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Rotator Cuff Tear

Rotator Cuff Tears

Incidence
Rotator cuff disease is an extremely common condition, accounting for 16% of all musculoskeletal complaints. This creates an estimated social cost of £100 million after workplace absenteeism and insurance payouts have been taken into consideration (Bongers, 2001). Rotator cuff tears are common in active people taking part in overhead sports and occupations however, the incidence of rotator cuff tears increases with age leading to Bunker's aphorism 'grey hair equals cuff tear' (Bunker, 2002).

What is the rotator cuff?
The rotator cuff is a functional unit of four muscles arising from the scapular and inserting onto the humeral head (Fig 1 below).
rotator cuff web

Figure 1. Muscle of the rotator cuff.


Supraspinatus acts to initiate and facilitate shoulder abduction, infraspinatus and teres minor externally rotate the humerus, subscapularis internally rotates the humerus. Most importantly, as a functional unit, these four muscles act as stabilisers to locate and centre the humeral head into the glenoid fossa, a process known as concavity depression.

Rotator cuff tears
The vast majority of rotator cuff tears occur in the supraspinatus tendon with only 16% of tears occurring in the biceps and subscapularis tendons (Walch 1992). Evidence suggests that a combination of intrinsic and extrinsic factors (Bunker, 2002) contribute to the aetiology of rotator cuff disease progression through the continuum from impingement to tear (Cook and Pardum, 2008). 

Intrinsic theory
Supraspinatus is at greater risk of tear for two main reasons; the morphology and the avascular blood supply to its tendon. The initiating factors of a tear are due to degeneration and/or overload that instigate pathological changes in the tendons collagen structure. Cross-sectional analysis of pathological tendons has found that the usual continuity of type I collagen is broken up by areas of disorganised type III collagen that is weaker and thinner than type I. Avascularity reduces healing properties so the build-up of type III collagen continues and further weakens the tendon therefore propagating a downward spiral of disrepair (Garg et al, 2010).

Extrinsic theory
As degenerative changes occur in the tendon of supraspinatus, secondary changes occur at its insertion sight where the bone becomes sclerotic and nodular. As the tendon lesion progresses, the rotator cuff loses concavity depression of the glenohumeral joint, allowing subacromial impingement. Studies have shown that 95% of cuff tears can be attributed to impingement (Cooper and Ali, 2013). Acromial morphology has also been shown to contribute to impingement and subsequent cuff tear with type III or hooked acromion being the aggravating factor (Wang and Shapiro, 1997). A combination of intrinsic and extrinsic factors leads to irreparable microtrauma progressing from a lesion to a tear over time or due to trauma.

Diagnosis

Clinical presentation
The clinician will use a comprehensive and evidence based battery of tests to isolate structures within the shoulder joint that may be damaged. In some cases, tests can also involve the use of local anesthetic to reduce pain so that structures can be fully evaluated (Neer, 1972). Common clinical presentation may show (Brukner and Khan, 2012):

  • Weakness
  • Limited range of movement
  • Pain – commonly into the badge area of the upper arm
  • Pain exacerbated by overhead movement
  • Tenderness on palpation
  • Positive subacromial impingement tests 

Diagnostic imaging may also be used. X-ray can be used to obtain images of the shoulder to rule out arthritis, avascular necrosis or tumour. Ultrasound imaging or MRI (Magnetic Resonance Imaging) can be used depending on availability, cost and operator preference to assess size and location of the tear. All methods of imaging have a high specificity and sensitivity in diagnosing rotator cuff tears.

Treatment

Conservative management
Research has shown that success of conservative management can range from 33-82% (Bunker, 2002). Long term follow up revealed that conservative management has higher success rates when applied to patients with preserved range of movement and strength. NSAID, steroid or hyaluronic acid injection therapy can be used to reduce pain. Once pain is under control, physical therapy should be used to heat, stretch and preserve passive and active range of movement (Cooper and Ali, 2013). Treatment may last up to six months before other options are considered such as surgery.

Surgery
The larger the cuff tear, extent of retraction and more fatty muscle atrophy, the less chance there is of successful repair (for classification see Cooper and Ali, 2013). 50% of tears progress and deteriorate over time.

Post surgical protocol is essential for good functional outcome but can be prolonged and demanding with 91-94% patients achieving excellent or good results following arthroscopic repair. Initial four week physiotherapy interventions will involve maintenance of passive range of movement. After this period, active movement and strength exercises are gradually introduced. Sedentary workers may return to work after 3-4 weeks. Heavy lifting should be avoided for the initial three month period therefore manual workers are advised to avoid returning to work during this period (Cooper and Ali, 2013).

How can the Blackberry Clinic help you?

  • Physiotherapy, Chiropractic and Osteopathic interventions would be fairly similar in their approach. Mobilisation, manipulation, soft tissue massage, deep transverse frictions, appropriate muscular loading regime with the possibility of using taping techniques and electrotherapy to assist you in your rehabilitation.
  • Use of NSAID, ice and/or heat.
  • Injection therapy which is available at the Blackberry Clinic.

Prevention
Good posture is key to keeping good scapulothoracic rhythm. Maintain good shoulder and thoracic spine mobility. Ensure a strong and functional rotator cuff. Follow a stretching programme of the large prime movers around the shoulder joint.

Subacromial impingement is a predisposing factor and should be treated to prevent deterioration as therapy can have most effect without surgical intervention at this stage. It is recommended that you seek a referral for treatment by seeking a referral from your GP or by booking an appointment directly with the clinic for a full assessment and treatment regime.

Contributing Author:
Fred Braithwaite BSc(Hons) Physiotherapy, MCSP, MACPSEM, HCPC

References
Bongers, P.M. (2001) The cost of shoulder pain at work. British Medical Journal; 322: 64-65.

Brukner, P., Khan, K. (2012) Clinical Sports Medicine. 4th Ed. London: McGraw-Hill

Bunker, T. (2002) Rotator cuff disease. Current Orthopaedics; 16: 223-233.

Cook, J., Pardum, C. (2008) The pathology continuum. British Medical Journal; 45(5): 385- 391.

Cooper, A., Ali, A. (2013) Rotator cuff tears. Surgery; 31(4): 168-171.

Garg, S., Prince, D., Cole, A. (2010) Managing rotator cuff disorders. Reports on the Rheumatic Diseases; 6(7): 1-11.

Kraushaar BS, Nirschl RP. (1999) Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies; 81(2): 259-78.

Neer, C. (1972) Anterior acromioplasty for chronic impingement lesions of the shoulder. Journal of Bone and Joint Surgery; 54: 41-50

Walch, G., Boileau, P. (1992) Impingement of the deep surface of the supraspinatus tendon. Journal of Shoulder and Elbow Surgery; 1: 238-245.

Wang, J.C., Shapiro, M.S. (1997) Changes in acromial morphology with age. Journal of Shoulder and Elbow Surgery; 6: 55-59.