Shoulder
Rotator Cuff Rupture
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Rotator Cuff Rupture
, Rotator Cuff Tear
See Also
Rotator Cuff Injury
Epidemiology
Rarely occurs under age 40 years
Exception: Athletes or with significant injury such as
Shoulder Dislocation
or MVA
Pathophysiology
Typically results from continued deterioration or degeneration
Rotator Cuff Tear typically occurs with minor
Trauma in Older Patients
Partial or complete rupture
Full thickness tears account for 5-40% of Rotator Cuff Tears
Rotator Cuff Rupture associated with
Shoulder Dislocation
Occurs in 50% of dislocations over age 50 years
Mechanism
Fall on Outstretched Hand
Lifting heavy object
Shoulder Dislocation
Motor Vehicle Accident
(or other high mechanism injury)
Symptoms
Usually no obvious
Trauma
or injury
Pain progressively worse
Pain referred down deltoid
Muscle
Unable to abduct or flex
Shoulder
Pain often worse with overhead activity or with sleep
Signs
Partial rupture appears similar as chronic
Tendonitis
Shoulder Range of Motion
may be completely intact
Shoulder
Weakness
Abduction weakness more common (Supraspinatus tear)
Active abduction
Painful arc over 50 degrees
Passive abduction
Results in painful catch at 50 to 100 degrees
Forward flexion weakness indicates subscapularis tear
Tenderness over Rotator Cuff Tear site
Defect palpated through deltoid in complete cuff tear
Atrophy of cuff
Muscle
s
Drop Arm Test
positive
Test Specificity
: 98%
Test Sensitivity
: 10%
Consider
Local Lidocaine
injection diagnostically
Persistent difficult abduction suggests cuff tear
Acute hemarthrosis and prominent
Ecchymosis
down arm
Indicative of long standing cuff tear and
Arthropathy
Chronic Sub-deltoid swelling indicates large cuff tear
Synovial Fluid
escaped from glenohumeral joint
Diagnosis
See
Shoulder Impingement Signs
Imaging
Shoulder XRay
Calcifications at
Humerus
tuberosity
Degenerative
Arthritis
Acromioclavicular joints
Glenohumeral joints
Subacromial space narrowed on
Shoulder
PA View (high riding humeral head)
Intact rotator cuff depresses the humeral head
Complete Rotator Cuff Tear allows the humeral head to rise toward the acromion
Cortical irregularity at supraspinatus insertion at greater tuberosity
Present in 75% of Rotator Cuff Tears (esp. age >40 years old)
No cortical irregularity at supraspinatus suggests no tear (misses 4% of tears)
Jacobson (2004) Radiology 230:234-42 [PubMed]
Shoulder MRI
Replaces arthrography
Identifies smaller partial thickness tears as well as other pathology (e.g. labral tears)
Best for younger patients (under age 40 years old)
Shoulder Ultrasound
Safe and noninvasive
Accurate in full thickness, large and moderate tears (esp. in patients over age 40 old)
Shoulder
Arthrography (MRI is preferred)
Differentiates full from incomplete Rotator Cuff Tear
Invasive test
Perform only if considering surgery
Differential Diagnosis
Rotator Cuff Tendonitis
Rotator Cuff Calcification
Management
Referral Indications for Orthopedic Surgery (earlier is better)
Young active patient with full thickness tear (best outcome with earlier intervention)
Competitive athletes
Severe functional deficit
Management
Algorithm
Initial Evaluation: Painful cuff range of motion
Start with
RICE-M
for first 3 days
Switch to moist heat after 2-3 days
Apply for 1 hour
Apply 2-3 times per day
Relative Rest
Avoid complete rest especially in older patients
Risk of
Frozen Shoulder
Gentle
Shoulder Range of Motion Exercises
Prevents
Frozen Shoulder
NSAID
s
Avoid overhead
Shoulder
activities or overuse
Consider
Shoulder XRay
if
Fracture
suspected
Re-evaluation in 2 weeks: Lack of improvement
Early orthopedic referral if criteria above met
Change
NSAID
s
Continue
Shoulder Range of Motion Exercises
Start
Shoulder
Strengthening
Exercise
s
Re-evaluation in 2 weeks: Lack of improvement
Sub-acromial space
Corticosteroid Injection
Risk of weakening tendons
Physical Therapy with
Phonophoresis
Re-evaluation in 2 weeks: Lack of improvement
Shoulder MRI
Orthopedics
Consultation
Complications
Partial Thickness Rotator Cuff Tears
Chronic
Shoulder Impingement
Calcific
Tendonitis
Rotator Cuff Tear progression
Rotator cuff atrophy
Full thickness tear progression (esp. older patients)
Full Thickness Rotator Cuff Tears
Suprascapular
Neuropathy
References
Greene in Wirth (2001) Musculoskeletal Care, p.141-3
Krishman in DeLee (2003) Sports Medicine, p. 1065-92
Monica (2016) Am Fam Physician 94(2): 119-27 [PubMed]
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