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Rotator Cuff RuptureAka: Rotator Cuff Tear

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  1. See Also
    1. Rotator Cuff Injury
  2. General
    1. Results from continued deterioration or degeneration
    2. Partial or complete rupture
    3. Rarely occurs under age 40 years (except athletes)
    4. Cuff rupture associated with Shoulder Dislocation
      1. Occurs in 50% of dislocations over age 50 years
  3. Mechanism
    1. Fall on Outstretched Hand
    2. Lifting heavy object
  4. Symptoms
    1. Usually no obvious trauma or injury
    2. Pain progressively worse
    3. Pain referred down deltoid muscle
    4. Unable to abduct or flex shoulder
  5. Signs
    1. Partial rupture appears similar as chronic Tendonitis
    2. Shoulder Range of Motion may be completely intact
    3. Shoulder Weakness
      1. Abduction weakness more common (Supraspinatus tear)
      2. Active abduction
        1. Painful arc over 50 degrees
      3. Passive abduction
        1. Results in painful catch at 50 to 100 degrees
      4. Forward flexion weakness indicates subscapularis tear
    4. Tenderness over rotator cuff tear site
    5. Defect palpated through deltoid in complete cuff tear
    6. Atrophy of cuff muscles
    7. Drop Arm Test positive
      1. Test Specificity: 98%
      2. Test Sensitivity: 10%
    8. Consider Local Lidocaine injection diagnostically
      1. Persistent difficult abduction suggests cuff tear
    9. Acute hemarthrosis and prominent Ecchymosis down arm
      1. Indicative of long standing cuff tear and arthropathy
    10. Chronic Sub-deltoid swelling indicates large cuff tear
      1. Synovial Fluid escaped from glenohumeral joint
  6. Diagnosis
    1. See Shoulder Impingement Signs
  7. Imaging
    1. Shoulder XRay
      1. Calcifications at humerus tuberosity
      2. Degenerative arthritis
        1. Acromioclavicular joints
        2. Glenohumeral joints
    2. Shoulder MRI
      1. Replaces arthrography
    3. Shoulder Arthrography (MRI is preferred)
      1. Differentiates full from incomplete rotator cuff tear
      2. Invasive test
      3. Perform only if considering surgery
    4. Shoulder Ultrasound
      1. Safe and noninvasive
      2. Accurate in large and moderate tears
  8. Differential Diagnosis
    1. Rotator Cuff Tendonitis
    2. Rotator Cuff Calcification
  9. Management: Referral Indications for Surgery (earlier is better)
    1. Young active patient with full thickness tear
    2. Competitive athletes
    3. Severe functional deficit
  10. Management: Algorithm
    1. Initial Evaluation: Painful cuff range of motion
      1. Start with RICE-M for first 3 days
      2. Switch to moist heat after 2-3 days
        1. Apply for 1 hour
        2. Apply 2-3 times per day
      3. Relative Rest
        1. Avoid complete rest especially in older patients
        2. Risk of Frozen Shoulder
      4. Gentle Shoulder Range of Motion Exercises
        1. Prevents Frozen Shoulder
      5. NSAIDs
      6. Avoid overhead shoulder activities or overuse
      7. Consider Shoulder XRay if Fracture suspected
    2. Re-evaluation in 2 weeks: Lack of improvement
      1. Early orthopedic referral if criteria above met
      2. Change NSAIDs
      3. Continue Shoulder Range of Motion Exercises
      4. Start Shoulder Strengthening Exercises
    3. Re-evaluation in 2 weeks: Lack of improvement
      1. Sub-acromial space Corticosteroid Injection
        1. Risk of weakening tendons
      2. Physical Therapy with Phonophoresis
    4. Re-evaluation in 2 weeks: Lack of improvement
      1. Shoulder MRI
      2. Orthopedics consultation
  11. References
    1. Greene in Wirth (2001) Musculoskeletal Care, p.141-3
    2. Krishman in DeLee (2003) Sports Medicine, p. 1065-92

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