Rotator Cuff

0
tear
Rotator Cuff Tear
Rashmi Jain
MPT Ortho
Introduction
Rotator cuff disorders are the most common cause of disability related to the
shoulder. Rotator cuff tendon tears and cuff abnormality are common in the adult
population and the incidence increases exponentially with age from 9.7% in patients
aged ≥20 years to 62% in patients aged ≥80 years.
Epidemiology
4.5 million patients refer to an orthopedic surgeon due to shoulder pain every year
in the United States and a 141% increase in rotator cuff repairs has been recorded
from 1996 to 2006.

The incidence of rotator cuff pathology was 87 per 100 000 person-years. It was
more common in women than in men (90 cases per 100 000 person-years in women
and 83 per 100 000 person-years in men; p < 0.001).
Classification
Rotator cuff tears can be classified by the mechanism of injury: acute, chronic or a
combination of both (acute on chronic).

• An acute rotator cuff tear has been defined as a tear involving an injury or trauma,
typically appearing in patients with no previous history of shoulder symptoms,
and presenting with pseudoparalysis of the shoulder.

• Chronic rotator cuff tears often occur due to progressive degeneration of the
tendon, developing over time and typically due to multiple factors such as
overuse, a lack of blood supply and other physiological factors.
Irrespective of the mechanism of the injury, rotator cuff tears can be classified into
two broad types: partial-thickness or full thickness.
Ellman has classified a partial-thickness RCT as articular, bursal, or
intratendinous and is further defined by size: grade 1, partial thickness with <3 mm
in depth ; grade 2, partial thickness with 3 mm-6 mm in depth ; and grade 3, >6
mm in depth, thereby affecting >50% of the tendon thickness. Full-thickness RCTs
are defined by size: small tears, 0 cm-1 cm; medium tears, 1 cm-3 cm; large
tears 3 cm-5 cm; and massive tears, >5 cm
Partial-thickness tears are generally more frequent than full-thickness tears, with a
prevalence of 13% versus 7%.
Ellman classification
 Clinical
Shoulder Resisted

Weakness
features
pain abduction or
external
rotation is
painful

Loss of active
shoulder Night pain
abduction and
elevation

Popping
Painful arc
sound
Pathogenesis
• It is considered to be a combination of ‘extrinsic’ factors such as impingement
from structures surrounding the cuff, and ‘intrinsic’ factors such as tissue-based
degenerative tendon changes that may occur with normal aging and mechanical
overuse from repetitive activities.

• As a result of repetitive microtrauma in a degenerative rotator cuff tendon,

inflammatory mediators alter the local environment and oxidative stress induces
tenocyte apoptosis, causing further rotator cuff tendon degeneration.
• The increased number of apoptotic cells in degenerative tendon could affect the
number of functional tendon fibroblasts which may contribute to an impaired rate
of collagen synthesis and repair resulting in a weaker tendon thereby promoting
tendon degeneration and eventually increasing the risk of rupture.

• The combination of reduced tensile strength and either a single traumatic insult, or
progressive microtrauma, can then lead to cuff tearing. Furthermore, after the
deep fibers tear, fiber retraction results in an increased load on the remaining
fibers that subsequently increases the likelihood of progressive tendon rupture.
• The chronic impingement syndrome theory described by Neer is a well-known
theory, which proposed that the impingement of the rotator cuff tendon against the
inferior part of the acromion and coracoacromial ligament was the primary factor
in causing tissue damage and tendon tears. Bigliani et al found a higher
prevalence of rotator cuff tears in patients with a hooked (type III) acromion
morphology compared to individuals with a curved (type II) or a flat (type I)
acromion.
Assessment
Subjective information

There are key features clinicians seek to extrapolate during the subjective
examination to enable effective clinical reasoning and goal setting.

Age, arm dominance and arm function in daily life

Hand dominance and older age were both noted to be significantly associated with
RCTs. The dominant hand had more than double the odds of sustaining an RCT as
compared to the non-dominant hand, while an individual aged 60 years or above
was approximately at a five-time higher odds of sustaining an RCT as compared to
an individual less than 60 years old.

Is the arm involved in over activity, under activity or highly repetitive actions (e.g.
swimming)? Has the patient started a ‘new’ activity, perhaps with weight or sustained
straight-arm activities (e.g. wall papering, pruning in garden, etc.) that may have
resulted in ‘overload’ of the cuff ?

Chief complaint

Is this predominantly pain, weakness, stiffness or fear of what it is? Night pain resulting
in sleep disturbance is debilitating. Although night pain is commonly reported as a
feature of rotator cuff tears as a stand alone symptom, it lacks specificity.However,
ongoing poor sleep interacts with depressive symptoms and increases pain perception.
History
An onset related to a definite event (e.g. awkward movement, lifting) with reports of feeling
or hearing ‘tearing’ or ‘something going’ in the shoulder is suggestive of rotator cuff tear.
Many indivdiuals cannot identify any trigger, and report an insidious onset with night or
increasing pain intensity and the inability to use the arm.

Pain
Initially the pain may be mild and occurs only with the overhead activities and with the
passage of time the pain intensity increases and pain occurs even during rest. Aching pain
located over the front or lateral aspect of the shoulder and upper arm. Night pain is common
with rotator cuff tear and may also cause sleep disturbances. Aggravating factors reported are
sleeping on the same side, lifting and overhead activities.
Physical examination
A comprehensive clinical examination must be conducted in a shoulder gown that
allows for visual inspection of the shoulder girdle.

• The examiner should first rule out any radicular pain originating from the cervical
spine.

• Full active and passive shoulder range of motion (ROM) is often exhibited
although should be compared with the contralateral side.

• A painful arc of motion from approximately 90º to 120º in flexion and/or

abduction may be present.
• Muscle strength of the rotator cuff muscles to be evalauted through strength testing.With rotator
cuff tears, muscle weakness of abductors and external rotators are reported.

• Pain with resisted external rotation with the arm at the side is more suggestive of infraspinatus
pathology

• Positive Neer and Hawkins subacromial impingement signs are associated with PRCTs, although
not diagnostic.

• The internal rotation resistance strength test is done with the patient’s shoulder in 90º abduction and
80º to 85º of external rotation. Apparent weakness with resisted internal rotation may suggest
internal impingement.

• Biceps or labral pathology may accompany RC changes and would be evidenced by a positive
Speed, O’Brien, or Yergason test.
Tests
Orthopedic tests were performed according
to original descriptions:

• Hawkins–Kennedy test

• Drop-arm test

• Empty can test

• External rotation lag sign

• Belly-press test

• Speed’s test

• Active-compression test
Clinical Prediction Rule for Full-Thickness Rotator Cuff Tear
(Park et.al)

The combination of the following 3 special tests have produced the highest post-test
probability to diagnose a full-thickness rotator cuff tear:

− The Drop-Arm Sign

− The Painful Arc Sign

− Infraspinatus Muscle Test

The study concluded that if all 3 tests were positive, the probability of the patient
having a full-thickness rotator cuff tear is 91%.
Scales/Measures
• Constant-Murley scale

• Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire

• Shoulder Pain and Disability Index (SPADI)

• Simple Shoulder Test

Western Ontario Rotator Cuff Index (WORC)

It was used as an outcome measure to determine the condition-specific functional

status and to gather comparative data. The WORC index is a valid and reliable 21-
question outcome measurement tool with each question scored 0-100 (maximum
raw score 2100, then scaled to 100)

9 Hole Peg Test

It is a standardized, validated method with normative values in a wide age range

that is widely administered to determine the hand and upper extremity function in
patients with RCT, as well as healthy adults objectively.
Imaging
• Initial evaluation should include plain radiographs, including true AP, axillary, and scapular-
Y views. Although plain imaging is often nonspecific, it can assess for fracture,
glenohumeral osteoarthritis, acromial spurs, or other sources of pain.

• A reduction in the acromiohumeral distance is usually indicative of a FTT (normal 9 to 14

mm).

• Ultrasonography (US) has been increasingly used as an imaging modality due to its
availability, portability, cost-effectiveness, and dynamic visualization. The reportedaccuracy,
sensitivity, and specificity of US in detecting PRCTs are 87%, 66.7%, and 93.5%,
respectively
• MRI provides valuable information on the anatomy and structural integrity of the RC,
including tear location, size, and muscle atrophy, as well as other soft-tissue injuries
(eg, labral tears and biceps tendon pathology). Sensitivity and specificity of MRI in
detecting PRCTs of 80% and 95% respectively.
Surgical intervention
• Surgical intervention should be considered when patients have failed 3 to 6 months
of conservative management and in younger patients with acute, traumatic injury and
is often directed by patient age, activity level, arm dominance, tear thickness, and
location.

• Biomechanical studies support tear thickness as a major determinant for surgical

decisions with tears. 50% of tendon thickness yielding increased strain on the
remaining portion of the intact tendon.
Arthroscopic Debridement A fullradius shaver is used to remove the frayed edges to
achieve a healthy rim to promote healing

In situ repairs preserve the intact tendon and repair the

In situ repairs delaminated medial tendon. Although the remaining
intact tendon is preserved, repair techniques are
technically challenging.

Conversion repair allows for the removal of degenerative

tissue and better access to the RC footprint for
Conversion repair
repair.
Biologic augments
Biologic augments include platelet rich plasma (PRP), platelet rich fibrin, platelet-derived
growth factor, anabolic growth factors, bone marrow aspirate concentrate, stem cells, and
proteinase inhibitors, have become an attractive adjunct to current repair techniques to improve
tendon healing.

A more recent meta-analysis suggested that the addition of PRP to repair of PRCTs and FTTs
decreases retear rate and improves healing and clinical outcomes.

Augmentation with biologic scaffolds has also gained popularity. Augments include synthetic,
xenografts, autografts, or allografts patches. A recent meta-analysis of multiple graft types
suggests that augmentation results in lower retear rate, with autograft augments achieving
superior graft integrity although no difference in clinical outcome scores was evidenced.
Physiotherapy Management
Electrotherapy
• Ultrasound

This modality may have an effect on pain and limited motion, but their impact on
0 underlying tear and repair is not known.

• H-wave stimulation

Repetitive H-wave device stimulation and program induces significant increases

in the range of motion of post operative rotator cuff reconstruction in a double-
blinded randomized placebo controlled human study (Blum, 2009).
• Neuromuscular Electrical Stimulation

Reinold et,al evaluated the effect of NMES of the IS on shoulder ER force

production after RCR surgery compared the muscle force of the ER using two
groups, one with NMES and one without NMES. They applied one session of
NMES with maximal intensity within the participant's comfort level, at a frequency
of 50 pulses per second, using a symmetrical waveform, and a one-second ramp
time, they found significant increase of volitional muscle force production
during ER (peak shoulder ER force increased by 22%) regardless of the age of
the patient, gender, size of tear, number of days PO and level of NMES intensity.
• Cryotherapy

Cryotherapy (ice 15-20 minutes every hour) used to decrease pain and inflammation . Van der
meijden et al, 2013 recommended the use of a home cryotherapy device for 10–14 days PO.
Cryotherapy is used PO to decrease pain, swelling, muscle spasm, and minimize the
inflammatory response.

• Aquatherapy

Aquatherapy can be started during the week 2-6 . Once the surgical incisions have healed, gentle
stretching and passive motion can be performed in a pool, 2 to 3 days per week, for 15 to 20
minutes per session. Aquatherapy with neck deep water at 6 to 8 weeks ,advanced with the
addition of active motion, at 10 to 12 weeks the patient can do underwater resistance exercises.
Aquatherapy decreased muscle activation allow for earlier active motion improving the GH
motion without compromising the integrity of the repair.
Exercise rehabilitation
Twenty-six patients with a diagnosis of partial rotator cuff tear were randomly assigned to: the
experimental group (eccentric, n ¼ 12) and the control (concentric, n ¼ 14).

The experimental group performed muscle strengthening with eccentric technique directed to o
deltoid, internal and external rotators, biceps, triceps,pectoral, and trapezius while the control group
performed the concentric technique.

Eccentric and concentric strengthening were well tolerated; both show early improvement in pain,
functionality and tendon structure. Eccentric training appears to be more effective than concentric in
the early improvement of functionality, strength and tendon healing.
Thirty voluntary patients with partial rotator cuff tear were randomized into two groups: video-based
rehabilitation (VBR) group and physiotherapist-supervised rehabilitation (PSR) group, for a common 6
weeks rehabilitation program.

Interventions: A video rehabilitation program was recorded by the physiotherapist with the
participation of a patient. Each exercise was described in detail to the patient in the video and then the
patient correctly performs the exercises according to the verbal and visual commands of the
physiotherapist.

Physiotherapist-supervised rehabilitation program: A physiotherapist conducted this rehabilitation

Patients participated in the supervised rehabilitation program for 2 days a week.

Active shoulder range of motion, pain, functional status, and health-related quality of life of the patients
were assessed before and after treatment. Also, treatment satisfaction level was assessed at the end of the
treatment.

There was statistically significant improvement in terms of active shoulder range of motion values (mean
differences at 95% confidence interval for abduction: 30.75-51.37 in the VBR group, 34.20- 54.45 in the
PSR group, P ¼ .001 in both groups) and secondary outcome measures within both groups (P < .05)
Evidence-based
rehabiltation

Peter Edwards, 2016

Post-operative rehab (Terrance A. Sgroi, 2018)
Phase 1 (weeks 0–6) ○ Continued hand and wrist exercises
• ROM ○ Elbow AROM with arm at side
○ FF to tolerance ○ Scapular protraction/depression
○ ER to 60° with arm in scapular plane
• Weeks 4–6: DC immobilizer
○ IR: None
○ PROM/AAROM with PT
• Weeks 0–2 weeks strict immobilization
○ Distal hand and wrist activity ▪ Flexion, ER
▪ Squeezing, AROM hand and wrist ○ Supine PROM shoulder elevation
• Weeks 2–4: continued immobilization • Criteria to advance
PROM initiated by patient in scapular
plane ○ Pain-free PROM
▪ 90° FF ○ FF beyond 120
▪ 30° ER ○ ER beyond 30
Phase 2 (weeks 7–11) Week 8:
• ROM ○ Standing shoulder extension
○ FF to tolerance • Criteria to advance
○ ER to tolerance ○ Full, pain-free PROM
○ IR to beltline: no aggressive stretching ○ Full AROM without compensation, no shoulder

• Week 7: progress AAROM ➔ AROM

“shrug”
○ Pain-free isometric exercises
○ Supine Cane FF in scapular plane
Phase 3 (weeks 12+)
○ Incline cane FF ➔ standing cane
• ROM
○ Towel slide scaption
○ FF unrestricted
○ Isometric exercise
○ ER unrestricted
▪ ER/IR/Ext
○ IR unrestricted
○ T band rows with retraction
Week 12: strengthening
○ T band ER/IR with towel
○ Standing row
○ Supine punch
○ Side lying ER
○ PNF diagonals
○ Prone mid and low traps
THANK YOU
References
• Sgroi, T. A., & Cilenti, M. (2018). Rotator cuff repair: post-operative
rehabilitation concepts. Current reviews in musculoskeletal medicine,
11(1), 86-91.
• Vrotsou, K., Ávila, M., Machón, M., Mateo-Abad, M., Pardo, Y., Garin,
O., ... & Cuéllar, R. (2018). Constant–Murley Score: systematic review
and standardized evaluation in different shoulder pathologies. Quality of
life research, 27(9), 2217-2226.
• Patte D. Classification of rotator cuff lesions. Clin Orthop Relat Res.
1990;(254):81–86
• Longo UG Berton A Marinozzi A Maffulli N Denaro V. Subscapularis
tears. Med Sport Sci. 2012;57:114–121.
• Edwards, P., Ebert, J., Joss, B., Bhabra, G., Ackland, T., & Wang, A. (2016).
Exercise rehabilitation in the non-operative management of rotator cuff tears: a
review of the literature. International journal of sports physical therapy, 11(2),
279.
• Judge, A., Murphy, R. J., Maxwell, R., Arden, N. K., & Carr, A. J. (2014).
Temporal trends and geographical variation in the use of subacromial
decompression and rotator cuff repair of the shoulder in England. The bone &
joint journal, 96(1), 70-74.
• White, J. J. E., Titchener, A. G., Fakis, A., Tambe, A. A., Hubbard, R. B., &
Clark, D. I. (2014). An epidemiological study of rotator cuff pathology using The
Health Improvement Network database. The bone & joint journal, 96(3), 350-
353.
• Moser, J. (2014). Physiotherapy assessment of patients with rotator cuff
pathology. Shoulder & Elbow, 6(3), 222-232.