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Rotator Cuff Injuries

Matt Baird, MD, Matthew DeLaney, MD, and Rick Pescatore, DO
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“Doc, my shoulder hurts.” We hear this all the time. But how often do we have a thoughtful, stepwise approach to diagnosing and managing rotator cuff disease? Dr. Matt Baird, an EM and Sports Medicine specialist, gives our own Matt DeLaney the lowdown on rotator cuff injuries and how we can diagnose and treat them like experts.

Pearls:

  • Consider life threatening/emergent diagnoses first such as referred pain from MI, cholecystitis, fracture, dislocation etc. before evaluating for rotator cuff pathology.

  • Repetitive overhead movements and family history of rotator cuff problems are significant risk factors.

  • Difficulty with ROM in abduction is most suggestive of rotator cuff pathology.

  • Specialist referral and MRI are recommended only in cases where conservative measures have failed.

  • Subacromial steroid and/or local anesthetic injections can offer immediate relief but do not improve speed or likelihood of recovery.

 

Background:

  • Differentiating between rotator cuff injuries and other causes of shoulder pain can be challenging, but with an appropriate history and exam, we can improve our ability to assess and diagnose rotator cuff issues.

  • Rotator Cuff pathology describes a large spectrum of disease, both acute and chronic, including impingement syndromes, tendonosis, partial, complete, and massive tears. 

 

Differential Diagnosis:

  • Can’t miss diagnose should be considered first! These include septic joint, fracture, dislocation, malignancy, and referred pain from visceral sources (e.g. MI, splenic rupture, cholecystitis) and radicular pathology.

  • Less urgent diagnoses can then be considered.  The common benign diagnoses to consider include strains, sprains, contusions, osteoarthritis, adhesive capsulitis, labral tear, biceps tendonosis, 

  • Less common causes of shoulder pain include Inflammatory arthritis, AVN, brachial Plexopathy/Parsonage-Turner Syndrome. 

 

History:

  • Vocations and hobbies that involve repetitive, overhead arm movements put patients at risk of subacromial disease, including rotator cuff injury (e.g. painters, throwers, swimmers, bow instrument musicians).

  • Patients often report difficulty with sleeping on the affected side. 

  • Family history of rotator cuff tears requiring surgery is a risk factor for rotator cuff injury.

    • There is a strong genetic component to these conditions likely due to the strength of patients’ connective tissues.   

 

Physical exam:

  • General components of basic exam are most important (i.e. inspection, palpation, ROM and neurovascular assessment).

    • Specifically, evaluate for difficulty with ROM in external and internal rotation and abduction (most suggestive of rotator cuff injury), and forward flexion. 

  • When assessing strength, objective weakness suggests a higher grade tear. 

  • Specialized/named impingement testing (e.g. Neer, Hawkins, Jobe/Empty Can etc.) can be helpful in equivocal cases , but are commonly overestimated in their clinical utility.

    • The Jobe (Empty Can) test is relatively specific for supraspinatus injury.

    • The drop arm test is relatively specific for supraspinatus injury.

    • External and internal rotation lag test is the most sensitive and specific test for full thickness rotator cuff tear.

    • Videos for these maneuvers can easily be found on YouTube. 

 

Imaging:

  • Initially, XRs are generally non-diagnostic and are most valuable in ruling out other (bony) shoulder pathology.

  • US and/or MRI can often confirm diagnosis, but obtaining these tests immediately is not recommended because they have little impact on initial management.

 

Initial treatment of suspected rotator cuff injury:

  • Gentle ROM, OTC topical (e.g. lidocaine, diclofenac gel) and oral analgesia (e.g. NSAID, APAP), Ice/Heat, and limiting heavy lifting will result in resolution in most mild cases.

  • After initial treatment, re-evaluation in about 2 weeks is appropriate. If no improvement, physical therapy referral is recommended

  • Subacromial steroid injection can offer significant relief of pain when less invasive, conservative strategies fail, but does not speed or increase likelihood of recovery.

    • Subacromial steroid injection can be performed with a variety of corticosteroids including triamcinolone, dexamethasone, and methylprednisolone.

    • A local anesthetic, such as lidocaine or marcaine, can be added 

    • Local anesthetics should not be injected into the shoulder joint itself because they can damage the cartilage, but are felt to be safe for soft tissue injections into the subacromial space.

 

Subacromial Injection Procedure:

  • Landmark approach generally works well

    • Identify soft tissue where lateral acromion becomes the posterior acromion and direct needle cranially towards AC joint.

    • Most common pitfall is not aiming superiorly enough. 

    • Use a 1 1/2 inch needle and insert at this point to the hub.

    • Watch several YouTube videos and ensuring supervision from an experienced provider are recommended before attempting this procedure. 

 

When to refer:

  • Most rotator cuff injuries can be managed by a proficient PCP.

  • Orthopedic, sports medicine, and/or physical therapy referrals are appropriate only for patients who have failed initial, conservative management. 



References:

  1. Karjalainen TV, Jain NB, et al. Subacromial decompression surgery for rotator cuff disease. Cochrane Database of Systematic Reviews 2019, Issue 1. Art. No.: CD005619. DOI: 10.1002/14651858.CD005619.pub3

  2. Jancuska J, Matthews J, et al. A systematic summary of systematic reviews on the topic of the rotator cuff. Orthop J Sports Med 2018;6(9):2325967118797891. doi:10.1177/2325967118797891

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Off The Cuff Full episode audio for MD edition 169:22 min - 79 MB - M4AHippo Urgent Care RAP September 2019 Written Summary 681 KB - PDF

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