Rotator Cuff Tears

Original Editor - Lina Taing and Jenna Fried as part of the Temple University Evidence-Based Practice Project

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Clinically Relevant Anatomy

http://i2.photobucket.com/albums/y12/shnazzyjazzy04/rotator_cuff_muscles.jpg
(Source : Rotator Cuff Muscles)

Key Points

• The shoulder consists of three bones: the humerus, scapula and clavicle.
• These bones create three joints: the glenohumeral, acromioclavicular, and sternoclavicular joints. 
• There are four muscles that make up the rotator cuff: supraspinatus, infraspinatus, teres minor, and subscapularis.
• These muscles contribute to shoulder elevation between 60 and 130 degrees. First there is the deltoid that contributes for 43%, next the subscapularis for 25%, then the infraspinatus and teres minor for 22% and finally the supraspinatus for 9%.
• The rotator cuff muscles are used in a variety of upper extremity movements.
• The supraspinatus muscle handles the humeral abduction.
• The Subscapularis muscle makes sure that internal humeral rotation is possible.
• A muscle combination of the infraspinatus and the teres minor operates the external humeral rotation.
• Another muscle combination of the infraspinatus, the teres minor and the subscapularis makes sure that the humeral head stays depressed to balance upward pull of the deltoid early in glenohumeral abduction.
• The concept of the ‘rotator cuff’ is not always correct. The name ‘muscle-tendon cuff’ would be more appropriate.
  

Mechanism of Injury / Pathological Process

Rotator cuff tears can be caused by degenerative changes, repetitive microtraumas, severe traumatic injuries, atraumatic injuries and secondary dysfunctions.
Traumatic injury to the rotator cuff can be caused by falling on an outstretched hand, unexpected force when pushing or pulling or during shoulder dislocation.

Normal muscle deterioration with age and excessive repetitive motion are examples of atraumatic causes. Rotation cuff dysfunctions include mostly shoulder impingement and tears of the referenced muscles. Impingement syndrome is a slowly developing process that eventually leads to shoulder pain. This pain, if it is left untreated, is able to lead to definite changes to the shoulder or even tearing of the rotator cuff muscles. Apart from shoulder impingement, also inflammation of the joint capsule (frozen shoulder) can lead to a higher risk of experiencing a rotator cuff tear. Certain risk factors for developing such a tear are e.g. old age and regular abduction of the arm.

Clinical Presentation

Individuals with a rotator cuff tear may suffer from severe pain at time of injury, pain at night, pain with overhead activities, positive painful arc sign, weakness of involved muscle and shoulder stiffness.Individuals with a tear of the supraspinatus may complain of tenderness over the greater tuberosity, pain located in the anterior shoulder and symptoms radiating down the arm.
The tear size has the greatest effect on stability in the inferior direction for people who had a circular tear centered at the critical area and on the anterior direction for people who had a circular tear centered at the rotator interval. The critical area is anterior to the acromion. The tear location has the most significant effect on stability in the inferior and anterior directions for the smaller tear and on the anterior direction for a larger tear.

On clinical examination stiffness may predominate with radiographic evidence of superior humeral head migration and arthritic changes.

For the patients that present primarily with pain, they may have full range of motion and be able to lift their arm overhead even though they have weakness with resisted external rotation as seen with a positive belly-off test.

Diagnostic Procedures

Many factors are considered in diagnosing rotator cuff tears. Subjective history, mechanism of injury, physical examination findings, and diagnostic imaging are all used to make the diagnosis. Additionally, the therapist should identify what activities are limited by the injury, activities that exacerbate or relieve the pain, and information regarding the onset of pain.

A shoulder examination starts by inspecting the scapula in a resting position from behind. Dynamic scapular dyskinesis is detected by asking the patient to raise and/or abduct both arms repeatedly in a rhythmic motion, until fatigue of the scapular stabilisers results in failure to keep the scapula well positioned in relation to the thoracic wall.
Active scapular retraction and elevation are checked.
The next step is to look for muscle atrophy. Active and passive range of motion should be examined and compared with the non‐injured shoulder.

The next step is to perform tests for impingement like: Neer test, empty can test, Hawkins test, external rotation resistance test and instability : sulcus sign, apprehension test, relocation test, hyper abduction test, posterior apprehension test. It is wise to perform several tests, because none of them are sufficiently sensitive and specific on their own.

The physical examination of a patient with a suspected rotator cuff injury may include the following:

· Screening of the cervical spine

· Active and passive range of motion

· Observation and palpation of key structures/regions

· Resistive testing

· Functional testing

· Clustered findings of special tests

There are several special tests for the shoulder that are purported to detect lesions of the rotator cuff; however, many commonly used tests have poor psychometric properties. To enhance the ability to detect full-thickness rotator cuff tears, two test-item clusters have been developed. These test-item clusters improve the post-test probability for the clinical diagnosis of full-thickness rotator cuff tears.

Cluster by Murell and Walton 2001

Signs: supraspinatus weakness, weakness in external rotation, signs of impingement

3 signs at any age      = 98% probability

2 signs and age < 60  = 98% probability

2 signs and age < 60  = 64% probability

1 sign and age > 70    = 76% probability

Cluster by Park et al 2005

Signs: Drop arm test, painful arc, infraspinatus muscle test

3 + signs = 91% probability

2 + signs = 69% probability

1 + sign = 33% probability

Test	Sensitivity	Specificity
Neer Impingement	.68-.89	.31-.69
Drop arm test	.27	.86
Painful arc sign	.33-.74	.79-.81
Supraspinatus muscle strength test	N/A	N/A
Infraspinatus muscle strength test	.42	.90

An IMPT (isokinetic muscle performance test) of the shoulder :

provides objective, reliable and valuable perioperative data, which can be used to estimate the functional status of the rotator cuff muscles and can provide quantitative data for anatomic assessment of the rotator cuff. These findings can also offer objective guidelines for interpreting muscle strength in patients with a rotator cuff disorder.

You need a Biodex System 3 PRO® (Biodex Corp, Shirley, NY) to perform the test. The IMPT reportedly has high accuracy and test-retest reliability in evaluating the shoulder musculature comple and provides information regarding patients’ actual muscle function and strength.

Outcome Measures

• Disabilities of the Arm, Shoulder and Hand (DASH)
The DASH is a questionnaire, scored in 2 subscales. First there is the disability or symptom section, which consists of 30 items, each scored from 1 to 5. And second there is the optional high performance sports/music or work section, which consists of 4 items, each also scored from 1 to 5.

• Quick DASH
The QuickDASH is the shorter version of the DASH outcome measure. The QuickDASH is also scored in 2 components. The first one is the disability or symptom section, which has only 11 items, scored from 1 to 5. And the second component is the optional high performance sports/music or work module, which has 4 items, also scored from 1 to 5.

• Penn Shoulder Score (PSS)
The PSS is a 100-point questionnaire consisting of 3 subscales, pain, function and satisfaction. It is a valid and reliable measure to report the outcome of patients with all kinds of shoulder disorders.

• Global Rating of Change Scale (GRCS)
The GRCS is a measure that rates the changes in symptoms, in this case in the shoulder. It compares the symptoms with those from 12 months earlier. There are 15 possible scores, ranging from -7 (the worst) to +7 (the best).

• Constant-Murley Score (CMS)
This measure rates objective and subjective elements of pain and function in the shoulder. The final score ranges from 0 to 100, with 0 as the worst result possible and 100 as the best result possible.

• Rotator Cuff Quality of Life Score (RC-QOL)
The RC-QOL is a disease-specific outcome measure that evaluates the impact of rotator cuff diseases on the general quality of life. It is a questionnaire with 34 items, divided into 5 domains. These 5 domains are: symptoms and physical complaints, work-related concerns, sports and recreation, lifestyle issues and finally social and emotional issues.

• Functional Shoulder Elevation Test (FSET)

• Shoulder Pain and Disability Index (SPADI)
The SPADI is created to measure pain and disabilities associated with shoulder pathology in patients with shoulder pain of musculoskeletal, neurogenic or undetermined origin. There are 2 domains, pain and disability, with 13 items in total. Every item is scored on a visual analog scale, ranging from 0 (no pain/no difficulty) to 10 (worst pain imaginable/so difficult that help is required).

• American Shoulder and Elbow Surgeons score (ASES)
The ASES is used to measure shoulder pain and functional limitations in patients with musculoskeletal complaints. The pain is measured with a visual analog scale. The domain ‘Function’ is divided into 10 questions, using a 4-point ordinal scale. The total score ranges from 0 to 100 points, where 0 is the worst and 100 is the best.

• UCLA Shoulder Score
The self-report part of the measure consists of 2 single-item subscales (pain and function). These are Likert-type scales and are scored from 1 to 10: a higher score indicates a lower pain and greater function.

• Simple Shoulder Test (SST)
The SST is a function scale with 12 items, checking the patients’ ability to tolerate or perform 12 activities of daily living. The scores range from 0 to 100 and are reported as the percentage of items that were answered.

Management / Interventions

Conservative management is warranted in most rotator cuff injuries. In addition to physical therapy, non-surgical treatment may include non-steroidal anti-inflammatory drugs and steroid injections, time, local rest, application of cold or heat and massage.
The judicious use of no more than three to four injections of steroids into the subacromial space or around the biceps tendon can be helpful in the early phase. ³⁸

Initial physical therapy interventions may include:
• Mobility exercises including PROM, AAROM, AROM

• Motor control training

• Scapular stabilization

• Stretching³⁷: Posterior capsular contracture is addressed by progressive stretching in adduction and internal rotation. Horizontal adduction or cross-body adduction exercises are recommended to release the posterior capsule. ³⁸

• Isometric and low-grade strengthening exercises: as pain decreases and the range of movement increases, strengthening exercises for the rotator cuff and periscapular musculature are prescribed to restore the normal mechanics of the shoulder girdle. Progressive resistive exercises are employed within the limits of the pain utilising rubber tubing or free weights.38

• Manual therapy directed at the GH, AC and SC joint
Manual therapy includes massage therapy, especially the use of deep frictions of the muscles, stretching of the radial nerve, mobilization of the scapula and the glenohumeral joint. More so, proprioceptive neuromuscular facilitation techniques have proven themselves useful. These manual therapies have some striking advantages, i.e. they are able to shorten the total treatment period and they relieve the pain significantly, which is along with the repair of the shoulder range of motion, the main goal of manual therapy.¹⁷

• Manual therapy of cervicothoracic spine and upper ribs

• Activity modification

• Late stages of rehabilitation of rotator cuff injury include progressive resistive strengthening, proprioception and sport-specific exercises.
In general there seems to be a higher success rate when using non-surgical methods of intervention. Whether or not a surgery will take place, depends on the wish and the individual characteristics of the patient.
As an example: for a younger patient it is more important to regain the strength and the functionality of his muscles, where for an older patient, surgery might hold too much risk and the main goal is to relieve the pain instead of reaching the full potential of the muscles.

Indications for a surgical repair are pain and/or weakness, even after 3 to 6 months of conservative therapy. Examples of surgical treatment include debridement, debridement with acromioplasty, or rotator cuff repair (arthroscopic).¹⁸

Differential Diagnosis

• Acromioclavicular injury
• Labral tears¹⁹
• Cervical nerve root injury
• Cervical Radiculopathy
• Cervical Spondylosis
• Subacromial Impingement
• Osteoarthritis
• Rheumatoid Arthritis
• Shoulder Instability
• Subscapular nerve entrapment¹⁹
• Fibromyalgia¹⁹
• Scapulothoracic bursitis¹⁹
• Slap Lesion
• Adhesive Capsulitis
• Biceps Tendonitis
• Rotator Cuff Tendinopathy
• Calcific Tendonitis Shoulder
• Hill Sachs Lesion
• Personage Turner Syndrome
• Thoracic Outlet Syndrome

Key Evidence

No randomized control trials have found an optimal conservative management of rotator cuff tears. Several studies have shown reduction in pain and disability by treating regions remote to the shoulder. This concept has been coined regional interdependce. Thrust and non-thrust manipulation of the cervicothoracic spine and/or ribs may lead to significant improvement in pain and disability in patients with a primary complaint of shoulder pain^7,8.

Case Studies

Conservative Management of a Large Rotator Cuff Tear to Increase Functional Abilities: A Case Report

Recent Related Research (from Pubmed)

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