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Rotator cuff tear
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Rotator cuff tear

Contributors: Connor Sholtis BA, Sandeep Mannava MD, PhD
Other Resources UpToDate PubMed

Synopsis

Classic history and presentation: This condition may present with pain located in the shoulder, but often pain localizes to the lateral aspect of the arm in the deltoid region. Tears due to traumatic injury (including a fall or shoulder dislocation) usually present with acute pain and limited motion, but chronic tears may have a more indolent course and a gradual onset of symptoms. Depending on the degree of the tear, patients may also show signs of weakness and limited active shoulder range of motion (ROM). Patients will often report difficulty in performing overhead tasks or repetitive tasks and lifting with the arms away from the body (reaching type activities).

Prevalence: Rotator cuff tears are very common in the elderly population.
  • Age – The condition is uncommon in patients younger than 40 years (less than 4% incidence), but it is estimated to affect between 20% and 30% of individuals older than 60 years. As many as 50% of patients older than 80 years have full-thickness rotator cuff tears. While young patients are much less likely to experience rotator cuff tears, those who do are usually involved in throwing / overhead sports or experience a major traumatic event affecting their shoulder (such as a dislocation, falling off a horse, motor vehicle accident, or power lifting injury).
  • Sex / gender – Men are more commonly affected than women.
Risk factors: Risk factors for rotator cuff tears, other than age, include smoking, hypercholesterolemia, and a family history of similar conditions. Additionally, look for a history of falls or shoulder dislocation in patients older than 40 years. Consider the possibility of Parkinson disease when evaluating an older individual, because rotator cuff injury is often seen in patients with Parkinson. Additionally, patients who use a wheelchair and depend upon their upper extremities to help transfer themselves are at increased risk for developing rotator cuff tears.

Pathophysiology: While acute tears are usually the result of traumatic injury, the pathophysiology of chronic or acute-on-chronic tears is thought to involve intrinsic degeneration of the supraspinatus, infraspinatus, teres minor, or subscapularis (SITS) muscles over time, due to a combination of impingement and imbalanced loading. There is likely a genetic component that has not been elicited that also contributes to rotator cuff tearing.

Grade / classification system: Goutallier Classification – described on CT or MRI is a way to evaluate the extent of fibrofatty infiltration of a torn rotator cuff muscle-tendon unit.

Stage 0: Normal muscle, no fat
Stage 1: Few fatty streaks in muscle
Stage 2: Less fat than muscle within the muscle
Stage 3: Same amount of fat and muscle within the muscle
Stage 4: More fat than muscle within the muscle

Codes

ICD10CM:
M75.100 – Unspecified rotator cuff tear or rupture of unspecified shoulder, not specified as traumatic

SNOMEDCT:
202842005 – Partial thickness rotator cuff tear
202843000 – Full thickness rotator cuff tear

Look For

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

  • Occult fracture of the greater or lesser tuberosity or proximal humerus
  • Cervical radiculopathy – Before assessing shoulder ROM, a cervical spine evaluation for motion and perispinal muscle spasm / pain should be performed to look for potential causes of referred pain to the shoulder. Medial scapular pain or pain radiating below the elbow may indicate cervical radiculopathy. Midline pain can indicate a spine fracture.
  • Proximal humerus fracture
  • Brachial plexus injury
  • Adhesive capsulitis (frozen shoulder) – Associated with diabetes or hypothyroidism, typically a frozen shoulder manifests with restricted active and passive ROM due to mechanical constraints. In rotator cuff tears, active motion is typically limited but passive motion is often normal.
  • AC joint arthritis – Can occur concurrently with rotator cuff pathology. Look for point tenderness of the AC joint. This pain can be exacerbated by cross-arm adduction.
  • AC joint separation – If there was a fall onto the side of the shoulder, there could be a shoulder separation or AC joint separation with observed superior migration of the clavicle relative to the acromion (typically from disruption of the AC joint capsule and/or the coracoclavicular ligaments).
  • Glenohumeral arthritis – Look for crepitus with passive ROM, history of traumatic shoulder injury.
  • Bursitis of the subdeltoid, subacromial, subcoracoid, or subscapular bursae

Best Tests

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Management Pearls

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Therapy

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References

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Last Reviewed:09/13/2020
Last Updated:11/24/2020
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Rotator cuff tear
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