Rotator Cuff Injuries 

Updated: Feb 12, 2016
Author: Eileen C Quintana, MD; Chief Editor: Trevor John Mills, MD, MPH 

Overview

Practice Essentials

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.

Rotator cuff tear, anterior view. Rotator cuff tear, anterior view.

 

Signs and symptoms

Signs and symptoms of rotator cuff injuries include the following:

  • Pain

  • Weakness

  • Decreased range of motion

  • Clicking

  • Catching

  • Stiffness

  • Crepitus

See Clinical Presentation for more detail.

Diagnosis

Examination of a patient with suspected rotator cuff injuries includes a systematic approach to the shoulder, cervical spine, and upper extremity involving the following[1] :

  • 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

Imaging studies

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[2]

  • 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.

Management

The goals of treatment for rotator cuff injuries are to reduce inflammation, relieve stress on the rotator cuff, and correct any biomechanical dysfunction.

Conservative therapy

Patients with chronic injuries that have progressed to a rotator cuff tear may be treated conservatively with the following[3] :

  • Rest and activity modification

  • Shoulder sling

  • Nonsteroidal anti-inflammatory drugs (NSAIDs)

  • Corticosteroid injections

  • Basic shoulder-strengthening programs

If NSAIDs alone do not provide adequate pain relief, consider adding acetaminophen to the treatment regimen.[4] Other analgesics such as ibuprofen and ketoprofen may also be used in the management of rotator cuff injuries.

Surgery

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]

See Treatment and Medication for more detail.

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.

A rotator cuff injury is shown in the image below.

Rotator cuff injury. Rotator cuff injury.

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.[3]

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.

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.

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%.[7]

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.[8, 9, 10]

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.[7]

  • Prevalence increases with age.[7]

  • 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.

 

Presentation

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.

In a study of 217 patients who presented to an emergency department after a trauma to the shoulder without fracture or dislocation, one 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% symptomatic rotator cuff ruptures.[11]

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 maxima 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.

 

DDx

 

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. (See the images below.)

Normal plain radiograph of the shoulder in interna 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[12, 13, 14] : 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 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.[2] 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%.[15, 7]

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.

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.[16]

In a study of diagnostic accuracy of ultrasonography, MRI, and MRA in characterizing full-thickness rotator cuff tears, overall sensitivity and specificity exceeded 0.90, whereas sensitivity was lower, at 0.67 to 0.83.[17]

 

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.[3] If NSAIDs alone do not provide adequate pain relief, consider adding acetaminophen to the treatment regimen.[4]  Various studies indicate a heterogeneous success rate ranging from 33-90%. Steroid injections can reduce pain, but there is no apparent improvement in function.

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%.[18, 19]  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.[18, 20]

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.[21, 22, 23]

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.[24]

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.[25]

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

Medication Summary

The goal of pharmacotherapy is to reduce pain and inflammation.

Analgesics

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.

 

Follow-up

Further Outpatient Care

See the list below:

  • 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.

Further Inpatient Care

See the list below:

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

Inpatient & Outpatient Medications

See the list below:

  • All NSAIDs are equally effective.

Deterrence/Prevention

See the list below:

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

Complications

See the list below:

  • Failure of conservative treatment requires surgical intervention.

  • Decreased range of motion may occur.

Prognosis

See the list below:

  • An estimated 4% of cuff ruptures develop a cuff arthropathy.[8]

  • Various authors report the success rate of conservative treatment to be 33-90%, with longer recovery time required in older patients.[10]

  • 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 with difficulty with daily activities. The symptom of "weakness” was associated with 2 very specific shoulder tasks: throwing hard and push-ups.[26]

  • 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.[27]

Patient Education

See the list below:

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