Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Rotator Cuff Injuries

Basics
Description
  • Comprises 4 musculotendinous structures (the supraspinatus, infraspinatus, teres minor, and subscapularis) 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.
    • 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.
  • Partial-thickness tears are likely to progress to full-thickness tears over time.
  • The incidence is higher in workers with increased overheard activities, throwing athletes, and swimmers.
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:
    • 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
    • Glenohumeral or AC arthritis
  • Arthrography:
    • Of historical interest only
    • Replaced by noninvasive MRI
  • Ultrasonography:
    • >90% sensitivity and specificity for full- and partial-thickness tears
    • 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
  • MRI:
    • 90% sensitivity and 100% specificity
    • 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
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.
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.

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