II. Epidemiology

  1. Rarely occurs under age 40 years
    1. Exception: Athletes or with significant injury such as Shoulder Dislocation or MVA

III. Pathophysiology

  1. Typically results from continued deterioration or degeneration
    1. Rotator Cuff Tear typically occurs with minor Trauma in Older Patients
  2. Partial or complete rupture
    1. Full thickness tears account for 5-40% of Rotator Cuff Tears
  3. Rotator Cuff Rupture associated with Shoulder Dislocation
    1. Occurs in 50% of dislocations over age 50 years

IV. Mechanism

  1. Fall on Outstretched Hand
  2. Lifting heavy object
  3. Shoulder Dislocation
  4. Motor Vehicle Accident (or other high mechanism injury)

V. Symptoms

  1. Usually no obvious Trauma or injury
  2. Pain progressively worse
  3. Pain referred down deltoid Muscle
  4. Unable to abduct or flex Shoulder
  5. Pain often worse with overhead activity or with sleep

VI. Signs

  1. Partial rupture appears similar as chronic Tendonitis
  2. Shoulder Range of Motion may be completely intact
  3. Shoulder Weakness
    1. Abduction weakness more common (Supraspinatus tear)
    2. Active abduction
      1. Painful arc over 50 degrees
    3. Passive abduction
      1. Results in painful catch at 50 to 100 degrees
    4. Forward flexion weakness indicates subscapularis tear
  4. Tenderness over Rotator Cuff Tear site
  5. Defect palpated through deltoid in complete cuff tear
  6. Atrophy of cuff Muscles
  7. Drop Arm Test positive
    1. Test Specificity: 98%
    2. Test Sensitivity: 10%
  8. Consider Local Lidocaine injection diagnostically
    1. Persistent difficult abduction suggests cuff tear
  9. Acute hemarthrosis and prominent Ecchymosis down arm
    1. Indicative of long standing cuff tear and Arthropathy
  10. Chronic Sub-deltoid swelling indicates large cuff tear
    1. Synovial Fluid escaped from glenohumeral joint

VII. Diagnosis

VIII. Imaging

  1. Shoulder XRay
    1. Calcifications at Humerus tuberosity
    2. Degenerative Arthritis
      1. Acromioclavicular joints
      2. Glenohumeral joints
    3. Subacromial space narrowed on Shoulder PA View (high riding humeral head)
      1. Intact rotator cuff depresses the humeral head
      2. Complete Rotator Cuff Tear allows the humeral head to rise toward the acromion
    4. Cortical irregularity at supraspinatus insertion at greater tuberosity
      1. Present in 75% of Rotator Cuff Tears (esp. age >40 years old)
      2. No cortical irregularity at supraspinatus suggests no tear (misses 4% of tears)
      3. Jacobson (2004) Radiology 230:234-42 [PubMed]
  2. Shoulder MRI
    1. Replaces arthrography
    2. Identifies smaller partial thickness tears as well as other pathology (e.g. labral tears)
    3. Best for younger patients (under age 40 years old)
  3. Shoulder Ultrasound
    1. Safe and noninvasive
    2. Accurate in full thickness, large and moderate tears (esp. in patients over age 40 old)
  4. Shoulder Arthrography (MRI is preferred)
    1. Differentiates full from incomplete Rotator Cuff Tear
    2. Invasive test
    3. Perform only if considering surgery

X. Management: Referral Indications for Orthopedic Surgery (earlier is better)

  1. Young active patient with full thickness tear (best outcome with earlier intervention)
  2. Competitive athletes
  3. Severe functional deficit

XI. Management: Algorithm

  1. Initial Evaluation: Painful cuff range of motion
    1. Start with RICE-M for first 3 days
    2. Switch to moist heat after 2-3 days
      1. Apply for 1 hour
      2. Apply 2-3 times per day
    3. Relative Rest
      1. Avoid complete rest especially in older patients
      2. Risk of Frozen Shoulder
    4. Gentle Shoulder Range of Motion Exercises
      1. Prevents Frozen Shoulder
    5. NSAIDs
    6. Avoid overhead Shoulder activities or overuse
    7. Consider Shoulder XRay if Fracture suspected
  2. Re-evaluation in 2 weeks: Lack of improvement
    1. Early orthopedic referral if criteria above met
    2. Change NSAIDs
    3. Continue Shoulder Range of Motion Exercises
    4. Start Shoulder Strengthening Exercises
  3. Re-evaluation in 2 weeks: Lack of improvement
    1. Sub-acromial space Corticosteroid Injection
      1. Risk of weakening tendons
    2. Physical Therapy with Phonophoresis
  4. Re-evaluation in 2 weeks: Lack of improvement
    1. Shoulder MRI
    2. Orthopedics Consultation

XII. Complications

  1. Partial Thickness Rotator Cuff Tears
    1. Chronic Shoulder Impingement
    2. Calcific Tendonitis
    3. Rotator Cuff Tear progression
      1. Rotator cuff atrophy
      2. Full thickness tear progression (esp. older patients)
  2. Full Thickness Rotator Cuff Tears
    1. Suprascapular Neuropathy

XIII. References

  1. Greene in Wirth (2001) Musculoskeletal Care, p.141-3
  2. Krishman in DeLee (2003) Sports Medicine, p. 1065-92
  3. Monica (2016) Am Fam Physician 94(2): 119-27 [PubMed]

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