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Rotator cuff tear occurs when the tendons that form the rotator cuff weaken and tear. The rotator cuff is a group of four muscles that surround the ball-like humeral head of the upper arm. The tendons of these muscles come under stress from repeated activities that require lifting and rotating the arm. Any abnormalities of the shoulder joint can aggravate the stress, especially joint looseness (laxity), rubbing of the front edge of the shoulder blade (acromion) on the rotator cuff (impingement syndrome), bone spurs, and bursitis. As the tendons become irritated, inflammation develops (tendinitis). Circulation to the rotator cuff decreases with age and the tendons themselves degenerate over time. Eventually, this can lead to weakening and even tears in the rotator cuff.
Tears are described as either partial thickness tears or complete rupture, depending on the amount of tissue damage. Partial tears do not go all the way through the cuff, although a large surface area may be involved. Complete tears create a gap in the cuff with concomitant loss of function. Tears are classified as acute or chronic depending on onset. Acute tears are the result of forceful injury to the shoulder and straining of the tendon beyond its mechanical limits. Chronic tears occur from repetitive wear and tear to the rotator cuff. Conditions that may predispose to rotator cuff tear include impingement syndrome, bone spurs, instability of the shoulder (glenohumeral) joint, or inborn (congenital) abnormalities of the shoulder.
Risk: Although rotator cuff tears can affect young adults, typically as the result of trauma, they are most often found in individuals over 40 years of age (Roy). Individuals at a higher risk of sustaining a rotator cuff tear include those who perform overhead work (e.g., warehouse workers, laborers, carpenters, painters, construction workers) and certain athletes (e.g., swimmers, tennis players, baseball players). Men are twice as likely as women to sustain rotator cuff tears (Tuite). This can be attributed to a greater proportion of men working in heavy labor. Incidence of degenerative tears increases with age in both genders (Malanga). Rotator cuff tears occur independently of race, ethnicity, or geographic location. Incidence and Prevalence: Rotator cuff tears may affect from 5% to 40% of the population (Malanga). Cadaver studies showed that 39% of individuals over the age of 60 have full-thickness tears (Malanga). Since rotator cuff tears may produce no symptoms, it is difficult to estimate incidence and frequency. |
Source: Medical Disability Advisor
| History: Most individuals with acute tears will describe an athletic injury, fall, or an attempt to break a fall by grabbing a rail. Those with a chronic tear will describe increasing pain and difficulty using the shoulder. Activity, especially overhead reaching, often increases shoulder pain. Individuals may report pain at night with inability to sleep on the affected shoulder. There may be shoulder weakness and the inability or limited ability to raise (abduct) their arm. Physical exam: Examination of the shoulder begins with a thorough inspection for any deformities, scars, edema, or decrease in muscle bulk (atrophy). Next, the entire shoulder joint and all of its muscle groups are palpated for tenderness. Both active and passive range of motion are determined by rotating the individual’s arm through different planes, noting any decrease in range of motion and any pain. A tear is indicated when an individual cannot, raise his or her arm away from their side toward the ear (abduction) or when the arm is raised by someone else, cannot hold the position. Pain may be more intense with certain movements or when pressure is applied. There may be a grating, clicking or cracking sound (crepitus) in the shoulder. Muscle strength testing and neurological testing should be performed. Special maneuvers during the physical examination (such as the Neer impingement, Hawkins-Kennedy impingement, drop-arm, apprehension, and relocation tests) may be helpful. A thorough exam includes evaluation of the cervical spine to detect any underlying pathologic changes. Tests: Plain x-rays are not diagnostic for rotator cuff tears but will show abnormalities in the bones, and shoulder structures, as well as inflammation and calcification of the shoulder bursa (calcific tendinitis). MRI is used most often to detect a tear. Arthrography, or CT scan, often with contrast media (CT-arthrography), may be helpful in certain circumstances. Widespread use of arthrography has decreased but remains useful in individuals for whom MRI is contraindicated (e.g., those with a pacemaker, cerebral aneurysm clip, or recent cardiac stent). Arthrography involves injection of contrast media into the glenohumeral joint followed by plain x-rays. Observed leakage of contrast material into the subacromial or subdeltoid spaces following injection indicates a full-thickness rotator cuff tear. Ultrasonography is used in some facilities, although differentiating a partial and full thickness tear may depend on the skill of the sonographer and may not be as accurate as other tests. A minimally invasive surgical procedure in which a special lighted microscope and tools are inserted through several incisions in the skin to look inside the shoulder joint (iagnostic arthroscopy) is occasionally done to evaluate the rotator cuff and shoulder mechanics, especially on acute tears in athletes. |
Source: Medical Disability Advisor
| The goals of treatment are pain relief and improved shoulder function. Partial tears that do not cause significant or progressive shoulder weakness can be treated conservatively with rest, ice, and the use of nonsteroidal anti-inflammatory drugs (NSAIDs). In some circumstances, corticosteroid is injected into the space above the rotator cuff tendon (subacromial corticosteroid injection). Physical therapy helps increase rotator cuff muscle strength, stabilize the shoulder blade (scapula), and increase range of motion. Use of heat on an inflamed or torn tendon may increase pain and worsen the situation. Although nonoperative treatment will not repair the tear, it often achieves the goals of pain relief and partial restoration of function. Disadvantages are that the individual may need to decrease his or her activity level, there may be no improvement in strength, and the tear may increase in size over time.
Complete tears and tears that cause marked weakness or interfere with daily activities in younger adults are repaired surgically, either arthroscopically or with open surgery (open rotator cuff repair). Rotator cuff surgery may be performed under regional or general anesthesia. Partial tears are sometimes cleaned (débrided) arthroscopically to remove the inflamed tissue and ragged edges of the tear. Treatment in older individuals is based on overall health, weakness of the rotator cuff muscles, pain, and impact on activities of daily living including work. Otherwise, a complete tear in an elderly individual is treated conservatively or with simpler procedures such as arthroscopic débridement and subacromial decompression. Large tears (greater than 3 cm) may be inoperable and are usually treated nonoperatively. Rotator cuff surgery may be performed as an inpatient or outpatient, depending on the specific procedure used. |
Source: Medical Disability Advisor
| Conservative treatment of small rotator cuff tears (less than 3 cm) of short duration (less than 6 to 12 months) results in a good return to normal functioning for 40% to 90% of individuals (Felsenstein). However, the rehabilitation process may take 6 months or longer and requires an ongoing commitment to a home exercise program to prevent recurrence. Younger individuals are more likely to regain complete function than older individuals. However, athletes are not always able to return to previous levels of competition, especially after a full-thickness rotator cuff tear. |
Source: Medical Disability Advisor
| Note on research and authorship Acute Phase: The early goals of rehabilitation in the acute phase of a rotator cuff tear are to decrease pain and inflammation, to reduce the stress on the torn tendon(s), and to prevent the development of joint stiffness, which can severely complicate recovery (Kelley).
In conjunction with pharmacological management, the individual will be instructed in the use of cold treatments to the shoulder to decrease inflammation. Reduction of stress to the healing tendon(s) is often achieved through education, ergonomic adjustments, and/or work modifications aimed at reducing painful activities (Breazeale; Mantone). Such activities often include positions in which the elbow is raised above the level of the shoulder, and should be avoided. Stiffness may be prevented by passive range of motion exercises conducted during supervised rehabilitation and a home exercise program (Mantone).
Healing Phase: As the pain and inflammation ease, treatment aims at improving strength and flexibility to the shoulder without irritating the healing tendon(s) (Breazeale). The strengthening exercises begin with scapular muscles. These are important muscles for normal shoulder function, and the exercises can usually be performed without excessively stressing the healing tendon(s). Gentle stretching exercises may be initiated, avoiding stress on the healing tendon(s). As the tendon heals, strengthening exercises are added, as indicated (Mantone).
Chronic Phase: The goal of rehabilitation in this phase is to restore pain-free function (Mantone). Strengthening exercises emphasize all muscles of the shoulder area. Flexibility exercises and manual therapy are incorporated within the available range of motion. Individuals who are not able to regain function or control pain may be evaluated for surgery.
If managed operatively, see Rotator Cuff Repair. |
| FREQUENCY OF REHABILITATION VISITS | | Nonsurgical (Acute Phase) | |
| Physical or Occupational Therapist | | Up to 16 visits within 8 weeks | | | | | | | | Surgical (Acute Phase) | |
| Physical or Occupational Therapist | | Up to 24 visits within 12 weeks | |
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| The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice. |
Source: Medical Disability Advisor
| Re-tear of the same tendon, infection, nerve injury, deltoid detachment, stiffness, and poor shoulder range of motion can all occur after surgery. Other potential complications include post-traumatic arthritis of the shoulder, impingement syndrome, osteoporosis of the humeral head, chronic inflammation of the subacromial bursa, and frozen shoulder (adhesive capsulitis). |
Source: Medical Disability Advisor
| Limiting use of the affected shoulder or avoiding use completely may be necessary. Reaching and arm use above shoulder level should be avoided. The arm and hand can be used at the individual's side for activities that do not require lifting, pushing, or carrying. These restrictions may become permanent. An ergonomic evaluation of the workplace may be necessary. Changing job duties, sharing or alternating tasks, working at a reduced rate, taking more frequent rest breaks, and limiting the time and frequency of repetitive activities are important accommodations. Work site modifications can include forearm rests for individuals who use computer keyboards frequently, headsets for those who answer telephones, and alterations such that repetitive activities are performed with the arms in a lower level of elevation.
Recovery from surgical repair is the most restrictive, with no use of the arm and shoulder for up to 2 months, followed by a gradual increase in allowed activities. Some individuals will never regain full range of motion or strength in the affected arm. Depending on job duties, individuals may require permanent reassignment, which may necessitate retraining. Use of prescription painkillers (analgesics) and other medications can affect dexterity and alertness. Use of these medications may require review of drug policies. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Does individual have any risk factors for a rotator cuff tear (those who perform overhead work, certain athletes, those who have impingement syndrome, instability of the glenohumeral joint, or congenital abnormalities of the shoulder)?
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Did individual fall?
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Did individual experience associated shoulder weakness or inability to raise his or her arm?
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Did individual have any positive findings on exam, such as muscle atrophy, or impaired range of motion?
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Has the diagnosis been confirmed by imaging studies (i.e., MRI, CT scan, arthroscopy)?
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If diagnosis was uncertain, were other conditions with similar symptoms ruled out (i.e., painful arc syndrome, impingement syndrome, rotator cuff tendinitis, biceps tendinitis, and subacromial bursitis)?
Regarding treatment:
- Has individual responded favorably to conservative treatment of rest, ice, NSAIDs, and physical therapy? If not, have steroid injections been tried?
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Did it become necessary to repair the tear surgically?
Regarding prognosis:
- Is individual active in physical therapy? Does individual follow a home exercise program?
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Is individual's employer able to accommodate necessary restrictions?
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Is affected shoulder on the dominant or nondominant side?
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Does individual have any other conditions, such as shoulder dislocation or other shoulder injuries, osteoarthritis, rheumatoid arthritis, diabetes, or osteoporosis that could affect recovery?
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Has individual experienced any complications that could affect recovery and prognosis?
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Source: Medical Disability Advisor
| Breazeale, N. M., and E. V. Craig. "Partial-Thickness Rotator Cuff Tears. Pathogenesis and Treatment." Orthopedic Clinics of North America 28 2 (1997): 145-155. National Center for Biotechnology Information. National Library of Medicine. 25 Sep. 2008 <PMID: 9113711>.Felsenstein, Chad H., and Robert M. McNamara. "Rotator Cuff Injury." eMedicine Consumer Health. Eds. Scott H. Plantz, et al. 7 Sep. 2004. Medscape. 29 Oct. 2004 <http://www.emedicinehealth.com/articles/5582-1.asp>. Kelley, M. J., and William A. Clark, eds. Orthopedic Therapy of the Shoulder. Philadelphia : J.B. Lippincott Company, 1995. Malanga, Gerard A. "Rotator Cuff Injury." eMedicine. Eds. Andrew L. Sherman, et al. 8 Jun. 2006. Medscape. 25 Sep. 2008 <http://emedicine.com/sports/topic115.htm>. Mantone, J. K., W. Z. Burkhead, and J. Noonan. "Nonoperative Treatment of Rotator Cuff Tears." Orthopedic Clinics of North America 31 2 (2000): 295-311. National Center for Biotechnology Information. National Library of Medicine. 25 Sep. 2008 <PMID: 10736398>. Roy, Andre. "Rotator Cuff Disease." eMedicine. Eds. Robert E. Windsor, et al. 6 Mar. 2006. Medscape. 25 Sep. 2008 <http://emedicine.com/pmr/topic125.htm>. Tuite, Michael. "Shoulder, Rotator Cuff Injury (MRI)." eMedicine. Eds. David S. Levey, et al. 22 Jun. 2007. Medscape. 25 Sep. 2008 <http://emedicine.com/radio/topic894.htm>. |
Source: Medical Disability Advisor
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