AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Rotator cuff injuries are problems commonly encountered in athletic and nonathletic patients. Symptoms include pain, weakness, and decreased range of motion. Early diagnosis is important for identifying causes, implementing effective treatment, and preventing further injury.

Pathophysiology

Knowledge of the mechanical and normal anatomical structure allows for understanding of rotator cuff injuries. The rotator cuff muscles are the supraspinatus, infraspinatus, subscapularis, and teres minor.

The subscapularis is a humeral head depressor and, in certain positions, an internal rotator. The infraspinatus and teres minor are external rotators. These muscles work as a unit, rather than individually, to maintain the dynamic glenohumeral stability. All are innervated by subscapular and axillary nerves. The vascular supply largely is dependent on the anterior humeral circumflex artery, which supplies the anterior cuff, and the posterior humeral circumflex and suprahumeral, which supply the posterior cuff.

Microscopically, all of the tendons of the rotator cuff fuse to form one continuous band, which is composed of a 5-layer structure. Because of this structure, none of the individual muscles have a higher incidence of tear, per se. However, the joint-side portion of the supraspinatus tendon is more susceptible to mechanical failure than the bursal side.

Most of the tears of the cuff are the result of chronic degeneration, which makes them susceptible to rupture. The chronic deterioration of the cuff results from the coracoacromial arch, which is composed of the bony acromion, the coracoacromial ligament, and coracoid process. Because of its position above the rotator cuff, the coracoacromial arch forms the roof through which the supraspinatus tendon must pass (ie, supraspinatus outlet). Repetitive microtrauma and anatomical variations lead to most of the rotator cuff injuries.

Tendon degeneration is classified in 3 stages (classification of the impingement syndrome) based on the supraspinatus outlet.

• Stage I - Edema and hemorrhage, affecting persons younger than 25 years
• Stage II - Fibrosis and tendinitis, affecting persons aged 25-40 years
• Stage III - Tears of cuff, affecting persons older than 50 years

Frequency

United States

The precise incidence of symptomatic rotator cuff injuries is not known. Many individuals with full-thickness cuff tears are not only asymptomatic but they have minimal functional disability. The most accepted figure is 20-30%. Cadaver studies of elderly persons have estimated full-thickness tears as high as 30%.

Mortality/Morbidity

An estimated 4% of cuff ruptures develop a cuff arthropathy. Various authors report a rate of success with conservative treatment ranging from 33-90%, with longer recovery time in older patients. Surgery results in improved function regardless of the patient's age.

Age

Rotator cuff injuries and tears usually do not occur in persons younger than 40 years (5-30%). The great majority is found in persons aged 55-85 years. Approximately 15% of patients with shoulder pain who are older than 70 years have rotator cuff injuries.

• Younger patients are more likely to have rotator cuff dysfunction because of overuse, subtle instability, and muscle imbalance.
• Older patients tend to have chronic shoulder pain and degeneration.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Assess any patient with shoulder pain with respect to the patient's age and occupation. Characterize pain according to its duration of onset, location, radiation, timing, and quality. In addition, investigate pain for its relationship to activities and sport.

• Pain is the most common symptom encountered with rotator cuff injury.
• • Pain usually is located anterolaterally and superiorly and referred to the level of the deltoid insertion with full-thickness tears.
  • Pain is aggravated in activities where the arm must be in an overhead or a forward-flexed position.
  • In an acute injury, pain suddenly is elicited after a fall, after lifting of a heavy object, or even after a trivial amount of force.
• Following pain, weakness and limitation of motion are the next most common symptoms of a rotator cuff tear.
• The patient also may complain of clicking, catching, stiffness, and crepitus.

Physical

Approach the shoulder examination systematically in every patient with inspection, palpation, range of motion, strength testing, neurologic assessment, and performances of special shoulder tests. Also, include evaluation of the cervical spine and upper extremity.

• Inspect for scars, color, edema, deformities, muscle atrophy, and asymmetry.
• Palpate the bony and soft-tissue structures, noting any areas of tenderness.
• • The subdeltoid and subacromial bursae can be palpated anteriorly under the acromion, and laterally with the deltoid muscle and the arm in extension.
  • The supraspinatus is palpated anteriorly when the arm is externally rotated and flexed.
  • Hyperextension permits the palpation of the infraspinatus.
• Assess active and passive range of motion. Note any pain elicited and loss of motion.
• • Determine muscle strength.
  • The supraspinatus is isolated with the arm forward 90 degrees in the scapular plane and the forearm rotated into pronation (ie, thumbs down). If drooping of this position occurs, full-thickness rotator cuff tears are suggested.
  • The subscapularis may be tested with the arm at the side with internal rotation resistance. However, this can produce false-negative results; instead, place the arm internally rotated with the dorsum on the buttock surface and actively lift the hand from the buttocks against resistance.
  • The external rotators, teres minor, and infraspinatus can be tested with the arm on the side and in 90 degrees of abduction.
• Neer impingement test: An injection of 1% lidocaine into the subacromial bursae, using the lateral or posterior approach, creates signs of relief on forward flexion in patients with rotator cuff disease, distinguishing cuff disease from other sources of shoulder pain. However, rotator cuff tears are not distinguished from early stages of inflammation or fibrosis.

Causes

An emerging consensus suggests that the etiology of rotator cuff disease is multifactorial. Extrinsic factors exist, such as the morphology of the coracoacromial arch, tensile overload, repetitive use, and kinematics abnormalities. Intrinsic factors also exist, such as altered tendon vascular supply, microstructural collagen fiber abnormalities, and regional variations.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Avascular necrosis of humerus
Acromioclavicular injury
Neurologic injuries (C5-C6) caused by repetitive trauma
Septic arthritis
Spleen rupture

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Imaging Studies

• Routine radiographic evaluations are an essential component of shoulder evaluation in the ED. Perform a routine radiographic examination in every patient with suspected rotator cuff injury. Shoulder radiography should include anteroposterior, axillary, and lateral views.
• A modified transscapular or supraspinatus outlet view is useful for surgical purposes. Radiographic changes are as follows:
• • Subacromial sclerosis (ie, "eyebrow" sign)
  • Osteophyte formation
  • Sclerosis and cystic changes in the greater tuberosity
  • Reduction of the acromiohumeral distance (<7 mm).

(Only the last 2 points were found to have 78% sensitivity and 98% specificity.)

• Reserve advanced imaging modalities for suspected rotator tears with no improvement in symptoms, despite adequate therapy for 3-6 weeks.
• • Arthrography of the glenohumeral joint has been used to diagnose rotator cuff disease. A complete tear is diagnosed when communication between the glenohumeral joint cavity and the bursae, either subacromial or subdeltoid, is evident. Partial tears are better evaluated with ultrasonography or MRI.
  • Ultrasonography is also used to evaluate rotator cuff disease. The 4 criteria for rotator cuff pathology are nonvisualization of the cuff, localized absence or focal nonvisualization, discontinuity, and focal abnormal echogenicity. Sensitivity and specificity are operator dependent and have been reported to be greater than 90%.
  • Magnetic resonance imaging (MRI) can reveal a great spectrum of rotator cuff disease from degeneration to partial or complete tears. MRI also can reveal soft tissue injuries. As a postoperative imaging modality, it has proven to be invaluable.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

Stabilization with a shoulder sling and an ice pack are sufficient for prehospital care.

Emergency Department Care

• Conservatively treat patients with chronic injuries that have progressed to a rotator cuff tear.
• The goals are to reduce inflammation, relieve stress on the rotator cuff, and correct any biomechanical dysfunction.
• Nonoperative therapy consists of rest and activity modification, shoulder sling, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, and a basic shoulder-strengthening program.
• Various studies indicate a heterogeneous success rate ranging from 33-90%. Steroid injections reduced pain, but no difference in improvement of function was observed.
• Schedule follow-up treatment as soon as possible; if the patient has not improved by a 6-week assessment, consider surgical therapy.
• Surgical therapy is indicated in patients younger than 60 years with a full-thickness tear demonstrated clinically or arthrographically, in patients who fail to improve after 6 weeks of rehabilitation, or in patients performing activity that requires shoulder use.
• • Emergent orthopedic evaluation is warranted in acute injuries or even severe extension of chronic rotator cuff injuries because they have a poor prognosis if conservative modalities are used.
  • The success rate of surgical therapy is reported to be 77-86%.
  • Findings generally suggest that early treatment precipitates a better outcome than late treatment.
  • Many studies have concluded that the need for surgery should consider not only age but also type of tear, duration of symptoms, and the patient's ability to comply with the rehabilitation regimen.

Consultations

Consider an orthopedic consultation in primarily acute injuries or even severe extension of chronic rotator cuff injuries. An orthopedic consultation for possible surgical intervention is required under the following conditions:

• In patients younger than 60 years
• For full-thickness tear demonstrated clinically or arthrographically
• For failure to improve after 6 weeks of rehabilitation
• If the patient's employment requires shoulder use

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goal of pharmacotherapy is to reduce pain and inflammation.

Drug Category: Analgesics

Pain control is essential to quality patient care, ensuring patient comfort, promoting pulmonary toilet, and enabling physical therapy regimens. Most analgesics have sedating properties, which are beneficial for patients who have sustained painful skin lesions.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Admit to orthopedic service in preparation for the operating room (only required if surgery is the treatment of choice).

Further Outpatient Care

• Arrange outpatient follow-up care within 1-2 days to an orthopedic surgeon and rehabilitation services to continue conservative therapy.
• A follow-up reassessment examination 6 weeks after beginning conservative therapy is essential to determine if treatment is successful or if further surgical treatment is needed.

In/Out Patient Meds

• All NSAIDs are equally effective.

Deterrence/Prevention

• Instruct patient to limit activities to ensure rest of the affected shoulder.

Complications

• Failure of conservative treatment requires surgical intervention.
• Decreased range of motion may occur.

Prognosis

• An estimated 4% of cuff ruptures develop a cuff arthropathy.
• Various authors report the success rate of conservative treatment to be 33-90%, with longer recovery time required in older patients.
• Surgery results in better function regardless of the patient's age.

Patient Education

• Refer patients to a physical therapist in conservative treatment and postoperatively.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Proper follow-up and care ensure prevention of rotator cuff arthropathies and long-term sequelae.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Barr KP. Rotator cuff disease. Phys Med Rehabil Clin N Am. May 2004;15(2):475-91. [Medline].
• Dalton SE. The conservative management of rotator cuff disorders. Br J Rheumatol. Jul 1994;33(7):663-7. [Medline].
• Ecklund KJ, Lee TQ, Tibone J, Gupta R. Rotator cuff tear arthropathy. J Am Acad Orthop Surg. Jun 2007;15(6):340-9. [Medline].
• Fongemie AE, Buss DD, Rolnick SJ. Management of shoulder impingement syndrome and rotator cuff tears. Am Fam Physician. Feb 15 1998;57(4):667-74, 680-2. [Medline].
• Fuchs S, Chylarecki C, Langenbrinck A. Incidence and symptoms of clinically manifest rotator cuff lesions. Int J Sports Med. Apr 1999;20(3):201-5. [Medline].
• Hayes K, Ginn KA, Walton JR, Szomor ZL, Murrell GA. A randomised clinical trial evaluating the efficacy of physiotherapy after rotator cuff repair. Aust J Physiother. 2004;50(2):77-83. [Medline].
• Millstein ES, Snyder SJ. Arthroscopic evaluation and management of rotator cuff tears. Orthop Clin North Am. Oct 2003;34(4):507-20. [Medline].
• Miniaci A, Salonen D. Rotator cuff evaluation: imaging and diagnosis. Orthop Clin North Am. Jan 1997;28(1):43-58. [Medline].
• Quillen DM, Wuchner M, Hatch RL. Acute shoulder injuries. Am Fam Physician. Nov 15 2004;70(10):1947-54. [Medline].
• Rokito AS, Cuomo F, Gallagher MA, Zuckerman JD. Long-term functional outcome of repair of large and massive chronic tears of the rotator cuff. J Bone Joint Surg Am. Jul 1999;81(7):991-7. [Medline].
• SooHoo NF, Rosen P. Diagnosis and treatment of rotator cuff tears in the emergency department. J Emerg Med. May-Jun 1996;14(3):309-17. [Medline].
• Soslowsky LJ, Carpenter JE, Bucchieri JS, Flatow FL. Biomechanics of the rotator cuff. Orthop Clin North Am. Jan 1997;28(1):17-30. [Medline].

Article Last Updated: Aug 22, 2007