Massive rotator cuff tear in an adolescent athlete: a case report

Rotator Cuff Injuries in the Pediatric Population: A Retrospective Review of Patient Characteristics and Treatment at a Single Center

BACKGROUND

As youth participation in contact and overhead sports has increased in recent decades, so has the occurrence of injuries of the shoulder. Rotator cuff injury (RCI) is an infrequent shoulder pathology in pediatric patients and its description in the literature has been scarce. A greater understanding of RCI characteristics and treatment outcomes in children and adolescents would improve our understanding of this pathology and help to better guide clinical decision-making.

HYPOTHESIS

To identify pediatric patients with magnetic resonance imaging-confirmed RCI treated at a single center to summarize injury characteristics, treatment, and outcomes. It was hypothesized that injuries would occur predominantly in overhead throwing athletes and would demonstrate good outcomes among both operatively and nonoperatively treated patients.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 4.

METHODS

A retrospective review of pediatric patients (<18 years old) diagnosed with and treated for an RCI between January 1, 2011 and January 31, 2021. Patient demographics, injury mechanism and type, treatment, and outcomes were collected. Descriptive statistics were performed. Bivariate testing was used to compare operatively and nonoperatively treated cohorts.

RESULTS

A total of 52 pediatric patients treated for a rotator cuff avulsion, partial tear, or complete tear were identified. Mean age was 15 years and 67% of patients were male. Injuries were related most commonly to participation in throwing sports. Operative management occurred in 23% of patients, while 77% were managed nonoperatively. Treatment cohorts differed based on tear type, with all complete tears being managed operatively (P < 0.01). Associated shoulder pathology was common, with the most frequent finding being anterior shoulder instability pathology. Return to play was longer for operatively managed patients (7.1 vs 4.5 months; P < 0.01).

CONCLUSION

The present study expands the limited data available regarding RCIs in pediatric patients. Most injuries are associated with sports and involve the supraspinatus tendon. RCIs were associated with good outcomes and low rates of reinjury in patients managed both nonoperative and operatively. RCI should be considered in throwing athletes with shoulder pain, even in skeletally immature patients.

CLINICAL RELEVANCE

This retrospective study fills the hole in the literature by detailing the patterns associated with RCI characteristics and treatment outcomes. In contrast to studies of adult RCIs, our results suggest that outcomes are good regardless of treatment type.

Traumatic avulsion of the subscapularis tendon in adolescents: Return to sport after surgical repair

INTRODUCTION

Traumatic complete rotator cuff tears are rare in the pediatric population. These injuries might be a result of shoulder dislocation or direct trauma experienced during contact sports (i.e., rugby, judo). The purpose of this study was to identify the epidemiologic and clinical characteristics of these injuries and assess the medium- and long-term outcomes following surgery, with return to sport as the primary endpoint.

MATERIALS AND METHODS

An electronic questionnaire was sent to all surgeons who were members of the French Shoulder and Elbow Society (SOFEC) and/or the French Society of Arthroscopy (SFA), asking if they ever had to surgically treat a traumatic complete tear of 1 or more rotator cuff tendons in a child or adolescent. Ninety (38.6%) of the 233 surgeons members of the SOFEC and/or the SFA responded to our questionnaire. We then contacted the 15 surgeons who answered affirmatively to collect the complete medical records of their patient(s).

RESULTS

We reviewed the records of 17 children and adolescents who underwent surgery for a traumatic complete rotator cuff tear. The mean age at surgery was 15.2 years (range, 12-17). Glenohumeral dislocation during contact sports (n=7/17) was a frequent mechanism of injury (41%). All of these cases involved at least the subscapularis muscle with an avulsed bony insertion. The injury involved other rotator cuff tendons in 29% of cases (5/17). The bone and tendon repair was either performed as open surgery (n=5/17) or arthroscopically (n=12/17). At a median follow-up of 24 months and a mean follow-up of 50 months, 82.4% of patients had returned to sport at their preinjury level. Three patients presented neurologic complications resulting from the traumatic event, but only 1 of them required nerve grafting with a favorable outcome. We also reported 3 cases of nonunion of the lesser tuberosity that required revision surgery with good outcomes. Only 1 patient out of all those with at least 1 episode of dislocation presented a recurrent anterior shoulder instability that required a bone block-type procedure 7 years after the initial surgery.

CONCLUSION

Traumatic complete rotator cuff tears are rare in children and adolescents. They often occur during contact sports. These types of injuries are diagnosed by clinical examination and confirmed by cross-sectional imaging, ideally magnetic resonance imaging. Tendon injuries mainly involve the subscapularis but can also affect other cuff tendons. Return to preinjury activity levels after surgical management was possible in more than 80% of cases.

LEVEL OF EVIDENCE

IV.

Rotator cuff injury in the pediatric population: a systematic review of patient characteristics, treatment, and outcomes

Rotator cuff injuries (RCIs), traditionally thought to be an adult-type pathology, have been reported in the pediatric population, but there remains limited evidence regarding this injury pattern in pediatric patients. The purpose of this study was to systematically review the literature to characterize the epidemiology, injury patterns, treatment modalities, and outcomes for pediatric patients with RCIs. A systematic review was performed in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, reviewing Pubmed, Embase, Cochrane, and CINAHL databases. Studies reporting imaging confirmed RCIs, and treatment outcomes in patients less than 18 years of age were included. Patient demographics, mechanism, injury type, and injury location were recorded. Treatment type and patient outcomes were abstracted when available and summarized with descriptive statistics. Our search identified 28 studies published from 1994 to 2020, which included 215 total tendons injured in 185 patients. Twenty-six studies were classified as level IV evidence, whereas only two were level III. When described, the most injured tendon ( n = 184) was the supraspinatus, whereas the most described injury type ( n = 215) was a partial tear. Surgical intervention was pursued in 75.8% of injuries, with arthroscopy being more common than open repair (79.4% vs. 20.6%). Nonoperative treatment was primarily utilized for partial tears. Among the 24 studies reporting on return to sports, nonoperatively managed patients returned later than those treated operatively (mean: 10.7 vs. 7 months). Only eight studies included patient reported outcome measures (PROMs), and just five had pre- and posttreatment scores. Three complications were noted, all in operative patients. RCIs in pediatric patients have been reported in the literature with increasing frequency over the last decade, but the quality of evidence remains poor with inconsistent injury descriptions and outcome reporting. Excellent results were seen for all injury types and locations with both operative and nonoperative treatments. The literature for pediatric RCIs remains limited in guiding management decisions indicating a need for more high-quality studies to compare outcomes across injury and treatment type. Level of evidence: level III.

Rotator Cuff Repair in the Pediatric Population Displays Favorable Outcomes: A Systematic Review

Purpose

To systematically review the literature to determine the injury mechanisms, presentation, and timing of diagnosis for pediatric patients with intratendinous rotator cuff tears and to determine the efficacy of surgical intervention for affected patients.

Methods

PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus were searched. Studies were included if they involved only pediatric patients, soft-tissue rotator cuff injuries managed surgically, and reported outcomes. Patient characteristics, injury mechanisms, physical examination and imaging findings, time to diagnosis, surgical technique, and treatment outcomes were extracted. Findings were descriptively analyzed with weighted means and proportions.

Results

Twenty-one studies comprising 78 patients were included. The age range was 8 to 17 years and 57 were male. The supraspinatus (n = 56) was the most injured tendon. American football was the most reported sport played at the time of injury. Most patients were diagnosed within 6 months of injury via magnetic resonance imaging. Arthroscopic management was undertaken in 68 patients. Forty-six of 51 patients for whom data were available returned to sports at a range of 2.5 to 12 months postoperatively. Repair failure occurred in three patients.

Conclusions

The extant literature regarding rotator cuff tears in pediatric patients is limited to reports of low methodological quality. Qualitative synthesis of this low-level literature reveals that rotator cuff tears are mostly reported in male collision sport athletes but may also occur in female athletes and/or throwing athletes. These injuries are often successfully managed via arthroscopic repair, and patients and their families can be reassured that the majority of patients return to sports following surgery.

Level of Evidence

Level IV, systematic review of level IV studies.

Acute massive rotator cuff rupture with posterior shoulder dislocation: arthroscopic novel repair of a rare injury. A case report

Acute massive rotator cuff tears and posterior shoulder dislocations are an extremely rare association, and a vast majority are treated by open surgery. We present a case of a man in his 20s who suffered closed left shoulder trauma after a road traffic accident. He was initially diagnosed with posterior shoulder dislocation and a reduction was successfully performed. However, the patient still complained of persistent weakness during active movements. We found a massive rotator cuff tear involving all the rotator cuff tendons, with significant supraspinatus retraction and persistent posterior shoulder subluxation. He underwent an all-arthroscopic repair of the rotator cuff with a double-row technique in the subscapularis, supraspinatus and infraspinatus muscles. Capsular repair and tenodesis of the biceps tendon were also performed. The patient had good recovery, reaching full preinjury function 3 months after surgery with a successful return to his regular activities.

Excellent Clinical Outcomes and Rates of Return to Play After Arthroscopic Rotator Cuff Repair for Traumatic Tears in Athletes Aged 30 Years or Less

Purpose

To evaluate clinical outcomes and rate of return to play (RTP) among athletes aged 30 years or younger who have undergone an arthroscopic rotator cuff repair (ARCR) after trauma.

Methods

We performed a retrospective review of patients who underwent an ARCR with a minimum of 12 months’ follow-up between 2012 and 2019. Patients were followed up to assess the American Shoulder and Elbow Surgeons score, Subjective Shoulder Value, visual analog scale score, and satisfaction level. Whether patients were able to RTP was reported, in addition to the timing of return and the level to which they returned.

Results

Our study included 20 athletes (20 shoulders), with a mean follow-up period of 31.8 months. All patients were satisfied with their surgical procedure, and all would opt to undergo surgery again. Overall, 85% returned to sport and 50.0% returned to the same level or a higher level. The overall mean American Shoulder and Elbow Surgeons score was 92.4; mean Subjective Shoulder Value, 87.0; and mean visual analog scale score, 0.7. At final follow-up, only 1 patient (5.0%) had undergone a revision procedure. Of the 15 patients who played collision sports, 93.3% returned to sport but only 60.0% returned to the same level or a higher level.

Conclusions

After ARCR, athletes aged 30 years or younger show excellent functional outcomes with high rates of patient satisfaction and RTP after the procedure.

Level of Evidence

Level IV, therapeutic case series.

Physeal-Sparing Transosseous-Equivalent Arthroscopic Rotator Cuff Repair

Rotator cuff injuries in the skeletally immature population are uncommon, with most tears resulting from trauma or overuse in throwing athletes. Although the literature has referenced multiple repair methods in the pediatric population, an arthroscopic physeal-sparing technique has yet to be described. Given the proximity of the proximal humerus growth plate to the typical anchor placement during rotator cuff repair, we advocate a technique that avoids violation of the proximal humeral physis. Our technique shows an arthroscopic physeal-sparing repair using standard arthroscopic equipment and fluoroscopy.

Rotator Cuff Repair in Adolescent Athletes

BACKGROUND

Rotator cuff tears are rare injuries in adolescents but cause significant morbidity if unrecognized. Previous literature on rotator cuff repairs in adolescents is limited to small case series, with few data to guide treatment.

HYPOTHESIS

Adolescent patients would have excellent functional outcome scores and return to the same level of sports participation after rotator cuff repair but would have some difficulty with returning to overhead sports.

STUDY DESIGN

Case series; Level of evidence 4.

METHODS

A retrospective search of the practice's billing records identified all patients participating in at least 1 sport who underwent rotator cuff repair between 2006 and 2014 with an age <18 years at the time of surgery and a minimum follow-up of 2 years. Clinical records were evaluated for demographic information, and telephone follow-up was obtained regarding return to play, performance, other surgery and complications, a numeric pain rating scale (0-10) for current shoulder pain, American Shoulder and Elbow Surgeons (ASES) Shoulder Assessment Form, and the Western Ontario Rotator Cuff Index.

RESULTS

Thirty-two consecutive adolescent athletes (28 boys and 4 girls) with a mean age of 16.1 years (range, 13.2-17.9 years) met inclusion criteria. Twenty-nine patients (91%) had a traumatic event, and 27 of these patients (93%) had no symptoms before the trauma. The most common single tendon injury was to the supraspinatus (21 patients, 66%), of which 2 were complete tendon tears, 1 was a bony avulsion of the tendon, and 18 were high-grade partial tears. Fourteen patients (56%) underwent single-row repair of their rotator cuff tear, and 11 (44%) underwent double-row repair. All subscapularis injuries were repaired in open fashion, while all other tears were repaired arthroscopically. Twenty-seven patients (84%) completed the outcome questionnaires at a mean 6.2 years after surgery (range, 2-10 years). The mean ASES score was 93 (range, 65-100; SD = 9); mean Western Ontario Rotator Cuff Index, 89% (range, 60%-100%; SD = 13%); and mean numeric pain rating, 0.3 (range, 0-3; SD = 0.8). Overall, 25 patients (93%) returned to the same level of play or higher. Among overhead athletes, 13 (93%) were able to return to the same level of play, but 8 (57%) were forced to change positions. There were no surgical complications, but 2 patients did undergo a subsequent operation.

CONCLUSION

Surgical repair of high-grade partial-thickness and complete rotator cuff tears yielded successful outcomes among adolescents, with excellent functional outcomes at midterm follow-up. However, overhead athletes may have difficulty playing the same position after surgery.

A Rare Case of Massive Rotator Cuff Tear and Biceps Tendon Rupture with Posterior Shoulder Dislocation in a Young Adult - Surgical Decision-making and Outcome

INTRODUCTION

Massive rotator cuff tears (RCTs) in the context of shoulder dislocations are relatively uncommon in the young adult (<40 years) and if reported are more commonly described in association with acute traumatic anterior glenohumeral dislocations. They have rarely been described with posterior dislocations, regardless of patient age. This is the 1^st case reported in the context of posterior dislocations, where a triad of biceps tendon rupture, posterior dislocation, and RCTs was observed during surgery. It provides an important reminder to readers about certain injuries commonly overlooked during the assessment of an acute traumatic shoulder.

CASE REPORT

We report an atypical case of a massive RCT involving a 34-year-old Asian male who landed on his outstretched hand after falling off a bicycle. A tear involving the supraspinatus and subscapularis was visualized during surgery, along with long head of biceps (LHB) tendon rupture. This was after an initial failure to achieve closed reduction of the posteriorly dislocated left shoulder.

CONCLUSION

It is easy to miss the posterior instability, the associated RCTs or the biceps tendon injuries. Biceps tendon rupture should be a consideration when one is unable to reduce a posteriorly dislocated shoulder. The interposed torn LHB tendon trapped within the glenohumeral joint was the likely physical block in the initial failure to achieve closed reduction. With timely diagnosis, prudent physical examination, early imaging and surgery, and excellent results can potentially be achieved to return a young patient to full functionality.

Transosseous Physeal-Sparing Rotator Cuff Repair in an Adolescent Football Player

Rotator cuff injuries in the pediatric and adolescent population are rare. These injuries are normally caused by an acute event or by repeated microtrauma as a result of poor mechanics during overhead sporting activities. Overall, these injuries account for fewer than 1% of all rotator cuff tears. Physeal injuries, tuberosity avulsions ("rotator cuff equivalents"), and proximal humeral fractures commonly occur in the pediatric population. Traumatic full-thickness rotator cuff ruptures that occur in this age group during contact sports are an extremely uncommon cause of shoulder pain. The rarity of this type of injury in the pediatric and adolescent population may be the result of the excellent tensile properties of rotator tendons in childhood that often resist mechanical forces better than the growth plate or the apophyses. This report describes a full-thickness rotator cuff tear and a posterior labral tear in a 12-year-old boy who had a direct injury to the shoulder while playing football. The authors' goal in reporting this case is to increase orthopedic surgeons' awareness of this type of injury. Early use of magnetic resonance imaging for persistent shoulder pain after direct injury during contact sports may avoid undue delay in diagnosis. This report also describes the mini-open transosseous extraphyseal technique of cuff repair and reviews the literature on this infrequent injury. Overall, excellent clinical outcomes and return to sports can be expected after surgical repair of torn and often retracted tendons.

Traumatic Supraspinatus Tears in Patients Younger Than 25 Years

Traumatic rotator cuff tears in patients younger than 25 years are rare events, with few reports in the literature. When compared with the more mature shoulder, the young, healthy supraspinatus tendon is a robust tendon that is able to absorb a significant amount of energy before tendon failure. Therefore, the diagnosis of a rotator cuff tear can be often overlooked in this population due to the patient's age. This is a report of traumatic supraspinatus repairs in patients younger than 25 years. Nine patients younger than 25 years were identified with a posttraumatic supraspinatus tear as visualized during routine diagnostic shoulder arthroscopy. These 9 patients represented 0.33% of all rotator cuff repairs during a 9-year period. Average patient age was 19.1 years (±3.7 years; range, 13 to 25 years). Magnetic resonance imaging failed to diagnose a rotator cuff tear in 50% of the patients. Mean delay from injury to surgery was 6.6 months. All tears were arthroscopically repaired. Concomitant anterior instability pathology was demonstrated among 66.7% of the patients. No complications were reported. At latest follow-up, all patients reported minimal to no shoulder pain and were tolerating strenuous work, activities, and sports without significant complaints. Even with advanced imaging, the diagnosis of a rotator cuff tear can often be missed in this patient population. Although clinical outcomes can be good, care must be taken to broaden the diagnostic differential in young patients with posttraumatic shoulder pain.