The rotator cuff muscles are the supraspinatus, infraspinatus, subscapularis, and teres minor. Repetitive microtrauma and anatomic variations lead to most rotator cuff injuries. Such injuries are commonly encountered in athletic and nonathletic patients. See the image below.
Signs and symptoms
Signs and symptoms of rotator cuff injuries include the following:
Decreased range of motion
See Clinical Presentation for more detail.
Examination of a patient with suspected rotator cuff injuries includes a systematic approach to the shoulder, cervical spine, and upper extremity involving the following  :
Inspection: Look for any scars, color, edema, deformities, muscle atrophy, asymmetry
Palpation of the bony and soft-tissue structures: Note any areas of tenderness
Range of motion (active and passive): Note any pain elicited and loss of motion
Strength testing: Compare bilaterally, and note any differences
Neurologic assessment: Include the Neer impingement test to distinguish cuff disease from other sources of shoulder pain
Special shoulder tests
Radiologic studies that may be used to assess suspected rotator cuff injuries include the following:
Shoulder radiography: Anteroposterior, axillary, and lateral views; modified transscapular or supraspinatus outlet view
Arthrography of the glenohumeral joint (advanced imaging): To diagnose rotator cuff disease 
Ultrasonography (advanced imaging): To diagnose rotator cuff disease
Magnetic resonance imaging (advanced imaging): To diagnose a spectrum of rotator cuff disease from degeneration to partial or complete tears, as well as soft-tissue injuries
See Workup for more detail.
The goals of treatment for rotator cuff injuries are to reduce inflammation, relieve stress on the rotator cuff, and correct any biomechanical dysfunction.
Patients with chronic injuries that have progressed to a rotator cuff tear may be treated conservatively with the following  :
Rest and activity modification
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Basic shoulder-strengthening programs
If NSAIDs alone do not provide adequate pain relief, consider adding acetaminophen to the treatment regimen.  Other analgesics such as ibuprofen and ketoprofen may also be used in the management of rotator cuff injuries.
If patients have not improved by a 6-week assessment following conservative management, consider surgical therapy. Surgical therapy is indicated in the following patients:
Those younger than 60 years
Those with a full-thickness tear demonstrated clinically or arthrographically
Those who fail to improve after 6 weeks of rehabilitation
Individuals performing activities that requires shoulder use
Emergent orthopedic evaluation is warranted in acute injuries or even severe extension of chronic rotator cuff injuries, because they have a poor prognosis with conservative modalities.
In a retrospective study of 152 patients who underwent open repair of a posterosuperior massive rotator cuff tear, Ciampi and colleagues found that polypropylene patch augmentation of rotator cuff repair was associated with significantly better 3-year outcomes than was use of an absorbable collagen patch. [5, 6]
Rotator cuff injuries are problems commonly encountered in athletic and nonathletic patients. Symptoms include pain, weakness, and decreased range of motion. Early diagnosis is important for identifying causes, implementing effective treatment, and preventing further injury.
A rotator cuff injury is shown in the image below.
Although pain management of this acute injury primarily consists of nonsteroidal anti-inflammatory drugs (NSAIDs), there is increasing evidence that a combination of acetaminophen and NSAIDs could offer superior analgesia. This could be considered as another option in the pain management of the acutely injured rotator cuff. 
Knowledge of the mechanical and normal anatomical structure allows for understanding of rotator cuff injuries (see Rotator Cuff Pathology). The rotator cuff muscles are the supraspinatus, infraspinatus, subscapularis, and teres minor.
The subscapularis is a humeral head depressor and, in certain positions, an internal rotator. The infraspinatus and teres minor are external rotators. These muscles work as a unit, rather than individually, to maintain the dynamic glenohumeral stability. All are innervated by subscapular and axillary nerves. The vascular supply largely is dependent on the anterior humeral circumflex artery, which supplies the anterior cuff, and the posterior humeral circumflex and suprahumeral, which supply the posterior cuff.
Microscopically, all of the tendons of the rotator cuff fuse to form one continuous band, which is composed of a 5-layer structure. Because of this structure, none of the individual muscles have a higher incidence of tear, per se. However, the joint-side portion of the supraspinatus tendon is more susceptible to mechanical failure than the bursal side.
Most of the tears of the cuff are the result of chronic degeneration, which makes them susceptible to rupture. The chronic deterioration of the cuff results from the coracoacromial arch, which is composed of the bony acromion, the coracoacromial ligament, and coracoid process. Because of its position above the rotator cuff, the coracoacromial arch forms the roof through which the supraspinatus tendon must pass (ie, supraspinatus outlet). Repetitive microtrauma and anatomical variations lead to most of the rotator cuff injuries.
Tendon degeneration is classified in 3 stages (classification of the impingement syndrome) based on the supraspinatus outlet.
Stage I - Edema and hemorrhage, affecting persons younger than 25 years
Stage II - Fibrosis and tendinitis, affecting persons aged 25-40 years
Stage III - Tears of cuff, affecting persons older than 50 years
The precise incidence of symptomatic rotator cuff injuries is not known. Many individuals with full-thickness cuff tears are not only asymptomatic but they have minimal functional disability. The most accepted figure is 20-30%. Cadaver studies of elderly persons have estimated full-thickness tears as high as 30%. 
An estimated 4% of cuff ruptures develop a cuff arthropathy. Various authors report a rate of success with conservative treatment ranging from 33-90%, with longer recovery time in older patients. Surgery results in improved function regardless of the patient's age. [8, 9, 10]
Rotator cuff injuries and tears usually do not occur in persons younger than 40 years (5-30%). The great majority is found in persons aged 55-85 years. Approximately 15% of patients with shoulder pain who are older than 70 years have rotator cuff injuries. 
Prevalence increases with age. 
Younger patients are more likely to have rotator cuff dysfunction because of overuse, subtle instability, and muscle imbalance.
Older patients tend to have chronic shoulder pain and degeneration.
What would you like to print?