Treating Full-Thickness Cuff Tears in the Athlete: Advances in Arthroscopic Techniques

The effect of supraspinatus tears on glenohumeral translations in passive pitching motion

BACKGROUND

Supraspinatus tears are common in pitchers. However, the effect of these tears on glenohumeral (GH) mechanics is incompletely understood.

PURPOSE/HYPOTHESIS

To describe the effect of supraspinatus tears and repairs on GH kinematics during an abbreviated throwing motion using the intact shoulder girdle. The hypothesis was that supraspinatus tears would lead to an increase of GH translation in the coronal plane and supraspinatus repairs would restore GH kinematics.

STUDY DESIGN

Controlled laboratory study.

METHODS

Six shoulders from 3 fresh-frozen cadavers were tested in a novel 7 degrees of freedom robotic testing system. Torsos were mounted and the wrist was pinned to an actuator mounted on an upper frame. After the deltoid was removed, the shoulders were studied during an abbreviated throwing motion (ATM) from maximum external rotation to the midcoronal plane to establish a baseline. The ATM was repeated after creation of a 1-cm supraspinatus tear, after creation of a 3-cm supraspinatus tear, and after repair with a transosseous equivalent (TOE) technique. Retroreflective bone markers and high-speed infrared cameras were used to measure GH kinematics and calculate the center of rotation of the GH joint (CORGH) instantaneously.

RESULTS

The 1- and 3-cm supraspinatus tears did not significantly alter GH translation. The TOE repair shifted the CORGH posteriorly, as evidenced by a significant decrease in the overall GH translation in all 3 planes (P = .003, .019, and .026, for x-y, y-z, and x-z planes, respectively).

CONCLUSION

In contrast to a TOE repair of the supraspinatus tendon, isolated supraspinatus tears did not perturb GH kinematics in this cadaveric model of the throwing shoulder.

CLINICAL RELEVANCE

In throwing athletes, treatment of rotator cuff tears should be addressed with caution to avoid an unintended alteration in GH kinematics due to overtightening of the tendon.

Rotator cuff tears in overhead athletes

The rotator cuff is under significant stress during overhead athletics, which can predictably lead to a certain spectrum of rotator cuff injuries in this population. Although the cause is often multifactorial; tensile overload, outlet impingement, and internal impingement are common causes of cuff pathologic conditions in this group. Identification of symptomatic rotator cuff disease can be challenging in the overhead athlete because abnormalities of the rotator cuff are common in asymptomatic throwers and rotator cuff pathologic conditions often occur in conjunction with other injuries. Although nonoperative options should be exhausted, surgical treatment is typically necessary for any rotator cuff tear for which conservative treatment fails. Tear thickness has been classically used to determine the surgical approach, with tears involving less than 50% of the tendon thickness treated with debridement and more substantial tears treated with formal repair. However, some authors and some noted surgeons with experience in managing this patient population have more recently advocated a higher threshold of tendon involvement before considering formal repair. Multiple repair options have been described, but few reports have focused specifically on the outcomes of rotator cuff surgery in overhead athletes. The limited available data do lead, however, to a few reasonable conclusions. Surgical results typically correlate with tear severity. Partial-thickness tears treated with arthroscopic debridement and management of concomitant pathologic conditions seem to have fairly good outcomes in the literature, with most athletes able to return to activity at their preinjury level. Full-thickness tears, however, have fared much more poorly in the overhead athlete, with largely dismal outcomes after surgical repair. What is abundantly clear is that further refinement of surgical options is necessary to improve patient outcomes after rotator cuff repair in this particularly challenging patient population and to allow more consistent return to sports. Identification of symptomatic rotator cuff disease can be challenging in the overhead athlete because abnormalities of the rotator cuff are common in asymptomatic throwers and rotator cuff pathologic conditions often occur in conjunction with other injuries. Although nonoperative options should be exhausted, surgical treatment is typically necessary for any rotator cuff tear for which conservative treatment fails. Tear thickness has been classically used to determine the surgical approach, with tears involving less than 50% of the tendon thickness treated with debridement and more substantial tears treated with formal repair. However, some authors and some noted surgeons with experience in managing this patient population have more recently advocated a higher threshold of tendon involvement before considering formal repair. Multiple repair options have been described, but few reports have focused specifically on the outcomes of rotator cuff surgery in overhead athletes. The limited available data do lead, however, to a few reasonable conclusions. Surgical results typically correlate with tear severity. Partial-thickness tears treated with arthroscopic debridement and management of concomitant pathologic conditions seem to have fairly good outcomes in the literature, with most athletes able to return to activity at their preinjury level. Full-thickness tears, however, have fared much more poorly in the overhead athlete, with largely dismal outcomes after surgical repair. What is abundantly clear is that further refinement of surgical options is necessary to improve patient outcomes after rotator cuff repair in this particularly challenging patient population and to allow more consistent return to sports.