THE CLINICAL SYNDROME

• Ruptures of the rotator cuff are a common source of pain and dysfunction in the shoulder.

• It's not uncommon for a rotator cuff tear to happen after what seems like a relatively minor injury to the musculotendinous unit of the shoulder.

• However, in the majority of cases, the pathologic process responsible for the tear has been in the making for a considerable amount of time and is the result of tendinitis that has been going on for some time.

• The rotator cuff is formed by the subscapularis, supraspinatus, and infraspinatus muscles, as well as the teres minor tendon, all of which are associated with one another.

• Along with the other muscles, tendons, and ligaments that make up the shoulder, the rotator cuff's job is to help provide stability to the shoulder joint so that the arm can be rotated.

• Tendinitis is especially likely to occur in the tendons of the supraspinatus and infraspinatus muscles for a number of different reasons.

• To begin, the joint is put through a variety of different motions that are repeated over and over again.

• Second, because the space in which the musculotendinous unit functions is restricted by the coracoacromial arch, impingement is more likely to occur during extreme movements of the joint.

• The third issue is that the blood supply to the musculotendinous unit is inadequate, which makes it difficult for the microtrauma to heal.

• Tendinitis of any one or more of the tendons that attach to the shoulder joint may be caused by any or all of these factors. If the inflammation does not go away, calcium may begin to deposit around the tendon, which will make subsequent treatment more difficult.

• Bursitis is a painful condition that frequently occurs in conjunction with rotator cuff tears and may call for specialized medical attention.

• Patients who suffer from rotator cuff tears, in addition to experiencing pain, frequently experience a gradual reduction in functional ability as a result of a decreasing shoulder range of motion.

• This decrease in shoulder range of motion makes it difficult to perform simple everyday tasks such as combing one's hair, fastening a brassiere, or reaching overhead. With continued disuse, muscle wasting may occur, and a frozen shoulder may develop.

SIGNS AND SYMPTOMS

• Patients who present with a torn rotator cuff frequently complain that they are unable to lift the affected arm above the level of the shoulder without the assistance of the other arm.

• At the time of the physical examination, a lack of strength in external rotation is observed if the infraspinatus is at fault, and a lack of strength in abduction above the level of the shoulder is observed if the supraspinatus is at fault.

• It's common for the subacromial region to be tender to the touch when you palpate it.

• Patients who have a partial tear in their rotator cuff will no longer be able to reach overhead in a smooth manner.

• Patients who have complete tears in their rotator cuffs show an anterior migration of the humeral head, and they are completely unable to reach any distance above the level of their shoulders.

• A positive drop arm test, also known as the inability to keep the arm abducted at the level of the shoulder after the supported arm is released, is typically observed in patients who have suffered complete tears of their rotator cuff.

• This test is performed by having the patient actively abduct the arm to 80 degrees and then adding gentle resistance, which forces the arm to drop if a complete rotator cuff tear is present.

• The result of Moseley's test for rotator cuff tear is also positive.

• Although the shoulder has a normal passive range of motion, the shoulder's active range of motion is severely restricted.

• The pain associated with a rotator cuff tear is constant and severe, and it is exacerbated by motions of the shoulder that involve abduction and external rotation.

• It is frequently reported that significant sleep disturbances occurred.

• Patients may attempt to splint the inflamed subscapularis tendon by limiting the medial rotation of the humerus in an effort to stabilize the tendon.

TESTING

• Radiographs in the plain format should be taken of every patient who comes in complaining of shoulder pain.

• The clinical presentation of the patient may suggest the need for additional testing, which may include an evaluation of the patient's complete blood count, erythrocyte sedimentation rate, and antinuclear antibody levels.

• If there is a suspicion of rotator cuff tendinopathy or tear, imaging tests such as magnetic resonance imaging (MRI) and ultrasound imaging of the shoulder should be performed.

DIFFERENTIAL DIAGNOSIS

• The diagnosis of rotator cuff tears is frequently delayed due to the fact that tears can occur even after seemingly minor trauma.

• The diagnosis could be further complicated by the fact that the tear could either be partial or complete; however, a thorough physical examination is the only way to differentiate between the two.

• Bursitis of the associated bursae of the shoulder joint frequently coexists with tendinitis of the musculotendinous unit of the shoulder, which results in additional pain and functional disability.

  • This condition is known as a "double-whammy."

• Because of this pain, the patient may splint the shoulder group, which can lead to abnormal movement of the shoulder.

• This abnormal movement places additional stress on the rotator cuff, which can result in additional trauma.

• If you have a torn rotator cuff, your passive range of motion will be normal, but your active range of motion will be limited.

• If you have frozen shoulder, your passive range of motion as well as your active range of motion will be limited.

• Tears of the rotator cuff almost never occur in people under the age of 40, with the exception of cases involving severe acute trauma to the shoulder.

TREATMENT

• The initial treatment for the pain and functional disability associated with a rotator cuff tear consists of a combination of physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs) or cyclooxygenase-2 inhibitors.

• Both of these types of medications are anti-inflammatory.

• The application of heat and cold to specific areas of the body may also be beneficial.

• Patients who do not respond to these various treatment modalities may benefit from the injection technique described in this article as a reasonable next step before undergoing surgical intervention.

• When administering an injection for a rotator cuff tear, the patient is first positioned in the supine position, and then an antiseptic solution is used to prepare the skin that lies over the superior shoulder, acromion, and distal clavicle.

• A sterile syringe that has 4 milliliters (mL) of bupivacaine with no added preservatives and 40 milligrams (mg) of methylprednisolone is threaded onto a 25-gauge needle that is 11.2 inches long.

• This is done using aseptic technique.

• The lateral edge of the acromion is located, and this is done both to improve the accuracy of needle placement and to locate the acromion itself.

• Recent clinical reports suggest that the injection of platelet-rich plasma and/or stem cells into the area affected by tendinopathy may assist in the relief of symptoms and healing of tendinopathy.

• After receiving an injection, the patient should wait several days before beginning any physical modalities.

• These modalities should include gentle range-of-motion exercises as well as local heat.

• In addition, transcutaneous nerve stimulation might lessen the need for pain medication.

• Exercises that are too strenuous for the patient to handle should be avoided because doing so will make their symptoms worse and may even cause a complete tendon rupture.

COMPLICATIONS AND PITFALLS

• A failure to correctly identify a partial rotator cuff tear and to treat it before it becomes a complete tear is one of the major complications that can arise.

• This is typically the case because a diagnostic MRI of the shoulder is not carried out, and instead, the diagnosis is based solely on clinical grounds.

• The described injection method is risk-free so long as the clinically relevant anatomy is paid close attention to throughout the process.

• In order to prevent infection, sterile technique must be utilized, and universal precautions must be taken in order to lessen the likelihood that the operator will be put in harm's way.

• If pressure is applied to the injection site immediately after the injection, this can help reduce the risk of complications such as ecchymosis and hematoma developing at the site.

• Infection is the most significant risk associated with the injection technique; however, if the aseptic technique is strictly adhered to, the risk of infection should be extremely low.

• There is also the possibility that the injection itself will cause damage to the rotator cuff.

• If an injection is given directly into a tendon while it is already severely swollen or has a history of being damaged, the tendon may rupture.

• This may cause a partial tear to become a complete tear.

• This complication can be avoided if the clinician uses a gentle technique and immediately stops injecting if significant resistance is encountered.

• Avoiding this complication is possible if the clinician uses a gentle technique.

• Patients should be made aware of the possibility that they may experience a temporary increase in pain after receiving an injection, as this affects approximately one quarter of all patients.