Nonacute Shoulder Disorders

I. ROTATOR CUFF DISORDERS

A. Anatomy. The rotator cuff is made up of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles. The spectrum of rotator cuff disorders is broad, ranging from rotator cuff tendinopathy to massive full-thickness tears. What many refer to as “impingement” is also commonly included within this spectrum, although the relationship between impingement and the subacromial space and rotator cuff disease is hotly debated within the orthopaedic surgery field. Some propose that narrowing of the subacromial space leads to rotator cuff injury,¹ while others believe there is no causal relationship between the two.² The subacromial space involves the area from the undersurface of the acromion and the acromioclavicular (AC) joint superiorly to the coracoacromial ligament and coracoid anteriorly, to the humeral head inferiorly. The subacromial bursa exists within the subacromial space above the rotator cuff, but underneath the acromion.

B. Mechanism of injury. Proponents of impingement pathology put forth that narrowing of the subacromial space may lead to compression of the rotator cuff against the overlying acromion and to eventual tearing of the rotator cuff. Thickening of the bursa, undersurface spurring of the AC joint, instability of the glenohumeral joint, or changes in the shape of the acromion are suggested as the most common reasons for rotator cuff compromise. The subacromial space narrowing from these causes and the patient’s symptoms that may result from this narrowing are referred to as impingement syndrome. The earliest form of rotator cuff disease involves bursitis and tendinosis and in some patients may progress to full-thickness cuff pathology. Others discard the concept of impingement and argue instead that intrinsic components such as age-related degeneration or diminished blood supply to the tendon are the primary etiology for rotator cuff disease. It is likely a combination of many of these factors that leads to the development of rotator cuff disease.

C. History. The typical patient with cuff disease is over age 40 and reports anterolateral shoulder or arm pain that is worse with overhead activities and while lying flat at night.

D. Examination. As with every shoulder examination, one begins with visual inspection. One significant finding for rotator cuff disease includes visible atrophy of the supraspinatus or infraspinatus fossa. Either a chronic massive rotator cuff tear or suprascapular nerve entrapment can cause atrophy of the muscle bellies that may be visible on inspection. Active and passive shoulder motion must be assessed, in addition to rotator cuff strength. Supraspinatus weakness may be present with rotator cuff tears, and significant external rotation weakness often indicates that a large rotator cuff tear is present. Evocative maneuvers such as Neer and Hawkins tests are often referred to as impingement tests and may give some indication of rotator cuff disease.

E. Imaging. A complete series of shoulder radiographs should be obtained. Cystic changes within the greater or lesser tuberosity may be suggestive of chronic rotator cuff disease. If rotator cuff disease is suspected with symptoms persisting despite nonoperative treatment or if a sizeable full thickness rotator cuff tear is suspected, an MRI is an appropriate next step in patient evaluation. For patients in whom an MRI is contraindicated, a CT arthrogram or ultrasound is the best manner to image the rotator cuff. In the hands of an experienced ultrasonagrapher, ultrasonagraphy can also provide visualization of rotator cuff pathology, and even assess the level of atrophy of the rotator cuff musculature.

F. Diagnosis. As previously mentioned, rotator cuff disease represents a wide spectrum of pathology from bursitis and tendinopathy to full-thickness rotator cuff tears. Diagnosis of a particular patient’s rotator cuff injury is made based on history, symptoms, response to nonoperative treatment, and finally additional imaging in the form of MRI, CT arthrogram, or ultrasound.

G. Treatment

Bursitis/tendinopathy/impingement.

a. Nonoperative treatment.

Physical therapy. The mainstay of treatment for patients without rotator cuff tears is physical therapy (PT). PT is typically the first line of treatment for patients with bursitis or rotator cuff tendinopathy, adhesive capsulitis, scapulothoracic dysfunction, and most nonacute shoulder pathology. The focus of treatment for these nonacute disorders includes regaining the patient’s normal range of motion first through a stretching program. This sometimes includes using modalities in order to diminish pain. Once range of motion is normalized, patients can be taught home exercises to improve strength and shoulder biomechanics. A focus on scapular stabilization is an essential component of rehabilitation for patients with chronic shoulder problems as this encourages healthy mechanics through the shoulder’s range of motion. A trial of several months of dedicated PT is very reasonable before considering surgery in the setting of many nonacute shoulder disorders.
Injections. Injections may be effective in the treatment of nonacute shoulder disorders. For example, a subacromial injection with a corticosteroid and an analgesic is frequently beneficial in this population. Of note, a prospective randomized clinical trial has not shown that inclusion of steroid in the injection solution improves outcome.³ Resolution of a patient’s pain or improvement in rotator cuff strength after the injection provides important information about the potential etiology of the patient’s symptoms. In addition, injections are often most important for patients with nonacute shoulder pathology who are otherwise unable to perform PT on account of pain. For many patients, this is also an effective long-term treatment option in the resolution of the patient’s symptoms.

b. Operative treatment is a reasonable option for patients who fail a minimum 6-month course of nonoperative treatment. Surgical management may include a bursectomy, recession of the coracoacromial ligament, and/or an anterior acromioplasty. These procedures may be completed through either open or arthroscopic techniques. Rotator cuff repair is extremely effective at providing improvements in pain and function and has been shown to be cost-effective as well.⁴ Arthroscopic techniques have the benefit of allowing a thorough examination of the glenohumeral joint for any concomitant pathology and improved cosmesis, and may provide quicker pain relief and return to activity postoperatively.

2. Rotator cuff tears

a. Nonoperative management. Although rotator cuff tears do not heal without surgery, some patients may not require surgical repair. Nonsurgical management is typically indicated for older, more sedentary patients or those whose activities do not demand normal shoulder strength. These patients may have improvement in their pain and function with PT alone. It is also important to note that some rotator cuff tears are not reparable based on the size of the tear, retraction of the tendon, or advanced atrophy of their rotator cuff muscles.⁵

b. Operative management. For most patients, rotator cuff repair offers the best chance at long-term improvement in shoulder pain and function.⁶ This can be achieved both open and arthroscopically.⁷ A recent study suggests that arthroscopic repair allows for a delayed rehabilitation program and potentially increased rates of tendon healing.⁸

3. Calcific tendinitis. This disorder involves consolidation of calcium within the substance of a rotator cuff tendon. This condition may be extremely painful, particularly when or if the calcium leaks out of the tendon as it causes an acute inflammatory bursitis. This disorder is treated symptomatically and a subacromial injection with corticosteroid and lidocaine may diminish acute symptoms and allow the patient to participate in PT. “Needling” the deposit (which in some cases is palpable) with an 18G needle and providing a subacromial injection may help to diminish the size of the deposit.⁹ This technique may also be done under ultrasound guidance. If needling or subacromial injections are ineffective in controlling the patient’s symptoms, the calcific deposit can be excised arthroscopically.

4. Long head of biceps (LHB) tendinitis often accompanies rotator cuff disease and frequently responds to bicipital groove injections or PT. If nonoperative treatment does not provide lasting relief, surgical treatment in the form of a tenotomy or tenodesis of the LHB may be indicated.

5. SLAP tears. Superior labrum anterior to posterior (SLAP) tears are common, particularly in older populations. Initial treatment should include an appropriate trial of nonoperative management.¹⁰

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