A Case With MR Study
A supraspinatus tear is the most common malady of the shoulder that appears in my orthopedic practice. The supraspinatus muscle provides stability to the glenohumeral joint and is a frequent source of pain and disability. Supraspinatus tears are often accompanied by adjacent structural deficits. Optimization of tendon architecture, restoration of pain-free range of motion, and implementation of strength training exercise are the goals of my treatment plan.
Rotator cuff tears are common among the general population. In a literature review1 of 2553 cadaveric studies, rotator cuff tears were found in 30% of subjects. Twelve percent had full-thickness tears, and 19% had partial-thickness tears. Patients with supraspinatus tears may present with a history of insidious onset of shoulder pain or an identified injury or fall with the affected arm in an outstretched position. Motor vehicle crashes and occupations involving overhead work or carrying of trays are common contributors. Forward rounded shoulders, fluoroquinolone use,2 hyperparathyroidism, hemodialysis, rheumatoid arthritis, alcoholism, utilization of statin medications,3 and corticosteroid use4 may be implicated. Supraspinatus tears are often accompanied by infraspinatus or subscapularis tears, fraying, and tendonosis. Labrum tears or paralabral anchoring fiber tears may be present and add a different treatment dimension to the resolution of shoulder function. For stabilization issues, all scapulohumeral ligaments must be accounted for.
The supraspinatus muscle resides on the spine of the scapula, and its tendon traverses the acromial outlet and attaches to the humeral greater tuberosity. The tendon fans over the superior-most aspect of the humerus and cuffs the humeral head; hence, it is the main tendon of the rotator cuff musculature. The muscle assists in abducting the arm but, most important, checks excess glenohumeral sheering when the humerus is under load. Such load places the glenoid labrum in a hostile environment. A study5 of professional baseball players determined that weak supraspinatus strength predisposes the shoulder to injury.
Imaging of the supraspinatus tendon may include magnetic resonance (MR) images and diagnostic ultrasonography. Radiographs are useful to survey only osseous degenerative change and areas of tendon calcification. The MR contrast gadolinium is widely used by orthopedic physicians to evaluate shoulder pathology. Although popular, gadolinium is not approved by the Food and Drug Administration for intra-articular administration and has recently been associated with inciting nephrogenic systemic fibrosis in patients with renal impairment.6 It is my opinion that the hyperintense signal of the contrast obscures fine architectural discrimination of the tendon when reading the films. For heightened representation of the tendon, an additional sequence such as inversion recovery can be obtained along with the standard T1-weighted and T2-weighted sequences.
I use a highly specialized microtrauma-induced repair injection technique to stimulate deficient and torn rotator cuff tendon and ligament fibers. A prescription of low-repetition isotonic free-weight strength training is needed to strengthen and balance the shoulder girdle as the shoulder repairs. The case depicted herein involved a patient who presented with a full-thickness and retracted supraspinatus tear and associated ligament deficiencies. His shoulder was treated 7 times utilizing platelet-rich plasma, autologous blood, and varicose vein sclerosants and then underwent posttreatment MR imaging. The posttreatment images revealed that the torn tendon had filled in. Although vastly improving in pain-free range of motion and strength, the most impactful improvement for the patient was the return of his golf swing.
David A. Tallman, DC, NMD continued his family tradition at the Ohio State University for his undergraduate education. He then attended Texas Chiropractic College in Pasadena, TX where he received a Doctorate of Chiropractic with an internship focus on orthopedics and radiology. He then went on to graduate from Southwest College of Naturopathic Medicine in Tempe, AZ. He is a board-certified, licensed chiropractic physician (DC) and a licensed naturopathic medical doctor (NMD). Dr. Tallman is also the publisher of ND News & Review (NDNR) and the International Journal of Naturopathic Medicine (IntJNM). Dr. Tallman is a pioneer of regenerative injection therapy (RIT), his practice is devoted exclusively to prolotherapy/RIT. He has designed a unique and highly specialized method of needle manipulation over the years. He pursues up-to-date developments in the fields of orthopedic and sports medicine in the U.S. and Europe. More information at AZ Prolotherapy.
REFERENCES
1. Reilly P, Macleod I, Macfarlane R, Windley J, Emery RJ. Dead men and radiologists don't lie: a review of cadaveric and radiological studies of rotator cuff tear prevalence. Ann R Coll Surg Engl. 2006;88(2):116-121.
2. Mehlhorn AJ, Brown DA. Safety concerns with fluoroquinolones. Ann Pharmacother. 2007;41(11):1859-1866.
3. Beri A, Dwamena FC, Dwamena BA. Association between statin therapy and tendon rupture: a case-control study. J Cardiovasc Pharmacol. 2009;53(5):401-404.
4. Tempfer H, Gehwolf R, Lehner C, et al. Effects of crystalline glucocorticoid triamcinolone acetonide on cultured human supraspinatus tendon cells. Acta Orthop. 2009;80(3):357-362.
5. Byram IR, Bushnell BD, Dugger K, Charron K, Harrell FE Jr, Noonan TJ. Preseason shoulder strength measurements in professional baseball pitchers: identifying players at risk for injury. Am J Sports Med. 2010;38(7):1375-1382.
6. Chen AY, Zirwas MJ, Heffernan MP. Nephrogenic systemic fibrosis: a review. J Drugs Dermatol. 2010;9(7):829-834.
