Rotator cuff tear: Difference between revisions
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==Background== | ==Background== | ||
*Majority of tears occur due to chronic impingement in | [[File:Shoulder_joint_back-en.png|thumb|Shoulder anatomy, anterior.]] | ||
*Acute tears require significant trauma: shoulder dislocation, FOOSH | [[File:Shoulder joint back 05r4v.png|thumb|Shoulder anatomy, posterior.]] | ||
*Consider rotator cuff tear in | *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 | *Supraspinatus is most commonly affected tendon | ||
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**Disuse atrophy may be present in chronic tears | **Disuse atrophy may be present in chronic tears | ||
**TTP lateral aspect of upper arm or in subacromial region | **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 | |||
==Diagnosis== | ==Differential Diagnosis== | ||
{{Shoulder DDX}} | |||
== | ==Evaluation== | ||
*See [[Shoulder (Tests)]] | |||
===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 | *Arm sling until acute symptoms subside | ||
*Analgesia | *[[Analgesia]] | ||
**NSAIDs, opioids, ice | **[[NSAIDs]], [[opioids]], ice | ||
*Exercises | *Exercises | ||
**Pendulum swings | **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 | ***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 | ***Swing to level of pain tolerance x 5-10min TID-QID | ||
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==Disposition== | ==Disposition== | ||
*Ortho | *Ortho follow-up within 1 week | ||
==See Also== | ==See Also== | ||
*[[Shoulder | *[[Shoulder diagnoses]] | ||
==References== | |||
<references/> | |||
[[Category: | [[Category:Orthopedics]] | ||
[[Category:Sports Medicine]] |
Latest revision as of 20:30, 21 May 2020
Background
- 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:
- Shoulder Dislocation
- Clavicle fracture
- Humerus fracture
- Scapula fracture
- Acromioclavicular joint injury
- Glenohumeral instability
- Rotator cuff tear
- Biceps tendon rupture
- Triceps tendon rupture
- Septic joint
Nontraumatic/Chronic:
- Rotator cuff tear
- Impingement syndrome
- Calcific tendinitis
- Adhesive capsulitis
- Biceps tendinitis
- Subacromial bursitis
- Cervical radiculopathy
Refered pain & non-orthopedic causes:
- Referred pain from
- Neck
- Diaphragm (e.g. gallbladder disease)
- Brachial plexus injury
- Axillary artery thrombosis
- Thoracic outlet syndrome
- Subclavian steal syndrome
- Pancoast tumor
- Myocardial infarction
- Pneumonia
- Pulmonary embolism
Evaluation
- See Shoulder (Tests)
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
- Pendulum swings
Disposition
- Ortho follow-up within 1 week
See Also
References
- ↑ 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.