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Biomechanics of Massive Rotator Cuff Tears: Implications for Treatment
Matthew L. Hansen, MD1; James C. Otis, PhD2; Jared S. Johnson, MD3; Frank A. Cordasco, MD, MS4; Edward V. Craig, MD4; Russell F. Warren, MD4
1 10494 West Thunderbird Boulevard, Suite 102, Sun City, AZ 85351. E-mail address: matthew.hansen@thecoreinstitute.com
2 136 Knobloch Lane, Stamford, CT 06902-1704
3 420 East 70th Street, Apartment 3B, New York, NY 10021
4 Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021
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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Orthopaedic Research and Education Foundation (OREF), the Institute for Sports Medicine, and the Hospital for Special Surgery Surgeon-in-Chief's Fund. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Hospital for Special Surgery, New York, N.Y

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Feb 01;90(2):316-325. doi: 10.2106/JBJS.F.00880
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Background: Some individuals with massive rotator cuff tears maintain active shoulder abduction, and some maintain good postoperative active range of motion despite high rates of repeat tears after repair. We devised a biomechanical rationale for these observations and measured the increases in residual muscle forces necessary to maintain active shoulder motion with rotator cuff tears of various sizes.

Methods: A custom cadaver shoulder controller utilizing position and orientation closed-loop feedback control was used. Six cadaver glenohumeral joint specimens were tested in open-chain scapular plane abduction with equivalent upper extremity weight. The shoulder controller limited superior translation of the humeral head to 3.0 mm while maintaining neutral axial rotation by automatically controlling individual rotator cuff forces. Three-dimensional position and orientation and rotator cuff and deltoid force vectors were recorded. Specimens were tested with an intact rotator cuff and with 6, 7, and 8-cm tears.

Results: All six specimens achieved full abduction with =3.0 mm of superior translation of the humeral head for all rotator cuff tear sizes. The effect of rotator cuff tear was significant for all tear sizes (p < 0.01). Compared with the intact condition, the subscapularis force requirements for the 6, 7, and 8-cm tears were increased by 30%, 44%, and 85%, respectively. For the combined infraspinatus and teres minor, the forces were increased by 32%, 45%, and 86%, respectively. The maximum deltoid force for the simulated tear condition never exceeded the deltoid force required at maximum abduction for the intact condition. However, between 10° and 45° of abduction, the average deltoid force requirement increased 22%, 28%, and 45% for the three tear sizes.

Conclusions: In the presence of a massive rotator cuff tear, stable glenohumeral abduction without excessive superior humeral head translation requires significantly higher forces in the remaining intact portion of the rotator cuff. These force increases are within the physiologic range of rotator cuff muscles for 6-cm tears and most 7-cm tears. Increases in deltoid force requirements occur in early abduction; however, greater relative increases are required of the rotator cuff, especially in the presence of larger rotator cuff tears.

Clinical Relevance: Rotator cuff tear size, rotator cuff muscle force, and deltoid muscle force are important determinants of shoulder function in the presence of a massive rotator cuff tear. These findings can provide guidance for the rehabilitation of patients with rotator cuff tears and after rotator cuff repair and may provide justification for early surgical repair of rotator cuff tears.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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