Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Rotator Cuff Tear


Related Terms

  • Full-thickness rotator cuff tear
  • Partial-thickness Rotator Cuff Tear
  • Torn Rotator Cuff

Differential Diagnosis

Specialists

  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Rheumatologist
  • Sports Medicine Physician

Comorbid Conditions

Factors Influencing Duration

The size of the tear, the individual's age, occupation, and overall health, dominant side involvement, the need for surgery, and the effectiveness of rehabilitation may affect the length of disability. There may be permanent restrictions on overhead work. The larger the tear, and the longer the interval from injury to surgery, the more likely that there will be some residual permanent weakness of the rotator cuff (Safran). Therefore, heavy or very heavy lifting may no longer be possible.

Medical Codes

ICD-9-CM:
726.10 - Disorders of Bursae and Tendons in Shoulder Region, Unspecified; Rotator Cuff Syndrome NOS; Supraspinatus Syndrome NOS
726.13 - Partial Tear of Rotator Cuff
727.61 - Rupture of Tendon, Nontraumatic, Complete Rupture of Rotator Cuff
840.4 - Sprains and Strains of Shoulder and Upper Arm, Rotator Cuff (Capsule)

Overview

© Reed Group
A rotator cuff tear occurs when the tendons that form the rotator cuff weaken and tear. The rotator cuff surrounds the ball-like humeral head of the upper arm. The rotator cuff comprises four muscles—the subscapularis, the supraspinatus, the infraspinatus and the teres minor—and their musculotendinous attachments The tendons that attach these four muscles in the shoulder area to the humerus, fuse together to form the rotator cuff. The tendons of these muscles come under stress from activities that require lifting and rotation of the arm often in a throwing type motion. Any abnormalities of the shoulder joint can aggravate the stress, especially joint looseness (laxity), muscle imbalance, 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 full-thickness, depending on the amount of tissue damage. Partial-thickness tears do not go all the way through the cuff, although a large surface area may be involved. Full-thickness (complete) tears create a gap in the rotator cuff with concomitant loss of function (range of motion and strength). 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 of the rotator cuff and are more common as we age. Conditions that may predispose an individual to a rotator cuff tear include impingement syndrome, bone spurs, instability of the shoulder (glenohumeral) joint, or congenital abnormalities of the shoulder.

Incidence and Prevalence: Rotator cuff tears may affect from 5% to 40% of the population (Malanga, "Rotator"). Cadaver studies showed that 39% of individuals over the age of 60 have full-thickness tears (Malanga, "Rotator"). Since some partial and full-thickness rotator cuff tears produce no symptoms, it is difficult to estimate incidence and frequency.

Source: Medical Disability Advisor



Causation and Known Risk Factors

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. One study found that men are twice as likely as women to sustain rotator cuff tears (Tuite). The author suggested that this might be attributed to a greater proportion of men working in heavy labor. A different study found increased risk for females with prevalence ratio 1.8; confidence interval 1.2-2.8) (Wendelboe). Again, the confusion may be to the fact that individuals with a rotator cuff tear may be asymptomatic. Incidence of degenerative tears increases with age in both genders (Malanga, "Rotator"). Rotator cuff tears occur independently of race, ethnicity, or geographic location. For more information, refer to "Disease and Injury Causation," pages 184-190.

Source: Medical Disability Advisor



Diagnosis

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 when 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 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 is 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 (diagnostic arthroscopy) is occasionally done to evaluate the rotator cuff and shoulder mechanics, especially on acute tears in athletes.

Source: Medical Disability Advisor



Treatment

The goals of treatment are pain relief and improved shoulder function. Partial-thickness 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 can help increase rotator cuff muscle strength, stabilize the shoulder blade (scapula), and increase range of motion. Use of heat or cool may help reduce the pain. Although nonoperative treatment will not repair the tear, it may reduce the pain and restore 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 (Hijioka).

Full-thickness (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-thickness 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 full-thickness tear in an elderly individual might be treated conservatively or with simpler procedures such as arthroscopic débridement and subacromial decompression. Large tears (greater than 3 cm) may be inoperable, though some will improve with bone anchors or bone trough surgery (the rotator cuff is not repaired to a normal anatomical position). Rotator cuff surgery may be performed as inpatient or outpatient, depending on the specific procedure used.

Source: Medical Disability Advisor



ACOEM

ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.*
 
Shoulder Disorders
 
* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Source: ACOEM Practice Guidelines



Prognosis

There is a high correlation between the onset of rotator cuff tears (either partial or full thickness) and increasing age. Bilateral rotator cuff disease, either symptomatic or asymptomatic, is common in patients who present with unilateral symptomatic disease. As the size of a tear appears to be an important factor in the development of symptoms (Yamaguchi).

Full-thickness rotator cuff tears tend to increase in size in about half of patients aged 60 years or younger. Patients treated nonoperatively should be routinely monitored for tear size increase, especially if they remain symptomatic. Surgery should be considered in these patients to prevent a probable increase in the size of a tear (Safran).

Recovery of strength is correlated primarily with the size of the tear. For small and medium tears recovery of strength was almost complete during the first year, and for large and massive tears it was much slower and less consistent (Rokito).

A larger acromial index (height between humeral head and acromion) suggests more tendons torn and an increased need for tendon anchors (Ames).

Mini-open rotator cuff repair led to improved shoulder function and health-related quality of life up to 5 years postoperatively (Baysal).

Open repair of massive rotator cuff tears may reach a favorable outcome in a significant proportion of patients, despite a high rate of recurrent or residual tears (Mellado).

Outcomes were poorer in workers’ compensation patients (Misamore) However, one study found 51 full-thickness rotator cuff tears in 49 NFL football players. After being injured, the majority continued to play at their usual level of activity and delayed surgery until the postseason. After surgery, most returned to professional football, but many were not totally symptom-free (Foulk).

Source: Medical Disability Advisor



Rehabilitation

Acute Phase: The early goals of rehabilitation in the acute phase of a partial rotator cuff tear or a full tear in older individuals 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 (Miller).

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 (Lin). 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.

Healing Phase: As the pain and inflammation ease, treatment aims at improving strength and flexibility to the shoulder without irritating the healing tendon(s) (Malanga, "Chapter 15"). 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 also be initiated, avoiding stress on the healing tendon(s). As the tendon heals, progressive rotator cuff strengthening exercises are added, as indicated (Malanga, "Chapter 15"). Pool therapy may be useful for some individuals.

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)
SpecialistRotator Cuff Tear
Occupational or Physical TherapistUp to 16 visits within 8 weeks
Surgical (acute phase)
SpecialistRotator Cuff Tear
Occupational or Physical TherapistUp to 24 visits within 12 weeks
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



Complications

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



Ability to Work (Return to Work Considerations)

Limiting use of the affected shoulder may be necessary. Reaching and arm use above shoulder level should be avoided in the initial recovery period. The arm and hand can be used at the individual's side for activities that do not require heavy lifting, pushing, or carrying. These guides may become permanent. An ergonomic evaluation of the workplace may be helpful. 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 may 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. For more information, refer to "Work Ability and Return to Work," page 187.

Recovery from surgical repair is the most restrictive, with limited use of the arm and shoulder for up to 2 months (depending of age and tear size), 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.

Risk: Reinjury is possible, but most individuals are on modified work. For more information, refer to "Work Ability and Return to Work," page 183, table 12-2, as well as page 186.

Capacity: Capacity is dependent on age and physical conditioning before onset of symptoms. For more information, refer to "Work Ability and Return to Work," page 187.

Tolerance: The ability to work through the pain is unique to each individual. If the tear cannot be repaired to a normal anatomical position, range of motion and strength will be permanently reduced. Tolerance can be modified by education and rewards. For example, a study found 51 full-thickness rotator cuff tears in 49 NFL football players. After being injured, the majority continued to play at their usual level of activity and delayed surgery until the postseason. After surgery, most returned to professional football, but many were not totally symptom-free (Foulk). For more information, refer to "Work Ability and Return to Work," Chapter 2.

Accommodations: As the individual ages, the need for permanent work accommodations will increase. Tolerance and accommodation determine the final ability to return to work. Modifications to the workplace or modifications to the job task may allow many individual to return to modified work.

Source: Medical Disability Advisor



Maximum Medical Improvement

MMI depends on size of tear, treatment, and age.

A young patient with an acute tear should reach MMI within 120 to 180 days.

A middle aged patient with a large tear and osteoarthritis should reach MMI within 180 to 240 days.

An older patient with a chronic tear should reach MMI within 240 to 360 days.

A non-surgical patient, 60 to 120 days if stable on two consecutive visits.

Source: Medical Disability Advisor



Failure to Recover

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)?
  • Did individual fall?
  • Did individual experience associated shoulder weakness or inability to raise his or her arm?
  • Did individual have any positive findings on exam, such as muscle atrophy, or impaired range of motion?
  • Has the diagnosis been confirmed by imaging studies (i.e., MRI, CT scan, arthroscopy)?
  • 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?
  • Did it become necessary to repair the tear surgically?

Regarding prognosis:

  • Is individual active in physical therapy? Does individual follow a home exercise program?
  • Is individual's employer able to accommodate necessary restrictions?
  • Is affected shoulder on the dominant or nondominant side?
  • Does individual have any other conditions, such as shoulder dislocation or other shoulder injuries, osteoarthritis, rheumatoid arthritis, diabetes, or osteoporosis that could affect recovery?
  • Has individual experienced any complications that could affect recovery and prognosis?

Source: Medical Disability Advisor



References

Cited

Ames, J. B. , et al. "Association between acromial index and outcomes following arthroscopic repair of full-thickness rotator cuff tears." Journal of Bone and Joint Surgery 94 (20) (2012): 1862-1869.

Baysal, D. , et al. "Functional outcome and health-related quality of life after surgical repair of full-thickness rotator cuff tear using a mini-open technique." American Journal of Sports Medicine 33 (9) (2005): 1346-1355.

Foulk, D. A. , et al. "Full thickness rotator cuff tears in professional football players." American Journal of Orthopedics 31 (11) (2002): 622-624.

Hijioka, A. , et al. "Degenerative change and rotator cuff tears. An anatomical study in 160 shoulders of 80 cadavers." Archives of Orthopaedic and Trauma Surgery 112 (2) (1993): 61-64.

Lin, Kenneth C., Sumant G. Krishnan, and Wayne Z. Burkhead. "Chapter 17 - Rotator Cuff. Section 1. Rotator Cuff: 1. Impingement Lesions in Adult & Adolescent Athletes." DeLee and Drez's Orthopaedic Sports Medicine. Eds. Jesse C. DeLee and David Drez. 2 ed. Saunders Elsevier, 2003.

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>.

Malanga, Gerard A. , Jay E. Bowen, and . "Chapter 15 - Rotator Cuff Tear." Essentials of Physical Medicine and Rehabilitation. Eds. Walter R. Frontera, Julie K. Silver, and Thomas Rizzo. 2nd ed. Philadelphia: Saunders, Elsevier, 2008.

Melhorn, J. Mark, and William Ackerman, eds. Disease and Injury Causation, Guides to the Evaluation of. AMA Press, 2008.

Mellado, J. M. , et al. "Surgically repaired massive rotator cuff tears: MRI of tendon integrity, muscle fatty degeneration, and muscle atrophy correlated with intraoperative and clinical findings." American Journal of Roentgenology 184 (5) (2005): 1456-1463.

Miller, Robert H., and Jeffrey A. Dlaback. "Chapter 44 - Shoulder and Elbow Injuries." Campbell's Operative Orthopaedics. Eds. S. Terry Canale and James H. Beaty. 11th ed. Philadelphia: Mosby Elsevier, 2008.

Misamore, G. W. , D. W. Ziegler, and J. L. Rushton. "Repair of the rotator cuff. A comparison of results in two populations of patients." Journal of Bone and Joint Surgery 77 (9) (1995): 1335-1339.

Rokito, A. S. , et al. "Strength after surgical repair of the rotator cuff." Journal of Shoulder and Elbow Surgery 5 (1) (1996): 12-17.

Roy, Andre, et al. "Rotator Cuff Disease." eMedicine. Eds. Robert E. Windsor, et al. 18 Jan. 2012. Medscape. 25 Feb. 2013 <http://emedicine.medscape.com/article/328253-overview>.

Safran, O. , et al. "Natural history of nonoperatively treated symptomatic rotator cuff tears in patients 60 years old or younger." American Journal of Sports Medicine 39 (4) (2011): 710-714.

Talmage, J. B. , J. M. Melhorn, and M. H. Hyman, eds. Work Ability and Return to Work, AMA Guides to the Evaluation of. Second ed. Chicago: AMA Press, 2011.

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>.

Wedro, Benjamin. "Rotator Cuff Injury." eMedicine Health. Ed. Melissa Conrad Stoppler. 12 Oct. 2010. WebMD, LLC. 1 Feb. 2013 <http://www.emedicinehealth.com/rotator_cuff_injury/article_em.htm#rotator_cuff_injury_overview>.

Wendelboe, A. M. , et al. "Associations between body-mass index and surgery for rotator cuff tendinitis." Journal of Bone and Joint Surgery 86-A (2004): 743-747.

Yamaguchi, K. , et al. "The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders." Journal of Bone and Joint Surgery 88 (8) (2006): 1699-1704.

Source: Medical Disability Advisor






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