Rotator Cuff Tears
Kenneth M. Bielak
Benjamin D. England
BasicsDescription
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Partial or complete tears or disruption of any one or combination of the 4 rotator cuff muscles of the glenohumeral joint
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Supraspinatus and infraspinatus muscle-tendon complexes are the most common tears.
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Rotator cuff muscles are the supraspinatus, infraspinatus, teres minor, and subscapularis muscles.
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Synonym(s): Tear of the supraspinatus; Tear of the infraspinatus; Tear of the teres minor; Tear of the subscapularis muscle
Epidemiology
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Rare in young athletes
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More common in athletes >40 yrs of age, especially those with a history of many years of repetitive overhead sports
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More common than osteoarthritis (shoulder is the only joint where soft tissue often wears out before joint)
Risk Factors
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Over-40 “weekend warrior” with years of repetitive overhead use (eg, swimming, tennis, volleyball, gymnastics, weight lifting, and throwing sports)
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Previous trauma
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Sports with potential fall risk, such as equestrian, skiing, and body surfing
Etiology
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Can present following specific trauma (acute traumatic tear)
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Usually degenerative (chronic impingement syndrome), especially in older athlete with overarm sports
DiagnosisHistory
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Mechanism of injury:
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Acute traumatic events such as a fall, direct blow, or forceful boxing punch
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Traumatic hyperextension of abducted arm
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Traumatic external or internal rotation of abducted arm
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Anterior dislocation
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Chronic overhead arm use may develop insidiously.
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Nocturnal pain and pain on sleeping on the affected side are common.
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Pain location can be variable (anterior, lateral, or posterior shoulder).
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Pain may radiate to elbow.
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Pain typically is aggravated with reaching motions: laterally, toward the back and/or overhead.
Physical Exam
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Diminished range of motion (ROM)
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Pain with arm abduction, especially at 80–120 degrees of arc (1)[B]
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Atrophy of cuff muscles, especially if chronic
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Crepitus of supraspinatus muscle during abduction
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Rotator cuff muscle weakness
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Drop-arm test is positive for partial-thickness tear (14.3% sensitive, 88.4% specific) and full-thickness tear (34.9% sensitive, 87.5% specific) (1)[B]:
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Arm is passively abducted to 90 degrees.
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Patient is instructed to slowly return the arm to the side.
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Severe pain or inability to do so is positive test for a torn rotator cuff complex.
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Empty-can test is positive for large or full-thickness tears (88% sensitive, 70% specific) (2)[B]:
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Resistance applied to arm abducted 90 degrees, angled 30 degrees anteriorly with a medially rotated forearm (thumbs down, “empty can”)
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Test is positive for inability to do so or severe pain, indicating a tear of the supraspinatus tendon.
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Test external rotation strength (partial tear 68.9% specific, 19.4% sensitive; full tear 84% specific, 50.5% sensitive) (1)[B]:
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Perform test with elbow flexed 90 degrees at the side.
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Pinpoints infraspinatus and teres minor involvement.
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Lift-off test for subscapularis is positive (3)[B]:
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Inability to lift the dorsum of the hand off the back hip.
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Modified lift-off test (cannot maintain lift-off position and springs back toward the back) is more accurate (3)[B].
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Significant pain with internal rotation can preclude an accurate test.
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Poor scapular stability is often present.
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Anterior glenoid-humeral laxity may be noted.
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Comprehensive testing of active and passive ROM, strength testing, and adequate neurovascular testing are recommended.
Diagnostic Tests & Interpretation
Imaging
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Plain radiographs, although not specific for rotator cuff tears, may show some findings that are suggestive:
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Calcifications along the tendons of the rotator cuff muscle (repetitive/chronic injury)
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Subacromial osteophytes (may predispose to tears)
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Superior or anterior migration of the humeral head (indicates full-thickness tear) (4)[B]
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MRI demonstrates an 80–97% sensitivity in detecting full-thickness rotator cuff tears. Partial tears are more difficult to detect, with a sensitivity of 67–89%. This improves if fat suppression is used (5)[B].
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Double-contrast arthrotomography (DCAT) is 100% sensitive and 94% specific in diagnosing complete rotator cuff tears. This study is much less sensitive for partial tears. The study is more appropriate in patients with signs of instability rather than pain alone.
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US is gaining attention as an imaging modality because it can be done relatively inexpensively and can localize areas of tenderness and dysfunction with patient present and in dynamic examination (technician-dependent) (6)[B].
Diagnostic Procedures/Surgery
Diagnostic injection: Subacromial bursa injection (10 mL of 1% lidocaine) may distinguish bursal pathology and minor impingement from distinct tears of the rotator cuff (no pain relief or strength improvement from the injection).
Differential Diagnosis
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Rotator cuff strains
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Glenoid labrum tear
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Subluxation or unstable shoulder
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Subacromial impingement
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Isolated bicipital tendonitis
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Acromioclavicular joint disorders
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Glenohumeral arthritis
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Rare subacromial abscess or tumors
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Adhesive capsulitis
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Cervical radiculopathy can radiate to the shoulder.
P.517
Treatment-
Acute treatment
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Analgesia:
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NSAIDs are the drugs of choice initially (level II-2).
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More potent analgesics may be necessary temporarily to relieve nocturnal symptoms.
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Immobilization: Sling may provide some relief for the acutely injured shoulder.
Additional Treatment
Additional Therapies
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Prolonged rehabilitation emphasizing increased ROM and strengthening is indicated for a partial tear.
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Normalizing scapulothoracic stabilization and posterior capsular flexibility with a 1:1 strength ratio for rotator cuff to anterior/middle cuff deltoid muscles
Surgery/Other Procedures
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For complete tears, surgery may be warranted in the young patient or active athlete.
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Early operative repair provides the best chance for functional recovery (level II-3).
Ongoing CareFollow-Up Recommendations
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Acute full-thickness tears should be referred early on.
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Partial tears after failed conservative therapy
Patient Education
Overhead athletes undergoing surgical repair may require 6 mos or longer before being able to return to full active sports participation.
References
1. Park HB, Yokota A, Gill HS, et al. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. J Bone Joint Surg Am. 2005;87:1446–1455.
2. Holtby R, Razmjou H. Validity of the supraspinatus test as a single clinical test in diagnosing patients with rotator cuff pathology. J Orthop Sports Phys Ther. 2004;34:194–200.
3. Hertel R, Ballmer FT, Lombert SM, et al. Lag signs in the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg. 1996;5:307–313.
4. Weiner DS, Macnab I. Superior migration of the humeral head. A radiological aid in the diagnosis of tears of the rotator cuff. J Bone Joint Surg Br. 1970;52:524–527.
5. Burks RT, Crim J, Brown N, et al. A prospective randomized clinical trial comparing arthroscopic single- and double-row rotator cuff repair: magnetic resonance imaging and early clinical evaluation. Am J Sports Med. 2009.
6. Teefey SA, Middleton WD, Yamaguchi K. Shoulder sonography. State of the art. Radiol Clin North Am. 1999;37:767–785, ix.
Additional Reading
Allen GM, Wilson DJ. Ultrasound of the shoulder. Eur J Ultrasound. 2001;14:3–9.
Bearcroft PW, Blanchard TK, Dixon AK, et al. An assessment of the effectiveness of magnetic resonance imaging of the shoulder: literature review. Skeletal Radiol. 2000;29:673–679.
Breazeale NM, Craig EV. Partial-thickness rotator cuff tears. Pathogenesis and treatment. Orthop Clin North Am. 1997;28:145–155.
Chang D, Mohana-Borges A, Borso M, et al. SLAP lesions: anatomy, clinical presentation, MR imaging diagnosis and characterization. Eur J Radiol. 2008.
Codsi MJ. The painful shoulder: when to inject and when to refer. Cleve Clin J Med. 2007;74:473–474, 477–478, 480–482 passim.
Farid N, Bruce D, Chung CB. Miscellaneous conditions of the shoulder: anatomical, clinical, and pictorial review emphasizing potential pitfalls in imaging diagnosis. Eur J Radiol. 2008.
Firestein: Kelley's Textbook of Rheumatology, 8th ed. 2008: W. B. Saunders Company
Fritz RC, Stoller DW. MR imaging of the rotator cuff. Magn Reson Imaging Clin N Am. 1997;5:735–754.
Howard TM, O'Connor FG. The injured shoulder. Primary care assessment. Arch Fam Med. 1997;6:376–384.
Hulstyn MJ, Fadale PD. Shoulder injuries in the athlete. Clin Sports Med. 1997;16:663–679.
Jost B, Zumstein M, Pfirrmann CW, et al. MRI findings in throwing shoulders: abnormalities in professional handball players. Clin Orthop Relat Res. 2005;130–137.
Meister K. Injuries to the shoulder in the throwing athlete. Part two: evaluation/treatment. Am J Sports Med. 2000;28:587–601.
Opsha O, Malik A, Baltazar R, et al. MRI of the rotator cuff and internal derangement. Eur J Radiol. 2008.
Stetson WB, Phillips T, Deutsch A. The use of magnetic resonance arthrography to detect partial-thickness rotator cuff tears. J Bone Joint Surg Am. 2005;87(Suppl 2):81–88.
Teefey SA, Rubin DA, Middleton WD, et al. Detection and quantification of rotator cuff tears. Comparison of ultrasonographic, magnetic resonance imaging, and arthroscopic findings in seventy-one consecutive cases. J Bone Joint Surg Am. 2004;86-A:708–716.
Toyoda H, Ito Y, Tomo H, et al. Evaluation of rotator cuff tears with magnetic resonance arthrography. Clin Orthop Relat Res. 2005;439:109–115.
CodesICD9
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726.10 Disorders of bursae and tendons in shoulder region, unspecified
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726.11 Calcifying tendinitis of shoulder
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726.19 Other specified disorders of bursae and tendons in shoulder region
Clinical Pearls
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Surgery is an option, especially for the young and/or active athlete, and should be considered early on for diagnosis of complete tears of the rotator cuff.
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Rehabilitation of a partial tear of the rotator cuff is a prolonged process that may take months to return to preinjury status.