Vol 3 | Issue 1 | Jan - Apr 2015 | page:31-37 | Yash Kishore Shah, M L  Saraf.

Author: Yash Kishore Shah[1], M.L. Saraf [1].

[1] Bombay Hospital Institute of Medical Sciences, Mumbai.
Institute at which research was conducted: Bombay Hospital Institute of Medical Sciences, Mumbai.
University Affiliation of Thesis: Maharashtra University of Health Sciences, Nashik, Maharashtra.
Year of Acceptance: 2012.

Address of Correspondence
Dr. Yash Kishore Shah,
Orthopaedic Consultant, Matruseva Hospital, 407/5(OLD) 665(NEW) Nana Peth, Quarter Gate, Pune 411002.
Email: dr.yashshah@gmail.com

 Abstract

Background: Rotator cuff tears are a common source of shoulder pain. The incidence of rotator cuff damage increases with age and is most frequently d/t degeneration of the tendon, rather than injury.
Methodology: 15 patients chosen having rotator cuff injuries and undergone conservative therapies and 15 patients chosen undergone operative management for the rotator cuff tear after failed conservative management.
Patients were assessed w.r.t
i.Range of Motion
ii.ADL (Activities of Daily Life) Affection
iii.Night pains
iv.Constant score
v.Tear size
Result and Conclusions: The incidence of rotator cuff damage increases with age and is most frequently due to degeneration of the tendon, rather than injury . Supraspinatus is one of the most consistently involved. Some tears are asymptomatic. Higher incidence of tears were seen in females than in males. Tear size has no relation in the final outcome of range of motion and pain scores. The indications for operative treatment are presence of bursitis, young age, large tear size. And for non operative treatment are presence of fatty degeneration and/ or muscle atrophy.
Keywords: Rotator cuff, supraspinatus tear.
Thesis Question: Is non –operative treatment just as good as operative treatment for rotator cuff injuries and whether all people need operative treatment?
Thesis Answer: Thus the mandatory indications for operative treatment are presence of bursitis, young age, large tear size. The mandatory indications of non operative treatment are presence of fatty degeneration and/ or muscle atrophy. Otherwise all cases must be tackled initially non operatively.

Introduction

Rotator cuff tears are a common source of shoulder pain. The incidence of rotator cuff damage increases with age and is most frequently due to degeneration of the tendon, rather than injury from sports or trauma. Treatment recommendations vary from rehabilitation to surgical repair of the torn tendon(s). The best method of treatment is different for every patient. The decision on how to treat rotator cuff tears is based on the patient's severity of symptoms and functional requirements, and presence of other illnesses that may complicate treatment.

Aims and Objectives

Rotator cuff tears are a common problem of the aged and often neglected in the earlier phases, but with better imaging and health care more and more cases are being seen.
1. To study the natural history and prognosticate the end result of disease with or without operative treatment
2. Further to see whether the natural history can be altered for the better using non operative or operative treatment.
3. To compare the results of operative vs non operative treatment
4. For the future to establish guidelines for treatment purposes, to discuss absolute and relative indications of treatment and to streamline the need for operative treatment and earmark the point of time when such treatment should be instituted.

Material and Method

Design: An observational study; prospective study; retrospective study
Sample size: - 15/15
In this study 15 patients were selected having rotator cuff injuries and undergone conservative therapies and 15 patients were selected having undergone operative management for the rotator cuff tear after having failed the conservative management.
All patients were assessed with respect to
I. Range of Motion
ii. ADL (Activities of Daily Life) Affection
iii. Night pains
iv. Constant score (which includes pain, activities of daily living, range of motion and power.)
v. Tears whether small/medium/large and whether full thickness/partial thickness
The patients had a pre-op USG and/or MRI done.
Definition of the subject to be studied
Inclusion criteria
a) Rotator cuff tears proven on imaging
b) Symptomatic patients who have failed conservative management will be included in the second group i.e. for operative treatment.
c) High Constant scores
Exclusion criteria
a) Concomitant plexus injuries along with cuff tears
b) Previous steroid injection with sepsis
Parameters studied
a) Range of movement
b) ADL (Activities of Daily Life) affection.
c) Night pains
d) Constant score
Duration of follow up
1-3 years
DATA AND RESULTS
Constant score of Group 1. (Operative treatment)
Mean constant score improvement in Operative group = 26.66
Constant score of Group 2. (Conservative treatment)
Mean constant score improvement in Conservative group=28.13
Night pains and A.D.L. (Activities of Daily living) in operative group
Mean improvement in night pain in conservative group is 33.33%
Night pains and A.D.L. (Activities of Daily living) in operative group
Mean improvement in night pain in operative group is 31.7%
Mean minimum time taken for complete pain relief for operative group is 97.46 days
Mean minimum time taken for complete pain relief for conservative group is 95.00 days
The TEAR SIZE has NO RELATION to outcome whatsoever.

Summary and Conclusions

1. Rotator cuff tears are a common source of shoulder pain. . The incidence increases with age and is more due to degeneration than injury.
2. Supraspinatus is one of the most consistently involved in the tears.
3. Higher incidence of tears were seen in females.
4. Tear size = no relation in outcome
5. It is essential to identify whether the patients will do better by surgery or not.
6. The time to complete recovery will be also be prolonged depending upon the pathology involved.
7. Bursitis or Bicipital tendinitis when present are bad prognostic factors.
8. Thus the factors affecting outcome are Bursitis, Fatty degeneration, Muscle atrophy, Original tear and age.
9. An average re- tear rate post surgery is 13% & is related to initial tear size.
10. Conservatively managed cases generally tend to become symptomatic in 5 years
11. In late cases surgery does more relief by decompression buy it may increase the chances of a re-rupture.

Bibliography

(1) Codman EA. The shoulder. The rupture of the supraspinatus tendon and other lesions in and about the subacromialbursa.1934; http://www.shoulderdoc. co.uk/article. asp?section=609.
(2) Ruotolo C, Nottage WM. Surgical and non-surgical management of rotator cuff tears. Arthroscopy 2002,18(5):527-31.
(3) Templehoff S, Rupp S Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg 1999, 8:296-299.
(4) Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance of asymptomatic shoulders. J Bone Joint Surg 1995, 77A: 10-15.
(5) Yamamoto A, Takagishi K, Osawa T, Yanagawa T, Nakajima D, Shitara H, et al. Prevalence and risk factors of a rotator cuff tear in the general population. J Shoulder Elbow Surg 2010;19:116-20.
(6) Reilly P, Dead man and radiologists don't lie. Ann R Coll Surg Engl 2006;88:116-21.
(7) Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am 1995;77:10-5.
(8) Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg 1999;8:296-9.
(9) Schibany N, Zehetgruber H, Kainberger F, Wurnig C, Ba-Ssalamah A, Herneth AM et al. Rotator cuff tears in asymptomatic individuals: a clinical and ultrasonographic screening study. Eur J Radiol 2004;51:263-8.
(10) Kim HM, Teefey SA, Zelig A, Galatz LM, Keener JD, Yamaguchi K. Shoulder strength in asymptomatic individuals with intact compared with torn rotator cuffs. J Bone Joint Surg Am 2009;91:289-96. 65
(11) Neer CS II. Anterior acromioplasty for the chronic impingement syndrome in the shoulder. A preliminary report. J Bone Joint Surg 1972;54:41-50.
(12) Bigliani LU, Ticker JB, Flatow EL, Soslowsky LJ, Mow VC. The relationship of acromial architecture to rotator cuff disease. Clin Sports Med 1991;10:823-8.
(13) Kibler WB. The role of the scapula in athletic shoulder function. Am J Sports Med 1998;26:325-37.
(14) Bateman JE. The diagnosis and treatment of ruptures of the rotator cuff. Surg Clin N Am 1963;43:1523-30.
(15) Patte D. Classification of rotator cuff lesions. Clin Orthop Rel Res 1990;254:81-6.
(16) Thomazeau H, Boukobza E, Morcet N, Chaperon J, Langlais F. Prediction of rotator cuff repair results by magnetic resonance imaging. Clin Orthop 1997;344:275-83.
(17) Zanetti M, Gerber C, Hodler J. Quantitative assessment of the muscles of the rotator cuff with magnetic resonance imaging. Invest Radiol 1998;33:163-70.
(18) Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuffruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop 1994;304:78-83.
(19) Fuchs B, Weishaupt D, Zanetti M, Hodler J, Gerber C. Fatty degeneration of the muscles of the rotator cuff: Assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elbow Surg 1999;8:599-605.
(20) Picture Journal of Shoulder and Elbow Surgery Volume 16, Issue 2 , Pages 174-180, March 2007 Anne K.B.Sørensen, MD KlausBak, MD,
(21) ) Clark JM, Harryman DT. Tendons, ligaments, and capsule of the rotator cuff.
Gross and microscopic anatomy. J Bone Joint Surg Am 1992;74:713-25.
(22) Curtis AS, Burbank KM, Tierney JJ, Scheller AD, Curran AR. The insertional footprint of the rotator cuff: An anatomic study. Arthroscopy 2006;22:603-9.
(23) Ide J, Tokiyoshi A, Hirose J, Mizuta H. An anatomic study of the subscapularis insertion to the humerus: The subscapularis footprint. Arthroscopy 2008;24:749-53.
(24) Kolts I. A note on the anatomy of the supraspinatus muscle. Arch Orthop Trauma Surg 1992;111:247-9.
(25) Mochizuki T, Sugaya H, Uomizu M, Maeda K, Matsuki K, Sekiya I, Muneta T, Akita K. Humeral insertion of the supraspinatus and infraspinatus. New anatomical findings regarding the footprint of the rotator cuff. J Bone Joint Surg Am 2008;90:962-9.
(26) Ruotolo C, Fow JE, Nottage WM. The supraspinatus footprint: An anatomic study of the supraspinatus insertion. Arthroscopy 2004;20:246-9.
(27) Harryman DT, Sidles JA, Harris SL, Matsen FA. The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53-66.
(28) Dugas JR, Campbell DA, Warren RF, Robie BH, Millett PJ. Anatomy and dimensions of rotator cuff insertions. J Shoulder Elbow Surg 2002;11:498-503.
(29) Habermeyer P, Magosch P, Pritsch M, Scheibel MT, Lichtenberg S. Anterosuperior impingement of the shoulder as a result of pulley lesions: A prospective arthroscopic study. J Shoulder Elbow Surg 2004;13:5-12.
(30) Nobuhara K, Ikeda H. Rotator interval lesion. Clin Orthop Rel Res 1987;223:44-50.
(31) Cooper DE, O'Brien SJ, Warren RF. Supporting layers of the glenohumeral joint. Clin Orthop Rel Res 1993;289:144-55. 62.
(32) Walch G, Nove-Josserand L, Levigne C, Renaud E. Tears of the supraspinatus tendon associated with “hidden” lesions of the rotator interval. J Shoulder Elbow Surg 1994;3:353-60.
(33) Werner A, Mueller T, Boehm D, Gohlke F. The stabilizing sling for the long head of the biceps tendon in the rotator cuff interval: A histoanatomic study. Am J Sports Med 2000;28:28-31.
(34) Bigoni BJ, Chung CB. MR imaging of the rotator cuff interval. Radiol Clin North Am 2006;44:525-36.
(35) DePalma AF. The classic: Surgical anatomy of the rotator cuff and the natural history of degenerative periarthritis. Clin Orthop Rel Res 2008;466:543-51.
(36) Prescher A. Anatomical basics, variations, and degenerative changes of the shoulder joint and shoulder girdle. Eur J Rad 2000;35:88-102.
(37) Neer, CORR, 1982
(38) Bigliani LU, Ticker JB, Flatow EL, Soslowsky LJ, Mow VC. The relationship of acromial architecture to rotator cuff disease. Clin Sports Med 1991;10:823-8.
(39) Gill et al. JSES, 2002
(40) Matava MJ, Purcell DB, Rudzki JR. Partial-Thickness Rotator Cuff Tears. Am J Sports Med. 2005;33:1405-1417.
(41) Rothman RH, Parke WW. The vascular anatomy of the rotator cuff. Clin Orthop 1965;41:176-86.
(42) Determe D, Rongières M, Kany J, Glasson JM, Bellumore Y, Mansat M et al. Anatomic study of the tendinous rotator cuff of the shoulder. Surg Radiol Anat1996;18:195-200.
(43) Ling SC, Chen CF, Wan RX. A study on the vascular supply of the supraspinatus tendon. Surg Radiol Anat 1990;12:161-5.
(44) Rudzki JR, Adler RS, Warren RF, Kadrmas WR, Verma N, Pearle AD et al. Contrast-enhanced ultrasound characterization of the vascularity of the rotator cuff tendon: Age- and activity-related changes in the intact asymptomatic rotator cuff. J Shoulder Elbow Surg 2008;17:96S-100S.
(45) Rathburn JB, Macnab I. The microvascular pattern of the rotator cuff. J Bone Joint Surg Br 1970;52:540-53.
(46) Levy O, Relwani J, Zaman T, Even T, Venkateswaran B, Copeland S. Measurement of blood flow in the rotator cuff using laser Doppler flowmetry. J Bone Joint Surg Br 2008;90:893-8.
(47) Matava MJ, Purcell DB, Rudzki JR. Partial-Thickness Rotator Cuff Tears. Am J Sports Med. 2005;33:1405-1417.
(48) Burkhart SS, Esch JC, Jolson RS. The rotator crescent and rotator cable: An anatomic description of the shoulder's “Suspension Bridge”. Arthroscopy 1993;611-6.
(49) Seibold CJ, Mallisee TA, Erickson SJ, Boynton MD, Raasch WG, Timins ME. Radiographics 1999;19:685-705.
(50) Lewis JS. Rotator cuff tendinopathy. Br J Sports Med 2009;43:236-41. 63
(51) Benjamin M, Evans EJ, Copp L. The history of tendon attachements to bone in man. J Anat 1986;149:89-100.
(52) Veeger HE, Van der Helm FC. Shoulder function: The perfect compromise between mobility and stability. J Biomech 2007;40:2119-29.
(53) Lee SB, Kim KJ, O'Driscoll SW, Morrey BF, An KN. Dynamic glenohumeral stability provided by the rotator cuff muscles in the mid-range and end-range of motion. J Bone Joint Surg Am 2000;82:849-57.
(54) Keating JF, Waterworth P, Shawn-Dunn, Crossan J. The relative strengths of the rotator cuff muscles. J Bone Joint Surg Br 1993;75:137-140.
(55) Kuhlman JR, Iannotti JP, Kelly MJ, Riegler FX, Gevaert ML, Ergin TM. Isokinetic and isometric measurement of strength of external rotation and abduction of the shoulder. J Bone Joint Surg Am 1992;74:1320-33.
(56) Otis JC, Peterson MG, Warren RF, Santner TJ. Changes in the moment arms of the rotator cuff and deltoid muscles with abduction and rotation. J Bone Joint Surg Am 1994;76:667-776.
(57) Kuechle DK, Newman SR, Itoi Eiji, Morrey BF, An KN. Shoulder muscle moment arms during horizontal flexion and elevation. J Shoulder Elbow Surg 1997;6:429-39.
(58) Liu J, Hughes RE, Schmutz WP, Niebur G, Nan-An K. Roles of deltoid and rotator cuff muscles in shoulder elevation. Clin Biomech 1997;12:32-38.
(59) Kronberg M, Németh G, Broström LA. Muscle activity and coordination in the normal shoulder. An electromyographic study. Clin Orthop Rel Res 1990;257:76- 85.
(60) Townsend H, Jobe FW, Pink M, Perry J. Electromyographic analysis of the glenohumeral muscles during a baseball rehabilitation program. Am J Sports Med 1991;19:264-72.
(61) Hughes RE, An KN. Force analysis of rotator cuff muscles. Clin Orth Rel Res 1996;330:75-83.
(62) Halder A, Zobitz ME, Schultz F, An KN. Mechanical properties of the posterior rotator cuff. Clin Biomech, 2000;15:456-62.
(63) (Nordin & Frankel, 2001).
(64) Parsons et al. J Orthop Res. 2002 ]
(65) Farin PU, Kaukanen E, Jaroma H, Vaatainen U, Miettinen H, Soimakallio S. Site and size of rotator cuff tear. Findings at ultrasound, double-contrast arthrography, and computed tomography arthrography with surgical correlation. Invest Radiol 1996;31:387-94.
(66) Sonnabend DH, Hughes JS, Giuffre BM, Farrell R. The clinical role of shoulder ultrasound. Aust NZ J Surg 1997;67:630-3.
(67) Read JW, Perko M. Shoulder ultrasound: diagnostic accuracy for impingement syndrome, rotator cuff tear, and biceps tendon pathology. J Shoulder Elbow Surg 1998;7:264-71.
(68) Teefey SA, Hasan SA, Middleton WD, Patel M, Wright RW, Yamaguchi K. Ultrasonography of the rotator cuff. J Bone Joint Surg Am 2000;82:498-504.
(69) Roberts CS, Walker JA, Seligson D. Diagnostic capabilities of shoulder ultrasonography in the detection of complete and partial rotator cuff tears. Am J Orthop 2001;30:159-62.
(70) Ferrari FS, Governi S, Burresi F, Vigni F, Stefani P. Supraspinatus tendon tears: comparison of US and MR arthrography with surgical correlation. Eur Radiol 2002;12:1211-7.
(71) Ziegler DW. The use of in-office, orthopaedist-performed ultrasound of the shoulder to evaluate and manage rotator cuff disorders. J Shoulder Elbow Surg 2004;13:291-7.
(72) Middleton WD, Teefey SA, Yamaguchi K. Sonography of the shoulder. Semin Musculoskelet Radiol 1998;2:211-21.
(73) Bouffard JA Lee S-M, Dhanju J. Ultrasonography of the Shoulder. Semin Ultrasound 2000;21:164-91.
(74) Kluger R, Mayrhofer R, Kröner A, Pabinger C, Partan G, Hruby W et al. Sonographic versus magnetic resonance arthrographic evaluation of full-thicknes rotator cuff tears in millimeters. J Shoulder Elbow Surg 2003;12:110-6. (79) van Holsbeeck MT, Kolowich PA, Eyler WR, Craig JG, Shirazi KK, Habra GK et al. US depiction of partial-thickness tear of the rotator cuff. Radiology 1995;197:443-6.
(75) Kenn W, Hufnagel P, Müller T, Gohlke F, Böhm D, Kellner M et al. Arthrography, ultrasound and MR imaging in the evaluation of the rotator cuff: a prospective study [in German]. Fortschr Röntgenstr 2000;172:260-6. 67
(76) Martin-Hervàs C, Romero J, Navas-Acién A, Reboiras JJ, Munuera L. Ultrasonographic and magnetic resonance images of rotator cuff lesions compared with arthroscopy or open surgery findings. J Shoulder Elbow Surg 2001;10:410-5.
(77) Wu HP, Dubinsky TJ, Richardson ML. Association of shoulder Sonographic findings with subsequent surgical treatment for rotator cuff injury. J Ultrasound Med 2003;22:155-61.
(78) Thomazeau H, Boukobza E, Morcet N, Chaperon J, Langlais F. Prediction of rotator cuff repair results by magnetic resonance imaging. Clin Orthop 1997;344:275-83.
(79) Kenn W, Hufnagel P, Müller T, Gohlke F, Böhm D, Kellner M et al. Arthrography, ultrasound and MR imaging in the evaluation of the rotator cuff: a prospective study [in German]. Fortschr Röntgenstr 2000;172:260-6.67
(80) Martin-Hervàs C, Romero J, Navas-Acién A, Reboiras JJ, Munuera L. Ultrasonographic and magnetic resonance images of rotator cuff lesions compared with arthroscopy or open surgery findings. J Shoulder Elbow Surg 2001;10:410-5.
(81) Lannotti JP, Zlatkin MB, Esterhai JL, Kressel HY, Dalinka MK, Spindler KP. Magnetic resonance imaging of the shoulder. Sensitivity, specificity, and predictive value. J Bone Joint Surg Am 1991;73:17-29.
(82) Teefey SA, Rubin DA, Middleton WD, Hildebolt CF, Leibold RA, Yamaguchi K. Detection and quantification of rotator cuff tears. Comparison of ultrasonographic, magnetic resonance imaging, and arthroscopic findings in seventy-one consecutive cases. J Bone Joint Surg Am 2004;86:708-11.
(83) Bryant L, Shnier R, Bryant C, Murrell GA. A comparison of clinical estimation, ultrasonography, magnetic resonance imaging and arthroscopy in determining the size of rotator cuff tears. J Shoulder Elbow Surg 2002;11:219-24.
(84) Gerber C, Fuchs B, Hodler J. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am 2000;82:505-15.
(85) Goutallier D, Postel JM, Gleyze P, Leguilloux P, Van Driessche S. Influence of cuff muscle fatty degeneration on anatomic and functional outcome after simple suture of full-thickness tears. J Shoulder Elbow Surg 2003;12:550-4.
(86) Cofield RH, Parvizi J, Hoffmeyer PJ, Lanzer WL, Ilstrup DM, Rowland CM..Surgical repair of chronic rotator cuff tears. A prospective long-term study. J Bone Joint Surg Am. 2001Jan:83-A(1):71-7
(87) Galatz LM, Griggs S, Cameron BD, Iannotti JP.. Prospective longitudinal analysis of postoperative shoulder function: a ten-year follow-up study of full-thickness rotator cuff tears. J Bone Joint Surg Am. 2001 Jul;83-A(7):1052-6.
(88) Neil S. Ghodara, MD Open, Mini-open, and All-Arthroscopic Rotator Cuff Repair Surgery: Indications and Implications for Rehabilitation Review article
(89) Levy HJ, Uribe JW, Delaney LG. Arthroscopic assisted rotator cuff repair: preliminary results. Arthroscopy. 1990;6:55-60.
(90) Ianotti JP, Naranja J, Gartsman G. Surgical treatment of the intact cuff and repairable
cuff defect: Arthroscopic and open techniques. In: Norris TR ed. Orthopaedic
Knowledge Update: Shoulder and Elbow. 1st ed. Rosemont, Illinois: American Academy of Orthopaedic Surgeons; 1997: 151-155
(91) Amstutz HC, Sew Hoy AL, Clarke IC: UCLA anatomic total shoulder arthroplasty. Clin Orthop 155:10–14, 1981
(92) Lippitt SB, Harryman II DT, Matsen III FA: A Practical Tool for Evaluating Function: The Simple Shoulder Test. In Matsen III FA, Fu FH, Hawkins RJ (eds). The Shoulder: A Balance of Mobility and Stability. Rosemont, IL, The American Academy of Orthopaedic Surgeons 545–559, 1993.
(92) Constant C R, Murley A H G. A clinical method of functional assessment of the shoulder. Clinical Orthopaedics and Related Research 1987; 214: 160-164.
(93) Constant C R. Assessment of the shoulder. In: Watson M. Surgical disorders of the shoulder. Churchill Livingstone, New York. 1991; 39-45.
(94) ) Constant C R. Constant Scoring Technique for Shoulder Function SECEC information. 1991. Nr 3
(95) ) Gerber C. Integrated Scoring Systems for the Functional Assessment of the Shoulder. In: Matsen F, Fu F, Hawkins (red). The Shoulder: A Balance of Mobility and Stability. Rosemont, 1992; 531-50.
(96) ) Circular to members of British Shoulder and Elbow Society. 1997.
(97) Yamaguchi, K., et al., Natural history of asymptomatic rotator cuff tears: a longitudinal analysis of asymptomatic tears detected sonographically. J Shoulder Elbow Surg, 2001. 10(3): p. 199‐203.
(98) Beaudreuil, J., et al., Natural history or outcome with conservative treatment of degenerative rotator cuff tears. Joint Bone Spine, 2007. 74(6): p. 527‐9.
(99) Ainsworth, R. and J.S. Lewis, Exercise therapy for the conservative management of full thickness tears of the rotator cuff: a systematic review. Br J Sports Med, 2007. 41(4): p. 200‐10.
(100) Goldberg, B.A., R.J. Nowinski, and F.A. Matsen, 3rd, Outcome of nonoperative management of fullthickness rotator cuff tears. Clin Orthop Relat Res, 2001(382): p. 99‐107.
(101) Melis, B., C. Nemoz, and G. Walch, Muscle fatty in5iltration in rotator cuff tears: descriptive analysis of 1688 cases. Orthop Traumatol Surg Res, 2009. 95(5): p. 319‐24.
(102) Caroit, M., et al., Outcome of rupture and complete perforation of the unoperated rotator cuff of the shoulder Rev Rhum Mal Osteoartic, 1989. 56(12): p. 815‐21.
(103) Bokor, D.J., et al., Results of nonoperative management of fullthickness tears of the rotator cuff. Clin Orthop Relat Res, 1993(294): p. 103‐10.
(104) Itoi, E. and S. Tabata, Conservative treatment of rotator cuff tears. Clin Orthop Relat Res, 1992(275): p. 165‐73.
(105) Vad, V.B., et al., Negative prognostic factors in managing massive rotator cuff tears. Clin J Sport Med, 2002. 12(3): p. 151‐7.
(106) Goutallier, D., et al., [In5luence of muscular degeneration of the supra and infraspinatus on the prognosis of surgical repair of the rotator cuff]. Acta Orthop Belg, 1998. 64 Suppl 2: p. 42‐5.
(107) Goutallier, D., et al., Fatty muscle degeneration in cuff ruptures. Preand postoperative evaluation by CT scan. Clin Orthop Relat Res, 1994(304): p. 78‐83.
(108) Maman, E., et al., Outcome of nonoperative treatment of symptomatic rotator cuff tears monitored by magnetic resonance imaging. J Bone Joint Surg Am, 2009. 91(8): p. 1898‐906.
(109) 54. Su, W.R., J.E. Budoff, and Z.P. Luo, The effect of anterosuperior rotator cuff tears on glenohumeral translation. Arthroscopy, 2009. 25(3): p. 282‐9.
(110) Hansen, M.L., et al., Biomechanics of massive rotator cuff tears: implications for treatment. J Bone Joint Surg Am, 2008. 90(2): p. 316‐25.
(111) Soslowsky, L.J., et al., Biomechanics of the rotator cuff. Orthop Clin North Am, 1997. 28(1): p. 17‐30.
(112) Soslowsky, L.J., et al., Quantitation of in situ contact areas at the glenohumeral joint: a biomechanical study. J Orthop Res, 1992. 10(4): p. 524‐34. 12): p. 2764‐76.
(113) Bartolozzi, A., Andreychik, D., & Ahmad, S. (1994). Determinants of outcome in the treatment of rotator cuff disease. Clinical Orthopaedics and Related Research, 308, 90-97.
(114) Ellman, H., Hanker, G. & Bayer, M. (1986). Repair of the rotator cuff: end-result study of factors influencing reconstruction. The Journal of Bone and Joint Surgery, 68A, 1136-1142.
(115) Samilson, R. L. & Binder, W. F. (1975) Symptomatic full thickness tears of the rotator cuff: an analysis of 292 shoulders in 276 patients. Orthopaedic Clinics of North America, 6, 2, 449-466.
(116) Itoi, E. & Tabata, S. (1992a). Conservative treatment of rotator cuff tears. Clinical Orthopaedics and Related Research, 275, 165-173.
(117) Itoi, E. & Tabata, S. (1992b). Incomplete rotator cuff tears: results of operative treatment. Clinical Orthopaedics and Related Research, 284, 128-135.
(118) Bokor, D.J., Hawkins, R.J., Huckell, G.H., Angelo, R.L., & Shickendantz, M.S. (1993). Results of nonoperative management of rotator cuff of full-thickness tears of the rotator cuff. Clinical Orthopaedics and Related Research, 294, 103-110.
(119) Hawkins, R. H. & Dunlop, R. (1995). Nonoperative treatment of rotator cuff tears. Clinical Orthopaedics and Related Research, 321, 178-188.
(120) Lippitt, S. B., Harryman II, D. T., Matsen II, F. A. (1993). A practical tool for evaluating function. The simple shoulder test. In Matsen II, F. A., Fu, F. H., Hawkins, R. J. (Eds.) The Shoulder: A Balance of Mobility and Stability. Rosemont, IL, American Academy of Orthopaedic Surgeons 501-518.
(121) Matsen III, F.A. (1996). Early effectiveness of shoulder arthroplasty for patients who have primary glenohumeral degenerative joint disease. The Journal of Bone and Joint Surgery, 78A, 2, 260-264.
(122) Matsen III, F. A., Smith, K. L. DeBartolo, S. E. (1997). A comparison of patients with late-stage rheumatoid arthritis and osteoarthritis of the shoulder using self-assessed shoulder function and health status. Arthritis Care Research, 10, 43-47.
(123) Matsen III, F. A. (2001). Rotator cuff treatment. [ on-line] Available:http: //www. orthop.washington. edu/shoulder_elbow/weakness/rotatorcuff/treatment/06.
(124) Fuchs, B., et al., Clinical and structural results of open repair of an isolated one tendon Tear of the rotator cuff. J Bone Joint Surg Am, 2006. 88(2): p. 309‐16.
(125) Jost, B., et al., Clinical outcome after structural failure of rotator cuff repairs. J Bone Joint Surg Am, 2000. 82(3): p. 304‐14.
(126) Jost, B., et al., Long-term outcome after structural failure of rotator cuff repairs. J Bone Joint Surg Am, 2006. 88(3): p. 472‐9.
(127) Klepps, S., et al., Prospective evaluation of the effect of rotator cuff integrity on the outcome of open rotator cuff repairs. Am J Sports Med, 2004. 32(7): p. 1716‐22.
(128) McKee, M.D. and D.J. Yoo, The effect of surgery for rotator cuff disease on general health status. Results of a prospective trial. J Bone Joint Surg Am, 2000. 82A( 7): p. 970‐9.
(129) MacDonaldPB, Clark P, Sutherland K. An analysis of the diagnostic accuracy of the Hawkins and Neer subacromial impingement signs. J Shoulder Elbow Surg2000; 9: 299–301.
(130) ) ZaslavKR. Internal rotation resistance strength test: a new diagnostic test to differentiate intraarticular pathology from outlet (Neer) impingement syndrome in the shoulder. J Shoulder Elbow Surg2001; 10: 23–27.
(131) NeerCS 2nd. Impingement lesions. Clin Orthop Relat Res1983; 173: 70–77.
(132) HawkinsRJ, Kennedy JC. Impingement syndrome in athletes. Am J Sports Med1980; 8: 151–158
(133) Paulos LE, Kody MH: Arthroscopically enhanced "miniapproach" to rotator cuff repair. Am J Sports Med 1994, 22(1):19-25.
(134) Razmjou H, Davis AM, Jaglal SB, Holtby R, Richards RR(PMID:21457534)(135) http://www.sportsmd. com/sportsmd_articles/id/262.aspx.

Download Full Text PDF |  Download Full Thesis