Tears of the rotator cuff are common and can be either traumatic or degenerative in nature.
Traumatic damage can occur from a fall, or from lifting or catching something heavy. Non-traumatic damage can be due to poor blood supply, inactivity, micro/macrotrauma from overuse or impingement.
Many people over the age of 60 have degenerative cuff tears and are asymptomatic.1 Cuff tears are also highly prevalent in throwing sports, but many athletes are asymptomatic and able to perform at a high level.2
Tears can be partial or full thickness. Full thickness tears will not heal and may require surgery.
Generally, tears larger than 5cm cannot be repaired and are known as 'massive cuff tears'. In these cases, cuff compensation programmes are the mainstay of treatment.
Key points
- Rotator cuff tear is common
- Usually traumatic or degenerative in nature
- Traumatic tear causes immediate pain, but in degenerative tears, symptoms develop gradually
- Initial pain relief with NSAIDs
- Physiotherapy improves strength and control
The GP
Presentation
The patient may describe a traumatic incident with immediate pain around the deltoid area, sometimes referring down the arm, which may be followed by a reduction in the active range of movement. With supraspinatus tears, abduction may be particularly difficult.
In degenerative tears, symptoms may start gradually, particularly with pain on overhead movements.
Examination and diagnosis
Differential diagnosis of rotator cuff tear can be difficult because of the presence of numerous other causes of pain and restriction of movement.
The mechanism of injury, presence of other pathology, the patient's age and work and leisure history all contribute to the differential diagnosis.
Comparing active and passive range of movement can help to identify a structural restriction.
The external rotator lag sign - inability to maintain the shoulder in external rotation with the elbow supported - can inform the diagnosis, but no single test is sensitive or specific enough to diagnose a cuff tear.3
Ultrasound is a reliable method for assessing pathology. Owing to the prevalence of asymptomatic cuff tears, partial tears may be found incidentally. Correlation of clinical findings with scan results should determine the relevance of any pathology.
Management
Early identification of massive or multi-tendon cuff tears and early referral can enhance the prognosis.4
Pain relief and NSAIDs can help to control symptoms initially. Physiotherapy can help to improve the strength of the rotator cuff, control and function of the shoulder girdle and flexibility of relevant structures. Corticosteroid injections should be used with caution because they can weaken the tendon further.
The surgeon
Early referral is appropriate for patients with high levels of functional restriction, pain and a traumatic injury, if there is no improvement with conservative measures.
Partial tears that do not exceed 50% of the tendon thickness can be debrided arthroscopically to aid healing. Larger tears and those that detach the tendon from the bone will need to be repaired.
Complete tears will not fully heal and may need repair if a high level of function is a required outcome. They can be repaired arthroscopically or by open surgery.
The physiotherapist
Irreparable cuff tears can be treated with physiotherapy and a rotator cuff compensation programme, which uses the deltoid to compensate for the lack of force compression of the humeral head in the glenoid from the cuff. This has been shown to improve pain and function.5
Patients with obvious shoulder girdle or rotator cuff weakness or movement dysfunction that could contribute towards poor function should be referred for physiotherapy. Those with pain three weeks after treatment with analgesia or corticosteroid injection should also be referred. Patients should be routinely referred for physiotherapy within two weeks following any orthopaedic intervention.
Working together
GPs and physiotherapists should work together to ensure adequate pain relief and early physiotherapy referral in the initial stages.
Liaising about diagnosis and the severity of the tear, and agreement on early intervention can improve the prognosis.
Support for time off work may be helpful to those in manual work and may be vital to allow healing.
Reiterating the importance of physiotherapy preand postoperatively may help with adherence.
Educating patients on the rehabilitation process will help to prepare them for what can be a long process.
Preparing the patient for functional limitations after a rotator cuff repair is important - in the first six weeks, protocols severely restrict the use of the limb, to facilitate healing.
- Mr Turpin is a senior physiotherapist, Royal Bournemouth and Christchurch NHS Foundation Trust; Dr Raymond is a GP in east London
References
1. Seitz AL, McClure PW, Finucane S et al. Clin Biomech 2011; 26(1): 11-12.
2. Shaffer B, Huttman D. Sports Med Arthrosc 2014; 22(2): 101-9.
3. Somerville LE, Willits K, Johnson AM et al. Am J Sports Med 2014; 42(8): 1911-19.
4. Cadogan A, McNair P, Laslett M et al. J Man Manip Ther 2013; 21(3): 148-59.
5. Ainsworth R. Musculoskeletal Care 2006; 4(3): 140-51. Key points
