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Rotator Cuff Tear
From WikiSM
Contents
Other Names
- Acute Rotator Cuff Tear
- Chronic Rotator Cuff Tear
- Partial Rotator Cuff Tear
- Complete Rotator Cuff Tear
- Rotator cuff arthropathy
Background
- This page refers to all tears of the rotator cuff muscles, including both acute and chronic presentations
- Can be considered part of a continuum of disease from Rotator Cuff Tendinitis including Subacromial Impingement, Calcific Tendinitis and acute and chronic rotator cuff tears and rotator cuff arthropathy
History
Epidemiology
- Prevalence
- 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
- Rotator Cuff Muscles
- Function
- Dynamic stability of glenohumeral joint in coronal, transverse plane
Associated Injuries
- Glenohumeral Arthritis
- Proximal Biceps Tendon Injuries
- Acromioclavicular Joint Pain
- Internal Impingement
Risk Factors
- 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
- Fractures
- Proximal Humerus Fracture
- Humeral Shaft Fracture
- Clavicle Fracture
- Scapula Fracture
- First Rib Fracture (traumatic or atraumatic)
- Dislocations & Separations
- Arthropathies
- Muscle & Tendon Injuries
- Rotator Cuff
- Bursopathies
- Ligament Injuries
- Neuropathies
- Other
- Pediatrics
- Coracoid Avulsion Fracture
- Humeral Head Epiphysiolysis (Little League Shoulder)
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
- External Rotation Lag Sign: Hold arm in internal rotation, observe for lag
- Hornblowers Sign: Inability to maintain arm in 90° elbow flexion and 90° shoulder abduction
- Resisted External Rotation Test: Elbow flexed to 90°, resist external rotation
- Subscapularis
- Lift Off Test: Arm placed behind back, lift off against resistance
- Belly Press Test: Internally rotate arm, press against abdomen
- Internal Rotation Lag Sign: Hold arm in external rotation, observe for lag
- Bear Hug Test: affected arm on contralateral shoulder, resist examiner
- Resisted Internal Rotation Test: resist internal rotation with elbow at 90°
Evaluation
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
- 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
- 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
- Indications
- Chronic tear
- Partial tear
- Patient is a poor surgical candidate
- Modalities
- Relative rest
- Activity modification
- Physical Therapy
- Corticosteroid Injection
- Medications including NSAIDS, Acetaminophen
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
- Nonsurgical
- Chronic pain
- Need for surgery
- Weakness
- Surgical
- Recurrence of pain
- Failure of repair
- Deltoid detachment
- Acromioclavicular Joint Pain
- Axillary Nerve Injury
- Suprascapular Nerve Injury
- Infection
- Loss of range of motion
- Pneumothorax
See Also
- Internal
- External
- Sports Medicine Review Shoulder Pain: https://www.sportsmedreview.com/by-joint/shoulder/
References
- ↑ 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.
- ↑ 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).
- ↑ Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg 1999;8:296-9.
- ↑ 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.
- ↑ Baumgarten, Keith M., et al. "Cigarette smoking increases the risk for rotator cuff tears." Clinical Orthopaedics and Related Research® 468.6 (2010): 1534-1541.
- ↑ Itoi, Eiji. "Rotator cuff tear: physical examination and conservative treatment." Journal of Orthopaedic Science 18.2 (2013): 197-204.
- ↑ https://radiopaedia.org/articles/rotator-cuff-tear?lang=us
- ↑ https://www.orthobullets.com/shoulder-and-elbow/3043/rotator-cuff-tears
- ↑ Mulieri, Philip, et al. "Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis." JBJS 92.15 (2010): 2544-2556.
- ↑ 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.
- ↑ 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:
1 October 2022 19:09:25
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