Difference between revisions of "Rotator cuff tear"

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==Background==
 
==Background==
*Shoulder pain after acute trauma, chronic injury, or acute extension of chronic impingement
+
[[File:Shoulder_joint_back-en.png|thumb|Shoulder anatomy, anterior.]]
*Tears due to chronic impingement in pts >40yr accounts for majority
+
[[File:Shoulder joint back 05r4v.png|thumb|Shoulder anatomy, posterior.]]
 +
*Majority of tears occur due to chronic impingement in patients >40yrs
 +
*Acute tears require significant trauma: [[shoulder dislocation]], FOOSH
 +
*Consider rotator cuff tear in patient with weakness for >3wk after acute shoulder dislocation
 +
*Supraspinatus is most commonly affected tendon
  
 +
==Clinical Features==
 +
*Acute Injury
 +
**"Tearing" sensation in shoulder followed by severe pain / inability to raise arm
 +
**Inability to abduct or externally rotate arm against even minimal resistance
 +
**Drop arm test is positive
 +
**Local swelling
 +
*Chronic Injury
 +
**Gradual and progressive pain, worse at night
 +
**Pain localizes to lateral aspect of upper arm
 +
**Arm elevation, external rotation, and lifting objects worsens the pain
 +
*Exam
 +
**Disuse atrophy may be present in chronic tears
 +
**TTP lateral aspect of upper arm or in subacromial region
 +
===Rotator Cuff Tests===
 +
*Supraspinatus Test (+ LR 3.2)
 +
**Abduct arm to 90', forward flex it 30' with thumb down ("empty beer can position")
 +
**Test for pain/weakness against resistance to continued abduction
 +
*Infraspinatus and Teres Minor Test
 +
**Stabilize the elbow against the patient's waist and bend the elbow to 90'
 +
**Test for pain/weakness against resistance to external rotation
 +
*External rotation lag sign - more specific to teres minor, given overlap between infraspinatus and teres minor<ref>Collin P et al. What is the Best Clinical Test for Assessment of the Teres Minor in Massive Rotator Cuff Tears? Clin Orthop Relat Res. 2015 Sep;473(9):2959-66.</ref>
 +
**Support the arm to 20-30 degrees in scapular plane, externally rotated, elbow flexed to 90 degrees
 +
**Positive test is pain or difficulty in keeping the arm from internally rotating when clinician lets go
 +
*Subscapularis (+ LR 1.9)
 +
**Place hand behind lower back
 +
**Test for pain/weakness as patient attempts to push examiner's hand away by moving dorsum of hand away from back
 +
*Drop arm test
 +
**Patient is unable to hold or smoothly lower an extended arm at 90' of shoulder abduction with out dropping it
  
#Injury: 90% chronic arms overhead
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==Differential Diagnosis==
 +
{{Shoulder DDX}}
  
==Diagnosis==
+
==Evaluation==
#result of extreme overuse in young adults (e.g. pitchers) or minor trauma in older adults
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*See [[Shoulder (Tests)]]
#sudden "pop" while lifting overhead
 
#lateral pain
 
#worse at night
 
#abduct arm pain after 20deg
 
#relief of pain w/ lido inject
 
#(pain free weakness = full tear)
 
  
===Physical===
+
===Imaging===
#loss of active BUT NOT passive ROM (due to pain)
+
*Diagnosis should rely on clinical findings; cannot use imaging to rule-out tear
#positive impingement signs
+
*May give some diagnostic information:
#weakness with drop arm test
+
**Narrowing of acromiohumeral space (<7mm) is most specific sign
 +
**May see humeral head sclerosis, osteophytes on undersurface of acromion/clavicle
  
==Treatment==
+
==Management==
#Acute --> sling, PT, ortho f/u
+
*Arm sling until acute symptoms subside
#Chronic --> PT, ortho
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*[[Analgesia]]
#Next: MRI, surgery for younger pts with big tear, rehab
+
**[[NSAIDs]], [[opioids]], ice
#PT:  arm dangle at side, circle 5-10wt
+
*Exercises
 +
**Pendulum swings
 +
***Patient bends slightly at waist with arm hanging freely in front of body
 +
***Arms should be swung in gentle arcs of motion both clockwise and counter-clockwise
 +
***Swing to level of pain tolerance x 5-10min TID-QID
 +
**Walk fingers up wall
 +
***Stand sideways an arm's length from wall and walk fingers up wall to level of pain tolerance TID-QID
 +
 
 +
==Disposition==
 +
*Ortho follow-up within 1 week
  
 
==See Also==
 
==See Also==
*[[Shoulder (Acute - Trauma)]]
+
*[[Shoulder diagnoses]]
 +
 
 +
==References==
 +
<references/>
 +
 
  
[[Category:Ortho]]
+
[[Category:Orthopedics]]
 +
[[Category:Sports Medicine]]

Latest revision as of 20:30, 21 May 2020

Background

Shoulder anatomy, anterior.
Shoulder anatomy, posterior.
  • Majority of tears occur due to chronic impingement in patients >40yrs
  • Acute tears require significant trauma: shoulder dislocation, FOOSH
  • Consider rotator cuff tear in patient with weakness for >3wk after acute shoulder dislocation
  • Supraspinatus is most commonly affected tendon

Clinical Features

  • Acute Injury
    • "Tearing" sensation in shoulder followed by severe pain / inability to raise arm
    • Inability to abduct or externally rotate arm against even minimal resistance
    • Drop arm test is positive
    • Local swelling
  • Chronic Injury
    • Gradual and progressive pain, worse at night
    • Pain localizes to lateral aspect of upper arm
    • Arm elevation, external rotation, and lifting objects worsens the pain
  • Exam
    • Disuse atrophy may be present in chronic tears
    • TTP lateral aspect of upper arm or in subacromial region

Rotator Cuff Tests

  • Supraspinatus Test (+ LR 3.2)
    • Abduct arm to 90', forward flex it 30' with thumb down ("empty beer can position")
    • Test for pain/weakness against resistance to continued abduction
  • Infraspinatus and Teres Minor Test
    • Stabilize the elbow against the patient's waist and bend the elbow to 90'
    • Test for pain/weakness against resistance to external rotation
  • External rotation lag sign - more specific to teres minor, given overlap between infraspinatus and teres minor[1]
    • Support the arm to 20-30 degrees in scapular plane, externally rotated, elbow flexed to 90 degrees
    • Positive test is pain or difficulty in keeping the arm from internally rotating when clinician lets go
  • Subscapularis (+ LR 1.9)
    • Place hand behind lower back
    • Test for pain/weakness as patient attempts to push examiner's hand away by moving dorsum of hand away from back
  • Drop arm test
    • Patient is unable to hold or smoothly lower an extended arm at 90' of shoulder abduction with out dropping it

Differential Diagnosis

Shoulder and Upper Arm Diagnoses

Traumatic/Acute:

Nontraumatic/Chronic:

Refered pain & non-orthopedic causes:

Evaluation

Imaging

  • Diagnosis should rely on clinical findings; cannot use imaging to rule-out tear
  • May give some diagnostic information:
    • Narrowing of acromiohumeral space (<7mm) is most specific sign
    • May see humeral head sclerosis, osteophytes on undersurface of acromion/clavicle

Management

  • Arm sling until acute symptoms subside
  • Analgesia
  • Exercises
    • Pendulum swings
      • Patient bends slightly at waist with arm hanging freely in front of body
      • Arms should be swung in gentle arcs of motion both clockwise and counter-clockwise
      • Swing to level of pain tolerance x 5-10min TID-QID
    • Walk fingers up wall
      • Stand sideways an arm's length from wall and walk fingers up wall to level of pain tolerance TID-QID

Disposition

  • Ortho follow-up within 1 week

See Also

References

  1. Collin P et al. What is the Best Clinical Test for Assessment of the Teres Minor in Massive Rotator Cuff Tears? Clin Orthop Relat Res. 2015 Sep;473(9):2959-66.