Question for Physiotherapists
Full Thickness Tear of Supraspinatus Tendon
QUESTION: My patient is a 67 year old female who has had pain during overhead activity (catching pain), going on for over 5 years. She is able to actively achieve full ROM (Including bra behind back). Her MRI shows a full thickness tear of supraspinatus tendon and a tear of the majority of the infraspinatus tendon (with a few lower infraspinatus fibers still attached). Superior subluxation of the humeral head.
I am intrigued by the patient’s symptoms and active shoulder range of motion versus her imaging.
How is she able to raise her arm up with full thickness tears of supraspinatus and the majority of the infraspinatus?
This is an excellent question and the answer is not immediately obvious. The short answer is that if 2 of the muscles are working then the shoulder can function almost normally.
Basic Anatomy and Function
As you know shoulder motion is dependent on a complex interplay of forces and moments around the glenohumeral joint. The glenohumeral joint (essentially a round ball on a flat socket) is inherently unstable. This is designed to maximise movement of the shoulder joint. The price we pay for this is the potential for instability. There is also a ‘vacuum’ within the joint capsule which stops the normal shoulder from dislocating, even with complete muscle relaxation (and after death). This vacuum is surprisingly quickly re-established by the body after the joint is surgically opened. The glenoid labrum also helps to deepen the socket but it is the rotator cuff which is responsible for keeping the joint centred with activity.
The deltoid muscle runs from the acromion to the lateral humerus (a relatively straight line) and moves the shoulder by pulling the humerus up (while the forces of the rotator cuff muscles effectively hold the humeral head in place) and allow the joint to rotate and the arm to move up in the air).
Forces and Moments
It makes sense that the forces and moments in the shoulder need to be balanced to keep the shoulder in place when the hand is moved above the head. The frictional force at the joint should be very small and therefore can be ignored. The anterior and posterior muscles work together to pull the humeral head into the glenoid and they work in both the coronal and axial planes. This is sometimes known as concavity compression.
In the coronal (frontal) plane, the rotator cuff force must be below (inferior to) the centre of rotation of the humerus for it to be balanced. This will biomechanically oppose the moment created by the deltoid and thus stabilize the humeral head in the glenoid. The subscapularis, infraspinatus, and teres minor are the primary depressors of the humeral head. The weight of the arm, the deltoid muscle force and the joint reaction force allow the humerus to be rotated, thereby moving the hand above the head.
The force couple in the axial (transverse) plane must also be balanced (Subscapularis anteriorly and the Infraspinatus, and Teres minor posteriorly). If there is a balanced force pulling downwards then the supraspinatus does not need to be intact for this to happen (You would know this as muscle-balancing). With a chronic progressive tear (as is likely from the history provided) the shoulder can adapt over time.
The Tear Pattern
In the most common clinical setting when just the supraspinatus is torn, the subscapularis and posterior cuff are usually intact. As the size of the cuff tear increases it tends to extend more posteriorly (even the larger tears tend to spare the subscapularis at the front). The tear can get big enough so that the posterior cuff can no longer balance the moment created anteriorly by the subscapularis and at this point the patient will no longer be able to raise their arm above their head (a pseudoparalytic shoulder). When this happens the axial (transverse) fulcrum is lost, the coronal plane equilibrium is lost and the result is anterior-superior translation of the humeral head with attempted elevation. When this is extreme you will see anterior/superior escape of the humeral head clinically.
In terms of imaging: the supraspinatus should fill the space between the humeral head and the acromion. When the supraspinatus retracts far enough the humeral head can ride up and press against the under surface of the acromion. The indicates a chronic tear and is seen as a high riding humeral head on the plain xrays. Once this happens the tear is no longer able to be repaired.
Several authors have shown that a patient with a two-tendon tear with retraction of the supraspinatus may benefit from a partial repair (ie repair of either the infraspinatus or subscapularis without repair of the supraspinatus). This is best done acutely and certainly within 3 months of any recent injury. There is also the option of performing an operation called a superior capsular reconstruction to replace the supraspinatus if you are able to get a good repair of the other 2 muscles.
In terms of your patient there must be enough of her infraspinatus still functioning to form a force couple to lift her arm in the air. If she were to extend the tear further this may no longer be possible.
QUESTION | How does a wrist ganglion relate to carpal instability? How is it best treated?
ANSWER | A ganglion is a benign synovium-lined cystic collection of fluid which arises from an adjacent area of injury. Although we may not know the exact mechanism of formation, the area of injury forms a ganglion which then expands out towards a region of least resistance, usually towards the skin. Sometimes, these are flat, sessile structures only found on ultrasound or MRI scan, while other times they are more like a balloon with a long stalk bulging out at the skin surface and noticeable by the patient.
In most cases, the ganglion itself is not painful, but the pain rather comes from the same underlying cause of injury which has caused the ganglion itself. Occasionally, we do find that the local pressure from the ganglion does cause pain in its own right.
In the context of carpal instability, a ganglion may result from a ligament tear or sprain, or as a result of degenerative change associated with ongoing carpal instability. A ganglion would not be the cause of carpal instability. Similarly, as described above, a ganglion is unlikely to be the cause of pain itself, but rather pointed to an underlying problem with dynamic or static carpal instability.
The most common dorsal wrist ganglion arises from the scapholunate ligament. This is usually a partial tear arising from chronic overuse or an acute injury. Sometimes, the acute injury itself goes untreated as it is thought to be a simple sprain. Ganglions on the volar side of the wrist often arise from the radiocarpal joint itself, from the base of the thumb or from the flexor tendons.
The first step in managing a ganglion is always taking a history from the patient. What is it that the patient is actually complaining of? Is it concern over what this lump is? Is it the cosmetic appearance? Are they experiencing pain and if so, what activities are affected? You may find that the patient just requires simple reassurance, or perhaps further treatment may be necessary.
On palpation, you may find that the ganglion is anywhere from soft and spongy through to quite firm and tense. Try to determine whether the ganglion itself is tender, or perhaps a directly adjacent anatomical structure, such as the scapholunate ligament.
A plain wrist x-ray and an ultrasound (or MRI) would be useful investigations in guiding treatment. Together, these will show overall wrist and carpal bone alignment, reveal any underlying degenerative change, and look for any acute or previous fracture which may contribute to the pain. They would also confirm the lump as a ganglion rather than another type of pathology.
In determining the best treatment, ensure that the patient understands that the ganglion arises from an underlying abnormality which is the more likely cause of pain or discomfort. Therefore, eradicating the ganglion itself doesn’t necessarily mean that the pain will subside.
Some ganglions will subside spontaneously over time. However, if the patient wishes treatment, then most wrist ganglions can initially be treated with aspiration and a steroid injection (as long as the underlying cause is not one that needs immediate treatment in its own right). The recurrence rate of a ganglion aspiration is above 50%, but it is a relatively simple procedure with low morbidity so is appropriate as a first step in treatment. The steroid injection reduces inflammation and pain from the underlying structural abnormality and reduces the risk of recurrence. Coupling this with targeted exercises will help the patient recover strength and function.
If there is significant pain or reoccurrence despite aspiration and injection, surgery may be warranted. Abnormalities found clinically or seen on plain x-ray, such as abnormal carpal alignment, warrant early referral to a surgeon as it is sometimes better that these are corrected.
Surgery is aimed at removing the whole ganglion, including the synovial sac and its stalk. The underlying cause of the ganglion, such as a joint capsule or ligament, is addressed at the same time by debridement or repair. There is still a recurrence rate after surgery of about 15%.
Surgery can be done as a day only procedure and the patient is usually back to full activities and sports within a couple of months.
Ultrasound showing wrist ganglion, indicated by the 4 “+” signs.
ANSWER | A ganglion is a benign synovium-lined cystic collection of fluid which arises from an adjacent area of injury. Although we may not know the
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