Rotator Cuff Tear

Aetiology

  • Usually occurs in older patients (> 40 years)
  • The tendons of the rotator cuff can tear with minimal or no trauma as a consequence of degenerate changes in the tendons
  • Acute tear - fall on outstretched arm, sudden jerk (e.g. holding a rail on a bus which suddenly stops)
  • Degenerative tear - wearing down over time
    • At least 20% of over 60 year olds have asymptomatic cuff tears due to tendon degeneration
  • Rotator cuff tendons can tear in young patients due to a significant injury (including shoulder dislocation) although this is very uncommon

Pathophysiology

Type of tear

  • Tears can be partial or full thickness
  • Tears usually involve supraspinatus
  • Large tears can extend into subscapularis and infraspinatus

Clinical presentation

Symptoms

  • Pain in front of shoulder that radiates down arm
  • Associated weakness

Signs

  • Wasting of supraspinatus
  • Tenderness in subdeltoid region
  • Tests: Jobe's test, infraspinatus, subscapularis

Investigations

  • X-ray
  • USS if good ROM
  • MRI if reduced ROM

Management

General measures

  • Rest, sling
  • Analgesia

Acute

  • Urgent investigation
  • Early physio, reassessment and surgical intervention
    • Surgery involves an arthroscopic or open repair of rotator cuff
    • Controversial - failure occurs in 1/3 of cases
    • Rehab involves a sling for 6 weeks, 12 weeks no heavy lifting, prolonged physiotherapy and a long recovery time (6-9 months)

Degenerative

  • Physiotherapy - anterior deltoid strengthening
  • Subacromial injections
  • Wait and see approach

Complications

  • The torn rotator cuff will mean the deltoid pulls the head of humerus upwards
  • Abnormal forces on glenoid leads to OA
  • Anatomic shoulder replacement will fail - reverse polarity shoulder replacement instead