Supraspinatus Tear

Supraspinatus tear

1. Search Strategy

Key words :
- supraspinatus
- rupture
- Tear
- rotator cuff
Search engines:
- PubMed
- Google Scholar

2. Definition/Description

A Supraspinatus tear. No tear is like another can be either partial or complete. Tendon or muscle?
A partial tear means that the soft tissue (the muscle fibers) will not be completely disrupted. Some fibers muscle are torn, while a complete tear splits the soft tissue into two pieces. The causes can be either traumatic or non-traumatic.

3. Clinical Relevant Anatomy

Structures:
Scapula
Clavicula
Humerus
Thorax
Joints:
Glenohumeral
Acromioclavicular
Sternoclavicular
Scapuathoracal
Rotator cuff:
m. supraspinatus
m. infraspinatus
m. teres minor
m. subscapularis

4. Epidemiology/Etiology

Rotator cuff tear is a common disease affecting the shoulder . According to general population surveys, the prevalence of rotator cuff tear is 25 % in those older than 50 years of age and 20 % in those older than 20 years of age. The interesting thing is that only 1/3th of the tears cause pain and 2/3ds are without pain.

5. Characteristics/Clinical Presentation

The most common symptoms of a rotator cuff tear include:
• Pain at rest and at night, particularly if lying on the affected shoulder
• Pain when lifting and lowering the arm or with specific movements
• Weakness when lifting or rotating the arm
• Crepitus or crackling sensation when moving the shoulder in certain positions
A rotator cuff injury can make it painful to lift the arm out to the side.
Tears that happen suddenly, such as from a fall, usually cause intense pain. There may be a snapping sensation and immediate weakness in the upper arm.
Tears that develop slowly due to overuse also cause pain and arm weakness. The patient may have pain in the shoulder when the patient lifts the arm to the side, or pain that moves down the arm. At first, the pain may be mild and only present when lifting the arm over the head, such as with reaching into a cupboard. Over-the-counter medication, such as aspirin or ibuprofen, may relieve the pain at first.
Over time, the pain may become more noticeable at rest, and no longer goes away with medications. The patient may have pain when the patient lies on his painful side at night. The pain and weakness in the shoulder may make routine activities such as combing hair or reaching behind the back more difficult.

6. Differential Diagnosis

- Acromioclavicular injury
- Cervical nerve root injury
- Cervical Radiculopathy
- Cervical Spondylosis
- Subacromial Impingement
- Osteoarthritis
- Rheumatoid Arthritis
- Shoulder Instability
- Subscapular nerve entrapment
7. Diagnostic Procedures
Diagnosis should be based on:
- History
- Clinical examination
- X-rays
- MRI
X-rays may be used as an extra test exclude sclerosis and osteophyte-formation on the acromion. The size of the subacromial space can also be measured. MRI can show full or partial tears in the tendons of the rotator cuff, cracks in the capsule and inflammation to weak structures.

8. Outcome Measures

- DASH (http://www.dash.iwh.on.ca/scoring)
ICC: 0.96 [13] Cronbach alpha: 0.97 [13]
- Quick DASH (http://www.dash.iwh.on.ca/scoring)
ICC: 0.94 [13] Cronbach alpha: 0.94 [13]
- Penn Shoulder Score: to measure outcome of patients with various shoulder disorders
ICC: 0.94 [14] Cronbach alpha: 0.93 [14]
- Global Rating of Change Scale: to measure improvement
ICC: 0.74 [15]

9. Examination

Physical examination starts with inspection. Atrophy of the shoulder muscles is a common finding in patients with rotator cuff tears. The position and motion of the scapula is also important. The scapula rotates upward and downward during arm elevation/depression. This smooth movement of the scapula on the thorax may have deteriorated because of subacromial impingement or rotator cuff defect. For the purpose of identifying which tendon is ruptured, various location-specific physical examinations have been reported. A tear of the supraspinatus tendon can be detected by the empty-can test or full-can test : apply downward force to the arm in 90° scaption and in internal rotation (thumb down). If there is a supraspinatus tear, the patient cannot resist this force because of muscle weakness. [3]

10. Medical Management

This consists of NSAID’s like ibuprofen, injections with corticosteroids and a surgical treatment. 5
The corticosteroid injections cannot heal the tear but in some cases it can make the tear
painless for a period of time in which the patient is capable of undergoing physical therapy more easily. However the tendon tissue can be weakened by these injections which would have an adverse effect on the outcome of a possible surgery, therefore one should not get more than 2 injections. [9] When an injection is chosen it will be placed in the sub-acromial space as seen below.

These treatments are conservative medical treatments, if these and physical therapy (see below) don’t work the patient will have to undergo surgery
The operative treatment is done mostly arthroscopically which is less invasive (than open/mini-open surgery) and leaves only a few small scars. Being less invasive the patients need to use less painkillers and will be able to start rehabilitation sooner. With time and development of better techniques the arthroscopic approach of rotator cuff tendon repair now even has a higher(20%) long term success rate. This was measured with the American Shoulder and Elbow Surgeons scores an reoccurrence of the supraspinatus tears. [4]
Depending on the severity of the tear (partial/complete) a different approach will be used.
If there is just a partial repair necessary the tendon and surrounding bone will be smoothed to avoid further damage and therefor allowing the tendon to heal mostly on its own.[5] In case of a complete tear in the middle of the tendon the surgeon will have to suture the two parts of the tendon back together. When the tear has occurred close or on its point of attachment on the head of the humerus another approach will be taken. This will be the case most of the times. The surgeon will attach the tendon back to its original place by way of an anchor(sometimes two). This anchor actually consists of a small screw that is bored into the head of the humerus with on the back surgical wires with witch to hold the tendon in place. [6]
4

11. Physical Therapy Management

In case of a complete tear of the supraspinatus muscle, significant pain and dysfuction after six months of treatment or repeated dislocations surgery will be preferred as treatment. However if it is only a partial tear in most cases a conservative treatment will reduce pain(2-6weeks) and over time even allow the patient to regain function (up to three months). [11] The reduced pain is not just the direct effect of the pain reducing abilities of NSAID’s. The long term effects will mostly be attributable to a well preformed physical therapy. This will consist of different parts: reduce pain, manipulate blood flow (control inflammation and speed up healing), increase range of motion, increase control of muscles and their strength. Massage can be used to reduce pain, cryotherapy is useful to reduce pain, but only in the first 48 hours after injury. Corticosteroid injection may be useful to reduce pain as well, but only works on short term. . To increase range of motion one can use stretching exercises of the ruptured muscle (not to soon in recovery since premature stretching might aggravate the injury)(see below), passive- and active range of motion exercises such as pendulum exercises and symptom limited active-assisted range of motion exercises(see below). To increase control and strength the patient will also be prescribed strengthening exercises for the rotator cuff specifically the functions of the supraspinatus muscle (abduction and exorotation) explain SS and external rotation [3] [12] (see below for a few examples).
[17]

[11]

Home exercises consisting of stretching and strengthening exercises prove to be effective, no matter what type of injury (partial defects, full thickness tears of the supraspinatus tendon or massive rotator cuff defects). Patients with rotator cuff defects do benefit from simple home exercises independent from the size of the defect. There is an improvement in range of motion and a downward trend for impingement. [7]

12. References

1. Heers G. et al. Efficacy of home exercises for symptomatic rotator cuff tears in correlation to the size of the defect. (2005) Klinik für Orthopädie der Universität Regensburg, Bad Abbach.
Level : 3B
2. Jobe F.W., Moynes D.R. Delineation of diagnostic criteria and a rehabilitation program for rotator cuff injuries. (1982) Am J Sports Med, 10, 336–339.
Level : 5
3. Orthop J. Rotator cuff tear: physical examination and conservative treatment
(2013) Department of Orthopaedic Surgery, Tohoku University, 18, 197–204.
Level : 5
4. Millar N.L. et al. Open versus two forms of arthroscopic rotator cuff repair. (2009) Clinical Orthopaedics and Related Research, 467, 966-78

5. American Academy of Orthopedic Surgeons. Rotator Cuff Tears: Surgical Treatment Options (2011)
Level: 5

6. Akpinar S. et al. Prospective evaluation of the functional and anatomical results of arthroscopic repair in small and medium-sized full-thickness tears of the supraspinatus tendon.(2011) Acta Orthop Traumatol Turc 45, 248-253
Level : 2B

7. Manhattan Orthopedic & Sports Medicine. Rotator Cuff Tendon Tears / Shoulder Arthroscopy. (2012) from: http://manhattanorthopedic.com/2010/09/rotator-cuff-tendon-tears-shoulder-arthroscopy/
Level: 5

8. Codsi M.J. The painful shoulder: When to inject and when to refer. (2007)Department of Orthopaedics, Cleveland Clinic, 74, 473-480
Level : 5
9. Bjorkenheim J.M. et al. Surgical repair of the rotator cuff and surrounding tissues. Factors influencing the results. (1988) Clinical Orthopaedic Relations, 236

10. Sarwark J.F. Essentials of Musculoskeletal Care. (2010) American Academy of Orthopaedic Surgeons, Rosemont
Level : 5
11. Dr. Romanski C., Schuldt J. Conservative Treatment of Rotator Cuff Injuries to Avoid Surgical Repair. (2009)
Level: 5

12. Tanaka M. et al. Factors related to successful outcome of conservative treatment for rotator cuff tears. (2010) Journal of Medical Sciences, Upsala, 115, 193–200
Level : 3B
13.
14.
15. Leggin B.J. et al. The Penn Shoulder Score: Reliability and Validity. (2006) from: http://www.jospt.org/issues/articleID.1021,type.14/article_detail.asp
Level : 3B
16. Kamper S.J. et al. Global Rating of Change Scales: A Review of Strengths and Weaknesses and Considerations for Design. (2009) from: level : 4
17. Kristian Berg. Prescriptive stretching; Human Kinetics; 2011