Mr Puneet Monga presenting on Rotator Cuff Tendinopathy at The Arm Clinic on Friday 20th January 2017.

1. Rotator Cuff Tendinopathy
Mr Puneet Monga
Consultant Orthopaedic Shoulder Surgeon
Wrightington Hospital

2. Terminology
• Tendonitis / Tendinitis
• Tendinoses
• Tendinopathy

3. What’s the correct term to use ?

4. Terminology
• Tendonitis / Tendinitis - Inflammation of the
tendon (rare)- Inappropriate terminology.
• Tendinoses- Degenerative condition-
Tendon damage at cellular level.
• Tendinopathy - Disease of the tendon

5. What’s the function of the
Rotator Cuff?

6. Function of a Tendon
Force Transmission from Muscle to bone

7. The Rotator Cuff
Image Courtesy- www.patient.info

8. Function of the RC
• Rotation of the humerus w.r.t Scapula
• Compresses the head into the glenoid-
dynamic stability
• Force coupling - Deltoid / Lattisimus / Pec
Major

9. What’s the Aetiology of RC
Tendinopathy

10. Causation of Rotator Cuff Tendinopathy
• Extrinsic factors
• Intrinsic factors

11. Acromial shapes
Bigliani, L. U.; Morrison, D. S.; and April, E. W.: The morphology of the acromion and its relationship to
rotator cuff tears. Orthop. Trans.,10: 228, 1986.10228 1986
Higher proportion of RC
tears seen in Curved and
Hooked Acromions
Image courtesy- Shoulderdoc.co.uk

12. Sub-acromial Wringer

13. Coronal Plane Patho-anatomy
AbductionNeutral Position
Repetitive Micro-trauma from external impingement

14. Sagittal - oblique Plane Pathoanatomy
Sub-Acromial volume

15. Subacromial Decompression
Sub-Acromial volume

16. Extrinsic Theory doesn’t explain it all
• RCT- Bursectomy vs Bursectomy + acromioplasty- No Difference
• Articular surface tendon damage more common
• No direct relation between acromial shape and impingement
symptoms
Lewis J. Subacromial impingement syndrome: a musculoskeletal condition or a clinical illusion? Physical Therapy Reviews. 16(5):388-98. 2011

17. Let’s understand the normal
tendon structure and healing….

18. Normal Tendon
Normal Cuff Tendon =
Collagen (Type I predominantly)
Elastin
Glycosaminoglycan
Proteoglycans
Water
Image Courtesy:
www.ouhsc.edu

19. Injured tendon- Usual repair
Total Collagen decreases
Increased gene expression of Type I,VI, IX and III
Decreased Type II expression.
Repair and replacement of normal collagen
Andrew Carr, Paul Harvie Chapter;Tendon Injuries pp 101-118 Rotator Cuff Tendinopathy.
In Tendon Injuries. Maffulli et al Springer, 2005.

20. Normal Healing
Repetitive loading
Micro tearsHealing
Cellular Repair

21. Compensated Overuse
Excessive loading
Healing
Cellular Repair

22. So, what goes wrong in
tendinopathy?

23. Tendinopathy
• Excessive remodelling in response to
tendon damage during tendon repair
• Aberrant “quality” Collagen
“Stiffer Extracellular matrix”

24. Normal
Tendinopathy-
Disorganised matrix
Cellular clumping
Is Tendon Structure Associated with symptoms in Chronic Achilles TEndinopathy?
An update on pain mechanisms– Written by Robert-Jan deVos,The Netherlands,Aspetar Sports Medicine Journal 2017

25. Tendinopathy
Repetitive loadingProne to
damage

26. Can we blame our genes ?

27. Role of genetics
Possible link with “ank” mutation
(This is seen in association with Progressive form of arthritis)
Gene codes for a protein which transports Pyrophosphate out of
the cells…..so a defective gene leads to high concentration of PPi.
Increased Calcium deposition
Andrew Carr, Paul Harvie Chapter;Tendon Injuries pp 101-118 Rotator Cuff Tendinopathy.
In Tendon Injuries. Maffulli et al Springer, 2005.

28. Ok, what about the tendon
blood supply?

29. Role of blood supply
Codman’s Critical zone
Debated- perhaps decreased
blood supply a result rather than
a cause
“Chicken or egg”
May explain the location along with external impingement
Andrew Carr, Paul Harvie Chapter;Tendon Injuries pp 101-118 Rotator Cuff Tendinopathy.
In Tendon Injuries. Maffulli et al Springer, 2005.

30. What’s the progression of Cuff
tendinopathy ?

31. Unified Continuum Theory

32. • Why do some partial tears progress to Full
• Why do some small tears progress to large
• Why do only 4% massive tears develop
Cuff tear arthritis
• Presence of Cuff tear without impingement
/ vice versa

33. Discontinuous and multifactorial model
Andrew Carr, Paul Harvie Chapter;Tendon Injuries pp 101-118 Rotator Cuff Tendinopathy.
In Tendon Injuries. Maffulli et al Springer, 2005.

34. Making a Diagnosis

35. Rotator Cuff Tendinopathy (and
tears) may be asymptomatic

36. Using a Cluster approach recommended
• History
• Look Feel Move + Special Tests
• Investigations
Making a Diagnosis

37. Positive Special Test = Diagnosis!

38. History and physical examination provide little
guidance on diagnosis of rotator cuff tears.
Jain NB, Yamaguchi K. Evid Based Med.
2014 Jun;19(3):108.

39. Role of Investigations
• Ultrasound - Good for soft tissues & dynamic
• Xray- Good screening tool for Bone / joint
• CT- Good for bone
• MRI- Good for soft tissues and cross sectional

40. Management

41. First line Management
• Activity Modification
• Analgesia
• Physiotherapy- Posture, motor control,
stretching, strengthening, Manual therapy-
6 weeks

42. Physiotherapy
Principles
• Pain relief
• Maintaining Range of movement
• Progressive Strengthening

43. When would I expect
physiotherapy to work?

44. Positive Predictors
(1) Patient expectation of ‘complete recovery’ compared to a
‘slight improvement’ as ‘a result of physiotherapy treatment’,
(2) Lower pain severity specifically at rest,
(3) The absence of a previous major operation (shoulder
surgery excluded),
(4) The absence of pain in the opposite upper quadrant and
(5) Change in pain or range of shoulder elevation with manual
facilitation of the scapula during elevation of the arm.

45. Cortisone Injection in Cuff
Tendinopathy

46. Is Tendinopathy inflammatory?
• No
• Biopsies- No inflammatory cells
• Degenerative changes
Sports Med. 1999 Jun;27(6):393-408.Histopathology of common tendinopathies.
Update and implications for clinical management. Khan KM1, Cook JL, Bonar F,
Harcourt P,Astrom M.

47. 1. Pragmatic reason
Neer’s Test - LA component Cross confirms the
diagnosis
So,Why inject?

48. And,…. what about bursitis ?

49. Is Bursitis inflammatory?
• Yes
• Presence of Inflammatory mediators in
Bursal biopsies
• Inflammatory mediators reduced following
NSAIDs or cortisone injection
Arch Orthop Trauma Surg. 1992;111(6):336-40. Inflammation of the subacromial bursa in chronic shoulder pain. Santavirta S1, KonttinenYT,Antti-Poika I, Nordström D
J Shoulder Elbow Surg. 2005 Jan-Feb;14(1 Suppl S):84S-89S.The molecular pathophysiology of subacromial bursitis in rotator cuff disease. Blaine TA1, KimYS,Voloshin I, Chen D, Murakami K, Chang SS,
Winchester R, Lee FY, O'keefe RJ, Bigliani LU.
J Orthop Res. 2006 Aug;24(8):1756-64. Stromal cell-derived factor 1 (SDF-1, CXCL12) is increased in subacromial bursitis and downregulated by steroid and nonsteroidal anti-inflammatory agents.
KimYS1, Bigliani LU, Fujisawa M, Murakami K, Chang SS, Lee HJ, Lee FY, Blaine TA.

50. Current Practice
Sub-acromial Steroid Injection
Usually 1
BOA/ BESS commissioning guide

51. Indications for Surgery
Failure of First line treatment
Symptoms lasting more than 6 months

52. Notable Exception
Acute Rotator Cuff Tears
Early surgery has better outcomes
Duncan NS, Booker SJ, Gooding BW, Geoghegan J, Wallace WA, Manning PA Surgery within 6 months of an acute rotator cuff tear significantly improves
outcome. J Shoulder Elbow Surg. 2015 Dec;24(12):1876-80.

53. Setup
• Patient Position - Beach chair / lateral
• Arm holder - traction vs mechanical
• Kit- Coblation/ shaver/ pump

54. Portals

56. Outcomes
20 year follow up 80% satisfied- 14% revision
Arthroscopy. 2015 Oct 24. pii: S0749-8063(15)00704-5. doi: 10.1016/j.arthro.2015.08.026. [Epub ahead of print]
Patients With Impingement Syndrome With and Without Rotator Cuff
Tears Do Well 20 Years After Arthroscopic Subacromial Decompression.
Jaeger M1, Berndt T2, Rühmann O2, Lerch S2.

57. Key Points
• Both Extrinsic and Intrinsic factors play a role
• Tendinopathy is degenerative not inflammatory
• ASD when first line treatment fails
• Reliable outcomes in carefully selected patients

58. Comments and questions?