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rotator cuff tear

Etiology: - tear of one of the rotator cuff muscles Epidemiology: - common in the elderly Clinical manifestations: 1) pain radiating from shoulder down lateral part of arm 2) pain worsened by abduction, internal rotation, external rotation or flexion of shoulder depending upon involved tendons [2] 3) overhead activities such as combing hair can be painful 4) in some cases, pain may be minor 5) muscle atrophy is common 6) pain & weakness of shoulder elevation & external rotation 7) active range of motion (shoulder) is impaired; passive range of motion is intact 8) inability to maintain the arm in an abducted position (drop sign) indicates a supraspinatus tear 9) loss of strength suggests full thickness tear [2] 10) a painful arc & weakness of the rotator cuff with the shoulder abducted to 90 degrees in the scapular plane with the thumb pointing down (positive empty can test) Radiology: - magnetic resonance imaging (MRI) of shoulder - severity of pain is unrelated to imaging characteristics of full-thickness rotator cuff tears [5] Management: - a brief period of rest & immobilization with a sling may be helpful [3] - pain control with acetaminophen or short course of NSAID - physical therapy (or home exercise) - assisted range of motion - wall walking - orthopedic surgery - younger patients with acute full-thickness tears benefit from surgery - surgery confers benefit only in patients with full-thickness tears [11] - if no improvement after 6-8 weeks of conservative manangement, refer to orthopedic surgery [3] - patients mean age, 60 years, 10 year outcomes better with surgery than with physical therapy [9] - surgery with better outcome than medical management for full-thickness tears [10], including symptomatic full-thickness rotator cuff tears not exceeding 3 cm [12] - older patients with symptomatic, atraumatic supraspinatus tears did not benefit from surgery [7] - ref [2] implies that arthroscopic surgery for rotator cuff tear in the elderly is indicated & would leave patient with significant disability if surgery not performed (seems a bit at odds with ref [7])

Related

rotator cuff tendonitis; impingement syndrome; painful arc syndrome; subacromial pain syndrome rotator cuff; musculotendinous cuff shoulder injury

General

rotator cuff disease

References

  1. Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  2. Medical Knowledge Self Assessment Program (MKSAP) 14, 17. American College of Physicians, Philadelphia 2006, 2015
  3. Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
  4. Seida JC, LeBlanc C, Schouten JR et al Systematic review: nonoperative and operative treatments for rotator cuff tears. Ann Intern Med. 2010 Aug 17;153(4):246-55 PMID: 20621893
  5. Brett AS Tenuous Relation Between Rotator Cuff Tears and Pain NEJM Journal Watch. May 27, 2014 Massachusetts Medical Society (subscription needed) http://www.jwatch.org - Dunn WR et al. Symptoms of pain do not correlate with rotator cuff tear severity: A cross-sectional study of 393 patients with a symptomatic atraumatic full-thickness rotator cuff tear. J Bone Joint Surg Am 2014 May 21; 96:793 PMID: 24875019
  6. Hermans J, Luime JJ, Meuffels DE, et al. Does this patient with shoulder pain have rotator cuff disease? The Rational Clinical Examination systematic review. JAMA. 2013;310:837-847 PMID: 23982370
  7. Kukkonen J et al. Treatment of nontraumatic rotator cuff tears: A randomized controlled trial with two years of clinical and imaging follow-up. J Bone Joint Surg Am 2015 Nov 4; 97:1729. PMID: 26537160
  8. Nam D, Maak TG, Raphael BS et al Rotator cuff tear arthropathy: evaluation, diagnosis, and treatment: AAOS exhibit selection. J Bone Joint Surg Am. 2012 Mar 21;94(6):e34. PMID: 22438007
  9. Moosmayer S, Lund G, Seljom US et al. At a 10-year follow-up, tendon repair is superior to physiotherapy in the treatment of small and medium-sized rotator cuff tears. J Bone Joint Surg Am 2019 Jun 19; 101:1050 PMID: 31220021 https://insights.ovid.com/crossref?an=00004623-201906190-00002
  10. Ramme AJ, Robbins CB, Patel KA et al. Surgical versus nonsurgical management of rotator cuff tears: A matched-pair analysis. J Bone Joint Surg Am 2019 Oct 2; 101:1775. PMID: 31577683 https://insights.ovid.com/crossref?an=00004623-201910020-00008
  11. Cederqvist S et al. Non-surgical and surgical treatments for rotator cuff disease: A pragmatic randomised clinical trial with 2-year follow-up after initial rehabilitation. Ann Rheum Dis. 2020 Dec 3;80(6):796-802 PMID: 33272959 Free PMC article. https://ard.bmj.com/content/80/6/796
  12. Moosmayer S, Lund G, Seljom US et al. Fifteen-year results of a comparative analysis of tendon repair versus physiotherapy for small-to-medium-sized rotator cuff tears. J Bone Joint Surg Am 2024 Oct 2; 106:1785 PMID: 39197154 https://journals.lww.com/jbjsjournal/fulltext/2024/10020/fifteen_year_results_of_a_comparative_analysis_of.6.aspx
  13. OrthoInfo: Rotator Cuff Tears http://orthoinfo.aaos.org/topic.cfm?topic=a00064