Upload
others
View
6
Download
0
Embed Size (px)
Citation preview
Rotator Cuff Disease: Rehab and Surgery Lori Michener, PhD, PT, ATC, SCS, FAPTA
2/12/2018
1
Lori Michener, PhD, PT, ATC, SCS, FAPTADirector of Clinical Outcomes and Research
Director – COOR LabUniversity of Southern California; Los Angeles, CA
[email protected]://pt.usc.edu/COOR/
Differential Diagnosis ofRotator Cuff Disease
COOR Lab
@LoriM_PT
Rotator Cuff Tendinopathy
Tendinopathy Partial thickness RC tear Full Thickness RC tear
• Tendinopathy
• Partial thickness RC tear– Articular, bursal, mid-substance
• Full-thickness RC tear– Complete rupture superior to inferior
– Not necessarily side to side
– “Hole’ in the sock
Rotator Cuff Disease: Rehab and Surgery Lori Michener, PhD, PT, ATC, SCS, FAPTA
2/12/2018
2
Rotator Cuff Tendinopathy
• Full-thickness RC tear
• Partial thickness RC tear
• Tendon pathology without tear
• Subacromial impingement
Single clinical diagnosticcategory:
Subacromial pain syndrome
COOR Lab @ USC@LoriM_PT
Tendon Pathology
What’s in a name….• ‘subacromial impingement’
– Limited support for compression mechanism
– Perpetuates flawed reasoning & treatment
• Subacromial Pain Syndrome (SPS)– Allows for uncertainty of the pain generator:
tendons, bursae, biceps, CNS, other…
– Allows for mechanisms other than impingement
• Other names – ex: RC Related Shoulder Pain
COOR LabCOOR Lab @ USC@LoriM_PT
Rotator Cuff Disease: Rehab and Surgery Lori Michener, PhD, PT, ATC, SCS, FAPTA
2/12/2018
3
SupraspinatusTendon
Tendon overload &Degeneration
Mechanical Compression in
SA Space
Subacromial Impingement Syndrome RCT 2 predominant theories
If mechanical compression is the predominant mechanism, then….
… ALL would benefit from an acromioplasty
• Acromioplasty + rehab was not clinically more beneficial than rehab alone in multiple trials (Brox et al; 1993, 1999; Haahr, 2005, 2006; Ketola S, 2009, 2013)
• Bony pathology is not the only mechanism
• ‘Impingement’ – May not be an appropriate label (Cools AM and Michener LA, BJSM, 2017)
COOR LabCOOR Lab @ USC@LoriM_PT
Rotator Cuff Disease: Rehab and Surgery Lori Michener, PhD, PT, ATC, SCS, FAPTA
2/12/2018
4
Mechanisms of RC (Tendon) Disease
• Mechanisms:– Overload and Compression
• Factors contributing to the mechanisms:– Intrinsic factors – within the tendon
– Extrinsic factors – external to the tendon
– Other factors –• Personal and Environmental factors
COOR LabCOOR Lab @ USC@LoriM_PT
Intrinsic factors:Within the tendon
VascularityMorphologyMechanical
AgingGenetics
SA space- impingement??
RCD
Extrinsic factors:Strength/ m. control Tightness & LaxityPosture: spine, shBony abnormalities
Scap & GH kinematicsNeurophysiological
Brain / CNS
Load Load
COOR Lab @ USC
Rotator Cuff Disease: Rehab and Surgery Lori Michener, PhD, PT, ATC, SCS, FAPTA
2/12/2018
5
Tendon overload• Neovascularization?
• Conflicting evidence (Lewis J, 2009; Kardouni JR, 2013)
• Is the tendon painful?
Tendon Degeneration with Overload• Inflammation present (Dean BJ, BJSM; 2015)
• Abnormal collagen laydown
• Tendon thickens initially then thins
• Thicker in SPS (Michener LA, 2015; Joensen J, 2009; Leong HT, 2012)
• Thins with progressive tendon disease
• *Thickens response to use Overhead athletes, Spinal Cord Injuires (SCI) (Belley AF, 2016; Maenhout A, 2012; Wang HK, 2005)
Rotator Cuff Disease: Rehab and Surgery Lori Michener, PhD, PT, ATC, SCS, FAPTA
2/12/2018
6
Is compression in the SA Outlet causing tendon changes?
Compression or ‘impingement’ of RC tendons
- Subacromial (SA) space
SA space measured
Scapular al, 2012)
AHD= acromiohumeral distance10 – 15 mm in healthy
AHD
Tendon compression – is it possible?
SA space and shoulder pain:
– Space is smaller: AHD in ‘impingement’ (Hekimoglu B, 2013; Leong H-T, 2012; Seitz AL, 2011, Hebert LJ, 2003, Graichen H, 1999)
– Tendon is thicker: initially with disease & ‘overuse’
– Occupation ratio > : supraspinatus tendon: AHD • ‘Impingement’: tendon occupies > amount of AHD
(Michener LA, 2013)
• Overhead athletes & Spinal Cord Injury (SCI) (Belley AF, 2016; Maenhout A, 2012; Wang HK, 2005)
COOR Lab @ USC@LoriM_PT
Rotator Cuff Disease: Rehab and Surgery Lori Michener, PhD, PT, ATC, SCS, FAPTA
2/12/2018
7
Tendon compression – is it possible?
• Compression observed– cadaveric (Hughes PC, et al, 2012)
• Compression risk:– Smallest AHD: supraspinatus tendon 0 - 60°
Smallest AHD: tendon footprint 30 - 90°(Lawrence R, JOR, 2017)
– Tendon is not ‘available’ for compression (under the acromion) above ~ 70 elevation (Giphart JE, 2012; Thompson MD, 2011; Bey MJ, 2007)
Tendon compression may occur @ < 70°
COOR Lab @ USC@LoriM_PT
Glenohumeral impingement
• Posterior / Internal– Compression between the
posterior glenoid and the humeral head
– Described in overhead athletes
– Recent evidence –maybe in non-overhead athletes (Lawence R, Ludewig P, et
al; CSM, 2017)
Rotator Cuff Disease: Rehab and Surgery Lori Michener, PhD, PT, ATC, SCS, FAPTA
2/12/2018
8
European Society of MSK Radiology: Shoulder MSK Technical Guidelines
Rotator Cuff Disease: Rehab and Surgery Lori Michener, PhD, PT, ATC, SCS, FAPTA
2/12/2018
9
So is it compression or is it degeneration?
• Both compression AND degeneration are causes– Less support for compression
COOR LabCOOR Lab @ USC@LoriM_PT
Rotator Cuff Tendinopathy:What’s the Evidence for Diagnosis?
• Subacromial Pain Syndrome (SPS)– SPS
– Partial- thickness RC tears
• Full-thickness Rotator Cuff Tear (FT-RCT)
COOR LabCOOR Lab @ USC@LoriM_PT
Rotator Cuff Disease: Rehab and Surgery Lori Michener, PhD, PT, ATC, SCS, FAPTA
2/12/2018
10
Key Metrics for Dx Accuracy
• Diagnostic Accuracy values:– Sensitivity
– Specificity
– PPV: Predictive value of a positive test
– NPV: Predictive value of a negative test
– LR+: Positive likelihood ratio
– LR- Negative likelihood ratio
COOR Lab
Rotator Cuff Disease: Rehab and Surgery Lori Michener, PhD, PT, ATC, SCS, FAPTA
2/12/2018
11
Sensitivity and Specificity
• Sensitivity • SnNOut = When Sn is high, a Negative test rules Out the
disease
• Specificity (SpPIn) • SpPIn = When Sp is high, a Positive test rules In the
disease.
• Interpretation:• Indicates if a test s or s disease probability
• BUT: No set cut-off to quantify shift in probability
COOR Lab
Likelihood Ratios
• More helpful for Dx• Indicate by how much a given diagnostic test
result will or the probability of the disease.• Quantify shifts in probability of the diagnosis
• Ex: +LR= 5: a patient with a + test is 5x more likely in a patient with the disease as compared to a patient without the disease
• Minimal affect of prevalence
COOR Lab
Rotator Cuff Disease: Rehab and Surgery Lori Michener, PhD, PT, ATC, SCS, FAPTA
2/12/2018
12
Likelihood Ratio“+” “—”
Interpretation
>10 <0.1 Large & often conclusive changes from pre-test to post-test probability
5 – 10 0.1 – 0.2 Moderate shifts in pre-test to post-test probability
2 – 5 0.5 – 0.2 Small but sometimes important changes in probability
1 – 2 0.5 – 1 Small and rarely important changes in probability
Pre-test Prob = 1%+LR = 5
Pre-test Prob = 50%+LR = 5
Post-test Prob= 85%
Post-test Prob= 5%
Rotator Cuff Disease: Rehab and Surgery Lori Michener, PhD, PT, ATC, SCS, FAPTA
2/12/2018
13
Recommendations for Diagnostic Values Interpretation
Screen (Rule/ Out)
– Sensitivity: SnNOut
* Sn > 80%
– Likelihood ratio (– LR)
* – LR < 0.5
Confirm (Rule/ IN)
– Specificity: SpPIn* Sp > 80%
– +Likelihood ratio (+LR)
* +LR > 2.0
COOR LabCOOR Lab @ USC@LoriM_PT
Dx SA pain - Systematic Reviews1. Hermans J, JAMA, 2013; 2. Hanchard NCA, Cochrane, 2013;
3. Hegedus EJ, BMJ, 2012; 4. Alqunaee M, APMR, 2012
Confirm SA pain(R/In) – single tests
1- Painful arc2- Resisted ER
(ERRT)– pain or weak3- Full Can4- Drop Arm
* Combo of tests too! *
Screen Out SA pain(R/Out) – single tests
1- Painful arc2- Resisted ER (ERRT)
– pain or weakness3- Hawkins4- Neer5- Full Can6- Empty/ Jobe Can
BLUF
Rotator Cuff Disease: Rehab and Surgery Lori Michener, PhD, PT, ATC, SCS, FAPTA
2/12/2018
14
Combo of Tests: SA Pain3/3 tests: (Park HB, JBJS; 2005)
Hawkins, Painful arc, ER resistance (Pain/Weak)
- All 3+: +LR of 10.56- All 3-: –LR of 0.17
3/5 tests: (Michener LA, APMR, 2009)
– Hawkins, Neer, Painful arc, Empty can, ER resistance
- If > 3+ / 5 : +LR of 2.93- If < 3+/ 5: –LR of 0.34
BLUF
Posterior Internal Impingement
• Impingement of the internal/deep aspect of RC tendons on posterior superior edge of the glenoid
• + for POSTERIOR or Post/ Superior should pain
• May be associated with anterior instability
COOR Lab
Rotator Cuff Disease: Rehab and Surgery Lori Michener, PhD, PT, ATC, SCS, FAPTA
2/12/2018
15
Diagnosis FT-RCT- Systematic Reviews1. Hermans J, JAMA, 2013; 2. Hanchard NCA, Cochrane, 2013;
3. Hegedus EJ, BMJ, 2012; 4. Alqunaee M, APMR, 2012
Confirm FT-RCT(R/In) – single tests
1- Painful arc2- Resist ER- marked weak
3- Drop Arm4- ER lag - massive tears
5- Atrophy infraspinatus
6- IR lag & lift off7- Belly off- subscap
Screen Out FT-RCT(R/Out) – single tests
1- Resisted ER marked weak
2- IR lag and lift off3- Full Can4- Empty/ Jobe Can
History: Age > 60/ 65yo and c/o night pain
Dx FT-RCT - Syst Reviews1. Hermans J, JAMA, 2013; 2. Hanchard NCA, Cochrane, 2013;
3. Hegedus EJ, BMJ, 2012; 4. Alqunaee M, APMR, 2012
Confirm FT-RCT(R/In) – single tests1- Painful arc2- Resisted ER – pain or weak3- ER lag test – supraspinatus
infraspinatus4- IR lag & Lift off
subscapularis5- Drop arm6- Atrophy of infraspinatus7- Belly off – Subscapularis**Combo of tests**
Screen Out FT-RCT(R/Out) – single tests1- Resisted ER (ERRT)
– pain or weakness2- IR lag & Lift-off
subscapularis3- Empty Can4- Full Can
COOR Lab
History: Age > 60/ 65yo and c/o night pain
BLUF
Rotator Cuff Disease: Rehab and Surgery Lori Michener, PhD, PT, ATC, SCS, FAPTA
2/12/2018
16
Combination of Tests: FT- RCT
• Test Combo (Litaker D, et al; J Am Geriatr Soc, 2000)
>65yo, ER weak (ERRT), night pain All 3 +: R/In +LR: 9.84All 3 -: R/Out - LR: 0.54
• Test Combo (Park HB, et al; JBJS, 2005)
3 Tests: Drop arm, Painful arc, ERRT All 3 tests + R/In +LR: 15.57 All 3 tests - R/Out -LR: 0.16
3 tests & >60yo:All 3 tests & >60yo + R/In +LR: 28.0 All 3 tests & >60yo - R/Out -LR: 0.09
COOR Lab
BLUF
Thank you!
COOR LabCOOR Lab @ USC@LoriM_PT