Intratendinous strain fields of the supraspinatus tendon: Effect of a surgically created articular-surface rotator cuff tear

doi:10.1067/mse.2002.126767

Journal of Shoulder and Elbow Surgery

Volume 11, Issue 6, November–December 2002, Pages 562-569

https://doi.org/10.1067/mse.2002.126767 Get rights and content

Abstract

Articular-surface partial-thickness rotator cuff tears play a significant role in shoulder pathology, but the role of the articular-surface tissue is poorly understood. This investigation assessed the effect of an articular-surface partial-thickness rotator cuff tear on intratendinous strain fields. A magnetic resonance imaging–based technique quantified intratendinous strains in healthy cadaveric shoulders at 15°, 30°, 45°, and 60° of glenohumeral abduction. A second set of magnetic resonance images was acquired after an articular-surface partial-thickness tear was created arthroscopically. Measures of strain were grouped into 3 tendon regions. A 3-factor analysis of variance assessed the effects of joint position, tendon region, and tendon tear. Intratendinous strains were influenced significantly by joint position, but few differences existed between tendon regions. The articular-surface partial-thickness tear increased intratendinous strain for all joint positions except 15°. The results lend insight into the mechanical behavior of the normal and pathologic rotator cuff. (J Shoulder Elbow Surg 2002;11:562-9)

Section snippets

Specimen preparation

Healthy fresh-frozen cadaveric shoulders (n = 7; mean age, 46 ± 16 years) were dissected free of soft tissue, retaining only the humerus, scapula, biceps long head tendon, glenohumeral and coracohumeral ligaments, and rotator cuff tendons. Specimens with visible rotator cuff pathology or glenohumeral joint arthritis were excluded from the study. The acromion was resected to permit positioning of an MRI surface coil adjacent to the rotator cuff's insertion site. To simulate muscle forces, the

Results

A map of the maximum principal strain for a representative specimen at all 4 joint positions is shown in Figure 4.

. Representative specimen demonstrating a map of maximum principal strain throughout the intact (A) and torn (B) supraspinatus tendon at all 4 glenohumeral joint positions.

The combined results from this investigation are reported in Figure 5.

. Maximum principal strain of the torn supraspinatus tendon. The horizontal bars indicate statistically significant differences (P <.05), and the

Discussion

The purpose of this investigation was to compare the intratendinous strain fields of intact cadaveric shoulder specimens and shoulders with a simulated articular-surface partial-thickness rotator cuff tear. We hypothesized that an articular-surface tear would cause an increase in maximum principal strain of the superior and middle regions of the supraspinatus tendon at 60° of glenohumeral abduction. Although this was indeed found to be true, the effect of the simulated rotator cuff tear was

Acknowledgements

We gratefully acknowledge the assistance of Mr Patrick Lee.

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To explore the feasibility of applying deep learning (DL) approach to detect supraspinatus tendon (ST) tear on shoulder MRI by using arthroscopy as the reference standard.
In this retrospective study, a total of 431 participants from two different manufacturers and two centers was used to build and validate a DL–based ST tear detection system. The proposed system was developed by using U-Net networks to segment and isolate ST followed by a swin transformer architecture to determine the presence or absence of a ST tear. The Densnet101 and Resnet50 as classifiers were also evaluated. Three radiologists performed subjective diagnoses to obtain the diagnosis results. Receptor operating characteristics (ROC) curves, area under the curve (AUC), sensitivity, specificity, and accuracy were used to evaluate the diagnosis performance of the proposed system and radiologists. We also compared the model’s performance to that of radiologists.
The proposed ST tear detection system with the classification network adapted from swin transformer achieved an AUC of 0.986, an accuracy of 0.929, a sensitivity of 0.918, and a specificity of 0.940 for detecting a ST tear, indicating high overall diagnostic accuracy. No statistically significant disparities in diagnostic efficacy were observed between the proposed ST tear detection system and musculoskeletal radiologist.
The proposed ST tear detection system exhibits a diagnostic performance on par with that of seasoned clinical radiologist.
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Various strain studies of the supraspinatus have been done in isolation. Given that rotator cuff muscles function as a group, it may be physiologically representative to measure strain behaviour with the glenohumeral joint intact. Here, we explored a novel method in measuring simultaneous strain behaviour of the rotator cuff tendons and investigated the effect of full-thickness anterior tear of the supraspinatus on the infraspinatus and subscapularis tendons.
Nine cadaveric shoulders were evaluated on a customized rig. Using linear differential variable transducers to measure strain, each shoulder was subjected to up to 60° of elevation in the coronal, scapular, and sagittal planes. We also assessed 30° of external rotation and up to 60° of internal rotation of the humerus. Full-thickness anterior tear of the supraspinatus was then made before re-assessing strain patterns in the scapular plane.
Findings:
Strain measurements of the intact tendons revealed a significant strain gradient between the articular and bursal sides of the supraspinatus during increasing degrees of elevation in the coronal and scapular planes. Full thickness anterior tear of the supraspinatus is localised to the tendon and does not affect the surrounding cuff musculature, with a potential shielding effect of the infraspinatus during early glenohumeral abduction.
Significant strain gradient exists between the articular and bursal sides of the supraspinatus during abduction but not during forward flexion in an intact glenohumeral joint. Rehabilitation exercises for anterior supraspinatus tears can be appropriately targeted on the remaining intact rotator cuff musculature.
Effect of shape and size of supraspinatus tears on rotator cuff strain distribution: an in vitro study
2023, Journal of Shoulder and Elbow Surgery
The impact of the size and shape of a supraspinatus tear on the strain of the intact rotator cuff and the kinematics of the shoulder is still unknown. This, however, can be relevant when deciding whether surgical reconstruction is required to prevent an increase in a tendon defect. In this study, the effect of tear width and shape on rotator cuff strain and glenohumeral kinematics was evaluated during active abduction.
Twelve fresh-frozen cadaveric shoulders with intact rotator cuffs were used in this study. We created 50% and 100% wide (full-thickness) crescent-shaped (CS) tears (n = 6) and reverse L–shaped (rLS) tears (n = 6) in the supraspinatus tendon and measured strain and kinematics during active humeral elevation until 30°.
Both tear shapes and sizes led to an increase in internal rotation, supraspinatus loading force, and superior translation of the humerus. For the 100% wide tear size, anterior translation was observed in the CS tear group, whereas in the rLS tear group, this translation occurred mainly in the posterior direction. Strain was higher in the infraspinatus during the first 25° of abduction in comparison with the supraspinatus tendon in both tear shape groups. An analysis of the anterior and posterior tear borders showed a higher strain concentration on the same side of the tear in the CS tear group with 50% and 100% wide tears.
The influence of different tear shapes on translation in the anterior-posterior direction was evident as both CS and rLS tears led to an oppositely directed translation of the humeral head. The strain analysis showed a stress-shielding effect of the infraspinatus at the beginning of abduction. Therefore, special attention must be paid to correctly identify the tear extension and adequately reconstruct the rotator cuff footprint. Moreover, the constant location of maximum strain in the CS tear group may lead to an earlier progression than in the rLS tear group.
Review of human supraspinatus tendon mechanics. Part I: fatigue damage accumulation and failure
2022, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
Another finding of significance is that strain remained in the inferior region after detachment from the humerus, suggesting interconnectedness among the 5 different layers of the SST.9,50 The mean strain of the SST in this study never exceeded 4% strain, but local tissue strains were reported to be as high as 12%, indicating the possibility for local tissue damage.9 A study by Andarawis-Puri6 on sheep infraspinatus tendons, which Tada et al48 showed to be similar to human SSTs, showed that tear size increased with high maximum and low minimum principal strains.
Repetitive stress injuries to the rotator cuff, and particularly the supraspinatus tendon (SST), are highly prevalent and debilitating. These injuries typically occur through the application of cyclic load below the threshold necessary to cause acute tears, leading to accumulation of incremental damage that exceeds the body’s ability to heal, resulting in decreased mechanical strength and increased risk of frank rupture at lower loads. Consistent progression of fatigue damage across multiple model systems suggests a generalized tendon response to overuse. This finding may allow for interventions before gross injury of the SST occurs. Further research into the human SST response to fatigue loading is necessary to characterize the fatigue life of the tendon, which will help determine the frequency, duration, and magnitude of load spectra the SST may experience before injury. Future studies may allow in vivo SST strain analysis during specific activities, generation of a human SST stress-cycle curve, and characterization of damage and repair related to repetitive tasks.
Review of human supraspinatus tendon mechanics. Part II: tendon healing response and characterization of tendon health
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Overuse injuries of the rotator cuff, particularly of the supraspinatus tendon (SST), are highly prevalent and debilitating in work, sport, and daily activities. Despite the clinical significance of these injuries, there remains a large degree of uncertainty regarding the pathophysiology of injury, optimal methods of nonoperative and operative repair, and how to adequately assess tendon injury and healing. The tendon response to fatigue damage resulting from overuse is different from that of acute rupture and results in either an adaptive (healing) or a maladaptive (degenerative) response. Factors associated with the degenerative response include increasing age, smoking, hypercholesterolemia, biological sex (variable by tendon), diabetes mellitus, and excessive load post fatigue damage. After injury, the average healing rate of tendon is approximately 1% per day and may be significantly influenced by biologic sex (females have lower collagen synthesis rates) and excessive load after damage. Although magnetic resonance imaging (MRI) is considered the gold standard in assessing acute tears as well as tendinopathic change in the SST, ultrasonography has proven to be a valuable tool to measure tendinopathic change in real time. Ultrasonography can determine multiple mechanical and structural parameters of the SST that are altered in fatigue loading. Thus, ultrasonography may be utilized to understand how these parameters change in response to SST overuse, and may aid in determining the activity level that places the SST at greater risk of rupture.
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Current surgical treatment options for partial-thickness tears (eg, takedown and repair, in situ repair) are limited by the degenerative nature of the underlying tendon and may require extensive intervention that can alter the anatomic footprint. The complexity of available techniques to address these issues led to the development of a resorbable collagen implant, which can be used to create a bioinductive repair of partial-thickness tears.
We prospectively enrolled 33 patients with chronic, degenerative, intermediate-grade (n = 12), or high-grade (n = 21) partial-thickness tears (11 articular, 10 bursal, 4 intrasubstance, and 8 hybrid) of the supraspinatus tendon in a multicenter study. After arthroscopic subacromial decompression without a traditional rotator cuff repair, a bioinductive implant was secured over the bursal surface of the tendon. Clinical outcomes were assessed using American Shoulder and Elbow Surgeons (ASES) and Constant-Murley scores (CMS) preoperatively and at 3 months, 1 year, and 2 years postoperatively. Magnetic resonance imaging was performed to assess postoperative tendon healing and thickness at the original tear site.
At 2-year follow-up, mean ASES and CMS scores improved both clinically and statistically at 1 and 2 years, compared with baseline, for intermediate- and high-grade tears. There was magnetic resonance imaging evidence of new tissue fill-in within the original baseline tear in 100% of the intermediate-grade tears and 95% of the high-grade tears. In 90.9% of the intermediate-grade tears and 84.2% of the high-grade tears, this new tissue fill-in represented at least an additional 50% of the volume of the initial lesion. From baseline to 2-year follow-up, the mean tendon thickness increased by 1.2 mm (standard deviation, 1.3; P = .012) and 1.8 mm (standard deviation, 2.2; P = .003) in the intermediate- and high-grade tears, respectively. The analysis of tear grade and location revealed no statistically significant difference in the change in mean tendon thickness at any time point. One patient with a high-grade articular lesion demonstrated progression to a full-thickness tear; however, the patient was noncompliant and the injury occurred while shoveling snow 1 month after surgery. Neither tear location nor treatment of bicep pathology affected the ASES or CMS scores at any follow-up point. No serious adverse events related to the implant were reported.
Final results from this 2-year prospective study indicate that the use of this resorbable bovine collagen implant for isolated bioinductive repair of intermediate- and high-grade partial-thickness rotator cuff tears of the supraspinatus is safe and effective, regardless of tear grade and location.

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^*: Supported by National Institutes of Health grants (AR07132 and CA74781) and the Whitaker Foundation.

^**: Reprint requests: Louis J. Soslowsky, PhD, University of Pennsylvania, McKay Orthopaedic Research Laboratory, 424 Stemmler Hall, 36th and Hamilton Walk, Philadelphia, PA 19104-6081 (E-mail: [email protected]).

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Original articleIntratendinous strain fields of the supraspinatus tendon: Effect of a surgically created articular-surface rotator cuff tear*,**

Abstract

Section snippets

Specimen preparation

Results

Discussion

Acknowledgements

Orthop Clin North Am

Orthop Clin North Am

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Orthop Clin North Am

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Clin Sports Med

Orthop Clin North Am

J Shoulder Elbow Surg

Arthroscopy

J Shoulder Elbow Surg

Texture correlation: a method for the measurement of detailed strain distributions within trabecular bone

J Orthop Res

A noncontact, nondestructive method for quantifying intratissue deformations and strains

J Biomech Eng

Original article
Intratendinous strain fields of the supraspinatus tendon: Effect of a surgically created articular-surface rotator cuff tear*,**