SYMPTOMS
There is usually exercise-related pain and weakness of the shoulder on abduction and in overhead activities. The player may relate that ‘something snapped’ in the shoulder. In many partial ruptures, the initial symptom is secondary impingement or muscle atrophy and weakness.
AETIOLOGY
The onset can be dramatic, with complete loss of abduction strength from a direct or indirect tackle. Development of symptoms in partial tears is more gradual. Tears may be under or upper surface flap tears, partial or complete avulsion tears from the humerus insertion, split tears in the mid-substance or a combination of degenerative and acute tears. The location of the tear may be posterior, lateral, medial or anterior. Thus, the symptoms
may vary.
CLINICAL FINDINGS
Since this injury often is associated with other injuries such as shoulder
dislocations or SLAP tears, a broad range of clinical tests must be performed. The active range in all directions of shoulder motion should be tested (it is almost always decreased), repeated against manual resistance and compared with the other side. Jobe’s test is positive in major or complete ruptures and internal impingement tests are positive in undersurface partial tears. Major tears are usually degenerative, affecting athletes over 40 years of age, while partial tears are common in younger athletes, but a severe tackle in rugby can tear a rotator cuff completely in a young player. In chronic cases, there is usually a restricted range of motion and muscle atrophy and secondary problems around the upper back and neck. Such rotator cuff tears may well be seen as a post-traumatic stiff shoulder.
INVESTIGATIONS
This is a clinical diagnosis. Ultrasound or MRI is helpful when the tear is complete but often misses smaller or partial tears.
TREATMENT
Physiotherapy, for restoration of thoraco-scapular control and posture, is essential. Arthroscopy is very valuable, both to investigate the extent of the injury and repair or treat tears.
REFERRALS
Refer to Dr Kevin Yip (+65 6664 8135) senior consultant orthopaedic surgeon to determine the diagnosis and for consideration of surgery. In almost all cases a thorough rehabilitation programme, including specific treatment, thoraco-scapular control training, strength, flexibility and posture training is required with or without surgery.
EXERCISE PRESCRIPTION
Most sports and activities are possible but secondary symptoms due to compensatory muscle activation are common and must be addressed. Running and swimming are usually difficult but warm water can be helpful to release the shoulder. The specific rehabilitation should aim to achieve over time a full range of controlled motion, good posture and thoraco-scapular control.
EVALUATION OF TREATMENT OUTCOMES
Normal clinical symptoms and signs. Jobes’ test
should be negative. Functional strength, control and
flexibility should be comparable with the other
shoulder.
DIFFERENTIAL DIAGNOSES
Post-traumatic stiffness, frozen shoulder, SLAP tear, external impingement, non-orchopaedic disorders carrying
referred pain.
PROGNOSIS
Excellent-Poor, depending on the extent of the injury.
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