ISAKOS SCORING SYSTEM FOR ROTATOR CUFF TEARS

Emilio Calvo, Guillermo Arce, Banno Enijsmann, Kevin P Shea

A classification for rotator cuff tears should follow several principles. First, the
classification system should be already in use, if possible, validated for
reliability, and easily used by physicians and researchers. Second, it should
be descriptive to define the location and anatomy of the tear, helping all
surgeons to understand precisely its characteristics. Third, the classification
should be useful to dictate appropriate treatment in each specific case, and
fourth, it should also have a predictive value both to guide physicians and to
transmit the patient realistic expectations of postoperative outcome. The
ISAKOS Shoulder Terminology Group developed a new complete and
straightforward method to describe rotator cuff tears. It relies on the fact that a
good system should allow the surgeon to predict difficulties during the
procedure and advise about prognostics. It is comprehensive and user-
friendly. This system encompasses five essentials characteristics with regards
to tears: pattern (P), extension (E), fatty atrophy (A), retraction(R), and
location (L), conforming the acronym “PEARL” (Table 1).

1. LOCATION: Since the characteristics as well as therapeutic and prognostic

implications of posterosuperior and anterior rotator cuff tears are often
different, we suggest defining first the anatomic location of the rotator cuff
tear, posterosuperior tears involving the supraspinatus, infraspinatus and
teres minor, or anterior tears involving the subscapularis.

2. EXTENSION: Traditionally, rotator cuff tears have been described as partial

or full thickness. Classification systems for full-thickness posterosuperior tears
have been based on the size of the tear or the number of tendons involved.
The information on the extension of the tear, either given as area or number
of tendons involved, is important predicting the extent of surgical procedure
and soft tissue releases necessary to repair it. However, the classifications
based on the size of the tear must be bidimensional since a unidimensional
description, as suggested by DeOrio and Cofield, can be misleading because
it measures the tear size only anterior to posterior. A complete cuff avulsion
described as massive, implying a difficult repair and unfavorable prognosis,
may in fact lie directly over the bed of the insertion site, be easy to repair, and
have a predictably good result. For these reasons we suggest following the
classification system of posterosuperior rotator cuff tears suggested by
Snyder that provides information not only on the size, but also on the number
of tendons involved and the degree of scarring. Full thickness tears are
classified as C1 (small complete tear, pinhole sized), C2 (moderate tear less
than 2cm of only one tendon without retraction), C3 (large complete tear with
an entire tendon with minimal retraction usually 3-4 cm), or C4 (massive
rotator cuff tear involving 2 or more rotator cuff tendon with associated
retraction and scarring of the remaining tendon).

With regard to partial thickness rotator cuff tears, experimental and clinical
studies have demonstrated that tears involving more than half of the tendon
thickness are a significant to threat tendon integrity, and that they outperform
better if treated surgically. Therefore we recommend defining the site and
tendon tissue involvement as over or fewer than 50% of tendon thickness in
partial thickness rotator cuff tears.

Lafosse et al. put forward extensively a classification system of subscapularis

tears that shows the pattern and the size of five different stages based on
anatomic observations with arthroscopy, and showed also the surgical
approach for its reconstruction (7) (Fig. 3). Type 1 lesions are simple erosions
of the superior third, without bone avulsion. Type II consists of detachment
restricted to the superior third. Type 3 involves the entire height of the tendon
insertion, but without muscular detachment of the inferior third, with limited
tendon retraction. Type 4 is complete subscapularis detachment from the
lesser tuberosity of the humerus, but with the humeral head remaining well
centered, without contact with the coracoid on internal rotation on CT-scan.
Type 5 also represents complete rupture, but with anterosuperior migration of
the humeral head, which comes into contact with the coracoid, with
associated fatty infiltration.
3. PATTERN: Davidson and Burkhart described a three-dimensional
geometric classification obtained from preoperative magnetic resonance
imaging or at arthroscopy that helps orthopaedic surgeons communicate
about tears of the supraspinatus, infraspinatus, and teres minor based on tear
pattern recognition, and furnishes important guidance on the treatment
technique and prognosis for each tear type. This geometric classification
defines four different patterns: crescent-shaped tears, U-shaped tears, L-
shaped tears, and reverse L-shaped tears. Crescent-shaped tears are
relatively short in the coronal image and wide on the sagittal image. They are
commonly mobile from medial to lateral and can usually be repaired by fixing
the tendon end directly to the footprint on the greater humeral tuberosity. U-
shaped and L-shaped tears are relatively long on the coronal and short on the
sagittal images. These tears are usually mobile in an anteroposterior direction
and frequently must be repaired by a side-to-side or margin convergence
technique. The advantage of this system is that it can be used pre- and
intraoperatively.

For partial thickness rotator cuff tears the classification scheme proposed by
Ellman that included specific considerations of the site of the tear along the
tendon thickness (articular surface, bursal surface, or intratendinous) is
suggested.

4. ATROPHY: Tear size and tendon retraction, fatty infiltration and muscle
atrophy are major prognostic factors of the structural and functional outcomes
after rotator cuff tear repair. Goutallier et al. first described a classification of
fatty infiltration of the supraspinatus based on the presence of fatty streaks
within the muscle belly using CT images, and later Fuchs et al. validated the
same system to be used with MRI images (11,12). The classification defines
five degrees of muscle fatty infiltration that can be ascribed to all the four
rotator cuff muscles (Grade 0 = Normal muscle, grade 1 = some fatty streaks,
grade 2 = less than 50% fatty muscle atrophy, i.e. more muscle than fat,
grade 3 = 50% fatty muscle atrophy, i.e. equal muscle and fat, and grade 4 =
more than 50% muscle atrophy, i.e. more fat than muscle).
 5. RETRACTION: Tendon retraction is a common phenomenon in rotator cuff
tears, and it has been shown that formation of a recurrent tendon defect
correlates with the timing of tendon retraction; and clinical outcome correlates
with its magnitude. The most commonly used portion of the classification is
retraction of the supraspinatus tendon in the coronal plane shown in imaging
studies as described by Patte (stage 1 = tear with minimal retraction, stage 2
= tear retracted medial to the humeral head footprint but not to the glenoid,
and stage 3 = tear retracted to the level of the glenoid. In addition, it is
recommended to test tendon retraction intraoperatively to establish a surgical
strategy defining the soft tissue releases and slides to be performed, and to
assist in the prediction of the final outcome of the repair.

In summary, the ISAKOS Upper Limb and Arthroscopy Committees believe

that the presented classification system for rotator cuff tears combine the
important factors from those classifications in current use into on unified
evaluation system easy to remember that fulfil the needs of the surgeons to
better classify the rotator cuff tears. Compared to the previous classifications,
this new system has advantages. It is fitted for both posterosuperior and
subscapularis tears and for partial or full thickness tears, gives details on the
size and geographic patterns of the tears useful to establish an appropriate
treatment, while providing relevant information on the prognosis of the repair
based not only on the size, but also on tendon retraction and the muscle
atrophy and fatty infiltration.

Table 1. ISAKOS Rotator cuff tear classification system

EXTENSION PATTERN FATTY ATROPHY RETRACTION
LOCATION (L) *
(E) (P) (A) (R)
Partial thickness >50% thickness A (Articular)
posterosuperior <50% thickness B (Bursal)
SS0 IS0
I (Interstitial)
SS1 IS1
Full thickness C1 C
SS2 IS2
posterosuperior C2 U
SS3 IS3
C3 L
SS4 IS4
C4 (Massive) rL (reverse
1
L)
2
Anterior 1 SC0
3
2 SC1
3 SC2
4 SC3
5 SC4
*SS, supraspinatus; IS, infraspinatus; SC, subscapularis