Tendon Transfer

[DBeach]

I am a women, 51 years old, and have had two surgeries on my left shoulder approx. 4-5 years ago. The shoulder repair is deemed "irrepairable" and I am still in pain (the bicep was also detached and could not be successfully reattached). Although I have good muscle strength and full range of motion, the pain has me looking at the "tendon transfer" operation for relief. Could you tell me if this might be a good choice for me and what is involved. Thank you!

[mtomaino]

Thanks for your question. Patient selection for this option is important--and typically the best results correlate with "better" preoperative function.In that light, it's really important to understand the nature of your problem: do you have pain, but good function? Do you have poor function, but little pain? Do you have pain and no function (pseudoparalysis)?
What your expectation is, coupled with what different options can provide will help--in combination--to choose the most optimal treatment strategy for you.

Firstly, in physiologically young patients with pain, weakness, and loss of range of motion due to either a chronic tear of the rotator cuff that is no longer fixable, or due to a failed repair, latissimus muscle tendon transfer is an option that can improve function and decrease pain by "substituting" for the absence of the torn posterosuperior cuff. Classically this option is indicated for massive tears (at least 2 tendons--supra- and infraspinatus.) The transfer is most successful when it provides "active motor control," which requires postoperative rehabilitation that involves, in many cases, biofeedback to encourage firing of the latissimus during external rotation and forward elevation, even though this muscle was an "adductor and internal rotator."

Dr JP Warner, who was one of my partners while at the University of Pittsburgh and now heads the Shoulder section at Harvard, has shown the value of retraining the transfer by beginning motion with adduction---and then combing external rotation and forward elevation--to encourage coactivation. The latissimus transfer affords it benefit partly by restoring active muscle contraction, and partly by restoring a force couple to "depress" the humeral head and improve its centering in the socket. The xray attached below shows superior elevation in a case of a 2 tendon chronic tear, and after a successful tenon transfer, the acromiohumeral interval can improve. When this happens, not only can range of motion improve, but the pain above shoulder level may diminish due to the improvement in "space" between the acromium and the greater tuberosity.

However, it is very important to appreciate that when overhead range of motion is good and when strength and external rotation are acceptable, this particular option--when performed primarily to improve pain-- is a hard to predict. In other words, it may be best to adapt, given good motion, and try to "work around" the pain.

Prior to having this option (which requires that you have functioning deltoid and subscapularis muscles, little or no arthritis, at least shoulder level active elevtion, and no stiffness), it may be worth considering an arthroscopic attempt at a partial repair----which may also help improve the "course" of the suprascapular nerve--thus improving the pain that may be due to subtle suprscapular neuropathy. Indeed, an EMG study preoperatively may be of value to evaluate for this, acknowleging, however, that electrodiagnostic changes in the supra- and infraspinatus muscles might be secondary to the chronic tear and not "de facto" proof that the nerve is in any way tethered or entrapped.

Rehabilitation following latissimus transfer involves 6 weeks in an abduction splint, with passive motion only until 8 weeks. Full recovery can take as long as 12-18 months. If you have good motion and strength, but pain-----it is important to evaluate the joint for early arthritis---since its presence may potentially support an option that "resurfaces" the humeral head with an "extended articular surface" (see attached pic).

Happy to continue this dialogue!

[mtomaino]

If you have good motion and pain-----it may be worth an arthroscopic evaluation. Indeed, a tendon transfer is probably not the ideal option in this case. The objective of an arthroscopic procedure would be two-fold: to perform a repair if possible, even if partial, and to decompress the suprascapular nerve. With chronic irreparable cuff tears, the suprascapular nerve can become tethered, if you will, and so a "release" may provide some pain relief that could be caused by this.

[PeakPT]

DBeach
Just wanted to chime in on your post.

I love Dr. Tomaino's reply re the possibility of the suprascapular nerve potentially contributing to your symptoms. I think a key here is you have to remember that determining why YOU have pain means everything in terms of WHAT treatments are chosen. Getting a thorough exam or 2nd opinon is at the heart of things. Based on the content of your original post I just want to confirm that you are, in fact, referring to an "irrepairable" rotator cuff (RC) tear and not possibly something else.

I've certainly had patients in the past who were told something they had was "irrepairable" and the Dr wasn't referring necessarily to a "torn" tissue not being able to be repaired or fixed but just simply that they didnt' feel surgery would help their problem. Maybe a small semantics thing but potentially the source of misunderstanding too. Just wanted to clarify.

I've seen patients with RC tears that could not be fixed who compensated fairly well. There is no doubt that if you do have a RC tear that you're going to be relying on a required amount of substitution or compensation from the remaining healthy muscles to produce function in the absence of those RC tendons. There are some limitations that people may have that inhibit the body's ability to do that "legal cheating" that will be required though. If, for example, your thoracic (mid back or trunk area) spine is restricted or your scapula (shoulder blade) is not mobile enough then the muscles that attach there might not adequately be able to do the extra work required to move your shoulder.

You mentioned that your motion and strength are good...but I'd still wonder where you're getting that "good" from. A good evaluation would help ascertain if you've got the motion at adjacent areas to optimize your function in the presence of a RC tear and if there are muscles that might be able to be trained to better help your function so that undue stresses are not placed on your shoulder or other tissues that might be contributing to your pain.

If there is a tear in there then no doubt you have altered mechanics of the joint and it is absolutely a source of stress and potentially the primary cause of your pain. But I have had patients who also had shoulder diagnoses and some even procedures done when ultimately it was later determined to be a cervical (neck) problem that was at cause of their shoulder pain. Thus, a thorough evaluation still must be done to attempt to decide where/what is causing your symptoms and then decide if there are any other things that might be tried before further surgery is required or if surgery is, in fact, the right thing to do first.

Thanks for posting your question. You've obviously done some research yourself in trying to figure out a solution. I'm sure that your diligence in seeking out answers and being actively involved in the process will help you reach the best solution possible.

Best wishes for success

Mike Napierala, PT, SCS, CSCS, FAFS
Peak Performance PT

[mtomaino]

Agree with all of Mike's comments!

[mtomaino]

The plan as posted on June 12th, was indeed possible. Arthroscopic release of the transverse scapular ligament was successful, as well as a repair of the Infraspinatus tendon. Although suprascapular nerve release is credited with pain relief in cases such as yours, time will tell. The first few days after surgery are the worse; hope you feel better!