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Evaluation and Management of the Persistently Painful Stiff Shoulder Following Rotator Cuff Repair

Introduction A painful, stiff shoulder is an undesired but not uncommon complication following rotator cuff repair. Postoperative shoulder stiffness, commonly known as POSS, is an “acquired” condition, and several authors have defined it in various ways, depending on the patterns of motion loss with a stabilized scapula. Simply put, it is a persistently painful, stiff shoulder 6–12 weeks following a rotator cuff repair, and this includes…

The Failed Rotator Cuff Repair: Evaluation and Surgical Management

Introduction Failed rotator cuff repair includes patients with recurrent tears; however, it also includes those patients who have not achieved adequate pain control or improved functional outcomes following the index procedure. There are intrinsic and extrinsic factors that contribute to persistent symptoms. The intrinsic factors are specific to the rotator cuff itself and a recurrent tear. The extrinsic factors include persistent biceps symptoms, symptomatic acromioclavicular (AC)…

Outcomes Following Rotator Cuff Repair: Are We Doing Better?

Introduction Ever since the first description over 200 years ago, rotator cuff tears have fascinated orthopedic surgeons. As surgeons moved away from simply identifying rotator cuff tears, focus moved toward treatment of these often debilitating injuries. The first English-language description of an open rotator cuff repair technique, now over 100 years ago, has been followed by a rapid evolution of changing management strategies, operative techniques, and…

Postoperative Rehabilitation Following Rotator Cuff Repair

Introduction Postoperative rehabilitation following rotator cuff repair has been shown to improve functional outcomes in varied patient populations. Owing to the fragile nature of the repair during the initial months after surgery, it is imperative that the rehabilitation professional follow an evidence-based postoperative progression in sync with the physiologic and biomechanical factors of healing to ensure optimal postoperative results and maximize return of functional mobility while…

The Suprascapular Nerve in the Setting of Rotator Cuff Pathology

Introduction Suprascapular neuropathy can have multiple potential etiologies, though it is typically secondary to traction or compression. It has usually been considered to be a rare cause of shoulder pain and dysfunction, and it was viewed as a diagnosis of exclusion. However, reports have emerged that have demonstrated a predilection for this condition in athletes who engage in high-level overhead activity and in those with a…

Greater and Lesser Tuberosity Fractures

Introduction Although the incidence of greater tuberosity fractures of the proximal humerus has been estimated to be 20% of all proximal humerus fractures, lesser tuberosity fractures account for only 2%. Contrary to proximal humerus fractures, the typical patient who sustains this type of injury is a male, younger (between the second and fifth decades of life), and with good bone quality and fewer comorbidities. Greater and…

Shoulder Stiffness (Adhesive Capsulitis) With A Rotator Cuff Tear: How to Manage

Introduction Most shoulder surgeons recognize that many patients with rotator cuff tear have some shoulder stiffness preoperatively. In general, these patients are managed with a shoulder mobilization program before surgical treatment; however, the ideal treatment for rotator cuff tears with shoulder stiffness remains controversial. Recently, simultaneous early treatment of the stiffness with rotator cuff repair has become popular because of several studies stating that there was…

Shoulder Instability with a Rotator Cuff Tear: Management of the Cuff and Labrum

Introduction The shoulder is the least constrained and most mobile joint, making instability a frequent condition in a young and active population. The rotator cuff creates a concavity compression mechanism that dynamically stabilizes the shoulder. Rotator cuff tear favors instability, and therefore the association of both pathologies should be researched even after a single dislocation. Treatment options include nonoperative and operative management. Careful evaluation should precede…

Subscapularis Tendon Tears: Arthroscopic Management

Introduction Tears of the subscapularis are present in nearly 30% of all arthroscopic shoulder procedures and approximately 50% of rotator cuff repairs. Repair of a torn subscapularis tendon is critically important to restoring anatomy and therefore to achieving the best functional outcome possible. The subscapularis is critical to maintaining overhead elevation and serves as the attachment for the anterior rotator cable. Repair is therefore critical to…

Arthroscopic Management of Massive Rotator Cuff Tears

Introduction Massive rotator cuff tears have historically been defined as tears that are greater than 5 cm in size in either the anterior-posterior or medial-lateral length, or tears involving at least two tendons. They account for 20% of all cuff tears and 80% of recurrent tears. Reparability is dependent mainly on tendon quality and retraction, muscle atrophy, and fatty infiltration as well as chronicity. Numerous arthroscopic…

Enhancing the Healing Environment : Cuff Biologies

Introduction Despite improvements in surgical techniques, biomechanical constructs, and implants, a proportion of patients still experience the sequelae (chronic shoulder pain and dysfunction) of a nonhealed rotator cuff. Tendon healing typically comprises four components: progenitor cells, growth factors, scaffold, and vascular supply. Unfortunately, tendons have a poor ability to regenerate owing in part to their poor vascular supply. The rotator cuff tendon has limited intrinsic ability…

When and How to Use Patches

Introduction Symptomatic large and massive rotator cuff tears are common with advancing age. Among those who undergo rotator cuff repair surgery, reasonable clinical outcomes have been reported in the majority of patients; however, complete tendon-to-bone healing is uncommon, with retear rates ranging from 40% to over 90%. In order to improve healing rates, various scaffolds have been investigated to augment these tears at high risk of…

Arthroscopic Rotator Cuff Repair: Double Row

Introduction Rotator cuff tears are common causes of shoulder complaints. Arthroscopic rotator cuff repair is an established treatment modality for rotator cuff tears with successful clinical outcomes. Improved repair techniques have been developed to maintain the integrity between the footprint and the tendon. Arthroscopic double-row and suture bridge repair improves the contact area between tendon and footprint and supports the healing at the repaired rotator cuff…

Arthroscopic Rotator Cuff Repair: Double-Row (Knotted Anchors Medial and Lateral)

Introduction With advances in arthroscopic surgery, several techniques have been developed to increase the tendon–bone contact area, reconstituting a more anatomic configuration of the rotator cuff footprint and providing a better environment for tendon healing. On the basis of magnetic resonance imaging (MRI) findings, the double-row repair is a more anatomic construct, which better restores the native structures of the rotator cuff footprint. However, this does…

Arthroscopic Rotator Cuff Repair: Double-Row Surgical Techniques

Introduction Rotator cuff tears are among the most common disorders affecting the upper extremity, particularly in patients over age 50. They may manifest with pain, weakness, or disability and can be extremely debilitating in active individuals. The goals of treatment are to restore strength and function with resolution of pain. Although nonoperative treatment may be beneficial in selected patients, surgery is often indicated in order to…

Arthroscopic Rotator Cuff Repair: Single-Row Repair (Classic)

Introduction Although arthroscopic rotator cuff repair has largely replaced traditional open surgery for the treatment of a symptomatic full-thickness rotator cuff tear, the optimal repair technique is still a matter of debate. Although the modern double-row repair techniques have been recommended to increase the coverage of the tendon–bone junction and thus enhance healing of the tendon–bone interface, a superior method regarding the clinical outcome and the…

Arthroscopic Management of Partial-Thickness Rotator Cuff Tears (PASTA) In Situ and Takedown Techniques

Introduction Partial-thickness rotator cuff tears (PASTA) are reported to be a common disorder of the shoulder. Improvements in imaging such as magnetic resonance imaging (MRI) and arthroscopic procedures have allowed more accurate characterization of partial rotator cuff tears. In recent years, arthroscopic transtendon or takedown repairs have been reported with good results and without statistically significant differences between techniques related to force or patient satisfaction. Procedure…

Calcific Tendinopathy

A. Evaluation and Management of Calcific Tendinopathy Nicola Maffulli Francesco Oliva Alessio Giai Via Introduction Rotator cuff calcific tendinopathy (RCCT) is a common cause of nontraumatic shoulder pain, characterized by calcium deposits in the substance of the tendon, first described by Painter in 1907. Calcific deposits can be found in up to 22% of patients during routine shoulder examination. A study from Louwerens et al. in 2015 found that…

What Type of Rotator Cuff Tear Is This? Tear Pattern Recognition and Soft-Tissue Releases

Introduction Rotator cuff tears are classically described as crescent-shaped, U-shaped, L-shaped, reverse L-shaped, and massive contracted immobile tears. Tear pattern recognition is critical to ensuring anatomic repair of the rotator cuff, restoring and balancing the force couples about the shoulder, and reestablishing a normal glenohumeral fulcrum of motion. Crescent-shaped tears have excellent medial-to-lateral mobility and can be repaired directly to bone. U- and L-shaped tears require…

Arthroscopic Rotator Cuff Repair: Instruments, Portal Placement, and Devices

Introduction Arthroscopic rotator cuff repair has advanced over the last 10 years, and many of the advancements are the result of continued product development and refinement in technique. However, multiple different techniques and instruments that can lead to the achievement of an excellent outcome continue to be available. Success is much less about the “right” instrument and much more about what works for each individual surgeon.…