TEARS

THE

OF

HUMERAL

A Radiological R. E COTTON, Fro,n

the

Pain

follow

Bland-Sutton

and

stiffness

often

somewhat the

and

to exclude of

persons

often

The

criteria

and

many

ito

history

of recent

diagnosis

fibrocartilaginous

into

which

the

Radiological

Survey

RIDEOUT,

LONDON,

Department,

or

ENGLAND

Middksex

and

no

comprise

to

relevant

tear the

the

of

made

confirm

condition

rupture

rotator

cuff.

are,

head

of

the

of

defined

attachment.

the

and

found

The

acromion

humerus

many

and

humerus

upper

along

therefore

greater

bursa

surface

of the

the biceps passes

lies

tuberosity

a non-communicating

on the

minor to the

neck. The tuberosities

cuff

the

tendinous anatomical

and teres is attached

itself

two-thirds of the anatomical in its groove between the this

the

in

of the

is a well

tuberosities

the

tear

however,

found

of a number This

infraspinatus, The cuff

under

cuff diagnosis

symptoms.

implies

tween

in various the

are

supraspinatus, muscles are inserted. upper tendon

which may may have a

shoulder

of a tear

this

London

is of a rotator to

diagnosis

ascribed

Hospital,

symptoms symptoms

examination

radiological

cuff

use

commonly

a radiological

for

subscapularis,

excessive

diagnosis

injury

which

and

features

of rotator

fibres

D. F.

exertion

for

dispute

clinical

structure

referred

Necropsy

and

clinical

disease.

some

with

The

are

CUFF

joint are extremely common Quite often, however, the

after

The

recreations.

patients

subject

and

presentation

and

and

ofPathology

the shoulder minor degree.

of

of

insidious

occupations

Pathological

NOTTINGHAM,

Institute

trauma,

and

ROTATOR

be-

of

the

is commonly

cuff

at this

point.

On its inner aspect the fibres of the cuff are closely applied to the synovial membrane which is reflected at the insertion of the cuff to the margin of articular cartilage In

(Fig. 1). view of these

surprising

that injury to the and violent strain, may

sudden

few

studies

condition

have during

been

performed

life.

In view

tears of varying severity as a past uncomfortable derangement is not use

of

ofstructure

the

This

persons

Radiological findings. 314

found

I) Cystic

seldom

and

on

patients

of the

natural

in thejoints

diagnosis appearances

acromion,

insertion,

the

cartilage. conservative

indicated,

at

might

account

be acceptable

of rotator in the

cuff bone

it must

tears of

a clear

has the

changes

been upper

made

JOURNAL

of this likely

that

or forgotten considerable

that the shoulder by compensatory

which

are

found

in

the

following

injury. previously

two-thirds THE

re-

history

it is most

be remembered can be avoided

of previous

are usually operation is

is available

condition

radiological

as evidence

at and

and the joint in changes; also,

which are either unnoticed seem surprising in view ofthe

movement for

had

by to

humerus

membrane

information

who

of the

it is not

the

synovial

Since symptoms measures and

little

necropsy

history

examined,

gleno-humeral

yet

the

relations

cuff, particularly also cause damage

garding the appearances of the cuff the acute stage, apart from radiological

and

joint

scapula.

tendon,

may occur in many patients episode. Although this may

a weight-bearing

asymptomatic

biceps tendinous

the articular relieved by

FIG. 1 shoulder with the capsule reflected the inner aspect of the rotator cuff by smooth synovial membrane.

Normal to show covered

the the

anatomical

of OF

on the

BONE

anatomical AND

JOINT

neck SURGERY

TEARS

of

the

humerus

irregularity,

sclerosis

1934,

Harrison

of the 1962).

head of the 4) Narrowing

formation Cysts described lacking.

(Codman 1934, or trabecular

1949,

Golding

on the

lateral

in the

anatomical

1962).

margin

of the

neck

and change

and

cause

women,

and

he found

and

that

also described avulsion, caverns containing “

rupture

further

insertion, group

and

clinical

the

irregularity

of patients

incidence

and

who

tear

site.

of the

This

the seen

injury,

1 1 1 of whom cuff

had

suggested rotator

200

studied

examination. seventy-four was

were

Codman

taken.

the also

He

anatomical

described factors of the acromion.

considered

necropsy

might

accepted were

of

from

cent.

also

102

In a

radiological and

he

also

in the shoulder of a anatomical neck were subsequently found at and

there

745 patients

factors

Codman

noted.

above,

neck

investigated

described

rough edge supraspinatus

reported

radiological and necropsy findings appearances of a cyst below the lined by fibrous tissue which was with

been

head of biceps and Sclerosis of bone at

factors 1, 2, 3 and 5 mentioned a fresh rupture of the cuff at operation.

(1949)

the the

32 per

tuberosity pain

often

evidence is been thought

shoulders

of the long tuberosity.

greater

have

Most of these patients men and twenty-eight

ruptures

of shoulder

Harrison

surface

that osteophytes cuff tears by local

suggested that wear through

He

cuff

of the

gap

but confirmatory neck and have

was

with

1, 2 and

1, 2, 3 and 4 as Cystic appearances

occurring were

an old

shoulder

3 as typical

in rotator cuff seen radiologically

but at necropsy no obvious communication with the joint cavity was found. In these cases, however, the covering of bone was very

It was

and

of rotator

radiographs

easily be pushed into the cavity demonstrated histologically. at

fibres.

communicated

tendon.

the articular

Harrison 1949, Golding 5) Irregular new bone

of

lesions.

Golding (1962) addition to sclerosis cases neck

cavity

subscapularis

rotator

(1934) may

radiological there being

complained

Harrison (1949) described the man of thirty-six. The radiological correlated with a multilocular cavity a comparable

the

recession

had

findings, including that he had never

commented

of

joint femoral

It has been further joint may cause Codman acromion

but without years old,

between

1934, 1962).

cortical (Codman

1934).

the shoulder occur in the

1952). of the

2) Recession, of the humerus

of the acromio-humeral

flattening, fraying and adhesion vascular tissue beneath the greater

“

cuff

also

or gap

(Codman (Golding

(Codman

narrowing

rheumatoid arthritis. in the acromio-clavicular

fraying

notch

tuberosity gap

of

(Watson-Jones lateral margin

315

CUFF

1949, Golding 1962). of the greater tuberosity

acromion

and

necropsies in a geriatric hospital were between sixty and eighty

ROTATOR

3) A distinct

as evidence of osteoarthritis Cysts of similar appearance

pressure and friction new bone along the

the

Harrison atrophy

humerus and the greater of the acromio-humeral

due to osteoarthritis from degenerative

tendon

HUMERAL

OF THE

as always

provide

that

the

radiologically

tears.

about

of Such

their

bone.

radiological

significance

diagnostic with

information

the cortical

a combined

clarify

associated

through

and

The

and

pathological

relative

rotator

cuff

a study

might

cystic

lesions

also

and

were

survey

importance tears

via the thin and

of confirm

correlate

anatomical a pin could subsequentJy

of shoulder the

various

that the

lesions in in some

these

severity

joints factors changes

of changes

pathogenesis.

MATERIAL

AND

METHODS

Antero-posterior radiographs of both shoulders were taken in an unselected series of 106 necropsy subjects over a period of nine months at the Middlesex Hospital. In only two cases was there any record in the clinical notes of symptoms referable to the shoulders, but it should be stressed that no other attempt was made to elicit a history of such symptoms other than by reference to the notes. The axial view was not done because the rigidity of the cadavers made such a view impossible. Rigidity also caused slight variation in the position of the shoulder are VOL.

at the

considered 46 B, NO.

time

of radiography.

to be unimportant. 2,

MAY

1964

For

the

practical

purpose

of this

study

these

variations

316

R.

In nearly was

all the cases, the body

removed

E. COTTON

AND

D.

when any radiological for dissection. This

from

F. RIDEOUT

abnormality was found the shoulder joint was done by reflecting the skin and dividing

the soft tissue and bone at the middle of the clavicle, of the uppermost and middle thirds of the humeral exposed

by dissection

attachment tuberosities

the

were

taken,

abnormalities were as slight, moderate affected

series

and

after

recorded or severe.

radiological

most

was

removed.

The

to the humeral neck and the capsule to expose the inside of the joint. After

examination

When

scapula

removed,

freezing,

the was further

of six radiologically In addition to the

evidence

of calcification

clavicular

joints

were but

normal radiological

sclerosis

rotator

humeral

in both

cuff

of the cortex

capsule

was

heads

shoulders both

of the

were

cut

in

which

Any

made

of the

to be

A small

control

of radiographic

changes

surface

serial.

appeared

explored.

osteoarthritic

inferior

at its lowest

severity of the findings taken of the specimens.

also excised and examined. already stated, note was tendons,

incised

were

the joint

joints

and the junction capsule had been

reflected upwards over the specimens for histological

made to grade the radiographs were

instances

joints were findings

in the

and

seen

in a few

joint

and rotator cuff formalin fixation,

and an attempt In some cases

abnormalities was

the neck of the scapula shaft. After the joint

in the

acromio-

acromion.

RESULTS

Both shoulders in sixty-eight

found bodies.

were examined shoulders-in

Thirty-six

specimens

abnormal

showed

rheumatoid

rotator

arthritis.

The

incidence

shoulders cuff

The

found to be anatomically in those with abnormal

tears

six

and

which

The ages and from

female

on 106 of thirty

were removed the exception

with

shoulders

normal. findings,

of male

radiologically both shoulders

bodies

The

diagnostic

1) Cysts

2) irregularity of the greater shoulders) articular

criteria

in the

upper

(Fig.

4) ; 4) exaggeration

surface

of the

head

and

Recession

trabecular

the

to have tears. case of rheumatoid

of the

cortex,

bilateral

glenoid surface. Fibrous The acromio-humeral

marking and

the

recorded

and

the

incidence

of

the

inferior

atrophy

aspect

as the smallest

arthritis

neck

(thirty-one it and the

groove

between

(eight

(Fig. surface

greater

(Fig.

5) ; 6) sclerosis

greater

tuberosity

of the

2);

and

humeral

tuberosity

was

showed

narrowing

and

more

the

of the surface

of

often

found

appearances tendons loss

at a point this

directly

line and

and

(Fig.

and

THE

the

JOURNAL

head

BONE

and

sclerosis

of

discovered. cortical bone of the

cortex OF

had

of which

cartilage

lipping

articular

three

6), all

of articular

some

above

the

in the

on the inferior margin not thought to be a factor

ankylosis with an articular pannus was subsequently interval was measured from a thin line of dense between

(Fig.

3); 3) sclerosis (twenty-seven

4) ; 5) narrowing

films. Osteophytes six cases and were

shoulders

acromio-humeral

distance

shoulders

shoulders)

shoulders) articular the

normal radiographic by dissection. in the rotator cuff

of the acromion

were

to ninety findings.

in sixty-eight

(fifty-six

shoulders)

(Fig.

normal in only

both

normal

twenty-eight with normal

the of

5).

of the

had otherwise confirmed calcification

and all evidence

radiologically

of them

anatomical

humerus

of which had otherwise joints were found

in tears of the cuff. Three evidence of tears subsequently Seven shoulders showed

erosion

of the

be

were of eight

FINDINGS

of the

interval (eleven shoulders) process (nine shoulders) (Fig.

older bodies, many of the acromio-clavicular

proved In one

tears

two-thirds

to

abnormalities shoulder

bodies there was

bodies ranged from to eighty in those

of the cortex of the greater tuberosity tuberosity or of the groove between

acromio-humeral the acromion

were

of cuff

one

equal.

RADIOLOGICAL

were:

and and

from thirty-three of one in which

appeared

of the thirteen

was

cadavers bodies

humerus

of the humeral AND

JOINT

SURGERY

TEARS

head.

Subjects

with

no

OF THE

radiological

HUMERAL

abnormality

ROTATOR

showed

317

CUFF

an acromio-humeral

interval

from

6 to 14 millimetres. Seven necropsy specimens so that the head of the humerus

showed a full-thickness tear of the rotator articulated with the acromion. In these

humeral interval was 1 millimetre 9 millimetres in another case.

in three cases, The full-thckness

2, 3 and 4 millimetres tear was almost

cuff and of the bursa subjects the acromio-

in three complete

other along

cases and its whole

FIG. 2 . cyst in the greater tuberosity. The cortex of the greater tuberosity is sclerosed and very slightly irregular. The tear in this case was not severe. Figure 3-The cortex over the greater tuberosity is irregular and there are poorly defined cysts along the anatomical neck. The acromio-clavicular joint shows subarticular cyst formation and osteophytes at the inferior margins. The tear was severe.

.:

Figure

2-A

Figure

4-The

FIG.

groove

4

between

FIG.

the greater

tuberosity

and the articular

surface

5

is exaggerated

with sclerosis of the underlying bone. The acromio-humeral gap is narrowed. Irregular cystic changes are present. Although the tear was severe acromio-humeral articulation was not present. Figure 5-Cysts are present and the cortex of the greater tuberosity shows sclerosis. The acromio-humeral gap is narrowed and there is sclerosis of the inferior surface of the acromion. Acromio-humeral articulation was present. VOL.

46 B, NO.

2,

MAY

1964

318

R.

E. COTTON

AND

D.

F. RIDEOUT

attachment in four cases in which the interval was between 1 and 4 millimetres, incomplete behind in a case with an interval of 2 millimetres, and incomplete in front in two cases with intervals of 3 and 9 millimetres. In 2 and

other radiologically 1 1 millimetres. The

abnormal case with

shoulders rheumatoid

the acromio-humeral arthritis had intervals

interval of 4 and

was

between

5 millimetres.

Of the seven cases with acromio-humeral articulation, six showed radiological sclerosis of the inferior surface of the acromion. Only three other shoulders showed this change and these were the opposite shoulders ofthose cases with acromio-humeral articulation. Irregularity of the bone at the lateral margin of the acromion was found in three cases, in all of which

FIG. 6 FIG. 7 Figure 6-Calcification in the rotator cuff and irregularity of the greater tuberosity. under the articular surface. A severe rotator cuff tear was present. Figure 7-Irregularity

outer

end of the acromion

tuberosity appearances

and

complete

tears

shoulders. In two which was The

of the

cuff

area

had

to be entirely

demonstrated thick and symmetrical,

a smooth

normal

over the greater

tuberosity.

The cortex

over the greater

it from the articular surface is sclerosed. There are irregular cystic neck. The rotator cuff tear was complete but acromio-humeral articulation was not present.

were

cases an unusually bilateral but not

sclerosed

found

and to a lesser degree

the groove dividing along the anatomical

A cyst can be seen of the bone at the

and

and

these

(Fig.

7).

This

feature

apparently sclerotic cortex was the only radiological regular

have

surface.

been

Both

included

was

seen

of the greater abnormality

shoulders

in the

not

were

figures

in other

tuberosity, (Fig. 8). removed

of the

and

radiologically

normal. lipping

Diagnostic of the

radiographic changes of osteoarthritis were found in two shoulders inferior articular margin of the humeral head in both and some

of the glenoid in one examination disclosed

(Fig. 9). osteoarthritic

Both

subsequently showed rotator cuff tears. changes in fifteen out of thirty-three cases,

moderate in two, age or more and

and mild or early in nine. Nearly all the presence or absence of osteoarthritic

significant

with

extent

The new region

shoulder

bone

the presence of the patient

formation

of the

anatomical

at the

or

with

fracture

neck

and

these patients were changes did not

of rotator cuff tears. previous fracture showed

with bony eburnation

Pathological severe in four, seventy correlate

years of to any

absence

the margins.

a partial

Small tear

subcortical

of the

cysts

rotator THE

cuff

JOURNAL

impaction were was

deformity also

found

subsequently

OF BONE

AND

JOINT

and in the found. SURGERY

TEARS

Of

the

subjects

subsequently were always Most

were

solitary

some

were

head.

This

site

the

radiological

HUMERAL

cysts

ROTATOR

in the

immediately

of cyst

cuff fibres,

absence

and

occasionally

subcortical, found

formation

and, in all particularly

distance

is immediately

cases those

when from

the

beneath

examined, readily of the inner aspect

neck

of the

humerus

and

to have rotator cuff tears. The cysts in numbers and in size (Figs. 2 and 7).

although

a little

319

CUFF

anatomical

pathologically examined, all were found in a similar situation but varied considerably

cases)

the rotator tendinous

showing

OF THE

the

multiple

(up

to three

cortex

of the

upper

insertion

recognisable of the cuff.

of the tears Cysts

inner

were were

in a few humeral fibres

of

found in not found

the in

of tears.

FIG. Figure 8-The cortex of the greater tuberosity is sclerosed but no other changes can be seen and no abnormality was found in the shoulder at necropsy. Note the thin line of the normal inferior acromial cortex. Figure 9-Acromio-humeral narrowing with sclerosis of the inferior surface of the acromion. The cortex of the greater tuberosity is irregular and there are cysts along the anatomical neck. The inferior articular margin of the humeral head is lipped. There was a complete tear with acromio-humeral articulation.

In greater these

seventeen

shoulders

tuberosity,

three

features

two

showed

not

show

were

not

irregularity either

with had

severe

sclerosis

tears only

demonstrated.

In sixteen

one

alone

sclerosis,

irregularity

46 B, NO.

and

irregularity

and

and

irregularity

only cases

in seven

with

less

five sclerosis

of the ; in three

severe

alone

tears

: eight

did

FINDINGS

were found were found

in the synovial membrane. in all cases in which the radiological

They varied considerably in their or severe degree or, in eight cases,

severity, complete

being and

2,

MAY

1964

ruptured ruptured

criteria

suggested

graded as incomplete of full thickness. The slight

as irregularity of the inner surface with fraying of the fibres the biceps tendon (Fig. 10). In moderately severe tears the

on both sides of the biceps tendon, were more definitely and in severe incomplete tears all but the outer fibres were VOL.

sclerosis

was

six radiologically normal cases showed no structural abnormality. a smooth inner surface lined by the synovial membrane of the joint and transition from articular surface on to the reflected capsular tissues.

slight folds tears-These

presence. moderate

tears showed of or behind

showed

feature.

Normal shoulders-All The rotator cuffs had there was a smooth

their slight,

there

radiologically

PATHOLOGICAL

Occasionally, Rotator cuff

four

and

usually just inner fibres,

with a small usually over

in front usually

gap (Fig. 1 1), a considerable

320

R. F. COTTON

FIG.

Figure of

the

present inner

10-A fibres

slight has

rotator

resulted

10 cuff tear in a groove

with at the

AND

fraying articular

D.

F. RIDEOUT

of the inner margin

fibres with

in the underlying bone. Figure 1 I-A moderately severe Small pores are visible in the anatomical neck and

fibres.

Figure 12-A with avulsion full-thickness

“

“

FIG. II the biceps a central “ pore.”

near

tendon. Avulsion There was a cyst tear of the cuff with avulsion of the the joint shows osteoarthritic change.

FIG. 12 FIG. 13 severe incomplete tear with marked irregularity of bone of the anatomical neck associated of the fibres. The head of the humerus shows osteoarthritic change. Figure 13-Complete tear of the rotator cuff. In areas of residual attachment anteriorly there are “ bridges” of tendinous tissue and the biceps tendon shows marked fraying. THE

JOURNAL

OF BONE

AND

JOINT

SURGERY

TEARS

length

cuff (Fig.

of the

12).

OF

THE

Complete

HUMERAL

tears

subacromial bursal wall (Fig. 13) leaving head of the humerus and the undersurface seen in seven of the eight cases of complete

ROTATOR

involved

the

full

a large gap which of the acromion tear.

and

their

adjacent

presence

the

to

tear

confirmed nearly

histologically

all

showed

(Fig.

loss

of

thickness

of the

cuff

and

the

allowed articulation between (Fig. 14). This articulation

In most cases the tear was greatest close to the insertion humeral head. Foci of calcification in the region of tears cases

321

CUFF

of the tendinous fibres were seen radiologically

1 5).

The

structure

with

ruptured

fibres

hyalinisation

the was

into the in seven and

and

those

areas

of

myxomatous degeneration (Fig. 16), but these changes were only found in the region of tears and were not found in their absence. It appears unlikely that such changes are primary ones but are secondary to the presence of the tear. Other

abnormalities were found almost be associated with tears. Rupture and detachment of the inner fibres of the cuff were uneven leaving narrow bands or bridges” constantly

to

“

of tendinous ment (Fig. with

the

tissue 17).

severity

in complete occasionally

of the tear

tears. represented

of fibres. A further larity

at the original These increased

the the

articular tendinous

were

severe

been

avulsed.

deep,

was

In this

the articular (Fig. I 8).

cartilage

was

the groove appearances

of this

the thirty-six

had

of

bone

in the

floor

of

and irregular. The avulsion or resorploose bodies examined.

were The cuff fibres.

of the bone shoulders

humerus

shoulders

head and of variable

immediately

Shoulder

viewed

from

millimetres

a constant no evidence VOL.

to one

These

features

gave

removed,

thirty-five

showed

their presence was subsequently severity. The only abnormal

beneath

centimetre

relationship to the of osteoarthritis.

46 B, NO.

2,

MAY

1964

aspect

showing

a complete tear of the cuff with erosion of the articular surface of the humerus. Acromiohumeral articulation was present.

the

severity

across.

rise to a characteristic

site

Neither

of the tears.

tuberosity in eight.

radiological

confirmed shoulder

and

evidence

by dissection. which did not

arthritis. in the subcortical bone of the anatomical of insertion of the inner fibres of the rotator

cuff (Fig. 19). They varied in number from one to three but were multiple some were one centimetre or more from the cortical margin. two

14

the lateral

in the groove between the greater and exaggeration of the grooves

cysts was from the case of severe rheumatoid The position of the cysts was constant being of the

I;’ FIG.

accurately

in the rotator

abnormal

upper humeral rotator cuff tears

the

distance

and the greater of the articular

corresponded

the tear

in the

ofcysts

neck

of

of

sometimes the

appearance of sclerosis surface in twenty-seven

Cysts-Of

have

the pitted either

avulsion

severity

radiological the articular

All

and

irregu-

margin

of insertion of when the tears ofthe cuff had

in

of a flake of bone. Bony seen in any of the joints

the

the

increase

commonly suggested

present

undermining

margin The margin

sharp

not

a groove,

with and

of attachnumber

was

and

way

apparent

between tuberosity

with

bone

surface at the site fibres, particularly and considerable areas

margin

degree

were

abnormality

cortical

articular

tion not

but

in

the slight tears they the only site of rupture

associated

the

of

In

site

the Cysts

number were

nor present

usually Their the

size in joints

solitary. size varied of the which

When from

cysts

bore

showed

322

R. E. COTTON

AND

D.

F. RIDEOUT

‘

.%

.‘,

4

-

‘‘

-

4, -

.?‘ -

‘.

\.

S

.

a

S

.

..

.

a

‘V I

e.c %

1

FIG. 15 Figure 15-Section showing a focus of calcification in torn myxomatous degenerative changes. (Haematoxylin and eosin, gross disorganisation of torn cuff fibres and areas of degeneration and eosin, x 30.)

FIG.

Figure

17-The

shoulder Figure 18-A

17 shows deep

a moderately severe tear with groove at the articular margin

FIG. 16 rotator cuff fibres which also show x 200.) Figure 16-Section showing at the site of a tear. (Haematoxylin

FIG. 18 multiple “ bridges “ of tendinous at the site of a partial tear.

THE

JOURNAL

OF

BONE

AND

JOINT

tissue.

SURGERY

TEARS

OF THE HUMERAL

ongitudinal section through the hL subcortical bone with a “ pore.” I “ inner aspect of the attached rotator

Figure

VOL.

323

CUFF

humer .

i-A

cuff shows

iocular ....

“

marked

a subcortical

46 B,

NO.

2,

MAY

1964

cystic

cyst.

irregularity.

21-Section through a “ pore “ which demonstrates continuity with the cystic showed a continuous lining of synovium. There is a second, deeper, cystic eosin, x 6#{149}5.) Figure 22-Sclerotic bone surrounds the cyst. The cortical bone missing. (Haematoxylin and eosin, x 8.)

specimen

and

ROTATOR

space. This particular lesion. (Haematoxylin is distorted and largely

324

R. E. COTTON

F1G.

AND

D.

F. RIDEOUT

23

24

FIG.

Figure 23-The cyst wall is composed of connective tissue of moderate vascularity. The bony margin shows considerable new bone formation with numerous cement lines. (Haematoxylin and eosin, #{149} 30.) Figure 24-Cyst lining showing strands of collagen and fibroblastic and osteoblastic activity. (Haematoxylin and eosin, x 160.)

In all but roof

which

joint

two

appeared

surface.

maximum

subjects either

These

of three

the cysts as

“

communicated

pits

“

communications

millimetres

(Fig.

with 20)

varied

or definite

from

in diameter.

the shoulderjoint “

pin-point

In the

two

25 spaces lined (Haematoxylin

pores in

by gaps “

size

instances

in the bony

when

viewed

(Figs.

21

where

from the 22) to a communication

no

and

FIG.

Showing

was

found

into

the

situated

the underlying in the

bony

loose connective tissue mesothelial appearance.

roof cavity

anatomical

was

extremely

in the

manner

neck

of the

with

thin

so that

described

by somewhat and eosin,

a pin

by Golding

could

flattened x 160.)

readily

(1962).

cells

of

be pushed

The

pores

were

through always

humerus. THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

TEARS

OF

THE

HUMERAL

ROTATOR

325

CUFF

lb 26 biceps tendon shows fraying of one border of the head of the humerus and villous FIG.

Figure

26-The Osteoarthritis

FIG.

Figure

28-Marked

Figure

29-Pigmented

46 B, NO.

VOL.

K

FIG.

28

villous

2,

FIG. 27 at the site of a rotator cuff tear. Figure proliferation of the synovial membrane.

proliferation

of the

synovial

membrane.

villous proliferation with a cellular villus containing granules. (Gomori’s method for haemosiderin,

MAY

1964

29

(Haematoxylin abundant 240.)

27-

and

iron-containing

eosin,

30.) pigment

326

R. E. COTTON

The

term

consisted

cyst

of

showed

was

a bony

several

small

spaces

porotic

but

in many

defect

was

few

(Fig.

flattened

cells,

case

from

fraying,

cases,

three

associated

had

Synovial

severe,

an

show

these with

gross

tears at the

fusion of appearances

villi

of

the

condition

as

and

from

markedly tissue

The

in a few

the

to were cases seen

of

(Fig.

for while

sclerotic

forming

cases

a definite

abnormality

presence

to grossly

the

roof “

lined

synovial

in eleven

of osteoarthritis.

of the

but in a by a layer

pores

“

some

24), others there were

lining

was

specimens,

in

Lesions

varied

to complete rupture in four articulation ; the fourth

tear.

FIG. 30 granules in phagocytic haemosiderin, x 600.)

to distortion

showed

varying

were

associated

cells.

(Gomori’s

and destruction degrees

ofthe

of villous

with

osteoarthritis

synovial

lesions

severe

in the

abnormalities

and

there

four

cuff were

cases

for

synovial

synovial

rotator

joint,

method

membrane

at the

proliferation, tears.

five

mostly

Although

cases

in ten

of osteoarthritis

of synovial

proliferation

in

change.

specimens

synovium

none

All

infiltration

the

caused

varied

structure.

of the

complete,

addition cases

of osteoarthritic

In nine

to these

tissue (Figs. 23 and material in which

bone with gaps at the sites of the tissue only. The cystic spaces were

irrespective

haemosiderin

associated

not

absence

with

profuse

27).

was

did

which the

almost

fourteen

(Fig. this

bone

normal

mesothelial,

tears

membrane-In

of tears,

applicable connective and fibrinous

surrounding

of more

possibly

with

Showing

cases

correctly

flattening and narrowing of the tendon (Fig. 26) which had complete cuff tears with acromio-humeral

of

a very

marked

The

was

F. RIDEOUT

with that of the shoulder joint. biceps tendon showed pathological

tendon-The

each

site

25).

cases

in continuity

case

always

of rather thin cortical it was composed of fibrous

instances

Biceps

not

D.

cavity lined by vascular filled with fibrous tissue

mostly

of rather evident

perhaps

definite defect

a

AND

abnormality

chronic

28).

Five

site of villous

the

typically

a simple cells,

specimens

changes in the

with,

The pigment of pigmented approach knee

non-specific presumably

showed

proliferation

form nodules. similar to those did

was

inflammatory

very

marked

in the case was found villonodular the

reactive related

villous to

brown

the

of the two more

tumour-like

which

pigmentation marked

to be iron and synovitis (Figs.

obvious

overgrowth damage

of the examples,

the histological 29 and 30).

proportions

of

In this

joint. DISCUSSION

The

radiological

are common and

confirmed

and

pathological

features

in necropsy specimens. In this series pathologically in thirty-five cases,

described

as associated

of 106 bodies usually being THE

with

rotator

they were present in both shoulders. JOURNAL

OF BONE

AND

cuff

tears

in thirty-eight The average JOINT

SURGERY

TEARS

age

of those

with

abnormal

years. Although sex distribution compared might be due to several expected and

that

with

the

it may

episodes

This What

of

cuff

and

be that

next

Rotator humerus,

articular

surface,

and

of the

torn

on

osteoarthritic

undersurface

of the

to the

site

pores It seems whether this “

would speed

be more

and

of these

Certainly and

fibres,

susceptible

with

of

reparative

efficiency

patients

it has

although

such

grooving

the

acquire

been

the

their

shown

the tendinous

a change

at this

inner

changes

aspect.

may

are not

margin

normal

advancing

lesions

that

age

processes. from

repetitive

related,

acromion.

The

cuff

some

to the

myxomatous

tear

are

situated

fibres

and

bridge

formation

biceps

tendon

in the in most

likely results of the

greater

rather

in the anatomical cuff, loss of the

it is of interest

the joint space. that all these changes are explicable from a solitary severe incident or

communicating

show

that

due

“

is also

the case

subcortical

cases

neck of marginal to uneven commonly

rupture of the head and the

bone

the cyst

than

of rheumatoid

head. Severe tears with complete the upper surface of the humeral

cysts

of the

“

to the

and

ther#{128} is no relationship

fibres

be secondary

with

Damage

any cysts in the humeral articulation between

of detachment

“

radiologically

years

structures.

or excessive

of fibres

but

form

many

in thejoints

to the

arthritis did not show cuff lead to additional next

majority

years

cuff tears are constantly related with cyst formation partial avulsion of the tendinous insertion of the

detachment found

the

707

327

CUFF

in men there was no significant difference in The older age of patients with rotator cuff tears is solely responsible for the lesion it might be

involved in

the over

change

degeneration primary.

was

ROTATOR

but with increasing deterioration on each occasion. fit with the lack of clinical evidence of acute injury in many patients. to assess is the part played, if any, by degenerative disease affecting the

trauma

adjacent

to osteoarthritic

the

tissues reduction

would certainly is more difficult

rotator

joints

more common the normals. If trauma

ligamentous

corresponding

Alternatively minor

shoulder slightly with factors.

5&25

OF THE HUMERAL

immediately

roof

is deficient

to

with

on many

a basis minor

of previous trauma episodes is a matter

but for

conjecture. Sclerosis rotator

cuff

tear

tuberosity

is an unreliable

was

found at necropsy. Golding ( 1962) measured

and

gave

fourteen interval

the

normal

range

the

tears.

of

the

inferior

from the abnormalities the radiological

Nevertheless,

tear

plays a significant The exact mechanism Their close relationship certainly

suggestive

cortex

of a traumatic

to produce direct disruption expect to find evidence ofcallus

could

be based 46 B,

NO.

on inflammatory 2,

MAY

1964

acromion

within cases a

complete indication

of the greater

tuberosity

of subcortical formation and reaction

the with

more

to the

stress

in range

150 cases was

six to

normal severe

range. It was but incomplete sign

of

acromial

rupture of the cuff or acromial of the severity of the tear. was

three

might

times

more

be

of synovial

common

margin in only three it is unlikely that this

humeral cysts avulsion of inner

cancellous bone. this was not found.

presence

the

reliable

tears (20 per cent). at the lateral acromial With this low incidence

The

humerus

series

of a

no abnormality

normal. The narrowing of this tear of the cuff and wall of the bursa.

with little

etiology.

evidence

series

and

In this

an interval and in two was

radiographic in this

part in the etiology of tears. of the production of the subcortical in situation with tears of the cuff and

cortex would

VOL.

the

surface

associated changes give

other

examined

millimetres.

showed arthritis

in severe tears (65 per cent) than in less severe Irregular new bone formation was seen shoulders, all of which had full-thickness tears. feature

of any

cases

between

to thirteen

acromial

of the

irregularity

interval

two

that were radiologically sign of a full-thickness

with a full-thickness the case of rheumatoid

Sclerosis

articulation. Apart articulation,

In the

as seven

millimetres in shoulders is not an entirely reliable

One shoulder narrowed in

in the absence

sign.

transmitted

is unknown. cuff fibres through

is the

In such an event one A further explanation fluid

in the

subcortical

328

R.

bone

which

gains

entry

E. COTTON

through

the

AND

pores

“

D.

F. RIDEOUT

found

“

after

avulsion

However, no pores were found in two cases, although this does of the bone which cannot be demonstrated macroscopically. While non-specific reactive villous hyperplasia of the synovial in damaged

joints,

the finding

of pigmented

villous

hyperplasia

of

not

rotator

exclude

cuff

undue

membrane

is not

is of some

fibres. porosity

unexpected

interest.

Although

the changes were not as florid as the tumour-like process seen in other joints, they may represent an intermediate stage of development of this lesion in a non-weight-bearing joint. This would lend some support to those who regard pigmented villonodular synovitis as a reactive rather than a neoplastic agents.

process

and

suggest

that

trauma

and

haemorrhage

may

on

106 unselected

be the

etiological

SUMMARY

I.

Radiographs

those

found

of both

shoulders

to be abnormal

were

were

performed

examined

2. Radiological abnormalities were found in sixty-eight Pathological examination showed rotator cuff tears and of these, 3. 4.

rheumatoid

The The

abnormalities lesions

The

are

synovial

histological

of this

the

case

complete

on

a traumatic

shoulders associated

fracture

of rotator indication

of

all

explicable

or absence of osteoarthritic biceps tendon may become

Villous

with

in

a previous

diagnosis give little

subjects

and

of thirty-eight subjects. abnormalities in thirty-five

in one,

and

cuff tears are of the severity

rupture

of

the

one

was

examined of the cuff

not

examined.

and discussed. tears or associated

when

acromio-humeral

occurs.

presence 6. The 7.

in one,

radiological changes

except

articulation

5.

arthritis

criteria for radiological

necropsy

pathologically.

finding

proliferation

was

appearances is briefly

disease damaged found

resembling

basis.

There

of the joint. or even ruptured in fourteen

in this

cases,

pigmented

is no

correlation

the

condition.

in five ofwhich

villonodular

with

it was

synovitis.

The

pigmented significance

discussed.

We would like to thank Dr F. Campbell Golding for his interest and helpful criticism in performing this survey and the post-mortem room and histological technical staff of the Bland-Sutton Institute of Pathology for their indispensable assistance and cooperation. Our thanks are also due to Mr M. Turney and the staff of the

Middlesex

Hospital

Photographic

Department

for help with the illustrations.

REFERENCES CODMAN,

GOLDING,

E. A. (1934): F. C. (1962):

Boston, Massachusetts: The Shoulder-the Forgotten Joint.

The

S. H. (1949): The Painful WATSON-JONES, Sir R. (1952): Fractures E. & S. Livingstone Ltd.

HARRISON,

Thomas

Shoulder.

British

Shoulder.

Journal

of Bone

andJoint

Injuries.

Fourth

Todd

Journal

and

Joint

edition,

THE

Company. of

Radiology,

Surge,-r,

pp. 445-446.

JOURNAL

N.S. 418. Edinburgh

35,

149.

31-B,

OF

BONE

AND

and London:

JOINT

SURGERY