Rotator Cuff Disease: Rehab and Surgery                                  Lori Michener, PhD, PT, ATC, SCS, FAPTA

4/18/2017

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Lori Michener, PhD, PT, ATC, SCS, FAPTAProfessor | Director of Clinical Outcomes and Research

Director – COOR LabUniversity of Southern California; Los Angeles, CA

lmichene@pt.usc.eduhttp://pt.usc.edu/COOR/

Rotator Cuff Tears and Subacromial Pain Syndrome:

Surgery vs Non-operative Care

COOR Lab

@LoriM_PT

Rotator Cuff Disease

Tendinopathy Partial thickness RC tear Full Thickness RC tear

• Tendinopathy – Potential inflammation (Dean, 2015)

• Partial thickness RC tear– Articular, bursal, mid-substance

• Full-thickness RC tear– Complete rupture superior to inferior

– Not necessarily side to side

– “Hole’ in the sock

Rotator Cuff Disease Rotator cuff disease• Full-thickness RC tear

• Partial thickness RC tear

• Bursitis• Tendinitis• Tendinopathy• Subacromial

impingement

Single clinical 

Dx category:

Subacromial pain syndrome

Same general 

approach, but 

impairments and 

irritability 

considered for 

staged approach 

for rehabilitation 

COOR Lab

Rotator Cuff Disease: Heterogeneous pathology

• Subacromial Pain Syndrome (SPS)

Includes: SPS, PT-RCT

Signs & Sx of FT-RCT can present as SPS

• Full-thickness Rotator Cuff Tear (FT-RCT)

…and heterogeneous mechanisms…

COOR Lab

Rotator Cuff Disease: Rehab and Surgery                                  Lori Michener, PhD, PT, ATC, SCS, FAPTA

4/18/2017

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SupraspinatusTendon

Tendon overload &Degeneration

Mechanical Compression in

SA Space

Subacromial Impingement Syndrome RCD2 predominant theories

If mechanical compression is the predominant mechanism, then….

… ALL patients would benefit with an acromioplasty

• Acromioplasty + rehab was not clinically more beneficial than rehab alone in multipleRCTs (Brox et al; 1993, 1999; Haahr, 2005, 2006; Ketola S, 2009, 2013)

• Bony pathology is not the only mechanism

• ‘Impingement’ – INappropriate umbrella term.

COOR Lab

Mechanisms of RC (Tendon) Disease

• Biomechanical– Tendon Overload

– Impingement• Subacromial: anterior – superior

• Internal: posterior – superior

COOR Lab

Tendon overload• Tendon degeneration with overload

• Micro-tearing to tearing? • Tendon thickens (Michener LA, 2015; Joensen J, 2009; Leong HT, 2012)

• Inflammation (Dean BJ, BJSM; 2015)

• Abnormal collagen laydown

Rotator Cuff Disease: Rehab and Surgery                                  Lori Michener, PhD, PT, ATC, SCS, FAPTA

4/18/2017

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Tendon overload

• Neovascularization? • Conflicting evidence (Lewis J, 2009; Kardouni JR, 2013)

• Is the tendon painful?

Outlet Impingement

Compression or ‘impingement’ of RC tendons

- SA space

SA space measured

Scapular al, 2012)

AHD= acromio-humeral distance10 – 15 mm in healthy

AHD

Tendon compression – is it possible?

SA space and shoulder pain:

– AHD in those with ‘impingement’ (Hekimoglu B et al, 2013; Leong H-T, 2012; Seitz AL, 2011, Hebert LJ, 2003, Graichen H, 1999)

– Greater occupation ratio of supraspinatus tendon / AHD in patients with ‘impingement’ pain (Michener LA, 2013)

• Compression observed– cadaveric (Hughes PC, et al, 2012)

• But in vivo…– Tendon is not ‘available’ for compression (under the

acromion) above ~ 70 elevation (Giphart JE, 2012; Thompson MD, 2011; Bey MJ, 2007)

• Compression MAY occur –lower arm angle• Is compression the culprit??

Glenohumeral impingement

• Posterior / Internal– Compression between

the posterior glenoid and the humeral head

– Described in overhead athletes

– Recent evidence –maybe in others (Lawence R, Ludewig P, et al; CSM, 2017)

Rotator Cuff Disease: Rehab and Surgery                                  Lori Michener, PhD, PT, ATC, SCS, FAPTA

4/18/2017

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So is it compression or is it degeneration?

• Both compression AND degeneration are causes– Less support for compression

COOR Lab

Intrinsic factors:of Tendon degeneration

AgingVascularityMorphologyMechanical

(& extrinsic factors)

SA space- impingement??

RCD

Extrinsic factors:Strength/ m. control Shoulder tightness

GH joint laxityPosture: spine, shBony abnormalities

Scap & GH kinematics

(Outlet SAIS)

Load Load

Impairments

• Weak and/or motor control

– Cuff, scapula, shoulder

• Tightness- pec minor, post shoulder

• Posture – thoracic & shoulder

• Scapular humeral motion deficits

Global

HumerusScapulaThorax

Rehabilitation or Surgery?

• What should the first approach be?– For whom: Tendinopathy, FT-RCT?

– Other considerations?• Patient expectations can predict outcome

• Psychosocial factors

• Lifestyle factors

• Other related diagnoses?

COOR Lab

Rotator Cuff Disease: Rehab and Surgery                                  Lori Michener, PhD, PT, ATC, SCS, FAPTA

4/18/2017

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Non-operative Treatment:how successful is it?

• Tendinopathy partial-thickness tears– 85- 90% of patients report ‘successful’

outcomes after rehabilitation

• No benefit of acromioplasty vs. rehab only (Brox et al; 1993, 1999; Haahr, 2005, 2006; Ketola S, 2009, 2013; Holmgen, 2012; Judge, 2014)

• Rehabilitation first

COOR Lab

Non-operative Treatment:how successful is it?

• Tendinopathy partial-thickness tears

• Surgery – for whom? – Failed treatment after 6 months

– Dependent on goals, functional demands, age, co-morbidities, psychosocial

COOR Lab

Non-operative Treatment:how successful is it?

• Full-thickness tears– 75 – 80% of patients do not request surgery

at 2 years follow-up (Moonsmayer; 2010, 2015; Kukkonen, 2014; Kuhn J, 2013; Cummins, 2012; Ainsworth, 2007)

– Limited evidence of substantial tear progression with non-surgical approach

– Older, chronic tears, respond to rehab in 3 – 4 months:** Rehab should be first option

COOR Lab

Considerations

• Full-thickness tears– Pain does not correlate with (Dunn W, 2014; Unrah, 2014)

• Size of the tear

• Tendon retraction

• Superior HH translation

• Impairments

– But - Are we ‘kicking the can down the road”?

COOR Lab

Rotator Cuff Disease: Rehab and Surgery                                  Lori Michener, PhD, PT, ATC, SCS, FAPTA

4/18/2017

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Who should have surgery as the first option?

• Full-thickness tears– Age, acute tears, functional demands, goals

Young/ younger, acute tear, hi function, hi goals

Younger with chronic tears, and hi function/ goals

** Consider surgery as the first option?

COOR Lab

Surgical Treatment?

• Full-thickness tears – Surgical repair– Good outcomes generally (Moosmayer, 2010, 2015; Koh,

2014; Carr, 2012)

– Re-tear rates – 22 – 48%• Difference in outcomes if re-tear vs. not? NO

COOR Lab

Rotator Cuff Disease

Chronic FT‐RCT 

> 60 yo

Irreparable tear?

Initial Non‐Operative Treatment

Acute Tears

Chronic FT‐RCT

< 60 yo

Early Surgical Repair

Tendiopathy

PT‐RCT – Small tears

< 1 cm

Prolonged Non‐Operative Treatment

Adapated from: Edwards P et al, IJSPT, 2016;  ‘ Tashjian RZ, Clin Sports med, 2012 

Questions?