendon and bone, providing an effective scaffold for aligned cellular growth and collagen assembly. This can be done using xenografts, allografts or synthetic ECM. Early results are encouraging but RCTs are needed.