Rotator Cuff Tears

Definition

Rotator cuff tendinitis, partial-thickness and full-thickness tears all fall under the category of rotator cuff disease and is the most common shoulder disorder treated by orthopedic surgeons and sports medicine specialists. In fact, with over 17 million people at risk, the prevalence of sustaining a full-thickness rotator cuff tear is between 7% and 40%. The treatment for each case must be carefully tailored to the individual patient, as each individual case differs due to a variety of factors and variables. These include, but are not limited to, patient factors such as age and occupation, history of the illness and previous trauma, medical comorbidities (ex. diabetes), relevant past surgical history, age related degenerative changes, work status and employment, handedness, and social factors including smoking history, among others. Tear characteristics are also vitally important to consider when deciding on the best treatment algorithm. These include size and pattern of the tear, tendon retraction, muscle atrophy and fatty infiltration, previous surgeries and scar tissue around the shoulder, and other degenerative changes and associated pathology within and around the shoulder joint.

Previously, symptomatic full-thickness rotator cuff tears were treated with open rotator cuff repair surgery. Open surgery was flawed by the fact that it required either a splitting or detachment of the deltoid muscle, along with a large surgical incision to visualize the tear and perform the repair. This ultimately caused higher complication rates and increased failure rates in patients undergoing open repair surgery. However, with advanced technology and improved surgical technique (along with the advent of the arthroscope), rotator cuff tears are now treated arthroscopically through three or four “keyhole” size incisions around the shoulder, utilizing one of two techniques. A single-row suture anchor repair is optimal for smaller tears. A double-row suture anchor repair can be very effective when treating larger rotator cuff tears but has not been clinically proven in prospective trials. Newer techniques, such as the superior capsular reconstruction (SCR), have enabled us to repair or reconstruct cuff tears that were previously deemed irreparable.

Anatomy

The rotator cuff is comprised of four muscles: supraspinatus, infraspinatus, teres minor and subscapularis, all of which begin from the scapula and insert onto the bony tuberosities of the proximal humerus. The four muscles combine into a common tendon that forms a “cuff” of tissue over the proximal humerus – hence, the “rotator cuff.” Both the supraspinatus and infraspinatus are responsible for two-thirds of the posterior rotator cuff and fuse into one tendon that inserts onto the tuberosity. Tears of these two tendons are the most common type of rotator cuff tear.

The insertion site of the rotator cuff is commonly referred to as the footprint. The footprint of the supraspinatus is shaped like a triangle and averages 6.9mm in length (medial to lateral) and 12.6mm in width (anteroposterior width). The footprint of the infraspinatus is shaped like a trapezoid and averages 10.2 mm in length (medial to lateral) and 32.7 mm in width (anteroposterior width). Understanding the natural cuff anatomy is important as this helps direct the surgeon to achieve an “anatomic repair” during surgery. Furthermore, the theoretic advantage of the double-row cuff repair is a more appropriate reconstruction of the anatomic footprint on the humerus.

Pathogenesis

The etiology of rotator cuff tears and disease is multifactorial. Tears are caused by various factors such as age-related degenerative changes, trauma, chronic subacromial impingement, and physiologic loading of the tendon and attrition over time. Genetics have also been shown to have a significant role in the predisposition of a patient to develop a tear; a family history of rotator cuff disease is very common. The most relevant factor in determining the presence of a tear in a patient presenting with shoulder pain is still patient age, which is supported by clinical studies. The older the patient, the higher the incidence of rotator cuff pathology.

Natural History

Because symptomatic rotator cuff tears are often treated, asymptomatic rotator cuff tears can tell us more about the natural history of the disease. Asymptomatic rotator cuff tears are surprisingly very common (in asymptomatic patients 60 years and older, 55% will have a RCT when evaluated by MRI). The progression of asymptomatic tears is an important consideration: in fact, one study showed that 51% of patients with an asymptomatic rotator cuff tear developed symptoms over an average time span of 2.8 years. As a general rule, 50% of asymptomatic rotator cuff tears will become symptomatic within 2 to 3 years. In addition, 50% of symptomatic full-thickness tears will progress at 2 years and bigger tears progress at a faster rate. Partial thickness tears are also likely to progress into full thickness tears with time. As a result, the management of a partial thickness rotator cuff tear poses a challenging clinical dilemma to the clinician. Generally speaking, partial thickness cuff tears where the tear is greater than 50% the diameter of the tendon are converted through surgery into full thickness tears and then repaired. If the tear is less than 50% of the tendon’s diameter, the approach and management strategy is more debatable. Biologics, including platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC) or mesenchymal stem cells, may bridge this gap in the near future by helping reduce the incidence of these tears progressing in size and severity.

Physical Examination

Patients with rotator cuff tears complain of pain, weakness, and decreased range of motion within the shoulder joint. They may also complain of weakness and pain when completing usual activities of daily living that involve the hand at or above shoulder level (ex. brushing one’s hair or reaching for a glass in an elevated cupboard). Patients will also complain of difficulty with regular sporting activities or exercises that involved the shoulder (ex. tennis, golf, swimming, etc). In most cases, the symptoms develop gradually over time. Surprisingly, some patients with large tears will have very reasonable functionality. The patient may complain of localized pain, pain with use of the affected shoulder, and sleep disruption due to pain. In the event of a chronic rotator cuff tear, the physician may be able to identify atrophy of the supraspinatus and infraspinatus muscles which may be evident on physical examination through inspection and comparison of the patient’s shoulders. In this case, the examiner should examine for the presence of previous surgical incisions and test the range of motion of the shoulder. The shoulder should be tested with strength tests to isolate the various muscle of the rotator cuff. Tests such as the Belly press test, Lift-off test, and Bear-hug test can help test strength of the rotator cuff. The Neer impingement test, the empty-can test, and hornblower’s sign (inability to achieve external rotation in a 90-degree abducted position) can all help diagnose a rotator cuff tear.

Imaging and Diagnostics

The four standard shoulder radiographs can be taken to help determine whether further imaging is needed and to diagnose associated pathology around the shoulder. An X-ray will not show a full-thickness rotator cuff tear. However, an X-ray may show proximal humeral migration which may indicate a large, retracted rotator cuff tear. A T2 MRI can show rotator cuff tears as well as muscle atrophy. Alternatively, patients with a pacemaker may need a CT scan or an ultrasound to diagnose a rotator cuff tear. The gold standard (aside from shoulder arthroscopy) to diagnose a rotator cuff tear is an MRI of the shoulder. It is important to remember that in asymptomatic patients older than 60, approximately 55% will have a rotator cuff tear on MRI. Full-thickness tears can be clearly identified, muscle atrophy can be graded (via the Goutallier classification), and associated pathology can be identified and assessed (ex. biceps pathology, SLAP or other labral tears, glenohumeral osteoarthritis, AC joint osteoarthritis, etc.). Dr. Dold will typically order an MRI to assess for a rotator cuff tear and review the findings with you in his office.

Differential Diagnosis

  • Rotator Cuff Tendinitis

  • Partial-Thickness Rotator Cuff Tear

  • Rotator Cuff Contusion

  • Adhesive Capsulitis

  • Arthritis

  • Calcific Tendinitis

  • Biceps Tendon Pathology

  • Suprascapular Nerve Entrapment

  • Internal Impingement

  • SLAP or Labral Tear

Non-Operative Management

Some non-operative management options include anti-inflammatory medications (NSAIDs) and physical therapy. In some cases, a subacromial corticosteroid injection may be used to help relieve pain. One should remember, however, that multiple studies have been published which illustrate the negative effect of corticosteroid injections on the results of future surgery, if later indicated. As I have mentioned above, the treatment of a partial thickness rotator cuff tear is a difficult clinical dilemma. Orthobiologics (PRP and mesenchymal stem cells) may help limit or prevent the progression of these partial thickness tears over time.

Surgical Management

With the failure of conservative management options, surgical repair of the rotator cuff is often indicated. Dr. Dold will repair the rotator cuff arthroscopically through 3 to 4 keyhole size incisions around the shoulder. In addition, associated pathology around the shoulder can be treated at the same time as the rotator cuff repair. Following surgery, a PRP or mesenchymal stem cell injection is often used to help expedite healing and improve the integrity of the repair for improved function of the shoulder.

Post-Op

Patients are placed in a sling for approximately 6 weeks after surgery.  An abductor pillow is often used to relieve tension off the repaired tissue. It is important to note that the rate-limiting step for recovery is biologic healing of the repaired rotator cuff tendon to the greater tuberosity, which is believed to take between 8 and 12 weeks. Physical therapy usually begins within 2 weeks of surgery and focuses on regaining range of motion in the shoulder through passive and active-assisted range of motion exercises for the first 6 weeks. Active abduction of the shoulder is usually restricted for the first 6 weeks following surgery. You will be given a personalized, structured, detailed physical therapy protocol by Dr. Dold following your surgery which you will take with you to your first PT appointment. This will outline your various phases of rehabilitation following surgery up until 6 to 9 months post-op.

Complications

  • Infection

  • Anesthetic Complications

  • Postoperative Stiffness or Arthrofibrosis

  • Neurologic injury

   

Rotator Cuff Tendonitis

Definition

Rotator cuff tendonitis refers to inflammation of the tendons in the rotator cuff. This inflammation can cause pain, difficulty with range of motion of the shoulder, stiffness, weakness, and eventually damage to the tendons. Calcific deposits can form inside the tendon and will appear in radiographic imaging. This process is known as “calcific tendonitis.”

Anatomy

The rotator cuff is a musculotendinous structure composed of four muscles: supraspinatus, infraspinatus, teres minor and subscapularis. The four muscles unite to form a cuff of tissue (tendon) that inserts on the humeral head and acts to initiate and control motion of the shoulder. The supraspinatus, infraspinatus, and teres minor insert onto the greater tuberosity of the humerus while the subscapularis inserts on the lesser tuberosity, just medial to the long head of biceps tendon that runs in the bicipital groove. Like all tendons in the body, the rotator cuff is susceptible to inflammation and tendonitis.

Pathogenesis

Rotator cuff tendonitis typically occurs as the result of repetitive overhead motion and movements in combination with altered biomechanics of the glenohumeral joint. Sports that include repetitive overhead motion, including swimming, tennis, volleyball, and baseball, will predispose the patient to tendonitis of the rotator cuff. Chronic degeneration and calcification of the tendons can occur near the insertion of the rotator cuff and lead to a specific form of tendonitis known as “calcific tendonitis”. The condition can also be associated with subacromial impingement of the shoulder due to abnormal morphology of the acromion leading to impingement of the cuff during overhead movements. Calcification of the cuff is divided into three phases:

  • Pre-Calcific: Abnormal changes in the fibrocartilage are occurring, however the patient is usually pain-free.

  • Calcific: The calcific stage is broken down into three phases: formative, resting and resorptive phase. Patients usually begin feeling the most pain during the resorptive phase of the calcific stage.

  • Postcalcific: Crystals are formed in the tissue.

Patient History and Physical Exam

The patient may present with pain and crepitus of the shoulder that is exacerbated with overhead movements. One should take note of the physical activity/sports and occupation of the patient, which may direct the physician to the cause of the pathology. Repetitive sports such as tennis, baseball, volleyball, and swimming and occupations associated with repetitive overhead work (ex. paintor or laborer) can cause tendonitis of the rotator cuff. The patient should be assessed for muscular atrophy of the cuff muscles, not isolated to supraspinatus. Range of motion (ROM) testing should be used to identify decreased active ROM and scapular dyskinesis which can predispose the patient to tendinopathy of the cuff. Provocative testing should be used to test the patient for subacromial impingement signs (ex. Hawkins’ test). Rotator cuff testing is vital to isolate the primary muscles/tendons affected and to rule out a full thickness cuff tear.

Imaging and Diagnostic Studies

Radiographs should be taken in the following views: anteroposterior (AP), supraspinatus outlet view, and axillary views. These radiographs should be examined for calcification of the cuff tissue near its insertion onto the humeral head. Radiographs taken in the internal rotation view should be examined for calcification in teres minor. Radiographs taken in the external rotation view should be examined for calcification in the subscapularis. Typically, calcification can be found ranging anywhere from 1 to 1.5 cm from the insertion point of the supraspinatus tendon. A CT scan can help visualize the shoulder in a three-dimensional view. A magnetic resonance image (MRI) may be ordered for patients with refractory pain and may help identify a rotator cuff tear and other internal derangement of the shoulder.

Differential Diagnosis

  • Subacromial bursitis

  • Biceps tendonitis

  • Subacromial impingement syndrome

  • Glenohumeral osteoarthritis

  • Superior Labral Tear (SLAP tear)

  • Acromioclavicular (AC) osteoarthritis

Nonoperative Management

Nonoperative management includes the use of:

  • NSAIDs (Nonsteroidal Anti-Inflammatories

  • Physical Therapy

  • Stretching Exercises

  • Strengthening Exercises

  • Corticosteroid Injections

  • Platelet-rich Plasma (PRP) or bone marrow aspirate concentrate (BMAC)

  • Extracorporeal Shock-Wave Therapy

Approximately 60-70% of patients can find relief within 6 months of conservative treatment. However, failure can occur when large calcification deposits are the root cause of rotator cuff tendonitis, or when the deposits form under or are medial to the acromion within the muscle tissue.

Surgical Management

Surgery is rarely necessary for the treatment of rotator cuff tendonitis.

Indications for surgery include:

  • A failed conservative treatment plan that consisted of a dedicated physical therapy rehabilitation program

  • Inability to perform basic tasks or activities of daily living

Rotator cuff tendonitis is a common problem that can affect any active patient. If you’re suffering from shoulder pain that is affecting your ability to take part in your regular exercise and activities, contact Dr. Dold’s office for an appointment today!

   

Partial Thickness Rotator Cuff Tears

Definition

Rotator cuff tears of the shoulder can be divided into partial-thickness (incomplete) and full-thickness (complete) tears. While surgery is generally indicated for full-thickness cuff tears that are associated with functional impairment, the management of partial thickness tears is more debatable. A partial-thickness rotator cuff tear is also known as an incomplete tear, because the tendon is not completely torn or detached from its insertion on the humeral head. New modalities such as stem cell therapy and collagen-based bioinductive implants are bridging the gap in our techniques to treat this incompletely understood pathology.

Anatomy

The rotator cuff is a musculotendinous structure that is comprised of four muscles: supraspinatus, infraspinatus, teres minor and subscapularis. The supraspinatus, infraspinatus, and teres minor insert on the greater tuberosity of the humerus; the subscapularis inserts on the lesser tuberosity. These musculotendinous structures serve as a fixed fulcrum for the arm and function to move and rotate the humerus. The rotator cuff sits under the coracoacromial arch; the components of the coracoacromial are the acromion, coracoacromial ligament, and the distal clavicle found at the acromioclavicular joint (AC) joint.

Differential Diagnosis

  • Rotator cuff tendonitis

  • Subacromial bursitis or impingement syndrome

  • Long head of biceps tenosynovitis or tear

  • Calcific tendonitis

  • AC joint arthritis

  • Suprascapular neuropathy

Management

The management of partial-thickness rotator cuff tears is quickly evolving due to new modalities that are emerging and bridging the gap in the surgeon’s armamentarium to deal with these tears. Historically, partial-thickness tears greater than 25-50% of the tendon diameter have been indicated for conversion (by the surgeon) to a full-thickness tear, followed by primary repair of the tendon similar to a repair of a full-thickness tear. Bursal-sided tears >25% and articular-sided tears >50% of the tendon diameter or depth have been considered indications for tear conversion to a complete tear and primary repair. The reason for this is because of the natural history of these tears; it is understood that most partial-thickness tears will progress to a full-thickness (complete) tear over a few years. However, newer innovations may prevent us from converting these partial thickness tears to complete tears, while preventing the natural history of progression of these tears.

Non-operative Management Options:

  • Physical therapy

  • Stem cell injections (BMAC)

  • Platelet-rich plasma (PRP) injections

  • Corticosteroid injections

  • NSAIDs

  • Corticosteroid injections

Surgical Management Options:

  • Arthroscopic tear conversion and primary repair

  • Bio-inductive collagen patch (Link)

  • Subacromial decompression and debridement vs. repair

Studies:

Dr. Dold specializes in the management of all rotator cuff injuries and tear patterns. You may be a candidate for non-operative treatment. Book a consultation today by calling 469.850.0680 or schedule online here. Please bring all previous imaging (XRays, MRI, CT) and all arthroscopic pictures from previous surgeries.

   

Subacromial Impingement Syndrome (Shoulder Impingement)

Definition

Shoulder impingement syndrome was originally described by Dr. Neer in 1972 as shoulder pain, weakness, and dysfunction caused by chronic impingement of the rotator cuff beneath the coracoacromial arch. Repetitive microtrauma of the supraspinatus tendon’s hypovascular area causes progressive inflammation and degeneration of the tendon, resulting in bursitis, tendinopathy, and progressive rotator cuff tearing (partial-thickness tears that progress into full-thickness tears with time). Extrinsic compression of the rotator cuff tendon can occur at the undersurface of the acromion (usually due to subacromial impingement spurs or abnormal morphology of the acromion), the coracoacromial (CA) ligament, and the acromioclavicular (AC) joint.

Anatomy

The acromion, together with the coracoid process and the CA ligament, form the coracoacromial arch. The arch is the rigid structure through which the rotator cuff tendons, subacromial bursa, and humeral head must pass. The primary tendon making up the rotator cuff is the supraspinatus tendon. This is the most common affected tendon in rotator cuff pathology, including subacromial impingement syndrome. The supraspinatus tendon is confined above by the subacromial bursa and coracoacromial arch and below by the humeral head in an area referred to as the “supraspinatus outlet.” On average, there is 9 to 10 mm of space between the undersurface of the acromion and the humeral head in the supraspinatus outlet. This space is narrowed by abnormalities of the coracoacromial arch. Additionally, internal rotation and forward flexion of the arm also decreased the distance between the CA arch and the humeral head, decreasing the space for the supraspinatus tendon and aggravating symptoms associated with impingement syndrome (ex. Hawkins test for impingement). The subacromial bursa tissue overlies the supraspinatus tendon. Its function is to serve as a cushion and lubricate the interface between the rotator cuff and the overlying acromion and AC joint. Importantly, the bursa may become thick and fibrotic in response to progressive subacromial inflammation, further decreasing the volume of the subacromial space while aggravating the symptoms associated with impingement syndrome. Additionally, the supraspinatus tendon has a watershed area of hypovascularity located approximately 1cm medial to the insertion of the rotator cuff on the humeral hand. Due to the lack of blood supply, this area is predisposed to degenerative tearing and tendinopathy as well as tearing from overuse and repetitive microtrauma against the acromion. Together, this is subacromial impingement syndrome.

Acromial morphology most commonly accounts for narrowing of the supraspinatus outlet. Bigliani et al. published a study that described three types of acromial morphology:

  • Type I acromion is flat.

  • Type II acromion is curved.

  • Type III acromion is hooked.

Interestingly, the study also noted that in 70% of cadaver shoulders with rotator cuff tears a type III acromion was present.

Pathogenesis

Extrinsic or outlet impingement of the rotator cuff is caused by abnormalities of the CA arch, resulting in an overall decreased area for the rotator cuff tendons within the supraspinatus outlet. Other processes or pathologies that narrow the supraspinatus outlet must be considered when assessing a patient for impingement syndrome of the shoulder. These include:

  • Osteophytes of the AC joint, due to progressive osteoarthritis of the AC joint

  • Hypertrophy of the CA ligament

  • Malunion of a greater tuberosity or a clavicle fracture

  • Inflammatory subacromial bursitis

  • Calcific rotator cuff tendinitis

  • A flap from a bursal-sided rotator cuff tear

  • An unstable os acrominale (failure of fusion in one of the acromial ossification centers).

Natural History

Neer classified subacromial impingement into three distinct stages:

  • Stage 1: Lesions occur initially with excessive overhead use in sports or at work. This is a reversible process of edema and hemorrhage that is found in the subacromial bursa and adjacent rotator cuff tissue. This typically occurs in patients younger than the age of 25 years old.

  • Stage 2: In stage II lesions, the subacromial bursa may become irreversibly fibrotic and thickened, and tendinitis develops in the supraspinatus tendon. Typically, this lesion is found in patients 25 to 40 years of age.

  • Stage 3: As subacromial impingement progresses, stage III lesions might occur, with partial or complete tears of the rotator cuff tendon. Changes in the bone architecture at the anterior acromion and greater tuberosity may also develop. These lesions occur almost exclusively to patients older than the age of 40.

In terms of the natural history, stage I and II lesions typically respond to non-operative modalities including rest, activity modification, and nonsteroidal anti-inflammatories (NSAIDs). A subacromial corticosteroid injection may also help treat the subacromial bursitis and relieve refractory symptoms. Refractory stage II lesions and stage III lesions require operative intervention.

Patient History and Physical Finding

Patients with subacromial impingement syndrome of the shoulder typically complain of shoulder pain that is aggravated by overhead activities. The pain is typically localized to the lateral aspect of the acromion, extending distally into the deltoid muscle belly. Patients may also experience pain during the night, especially when lying on the affected shoulder. Most commonly, patients do not complain of a restriction in their range of motion but do experience aggravation of their symptoms with internal rotation and forward flexion of the shoulder that is most common with overhead exercises and activity. Physical examination methods to identify subacromial impingement syndrome include:

  • Palpation over the point of Codman: Palpation just anterior to the anterolateral corner of the acromion may produce tenderness that is a sign of supraspinatus tendinitis, tendinopathy, or an acute tear of the supraspinatus tendon.

  • Range of motion (ROM) Testing: patients with impingement often have limited internal rotation due to contracture of the posterior shoulder capsule. Active motion is typically more painful than passive motion especially during the eccentric phase of the motion arc.

  • Neer Impingement Sign.

  • Neer Impingement Test:  an injection of local anesthetic into the subacromial space followed by relief of pain on clinical impingement tests.

  • Hawkins Sign

A complete physical examination of the shoulder should be performed to evaluate and rule out other associated pathologies and other processes in the differential diagnosis. These include:

  • Acromioclavicular (AC) Osteoarthritis

  • Rotator Cuff Tears

  • Glenohumeral Instability

  • Biceps Pathology

  • Glenohumeral osteoarthritis

Imaging/ Diagnostic Studies

Standard radiographs of the shoulder should be taken that include standard anteroposterior (AP) orientations including internal and external rotation views as well as a supraspinatus outlet view. Acromiohumeral distance is the minimal distance between the undersurface of the acromion and the uppermost point of the humeral head. An acromiohumeral distance of less than 7 mm is considered abnormal and a potential cause of subacromial impingement.  An AP radiograph of the contralateral normal shoulder might be taken and used as a comparison view for the acromiohumeral distance.

Other studies, including MRI, CT scan, arthrography, and ultrasonography might be indicated based on the patient’s presentation and clinical examination as well as the findings on plain radiographs. Typically, these tests are reserved for patients whose diagnosis of impingement syndrome is not completely clear or understood from the history, physical examination, and plain radiographs. Additionally, these other modalities may help diagnose associated pathology of the soft tissues around the shoulder including the long head of biceps tendon, labrum, and rotator cuff tendon.

Differential DIagnosis

  • Rotator cuff pathology, including partial and full-thickness tears

  • AC joint osteoarthritis

  • Glenohumeral instability

  • Posterior glenoid and rotator cuff (internal) impingement

  • Glenohumeral osteoarthritis

  • Biceps tendon pathology (biceps tenosynovitis)

  • Adhesive capsulitis (aka. Frozen shoulder)

  • Cervical spine disease

  • Viral brachial plexopathy

  • Thoracic outlet syndrome

  • Neoplasm of the proximal humerus or shoulder girdle

  • SLAP tear

Nonoperative Management

All patients with subacromial impingement syndrome should undergo a course of non-operative management for at least 3 to 6 months. Non-operative treatment  modalities include:

  • Subacromial corticosteroid injections

  • NSAIDs (Nonsteroidal anti-inflammatory drugs)

  • Hot and cold therapies

  • Ultrasound

  • Physical Therapy

Approximately 70% of patients will respond to a conservative treatment protocol with success. The goal of therapy is to regain or improve ROM while improving symptoms of pain. Therapy should be advanced as the pain and inflammation subside. Posterior capsular contracture should also be addressed in physical therapy with progressive adduction and internal rotation stretching. Modalities to control pain are indicated in the acute setting.

Surgical Management

Operative intervention is indicated in patients that continue to have symptoms of impingement syndrome that are refractory to a progressive rehabilitation protocol of stretching and strengthening over a minimum 3- to 6-month period. If the diagnosis is not completely clear based on the initial tests, a more extensive diagnostic workup is warranted before surgical intervention. This will usually include an MRI or an MR arthrography (MRA) of the shoulder to rule out rotator cuff pathology and other internal derangement of the shoulder. Particular attention should be  paid to the acromial morphology, the status of the AC joint, and evidence of rotator cuff disease, as these disease processes often coexist in subacromial impingement syndrome. The mainstay of surgical management is subacromial decompression and acromioplasty in order to increase the acromiohumeral distance and supraspinatus outlets for the rotator cuff to pass without further impingement.

Subacromial Decompression / Acromioplasty

During subacromial decompression, an arthroscopic burr is introduced into the subacromial space and is used to resect abnormal, pathologic bone from the undersurface of the acromion. Resection begins at the anterolateral corner of the acromion and the desired depth of resection is estimated based on the diameter of the burr (usually 5.5mm). The depth of resection is achieved anteriorly from the anterolateral corner of the acromion to the medial acromial facet of the AC joint. All abnormal subacromial spurs are removed during the resection. AC joint bone spurs are also removed. Dr. Dold will also resect and release the coracoacromial (CA) ligament completely and visualize the undersurface of the deltoid at least 15mm posterior to the anterolateral corner of the acromion to ensure a complete subacromial decompression. The entirety of the procedure is done arthroscopically through small keyhole incisions. The patient is placed in a sling for comfort post-operatively and begins passive and active range of motion in physical therapy immediately following surgery. The physical therapy protocol is advanced as rapidly as motion and pain will allow. Full recovery is generally achieved by approximately 3 months postoperatively. However, patients with significant rotator cuff pathology or full thickness tears me take much longer to improve. The success rate of arthroscopic subacromial decompression ranges from 73% to 95%.

To schedule a consultation with Dr. Dold, contact us here.