Rotator Cuff Tear
Joseph A. Abboud
William J. Warrender
 A 58-year-old man presents with shoulder pain, difficulty sleeping, and decreased strength and range of motion with attempted overhead activities. |
CLINICAL PRESENTATION
Rotator cuff injuries are seen both in the young and old, but they are much more common in the older population. In younger patients, there usually is either a traumatic injury or the patient is demanding unusual use of the shoulder, as seen in professional baseball pitchers. As people age, the muscle and tendon tissue of the rotator cuff loses some elasticity, becomes more susceptible to injuries, and is often damaged while performing everyday activities. This is the reason that rotator cuff tears are more commonly seen in older patients.1-5
The most common symptom of a rotator cuff tear is pain. Often, the pain is felt over the outside of the shoulder and upper arm in the deltoid region. Patients will describe it as a generalized discomfort that is exacerbated with specific movements of the shoulder. Depending on the severity of the rotator cuff tear, there may also be a loss of motion. The patient also may complain of crepitus, catching, and stiffness.
If the injury is an incomplete tear, pain will likely be the most prominent symptom; decreased strength may be demonstrated but is usually not the patient’s primary complaint. However, in a complete rotator cuff tear, the patient will likely be unable to move the shoulder through some normal motions. The diagnosis of a rotator cuff tear is best made by a physical examination where the specific muscles that form the rotator cuff can be isolated and tested.
CLINICAL POINTS
The condition is much more frequently seen in patients over 45 years of age.
Pain into the lateral deltoid and biceps is the most common symptom.
A complete tear may result in an inability to move the shoulder, however, some patients demonstrate minimal functional limitations with a tear.
PHYSICAL FINDINGS
Approach the shoulder examination systematically in every patient with inspection, palpation, range of motion, strength testing, neurologic assessment, and performances of special shoulder tests.
Also, include evaluation of the cervical spine and distal portions of the upper extremity.
Inspect for scars, color, edema, deformities, muscle atrophy, and asymmetry.
Palpate the bony and soft tissue structures, noting any areas of tenderness.
Assess active and passive range of motion.
If a rotator cuff tear or subacromial impingement is suspected, then focus the examination and perform specific tests to reproduce the patient’s symptoms.
Patients with subacromial impingement have reproducible pain with the Neer and Hawkins tests (see Figs. 35-10 and 35-11). Both of these tests bring the greater tuberosity, the biceps tendon, and the rotator cuff under the coracoacromial arch and reproduce painful symptoms.2,6
Patients with full-thickness tears of the rotator cuff may exhibit weakness during testing of the particular muscle involved, may have a difference between active and passive range of motion of the shoulder, and may have atrophy of the muscles involved if it is a chronic tear.
During range-of-motion testing, patients will often initially shrug their affected shoulder when attempting to abduct their arms if a cuff tear is present, because they are using scapulothoracic motion to compensate for the inability of the cuff to abduct the arm2 (Fig. 39-1).
Pain and weakness with the active compression test indicates weakness of the supraspinatus2 (see Fig. 35-16).
Weakness or rupture of the external rotators of the shoulder should also be tested during the physical examination. Persons with large or massive cuff tears involving multiple tendons are often unable to actively externally rotate their arms while at their side.1,2,3,7
Another way of testing the integrity of the external rotators is to place the arm at the side of the patient with the elbow bent to 90 degrees and the arm passively externally rotated; once the arm is released, if the posterior cuff (infraspinatus) is torn, the arm will drift back into internal rotation because of the unopposed action of the subscapularis (external rotation lag sign) (see Fig. 35-13).
Similarly, the inability to actively externally rotate the abducted arm has been termed the hornblower’s sign (see Fig. 35-14).
One test that is specifically used to identify weakness of the subscapularis tendon is the belly-press test, also called the abdominal compression test (see Fig. 35-15). The test assesses the strength of internal rotation by having the patient place the hand of the affected side on the abdomen and then pressing the hand against the abdomen with the elbows in front of the torso. If the subscapularis is not intact, the patient cannot press against the abdomen and the elbow drops behind the torso.2,8
If there is a question as to the integrity of the rotator cuff with subacromial impingement, the author routinely injects the subacromial bursa with lidocaine, and after several minutes, the strength of the rotator cuff musculature is retested (Fig. 39-2).Related posts:
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