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Dr. Tomaino's Blog

Irreparable Rotator Cuff? There may be a minimally invasive solution

December 19th, 2009
This week alone, I saw 3 patients older than 70, who were told that repair was not possible and that they needed to consider Reverse shoulder replacement. Indeed, reverse arthroplasty provides very favorable overhead function and pain relief. Last year alone I performed 30 or so Reverse procedures with great success. HOWEVER, if one can elevate to shoulder level, but not above, pain from a degenerative Biceps tendon may be the cause.

Dr Pascal Boileau (see article below) has shown that a simple biceps tenotomy (or tenodesis) may help---thus obviating the need for shoulder replacement. Further, this option, which takes about 15 minutes, and can be performed as an outpatient, does not " burn the bridge" of arthroplasty in the future. So, if you know a friend, or loved one who is disadvantaged by shoulder pain, and lack of motion, there may be hope even if their rotator cuff is not fixable.
The article below was published in The Journal of Bone and Joint Surgery: 2007;89:747-757.

Isolated Arthroscopic Biceps Tenotomy or Tenodesis Improves Symptoms in Patients with Massive Irreparable Rotator Cuff Tears
Pascal Boileau, MD1, François Baqué, MD1, Laure Valerio, MD1, Philip Ahrens, MD, FRCS2, Christopher Chuinard, MD1 and Christophe Trojani, MD1

Background: Lesions of the long head of the biceps tendon are often associated with massive rotator cuff tears and may be responsible for shoulder pain and dysfunction. The purpose of this study was to evaluate the clinical and radiographic outcomes of isolated arthroscopic biceps tenotomy or tenodesis as treatment for persistent shoulder pain and dysfunction due to an irreparable rotator cuff tear associated with a biceps lesion.
Methods: We conducted a retrospective study of sixty-eight consecutive patients (mean age [and standard deviation], 68 ± 6 years) in whom a total of seventy-two irreparable rotator cuff tears had been treated arthroscopically with biceps tenotomy or tenodesis. A simple tenotomy was performed in thirty-nine cases, and a tenodesis was performed in thirty-three. No associated acromioplasty was performed. All patients were evaluated clinically and radiographically by an independent observer at a mean of thirty-five months postoperatively.

Results: Fifty-three patients (78%) were satisfied with the result. The mean Constant score improved from 46.3 ± 11.9 points preoperatively to 66.5 ± 16.3 points postoperatively (p < 0.001). A healthy-appearing teres minor on preoperative imaging was associated with significantly increased postoperative external rotation (40.4° ± 19.8° compared with 18.1° ± 18.4°) and a significantly higher Constant score (p < 0.05 for both) compared with the values for the patients with an absent or atrophic teres minor preoperatively. Three patients with pseudoparalysis of the shoulder did not benefit from the procedure and did not regain active elevation above the horizontal level. In contrast, the fifteen patients with painful loss of active elevation recovered active elevation. The acromiohumeral distance decreased 1.1 ± 1.9 mm on the average, and glenohumeral osteoarthritis developed in only one patient. The results did not differ between the tenotomy and tenodesis groups (mean Constant score, 61.2 ± 18 points and 72.8 ± 12 points, respectively). The "Popeye" sign was clinically apparent in twenty-four (62%) of the shoulders that had been treated with a tenotomy; of the sixteen patients who noticed it, none were bothered by it.

Conclusions: Both arthroscopic biceps tenotomy and arthroscopic biceps tenodesis can effectively treat severe pain or dysfunction caused by an irreparable rotator cuff tear associated with a biceps lesion. Shoulder function is significantly inferior if the teres minor is atrophic or absent. Pseudoparalysis of the shoulder and severe rotator cuff arthropathy are contraindications to this procedure.


jim briggs

In school and during my internships I only remember my teachers accusing the rotator cuff/supraspinatus for the inconvenience of shoulder pain, especially with elevation. I have noticed that a certain population of patients have more pain inhibition and difficulty with load tolerance tests of the long head of the bicep versus the supraspinatus which always made me curious as to the culprit of the pain and lost function. Was it bicep tendon? Slap? Both? The special tests aren't necessarily reliable... Ofcourse the shoulder tendons are more victims of overuse or faulty mechanics than the actual culprits of shoulder pain but I've noticed a trend in addressing the rotator cuff interval. Curious area.... Dr. Tomaino and a few of his contemporaries here in Rochester speak often of this area... kinda the Bermuda Triangle of the shoulder. Anyhow... any info you can pass towards me regarding mechanics of the RC interval and it's contribution to shoulder patjology would be greatly appreciated.

April 2nd, 2010 @ 2:16 pm

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