|Year : 2022 | Volume
| Issue : 2 | Page : 92-94
Return to sports and physical activity after a surgical repair of musculotendinous junction tear of supraspinatus
Hari Krishna Yadoji1, Chandrasekhar Bodanki2, MV Reddy1, AV Gurava Reddy1
1 Department of Orthopaedics, Sunshine Hospital, Secunderabad, Telangana, India
2 Department of Arthroscopy and Shoulder Surgery, Sunshine Hospital, Secunderabad, Telangana, India
|Date of Submission||06-Oct-2022|
|Date of Decision||06-Oct-2022|
|Date of Acceptance||07-Oct-2022|
|Date of Web Publication||09-Feb-2023|
Hari Krishna Yadoji
Sunshine Hospital, Secunderabad - 500 003, Telangana
Source of Support: None, Conflict of Interest: None
Rotator cuff tears commonly occur at their attachment on greater tuberosity. Musculotendinous junction (MTJ) tears in itself are relatively uncommon and a partial musculotendinous junction tear is even more uncommon. These tears are difficult to treat. All MTJ tears may not require surgery. There are reports stating the role of conservative management. However, a high-demanding individual may not be beneficial with conservative management. A case of a 35-year-old male came with the complaint of sudden onset of pain in the shoulder while doing gym 3 days ago. In magnetic resonance imaging, we identified a partial tear in MTJ of supraspinatus (SSP). Given his high-demanding lifestyle, we opted for a surgical repair and describe the surgical procedure in this case report. The aim of this case report is to emphasize on the existence of partial tear in MTJ of SSP and the need for surgical repair in high-demanding individuals. A partial tear of SSP MTJ may need surgical repair in high-demanding individuals, for them to return to their previous level of activity.
Keywords: Musculotendinous junction, sports, supraspinatus
|How to cite this article:|
Yadoji HK, Bodanki C, Reddy M V, Gurava Reddy A V. Return to sports and physical activity after a surgical repair of musculotendinous junction tear of supraspinatus. J Orthop Assoc South Indian States 2022;19:92-4
|How to cite this URL:|
Yadoji HK, Bodanki C, Reddy M V, Gurava Reddy A V. Return to sports and physical activity after a surgical repair of musculotendinous junction tear of supraspinatus. J Orthop Assoc South Indian States [serial online] 2022 [cited 2023 Mar 27];19:92-4. Available from: https://www.joasis.org/text.asp?2022/19/2/92/369406
| Introduction|| |
Although tears near the musculotendinous junction (MTJ) are common in some areas of the body, they infrequently involve the rotator cuff in which the majority of tears present with the detachment of the footprint from the greater tuberosity. Medial tears of the rotator cuff at the MTJ can occur primarily (without prior surgery), or secondarily after previous rotator cuff repair. Primary failure usually occurs from a traumatic injury to the shoulder. Secondary medial cuff failure near the MTJ after repair (type 2 failure) has been associated with the placement of knots and abrasive suture materials near the MTJ which potentially result in acute or chronic subacromial knot impingement, medial stress concentration, tendon strangulation, and/or suture cut out in this area.,, Surgical treatment of MTJ tears is challenging because of 1) the short or absent medial tendon stump, 2) the susceptibility of sutures to tear through degenerated tendinous tissues or the medial muscle fibers at the MTJ, 3) the difficulty in restoring the length–tension relation of the cuff tendon without overtensioning the repair, 4) the bone quality of the greater tuberosity, and the acromion morphology. When surgeons encounter these types of tears, there is little information to guide them.,
Millett et al. classified MTJ tear based on retraction of the medial stump as in [Figure 1].
|Figure 1: Classification of supraspinatus Musculotendinous junction tear. (a) Tendon on footprint, short but adequate medial tendon, (b) Tendon on footprint, deficient medial tendon, with healthy muscle (MTJ can reach medial footprint), (c) Tendon on footprint laterally but deficient medial tendon with retracted, atrophied muscle with fatty infiltration|
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Type A tears occur when the tendon and muscle are both healthy and adequate. This tear pattern is seen frequently with primary tears.
Type B tears occur when there is a healthy tendon laterally, but the remaining medial tendon is short and retracted.
Type C tears occur when the tears become chronic. In such cases, there may be tendon remaining at the footprint but the muscle is retracted, is of insufficient length, and has fatty infiltration (i.e., Goutallier Grade 3 or 4).
Lädermann et al. in their study, treated five cases of supraspinatus (SSP) MTJ injuries nonoperatively and found improvement in cases having stretch injuries and no improvement in cases having complete rupture.
| Case Report|| |
In this case report, we present a case of a 35-year-old male who came with the complaint of sudden onset of pain in the shoulder while doing gym 3 days ago. On examination, there was pain in doing the overhead activity, and active forward and lateral elevations were 0°–80°.
Magnetic resonance imaging (MRI) shows partial MTJ tear of SSP as in [Figure 2].
|Figure 2: MRI and arthroscopic view showing bursal surface MTJ tear of supraspinatus. MTJ: Musculotendinous junction, MRI: Magnetic resonance imaging|
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Although in the present study, the patient had a partial tear, being young and active high-demanding individual we opted for surgical management. The aim of this case report is to emphasize on the existence of partial tear in MTJ of SSP and the need for surgical repair in high-demanding individuals.
Interscalene brachial plexus block was used as mode of anaesthesia. Patient was placed in beach chair position
A standard posterior viewing portal which is 2 cm inferior and 1–2 cm medial from the acromion posterolateral corner was established. A standard anteroinferior working portal through the rotator interval which is inferolateral to the tip of coracoid process was made using outside in technique with 18 G spinal needle. A diagnostic arthroscopy was performed. The labrum, glenoid, humerus, and long head of biceps were normal. No defect was seen on the articular surface of SSP. After diagnostic arthroscopy, we entered subacromial space and found bursal surface tear in MTJ junction of supraspinatus. Additional portals like anterolateral which is 2 cm lateral and posterior to the anterolateral corner of the acromion, posterolateral which lies 2 cm lateral and 2 cm anterior from the posterolateral corner of the acromion was made using outside-in technique.
With anterolateral portal as viewing portal, an L-shaped bursal tear is found as in [Figure 2]. We freshened the edges of tear and with Accupass we passed a suture tape in the figure of 8 manners as in [Figure 3] and tied knots. With the posterolateral portal as viewing portal and anterolateral portal as working portal, the suture tape was loaded into a 4.75 mm knotless anchor and fixed about 1 cm inferior to the lateral surface of greater tuberosity [Figure 4]. The repair is found to be stable as in [Figure 5]. The wound closed in layers.
|Figure 3: Shuttling suture tape in the figure of 8 and use of knotless anchor|
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|Figure 5: Postoperative MRI showing healed repair. MRI: Magnetic resonance imaging|
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Postoperative rehabilitation: the patient was put in a 30° abduction brace and was allowed to do active elbow, wrist, and hand movements. No movements were allowed in the shoulder for 4 weeks. From the 5th to 6th week, passive shoulder ROM slowly progressing to full range. Seven to eight weeks active-assisted ROM slowly progressing to full range and isometric cuff strengthening was started. Nine to twelve weeks of scapular stabilizing exercises. From 13 weeks along with above exercises, theraband strengthening was advised. Lifting weights up to 5 kg was allowed after 6 months postoperative. Gym workouts were allowed after 9 months postoperative.
Follow-up and outcome
At a 2-year follow-up, the patient was able to perform all his daily activities. He returned preinjury level of sports and gym activities. Postoperative MRI done at a 2-year follow-up showed healing and no fatty degeneration [Figure 5].
| Discussion|| |
Rupture of the rotator cuff usually occurs either within the tendon or as an avulsion from the greater tuberosity, when it occurs between insertion and the muscular part of a tendon, it is described as MTJ tear. MTJ tear is an uncommon injury. There are studies on conservatively managed MTJ tear of SSP. Lädermann et al. in their study conservatively treated two cases of stretch injury and three cases of complete rupture of SSP MTJ and found improvement in cases having stretch injuries and no improvement in cases having complete rupture, there was no mention of partial injuries in this study. Benazzo et al. in a case report, conservatively treated complete rupture of MTJ of SSP in a 23-year-old woman. In both studies, patients who recovered were able to perform their daily activities; there was no mention of high-level activities such as gym and sports. In our study, although the patient had a partial tear, in view of his high-level activity, we treated him surgically.
To our knowledge, no study has mentioned return to sports or any high-level activity after conservative or operative treatment of MTJ SSP tears. In our study, at a 2-year follow-up, the functional outcome of the patient improved and he was able to return to the previous level of sports and gym activities. The postoperative MRI at a 2-year follow-up has shown evidence of healing.
| Conclusion|| |
In high-demanding individuals, even a partial tear of SSP MTJ may need surgical repair for them to return to the previous level of activity.
The study was approved by the institutional Ethics Committee of sunshine hospitals. Approval number- SIEC/2020/46.
The patient has given his informed consent for the case report to be published.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Cho NS, Lee BG, Rhee YG. Arthroscopic rotator cuff repair using a suture bridge technique: Is the repair integrity actually maintained? Am J Sports Med 2011;39:2108-16.
Christoforetti JJ, Krupp RJ, Singleton SB, Kissenberth MJ, Cook C, Hawkins RJ. Arthroscopic suture bridge transosseus equivalent fixation of rotator cuff tendon preserves intratendinous blood flow at the time of initial fixation. J Shoulder Elbow Surg 2012;21:523-30.
Kim SH, Kim J, Choi YE, Lee HR. Healing disturbance with suture bridge configuration repair in rabbit rotator cuff tear. J Shoulder Elbow Surg 2016;25:478-86.
Benazzo F, Marullo M, Pietrobono L. Supraspinatus rupture at the musculotendinous junction in a young woman. J Orthop Traumatol 2014;15:231-4.
Hertel R, Lambert SM. Supraspinatus rupture at the musculotendinous junction. J Shoulder Elbow Surg 1998;7:432-5.
Millett PJ, Hussain ZB, Fritz EM, Warth RJ, Katthagen JC, Pogorzelski J. Rotator cuff tears at the musculotendinous junction: Classification and surgical options for repair and reconstruction. Arthrosc Tech 2017;6:e1075-85.
Lädermann A, Christophe FK, Denard PJ, Walch G. Supraspinatus rupture at the musclotendinous junction: An uncommonly recognized phenomenon. J Shoulder Elbow Surg 2012;
Codman EA, Durig M, Schuppisser JP, Gauer EF, Muller W. The Shoulder; Rupture of Supraspinatus Tendon and Other Lesions in or About the Subacromial Bursa. Malabar [FL): Robert E. Krieger; 1984.
Resch H, Thöni H. Dislocation fractures of the shoulder. Special status and therapeutic concepts. Orthopade 1992;21:131-9.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]