eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Rotator Cuff Injuries

Author: Eileen C Quintana, MD, Assistant Professor, Departments of Pediatrics and Emergency Medicine, St Christopher's Hospital for Children
Coauthor(s): Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Contributor Information and Disclosures

Updated: Apr 15, 2009

Introduction

Background

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.

Rotator cuff injury.

Rotator cuff injury.

Rotator cuff injury.

Rotator cuff injury.


Pathophysiology

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.


Rotator cuff, normal anatomy.

Rotator cuff, normal anatomy.

Rotator cuff, normal anatomy.

Rotator cuff, normal anatomy.


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.

Rotator cuff tear, anterior view.

Rotator cuff tear, anterior view.

Rotator cuff tear, anterior view.

Rotator cuff tear, anterior view.


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

Frequency

United States

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%.1

Mortality/Morbidity

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.2,3,4

Age

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.1

  • Prevalence increases with age.1
  • 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.

Clinical

History

Assess any patient with shoulder pain with respect to the patient's age and occupation. Characterize pain according to its duration of onset, location, radiation, timing, and quality. In addition, investigate pain for its relationship to activities and sport.

  • Pain is the most common symptom encountered with rotator cuff injury.
    • Pain usually is located anterolaterally and superiorly and referred to the level of the deltoid insertion with full-thickness tears.
    • Pain is aggravated in activities where the arm must be in an overhead or a forward-flexed position.
    • In an acute injury, pain suddenly is elicited after a fall, after lifting of a heavy object, or even after a trivial amount of force.
  • Following pain, weakness and limitation of motion are the next most common symptoms of a rotator cuff tear.
  • The patient also may complain of clicking, catching, stiffness, and crepitus.

Physical

Approach the shoulder examination systematically in every patient with inspection, palpation, range of motion, strength testing, neurologic assessment, and performances of special shoulder tests. Also, include evaluation of the cervical spine and upper extremity.

  • Inspect for scars, color, edema, deformities, muscle atrophy, and asymmetry.
  • Palpate the bony and soft-tissue structures, noting any areas of tenderness.
    • The subdeltoid and subacromial bursae can be palpated anteriorly under the acromion, and laterally with the deltoid muscle and the arm in extension.
    • The supraspinatus is palpated anteriorly when the arm is externally rotated and flexed.
    • Hyperextension permits the palpation of the infraspinatus.
  • Assess active and passive range of motion. Note any pain elicited and loss of motion.
    • Determine muscle strength.
    • The supraspinatus is isolated with the arm forward 90 degrees in the scapular plane and the forearm rotated into pronation (ie, thumbs down). If drooping of this position occurs, full-thickness rotator cuff tears are suggested.
    • The subscapularis may be tested with the arm at the side with internal rotation resistance. However, this can produce false-negative results; instead, place the arm internally rotated with the dorsum on the buttock surface and actively lift the hand from the buttocks against resistance.
    • The external rotators, teres minor, and infraspinatus can be tested with the arm on the side and in 90 degrees of abduction.
  • Neer impingement test: An injection of 1% lidocaine into the subacromial bursae, using the lateral or posterior approach, creates signs of relief on forward flexion in patients with rotator cuff disease, distinguishing cuff disease from other sources of shoulder pain. However, rotator cuff tears are not distinguished from early stages of inflammation or fibrosis.
Neer impingement test. The patient's arm is maxim...

Neer impingement test. The patient's arm is maximally elevated through forward flexion by the examiner, causing a jamming of the greater tuberosity against the anteroinferior acromion. Pain elicited with this maneuver indicates a positive test result for impingement.

Neer impingement test. The patient's arm is maxim...

Neer impingement test. The patient's arm is maximally elevated through forward flexion by the examiner, causing a jamming of the greater tuberosity against the anteroinferior acromion. Pain elicited with this maneuver indicates a positive test result for impingement.


Causes

An emerging consensus suggests that the etiology of rotator cuff disease is multifactorial. Extrinsic factors exist, such as the morphology of the coracoacromial arch, tensile overload, repetitive use, and kinematics abnormalities. Intrinsic factors also exist, such as altered tendon vascular supply, microstructural collagen fiber abnormalities, and regional variations.

More on Rotator Cuff Injuries

Overview: Rotator Cuff Injuries
Differential Diagnoses & Workup: Rotator Cuff Injuries
Treatment & Medication: Rotator Cuff Injuries
Follow-up: Rotator Cuff Injuries
Multimedia: Rotator Cuff Injuries
References

References

  1. Moosmayer S, Smith HJ, Tariq R, Larmo A. Prevalence and characteristics of asymptomatic tears of the rotator cuff: an ultrasonographic and clinical study. J Bone Joint Surg Br. Feb 2009;91(2):196-200. [Medline].

  2. Ecklund KJ, Lee TQ, Tibone J, Gupta R. Rotator cuff tear arthropathy. J Am Acad Orthop Surg. Jun 2007;15(6):340-9. [Medline].

  3. Fongemie AE, Buss DD, Rolnick SJ. Management of shoulder impingement syndrome and rotator cuff tears. Am Fam Physician. Feb 15 1998;57(4):667-74, 680-2. [Medline].

  4. Hayes K, Ginn KA, Walton JR, Szomor ZL, Murrell GA. A randomised clinical trial evaluating the efficacy of physiotherapy after rotator cuff repair. Aust J Physiother. 2004;50(2):77-83. [Medline].

  5. SooHoo NF, Rosen P. Diagnosis and treatment of rotator cuff tears in the emergency department. J Emerg Med. May-Jun 1996;14(3):309-17. [Medline].

  6. Fuchs S, Chylarecki C, Langenbrinck A. Incidence and symptoms of clinically manifest rotator cuff lesions. Int J Sports Med. Apr 1999;20(3):201-5. [Medline].

  7. Miniaci A, Salonen D. Rotator cuff evaluation: imaging and diagnosis. Orthop Clin North Am. Jan 1997;28(1):43-58. [Medline].

  8. Millstein ES, Snyder SJ. Arthroscopic evaluation and management of rotator cuff tears. Orthop Clin North Am. Oct 2003;34(4):507-20. [Medline].

  9. Hashefi M. Ultrasound in the diagnosis of noninflammatory musculoskeletal conditions. Ann N Y Acad Sci. Feb 2009;1154:171-203. [Medline].

  10. Dalton SE. The conservative management of rotator cuff disorders. Br J Rheumatol. Jul 1994;33(7):663-7. [Medline].

  11. Hanusch BC, Goodchild L, Finn P, Rangan A. Large and massive tears of the rotator cuff: functional outcome and integrity of the repair after a mini-open procedure. J Bone Joint Surg Br. Feb 2009;91(2):201-205. [Medline].

  12. Zumstein MS, Jost B, Hempel J, Hodler J, Gerber C. The clinical and structural long-term results of open repair of massive tears of rotator cuff. J Bone Joint Surg Am. Nov 2008;90(11):2423-31.

  13. Morse K, Davis AD, AFra R, Kaye EK, Schepsis A, Voloshin I. Arthroscopic versus mini-open rotator cuff repair: a comprehensive review and meta-analysis. Am J Sports Med. Sept 2008;26(9):1824-1828. [Medline].

  14. Tonino PM, Gerber C, Itoi E, Porcellini G, Sonnabend D, Walch G. Complex shoulder disorders: evaluation and treatment. J Am Acad Orthop Surg. Mar 2009;17(3):125-36. [Medline].

  15. Rudzki JR, Shaffer B. New approaches to diagnosis and arthroscopic management of partial-thickness cuff tears. Clin Sports Med. Oct 2008;27(4):691-717. [Medline].

  16. Barr KP. Rotator cuff disease. Phys Med Rehabil Clin N Am. May 2004;15(2):475-91. [Medline].

  17. Quillen DM, Wuchner M, Hatch RL. Acute shoulder injuries. Am Fam Physician. Nov 15 2004;70(10):1947-54. [Medline].

  18. Rokito AS, Cuomo F, Gallagher MA, Zuckerman JD. Long-term functional outcome of repair of large and massive chronic tears of the rotator cuff. J Bone Joint Surg Am. Jul 1999;81(7):991-7. [Medline].

  19. Soslowsky LJ, Carpenter JE, Bucchieri JS, Flatow FL. Biomechanics of the rotator cuff. Orthop Clin North Am. Jan 1997;28(1):17-30. [Medline].

Further Reading

Keywords

rotator cuff tears, shoulder pain, rotator cuff dysfunction, rotator cuff disease, glenohumeral instability, impingement syndrome, rotator cuff injury

Contributor Information and Disclosures

Author

Eileen C Quintana, MD, Assistant Professor, Departments of Pediatrics and Emergency Medicine, St Christopher's Hospital for Children
Eileen C Quintana, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Joseph A Salomone, III, MD, Associate Professor, Department of Emergency Medicine, Truman Medical Center, University of Missouri at Kansas City School of Medicine
Joseph A Salomone, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, Society for Academic Emergency Medicine, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

David B Levy, DO, FACEP, FAAEM, Chairman, Department of Emergency Medicine, St Elizabeth Health Center; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine
David B Levy, DO, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Informatics Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

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