Rotator cuff tears (RCT) are classified as partial thicknes or full thickness, depending on the degree of injury. A useful arthroscopic classification for partial tears devised by Snyder and Cofield divides RCT locations into articular (A) or bursal (B) surfaces. This classification further subdivides RCTs based on size into: normal tendon with smooth synovium and bursal coverings (0), minimal bursal or synovial irritation with fraying less than 1 cm (I), fraying of bursa or synovium with tendon involvement 1 to 2 cm (II), severe injury with involvement of entire surface of cuff tendon usually 2-3 cm, and very severe fragmentation with involvement of flap tear measuring more than 4 cm (IV).24
Another RCT classification described by Jacobsen divides RTCs into articular surface, bursal surface, intrasubstance, or combination tears depending on which surface is effected.20
Massive RCTs are usually >5cm and involve complete detachment of at least 2 tendons1; long head of biceps tendon (LHB) tears are partial or complete2; and pectoralis major (PM) tears are classified by degree of injury and location.3 Pectoralis minor and deltoid tears are rare without a formal classification scheme.
Finally, it is important to distinguish between traumatic and non-traumatic rotator cuff tears as it guides treatment options. Surgery is usually indicated in traumatic cases, while a trial of non-surgical treatment is warranted in non-traumatic injuries.
Rotator cuff injury occurs when any of the 4 muscle-tendon units that surround the shoulder become damaged. Acute tears result from increased tensile force/overload or by direct laceration. Nontraumatic tears result from chronic changes of a preexisting injury or by diminished vascularization because of age, generalized comorbidities, or tobacco usage. Subacromial impingement syndrome is possibly the most common cause of rotator cuff tears.25
Epidemiology including risk factors and primary prevention
RCTs primarily affect persons aged 40 and older. In addition to degeneration and direct trauma, traumatic tears are associated acutely with shoulder dislocation4 as well as repeated, overhead motion. In addition, LHB tears are associated with RCTs almost 75% of the time.5 Massive RCTs can be associated with deltoid rupture because of superior humeral head migration causing rupture of the deltoid muscle fibers.6 PM injury is typically associated with indirect trauma, such as weight lifting.7
The rotator cuff is composed of 4 separate muscle tendon units (supraspinatus, infraspinatus, subscapularis, and teres minor) originating from the scapula and inserting into the humerus. The PM arises in 2 divisions (superior and inferior). Both divisions converge and form the tendinous insertion on the humerus lateral to the bicipital groove. The LHB arises in the shoulder joint capsule with intra-articular and extra-articular portions.
SAIS occurs due to narrowing of the acromiohumeral distance (AHD). In healthy shoulders, this measures to be 7-14 mm. Variations in shape of acromion have been widely accepted to increase risk of RCTs by decreasing AHD. Acromion morphology can be flat (type 1), curved (type 2), or hooked (type 3). This can lead to extrinsic impingement.
Internal impingement, which also a form of extrinsic impingement, is not necessarily related to AHD. Internal impingement occurs on the articular surface of the tendon, usually between the superior glenoid and humeral head when shoulder is in an abducted, externally rotated, and extended position.
On the other hand, intrinsic impingement occurs due to degenerative process of the tendon itself described below. 26
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
Rotator cuff disease and impingement begins in early adulthood, and progresses in subsequent years. According to Neer, the first phase of rotator cuff impingement begins at around twenty years of age, where there is increased edema and hemorrhage of subacromial bursa and rotator cuff tendons. This stage is usually reversible. The second stage involves inflammatory remodeling changes and degeneration of the tendon. Inflammation can lead to calcific deposits resulting in rotator cuff tendonitis. This stage usually begins in mid-twenties. Finally, in stage three, partial or full rotator cuff tears occur. This occurs after forty years of age. 27
Specific secondary or associated conditions and complications
Associated conditions with RCTs and LHB, PM, and deltoid tears include glenohumeral dislocation/subluxation, acromioclavicular separations, glenoid labrum tears, and instability. A significant complication of these conditions (especially in the acute setting) is adhesive capsulitis.
2. ESSENTIALS OF ASSESSMENT
Essential components of a history with shoulder injuries include when the injury occurred, what was the mechanism of injury, if the event was acute or chronic, the location of the symptoms, and if there is any radiation of symptoms. Other important components include prior shoulder injuries, what makes the symptoms better or worse, and what interventions have been attempted thus far.
Examination includes inspection for atrophy, bruising, or deformity (Popeye or Ludington signs) and palpation of region. Then, active and passive range of motion, strength, neurovascular testing, and special tests are performed. Special attention should be paid attention to muscle tone, symmetry, and deformity. An examination of the opposite shoulder should always be performed as a comparison as well as a cervical spine examination, if needed, to rule out spine pathology.
Special testing should include rotator cuff strength (empty can, external rotation, belly/lift-off), impingement testing (Hawkins sign and Neer sign), LHB testing (Yergason and/or Speed tests), and labral testing (O’briens).
At the beginning stages of supraspinatus tears, Jobe sign (PPV 0.84) may be positive. As tears progress, the external rotation lag sign (PPV 1.0) can be used to test the integrity of supraspinatus and infraspinatus muscles. The drop test (PPV 1.0) can distinguish infraspinatus tears from supraspinatus. The internal rotation lag sign (PPV 0.97) can be used to test supraspinatus, as well as the lift-of (PPV 1.0).28 The bear hug test was found to have a sensitivity of 0.60, and specificity of 0.92. 30 The bear hug test can detect subscapularis tears as small as 30%, while the lag-sign becomes positive when more than 75% of the tendon is torn.30
For rotator cuff impingement, the Neer sign has a sensitivity of 0.68 and specificity of 0.69, while Hawkin’s sign has a sensitivity of 0.72 and specificity of 0.66. The best post-test probability for any degree of impingement can be yielded by combining the Hawkin’s-Kennedy impingement sign with the painful arc sign, and the infraspinatus muscle test (95%).29
Other rotator cuff tests include the infraspinatus muscle strength test, with a sensitivity of 0.42 and specificity of 0.90. The painful arc sign has a sensitivity of 0.74 and specificity of 0.83. Drop-arm test has low sensitivity of 0.27 but highly specific (0.84).
For long head biceps testing, Yergason’s test can be used. Speed’s test has a sensitivity of 0.38 and specificity of 0.83.29
Since cervical spine pain can closely mimic shoulder pain, The Arm Squeeze Test can be used to evaluate for neck symptoms, with a sensitivity of 0.96 and specificity of 0.91-1.0.18
Activities of daily living (ADLs) may be limited in older adults, specifically self-care activities above shoulder level and behind the back; this includes the ability to dress oneself, reaching for a wallet, combing one’s hair, and donning a jacket. Evaluation of biomechanics with the intent to improve form and posture should also be assessed as well.
Although laboratory studies are not considered routine, tears are more often seen in those with diabetes, rheumatologic conditions, and other conditions that may affect localized blood flow to the cuff (eg, small vessel disease).
According to New Zealand Guidelines group, plain radiography of shoulder should be ordered when there is a high suspicion for fracture, a dislocated shoulder in someone older than 40 years of age, or when surgery is considered.30 Suggested plain radiography views include anterior-posterior, axillary, and supraspinatus outlet used to examine alignment and degenerative changes about the shoulder. Ultrasound may be utilized to diagnose rotator cuff and biceps tendon pathology, having the advantage of being quick, noninvasive, dynamic, and inexpensive. A limitation to ultrasounds is its diagnostic accuracy and that it is operator dependent.8 Magnetic resonance imaging (MRI) may be used to diagnose full thickness RCTs and PM tears. MRI arthrography of the shoulder is the criterion standard performed when there is clinical suspicion of a full thickness RCT and/or a labral tear or postoperative complications. In one retrospective study, US identified rotator cuff tears with a sensitivity of 0.88 and specificity of 0.89 in comparison to MRI which had a sensitivity of 0.91 and specificity of 0.84.19 Therfore, US is an important imaging modality to evaluate for RTC tears prior to obtaining an MRI.19
Supplemental assessment tools
The Western Ontario Rotator Cuff Index (WORC) is a well-validated condition-specific self-reported assessment tool designed to assess quality of life in patients with shoulder complaints because of rotator cuff disease. It comprises 21 visual analog scale items in 5 domains: physical symptoms, sports/recreation, emotions, lifestyle, and work.9-10 Additionally, another common shoulder assessment tool is the Penn Shoulder Score, a 100-point shoulder-specific self-report questionnaire consisting of 3 subscales of pain, satisfaction, and function.
Patient outcomes can also be assessed with the Simple Shoulder Test (SST). Patients without RTCs typically have lower SST scores than those with RCT tears. Restrictions in ADLs were greater in patients with higher SST scores and associated RCTs.15 Another index that can be used in the postoperative period is the Penn Shoulder Score. The Penn Shoulder Score is a shoulder-specific self-report questionnaire consisting of 3 subscales of pain, satisfaction, and function utilized to assess functional gains.16
Early predictions of outcomes
Conservative treatment is reasonable for a partial tear or if it is irreparable, whereas surgical intervention should be considered for younger patients with acute tears or for reparable tears, particularly for traumatic ruptures11. Surgical success is reduced when fatty infiltration or RCT retraction is present. Recreational athletes have a good prognosis for return to sport, but return to prior level of play is reduced in elite overhead athletes. PM tears in older, sedentary patients or other proximal muscle belly tears are usually treated non-surgically. In other types of PM tears or with younger patients, surgical intervention results in increased functional outcome.12
Trauma is typically the root of RCTs and PM and deltoid tears; LHB tears are associated with RCTs. A weakened rotator cuff with a normal deltoid can result in superior migration of the humeral head, allowing the tuberosity to repetitively abut the coracoacromial arch. This migration can result in further injury to the supraspinatus, and may lead to tearing of the tendon. Repetitive traction, friction, and glenohumeral rotation because of upward migration of the humeral head can lead to LHB tendinopathic changes.12
Social role and social support system
Rehabilitative services designed to improve ADLs are imperative for a successful outcome. Injury prevention must include strengthening the dynamic and static muscle stabilizers. Dynamic muscular imbalances developed in some athletes by excessive weightlifting (eg, bench press) works against the function and may lead to further injury.
Developing a strong working relationship with orthopedic colleagues will facilitate initiation of treatment algorithms quicker. One algorithm is the 50% rule, which states that tendon and ligament injuries with involvement of less than 50% are best treated by non-operative management, which can allow physiatrists to determine quickly if a patient can rehabilitate an injury or will require surgical referral.13
3. REHABILITATION MANAGEMENT AND TREATMENTS
Available or current treatment guidelines
Current treatment guidelines are based on the degree of tendon tear and location. If there is not a complete or full thickness tear, initial treatment involves activity modification, physical therapy, pain control, corticosteroid injections, and analgesic medications.
At different disease stages
A rotator cuff tear (RCT) is considered irreparable if the defect cannot be closed operatively or if repair will lead to structural failure. Imaging findings suggesting irreparability of the RCT include static superior subluxation of the glenohumeral joint with an acromiohumeral interval of less than 7 mm or fatty infiltration.1 If the patient fails to make progress after several weeks, a subacromial corticosteroid injection may provide significant pain control and allow progression in physical therapy.
Corticosteroid injections can be used for rotator cuff partial tears that don’t improve with conservative treatment or for older patients with operable lesions but, medically, are not good surgical candidates. Injections may also be used for individuals for full thickness tears that are not surgical candidates for pain control. One must pay particular attention for potential chondrotoxicity with use of bupivacaine when used in shoulder injections, or via an infusion pump.21
In one review study comparing the accuracy of landmark guided subacromial injections in both live human subjects and cadavers to ultrasound guided injections, no significant difference between the two existed (65% in the landmark group vs 70% in the ultrasound group). However, there was a significant difference in the glenohumeral intra-articular injection group where landmark guidance yielded only 73% accuracy versus %93 percent in the ultrasound group. Therefore, in impingement cases where there is a superimposed adhesive capsulitis or glenohumeral arthrosis, one may consider ultrasound guided glenohumeral injections as opposed to landmark guided glenohumeral injections. In isolated impingement cases, either ultrasound guided or landmark guided subacromial may be considered. 32
In cases of calcific tendonitis, ultrasound guided percutaneous tenotomy and has emerged as an option when conservative management including analgesics, physical therapy, and corticosteroid injections failed whereas in the past. In the past, surgery would have been the only option.22 Platelet rich plasma and bone marrow stem cells have been emerging as alternatives to corticosteroids in conservative management of RCTs and impingement syndrome as discussed in a subsequent section of this article.
If there is no improvement after 3 to 6 months of therapy, surgical consultation for operative repair is recommended. Traumatic rotator cuff tears are usually treated surgically. Chronic, full thickness tears are treated surgically if they are symptomatic. There is weak evidence for surgical repair of chronic partial rotator cuff tears. There is weak consensus evidence on negative outcomes in diabetics, smokers, patients on with previous shoulder injection, or cervical pathology. There is moderate consensus on negative outcomes for patients on disability.33
Most shoulder RTC rehabilitation programs, especially those at home with therabands, emphasize open kinetic chain (OKC) exercises. Closed kinetic chain exercises are also used to promote dynamic joint stability. Other rehabilitation strategies include correction of kinetic chain deficits, muscle recruitment patterns, posture, and scapulohumeral kinesis. This is followed by proprioceptive and neuromuscular training, then integrating the entire kinetic chain into occupational and sport-specific training. OKC exercises are essential to regain high demand functionality, as in overhead throwers.
Transition from physical therapy to a home program in order to maintain active range of motion, proprioception, and strength is recommended. Avoidance of aggravating factors is suggested (eg, increased loads overhead).
Coordination of care
Outcomes are improved when there is communication between all members of the care team. Facilitating a smooth transition of care between different members of the treatment team is essential for a successful outcome.
Patient & family education
Patients should be educated on the various treatment options and recovery timeline for their injury. Explaining the differences between full-thickness versus partial thickness RCTs is imperative to facilitate long-term expectations. Compliance in a formal physical therapy program will lead to a successful transition to a long-term home exercise program.14
Platelet rich plasma (PRP) has gained substantial coverage in the media, and popularity among professional athletes. However, evidence for benefit is lacking in research. In one Cochrane review, Khan et. al. found no benefit for use of PRP after a literature search.34 Keene et. al went further to suggest possible microbial growth in PRP preparations. 35 Greenspoon et. al found no benefit of use of PRP in RTC repair. 36
Conversely, one randomized study in 40 patients showed similar results of PRP subacromial bursa injection to corticosteroid but with better outcomes for PRP group at 12 weeks using Shoulder Assessment Form, Simple Shoulder Test, Constant-NMurley Score, and Visual Analogue scale. 37
Regenerative treatments using bone marrow autologous cells concentrate (BMC) have been emerging for treatment of shoulder osteoarthritis and rotator cuff tendonopathy. Even though BMC has showed promised in a multi-center prospective study, the results have yet to be reproduced, and the study was funded by a party with financial investment in BMC.23
Therefore, for patients that have failed conservative therapy and would like to avoid surgery, regenerative treatments such as PRP, prolotherapy, and BMC are worthy of consideration. However, patients need to be reminded that these are experimental treatments with potentials for harm.
Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
For young overhead athletes, make sure that the athlete is pain free with normative range of motion and strength prior to letting the patient return to full participation. Sport-specific or work-specific exercises must be included at the end of rehabilitation to complete the treatment and prevent future injury. Consider imaging and surgical consult early for younger patients with acute injuries and loss of range of motion.
4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE
Cutting edge concepts and practice
Musculoskeletal ultrasound has become a popular imaging modality for direct visualization of the rotator cuff.17 Ultrasound has the advantage of being a quick and dynamic technique and allows for image-guided injections. However, the technique is based on operator experience.8
Cutting-edge concepts in tendon healing include extracorporeal shockwave therapy (ECSWT), regenerative therapies (ie, platelet-enriched plasma [PRP]), and tenotomy with and without PRP. Each intervention shows some promise for pain and healing, however evidence remains inconclusive.34,35,36
5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE
Gaps in the evidence-based knowledge
Questions that remain to be answered include if eccentric exercise improves outcomes for shoulder tendon injuries similarly to the hamstrings and Achilles and whether PRP or ECSWT play a role in treatment of partial RCTs. Also, the role of biologics, such as PRP and stem cells in the setting of frank tears, is not clear.34,35,36
- Gerber C, Wirth SH, Farshad M. Treatment options for massive rotator cuff tears. J Shoulder Elbow Surg. 2011;20 (2 Suppl):S20-S29.
- Chen CH, Hsu KY, Chen WJ, Shih CH. Classification and analysis of pathology of the long head of the biceps tendon in complete rotator cuff tears. Chang Gung Med J. 2012;3:263-270.
- Tietjen R. Closed injuries of the pectoralis major muscle. J Trauma. 1980;20:262-264.
- Robinson CM, Shur N, Sharpe T, Ray A, Murray IR. Injuries associated with traumatic anterior glenohumeral dislocations. J Bone Joint Surg Am. 2012;94:18-26.
- Miller C, Savoie FH. Glenohumeral abnormalities associated with full-thickness tears of the rotator cuff. Orthop Rev. 1994;23:159-162.
- Morisawa K, Yamashita K, Asami A, Nishikawa H, Watanabe H. Spontaneous rupture of the deltoid muscle associated with massive tearing of the rotator cuff. J Shoulder Elbow Surg. 1997;6:556-558.
- El Maraghy AW, Devereauz MW. A systemic review and comprehensive classification of pectoralis major tears. J Shoulder Elbow Surg. 2012;21:412-422.
- Finnoff JT, Smith J, Peck ER. Ultrasonography of the shoulder. Phys Med Rehabil Clin N Am. 2010;21:481-507.
- Kirkley A, Griffin S, Dainty K. Scoring systems for the functional assessment of the shoulder. Arthroscopy. 2003;19:1109-1120.
- de Witte PB, Henseler JF, Nagels J, Vliet Vlieland TP, Nelissen RG. The Western Ontario rotator cuff index in rotator cuff disease patients: a comprehensive reliability and responsiveness validation study. Am J Sports Med. 2012;40:1611-1619.
- Petilon J, Carr DR, Sekiya JK, Unger DV. Pectoralis major muscle injuries: evaluation and management. J Am Acad Orthop Surg. 2005;13:59-68.
- Refior HJ, Sowa D. Long tendon of the biceps brachii: sites of predilection for degenerative lesions. J Shoulder Elbow Surg. 1995;4:436-440.
- Pedowitz RA, Higashigawa K, Nguyen V. The “50% rule” in arthroscopic and orthopaedic surgery. Arthroscopy. 2011;27:1584-1587.
- Brox JI, Gjengedal E, Uppheim G, et al. Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II impingement syndrome): a prospective, randomized, controlled study in 125 patients with a 2 1/2-year follow-up. J Shoulder Elbow Surg. 1999;8:102-111.
- Nakajima D, Yamamoto A, Kobayashi T, et al. The effects of rotator cuff tears, including shoulders without pain, on activities of daily living in the general population. J Orthop Sci. 2012;17:136-140.
- Leggin BG, Michener LA, Shaffer MA, Brenneman SK, Iannotti JP, Williams GR Jr. The Penn shoulder score: reliability and validity. J Orthop Sports Phys Ther. 2006;36:138-151.
- Smith TO, Back T, Toms AP, Hing CB. Diagnostic accuracy of ultrasound for rotator cuff tears in adults: a systematic review and meta-analysis. Clin Radiol. 2011;66:1036-1048.
- Gumina S, Carbone S, Albino P, Gurzi M, Postacchini F. Arm Squeeze Test: A new test to distinguish neck from shoulder pain. European Spine Journal. 2013: 22: 1588-1563.
- Nagvi GA, Jadaan M, Harrington P.Accuracy of ultrasonography and magnetic resonance imaging for detection of full thickness rotator cuff tears. International Journal of Shoulder Surgery. 2009: 3(4): 94-97.
- Jacobson, J. Fundamentals of musculoskeletal ultrasound. 2013: 2nd Edition: 18-24.
- Webb ST, GhoshS. Intra-Articular Bupivacaine: potentially chondotoxic? British Journal of Anesthesia. 2009: 102(4): 438-441.
- Lin JT, Adler RS, Bracilovic A, Cooper G, Sofka C, Lutz G. Clinical outcomes of ultrasound-guided aspiration and lavage in calcific tendinosis of the shoulder. Hospital for Special Surgery Journal. 2007: 3(1): 99-105.
- Centeno CJ, Al-Sayegh H, Bashir J, Goodyear S, Freeman M. A prospective multi-site registry study of specific protocol of autologous bone marrow concentrate for the treatment of shoulder rotator cuff tears and osteoarthritis. Journal of Pain Ressearch. 2015: 8: 269-276.
- Lee CS, Davis SM, Doremus B, Kouk S, Stetson WB. Interobserver agreement in the classification of partial-thickness rotator cuff tears using the Snyder classification system. Orthopedic Journal of Sports Medicine. 2016: 4(9): eCollection 2016.
- Van der Windt DA, Koes BW, de Jong BA, Bouter LM. Shoulder disorders in general practice: incidence, patient characteristics, and management. Annals of Rheumatic Disease. 1995: 54(12): 959-64.
- Umer M, Qadir I, Azam M. Subacromial impingement syndrome. Orthopedic Reviews. 2012: 4(2): e18 online.
- Neer CS 2nd. Impingement Lesions. Clinical Orthopedics and Related Research. 1983. 70-7.
- Hertel R, Ballmer FT, Lambert SM, Gerber C. Lag signs in the diagnosis of rotator cuff rupture. Journal of Shoulder and Elbow Surgery. 1995: (95): 80101-4.
- Park HB, yokota A, Gill HS, El Rassi G, McFarland EG. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. Journal of bone and Joint Surgery. 2005: (87):7: 1446-1455.
- Barth JR, Burkhart SS, De beer JF. The bear-hug test: a new and sensitive test for diagnosing a subscapularis tear. Arthroscopy. 2006: 22(10): 1076-84.
- New Zealand Guidelines Group. The management and diagnosis of soft tissue shoulder injuries and related disorders. July 2014.
- Aly AR, Rajasekaran S, Ashworth N. Ultrasound-guided shoulder girdle injections are more accurate and more effective than landmark-guided injections: a systematic review and meta-analysis. British Journal of Sports Medicine. 2015: 49(16): 1042-9.
- Pedowitz RA, Yamaguchi K, Ahmad CS, Burks RT, Flatow EL, Green A, Weis JL, St Ander J, Boyer K, Iannotti JP, Miller BS, Tashjian R, Walters WC 3rd, Weber K, Turkelson CM, Raymond L, Sluka P, McGowan R. American Academy of Orthopaedic Surgeons Clinical Practice Guideline on: optimizing the management of rotator cuff problems. Journal of Bone and Joint Surgery of America. 2012: 94(2): 163-7.
- Khan M, bedi A. Cochrane in CORR: Platelet-rich Therapies for Musculoskeletal Soft Tissue Injuries (Review). Clinical orthopaedics and related research.2015: 473: 2207-13.
- Keene, D, Alsousou J, Willett K. How effective are platelet rich plasma injections in treating musculoskeletal soft tissue injuries? BMJ. 2016: 352:i517
- Greenspoon JA, Moulton SG, Millett PJ, Petri M. The Role of Platelet Rich Plasma (PRP) and other biologics for rotator cuff repair. Open Orthopedic Journal. 2016: 10:309-14.
- Shams A, El-Sayed M, Gamal O, Ewes W. Subacromial injection of autologous platelet-rich plasma versus corticosteroid for the treatment of symptomatic partial rotator cuff tears. European Journal of Orthopaedic Surgery and Traumatology. 2016: Dec 26(8): 837-42.
Original Version of the Topic
Jason L. Zaremski, MD, Kevin Vincent, MD. Shoulder tendon and muscle injuries. 09/20/2013.
Original Version of the Topic
Tariq Hilal, MD
Nothing to Disclose