Journal of Shoulder and Elbow Surgery

Microvascular blood flow in normal and pathologic rotator cuffs

Published:September 29, 2015DOI:


      Microvascular blood flow in the tendon plays an important role in the pathogenesis of rotator cuff abnormalities. There are conflicting views about the presence of a hypovascular zone in the supraspinatus tendon. Besides, no studies have looked at the pattern of blood flow around a partial-thickness tear. Our aim was to measure microvascular blood flow in normal and a range of pathologic rotator cuff tendons using laser doppler flowmetry.


      A total of 120 patients having arthroscopic shoulder surgery were divided into 4 equal groups on the basis of their intraoperative diagnosis: normal rotator cuff, subacromial impingement syndrome, and partial-thickness or full-thickness rotator cuff tear. Microvascular blood flow was measured at 5 different regions of each cuff using a laser doppler probe. The values were compared to assess variability within and between individuals.


      Total blood flow was greater in the normal rotator cuff group compared with the groups with pathologic rotator cuffs, with the largest difference seen in the subacromial impingement group. Within individuals, blood flow was highest at the musculotendinous junction and lowest at the lateral insertional part of the tendon. Among groups, the blood flow was significantly lower at the anteromedial and posteromedial cuff in the groups with impingement and full-thickness tears compared with the group with normal cuff.


      Real-time in vivo laser doppler analysis has shown that microvascular blood flow is not uniform throughout the supraspinatus tendon. Blood flow in the pathologic supraspinatus tendon was significantly lower compared with the normal tendon.

      Level of evidence


      To read this article in full you will need to make a payment


        • Adler R.S.
        • Fealy S.
        • Rudzki J.R.
        • Kadrmas W.
        • Verma N.N.
        • Pearle A.
        • et al.
        Rotator cuff in asymptomatic volunteers: contrast-enhanced US depiction of intratendinous and peritendinous vascularity.
        Radiology. 2008; 248: 954-961
        • Astrom M.
        • Westlin N.
        Blood flow in the human Achilles tendon assessed by laser Doppler flowmetry.
        J Orthop Res. 1994; 12: 246-252
        • Bigliani L.U.
        • Ticker J.B.
        • Flatow E.L.
        • Soslowsky L.J.
        • Mow V.C.
        The relationship of acromial architecture to rotator cuff disease.
        Clin Sports Med. 1991; 10: 823-838
        • Chansky H.A.
        • Iannotti J.P.
        The vascularity of the rotator cuff.
        Clin Sports Med. 1991; 10: 807-822
        • Chard M.D.
        • Hazleman R.
        • Hazleman B.L.
        • King R.H.
        • Reiss B.B.
        Shoulder disorders in the elderly: a community survey.
        Arthritis Rheum. 1991; 34: 766-769
        • Codman E.
        The shoulder: rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa.
        Thomas Todd, Boston1934
        • Codman E.A.
        • Akerson I.B.
        The pathology associated with rupture of the supraspinatus tendon.
        Ann Surg. 1931; 93: 348-359
        • Determe D.
        • Rongieres M.
        • Kany J.
        • Glasson J.M.
        • Bellumore Y.
        • Mansat M.
        • et al.
        Anatomic study of the tendinous rotator cuff of the shoulder.
        Surg Radiol Anat. 1996; 18: 195-200
        • Fealy S.
        • Adler R.S.
        • Drakos M.C.
        • Kelly A.M.
        • Allen A.A.
        • Cordasco F.A.
        • et al.
        Patterns of vascular and anatomical response after rotator cuff repair.
        Am J Sports Med. 2006; 34: 120-127
        • Fredriksson I.
        • Fors C.
        • Johansson J.
        Laser Doppler flowmetry—a theoretical framework: Department of Biomedical Engineering.
        Linköping University, Linköping, Sweden2007
        • Fukuda H.
        • Hamada K.
        • Yamanaka K.
        Pathology and pathogenesis of bursal-side rotator cuff tears viewed from en bloc histologic sections.
        Clin Orthop Relat Res. 1990; 254: 75-80
        • Funakoshi T.
        • Iwasaki N.
        • Kamishima T.
        • Nishida M.
        • Ito Y.
        • Kondo M.
        • et al.
        In vivo visualization of vascular patterns of rotator cuff tears using contrast-enhanced ultrasound.
        Am J Sports Med. 2010; 38: 2464-2471
        • Hashimoto T.
        • Nobuhara K.
        • Hamada T.
        Pathologic evidence of degeneration as a primary cause of rotator cuff tear.
        Clin Orthop Relat Res. 2003; 415: 111-120
        • Hegedus E.J.
        • Cook C.
        • Brennan M.
        • Wyland D.
        • Garrison J.C.
        • Driesner D.
        Vascularity and tendon pathology in the rotator cuff: a review of literature and implications for rehabilitation and surgery.
        Br J Sports Med. 2010; 44: 838-847
        • Hermans J.
        • Luime J.J.
        • Meuffels D.E.
        • Reijman M.
        • Simel D.L.
        • Bierma-Zeinstra S.M.
        Does this patient with shoulder pain have rotator cuff disease? The Rational Clinical Examination systematic review.
        JAMA. 2013; 310: 837-847
        • Holloway Jr., G.A.
        • Watkins D.W.
        Laser Doppler measurement of cutaneous blood flow.
        J Invest Dermatol. 1977; 69: 306-309
        • Levy O.
        • Relwani J.
        • Zaman T.
        • Even T.
        • Venkateswaran B.
        • Copeland S.
        Measurement of blood flow in the rotator cuff using laser Doppler flowmetry.
        J Bone Joint Surg Br. 2008; 90: 893-898
        • Ling S.C.
        • Chen C.F.
        • Wan R.X.
        A study on the vascular supply of the supraspinatus tendon.
        Surg Radiol Anat. 1990; 12: 161-165
        • Lohr J.F.
        • Uhthoff H.K.
        The microvascular pattern of the supraspinatus tendon.
        Clin Orthop Relat Res. 1990; : 35-38
        • MacDermid J.C.
        • Ramos J.
        • Drosdowech D.
        • Faber K.
        • Patterson S.
        The impact of rotator cuff pathology on isometric and isokinetic strength, function, and quality of life.
        J Shoulder Elbow Surg. 2004; 13: 593-598
        • Matthews T.J.
        • Hand G.C.
        • Rees J.L.
        • Athanasou N.A.
        • Carr A.J.
        Pathology of the torn rotator cuff tendon. Reduction in potential for repair as tear size increases.
        J Bone Joint Surg Br. 2006; 88: 489-495
        • Moseley H.F.
        • Goldie I.
        The arterial pattern of the rotator cuff of the shoulder.
        J Bone Joint Surg Br. 1963; 45: 780-789
        • Neer 2nd, C.S.
        Impingement lesions.
        Clin Orthop Relat Res. 1983; 173: 70-77
        • Neer 2nd, C.S.
        Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report.
        J Bone Joint Surg Am. 1972; 54: 41-50
        • Oliva F.
        • Zocchi L.
        • Codispoti A.
        • Candi E.
        • Celi M.
        • Melino G.
        • et al.
        Transglutaminases expression in human supraspinatus tendon ruptures and in mouse tendons.
        Biochem Biophys Res Commun. 2009; 379: 887-891
        • Papakonstantinou M.K.
        • Pan W.R.
        • le Roux C.M.
        • Richardson M.D.
        Arterial supply of the tendinous rotator cuff insertions: an anatomical study.
        ANZ J Surg. 2012; 82: 928-934
        • Picavet H.S.
        • Schouten J.S.
        Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC(3)-study.
        Pain. 2003; 102: 167-178
        • Rathbun J.B.
        • Macnab I.
        The microvascular pattern of the rotator cuff.
        J Bone Joint Surg Br. 1970; 52: 540-553
        • Rechardt M.
        • Shiri R.
        • Karppinen J.
        • Jula A.
        • Heliovaara M.
        • Viikari-Juntura E.
        Lifestyle and metabolic factors in relation to shoulder pain and rotator cuff tendinitis: a population-based study.
        BMC Musculoskelet Disord. 2010; 11: 165
        • Rothman R.H.
        • Parke W.W.
        The vascular anatomy of the rotator cuff.
        Clin Orthop Relat Res. 1965; 41: 176-186
        • Rudzki J.R.
        • Adler R.S.
        • Warren R.F.
        • Kadrmas W.R.
        • Verma N.
        • Pearle A.D.
        • et al.
        Contrast-enhanced ultrasound characterization of the vascularity of the rotator cuff tendon: age- and activity-related changes in the intact asymptomatic rotator cuff.
        J Shoulder Elbow Surg. 2008; 17: 96S-100S
        • Sano H.
        • Ishii H.
        • Trudel G.
        • Uhthoff H.K.
        Histologic evidence of degeneration at the insertion of 3 rotator cuff tendons: a comparative study with human cadaveric shoulders.
        J Shoulder Elbow Surg. 1999; 8: 574-579
        • Schlehr F.J.
        • Limbird T.A.
        • Swiontkowski M.F.
        • Keller T.S.
        The use of laser Doppler flowmetry to evaluate anterior cruciate blood flow.
        J Orthop Res. 1987; 5: 150-153
        • Silvestri E.
        • Biggi E.
        • Molfetta L.
        • Avanzino C.
        • La Paglia E.
        • Garlaschi G.
        Power Doppler analysis of tendon vascularization.
        Int J Tissue React. 2003; 25: 149-158
        • Swiontkowski M.F.
        • Iannotti J.P.
        • Boulas H.J.
        • Esterhai J.L.
        Intraoperative assessment of rotator cuff vascularity using laser Doppler flowmetry.
        in: Post M. Morrey B.F. Surgery of the shoulder. Mosby, St. Louis1990