Updated: 12/27/2021

Rotator Cuff Injury

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  • Snapshot
    • A 70-year-old man presents to his physician for left shoulder pain for the past several months. He reports that he cannot reach above his head without any pain. As a retired carpenter, he reports that this has significantly impacted his quality of life. Additionally, he is unable to lie on his left side at night due to shoulder pain. On physical exam, there is focal tenderness over the left anterolateral shoulder. Radiography reveals reduced space between the acromion and humeral head.
  • Introduction
    • Clinical definition
      • injury to 1 or more of the rotator cuff muscles
        • injury is typically due to tear or tendinopathy
        • rotator cuff muscles, which are all innervated by C5 and C6, are the SITS
          • Supraspinatus
            • innervation
              • suprascapular nerve
            • function
              • initial abduction of the arm (0-15°)
          • Infraspinatus
            • innervation
              • suprascapular nerve
            • function
              • lateral rotation of the arm
          • Teres minor
            • innervation
              • axillary nerve
            • function
              • adduction and lateral rotation of the arm
          • Subscapularis
            • innervation
              • upper and lower subscapular nerves
            • function
              • adduction and medial rotation of the arm
  • Epidemiology
    • Incidence
      • the supraspinatus muscle is most commonly injured
    • Demographics
      • adults
    • Risk factors
      • older age
      • smoking
      • repetitive overhead reaching
  • Etiology
    • Pathogenesis
      • acute avulsion injuries
        • typically following trauma
      • chronic degenerative tears
        • repetitive overhead motions
        • tendon weakening due to degenerative changes and chronic impingement
    • Associated conditions
      • biceps tendinopathy
      • osteoarthritis
  • Presentation
    • Symptoms
      • shoulder pain
        • exacerbated by
          • sleeping on the affected shoulder
          • reaching overhead
      • limited function of the shoulder
    • Physical exam
      • severe focal tenderness at the insertion of supraspinatus (anterolateral shoulder)
      • decreased active elevation with normal passive range of motion
      • Hawkins impingement test
        • passive internal rotation of the shoulder with the patient seated and elbow flexed 90°
        • test is positive if there is pain
      • Neer impingement test
        • passive elevation of the arm while internally rotated with the patient standing
        • test is positive if there is pain
      • painful arc sign
        • pain with active abduction between 60° and 120°
      • empty can test
        • patient with arm elevated to 90° with elbow extended and thumbs down
          • clinician applies a downward force on the arm while patient resists
        • test is positive if there is pain
        • 90% specificity for supraspinatous pathology
  • Imaging
    • Radiography
      • indication
        • for all patients as initial imaging
      • findings
        • loss of subacromial space, due to upward migration of humeral head
    • Magnetic resonance imaging (MRI)
      • indications
        • if radiography is normal but there is suspicions for rotator cuff injury
        • not indicated for all patients
        • most accurate test
  • Studies
    • Making the diagnosis
      • most cases are clinically diagnosed
  • Differential
    • Adhesive capsulitis
      • distinguishing factor
        • active and passive range of motion are limited
  • Treatment
    • Conservative
      • physical therapy
        • indication
          • for all patients
    • Medical
      • nonsteroidal anti-inflammatory drugs (NSAIDs)
        • indications
          • for all patients
          • pain management
      • steroid injections
        • indication
          • for patients who fail NSAIDs as pain management
    • Operative
      • surgical repair
        • indications
          • for patients with complete tears
          • for patients who fail all other more conservative management of 3-6 months
  • Complications
    • Functional limitations
    • Adhesive capsulitis
  • Prognosis
    • Re-tear may occur
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Questions (4)
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(M2.OR.17.4799) A 69-year-old gentleman presents to his primary care physician for pain in his right shoulder. The patient was helping his son move this past weekend, and he noticed after the move that he had pain and weakness in his right shoulder. The patient thought that this pain was just him being in poor shape so he started going to the gym and lifting weights which made his symptoms significantly worse. The patient has a past medical history of diabetes, obesity, and asthma. His current medications include albuterol, lisinopril, metformin, and glipizide. On physical exam you note an obese gentleman who seems to be in pain. You note prominent weakness of external rotation of his right upper extremity. When you ask the patient to slowly lower his right arm to his side when he holds it overhead, you note that he suddenly drops his arm and appears to be in pain. The patient's strength is 1/5 for abduction of the right arm. Which of the following is most likely injured in this patient?

QID: 109204

Supraspinatus

65%

(15/23)

Infraspinatus

17%

(4/23)

Teres minor

4%

(1/23)

Subscapularis

4%

(1/23)

Deltoid

4%

(1/23)

M 6 C

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