Rotator Cuff Injury Management in the ED

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.

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 the 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 anatomic variations lead to most of the rotator cuff injuries.

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

Genetic factors may play a role in the pathogenesis of rotator cuff disease. A systematic review by Longo et al found significant associations between single-nucleotide polymorphisms and rotator cuff disease for DEFB1, FGFR1, FGFR3, ESRRB, FGF10, MMP-1, TNC, FCRL3, SASH1, SAP30BP, and rs71404070 (located next to cadherin8).[21]  

An estimated 4% of cuff ruptures develop a cuff arthropathy.[18]  Various authors report the success rate of conservative treatment to be 33-90%, with longer recovery time required in older patients.[20]  Surgery results in better function regardless of the patient's age.

Based on the Western Ontario Rotator Cuff Index groupings, it appears that symptoms of pain are associated with emotions and lack of range of motion or stiffness, along with difficulty with daily activities. The symptom of "weakness” was associated with 2 very specific shoulder tasks: throwing hard and push-ups.[22]

In arthroscopic repair, massive and large tears tended to show a higher re-tearing when compared to medium tears. Repair showed improvement in functional outcomes when compared to preoperative findings.[23]

Navarro et al found that outpatient rotator cuff repair led to more unplanned ED and urgent care visits than other common outpatient orthopedic surgical procedures. Of 1306 outpatient rotator cuff repairs, 90 patients returned for ED or urgent care visits (6.9%).[24]

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 and usually is located anterolaterally and superiorly and referred to the level of the deltoid insertion with full-thickness tears. It is aggravated by activities in which 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.

In a study of 217 patients who presented to an emergency department after a trauma to the shoulder without fracture or dislocation, 1 year after trauma, 20 patients were diagnosed with a symptomatic rotator cuff rupture. The authors noted that normal radiography does not exclude the presence of a rotator cuff tear in patients with a history of shoulder trauma and that regular follow-up is essential for discovering rotator cuff injuries. In this study, 32% still suffered from shoulder pain 1 year after shoulder trauma, and reexamination revealed a prevalence of 9% of symptomatic rotator cuff ruptures.[25]

Approach the shoulder examination systematically in every patient with inspection, palpation, range of motion, strength testing, neurologic assessment, and performance 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 90º 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 90º  of abduction.

In the Neer impingement test (see the image below), 1% lidocaine is injected into the subacromial bursae, using the lateral or posterior approach. In patients with rotator cuff disease, there are signs of relief on forward flexion, distinguishing it 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.

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. (See the images below.)

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[26, 27, 28] : subacromial sclerosis (ie, "eyebrow" sign), osteophyte formation, sclerosis and cystic changes in the greater tuberosity, and reduction of the acromiohumeral distance (< 7 mm). (Only the 

Reserve advanced imaging modalities for suspected rotator tears with no improvement in symptoms, despite adequate therapy for 3-6 weeks.

Partial-thickness rotator cuff tears may be difficult to diagnose with a single imaging modality. Plain films are recommended for identification of other causes of shoulder pain, such as calcific tendinosis, osteoarthritis, or fracture. A high-riding humeral head (≤7 mm of acromiohumeral distance) may be identifiable on anteroposterior radiographs and suggests a large rotator cuff tear. MRI and ultrasonography have excellent diagnostic accuracy for full-thickness tears.[6, 7, 8, 9, 10, 11]

Arthrography of the glenohumeral joint has been used to diagnose rotator cuff disease.[12] 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%.[4, 29]  In a study, by Saragaglia et al, of acute shoulder injury in 48 patients who presented to the ED, ultrasonography recorded an 82% positive predictive value for cuff tear.[13]

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.[7, 8, 9, 11]

In a study of MRI, 2-dimensional MRA, and 3-dimensional isotropic MRA at 3-T to diagnose rotator cuff injuries, MRI appeared equivalent to MRA in the diagnosis of full- and partial-thickness tears, although there was a trend toward greater accuracy in the diagnosis of subscapularis tears with MRA. 3-T 3D isotropic MRA appeared equivalent to 3-T 2D MRA for all types of tears.[30]

In a study of diagnostic accuracy of ultrasonography, MRI, and MRA in characterizing full-thickness rotator cuff tears, overall sensitivity and specificity exceeded 90%, whereas sensitivity was lower, at 67-83%.[31]

Stabilization with a shoulder sling and use of an ice pack are sufficient for prehospital 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.[2] If NSAIDs alone do not provide adequate pain relief, consider adding acetaminophen to the treatment regimen.[14]  Various studies indicate a heterogeneous success rate ranging from 33 to 90%. Steroid injections can reduce pain, but there is no apparent improvement in function.

A randomized, controlled trial by Ranebo et al indicated that physical therapy alone works just as well as surgical repair in the treatment of small rotator cuff supraspinatus tears. Median sagittal tear size in the study was 9.7 mm. The investigators reported that at 12-month follow-up, the median Constant-Murley score for the surgery patients was 83, compared with 78 for the physical therapy group, while the scores for the Western Ontario Rotator Cuff Index were 91% and 86%, respectively. The 2 groups did not differ with regard to the Numerical Rating Scale (for pain).[32]

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 patients with 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%.[33, 34]  Findings generally suggest that early treatment precipitates a better outcome than late treatment. Studies have shown that arthroscopic repair is fully comparable to the open surgical technique.[33, 35]

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.[36, 37, 38]

In a study of 196 adult patients with full-thickness rotator cuff tears (112 underwent surgical intervention, and 84 nonoperative management), patient characteristics predictive of surgical treatment included younger age, lower body mass index (BMI), and duration of symptoms less than 1 year. Increasing age, higher BMI, and duration of symptoms longer than 1 year were predictive of nonsurgical treatment.[39]

In a study of rotator cuff tears in patients younger than 40 years (mean, 28 years; range, 16-40 years), most patients typically had a full-thickness tear with an acute traumatic etiology and responded well to both arthroscopic and open rotator cuff repair in terms of pain relief and self-reported outcomes postoperatively. These patients reported high levels of satisfaction and return to preinjury level of play. However, a subgroup of elite throwers with partial-thickness tears from chronic overuse had improved outcomes but suboptimal return to play.[40]

Navarro et al found that outpatient rotator cuff repair led to more unplanned ED and urgent care visits than other common outpatient orthopedic surgical procedures. Of 1306 outpatient rotator cuff repairs, 90 patients returned for ED or urgent care visits (6.9%).[24]

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.

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

The goal of pharmacotherapy is to reduce pain and inflammation.

Class Summary

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.

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.

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.