eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Rotator Cuff Injuries

Eileen C Quintana, MD, Assistant Professor, Departments of Pediatrics and Emergency Medicine, St Christopher's Hospital for Children
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

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.

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.

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.

• 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 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.

Differential Diagnoses

Cervical Strain
Dislocations, Shoulder
Myocardial Infarction
Myopathies

Other Problems to Be Considered

Avascular necrosis of humerus
Acromioclavicular injury
Neurologic injuries (C5-C6) caused by repetitive trauma
Septic arthritis
Spleen rupture

Workup

Imaging Studies

• Routine radiographic evaluations are an essential component of shoulder evaluation in the ED. Perform a routine radiographic examination in every patient with suspected rotator cuff injury. Shoulder radiography should include anteroposterior, axillary, and lateral views.

Normal plain radiograph of the shoulder in internal, external, and neutral positions.

• A modified transscapular or supraspinatus outlet view is useful for surgical purposes. Radiographic changes are as follows^5,6,7 :
  • Subacromial sclerosis (ie, "eyebrow" sign)
  • Osteophyte formation
  • Sclerosis and cystic changes in the greater tuberosity
  • Reduction of the acromiohumeral distance (<7 mm).

(Only the last 2 points were found to have 78% sensitivity and 98% specificity.)

• Reserve advanced imaging modalities for suspected rotator tears with no improvement in symptoms, despite adequate therapy for 3-6 weeks.
  • Arthrography of the glenohumeral joint has been used to diagnose rotator cuff disease.⁸ A complete tear is diagnosed when communication between the glenohumeral joint cavity and the bursae, either subacromial or subdeltoid, is evident. Partial tears are better evaluated with ultrasonography or MRI.
  • Ultrasonography is also used to evaluate rotator cuff disease. The 4 criteria for rotator cuff pathology are nonvisualization of the cuff, localized absence or focal nonvisualization, discontinuity, and focal abnormal echogenicity. Sensitivity and specificity are operator dependent and have been reported to be greater than 90%.^9,1
  • Magnetic resonance imaging (MRI) can reveal a great spectrum of rotator cuff disease from degeneration to partial or complete tears. MRI also can reveal soft tissue injuries. As a postoperative imaging modality, it has proven to be invaluable.

Full-thickness tear.

Treatment

Prehospital Care

Stabilization with a shoulder sling and an ice pack are sufficient for prehospital care.

Emergency Department Care

• Conservatively treat patients with chronic injuries that have progressed to a rotator cuff tear.
• The goals are to reduce inflammation, relieve stress on the rotator cuff, and correct any biomechanical dysfunction.
• Nonoperative therapy consists of rest and activity modification, shoulder sling, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, and a basic shoulder-strengthening program.¹⁰
• Various studies indicate a heterogeneous success rate ranging from 33-90%. Steroid injections reduced pain, but no difference in improvement of function was observed.
• Schedule follow-up treatment as soon as possible; if the patient has not improved by a 6-week assessment, consider surgical therapy.
• Surgical therapy is indicated in patients younger than 60 years with a full-thickness tear demonstrated clinically or arthrographically, in patients who fail to improve after 6 weeks of rehabilitation, or in patients performing activity 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 if conservative modalities are used.
  • The success rate of surgical therapy is reported to be 77-86%.^11,12
  • Findings generally suggest that early treatment precipitates a better outcome than late treatment. Current studies find that arthroscopic repair is fully comparable with the open surgical technique.^11,13
  • Functional status needs to be determined before considering any surgical intervention.  Many studies have concluded that the need for surgery should consider not only age but also type of tear, duration of symptoms, and the patient's ability to comply with the rehabilitation regimen.^14,15,16

Consultations

Consider an orthopedic consultation in primarily acute injuries or even severe extension of chronic rotator cuff injuries. An orthopedic consultation for possible surgical intervention is required under the following conditions:

• In patients younger than 60 years
• For full-thickness tear demonstrated clinically or arthrographically
• For failure to improve after 6 weeks of rehabilitation
• If the patient's employment requires shoulder use

Medication

The goal of pharmacotherapy is to reduce pain and inflammation.

Analgesics

Pain control is essential to quality patient care, ensuring patient comfort, promoting pulmonary toilet, and enabling physical therapy regimens. Most analgesics have sedating properties, which are beneficial for patients who have sustained painful skin lesions.

Ibuprofen (Ibuprin, Advil, Motrin)

Usually the DOC for the treatment of mild to moderate pain if no contraindications exist. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Dosing

Adult

400 mg PO q4-6h, 600 mg PO q6h, or 800 mg PO q8h while symptoms persist; not to exceed 3.2 g/d

Pediatric

<6 months: Not established
6 months to 12 years: 10-70 mg/kg/d PO divided tid/qid; begin at lower end of dosing range and titrate upward; not to exceed 2.4 g/d
>12 years: Administer as in adults

Interactions

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Ketoprofen (Orudis, Actron, Oruvail)

For relief of mild to moderate pain and inflammation.
Small dosages initially are indicated in small and elderly patients and in persons with renal or liver disease. Doses more than 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patients for response.

Dosing

Adult

25-50 mg PO q6-8h prn; not to exceed 300 mg/d

Pediatric

<3 months: Not established
3 months to 14 years: 0.1–1 PO mg/kg q6-8h
>14 years: Administer as in adults

Interactions

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; GI disease

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Acetaminophen (Tylenol, Aspirin-free Anacin, Acephen)

DOC for the treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs, persons with upper GI disease, or those taking oral anticoagulants.

Dosing

Adult

325-650 mg PO q4-6h or 1000 mg PO tid/qid; not to exceed 4 g/d; Alternately, 1000 mg PO tid/qid; not to exceed 4 g/d

Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 dose/d

Interactions

Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity

Contraindications

Documented hypersensitivity; G-6-PD deficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose

Follow-up

Further Inpatient Care

• Admit to orthopedic service in preparation for the operating room (only required if surgery is the treatment of choice).

Further Outpatient Care

• For patients with rotator cuff injury, arrange outpatient follow-up care within 1-2 days to an orthopedic surgeon and rehabilitation services to continue conservative therapy.
• A follow-up reassessment examination 6 weeks after beginning conservative therapy is essential to determine if treatment is successful or if further surgical treatment is needed.

Inpatient & Outpatient Medications

• All NSAIDs are equally effective.

Deterrence/Prevention

• Instruct patient to limit activities to ensure rest of the affected shoulder.

Complications

• Failure of conservative treatment requires surgical intervention.
• Decreased range of motion may occur.

Prognosis

• An estimated 4% of cuff ruptures develop a cuff arthropathy.²
• Various authors report the success rate of conservative treatment to be 33-90%, with longer recovery time required in older patients.⁴
• Surgery results in better function regardless of the patient's age.

Patient Education

• Refer patients to a physical therapist in conservative treatment and postoperatively.

Miscellaneous

Medicolegal Pitfalls

• Proper follow-up and care ensure prevention of rotator cuff arthropathies and long-term sequelae.^2,3

Multimedia

Media file 1: Rotator cuff, normal anatomy.

Media file 2: Rotator cuff tear, anterior view.

Media file 3: The acromioclavicular arch and the subacromial bursa.

Media file 4: 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.

Media file 5: Rotator cuff injury.

Media file 6: Normal intratendinous signal.

Media file 7: Partial-thickness tear seen better on angled oblique sagittal views.

Media file 8: Full-thickness tear.

Media file 9: Normal plain radiograph of the shoulder in internal, external, and neutral positions.

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].

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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