Rotator Cuff Tear

Question 1

What are the rotator cuff muscles?

Answer 1

Supraspinatus - abduction

Infraspinatus - external rotation

Teres minor - external rotation

Subscapularis - internal rotation

They also stabilise the humeral head in the glenoid fossa and prevents dislocations.

Question 2

Rotator cuff tear (RCT) epidemiology.

Answer 2

Common

40-70 usually

Question 3

Classifications of RCT

Answer 3

Acute < 3mo

Chronic > 3 mo

Partial or full thickness tears

Question 4

Classifications of full thickness tears

Answer 4

Small < 1cm

Medium 1-3 cm

Large 3-5 cm

Massive >5cm or multiple tendons

Question 5

Pathophysiology of acute tears

Answer 5

Pre-existing degeneration usually and typically occur alone following minimal force

Acute tears in young can be due to large force and the injury isn’t usually isolated.

Question 6

Pathophysiology chronic tears

Answer 6

Degenerative microtears from overuse and in work

More common in increasing age

Question 7

Risk factors

Answer 7

Age

Trauma

Overuse

Repetitive overhead shoulder motions (athletes, occupations)

BMI >25

Smoking

DM

Question 8

Clinical features

Answer 8

Pain over the lateral aspect of the shoulder

Inability to abduct the arm above 90 degrees

Question 9

Examination findings

Answer 9

Tenderness over greater tuberosity and subacromial bursa regions

Supraspinatus and infraspinatus atrophy if massive tear

Question 10

Specific tests of RCT

Answer 10

Jobe’s test (empty can test)

Gerber’s lift-off test

Posterior cuff test

Question 11

Explain Jobe’s test

Answer 11

Also called empty can test

Tests supraspinatus

Place shoulder in 90 abduction and 30 of forward flexion and internally rotate the arm fully.

Gently push downwards on the arm

+ve = weakness on resistance

Question 12

Explain Gerber’s lift-off test

Answer 12

Tests subscapularis

Internally rotate the arm so the dorsal surface of the hand rests on lower back.

Ask patient to lift hand away from back against examiner resistance.

+ve = Weakness in actively lifting the hand away from back

Question 13

Explain posterior cuff test

Answer 13

Tests infraspinatus and teres minor

Arm is positioned at patient’s side with the elbow flexed to 90.

Patient is instructed to externally rotate their arm against resistance.

+ve = Weakness on resistance

Question 14

Dx

Answer 14

Fracture

Glenohumeral subluxation

Brachial plexus injury

Radiculopathy

Question 15

Ix of RCT

Answer 15

Urgent plain film radiograph to exclude fracture

Once fracture has been excluded the tear can be assessed through further imaging.

USS = size of tear

MRI = size, characteristics and location of tear

Question 16

Prognosis of RCT

Answer 16

Main complication is adhesive capsulitis

Age-related tears usually gets enlarged within 5 years.

Question 17

What does management depend on?

Answer 17

Type of tear and functional status of the patient

Question 18

When should conservative management be done?

Answer 18

Not limited by pain or loss of function

Significant co-morbidities and unsuitable for surgery

Question 19

Explain conservative management.

Answer 19

If they present within 2 weeks since injury.

Includes analgesia and physio

Corticosteroid injections into the subacromial space can also be trialled

Question 20

Indications for surgical management

Answer 20

Presenting 2 weeks since injury or remaining symptomatic despite conservative management.

Large and massive tears

Question 21

Surgical management of RCT

Answer 21

Arthroscopical repair (allows earlier recovery)

Open approach (if large or complex tears)

Question 22

Prognosis of surgical repair

Answer 22

Tends to be very good

Might be worse if large or massive, >65 yo, poor compliance to rehab or current smokers.

Question 23

X-ray findings

Answer 23

Usually unremarkable and used to exclude fracture

Chronic tears might show reduced acromiohumeral distance, sclerosis or cyst formation