Rotator Cuff Rupture

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Tendon rupture often responsible for shoulder pain

 

In a society in which persons are still being very active and participate in sports even at an advanced age, the number of patients having to consult their physician or therapist for shoulder complaints increases steadily. Because shoulder pain can have many causes, an accurate diagnosis is decisive for a successful treatment of shoulder conditions and injuries. Among the wide range of complains, a torn tendon in the shoulder– rotator cuff tear–is the most common cause for shoulder complaints. This is true in particular for middle and older aged persons. There are a number of factors determining the optimal treatment strategy of lesions at the rotator cuff. Nevertheless, arthroscopic surgical procedures at the shoulder joint provide new, highly successful treatment options. With our contribution "from the practice for the practice", we would like to give you an overview of causes, clinical examinations, diagnosis and treatment options of a rather frequent shoulder disease, e.g. the ROTATOR CUFF TEAR. We hope our practical information can support your therapeutic work effectively.

Anatomy

The very complex interaction between the humeral head and glenoid plays a prominent role in the movement of the shoulder joint. The humeral head is controlled in particular by the rotator cuff, a collection of muscles and tendons. These include the supraspinatus, infraspintaus, teres minor and subscapularis. The supraspinatus acts as flexor and abductor, infraspinatus and teres minor are external rotators. They insert at the tuberculum majus of the humeral head. The subscapularis is acting as medial rotator and inserts at the lesser tuberosity. Between the rotator cuff tendons and the acromion as a sliding layer, is the subacromial bursa, which merges directly into the bursa subdeltoid. For a comprehensive video on the anatomy of the shoulder go to  http: //flexikon.doccheck.com/de/Schultergelenk http://flexikon.doccheck.com/d...

Causes

A rotator cuff tear may result from traumatic incidents, such as an acute injury such as a fall on the arm, an accident or chronic wear and tear with degeneration of the tendon. Mostly, however, a pre-existing chronic degeneration of the tendon is the main reason for a tendon rupture. With a previously damaged tendon, even everyday activities can at times be sufficient to cause a partial or complete rupture of the tendon. Responsible for a rotator cuff tear is a chronic subacromial impingement, meaning an increased narrowness below the acromion caused by an acromion spore or an increased lateral slope of the acromion. In particular, a rupture often affects the supraspinatus tendon. In elderly patients, there are frequently asymptomatic ruptures of the rotator cuff. We differentiate between partial and complete tendon ruptures. In a so-called partial tendon rupture, the soft tissue is damaged, but not completely severed, while in a complete tear, the entire tendon (full-thickness tear) is ruptured splitting the soft tissue into two pieces. A partial tendon rupture has a general tendency to progress into a full-thickness tear. Likewise, even a complete tendon rupture tends to worsen when the cause is not addressed.

Diagnosis

Case history

In an acute injury to the rotator cuff, the person concerned complains of sudden, often stabbing pain, especially when moving the arm upwards. Frequently, the function, in particular the strength of the arm is noticeably reduced. Because of a developing inflammation, frequently chronic nighttime shoulder pain radiates regularly into the upper arm.

Clinical examination

On examination, the shoulder is in most cases not very conspicuous. Passive the shoulder is usually freely rotated (170 ° flexion, abduction 90 °, internal / external rotation 70/0/90 °), but usually indicates a more or less strong pain. In particular, specific provocation tests for each tendon section are important for a differential diagnosis. If there is a rupture of the supraspinatus tendon, lifting the arm sideward or forward is painful. Often the strength is weakened. If there is a rupture of the infraspinatus tendon (optionally in combination with damage to the teres minor), the external rotational force is weakened or painful. In tendon rupture of the subscapularis, internal rotation force of the arm is likewise weakened or painful. To examine the shoulder, it is mandatory to perform a motion and functional examination of the cervical spine in addition to an orientational neurological status of the upper limb, to exclude that the cause for the shoulder complaints originates here.

Image Diagnostics

If a rotator cuff tear is suspected, targeted instrumental tests such as ultrasound or MRI are strongly indicated for the presentation of the tendons. The MRI certainly provides the more comprehensive information and is essentially mandatory for suspected rotator cuff tear.

Therapy

Fact is that a torn rotator cuff has no self-healing tendency, whereby, the tear is, nevertheless chronically progressive. The decision here is whether with conservative treatment measures, despite a torn tendon, a functional, pain-free or pain-poor shoulder joint can be expected long term or whether this damage at the shoulder should be repaired surgically. All treatment strategies are generally based on the individual symptoms, the patient’s expectations and individual life style. In young patients or physically very active people, a tendon reconstruction, e.g. suturing the tendon, should be done even in case of a smaller tear. Simultaneously, a possibly existing impingement must be eliminated. The lower the patient’s expectations with regard to motion and strength, e.g. as in elderly people, the higher the likelihood that a reconstruction of a ruptured tendon can be avoided. In such cases, quality of life can  possibly be restored even with conservative therapy measures.

Conservative treatment

The aim of a conservative therapy for an injury of the rotator cuff is to relieve the pain symptoms and functional deficits, e.g. reduce loss of muscle function at the arm and to reduce the risk of the damage progressing. A very important measure is that the patient avoids movements causing pain and straining the shoulder.

Medicinal Treatment

A very significant proportion of the pain associated with rotator cuff tears is due to an inflammatory process of the soft tissues in particular the subacromial bursa. Therefore, an anti-inflammatory treatment is paramount: As medicinal based therapy usually includes topical or oral NSAIDs recommended (e.g. diclofenac 2 x 75 mg/d or ibuprofen 3 x 600 mg/d for 2 to 3 weeks max. An alternative is a local infiltration treatment of the subacromial space, e.g. peritendinous in the subacromial bursa. Since injections with corticosteroids affect the tendon healing negatively, it should only be used when a tendon rupture has been excluded or if the treating physian decided together with the patient against the repair! In this case, triamcinolone 10 mg and dexamethasone 4 mg in 10 mL bupivacaine 0.5% are injected (caution with corticoids: intervall between two doses at least 4 weeks, a total of no more than 3 repeats!). In chronic cases, if necessary, one amp. Traumeel on 10 ml bupivacaine 0.5% up to 6 times at weekly intervals. Regarding joint injections, we refer to the recommendation of the German Society of Orthopedics and Traumatology (DGOU). The painfully inflammed condition may also be improved with alternative therapies such as acupuncture, neural therapy or homeopathy.

Physiotherapy

In general, the treatment of the cervical spine must be included. The exact treatment orientation should be individualized and possibly agreed upon between physician and therapist. It is based on the respective peripheral damage of the rotator cuff, accompanying pathologies of the shoulder joint, and ultimately the needs of the patient.

Surgical treatment

Today modern shoulder surgery offers the possibility to treat tendon tears within the scope of arthroscopic procedures. With the arthroscopic surgical technique used by experienced shoulder specialists torn tendons can today be repaired in such an effective way as was previously in open, also very traumatic surgeries not possible. For the reconstruction, the torn tendon ends are reattached to the bone using small suture anchors (titanium, peak or bioresorbable materials), so that they can firmly heal at the bone. Simultaneously, it is generally necessary to expand the space below the acromion to protect the tendon against unnecessary pressure load and to ensure their healing. The fresher and smaller a rotator cuff tear, the better the chances of recovery. Extensive ruptures that might exist for months require special skill and operational experience to achieve success. If a reconstruction is no longer possible, the focus lies on a smoothing of the torn tendon stumps and removal of the inflamed tissue. Only in exceptional cases is an elaborate reconstruction through shifting tendons of other muscles (latissimus dorsi transfer) meaningful. Complex ruptures of the rotator cuff that cannot be reconstructed and cause excessive pain, may require the implantation of an inverse shoulder prosthesis.

Post surgical treatment

For the tendon to heal properly to the bone after a rotator cuff repair, it needs rest. To assure appropriate healing, the shoulder is first protected with a sling for three to six weeks. is highly recommended to start intensive physiotherapy as a part of the postoperative treatment. Initial post-operative drainage is indicated. For the prophylaxis of a frozen shoulder, the joint must be passive mobilization as early as possible. Gentle isometrics exercises in the neutral position of the shoulder are to prevent an increased muscular atrophy. Accompanying muscular imbalances, particularly tension in the cervical spine, must be compensated. Targeted muscle training can be started after a minimum of 6-8 weeks after the surgery. During postoperative treatment it is important to include the patient in the treatment plan and to provide guidance for exercising on his/her own.

From the practice for the practice

A systematic function examination of the shoulder in combination with the patient’s history is in most cases sufficient to establish a clinically accurate diagnosis. Central is here a testing of the active and passive range of motion, and secondly, the strength behavior on the various levels of motion. Following, we present the from our view most viable functional tests on a suspected rotator cuff tear. Comprehensive information on assessment techniques of the shoulder can be found, inter alia, in the review article SCHEIBEL M, HABER MEYER P (2005) Clinical examination of the shoulder. Orthopedist 2005 34: 267-284.

Shoulder mobility assessment

The active and passive mobility test of the shoulder should be performed by comparing both sides. The range of motion is determined according to the range of motion for flexion, abduction and internal and external rotation. A limitation of the active mobility with passive range of motion indicates a lesion of the rotator cuff.

The clinical symptoms associated with rotator cuff tear usually depend on their location and extent. While smaller lesions are more associated with pain, major ruptures are indicated by a more or less strongly pronounced loss of strength. Isometric functional tests assessing resistance provide information and/or the weakening of individual muscles.

Testing flexors and abductors (M. supraspinatus)

To assess the supraspinatus, the elevation motor is tested in the scapula plane of 90 degrees abduction with the arm rotated inward. The test is considered positive if there is pain or weakness on resisting force.

Testing rotators (infraspinatus, teres minor)

The external rotation test in the neutral position of the shoulder and the assessment of the force or the triggering of pain provides information about the function of the infraspinatus and the teres minor.

Testing rotators (subscapularis)

The internal rotation test in the neutral position of the shoulder and the assessment of the force or the triggering of pain provides information about the function of subscapularis.

The lift-off test can be performed as an alternative. Here, the patient is asked to place the back of his/her hand against the small of the back. In a decrease to the opposite site, rupture of the subscapularis tendon is suspected.

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