Rotator Cuff Injuries

By admin On Feb 27, 2024

Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.

Title: 5-Minute Orthopaedic Consult, 2nd Edition

> Table of Contents > Rotator Cuff Injuries

Rotator Cuff Injuries

Kevin W. Farmer MD

John H. Wilckens MD

Bill Hobbs MD

Basics

Description

Comprises 4 musculotendinous structures (the supraspinatus, infraspinatus, teres minor, and subscapularis) (1,2) that:
- Compress the humeral head into the glenoid, allowing the larger muscle groups to function properly
- Provide muscular balance to the glenohumeral joint
Injuries to the cuff can occur at any
age, but injuries to people >60 years old are likely to occur
secondary to degenerative changes, whereas injuries in younger patients
are less common and tend to follow trauma.
Injuries affect males slightly more often
than females, but females have statistically significant lower shoulder
function scores than males (3,4).
- Full-thickness tears are more common in patients >60 years old.
Classification:
- Degenerative tear versus traumatic tear
- Full-thickness versus partial-thickness tear
- Size

General Prevention

Correct mechanics with overhead athletes
Overall body conditioning, flexibility, and strengthening are important.

Epidemiology

60% of cuff tears occur in those >60 years old (5).
Partial-thickness tears are likely to progress to full-thickness tears over time (6).
The incidence is higher in workers with increased overheard activities, throwing athletes, and swimmers (2).

Risk Factors

Age >60 years
Occupations with overhead activity
Overhead athletics
Dislocations

Genetics

No known inheritance patterns

Pathophysiology

Tendon degeneration
Impingement of the rotator cuff onto the acromion
An eccentric load that exceeds the strength of the cuff insertion or musculotendinous junction
Acute traumatic injury/dislocation

Associated Conditions

Subacromial impingement/bursitis
Proximal biceps tendinitis/rupture
Rotator cuff arthropathy
Glenohumeral arthritis

Diagnosis

Signs and Symptoms

Shoulder pain:
- Especially over the superolateral shoulder
- Typically, pain is increased with shoulder motion, especially with attempts at overhead activity.
Pain at night:
- Patients describe difficulty with sleeping on the affected side.
- Pain often wakes patients up at night.
Shoulder stiffness limiting internal rotation, external rotation, flexion, and abduction is common.
Weakness:
- On manual muscle testing of supraspinatus
  (abduction in the plane of the scapula) and infraspinatus (external
  rotation with arms at the side); common with full-thickness tears
- May be secondary to pain inhibition in partial cuff tears
Instability (2):
- Loss of compressive forces may lead to increased glenohumeral instability.
- Subscapularis tears may lead to anterior glenohumeral instability.
- Anterior-superior subluxation of the humeral head is seen with massive cuff tears.
Subacromial crepitus with passive ROM

History

Acute shoulder pain and weakness after trauma/activity
Chronic shoulder pain/weakness that may be progressive over time

Physical Exam

Evaluate the shoulder for:
- Muscle atrophy
- Points of tenderness
- Active and passive ROM; patients with cuff tears typically have greater passive than active ROM.
- Muscle strength:
  - Active abduction in the plane of the scapula (supraspinatus)
  - Active external rotation with arms at the side (infraspinatus)
  - Gerber lift-off test (lift the hand off
    the lower back) and belly press (pressing the hand into the belly while
    trying to keep the elbow from falling posteriorly) (subscapularis)
Rule out cervical spine pathology.
- Thorough neurovascular examination
- Neck ROM
- Any pain past the elbow and along the medial border of the scapula should increase suspicion for cervical spine abnormalities.

Tests

Tests for impingement:
- Positive Hawkins test produces pain with passive internal rotation of shoulder with arm in 90° of flexion.
- Positive Neer test produces pain with passive flexion of shoulder while scapula is stabilized.
- Positive impingement test: Pain improves with injection of lidocaine into the subacromial space.

Lab

None specific

Imaging

Radiography:
- May see avulsion fragment from greater tuberosity in acute tears
- Chronic cuff disease may show:
  - Sclerosis of undersurface of acromion (or eyebrow sign)
  - Traction spurs of the coracoacromial ligament
  - Cystic changes at the greater tuberosity
  - Calcification in the subacromial space
- Larger tears may show superior migration of the humeral head.
- Cuff tear arthropathy:
  - Superior migration of the humeral head
    with “femoralization” of the humeral head and “acetabularization” of
    the coracoacromial arch (2)
- Glenohumeral or AC arthritis
Arthrography:
- Of historical interest only
- Replaced by noninvasive MRI
Ultrasonography:
- >90% sensitivity and specificity for full- and partial-thickness tears (7)
- Efficient and cost-effective method for examining cuff, but is user-dependent
- Also helpful in evaluation of the biceps tendon
- Useful after rotator cuff repair (2)
MRI:
- 90% sensitivity and 100% specificity (8)
- Helpful for determining size of tear for preoperative planning
- Less useful after rotator cuff repair

Diagnostic Procedures/Surgery

Diagnostic shoulder arthroscopy for definitive diagnosis

Pathological Findings

Thinning and degeneration of the rotator cuff with frayed edges at the tear
Subacromial bone spur
Cystic change at the cuff insertion site into the greater tuberosity
Calcific changes of rotator cuff
Glenohumeral arthritis

Differential Diagnosis

Glenohumeral instability
Proximal biceps tendinitis
Subacromial impingement/bursitis
Cervical radiculopathy
Snapping scapula
Adhesive capsulitis
AC arthritis
Suprascapular neuropathy
SLAP lesion

P.361

Treatment

Initial Stabilization

May use a sling temporarily for comfort, but immobilization not for more than a few days
Ice is helpful for the associated inflammation.

General Measures

Determine the effect on the patient’s daily life.
For the acute traumatic full-thickness tear in the athlete or young patient, typically operative treatment
For degenerative tears, a trial of nonoperative management before surgical intervention

Activity

No activities with >60° of flexion or abduction during the acute period

Special Therapy

Physical Therapy

Rotator cuff program:
- Gradually increase strength and ROM
- No active movements with >60° of flexion or abduction while painful
Strengthen cuff muscles, deltoid, biceps, scapular stabilizers.
Improve scapulothoracic motion.
Ice, ultrasound, electrical stimulation

Complementary and Alternative Therapies

None described

Medication

Medications are the initial choice for managing the pain and inflammation associated with rotator cuff injuries.
- NSAIDs are beneficial during pain exacerbations.
- Acetaminophen

Surgery

Repair of rotator cuff:
- Side-to-side repair of tendons
- Repair of tendon to bone
Open, mini-open, arthroscopic repair:
- Arthroscopic repair allows for complete evaluation of the shoulder but is technically challenging.
- Tear type and pattern may dictate procedure.
Almost always accompanied by subacromial decompression and acromioplasty

Follow-up

Follow the patient to check progression of the physical therapy regimen and to watch for complications such as stiffness.
Take care to avoid overly aggressive therapy, which could put the repair at risk.

Disposition

Issues for Referral

Almost all patients benefit from a referral to physical therapy.

Prognosis

Most patients respond well to nonoperative intervention.
Surgical intervention usually is successful in patients for whom nonoperative intervention fails.
Chronic rotator cuff tears with rotator cuff arthropathy have a poor prognosis.

Complications

Stiff shoulder:
- May occur secondary to postoperative scarring
- Early postoperative pendulum or Codman exercises and passive ROM exercises minimize the risk.
Repair failure is higher in those who smoke, have diabetes, or undergo too-aggressive rehabilitation.
Postoperative infection
Deltoid avulsion: Releasing the deltoid during an open procedure requires a secure reattachment.

Patient Monitoring

Closely monitor ROM; preserving shoulder ROM is
critical, but care should be taken to avoid stressing the repair in the
postoperative period.

References

1. Krishnan
SG, Hawkins RJ. Shoulder. Section L: Rotator cuff and impingement
lesions in adult and adolescent athletes. In: DeLee JC, Drez D, Jr,
eds. Orthopaedic Sports Medicine: Principles and Practice, 2nd ed.
Philadelphia: WB Saunders, 2003:1065–1095.

2. Matsen
FA, III, Titelman RM, Lippitt SB, et al. Rotator cuff. In: Rockwood CA,
Jr, Matsen FA, III, Wirth MA, et al., eds. The Shoulder, 3rd ed
Philadelphia: WB Saunders, 2004:795–878.

3. Fealy S, April EW, Khazzam M, et al. The coracoacromial ligament: morphology and study of acromial enthesopathy. J Shoulder Elbow Surg 2005;14:542–548.

4. Nicholson
GP, Goodman DA, Flatow EL, et al. The acromion: morphologic condition
and age-related changes. A study of 420 scapulas. J Shoulder Elbow Surg 1996;5:1–11.

5. Sher JS, Uribe JW, Posada A, et al. Abnormal findings on magnetic resonance images of asymptomatic shoulders [see comments]. J Bone Joint Surg 1995;77A:10–15.

6. Yamanaka K, Matsumoto T. The joint side tear of the rotator cuff. A followup study by arthrography. Clin Orthop Relat Res 1994;304:68–73.

7. Mack LA, Matsen FA, III, Kilcoyne RF, et al. US evaluation of the rotator cuff. Radiology 1985;157:205–209.

8. Shellock
FG, Bert JM, Fritts HM, et al. Evaluation of the rotator cuff and
glenoid labrum using a 0.2-Tesla extremity magnetic resonance (MR)
system: MR results compared to surgical findings. J Magn Reson Imaging 2001;14:763–770.

Additional Reading

Cofield RH. Rotator cuff disease of the shoulder. J Bone Joint Surg 1985;67A:974–979.

Lehman C, Cuomo F, Kummer FJ, et al. The incidence of full thickness rotator cuff tears in a large cadaveric population. Bull Hosp Joint Dis 1995;54:30–31.

Smith
KL, Harryman DT, II, Antoniou J, et al. A prospective, multipractice
study of shoulder function and health status in patients with
documented rotator cuff tears. J Shoulder Elbow Surg 2000;9: 395–402.

Miscellaneous

Codes

ICD9-CM

726.11 Rotator cuff tendinitis
840.4 Rotator cuff tear

Patient Teaching

Activity

Avoidance of strenuous overhead activities
Proper throwing mechanics in throwing athletes

FAQ

Q: Do patients with small, full-thickness rotator cuff tears need surgery?

A:
Most patients with rotator cuff tears, small or large, will improve
with an appropriate rotator cuff rehabilitation program. If pain
persists or function is still limited thereafter, such patients will
benefit from rotator cuff repair and postoperative rehabilitation.