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Musculoskeletal System ORGAN SYSTEMS

Rotator cuff tears

Shoulder injury where one or more of the tendons or muscles of the rotator cuff of the shoulder get torn.

Introduction

Shoulder injury where one or more of the tendons or muscles of the rotator cuff of the shoulder get torn.

  • M/C tendon injury in adults

Anatomy

Rotator cuff (RC) muscles:

Rotator cuff tendons form confluence with the joint capsule and coracohumeral ligament, and insert on the humeral tuberosity.
  • Subscapularis (SC) (largest and strongest RC muscle)
  • Supraspinatus (SS)
  • Infraspinatus (IS)
  • Teres minor (TM)

Classification

  • Partial-thickness tears (PTT): Can be bursal-sided or articular-sided tears
  • Full-thickness tears (FTT): Over the course of time, PTT enlarge and propagate into FTT

Aetiology

Risk factors:

  • Age (M/C risk factor)
  • Smoking
  • Family history
  • Poor posture
  • Other risk factors: Trauma, hypercholesterolemia, and occupations or activities requiring significant overhead activity

Causative factors:

  • Younger patients: Overuse tendinopathy
  • Older patients: Osteoarthritis

Pathophysiology

The rotator cuff is weakened by both extrinsic and intrinsic factors, leading to gradual failure of tendon with or without superimposed acute injury, which finally results in full-thickness tear.

Summary of extrinsic and intrinsic pathways of rotator cuff tear. | ECM = extracellular matrix; MMP-1 = matrix metalloproteinase-1; ROS = reactive oxygen species. | Pandey, V., & Jaap Willems, W. (2015). Rotator cuff tear: A detailed update. Asia-Pacific journal of sports medicine, arthroscopy, rehabilitation and technology, 2(1), 1–14. https://doi.org/10.1016/j.asmart.2014.11.003

Clinical features

Depending on when the patient presents, the tendon will be anywhere from tendinopathy to partial tear to complete tear.

Shoulder pain:

Pain can be acute and arise from a traumatic event, or it can be gradual and mild, but steadily increasing. Active individuals present when they can no longer do their sport, activity, or job without causing pain. Often they will try to adapt or alter their biomechanics to remain active. Only when they can no longer adapt will they present.
  • Increasing pain and difficulty with:
  • Overhead activity, activities of daily living
  • Lifting/carrying heavy objects
  • When lying on their side to sleep
  • Radiation down into the area of deltoid muscle (occasionally)
Atrophy of the supraspinatus and infraspinatus fossas can be visible in chronic tears. | Hsu, J., & Keener, J. D. (2015). Natural History of Rotator Cuff Disease and Implications on Management. Operative techniques in orthopaedics, 25(1), 2–9. https://doi.org/10.1053/j.oto.2014.11.006

Diagnosis

Clinical examination:

Plain radiograph:

  • Grashey view: Activates deltoid muscle allowing proximal humeral migration in chronic, larger tears
  • Scapular Y view: Assess acromial spurs associated with cuff tears that may need to be addressed at the time of surgery
  • Axillary view: Demonstrate joint space narrowing as well as potential anterior or posterior humeral subluxation
Proximal humeral migration is best viewed on a true AP radiograph with the arm in 30 degrees of abduction. | Hsu, J., & Keener, J. D. (2015). Natural History of Rotator Cuff Disease and Implications on Management. Operative techniques in orthopaedics, 25(1), 2–9. https://doi.org/10.1053/j.oto.2014.11.006

MRI:

The presence or absence of muscle atrophy should be documented in full-thickness tears and graded according to the Goutallier classification. Concomitant pathology to other structures such as the long head of the biceps, labrum and early glenoid and humeral chondrosis should be assessed.
Fatty muscle degeneration of the rotator cuff muscle bellies is best visualized on MRI with T1 oblique sagittal cuts. | Hsu, J., & Keener, J. D. (2015). Natural History of Rotator Cuff Disease and Implications on Management. Operative techniques in orthopaedics, 25(1), 2–9. https://doi.org/10.1053/j.oto.2014.11.006

Management

Conservative management:

Physical therapy along with activity modifications, anti-inflammatory and analgesic medications form the pillars of nonoperative treatment.
  • NSAIDs (first-line medication)
  • Subacromial corticosteroid injections (short-term pain relief and to facilitate rehabilitation)
  • Physical therapy and home exercise programs

Surgical management:

Single and double row repairs of full thickness tears. | Sambandam, S. N., Khanna, V., Gul, A., & Mounasamy, V. (2015). Rotator cuff tears: An evidence based approach. World journal of orthopedics, 6(11), 902–918. https://doi.org/10.5312/wjo.v6.i11.902

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