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Rotator Cuff Tear

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Other Names

  • Acute Rotator Cuff Tear
  • Chronic Rotator Cuff Tear
  • Partial Rotator Cuff Tear
  • Complete Rotator Cuff Tear
  • Rotator cuff arthropathy

Background

History

Epidemiology

  • Prevalence
    • 20% in individuals older than 20[1]
    • 25% in individuals older than 50[2]
    • Approaches 50% in patients greater than 70
  • Asymptomatic
    • 6-23% of individuals without shoulder pain have full thickness rotator cuff tears[3][4]
    • Up to 2/3 of tears are asymptomatic

Pathophysiology

Etiology

  • Acute trauma +/- avulsion
    • In young people following a fall
    • In middle aged patients folowing shoulder dislocation
  • Chronic, degenerative
    • Commonly seen in elderly patients
  • Subacromial Impingement
  • Hypovascularity
  • Iatrogenic
    • Due to failed surgical repair, often after open shoulder surgery

Pathoanatomy

Associated Injuries


Risk Factors

XR of shoulder with high riding humeral head and 'geyser sign', both suggestive of rotator cuff tear
  • Epidemiological
    • Greater age (OR 1.22)
    • Dominant arm (OR 1.66)
  • Extrinsic
    • Subacromial impingement
    • Internal impingement
    • Tensile overload
    • Repetitive stress
  • Intrinsic
    • Poor vascularity
    • Alterations in material properties
    • Alterations in matrix composition
  • History of trauma (OR 2.46)
  • Cigarette Smoking[5]
  • Hyperlipidemia (need citation)
  • Family History

Differential Diagnosis


Clinical Features

  • History
    • Patients most commonly report pain (87.9 %), weakness (10.8%)[6]
    • Most often insidious onset but may report acute trauma
    • Pain located around lateral shoulder, worse at night
  • Physical: Physical Exam Shoulder
    • Look for muscle atrophy of the rotator cuff muscles
    • Evaluate position of scapula, look for winging, protraction
    • Palpation of the cuff insertion should elicit pain
  • Special Tests
    • Rent Test: Can demonstrate defect with passive extension
    • Hawkins Test: Shoulder and elbow flexed to 90°, internally rotated
    • Neers Test: Shoulder flexed to 90°, thumb pointed towards floor and flexed against resistance
  • Supraspinatus
    • Drop Arm Test: Arm is passively abducted and slowly allowed to return to a neutral position
    • Painful Arc Test: Painful active abduction and adduction
    • Jobes Test: Similar to empty can test
    • Empty Can Test: Shoulder flexed to 90°, thumb pointed towards floor and flexed against resistance
    • Full Can Test: Similar to empty can but with external rotation
  • Infraspinatus/ Teres Minor
  • Subscapularis

Evaluation

Full thickness supraspinatus tear on MRI. Note approximately 2 cm of tendon retraction.

Radiographs

  • Start with Standard Radiographs Shoulder[7]
  • In acute tear, typically normal
  • In chronic tear may see the following
    • Decreased acromiohumeral interval
    • Decreased supraspinatus opacity, bulk
    • Humeral head subluxation
    • Features of acromial impingement, hooked acromion
    • Degenerative changes
    • Calcific tendonitis
  • Arthrogram can be considered if MRI contraindicated
Ultrasound demonstrating full thickness tear and retraction of the supraspinatus tendon

Ultrasound

  • Up to 90% sensitive and specific for rotator cuff tear (need citation)
  • Useful to evaluate other causes of pain (calcific tendinitis, bursitis, capsulitis, etc)
  • Allows for dynamic testing
  • Direct
    • Inability to visualize supraspinatus tendon (due to retraction)
    • Hypoechoic tendon features
  • Indirect
    • Double cortex sign
    • Sagging peribursal fat sign
    • compressibility
    • Muscle atrophy
  • Secondary signs
    • Cortical irregularity of greater tuberosity
    • Glenohumeral joint effusion
    • Biceps tendinitis with peritendinous fluid
    • Fluid in posterior recess

MRI

MRI of large supraspinatus tear with tendon retraction
  • Gold standard for evaluating rotator cuff
  • Complete tear
    • Presence of tendon defect with fluid is most obvious finding
    • Tendon retraction
    • Subdeltoid bursal effusion
    • Medislocation of biceps
    • Fluid along biceps tendon
  • Partial tear
    • Can extend to bursal, articular surface, intrasubstance

Classification

  • Full thickness[8]
  • Complete cuff tear: full thickness as well as full-width tear
  • Vertical tear: from joint to bursa (not involving the whole breadth of tendon)
  • Partial thickness tear
    • Bursal surface
    • Articular surface
    • Rim rent tear (articular surface tear of the footprint)
    • Critical zone tear: partial or full thickness
    • Intratendinous or central

Cuff Tear Size

  • Small: 0-1 cm
  • Medium: 1-3 cm
  • Large: 3-5 cm
  • Massive: >5 cm

Ellman Classification of Partial-Thickness Rotator Cuff Tears

  • Grade
    • I: <3mm (<25% thickness)
    • II: 3-6mm (25-50%)
    • III: > 6 mm (>50%)
  • Location
    • A: Articular sided
    • B: Bursal Sided
    • C: Intratendinous

Cuff Atrophy

  • 0: Normal
  • 1: Some fatty streaks
  • 2: More muscle than fat
  • 3: Equal amounts fat and muscle
  • 4: More fat than muscle

Management

Nonoperative

Operative

  • Indications
    • Acute tear
    • Chronic tear refractory to conservative management
  • Technique
    • Primary repair in young, healthy acute injuries
    • Reverse total shoulder arthroplasty in chronic cases[9]
    • Subacromial decompression, rotator cuff debridement
    • Tendon transfer

Rehab and Return to Play

Rehabilitation

  • Consider MOON protocol for rotator cuff tear

Return to Play

  • Needs to be updated

Complications and Prognosis

Prognosis

  • Success with nonoperative management ranges from 33% - 82%[10][11]
  • Considerations
    • Age of patient
    • Activity level
    • Acute or chronic
    • Characteristics of the tear

Complications


See Also


References


  1. Yamamoto A, Takagishi K, Osawa T, Yanagawa T, Nakajima D, Shitara H, Kobayashi T. Prevalence and risk factors of a rotator cuff tear in the general population. J Should Elbow Surg. 2010;19:116–20.
  2. Minagawa H, Itoi E, Abe H, Fukuta M, Yamamoto N, Seki N, Kikuchi K. Epidemiology of rotator cuff tears. J Jpn Orthop Assoc. 2006;80:S217 (in Japanese).
  3. Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg 1999;8:296-9.
  4. Schibany N, Zehetgruber H, Kainberger F, Wurnig C, Ba-Ssalamah A, Herneth AM, et al. Rotator cuff tears in asymptomatic individuals: a clinical and ultrasonographic screening study. Eur J Radiol 2004;51: 263-8.
  5. Baumgarten, Keith M., et al. "Cigarette smoking increases the risk for rotator cuff tears." Clinical Orthopaedics and Related Research® 468.6 (2010): 1534-1541.
  6. Itoi, Eiji. "Rotator cuff tear: physical examination and conservative treatment." Journal of Orthopaedic Science 18.2 (2013): 197-204.
  7. https://radiopaedia.org/articles/rotator-cuff-tear?lang=us
  8. https://www.orthobullets.com/shoulder-and-elbow/3043/rotator-cuff-tears
  9. Mulieri, Philip, et al. "Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis." JBJS 92.15 (2010): 2544-2556.
  10. Wolfgang GL. Surgical repair of tears of the rotator cuff of the shoulder. Factors influencing the result. J Bone Joint Surg Am. 1974;56:14–26.
  11. Itoi E, Tabata S. Conservative treatment of rotator cuff tears. Clin Orthop. 1992;275:165–73.
Created by:
John Kiel on 17 June 2019 19:17:51
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Last edited:
13 August 2022 00:26:41
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