Rotator cuff tears

• Rotator cuff tears:

  • Injury to the tendons of the rotator cuff muscles
  • Very common
  • Can be partial thickness or full thickness
  • Acute: <3 months, normally following injury
  • Chronic: >3 months, normally in people with degenerative microtears, most commonly due to increasing age and overuse
• Risk factors:

  • Increasing age
  • Significant trauma
  • Repetitive overhead shoulder motions
  • Obesity
  • Smoking
  • Diabetes
• Clinical features:

  • In acute tears symptoms come on rapidly
  • In chronic tears symptoms come on gradually
  • Pain over lateral aspect of shoulder
  • Weakness and pain with specific movement e.g. abduction with supraspinatus tear
  • Disrupted sleep - difficult to get comfortable due to shoulder pain
  • Tears more common in dominant arm
• Examination:

  • Tenderness over greater tuberosity and subacromial bursa regions
  • Special tests: Empty can/Jobe's test (supraspinatus), posterior cuff test (infraspinatus and teres minor), Gerber's lift off test (subscapularis)
• Diagnosis:

  • May be able to make diagnosis from history and examination findings alone
  • May consider getting x-ray to rule out other causes of shoulder pain e.g. fracture, OA
  • Might request other imaging such as USS or MRI but may need to refer to MSK services for these to be requested
• When to refer urgently:

  • Same day assessment - any signs of infection
  • Urgent OP:
  • Acute tear caused by trauma - likely to need X-ray to rule out fracture, and then USS/MRI which are the best imaging modalities to assess tears
  • Concerns about malignancy
  • Inflammatory arthritis
  • Neurological lesion
• When to manage in primary care initially:

  • If no signs of acute/significant rotator cuff tear then manage conservatively first
  • Initially rest and then gradually increase activity - modify activities that exacerbate symptoms
  • Physiotherapy
  • Analgesia - first line is regular paracetamol, if ineffective consider oral NSAID or codeine
  • Consider corticosteroid injection - do not give more than 2 - risk of tendon damage from repeated injections
• If no benefit from 6 weeks of conservative management or if diagnosis uncertain refer to secondary care for consideration of surgical management:

  • Tendon repair - transfer or replacement either arthroscopic or open
• Prognosis:

  • Most people improve with nonsurgical treatment
  • When surgery is required most people regain good function following this