Repair of

rotator cuff tears in tennis

LOUIS U. BIGILIANI,† MD, JAY KIMMEL,† MD, PETER D.

From the

players*

McCANN,‡§ MD, AND IRA WOLFE†

†Columbia Presbyterian Medical Center, New York, New York, and the ‡Helen Hayes Hospital, West Haverstraw, New York the rotator cuff from impingement on the anterior acromion and the coracoacromial ligament.4~’~a.lo,m,zo,z~,24 Most young athletes respond to conservative treatment including rest, antiinflammatory agents, and physical therapy.4,7 However, in older athletes the wear on the rotator cuff may progress to frank tears of the rotator cuff8-1° that may require surgical repair. Operative treatment of rotator cuff tears provides excellent pain relief and good return of function in the general population. 1-3,5,12,13,15,19, 25 However, very little is known about the effect of rotator cuff surgery in tennis players specifically. Tibone et al. 23 reported that surgical treatment of tears of the rotator cuff in a young, athletic population provided satisfactory pain relief, but only 56% of the patients returned to their former competitive status. Only 4 of the 45 (8%) athletes in this study were tennis players, with an average age of 39 years. Furthermore, 3 of the 4 players (75%) had a partial-thickness tear and all returned to their prior level of competition. By the time most throwing athletes reach the age at which full-thickness rotator cuff tears occur, they have retired from their sport. On the other hand, many tennis players continue to participate in their sport during the same years that rotator cuff tears may develop. Therefore, the orthopaedic surgeon may be faced with a tennis player over 40 years of age with a tear of the rotator cuff and whose primary concern is to regain prior performance level. The purpose of this study is to report the results of anterior acromioplasty and rotator cuff repair in a group of tennis players in whom one of the primary goals was to return to playing tennis.

ABSTRACT

wear on

tennis players with a symptomatic fullthickness rotator cuff tear underwent anterior acromioplasty and rotator cuff repair. There were 8 small tears (5 cm). The dominant shoulder was involved in all patients and all were unable to play tennis before surgery. Eleven patients experienced a traumatic event that caused an injury, 6 while playing tennis, and 12 patients had a gradual onset of symptoms. At average followup of 42 months, 19 patients (83%) achieved a good result, were pain-free, and were able to play tennis at their presymptomatic competitive level. Three patients (13%), all with massive tears, had a satisfactory result and were able to play tennis, although at a lower competitive level secondary to weakness. One patient (4%), who also had a massive tear, had an unsatisfactory result and was unable to play tennis.

Twenty-three

Anterior shoulder pain is a common complaint among tennis players. Lehmanll has reported an incidence of 24% among young players (aged 12 to 19) and as high as 50% in older players. Many of the strokes involved in playing tennis require shoulder rotation, abduction, and elevation often at the extreme limits of range of motion. Consequently, the high incidence of shoulder symptoms in tennis players is not surprising, since there is repetitive, stressful use of the arm in the overhead position. One of the factors responsible for anterior shoulder pain is the subacromial impingement syndrome described by

Neer’,&dquo;, 11,13,14,18,20,11,24 Several reports have stated that

MATERIALS AND METHODS

re-

petitive use of the arm above the horizontal position, as in throwing, swimming, or serving a tennis ball, may produce

From

January 1981

to

January 1989, 23 tennis players

underwent operative repair of their torn rotator cuff by the senior author at Columbia Presbyterian Medical Center. All patients were examined by the senior author, and the medical records and office charts of these patients were retrospectively reviewed.

*

Presented at the 16th Annual Meeting of the AOSSM, Sun Valley, Idaho, July 1990 § Address correspondence and repnnt requests to: Peter D. McCann, MD, Helen Hayes Hospital, Route 9W, West Haverstraw, NY 10993

112

113

There

were

17

men

and 6

women

with

an

average age of

(range, 39 to 71). Only patients whose dominant extremity was involved were included in the study. The average duration of symptoms was 14 months. In 11 patients a definitive injury preceded the onset of their symptoms. Six of these 11 (55%) patients injured their shoulder while playing tennis. The remaining 12 patients could not recall a traumatic episode accounting for their shoulder symptoms. All patients had pain preoperatively and could no longer play tennis. The patients’ pain was graded using the following system: Grade 0, no pain; Grade 1, mild pain that did not interfere with their ability to play tennis; Grade 2, moderate or severe pain with playing tennis; Grade 3, pain with activities of daily living; Grade 4, pain at rest or night pain. Preoperatively, 16 patients had Grade 4 pain, 4 patients had Grade 3 pain, and 3 patients had Grade 2 pain. The average preoperative pain grade was 3.5 (Table 1). Preoperatively, the average range of passive forward ele58 years

vation was 173°and external rotation was 61°. With manual testing, all patients showed weakness in external rotation and 14 patients were weak in forward elevation. The average preoperative active range of motion was 137° forward elevation and 39° external rotation. Nine of the 23 patients (39%) had atrophy of the spinati muscles and 19 of 23 patients (83%) had a positive impingement sign. The 4 patients with negative impingement signs had pain only while playing tennis. Seven of the 23 patients (30%) had acromioclavicular tenderness, 2 of which were severe. Finally, 5 of 23 patients (22%) had clinical evidence of a tear of the long head of the biceps tendon. All of the patients had a shoulder series (AP radiographs with the humerus and internal, external, and neutral rota-

tions, lateral in the scapular plane and

an

axillary view)

as

well as an arthrogram of the involved shoulder. Currently, the lateral scapular view is performed with a caudal tilt of between 5° to 10° to allow for better visualization of the anterior acromial morphology (Fig. 1). Neer17 has termed this the supraspinatus outlet view. Twelve patients (52%) had evidence of a subacromial spur, 9 (39%) had evidence of acromial clavicular arthritis, and 5 patients (22%) had evidence of an excrescence on the greater tuberosity. The acromiohumeral distance could be adequately evaluated in only 11 patients. This distance was less than 7 mm in 4 patients, all of whom had a massive rotator cuff tear at surgery. All patients had a positive arthrogram (Fig. 2). Twenty of the 23 patients were treated initially with rest, external rotation strengthening, range of motion exercises, and nonsteroidal antiinflammatory medications for a minimum of 3 months. Despite this regimen, all patients had persistent pain and could not play tennis. Three avid tennis players (average age, 49 years) had an acute injury with immediate shoulder weakness, obtained an arthrogram, and underwent operative repair within 1 month. Because tennis was an important part in the lives of these patients, many underwent operative repair with the hope that they could eventually return to playing. The level of player was classified as follows: tournament players who participated in sanctioned regional tournaments, club players who participated regularly in club-sponsored tournaments, and recreational players. There were 4 tournament players who played on average 3.5 times per week, 5 club players who played 2.8 times per week, and 14 recreational players who played on average 3.2 times per week.

TABLE 1 Patient data

114

Operative findings The type of surgical repair varied according to the abnormality involved. All patients had anterior acromioplasty as described by Neer18 and 19 patients underwent modified acromioclavicular arthroplasty for excrescences on the under surface of the acromioclavicular joint. Two patients underwent complete acromioclavicular arthroplasty, the indication for which was severe preoperative acromioclavicular tenderness. One patient underwent biceps tenodesis for a symptomatic long head of biceps tendon tear, characterized by cramping pain in the distally retracted biceps muscle belly. The remaining four long heads of biceps tendon rup-

asymptomatic and not repaired. eight massive tears involving the supraspinatus, infraspinatus, and teres minor tendons (Fig. 3), two large tears involving the supraspinatus and infraspinatus, five moderate tears, and eight small tears all centered on the supraspinatus tendon (Fig. 4). Twenty-two patients had rotator cuff mobilization and suture of tendon-to-bone. One patient had a small tear, which was linear and could be repaired tendon-to-tendon. Early in the series, one patient with a massive tear was treated in an abduction brace postoperatively. Currently, regardless of the size of the rotator cuff tear, the arm is supported at the side in a sling. The postoperative rehabilitation program was modeled on the three-phase program described by Neer6,17 and was vartures

were

There

1. A supraspinatus outlet view anterior acromial spur (arrow).

Figure

showing

a

prominent

were

ied according to the size of the rotator cuff tear. Patients with small or medium tears were started on passive exercises on the 1st day after surgery and progressed to active exercises at 6 weeks. Patients with large or massive tears requiring mobilization of the remaining tendons were started on three exercises on the lst postoperative day: pendulum, assisted forward elevation, and assisted external rotation with a stick to 30°. This program was maintained for 8 weeks, at which time passive and active exercises were begun. Resistive strengthening exercises were started slowly at 3 months. At 3 to 6 months after surgery, the resistive strengthening program was modified by the addition of the

Figure 2.

A positive arthrogram showing a full-thickness rotator cuff tear with contrast fluid in the subacromial space and lateral to the greater tuberosity.

Figure 3. Operative photograph of a massive rotator cuff tear.

115

Figure 4. Operative photograph of a moderate size rotator cuff tear with acute extension into the infraspinatus tendon (long arrow). There is a subacromial spur (short arrow) and an area of impingement wear on the greater tuberosity (curved arrow). medicine ball exercise (Fig. 5), which served to strengthen the external and internal rotators in the overhead position. Ground strokes were usually allowed between 6 and 9 months, and serving was generally not permitted before 1 year.

RESULTS were evaluated with respect to pain, range of motion, strength, and return to playing tennis. The pain rating system has been previously described. Range of mo-

Figure 5. A patient raising a 7-pound medicine ball. This exercise served to strengthen the external and internal rotators in the overhead position after surgery.

The results

tion was measured in forward elevation and external rotation. Strength measurements with manual testing by the senior author were recorded as well. No Cybex strength measurements were available during the course of this study. The overall grade of postoperative results depended on the level of tennis performance that was achieved. The results were graded as follows: good-no pain, no weakness, and playing tennis at presymptomatic competitive

level; satisfactory-occasional pain, slight weakness, playing a lower competitive level than before injury; and unsatisfactory-persistent pain or weakness that prevented tennis playing. The results were reviewed at an average followup of 39 months (range, 18 to 109). Nineteen of 23 patients (83%) were rated as having a good outcome. These patients were pain-free and playing tennis at their presymptomatic level. However, 2 of these 19 patients were no longer playing tennis at the time of followup secondary to medical conditions unrelated to their shoulder, and 1 patient had died. Nevertheless, since all 3 had returned tennis at

to their prior level of play postoperatively, they were considered to have good results. Three patients had satisfactory outcomes. All had some

weakness of external rotation, and one had mild discomfort in her shoulder while playing tennis. These three patients complained of slight difficulty with serving and overhead strokes and were playing at a lower competitive level. One patient had an unsatisfactory outcome. This patient had persistent pain and weakness with overhead activity and was unable to play tennis. We suspect that this patient may have reruptured the rotator cuff, but at the time of followup the patient had refused further evaluation. Seventeen of 23 patients (74%) had complete relief of their pain and 5 patients had mild weather ache and were given a Grade 1 pain rating. None of these patients required analgesics for control of their pain. One patient had pain with activities of daily living and received a pain grade of 3. The average pain grade for the series decreased from 3.5

preoperatively to

0.3 postoperatively. The average passive range of motion in forward elevation was 176° and in external rotation was 62°. The average

116

active forward elevation was 168°, and the average active external rotation was 57°. Six patients (26%) had weakness of external rotation on manual testing. The one patient with an unsatisfactory result had weakness of forward elevation. The results were analyzed according to the size of the tear found at surgery. All 15 patients with small, moderate, or large tears achieved a good result. Of the 8 patients with massive tears, 4 had a good result, 3 had a satisfactory result, and 1 had an unsatisfactory result. Therefore, all of the satisfactory and unsatisfactory results were in patients with massive rotator cuff tears. There were two complications in this series. The first was a superficial wound infection in one patient that resolved with conservative care, and the second was a small suture granuloma that resolved with conservative care as well. In addition, three patients showed evidence of tendinitis in the shoulder during their rehabilitation between the 3rd and 6th month. These patients were progressing too quickly with their therapy, and symptoms resolved after a period of rest

and nonsteroidal antiinflammatory medication.

Twenty of 23 patients (87%) were playing tennis at the time of followup. Subjectively, 22 of 23 patients (95%) were satisfied with their operation in terms of pain relief and ability to return to playing tennis, and stated that they would undergo surgical treatment of their rotator cuff tear again. DISCUSSION The results of this study with respect to pain relief, range of motion, and strength compare favorably with other reports in the literature.1-3,12 14,18,19,25 However, these patients must not only be rated by these routine parameters, but also with respect to their ability to resume playing, which was an important consideration for all of these patients. A high percentage of patients (95%) was able to resume playing. Furthermore, 19 of 23 patients (83%) were able to return to their former competitive level. Only 1 patient was unable to return to playing tennis. Therefore, it appears that repair of rotator cuff tears affords reliable return to activity for most active tennis players. Several factors are responsible for the high percentage of favorable results. First, most of these patients were highly motivated. They diligently followed a prolonged and intensive rehabilitation program designed for athletes involved in sports that require overhead motion. Ground strokes were not allowed before 6 months, and then only after sufficient motion and strength had been achieved. Overhead strokes and serves were delayed until 1 year after surgery. The operative technique emphasized meticulous preservation of the deltoid origin, adequate anterior acromioplasty with sufficient decompression of the subacromial space, and repair of the rotator cuff with mobilization of retracted tendons to permit tendon-to-bone fixation with the arm at the side. Finally, in our series the patients competed in tennis at regional tournament and club levels. The demand on these patients’ shoulders cannot be compared to that of

the collegiate and professional pitchers in the series of Tibone et al. 23 This may account for the higher rate of return to former competitive levels reported in our patients. The patients in this series were not young (average age, 58). Only one patient (aged 39) was under 40 years of age. Since young patients were not eliminated from this study, it seems reasonable to assume that rotator cuff tears occur in older tennis players over a long period of time from chronic repetitive mechanical wear. In tennis there is considerable overhead activity that may place stress on the shoulder and wear on the rotator cuff. Six of the 23 patients (26%) in this study injured their shoulders while playing tennis, 2 of whom had prior shoulder symptoms. Overall, 10 patients could recall a shoulder injury and 13 of the 21 patients (57%) felt their symptoms had begun gradually. Ellman et al.3 and Neer 14 reported that 24% and 50%, respectively, of their patients could not recall a traumatic event leading to the development of shoulder symptoms. Therefore, it appears that the cause of the rotator cuff tears in this study parallels that reported in other studies of rotator cuff tears in the general population-namely, chronic impingement wear. As an overhead activity that places stress on the shoulder, tennis playing may exacerbate the symptoms of the impingement syndrome. The size of the rotator cuff tear was the only variable that affected the results. All of the satisfactory (three patients) and unsatisfactory (one patient) results occurred in those patients with massive tears. Although the remaining four patients with massive tears did achieve a good outcome, we believe that patients with a massive tear should be cautioned that they may not attain their preinjury level of competition secondary to residual weakness. Ellman et a1.3have correlated the size of cuff tear with the duration of symptoms. Bassett and Cofield’ reported that early surgical repair (0 to 3 weeks) led to better shoulder function in terms of active abduction. Tennis players over 40 years of age with shoulder symptoms for 3 months and physical signs suggestive of impingement should be evaluated further by either magnetic resonance imaging or arthrogram for a rotator cuff tear. Furthermore, if a sudden event leads to shoulder pain and weakness that does not respond to conservative measures in a short period of time (4 weeks), the rotator cuff should be further evaluated for a possible tear. Results of rotator cuff surgery may be improved if massive cuff tears are avoided by earlier diagnosis and treatment.

CONCLUSIONS In conclusion, subacromial impingement with rotator cuff tears may account for shoulder pain in the active tennis player, especially over 40 years of age. In this series, satis-

factory pain relief following anterior acromioplasty and repair of full-thickness rotator cuff tears was achieved in 95% of patients. A massive rotator cuff tear was associated with considerable postoperative weakness that compromised tennis performance. Nevertheless, 83% of the patients were

117

able to return to their presymptomatic performance level after surgery and a prolonged and intensive rehabilitation program.

REFERENCES

21 Priest JD, Nagle DA Tennis shoulder Am J Sports Med 4 28-42, 1976 22 Ryu RK, McCormick J, Jobe FW, et al An electromyographic analysis of shoulder function in tennis players Am J Sports Med 16 481-485, 1988 23 Tibone JE, Elrod B, Jobe FW Shoulder impingement syndrome in athletes treated by an anterior acromioplasty J Bone Joint Surg 68A 887-891,1986 24 Tibone JE, Jobe FW, Kerlan RK, et al Shoulder impingement syndrome in athletes treated by an anterior acromioplasty Clin Orthop 198 1334-

1339, 1985 25

Bassett RW, Cofield RH. Acute tears of the rotator cuff: The timing of surgical repair Clin Orthop 175 12-24, 1983 2 Bateman JE The diagnosis and treatment of ruptures of the rotator cuff 1

Surg Clin North Am 43 1523-1530, 1963 3 Ellman H, Hanker G, Bayer M Repair of the rotator cuff. J Bone Joint Surg 68A 1136-1144, 1986 4 Hawkins RJ, Kennedy JC: Impingement syndrome in athletes. Am J Sports Med 8 151-157, 1980 5 Hawkins RJ, Misamore GW, Hobieka PE Surgery for full thickness rotator cuff tears J Bone Joint Surg 67A: 1349-1355, 1985 6 Hughes M, Neer CS Glenohumeral joint replacement and post operative rehabilitation Phys Ther 55 850-859, 1975 7 Jackson DW Chronic rotator cuff Impingement in the throwing athlete Am J Sports Med4 231-240, 1976 8 Jackson DW Techniques in Orthopaedics-Shoulder Surgery in the Athlete Rockville, Maryland, Aspen Systems Corp, 1985, pp 73-82 9 Jobe FW Serious rotator cuff injuries. Clin Sports Med 2 407-413, 1983 10 Jobe FW, Jobe CM Painful athletic injuries of the shoulder Clïn Orthop 173 117-124, 1983 11 Lehman RC Shoulder pain in the competitive tennis player Clin Sports Med 7 309-327, 1988 12 McClaughlin HL Repair of major cuff repairs Surg Clin North Am 43

1535-1540,1963 13 Neer CS Impingement lesions Clin Orthop 173 70-77, 1983 14 Neer CS Anterior acromioplasty for the chronic impingement syndrome in the shoulder. A prelimmary report J Bone Joint Surg 54A 41-50, 1972 15 Neer CS, Marberry TA On the disadvantages of radical acromionectomy J Bone Joint Surg 63A 416-419, 1981 16 Neer CS, McCann PD, MacFarlane EA, et al: Earlier passive motion following shoulder arthroplasty and rotator cuff repair-A prospective study Orthop Trans 11 231, 1987 17 Neer CS, Poppen NK Supraspinatus outlet Orthop Trans 11 234, 1987 18 Neer CS, Welsh RP The shoulder in sports. Orthop Clin North Am 8 583-

591, 1977 19 Packer NP, Calvert PT, Bayley JIL. Operative treatment of chronic ruptures of the rotator cuff of the shoulder J Bone Joint Surg 65B 171-175, 1983 20 Penny JN, Welsh RP Shoulder impingement syndromes in athletes and their surgical management Am J Sports Med 9 11-15, 1981

Wolfgang GL Surgical repair of tears of the rotator cuff of the shoulder Factors influencing the result J Bone Joint Surg 56A. 14-26, 1974

DISCUSSION James Tibone, MD, Inglewood, California: This paper on repair of rotator cuff tears in tennis players makes several important points. I agree with the authors’ findings that competitive tennis players can return to similar competitive levels after rotator cuff surgery. In our series at the KerlanJobe Clinic, we had eight tennis players younger than 40 years old who had acromioplasty with or without a rotator cuff repair. All of these patients had an excellent result. This is in contrast to other athletes in the series, especially the throwers, where the results were less favorable and predictable. Tennis does not place the same demands on the shoulder as repetitive throwing or pitching a baseball. In this middle-aged group, you will find that a number of athletes have incomplete rotator cuff tears. I would not open the shoulders in these individuals, but would do an arthroscopic acromioplasty with resection of the coracoacromial ligament and subacromial bursa, and would leave the rotator cuff alone. This paper emphasizes that rotator cuff surgery with acromioplasty can produce excellent results if the surgery is done early. If the tears are neglected, a massive tear results and the outcome becomes unpredictable. In general, a complete rotator cuff tear is a condition that can be best helped by surgery.

Repair of rotator cuff tears in tennis players.

Twenty-three tennis players with a symptomatic full-thickness rotator cuff tear underwent anterior acromioplasty and rotator cuff repair. There were 8...
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