Rotator Cuff

Rotator Cuff It is often difficult to tell where concepts actually begin. It is certainly not obvious who first used the term rotator or musculotendinous cuff. Credit for first describing ruptures of this structure is often given to J. G.

Smith, who in 1834 described the occurrence of tendon ruptures after shoulder injury in the London Medical Gazette. (Smith, 1834) In 1924 Meyer published his attrition theory of cuff ruptures.(Meyer, 1924) In his 1934 classic monograph, Codman summarized his 25 years of observations on the musculotendinous cuff and its components and discussed ruptures of the supraspinatus tendon. (Codman, 1934b) Beginning 10 years after the publication of Codman’s book and for the next 20 years, McLaughlin wrote on the etiology of cuff tears and their management. (McLaughlin, 1944, McLaughlin and Asherman, 1951) Oberholtzer first carried out arthrography in 1933 using air as the contrast medium.

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(Oberholtzer, 1933) Lindblom and Palmer (Lindblom and Palmer, 1939) used radio-opaque contrast and described partial-thickness, full-thickness, and massive tears of the cuff. Codman recommended early operative repair for complete cuff tears. He carried out what may have been the first cuff repair in 1909.(Codman, 1934b) Current views of cuff tear pathogenesis, diagnosis, and treatment are quite similar to those that he proposed over 50 years ago. Pettersson has provided an excellent summary of the early history of published observations on subacromial pathology.

Because of its completeness, his account is quoted here. (Pettersson, 1942) As already mentioned, the tendon aponeurosis of the shoulder joint and the subacromial bursa are intimately connected with each other. An investigation on the pathological changes in one of these formations will necessarily concern the other one also.

A historical review shows that there has been a good deal of confusion regarding the pathological and clinical observations on the two.The first to observe morbid processes in the subacromial bursa was Jarjavay, (Jarjavay, 1867) who on the basis of a few cases gave a general description of subacromial bursitis. His views were modified and elaborated by Heineke (Heineke, 1868) and Vogt.

(Vogt, 1881) Duplay (Duplay, 1872) introduced the term periarthritis humeroscapularis to designate a disease picture characterized by stiffness and pain in the shoulder joint following a trauma. Duplay based his observations on cases of trauma to the shoulder joint and on other cases of stiffness in the shoulder following dislocation, which he had studied at autopsy. The pathological foundation for the disease was believed by Duplay to lie in the subacromial and subdeltoid bursa. He thought that the cause was probably destruction or fusion of the bursa. Duplay’s views, which were supported by his followers, Tillaux (Tillaux, 1888) and Desch, (Desche, 1892) were hotly disputed.His opponents, Gosselin and his pupil Duronea (Duronea, 1873) and Desplats, (Desplats, 1878) Pingaud and Charvot, (Pinguad and Charvot, 1879) tried to prove that the periarthritis should be regarded as a rheumatic affection, neuritis, etc.

In Germany, Colley (Colley, 1899) and Kuster (Kuster, 1882) were of practically the same opinion regarding periarthritis humeroscapularis as Duplay. Roentgenography soon began to contribute to the problem of humeroscapular periarthritis. It was not long before calcium shadows began to be observed in the soft parts between the acromion and the greater tuberosity. (Painter, 1907) The same finding was made by Stieda, (Stieda, 1908) who assumed that these calcium masses were situated in the wall and in the lumen of the subacromial bursa. These new findings were indiscriminately termed bursitis calcarea subacromialis or subdeltoidea.The term bursoliths was even used by Haudek (Haudek, 1911) and Holzknecht. (Holzknecht, 1911) Later, however, as the condition showed a strong resemblance to humeroscapular periarthritis, it became entirely identified with the latter.

In America, Codman(Codman, 1984) made a very important contribution to the question when he drew attention to the important role played by changes in the supraspinatus in the clinical picture of subacromial bursitis. Codman was the first to point out that many cases of inability to abduct the arm are due to incomplete or complete ruptures of the supraspinatus tendon. With Codman’s findings it was proved that humeroscapular periarthritis was not only a disease condition localized in the subacromial bursa, but that pathological changes also occurred in the tendon aponeurosis of the shoulder joint.This theory was further supported by Wrede, (Wrede, 1912) who, on the basis of one surgical case and several cases in which roentgenograms had revealed calcium shadows in the region of the greater tuberosity, was able to show that the calcium deposits were localized in the supraspinatus tendon. More and more disease conditions in the region of the shoulder joint have gradually been distinguished and separated from the general concept, periarthritis humeroscapularis.

For example, Sievers (Sievers, 1914) drew attention to the fact that arthritis deformans in the acromioclavicular joint may give a clinical picture reminiscent of periarthritis humeroscapularis. Bettman (Bettman, 1926) and Meyer and Kessler (Meyer and Kessler, 1926) pointed to the occurrence of deforming changes in the intertubercular sulcus, the canal in which the biceps tendon glides. Payr (Payr, 1931) attempted to isolate the clinical picture, which appears when the shoulder joint without any previous trauma is immobilized too long in an unsuitable position.Julliard (Julliard, 1933) demonstrated apophysitis in the coracoid process (coracoiditis) as forming a special subdivision of periarthritis. Wellisch (Wellisch, 1934) described apophysitis at the insertion of the deltoid muscle on the humerus, giving it the name of deltoidalgia.

Schar and Zweifel(Schar and Zweifel, 1936)described deforming changes in connection with certain cases of os acromiale. In addition to this excellent review, Pettersson himself made a number of important contributions to the study of the rotator cuff, as will be seen subsequently in this chapter. The cuff story continues with the recognition of subacromial abrasion as an element in rotator cuff disease by a number of well-known surgeons including Codman,(Codman, 1984) Armstrong,(Armstrong, 1949) Hammond,(Hammond, 1962, Hammond, 1971) McLaughlin,(McLaughlin, 1944) Moseley,(Moseley, 1969) Smith-Petersen and colleagues,(Smith-Petersen, Aufranc, 1943) and Watson-Jones(Watson-Jones, 1960).Some of these surgeons proposed complete acromionectomy(Armstrong, 1949, Diamond, 1964, Hammond, 1962, Hammond, 1971, Watson-Jones, 1960) while others advocated lateral acromionectomy(McLaughlin, 1944, Smith-Petersen, Aufranc, 1943) for relief of these symptoms. The term impingement syndrome was popularized by Charles Neer in 1972.(Neer, 1972) In 100 dissected scapulae, Neer found eleven with a characteristic ridge of proliferative spurs and excrescences on the undersurface of the anterior process (of the acromion), apparently caused by repeated impingement of the rotator cuff and the humeral head, with traction of the coracoacromial ligament .

. . Without exception it was the anterior lip and undersurface of the anterior third that was involved.Neer emphasi …