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

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http://www.umm.edu/orthopaedic/rotator_cuff.htm

The shoulder is made up of three main bones^1,2: 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. The rotator cuff muscles are used in a variety of upper extremity movements including flexion, abduction, internal rotation and external rotation.

Mechanism of Injury / Pathological Process

Rotator cuff tears can be caused by degenerative changes, repetitive microtrauma or traumatic injury. Normal muscle deterioration with age and overuse repetitive motion are examples of atraumatic causes². 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.

Clinical Presentation

Individuals with a rotator cuff tear may present with severe pain at time of injury, pain at night, pain with overhead activities, positive painful arc sign, weakness of involved muscle, and shoulder stiffness⁸. 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.

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 diagnosis⁵. 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.

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^3,4.

Cluster by Murell and Walton 2001⁵

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 2005^₄

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

3 + signs = 91% probability

2 + signs = 69% probability

1 + sign = 33% probability

Test	Sensitivity4	Specificity4
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

Outcome Measures

• DASH
• Quick DASH
• Penn Shoulder Score
• Global Rating of Change Scale

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.

Initial physical therapy interventions may include:

• Mobility exercises including PROM, AAROM, AROM
• Motor control training
• Scapular stabilization
• Isometric and low-grade strengthening exercises
• Manual therapy directed at the GH, AC and SC joint 
• 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.
  

Surgical interventions may be considered when a patient has failed to significantly improve after 3-6 months of conservative therapy². Examples of surgical treatment include debridement, debridement with acromioplasty, or rotator cuff repair (arthroscopic, mini-open, open).

Differential Diagnosis

• Acromioclavicular injury
• Cervical nerve root injury
• Cervical Radiculopathy
• Cervical Spondylosis
• Subacromial Impingement
• Osteoarthritis
• Rheumatoid Arthritis
• Shoulder Instability
• Subscapular nerve entrapment

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.

Resources

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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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References

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1. Minimally Invasive Rotator Cuff Repair Surgery: An Interview with Dr. James Dreese http://www.umm.edu/orthopaedic/rotator_cuff.htm. Accessed 3/17/2011, 2011.
2. Moore KL, Dalley AF. Clinically oriented anatomy Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2010:1134.
3. Smith M, Smith W. Rotator cuff tears: an overview. Orthopaedic Nursing [serial online]. September 2010;29(5):319-324. Available from: CINAHL, Ipswich, MA. Accessed March 17, 2011.
4. Park HB, Yokota A, Gill HS, El Rassi G, McFarland EG. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome J Bone Joint Surg Am. 2005;87(7):1446-1455.
5. Murrell GA, Walton JR. Diagnosis of rotator cuff tears. The Lancet. 2001;357(9258):769-770.
6. Lyons AR, Tomlinson JE. Clinical diagnosis of tears of the rotator cuff J Bone Joint Surg Br. 1992;74(3):414-415.
7. Bergman G et al. Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder Dysfunction and Pain A Randomized, Controlled Trial. 432-440. September 2004 Annals of Internal Medicine Volume 141 • Number 6
8. Strunce JB, Walker MJ, Boyles RE, Young BA. The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain J Man Manip Ther. 2009;17(4):230-236.
9. Boyd Anne S, Martinez Ronica A, "Chapter 36. Acute Musculoskeletal Complaints" (Chapter). South-Paul JE, Matheny SC, Lewis EL: CURRENT Diagnosis & Treatment in Family Medicine, 2e: http://www.accessmedicine.com/content.aspx?aID=3035910.