Massive Rotator Cuff Tear

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Massive rotator cuff tears are a disabling problem. These tears can cause pain, weakness, and sometimes swelling of the shoulder. The rotator cuff consists of four muscles that function to stabilize the shoulder joint: supraspinatus rotator cuff tendon, subscapularis tendon, infraspinatus rotator cuff tendon, and the teres minor rotator cuff tendon. The supraspinatus tendon is the most common of the rotator cuff tendons to become ruptured. Massive tears of the rotator cuff that are greater than 5cm usually involving both the supraspinatus and infraspinatus tendons.

Massive tears of the rotator cuff are defined as tears greater than 5cm, usually involving both the supraspinatus and infraspinatus tendons. Retraction of the rotator cuff tendons along with muscle atrophy and fatty infiltration can occur. This makes surgical reconstruction difficult with the surgical outcome being unpredictable and less than satisfactory.

Treatment varies from physiotherapy to replacement of the humeral head. Arthroscopic or open repair is usually the selected treatment. Reconstruction can be done in selected cases. A rotator cuff arthropathy is performed on massive cuff tears that are associated with superior migration of the humeral head as well as instability and arthritis of the shoulder. The patient will have pseudoparalysis and an x-ray will show shift of the humerus proximally. An MRI will show massive cuff tear with retraction at the level of the glenoid with atrophy of the muscle and fatty infiltration. A reverse shoulder is the treatment of choice for the elderly with rotator cuff arthropathy as it improves the pain and function. Hemiarthroplasty is the treatment for younger patients. A standard head or a big humeral head can be selected.

A patient with a massive tear of the cuff usually develops weakness of the shoulder and becomes unable to actively lift the arm without assistance. Fluid collection within the shoulder may occur with a massive tear of the rotator cuff.

Patellar Tendon Rupture

A patellar tendon rupture is a rupture of the tendon that connects the patella to the tibia. Rupture often occurs at the lower pole insertion site of the patella and it could be associated with degenerative changes. Rupture most often occurs in patients younger than 40 years of age. When the tendon is ruptured, the quadriceps muscle pulls the patella upward. One way to measure the height of the patella is by measuring the Blumensaat’s line. The knee needs to be flexed at least 30 degrees, then a line can be drawn through the roof of the intercondylar notch and usually touches the tip of the patella. The patella moves upward with the patellar tendon rupture (patella alta).

Associated Risk Factors

• Rheumatoid Arthritis
• Diabetes
• Chronic Renal Failure
• Systemic Corticosteroid Therapy
• Chronic Patellar Tendonitis
• Degenerative Changes

During the radiographic evaluation, an AP and Lateral x-ray is necessary. The patella alta is seen on the lateral view (*patella superior to Blumensaat’s line). An MRI is effective in assessing the patellar tendon, especially if other intraarticular or soft tissue injuries are suspected.

Treatment consists of a surgical reattachment of the tendon. The patient will need to keep their knee in extension and in a knee immobilizer for about 4-6 weeks.