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Review
. 2019 Mar 1;27(5):156-165.
doi: 10.5435/JAAOS-D-17-00480.

Degenerative Rotator Cuff Tears: Refining Surgical Indications Based on Natural History Data

Jay D Keener  1 , Brendan M Patterson, Nathan Orvets, Aaron M Chamberlain
Affiliations
Review

Degenerative Rotator Cuff Tears: Refining Surgical Indications Based on Natural History Data

Jay D Keener et al. J Am Acad Orthop Surg. .

Abstract

Degenerative rotator cuff tears are the most common cause of shoulder pain and have a strong association with advanced aging. Considerable variation exists in surgeons' perceptions on the recommended treatment of patients with painful rotator cuff tears. Natural history studies have better outlined the risks of tear enlargement, progression of muscle degeneration, and decline in the function over time. This information combined with the known factors potentially influencing the rate of successful tendon healing such as age, tear size, and severity of muscle degenerative changes can be used to better refine appropriate surgical indications. Although conservative treatment can be successful in the management of many of these tears, risks to nonsurgical treatment also exist. The application of natural history data can stratify atraumatic degenerative tears according to the risk of nonsurgical treatment and better identify tears where early surgical intervention should be considered.

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Figures

Figure 1.
Figure 1.
Insertional rotator cuff anatomy according to Mochizuki in an illustration of the superior right proximal humerus. HH = humeral head, LT = lesser tuberosity, GT = greater tuberosity, SSP-I = supraspinatus insertion, ISP-I = infraspinatus insertion. (Mochizuki, T, Sugaya, H, Uomizu, M, Maeda, K, Matsuki, K, Sekiya, I, Muneta, T, Akita, K: Humeral Insertion of the Supraspinatus and Infraspinatus. New Anatomical Findings Regarding the Footprint of the Rotator Cuff. J Bone Joint Surg Am 2008;90:962–9.)
Figure 2.
Figure 2.
A: Anterior Cable Intact Tear. Typical appearance of degenerative rotator cuff tear. Tear involves the supraspinatus and anterior infraspinatus within the rotator crescent. The anterior attachment of the supraspinatus is intact preventing severe retraction of the supraspinatus tendon. * = biceps tendon. B: Anterior Cable Disrupted Tear. This degenerative cuff tear involves the anterior supraspinatus tendon uncovering the biceps tendon. More severe retraction of the supraspinatus muscle is seen. * = biceps tendon.
Figure 2.
Figure 2.
A: Anterior Cable Intact Tear. Typical appearance of degenerative rotator cuff tear. Tear involves the supraspinatus and anterior infraspinatus within the rotator crescent. The anterior attachment of the supraspinatus is intact preventing severe retraction of the supraspinatus tendon. * = biceps tendon. B: Anterior Cable Disrupted Tear. This degenerative cuff tear involves the anterior supraspinatus tendon uncovering the biceps tendon. More severe retraction of the supraspinatus muscle is seen. * = biceps tendon.
Figure 3.
Figure 3.
T1 weighted parasagittal MRI images demonstrating rotator cuff muscle health. A: Right shoulder. All cuff muscles healthy. B: Right shoulder. Supraspinatus (thin arrow) with Goutallier grade II changes (fatty change noted but more muscle than fat). Infraspinatus (thick arrow) with grade III changes (equal muscle and fat). Teres minor (*) with advanced fatty infiltration. C: Left Shoulder. Supraspinatus (thin arrow) and Infraspinatus (thick arrow) with grade IV changes (more fat than muscle).
Figure 3.
Figure 3.
T1 weighted parasagittal MRI images demonstrating rotator cuff muscle health. A: Right shoulder. All cuff muscles healthy. B: Right shoulder. Supraspinatus (thin arrow) with Goutallier grade II changes (fatty change noted but more muscle than fat). Infraspinatus (thick arrow) with grade III changes (equal muscle and fat). Teres minor (*) with advanced fatty infiltration. C: Left Shoulder. Supraspinatus (thin arrow) and Infraspinatus (thick arrow) with grade IV changes (more fat than muscle).
Figure 3.
Figure 3.
T1 weighted parasagittal MRI images demonstrating rotator cuff muscle health. A: Right shoulder. All cuff muscles healthy. B: Right shoulder. Supraspinatus (thin arrow) with Goutallier grade II changes (fatty change noted but more muscle than fat). Infraspinatus (thick arrow) with grade III changes (equal muscle and fat). Teres minor (*) with advanced fatty infiltration. C: Left Shoulder. Supraspinatus (thin arrow) and Infraspinatus (thick arrow) with grade IV changes (more fat than muscle).
Figure 4.
Figure 4.
Acute on chronic rotator cuff tear, right shoulder. A: Coronal T2 weighted MRI image. Large retracted tear of the supraspinatus tendon (thin arrow). B: Coronal T2 weighted MRI image. Retracted and kinked infraspinatus tendon (thin arrow). Intramuscular edema noted within the infraspinatus (thick arrow). C: Parasagittal T2 weighted MRI image. Perimuscular edema noted within the supraspinatus and infraspinatus muscles. D: Parasagittal T1 weighted MRI image. Grade III Goutallier fatty changes within the supraspinatus (thin arrow). Grade I/II Goutallier fatty changes within the infraspinatus (thick arrow).
Figure 4.
Figure 4.
Acute on chronic rotator cuff tear, right shoulder. A: Coronal T2 weighted MRI image. Large retracted tear of the supraspinatus tendon (thin arrow). B: Coronal T2 weighted MRI image. Retracted and kinked infraspinatus tendon (thin arrow). Intramuscular edema noted within the infraspinatus (thick arrow). C: Parasagittal T2 weighted MRI image. Perimuscular edema noted within the supraspinatus and infraspinatus muscles. D: Parasagittal T1 weighted MRI image. Grade III Goutallier fatty changes within the supraspinatus (thin arrow). Grade I/II Goutallier fatty changes within the infraspinatus (thick arrow).
Figure 4.
Figure 4.
Acute on chronic rotator cuff tear, right shoulder. A: Coronal T2 weighted MRI image. Large retracted tear of the supraspinatus tendon (thin arrow). B: Coronal T2 weighted MRI image. Retracted and kinked infraspinatus tendon (thin arrow). Intramuscular edema noted within the infraspinatus (thick arrow). C: Parasagittal T2 weighted MRI image. Perimuscular edema noted within the supraspinatus and infraspinatus muscles. D: Parasagittal T1 weighted MRI image. Grade III Goutallier fatty changes within the supraspinatus (thin arrow). Grade I/II Goutallier fatty changes within the infraspinatus (thick arrow).
Figure 4.
Figure 4.
Acute on chronic rotator cuff tear, right shoulder. A: Coronal T2 weighted MRI image. Large retracted tear of the supraspinatus tendon (thin arrow). B: Coronal T2 weighted MRI image. Retracted and kinked infraspinatus tendon (thin arrow). Intramuscular edema noted within the infraspinatus (thick arrow). C: Parasagittal T2 weighted MRI image. Perimuscular edema noted within the supraspinatus and infraspinatus muscles. D: Parasagittal T1 weighted MRI image. Grade III Goutallier fatty changes within the supraspinatus (thin arrow). Grade I/II Goutallier fatty changes within the infraspinatus (thick arrow).
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