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Rotator Cuff Degeneration and Lateral Epicondylitis: Ann Rheum Dis: First Published As 10.1136/Ard.53.1.30 on 1 January 1994

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Rotator Cuff Degeneration and Lateral Epicondylitis: Ann Rheum Dis: First Published As 10.1136/Ard.53.1.30 on 1 January 1994 30 Annals of the Rheumatic Diseases 1994; 53: 30-34 Rotator cuff degeneration and lateral epicondylitis: Ann Rheum Dis: first published as 10.1136/ard.53.1.30 on 1 January 1994. Downloaded from a comparative histological study M D Chard, T E Cawston, G P Riley, G A Gresham, B L Hazleman Abstract rotator cuff with age would at least give insight Objectives-Rotator cuff tendinitis and into changes that occur which might pre- lateral epicondylitis are common in clini- dispose individuals to symptomatic lesions. cal practice but the underlying pathology Studies on cadavers have described changes is poorly understood. The study examined within the rotator cuff and also at their both normal and biopsy tendon specimens insertion. It is probable that changes within the histologically, to determine the mechan- tendon itself are of most relevance to clinical isms involved in tendon degeneration. symptoms. Rupture of the cuff and calcifi- Methods-Rotator cuff tendons from 83 cation is usually seen within the substance of cadavers aged 11-94 and tendon biopsy the tendon, 1-2 cm from the insertion. As this specimens from 20 patients with lateral area is the 'watershed zone' of blood supply epicondylitis aged 27-56 years were from muscle and bone it is relatively avascular examined histologically. making it prone to ischaemic stress and has Results-The microscopic changes found been called the critical zone. However, a recent in the tendon biopsies from the elbow were qualitative study5 on the number and size of similar to those found in the cadaveric blood vessels in this region suggests that there rotator cufftendons. Abnormalities ranged is little difference between the supraspinatus from minor blood vessel wall changes and and infraspinatus tendons. As most problems loss oftenocytes to calcification. The most occur in the supraspinatus tendon, other frequent abnormality was glycosamino- factors in addition to blood supply most pre- glycan infiltration and fibrocartilaginous dispose this tendon to degenerate. transformation. There appeared to be Rotator cuff degeneration has had limited some sequence in the changes observed study. An early investigation by Lindblom in which were milder in younger patients. 1939,6 was followed by an extensive study on Only 17% of cadaver tendons, below the 125 cases by Wilson and Duff in 19437 who age of39 were abnormal but abnormalities attempted to grade the severity of changes and increase in later life to around 40-50%. looked at the effects of age. A later paper by Conclusions-There was an increasing Brewer on just three tendons8 included some http://ard.bmj.com/ incidence of degenerative changes in ten- electron microscopy studies and most recently dons with age. The changes observed in an investigation by Clark9 emphasised the inter- biopsy samples of common extensor ten- dependance of the individual components of dons were the same as those seen in aged the rotator cuff. These studies are descriptive supraspinatus tendons, but these changes and it is often unclear how frequently changes were not seen in control common extensor were found and at what age. tendons. The region of the tenoperiosteal junction is on September 26, 2021 by guest. Protected copyright. believed to be the usual site of the lesion in (Ann Rheum Dis 1994; 53: 30-34) lateral epicondylitis, although only minor age- related changes have been documented. A variety ofabnormalities have been documented Rotator cuff tendinitis and lateral epicondylitis in operative specimens. Tendon rupture is (tennis elbow) are the principal soft tissue uncommon and the relationship to previous lesions affecting the upper limb and are local steroid injections is uncertain.'° Micro- Rheumatology commonly seen in rheumatological and ortho- fractures, cystic and fibrinoid degeneration Research Unit, paedic practice.' Together they give rise to and round cell infiltrations (often considered Addenbrooke's Hospital, considerable disability within the adult popu- to be inflammatory granulation tissue) and Cambridge, lation, yet the underlying pathology remains attempts at repair have been described in some United Kingdom unclear. Like many soft tissue lesions, biopsy specimens.'13 Macnab reported that some M D Chard T E Cawston is not necessary for diagnosis and surgery is not degenerate cadaver rotator cuff tendons show G P Riley often indicated. Therefore material for patho- changes that might be interpreted as granu- B L Hazleman logical study is rarely available. lation tissue.'4 Department of Age-related or degenerative changes in We proposed that there might be similarities Histopathology, tendon would appear to predispose to lesions, in the pathological changes that occur with age Addenbrooke's Hospital, as rotator cuff tendinitis and tennis elbow in the rotator cuff, and which probably pre- Cambridge, are infrequently seen before middle age.2 3 In dispose to symptomatic lesions, and those seen United Kingdom addition, rotator cuff rupture is a frequent in the condition of lateral epicondylitis. In this G A Gresham finding in elderly cadavers, although the study we investigated the changes with respect Correspondence to: Dr Hazleman. relationship of age-related change to symptoms to age that occur in rotator cuff tendons and Accepted for publication has been thought to be poor.4 In the absence compare them with those seen in tendons IAugust 1993 of operative material, a study of changes in the removed from patients with lateral epicondyli- Rotator cuff degeneration and lateral epicondylitis 31 tis. It was hoped that this study would give thinning, or a small perforation (8 right and insight into the frequency of the changes that 2 left). There were also 7 which had areas of occur in tendon with age and disease. thickening in the tendon, with calcification in Ann Rheum Dis: first published as 10.1136/ard.53.1.30 on 1 January 1994. Downloaded from 4 cases. Twenty eight rotator cuff tendons had histo- Methods logical abnormalities and these changes are The rotator cuffs were obtained from cadavers listed in table 1. The mild changes included at necropsy within 48 hours of death. For local thickening of the blood vessel walls with the ethical considerations the rotator cuff was formation of collagen in association with them removed without removal of the shoulder (fig 1A). Cell 'fall-out' (that is, a reduction joint itself. A longitudinal incision was made in the number of tenocytes) was the next extending over the lateral aspect of the visible abnormality. Fifteen specimens, showed shoulder to below the deltoid insertion. The the most frequent change, an increase in deltoid was reflected back and the shoulder glycosaminoglycans. This was laid down positioned to reveal the rotator cuff. The between the tendon fibrils. It was pre- conjoined tendons of supraspinatus and infra- dominantly found close to blood vessels, but it spinatus (plus a variable amount of sub- was more diffuse in those with the most scapularis) were removed by incision at the marked changes (fig 1B). In 9 of the 15 cases bony insertion and muscle origin. The bony where glycosaminoglycan infiltration of the insertion could therefore not be examined tendon was found, there was also patches of microscopically and the area of interest for this fibrocartilaginous change. In 7 specimens, how- study was the 'critical area' approximately 1" ever, fibrocartilaginous change was found from the point of insertion.15 16 Specimens alone, without glycosaminoglycan infiltration. were then trimmed to remove all muscle tissue, These occurred either in plaques or as more fat and as far as possible, all remains of the diffuse change. subacromial bursa and shoulder joint lining, Rounded cells with the appearance of chon- without disrupting the tendon which forms drocytes, sometimes arranged in rows between the bonding between the two. No cadaver the collagen fibrils, were found (fig 1 C). These had a known history of shoulder pain as changes were sometimes accompanied by assessed from medical records. Cadavers who areas of fibrocartilage within the tendon sub- had a large rupture of the rotator cuff were stance associated with glycosaminoglycan pro- excluded. duction (fig 1B), but in some cases no increase All specimens from the shoulder and elbow in glycosaminoglycan was seen (fig 1 C). This were preserved in formal saline until processed. could be due to difficulties with reliably Histological examination including staining with staining the glycosaminoglycans in the sections. Haematoxylin and Eosin, Weigert's Resorcin This section (fig 1 C) illustrates the classic Fuchsin, Ponceau S (showing elastic fibres 'glassy' appearance observed in some tendon black and collagen red) and Alcian Blue at biopsy specimens. In its most severe form the Acid pH (to show glycosaminoglycan). Speci- fibrocartilage was undergoing calcification http://ard.bmj.com/ mens were batch processed and microscopic producing poorly formed bone. The most examination was performed by the same florid cases were seen in association with syn- investigator (GAG) and was undertaken with- ovial chondromatosis. Some tendons (fig 1D) out knowledge of specimen details to ensure showed the deposition of calcium in regions blind conditions. that also stained positively with Alcian blue. These calcium deposits did not always stain well with von Kossa stain. This may indicate on September 26, 2021 by guest. Protected copyright. SPECIMENS that hydroxy-apatite may not be the pre- Eighty three rotator cuff tendons were dominant form of calcium deposited. examined with an age range of 11 to 94 years. The numbers of the rotator cuff tendons in There were 48 men, 21 specimens were from each decade and the relative percentage found the left and 27 were from the right shoulder. to be abnormal are listed in table 2. Abnor- Thirty five women were studied, 16 were from malities increase in middle life to remain fairly the left shoulder and 19 from the right. Rotator constant at around 40% and then increase to cuffs were removed from both shoulders in 57% for those of 90 years and over.
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