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Rotator Cuff Tears
Description
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Figure 1: Drawing of the rotator cuff muscles as seen from behind. (Modified from https://en.wikipedia.org/wiki/Rotator_cuff#/media/File:Shoulder_joint_back-en.svg)
Figure 2: Drawing of the rotator cuff muscles as seen from the front. There are two lines pointing to the biceps (long head in blue, short head in red) and two lines pointing to the supraspinatus (tendon insertion in blue, muscle belly in red). Artistic license was taken to perform a small acromioplasty (removing the anterior edge of the acromion) to show the path of the supraspinatus tendon, which would ordinarily be covered by some bone.
(Modified from https://en.wikipedia.org/wiki/Rotator_cuff#/media/File:Shoulder_joint_back-en.svg)
The supraspinatus originates in the supraspinatus fossa on the posterior scapula, crosses the superior humeral head, and inserts on the greater tuberosity.
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The physical examination should measure active and passive motion in elevation, abduction, and internal and external rotation, both actively and passively. Specific maneuvers are shown in figure 3 to 6.
Figures 3-6 NEED CLINICAL PHOTOS
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Figure 3: Neer test
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. The patient's scapula is stabilized with one hand, while the arm is internally rotated and flexed to 180 degrees. If the patient experiences pain with flexion a lesion of the supraspinatus is suspected.
Fig
Figure 4
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: The
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supraspinatus test. The patient attempts, against resistance, to abduct the arms in the scapular plane (30 anterior to the body)
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with the elbows extended.
Figure 5
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: Infraspinatus/teres minor examination. The patient attempts to externally rotate the arms against resistance while the arms are at the sides and the elbows are flexed to 90 degrees. Holding the arms at the sides minimizes the effect of the deltoid.
Figure 6
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: Lift-off test
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. The patient places the dorsum of the hand against mid-lumbar spine. The patient is asked to lift the hand away from the back. If the patient is unable to complete the task a lesion of the subscapularis is suspected.
Loss of the bulk of the rotator cuff muscles on the posterior aspect of the scapula may suggest a chronic tear.
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Figure 7: An MRI of a torn supraspinatus. The edge of the tendons are shown in red. (Case courtesy of Dr Ahmed Abdrabou, Radiopaedia.org, rID: 36724
Epidemiology
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Figure 8: The pectoralis major has two “heads”, named for their point of origin: the clavicular head which originates from the clavicle (shown in green) and a sternocostal head which originates from the sternum and rib cage (shown in blue). Both insert on the humerus and serve to adduct and flex the humerus. (https://en.wikipedia.org/wiki/Pectoralis_major#/media/File:Pectoralis_major.png)
Red Flags
Neurological red flags include sensory deficits, winged scapula, or abnormal reflexes.
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Patients who have retained function but are limited by pain may do well with non-operative treatment. It is critical to avoid immobilization of the shoulder during recuperation as that will likely induce stiffness.
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Figure 9: At left, an arthroscopic view of a rotator cuff tear, denoted by the red star. The middle and left panels show a photo and drawing of the repair, respectively. (http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-36162017000200164)
Most patients with rotator cuff disorders improve. It is not clear if this is necessarily from the intervention or the natural waxing and waning of the underlying disease.
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