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Rotator Cuff Tear

Rotator cuff injuries embody a wide range of diseases ranging from acute reversible tendinitis to massive tears involving any of the rotator cuff muscles. It is a common cause of shoulder pain and disability in people of all age groups. A rotator cuff tear weakens the shoulder making normal daily activities like combing the hair painful and difficult to do.


Presentation

A thorough examination is important to help rule out other causes of shoulder pain. Some of the symptoms a patient will present with are pain, which is often worse when the arm is raised overhead, instability, weakness and limited range of motion. Other complaints are swelling, numbness and propping of the shoulder. The pain could start acutely or worsening in a course of a known repetitive activity. In older people, the symptoms are often deceptive with no precise injury [6].

Arm Pain
  • When to See the Doctor Any time you have an acute shoulder injury, or chronic shoulder or arm pain, you should see a doctor for a diagnosis and treatment.[medicinenet.com]
  • If you sustain a rotator cuff tear you are likely to experience shoulder and arm pain, restricted shoulder movement and pain at night. Sometimes rotator cuff tears can occur slowly without any pain or discomfort.[psmgroup.com.au]
  • If you have injured your shoulder or have chronic shoulder and arm pain, it is best to see your orthopaedic surgeon. He or she can then make a diagnosis and begin treatment.[orthoinfo.aaos.org]
Shoulder Pain
  • Shoulder pain is a very common symptom. Disorders of the rotator cuff tendons due to wear or tear are among the most common causes of shoulder pain and disability.[ncbi.nlm.nih.gov]
  • The aim of this study was to assess the reliability of ultrasonography (US) for the detection of recurrent rotator cuff tears in patients with shoulder pain after RCR.[ncbi.nlm.nih.gov]
  • Rotator cuff tears and subacromial impingement are second only to acromioclavicular joint disorders as the most common causes of shoulder pain.[ncbi.nlm.nih.gov]
  • Rotator cuff tears are common and are a frequent source of shoulder pain and disability. A wide variation in the prevalence of rotator cuff tears has been reported.[ncbi.nlm.nih.gov]
  • After systematic rehabilitation, the patient had relief of shoulder pain and full range of motions in 14-months follow-up. Case report, Level IV.[ncbi.nlm.nih.gov]
Frozen Shoulder
  • You can end up with a frozen shoulder or arthritis that is harder to treat. Diagnosis To find out if you have a torn rotator cuff, your doctor will start with a history of the injury and a physical examination of the shoulder.[webmd.com]
  • Frozen Shoulder The signs and symptoms of a frozen shoulder include: Stiffness in the joint. Tightness. Unable to lift the arm. Fracture The signs and symptoms of a fracture include: Severe pain. Redness. Bruising.[niams.nih.gov]
  • The most serious complication of rotator cuff disease is frozen shoulder. Frozen shoulder is a result of scarring that occurs around the inflamed joint and leads to loss of range of motion and function of the joint.[medicinenet.com]
  • The most common condition that mimics a rotator cuff tear is shoulder stiffness or a frozen shoulder . This condition is characterized by reduced range of motion — the shoulder will only move so far before starting to hurt.[hopkinsmedicine.org]
Shoulder Arthritis
  • However, for some people, an untreated rotator cuff tear can lead to ongoing pain and dysfunction of the shoulder. Arthritis. Sometimes a complete tear of the rotator cuff can lead to arthritis of the shoulder joint.[phongtran.com.au]
  • Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link Use the "Search" box to the right to find other topics of interest to you.[shoulderarthritis.blogspot.com]
  • Arthritis: Barb’s Story Barb Meshulam, 63, tore her rotator cuff twice and had two surgeries to repair it.[hopkinsmedicine.org]
  • Arthritis Shoulder Impingement Shoulder Tendonitis Swimmer's Shoulder[physioworks.com.au]
Stiffness of the Shoulder
  • It is common for a patient to develop a stiff and painful shoulder with no injury. A radiologist may read the resulting MRI scan as showing tendinosis or a partial tear of the rotator cuff.[hopkinsmedicine.org]
  • Pain that may be constant or come and go (such as only when you lie on the injured shoulder) Pain or stiffness in your shoulder that travels down your arm Trouble lifting your arm or placing it behind your back Trouble moving or using your shoulder A[drugs.com]
  • Gentle physical therapy guided motion is instituted at this phase, only to prevent stiffness of the shoulder; the rotator cuff remains fragile.[en.wikipedia.org]
Left Shoulder Pain
  • In this case, a 51-year-old woman presented with several weeks of left shoulder pain and was diagnosed with rotator cuff tendonitis.[ncbi.nlm.nih.gov]
  • Matthew Pifer Shoulder & Elbow - Rotator Cuff Tears Questions (65) (OBQ13.243) A 47-year-old landscaper presents with worsening left shoulder pain and weakness.[orthobullets.com]

Workup

Imaging tests are the gold standard in rotator cuff tears. A plain radiograph of the shoulder is useful and the typical views are AP view to determine acromiohumeral distance which may be reduced. It will also show reactive changes at the rotator cuff insertion site like sclerosing and cyst formation. An outlet view will show the acromion shape and slope while the axillary view identifies the position of the humeral head in relation to the glenoid [7]. Magnetic resonance imaging is highly sensitive and specific and it shows the site, size and characteristics of rotator cuff injuries.

Ultrasonography is also useful and highly sensitive in detecting full thickness tears but it is extremely dependent on the skill of the observer. Electrodiagnostic testing can also be done to rule out nerve involvement and nerve conduction as a source of pain.

Treatment

This could either be non-operative or operative. Non-operatative treatment is reserved for those who have relatively normal function in the affected limb. The modality includes the use of oral and topical analgesics to relieve pain, a shoulder sling to reduce movement of the joint, physical therapy to avoid joint stiffness due to immobility. As pain decreases, a strengthening program is instated to return the joint to its normal strength [8].

When operative treatment is indicated, the surgeries of choice are arthroscopy, mini-open and open repair. Arthroscopy was initially reserved for very small tears but with the advancement in technology, have been as successful as open surgery in the repair of large tears.

Prognosis

Most athletes respond well to nonsurgical treatment in primary outlet impingement without full thickness rotator cuff tears. When surgery is done, response is determined by a number of factors including age, size and pattern of the injury, degree of retraction, quality of the tissue and quality of the repair.

Etiology

Rotator cuff tear could either be an acute episode or from a chronic degenerative insult. An acute episode results from a great force on the muscle such as a fall on the outstretched arm. A lesser force could also cause a tear if the muscle has already started undergoing some degeneration. It could also result from sudden heavy lifting.

Chronic causes include reduced perfusion, degeneration related to old age, repeated heavy lifting especially overhead and bone spurs, which are extra pieces of bone that may grow and irritate the muscle [2].

People at risk for this injury are older people, certain athletes like basket-ballers, and construction workers.

Epidemiology

Rotator cuff injury occurs in as much as 40% of the population with the incidence increasing with age. Rotator cuff tears are commoner in males, affect the dominant arm more, and people that are involved in physical activity and those with a history of trauma [3].

Sex distribution
Age distribution

Pathophysiology

The two main mechanisms of rotator cuff tears are injury and degeneration and they could either be due to intrinsic, when it occurs from within the rotator cuff itself, and extrinsic, when the source is from surrounding structures like the acromion, factors. A rotator cuff tear could also either be a partial thickness or a full thickness tear.

The amount of stress needed to acutely tear a rotator cuff depends on the condition before application of the force. In a healthy tendon, the force required is greater than that required in a tendon with preexisting degeneration [4].

Chronic tears are a result of wear that occurs over time, due to extended use, poor biomechanics or muscular imbalance and aging. They usually occur more in the dominant arm and the stressor is mainly from repeating the same shoulder motions frequently. Another factor in chronic tear is diminished blood supply. This occurs mainly in older people and it impairs the ability if the tendons to repair themselves leading to tears.

A third mechanism is what is referred to as impingement syndrome. The tendons of the rotator cuff pass through the subacromial space below the acromion, when they become inflamed, the space becomes smaller and there is pain on motion. Repeated impingement can lead to inflammation of the tendons and bursa and result in the syndrome [5].

Prevention

Some preventive measures include, resting shoulder when experiencing pain, regular shoulder exercises, using proper form when lifting weight, and adequate rest periods in occupations that involve heavy lifting [9].

Summary

The shoulder joint has a wide range of motion, and it gives up stability for this wide range of motion making it a relatively unstable joint. Its stability is ensured by bony and muscular components. Part of this muscular component is the rotator cuff muscles. It is made up by 4 muscles; the supraspinatus, infraspinatus, subscapularis and teres minor [1]. These muscles come together via their tendons to stabilize the joint while it is in motion.

Patient Information

Definition

Rotator cuff tear is a tear in the muscles that help to stabilize the shoulder joint. These tears could be partial or full. They could also occur suddenly or build up over time.

Cause

It can result suddenly from trauma. It can also result from long term degeneration of the tendon associated with aging. Repeated motions of the joint in occupation that require lifting and reaching can also cause it as well as reduced blood supply to the tendon from any cause.

Symptoms

Symptoms include pain which could be worsened by raising the hand above the head. There could also be swelling and redness of the shoulder. The shoulder may also be numb and the range of motion may be lost. 

Diagnosis

Diagnosis is usually done by a plain X-ray of the joint. An MRI which is a more expensive procedure is also a very reliable diagnostic tool. An ultrasound in the hands of a skilled observer can also diagnose the condition.

Treatment

This involves the use of pain medications to reduce pain, shoulder slinging and physical therapy. For those who do not respond to conservative management or in whom rapid recovery is required, surgery may be performed [10]. 

References

Article

  1. Baker CL, ed. Shoulder impingement and rotator cuff lesions. The Hughston Clinic Sports Medicine Book. Baltimore, Md: Lippincott Williams and Wilkins; 1995:272-9.
  2. Inman VT, Saunders JB, Abbott LC. Observations of the function of the shoulder joint. J Bone Joint Surg Am. 26:1-30.
  3. Janda DH, Loubert P. Basic science and clinical application in the athlete's shoulder. A preventative program focusing on the glenohumeral joint. Clin Sports Med. Oct 1991;10(4):955-71.
  4. Nuber GW, Jobe FW, Perry J, Moynes DR, Antonelli D. Fine wire electromyography analysis of muscles of the shoulder during swimming. Am J Sports Med. Jan-Feb 1986;14(1):7-11.
  5. Malanga GA, Bowen JE, Nadler SF, Lee A. Nonoperative management of shoulder injuries. J Back Musculoskeletal Rehab. 1999;12:179-89.
  6. Lohr JF, Uhthoff HK. The microvascular pattern of the supraspinatus tendon. Clin Orthop Relat Res. May 1990;254:35-8.
  7. Teefey SA, Hasan SA, Middleton WD, Patel M, Wright RW, Yamaguchi K. Ultrasonography of the rotator cuff. A comparison of ultrasonographic and arthroscopic findings in one hundred consecutive cases. J Bone Joint Surg Am. Apr 2000;82(4):498-504. 
  8. Rodeo SA, Delos D, Williams RJ, Adler RS, Pearle A, Warren RF. The effect of platelet-rich fibrin matrix on rotator cuff tendon healing: a prospective, randomized clinical study. Am J Sports Med. Jun 2012;40(6):1234-41.
  9. Arroyo JS, Hershon SJ, Bigliani LU. Special considerations in the athletic throwing shoulder. Orthop Clin North Am. Jan 1997;28(1):69-78.
  10. Cohen RB, Williams GR Jr. Impingement syndrome and rotator cuff disease as repetitive motion disorders.Clin Orthop Relat Res. Jun 1998;351:95-101.

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Last updated: 2019-07-11 21:36