Category Archive Anatomy A – Z

Causes, Symptoms of Rotator Cuff Tears/Rotator Cuff Tears (inflammation) and rotator cuff tears are common conditions inactive people. Both conditions are usually caused by a prolonged period of repetitive stress (and the tendonitis condition itself may, over time, lead to an eventual tear). This type of stress is usually associated with overhead work-related activities or athletics such as tennis or throwing sports like baseball, cricket or jai alai. However, the rotator cuff may also be acutely injured in trauma involving a fall on the arm and shoulder or from heavy lifting.[rx]

Rotator cuff tears are a common cause of shoulder pain and dysfunction. A rotator cuff tear frequently occurs after seemingly minor trauma to the musculotendinous unit of the shoulder. However, in most cases, the pathologic process responsible for the tear has been a long time in the making and is the result of ongoing tendinitis. The rotator cuff is made up of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles and the associated tendons. The function of the rotator cuff is to rotate the arm and help provide shoulder joint stability along with the other muscles, tendons, and ligaments of the shoulder.

Mechanism Of Rotator Cuff Tears

Chronically, RC tendinopathy can occur secondary to a variety of proposed mechanisms:

• Extrinsic compression – The extrinsic theory of mechanical impingement and pathologic contact between the undersurface of the acromion and the RC results in repetitive injury to the cuff. RC tendinopathy results in weakened areas of the cuff, eventually resulting in PTTs and/or FTTs. The mechanical compression can occur secondary to a degenerative bursa, acromial spurring, and predisposing acromial morphologies (i.e., the hooked-type acromion). Theories were popularized and modified by Watson-Jones, Neer, and Bigliani.[2][4][5]
• Intrinsic mechanisms – Several theories exist to support intrinsic degeneration of the cuff as the primary source of shoulder impingement. In general, the intrinsic degenerative theories cite that cuff degeneration eventually compromises the overall stability of the glenohumeral joint. Once compromised, the humeral head migrates superiorly, and the subacromial space decreases in size. Thus, the cuff becomes susceptible to secondary extrinsic compressive forces, ultimately leading to cuff degeneration, tendinopathy, and tearing.[rx][rx]
• Vascular changes – Advocates for intrinsic degenerative theories cite focal vascular adaptations that occur secondary to age-related changes and intrinsic cuff failure from repetitive eccentric forces directly experienced by the cuff itself. Controversy proposed by other studies, however, supports that the attritional areas develop secondary to the preceding impingement mechanisms. Subsequently, external impingement (EI) leads to blood vessel damage, ensuing ischemia, tenocyte apoptosis, gross tendinopathy, and attritional cuff damage.[rx] Furthermore, many studies cite increased vascularity in focal areas of the cuff, and the hypervascularity has been associated with age-related changes, tendinopathy, and PTTs and/or FTTs.[rx][rx]
• Age, sex, and genetics –Histologically, age-related RC changes include collagen fiber disorientation and myxoid degeneration.[rx] The literature favors increasing frequencies of RC abnormalities with increasing age. The frequency increases from 5% to 10% in patients younger than 20 years of age, to 30% to 35% in those in their sixth and seventh decades of life, topping out at 60% to 65% in patients over 80 years of age.[rx][rx][rx]
• Tensile forces –A study by Budoff et al. proposed that the primary mode of failure of the cuff occurs intrinsically within the cuff itself as it repeatedly withstands significant eccentric tensile forces during physical activity.[rx]

Pathophysiology of Rotator Cuff Tears

Acute rotator cuff (RC) tendonitis can occur secondary to direct blows to the shoulder, poor throwing mechanics in overhead sports, or from falls on an outstretched arm.[rx]

Tendinopathy ensues after repetitive RC injury triggers a recurrent pathological cycle that results in acute on chronic tendonitis, increasing levels of tendinopathy and tendinosis, and ultimately, PTTs and/or FTTs to varying degrees of tear sizes and retraction. The exact pathogenesis of RC tears still remains controversial, but most clinicians agree the underlying mechanism is comprised of a combination of extrinsic impingement from structures surrounding the cuff and intrinsic degeneration from changes within the tendon itself.[rx]

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Acute Tear

If you fall down on your outstretched arm or lift something too heavy with a jerking motion, you can tear your rotator cuff. This type of tear can occur with other shoulder injuries, such as a broken collarbone or dislocated shoulder.

Degenerative Tear

Most tears are the result of a wearing down of the tendon that occurs slowly over time. This degeneration naturally occurs as we age. Rotator cuff tears are more common in the dominant arm. If you have a degenerative tear in one shoulder, there is a greater likelihood of a rotator cuff tear in the opposite shoulder even if you have no pain in that shoulder.

Several factors contribute to degenerative, or chronic, rotator cuff tears.

• Repetitive stress – Repeating the same shoulder motions, again and again, can stress your rotator cuff muscles and tendons. Baseball, tennis, rowing, and weightlifting are examples of sports activities that can put you at risk for overuse tears. Many jobs and routine chores can cause overuse of tears, as well.
• Lack of blood supply – As we get older, the blood supply in our rotator cuff tendons lessens. Without a good blood supply, the body’s natural ability to repair tendon damage is impaired. This can ultimately lead to a tendon tear.
• Bone spurs – As we age, bone spurs (bone overgrowth) often develop on the underside of the acromion bone. When we lift our arms, the spurs rub on the rotator cuff tendon. This condition is called shoulder impingement, and over time will weaken the tendon and make it more likely to tear.
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of injury.
• Sports injuries – Many Injury occurs during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause necks of femur fracture to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate intake of calcium or vitamin D
• Football or soccer, especially on artificial turf
• Rugby
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• In-line skating
• Jumping on a trampoline

Rotator cuff (RC) tendinopathic histologic changes include the following [rx][rx][rx][rx][rx]

• Rounded tenocytes (apoptosis)
• Extracellular matrix disorganization and myxoid degeneration
• Vascular changes (focal hypervascularity; focal hypovascular regions as well)
• Reduced total cellularity
• Calcified depositions
• Collagen fiber thinning
• Degenerative acromion, coracoacromial ligament (CAL)

Diagnosis of Rotator Cuff Tears

A comprehensive history should be obtained by clinicians evaluating patients with acute or chronic shoulder pain.  Characteristics of a history of potential rotator cuff (RC) injury include

• Acute RC tendonitis –  history of trauma and/or acute on chronic exacerbation
• Chronic RC tendinopathy – either acute on chronic history/mechanism or an atraumatic, insidious onset presentation
• Symptom exacerbation with overhead activity
• Pain at night

Physical Examination Pearls

• C-spine/neck exam – Co-existing cervical radiculopathy should be ruled out in any situation where neck and/or shoulder pathology is in consideration. Observation of neck posturing, muscular symmetry, palpable tenderness, and active/passive ROM should be evaluated. Special tests that are helpful in this regard include the Spurling maneuver, myelopathic testing, reflex testing, and a comprehensive neurovascular exam.[rx]
• Shoulder exam – Clinicians must observe the overall shoulder girdle for assessment of symmetry, shoulder posturing, and overall muscle bulk and symmetry.  Scapular winging should also be ruled out. The skin should be observed for the presence of any previous surgical incisions, lacerations, scars, erythema or induration. In the absence of advanced degenerative changes affecting the glenohumeral joint, limited passive ROM is considered diagnostic for adhesive capsulitis and involves a separate treatment algorithm from RC tendinopathy/impingement.[rx][rx][rx][rx][rx]

The clinician can assess motor strength grading for C5 to T1 nerve roots in addition to specific RC muscle strength testing. Specifically, RC strength and/or pathology can be assessed via the following examinations:

Supraspinatus (SS)

• Jobe’s test – a positive test is a pain/weakness with resisted downward pressure while the patient’s shoulder is at 90 degrees of forwarding flexion and abduction in the scapular plane with the thumb pointing toward the floor.
• Drop arm test – the patient’s shoulder is brought into a position of 90 degrees of shoulder abduction in the scapular plane. The examiner initially supports the limb and then instructs the patient to slowly adduct the arm to the side of the body. A positive test includes the patient’s inability to maintain the abducted position of the shoulder and/or an inability to adduct the arm to the side of the trunk in a controlled manner.

Infraspinatus (IS)

• Strength testing – is performed while the shoulder is positioned against the side of the trunk, the elbow is flexed to 90 degrees, and the patient is asked to externally rotate (ER) the arm while the examiner resists this movement.
• External rotation lag sign – the examiner positions the patient’s shoulder in the same position, and while holding the wrist, the arm is brought into maximum ER. The test is positive if the patient’s shoulder drifts into internal rotation (IR) once the examiner removes the supportive ER force at the wrist.

Teres Minor (TM)

• Strength testing – is performed while the shoulder positioned at 90 degrees of abduction and the elbow is also flexed to 90 degrees.  Teres minor (TM) is best isolated for strength testing in this position while ER is resisted by the examiner.
• Hornblower’s sign – the examiner positions the shoulder in the same position and maximally ERs the shoulder under support. A positive test occurs when the patient is unable to hold this position, and the arm drifts into IR once the examiner removes the supportive ER force.

Subscapularis (SubSc)

• IR lag sign –  the examiner passively brings the patient’s shoulder behind the trunk (about 20 degrees of extension) with the elbow flexed to 90 degrees. The examiner passively IRs the shoulder by lifting the dorsum of the handoff of the patient’s back while supporting the elbow and wrist. A positive test occurs when the patient is unable to maintain this position once the examiner releases support at the wrist (i.e., the arm is not maintained in IR, and the dorsum of the hand drifts toward the back).
• Passive ER ROM –  a partial or complete tear of the subscapularis (SubSc) can manifest as an increase in passive ER compared to the contralateral shoulder.
• Lift-off test – more sensitive/specific for lower SubSc pathology. In the same position as the IR lag sign position, the examiner places the patient’s dorsum of the hand against the lower back and then resists the patient’s ability to lift the dorsum of the hand away from the lower back.
• Belly press –  more sensitive/specific for upper subscapularis pathology. The examiner has the patient’s arm at 90 degrees of elbow flexion, and IR testing is performed by the patient pressing the palm of his/her hand against the belly, bringing the elbow in front of the plane of the trunk. The elbow is initially supported by the examiner, and a positive test occurs if the elbow is not maintained in this position upon the examiner removing the supportive force.
• Hawkins-Kennedy Impingement Sign—with the arm in 90 degrees of forwarding flexion, the patient’s arm is internally rotated; pain with internal rotation is a positive sign.
• Painful Arc Sign—arm is abducted as far as possible; the positive result if the patient has pain from 60 to 120 degrees.
• Cross-Body Adduction Test—with the arm in 90 degrees of forwarding flexion, examiner adducts arm across body; pain with adduction is a positive sign.
• Drop Arm Test—patient slowly elevates arm and reverses motion; if the arm drops suddenly or pain occurs, the test s considered positive.

External impingement/SIS

• Neer impingement sign – positive if the patient reports pain with passive shoulder forward flexion beyond 90 degrees. With the scapula stabilized, the arm is forward flexed passively; anterior or lateral pain in the range of 90 to 140 degrees is a positive sign for tear.
• Neer impingement test – positive test occurs after a subacromial injection is given by the examiner and the patient reports improved symptoms upon repeating the forced passive forward flexion beyond 90 degrees.
• Hawkins test – positive test occurs with the examiner passively positioning the shoulder and elbow at 90 degrees of flexion in front of the body; the patient will report pain when the examiner passively IR’s the shoulder.

Internal impingement

•  Internal impingement test – the patient is placed in a supine position and the shoulder is brought into terminal abduction and external rotation; a positive test consists of the reproduction of the patient’s pain.

Radiographs

• Recommended imaging includes a true anteroposterior (AP) image of the glenohumeral joint (i.e., the “Grashey” view). The true AP image is taken with the patient rotated between 30 and 45 degrees offset the cassette in the coronal plane. Alternatively, the beam can be rotated while the patient remains neutral in the coronal plane. The distance between the acromion and the humeral head (i.e., the acromiohumeral interval) can be calculated. A normal interval is between 7 and 14 mm, and this interval is decreased in cases of advanced degenerative arthritis and RCA.[rx]

Pertinent findings

The following are the most common radiographic changes associated with rotator cuff (RC) pathology:

• RCA – Proximal humeral migration and decreases in the acromiohumeral interval to <7mm
• Degenerative findings
  • osteophytes on the acromion, proximal humerus and/or glenoid are often seen in cases of advanced disease
  • calcification of the CAL and/or coracohumeral ligament (CHL)
  • greater tuberosity cystic degeneration
  • AC joint arthritis
• “Hooked” acromion – best appreciated on the supraspinatus outlet view
• Os acromiale – best seen on an axillary lateral radiograph

Ultrasound

• Ultrasound (US) is an often-underutilized imaging modality to detect RC tendon and muscle belly integrity. In 2011, a meta-analysis of over 6,000 shoulders revealed a sensitivity of 0.96 and specificity of 0.93 in assessing shoulders for PTTs or FTTs.[rx]

Magnetic Resonance Imaging

• Magnetic resonance imaging (MRI) is useful in evaluating the overall degree of RC pathology. MRI can be helpful in providing more accurate cuff tear details, including partial- versus full-thickness tears, the extent and size of the tear(s), location, and degree of retraction.
• In cases of chronic RC pathology, the cuff can be assessed for fatty degenerative changes on the T1-weighted sagittal sequence series.[rx]

Treatment of Rotator Cuff Tears

• Rest – Continuing to use your arm when it is painful prevents your supraspinatus tear from healing.
• Avoiding activities that aggravate the pain –  like overhead reaching or reaching behind the back
• Keep your arm down – in front of and close to your body (avoid an arm sling, as you risk the development of a frozen shoulder)
• Ice to reduce initial inflammation in tendonitis – (apply a cold pack to shoulder for 15 to 20 minutes every four to six hours)
• For a partial rupture – complete rest is best. Your shoulder should be immobilized in a sling or similar. See a sports injury specialist or doctor who can advise on treatment and rehabilitation.
• When your injury – has healed and you are pain-free, begin rotator cuff rehabilitation exercises. These should include mobility, strengthening and functional or sports specific exercises that should be done.
• Apply ice – after you get home from the hospital (regardless if you had surgery or not), you should apply a bag of crushed ice (or something cold) to your injured in order to reduce the swelling and numb the pain. Ice therapy is effective for acute (recent) injuries that involve swelling because it reduces blood flow by constricting local blood vessels. Apply the crushed ice to your injured area for 15 minutes three to five times daily until the soreness and inflammation eventually fade away or Ice can be applied for 15 minutes every 2 hours for the first day or two. From then on the frequency can be gradually reduced over a period of days.
• Lightly exercise after the pain fades – after a couple of weeks when the swelling has subsided and the pain has faded away, remove your arm sling for short periods and carefully move in all different directions. Don’t aggravate the necks but gently reintroduce movements to the involved joints and muscles. Start cautiously, maybe starting with light and then progress to holding light weights (five-pound weights to start).
• Practice stretching and strengthening exercises – of the fingers, leg if your doctor recommends them.
• A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
• A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)
• Get a referral to physical therapy – Once you’ve recovered and able to remove your arm sling splint for good, you’ll likely notice that the muscles surrounding your shoulder joint look smaller and feel weaker. That’s because muscle tissue atrophies without movement. If this occurs, then you’ll need to get a referral for some physical rehabilitation. Rehab can start once you are cleared by your orthopedist, are pain-free, and can perform all the basic arm and necks of femur fracture movements. A physiotherapist or athletic trainer can show you specific rehabilitation exercises and stretches to restore your muscle strength, joint movements, and flexibility.
• For RC tendonitis, the most utilized injection includes one into the subacromial space.  Patients can experience symptomatic relief almost instantaneously after the injection is given, allowing them to participate in subsequent PT therapy sessions ideally.

Medication

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any other cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema. Antibiotics and tetanus vaccination may be used if the bone breaks through the skin creating immunization.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Cortisone injections – First-line nonoperative management also includes the use of non-steroidal anti-inflammatory (NSAIDs) medications in conjunction with PT modalities.iontophoresis, transcutaneous electrical nerve stimulations (TENS), and other similar therapy modalities in the presence of FTTs, the committee reported a “moderate” recommendation grade for exercises and/or NSAIDs in the presence of RCS symptoms in the absence of FTTs.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms or injury
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – To improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament.
• Dietary supplement -to remove general weakness & healing and improved health.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Menthol – provides deep penetrating pain relief with a nice cooling sensation
• Vitamin B1, B6, B12– promotes normal nerve function
• Vitamin E – anti-inflammatory, enhances circulation, hydrates the skin
• Aloe vera – anti-inflammatory properties, soothes the skin
• Tea Tree – enhances the penetration of ingredients
• MSM – supports healthy connective tissues, anti-inflammatory
• Ilex Leaf Extract – increases circulation, skin conditioner

Rehabilitation of Rotator Cuff Tears

Group 1: Partial-Thickness (PTT) or Full-Thickness RC Tears (FTTs), Asymptomatic Patient 

Patients presenting with MRI-evidence of PTTs or FTTs often present without any symptoms. The most recent American Academy of Orthopaedic Surgeons (AAOS) clinical practice guideline (CPG) summary reported the growing awareness of incidental RC pathology revealed via shoulder MRIs in asymptomatic patient populations. Although there is evidence of the increasing prevalence of RC disease in the aging population, there is no reliable evidence that surgical intervention prevents tear propagation or the development of clinical symptoms.  Thus, the committee recommended symptomatic management via nonoperative modalities alone.[rx]

Group 2: Partial-Thickness (PTT), Symptomatic Patients

Patients presenting with symptoms of EI/SIS in the absence of FTTs are first managed with nonoperative treatment modalities. There is no agreed-upon time interval of when is most appropriate to proceed with surgical intervention in this particular group of patients. The literature ranges from 3 months to 18 months. Surgical intervention should be individually tailored based on the patient’s symptoms, improvement with nonoperative modalities, and overall goals of the patient.[rx][rx]

Group 3: Chronic RC Tears, Symptomatic Patients

The AAOS CPG reported a “weak” recommendation grade secondary to limited available evidence in the literature comparing rotator cuff repair (RCR) to continued nonoperative treatment modalities in this subset of patients. Certainly, the overall clinical picture must be considered, and the treatment tailored to the individual patient in each scenario.[rx]

Nonoperative RCS Treatment Modalities

Physical therapy (PT)

• Physical therapy (PT) remains the mainstay of first-line treatment for RC tendonitis.  Even in the setting of PTTs, patients can still be managed with PT alone.
• PT modalities include aggressive RC and periscapular stabilizer strengthening programs, as well as ROM exercises.

Rest/Activity modifications

• Patients benefit from an initial period of rest from the exacerbating activity (occupation or sport), especially repetitive overhead activity and heavy lifting.

Surgical Management

RCS surgical techniques range from debridement, subacromial decompression (SAD), and/or acromioplasty to RC debridement and, when indicated, RC bursal- or articular-sided tear completion with RCR.  The latter will not be discussed in this review. Assuming no RC FTTs are present, the extent of surgical management for external impingement/SIS alone includes[rx][rx][rx]:

Subacromial decompression

• Extensive debridement of the subacromial space is beneficial in patients with persistent symptoms of EI/SIS after at least 4 to 6 months of failed nonoperative modalities.
• Comprehensive bursectomy allows for the thorough and more accurate evaluation of thehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4004132/ bursal side of the cuff itself.
• CAL debridement is recommended in the setting of substantial CAL fraying and/or calcification as this is considered an additional source of impingement.
• A meta-analysis of 9 studies comparing open versus arthroscopic procedures yielded equivalent surgical times, outcomes, and complication rates at 1-year follow-up; the arthroscopic cohort returned to work quicker compared to the open cohort.

Acromioplasty

• Shaving the undersurface of the acromion, especially in the setting of significant spurring, improves the environment surrounding the cuff and allows additional clearance distance between the acromion and cuff itself throughout mid-arc and terminal range of motion (ROM) and impingement positions.
• In the case of hooked acromion morphologies, care is taken to debride this area with a shaver, burr, or rasp to flatten the undersurface.
• The anterior extent of the acromioplasty is demarcated by the anterior deltoid origin. This area should be respected in the debridement process. The anteroinferior region of the acromion is a common site of spurring and causes impingement symptoms in these patients.

Os acromiale

• In the case of persistent symptoms, a two-stage procedure is often utilized. First, the os acromiale is fused using bone grafting-techniques, followed by a formal acromioplasty after healing is achieved.

Differential Diagnosis

The differential diagnosis for chronic shoulder pain includes several etiologies:

Impingement

• External/SIS
• Subcoracoid
• Calcific tendonitis
• Internal (including SLAP lesions, glenohumeral internal rotation deficit (GIRD), Little league shoulder, posterior labral tears)

Rotator Cuff (RC) Pathology

• Tendonitis (acute), tendinopathy (chronic or acute on chronic)
• Partial- versus full-thickness tears (PTTs versus FTTs)
• RCA

Degenerative

• Advanced DJD, often associated with RCA
• Glenohumeral arthritis
• Adhesive capsulitis
• Avascular necrosis (AVN)
• Scapulothoracic crepitus

Proximal Biceps

• Subluxation–often seen in association with SubSc injuries
• Tendonitis and tendinopathy

AC Joint Conditions

• AC separation
• Distal clavicle osteolysis
• AC arthritis

Instability

• Unidirectional instability–seen in association with an inciting event/dislocation (anterior, posterior, inferior)
• Multidirectional instability (MDI)
• Associated labral injuries/pathology

Neurovascular Conditions

• Suprascapular neuropathy – can be associated with paralabral cyst at the spinoglenoid notch
• Scapular winging–medial or lateral
• Brachial neuritis
• Thoracic outlet syndrome (TOS)
• Quadrilateral space syndrome

Other Conditions

• Scapulothoracic dyskinesia
• Os acromiale
• Muscle ruptures (pectoralis major, deltoid, latissimus dorsi)
• Fracture (acute injury or pain resulting from long-standing deformity, malunion, or nonunion)

Prognosis

The majority of patients with rotator cuff (RC) tendinopathy in the absence of FTTs improve with nonoperative management. The most recent AAOS CPGs touted a “moderate” recommendation grade for initial treatment of NSAIDs and/or exercises programs based on multiple level II studies in the literature

Complications

Complications associated with rotator cuff syndrome (RCS) are best broken down into nonoperative- versus operative-related complications:

Nonoperative Management

• Persistent pain/recurrent symptoms
• In the setting of PTTs, there is at least a theoretical risk of tear propagation, lack of healing, fatty infiltration, atrophy, and retraction.
  • Overall a controversial topic, a 2017 study analyzed independent risk factors for symptomatic RC tear progression over a 19-month period of nonoperatively managed shoulders; risk factors for tear progression included:
    • The initial presence of an FTT
    • Medium-sized cuff tears (1 to 3 cm)
    • Smoking
    • While PTTs were included in the study, the presence of a PTT was not a risk factor for cuff tear progression
• In the setting of chronic/atrophic tears, especially with RC tear propagation, degenerative joint disease and RCA ensue

Surgical Management

• Surgical treatment tends to be most effective in patients that have failed or reported persistent or worsening symptoms despite at least 4-6 months of exhaustive nonoperative treatment modalities
• The standard risks of surgery, including recurrent pain/symptoms, infection, stiffness, neurovascular injury, and risks associated with anesthetic use
• SAD/acromioplasty
  • Deltoid dysfunction: can occur secondary to failed deltoid repair following an open acromioplasty or excessive debridement during arthroscopy
  • Anterosuperior escape: occurs secondary to aggressive CAL release–the coracoacromial arch and suspensory system becomes compromised, and with CAL release in the setting of massive, retracted, and irreparable RC tears, the humeral head migrates superiorly and anteriorly to compromise patient functional outcomes

References

How long does rotator cuff tendonitis take to heal?/Rotator cuff tendonitis (inflammation) and rotator cuff tears are common conditions in active people. Both conditions are usually caused by a prolonged period of repetitive stress (and the tendonitis condition itself may, over time, lead to an eventual tear). This type of stress is usually associated with overhead work-related activities or athletics such as tennis or throwing sports like baseball, cricket or jai alai. However, the rotator cuff may also be acutely injured in trauma involving a fall on the arm and shoulder or from heavy lifting.[rx]

Rotator cuff tears are a common cause of shoulder pain and dysfunction. A rotator cuff tear frequently occurs after seemingly minor trauma to the musculotendinous unit of the shoulder. However, in most cases, the pathologic process responsible for the tear has been a long time in the making and is the result of ongoing tendinitis. The rotator cuff is made up of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles and the associated tendons. The function of the rotator cuff is to rotate the arm and help provide shoulder joint stability along with the other muscles, tendons, and ligaments of the shoulder.

Mechanism Of Rotator Cuff Tendonitis

Chronically, RC tendinopathy can occur secondary to a variety of proposed mechanisms:

• Extrinsic compression – The extrinsic theory of mechanical impingement and pathologic contact between the undersurface of the acromion and the RC results in repetitive injury to the cuff. RC tendinopathy results in weakened areas of the cuff, eventually resulting in PTTs and/or FTTs. The mechanical compression can occur secondary to a degenerative bursa, acromial spurring, and predisposing acromial morphologies (i.e., the hooked-type acromion). Theories were popularized and modified by Watson-Jones, Neer, and Bigliani.[2][4][5]
• Intrinsic mechanisms – Several theories exist to support intrinsic degeneration of the cuff as the primary source of shoulder impingement. In general, the intrinsic degenerative theories cite that cuff degeneration eventually compromises the overall stability of the glenohumeral joint. Once compromised, the humeral head migrates superiorly, and the subacromial space decreases in size. Thus, the cuff becomes susceptible to secondary extrinsic compressive forces, ultimately leading to cuff degeneration, tendinopathy, and tearing.[rx][rx]
• Vascular changes – Advocates for intrinsic degenerative theories cite focal vascular adaptations that occur secondary to age-related changes and intrinsic cuff failure from repetitive eccentric forces directly experienced by the cuff itself. Controversy proposed by other studies, however, supports that the attritional areas develop secondary to the preceding impingement mechanisms. Subsequently, external impingement (EI) leads to blood vessel damage, ensuing ischemia, tenocyte apoptosis, gross tendinopathy, and attritional cuff damage.[rx] Furthermore, many studies cite increased vascularity in focal areas of the cuff, and the hypervascularity has been associated with age-related changes, tendinopathy, and PTTs and/or FTTs.[rx][rx]
• Age, sex, and genetics –Histologically, age-related RC changes include collagen fiber disorientation and myxoid degeneration.[rx] The literature favors increasing frequencies of RC abnormalities with increasing age. The frequency increases from 5% to 10% in patients younger than 20 years of age, to 30% to 35% in those in their sixth and seventh decades of life, topping out at 60% to 65% in patients over 80 years of age.[rx][rx][rx]
• Tensile forces –A study by Budoff et al. proposed that the primary mode of failure of the cuff occurs intrinsically within the cuff itself as it repeatedly withstands significant eccentric tensile forces during physical activity.[rx]

Pathophysiology of Rotator Cuff Tendonitis

Acute rotator cuff (RC) tendonitis can occur secondary to direct blows to the shoulder, poor throwing mechanics in overhead sports, or from falls on an outstretched arm.[rx]

Tendinopathy ensues after repetitive RC injury triggers a recurrent pathological cycle that results in acute on chronic tendonitis, increasing levels of tendinopathy and tendinosis, and ultimately, PTTs and/or FTTs to varying degrees of tear sizes and retraction. The exact pathogenesis of RC tears still remains controversial, but most clinicians agree the underlying mechanism is comprised of a combination of extrinsic impingement from structures surrounding the cuff and intrinsic degeneration from changes within the tendon itself.[rx]

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Acute Tear

If you fall down on your outstretched arm or lift something too heavy with a jerking motion, you can tear your rotator cuff. This type of tear can occur with other shoulder injuries, such as a broken collarbone or dislocated shoulder.

Degenerative Tear

Most tears are the result of a wearing down of the tendon that occurs slowly over time. This degeneration naturally occurs as we age. Rotator cuff tears are more common in the dominant arm. If you have a degenerative tear in one shoulder, there is a greater likelihood of a rotator cuff tear in the opposite shoulder even if you have no pain in that shoulder.

Several factors contribute to degenerative, or chronic, rotator cuff tears.

• Repetitive stress – Repeating the same shoulder motions, again and again, can stress your rotator cuff muscles and tendons. Baseball, tennis, rowing, and weightlifting are examples of sports activities that can put you at risk for overuse tears. Many jobs and routine chores can cause overuse of tears, as well.
• Lack of blood supply – As we get older, the blood supply in our rotator cuff tendons lessens. Without a good blood supply, the body’s natural ability to repair tendon damage is impaired. This can ultimately lead to a tendon tear.
• Bone spurs – As we age, bone spurs (bone overgrowth) often develop on the underside of the acromion bone. When we lift our arms, the spurs rub on the rotator cuff tendon. This condition is called shoulder impingement, and over time will weaken the tendon and make it more likely to tear.
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of injury.
• Sports injuries – Many Injury occurs during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause necks of femur fracture to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate intake of calcium or vitamin D
• Football or soccer, especially on artificial turf
• Rugby
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• In-line skating
• Jumping on a trampoline

Rotator cuff (RC) tendinopathic histologic changes include the following [rx][rx][rx][rx][rx]

• Rounded tenocytes (apoptosis)
• Extracellular matrix disorganization and myxoid degeneration
• Vascular changes (focal hypervascularity; focal hypovascular regions as well)
• Reduced total cellularity
• Calcified depositions
• Collagen fiber thinning
• Degenerative acromion, coracoacromial ligament (CAL)

Diagnosis of Rotator Cuff Tendonitis

A comprehensive history should be obtained by clinicians evaluating patients with acute or chronic shoulder pain.  Characteristics of a history of potential rotator cuff (RC) injury include

• Acute RC tendonitis –  history of trauma and/or acute on chronic exacerbation
• Chronic RC tendinopathy – either acute on chronic history/mechanism or an atraumatic, insidious onset presentation
• Symptom exacerbation with overhead activity
• Pain at night

Physical Examination Pearls

• C-spine/neck exam – Co-existing cervical radiculopathy should be ruled out in any situation where neck and/or shoulder pathology is in consideration. Observation of neck posturing, muscular symmetry, palpable tenderness, and active/passive ROM should be evaluated. Special tests that are helpful in this regard include the Spurling maneuver, myelopathic testing, reflex testing, and a comprehensive neurovascular exam.[rx]
• Shoulder exam – Clinicians must observe the overall shoulder girdle for assessment of symmetry, shoulder posturing, and overall muscle bulk and symmetry.  Scapular winging should also be ruled out. The skin should be observed for the presence of any previous surgical incisions, lacerations, scars, erythema or induration. In the absence of advanced degenerative changes affecting the glenohumeral joint, limited passive ROM is considered diagnostic for adhesive capsulitis and involves a separate treatment algorithm from RC tendinopathy/impingement.[rx][rx][rx][rx][rx]

The clinician can assess motor strength grading for C5 to T1 nerve roots in addition to specific RC muscle strength testing. Specifically, RC strength and/or pathology can be assessed via the following examinations:

Supraspinatus (SS)

• Jobe’s test – a positive test is a pain/weakness with resisted downward pressure while the patient’s shoulder is at 90 degrees of forwarding flexion and abduction in the scapular plane with the thumb pointing toward the floor.
• Drop arm test – the patient’s shoulder is brought into a position of 90 degrees of shoulder abduction in the scapular plane. The examiner initially supports the limb and then instructs the patient to slowly adduct the arm to the side of the body. A positive test includes the patient’s inability to maintain the abducted position of the shoulder and/or an inability to adduct the arm to the side of the trunk in a controlled manner.

Infraspinatus (IS)

• Strength testing – is performed while the shoulder is positioned against the side of the trunk, the elbow is flexed to 90 degrees, and the patient is asked to externally rotate (ER) the arm while the examiner resists this movement.
• External rotation lag sign – the examiner positions the patient’s shoulder in the same position, and while holding the wrist, the arm is brought into maximum ER. The test is positive if the patient’s shoulder drifts into internal rotation (IR) once the examiner removes the supportive ER force at the wrist.

Teres Minor (TM)

• Strength testing – is performed while the shoulder positioned at 90 degrees of abduction and the elbow is also flexed to 90 degrees.  Teres minor (TM) is best isolated for strength testing in this position while ER is resisted by the examiner.
• Hornblower’s sign – the examiner positions the shoulder in the same position and maximally ERs the shoulder under support. A positive test occurs when the patient is unable to hold this position, and the arm drifts into IR once the examiner removes the supportive ER force.

Subscapularis (SubSc)

• IR lag sign –  the examiner passively brings the patient’s shoulder behind the trunk (about 20 degrees of extension) with the elbow flexed to 90 degrees. The examiner passively IRs the shoulder by lifting the dorsum of the handoff of the patient’s back while supporting the elbow and wrist. A positive test occurs when the patient is unable to maintain this position once the examiner releases support at the wrist (i.e., the arm is not maintained in IR, and the dorsum of the hand drifts toward the back).
• Passive ER ROM –  a partial or complete tear of the subscapularis (SubSc) can manifest as an increase in passive ER compared to the contralateral shoulder.
• Lift-off test – more sensitive/specific for lower SubSc pathology. In the same position as the IR lag sign position, the examiner places the patient’s dorsum of the hand against the lower back and then resists the patient’s ability to lift the dorsum of the hand away from the lower back.
• Belly press –  more sensitive/specific for upper subscapularis pathology. The examiner has the patient’s arm at 90 degrees of elbow flexion, and IR testing is performed by the patient pressing the palm of his/her hand against the belly, bringing the elbow in front of the plane of the trunk. The elbow is initially supported by the examiner, and a positive test occurs if the elbow is not maintained in this position upon the examiner removing the supportive force.
• Hawkins-Kennedy Impingement Sign—with the arm in 90 degrees of forwarding flexion, the patient’s arm is internally rotated; pain with internal rotation is a positive sign.
• Painful Arc Sign—arm is abducted as far as possible; the positive result if the patient has pain from 60 to 120 degrees.
• Cross-Body Adduction Test—with the arm in 90 degrees of forwarding flexion, examiner adducts arm across body; pain with adduction is a positive sign.
• Drop Arm Test—patient slowly elevates arm and reverses motion; if the arm drops suddenly or pain occurs, the test s considered positive.

External impingement/SIS

• Neer impingement sign – positive if the patient reports pain with passive shoulder forward flexion beyond 90 degrees. With the scapula stabilized, the arm is forward flexed passively; anterior or lateral pain in the range of 90 to 140 degrees is a positive sign for tear.
• Neer impingement test – positive test occurs after a subacromial injection is given by the examiner and the patient reports improved symptoms upon repeating the forced passive forward flexion beyond 90 degrees.
• Hawkins test – positive test occurs with the examiner passively positioning the shoulder and elbow at 90 degrees of flexion in front of the body; the patient will report pain when the examiner passively IR’s the shoulder.

Internal impingement

•  Internal impingement test – the patient is placed in a supine position and the shoulder is brought into terminal abduction and external rotation; a positive test consists of the reproduction of the patient’s pain.

Radiographs

• Recommended imaging includes a true anteroposterior (AP) image of the glenohumeral joint (i.e., the “Grashey” view). The true AP image is taken with the patient rotated between 30 and 45 degrees offset the cassette in the coronal plane. Alternatively, the beam can be rotated while the patient remains neutral in the coronal plane. The distance between the acromion and the humeral head (i.e., the acromiohumeral interval) can be calculated. A normal interval is between 7 and 14 mm, and this interval is decreased in cases of advanced degenerative arthritis and RCA.[rx]

Pertinent findings

The following are the most common radiographic changes associated with rotator cuff (RC) pathology:

• RCA – Proximal humeral migration and decreases in the acromiohumeral interval to <7mm
• Degenerative findings
  • osteophytes on the acromion, proximal humerus and/or glenoid are often seen in cases of advanced disease
  • calcification of the CAL and/or coracohumeral ligament (CHL)
  • greater tuberosity cystic degeneration
  • AC joint arthritis
• “Hooked” acromion – best appreciated on the supraspinatus outlet view
• Os acromiale – best seen on an axillary lateral radiograph

Ultrasound

• Ultrasound (US) is an often-underutilized imaging modality to detect RC tendon and muscle belly integrity. In 2011, a meta-analysis of over 6,000 shoulders revealed a sensitivity of 0.96 and specificity of 0.93 in assessing shoulders for PTTs or FTTs.[rx]

Magnetic Resonance Imaging

• Magnetic resonance imaging (MRI) is useful in evaluating the overall degree of RC pathology. MRI can be helpful in providing more accurate cuff tear details, including partial- versus full-thickness tears, the extent and size of the tear(s), location, and degree of retraction.
• In cases of chronic RC pathology, the cuff can be assessed for fatty degenerative changes on the T1-weighted sagittal sequence series.[rx]

Treatment of Rotator Cuff Tendonitis

• Rest – Continuing to use your arm when it is painful prevents your supraspinatus tear from healing.
• Avoiding activities that aggravate the pain –  like overhead reaching or reaching behind the back
• Keep your arm down – in front of and close to your body (avoid an arm sling, as you risk the development of a frozen shoulder)
• Ice to reduce initial inflammation in tendonitis – (apply a cold pack to shoulder for 15 to 20 minutes every four to six hours)
• For a partial rupture – complete rest is best. Your shoulder should be immobilized in a sling or similar. See a sports injury specialist or doctor who can advise on treatment and rehabilitation.
• When your injury – has healed and you are pain-free, begin rotator cuff rehabilitation exercises. These should include mobility, strengthening and functional or sports specific exercises that should be done.
• Apply ice – after you get home from the hospital (regardless if you had surgery or not), you should apply a bag of crushed ice (or something cold) to your injured in order to reduce the swelling and numb the pain. Ice therapy is effective for acute (recent) injuries that involve swelling because it reduces blood flow by constricting local blood vessels. Apply the crushed ice to your injured area for 15 minutes three to five times daily until the soreness and inflammation eventually fade away or Ice can be applied for 15 minutes every 2 hours for the first day or two. From then on the frequency can be gradually reduced over a period of days.
• Lightly exercise after the pain fades – after a couple of weeks when the swelling has subsided and the pain has faded away, remove your arm sling for short periods and carefully move in all different directions. Don’t aggravate the necks but gently reintroduce movements to the involved joints and muscles. Start cautiously, maybe starting with light and then progress to holding light weights (five-pound weights to start).
• Practice stretching and strengthening exercises – of the fingers, leg if your doctor recommends them.
• A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
• A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)
• Get a referral to physical therapy – Once you’ve recovered and able to remove your arm sling splint for good, you’ll likely notice that the muscles surrounding your shoulder joint look smaller and feel weaker. That’s because muscle tissue atrophies without movement. If this occurs, then you’ll need to get a referral for some physical rehabilitation. Rehab can start once you are cleared by your orthopedist, are pain-free, and can perform all the basic arm and necks of femur fracture movements. A physiotherapist or athletic trainer can show you specific rehabilitation exercises and stretches to restore your muscle strength, joint movements, and flexibility.
• For RC tendonitis, the most utilized injection includes one into the subacromial space.  Patients can experience symptomatic relief almost instantaneously after the injection is given, allowing them to participate in subsequent PT therapy sessions ideally.

Medication

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any other cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema. Antibiotics and tetanus vaccination may be used if the bone breaks through the skin creating immunization.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, Naproxen, Etoricoxib.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Cortisone injections – First-line nonoperative management also includes the use of non-steroidal anti-inflammatory (NSAIDs) medications in conjunction with PT modalities.iontophoresis, transcutaneous electrical nerve stimulations (TENS), and other similar therapy modalities in the presence of FTTs, the committee reported a “moderate” recommendation grade for exercises and/or NSAIDs in the presence of RCS symptoms in the absence of FTTs.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms or injury
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – To improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament.
• Dietary supplement -to remove general weakness & healing and improved health.
• Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Menthol – provides deep penetrating pain relief with a nice cooling sensation
• Vitamin B1, B6, B12– promotes normal nerve function
• Vitamin E – anti-inflammatory, enhances circulation, hydrates the skin
• Aloe vera – anti-inflammatory properties, soothes the skin
• Tea Tree – enhances the penetration of ingredients
• MSM – supports healthy connective tissues, anti-inflammatory
• Ilex Leaf Extract – increases circulation, skin conditioner

Rehabilitation of Rotator Cuff Tendonitis

Group 1: Partial-Thickness (PTT) or Full-Thickness RC Tears (FTTs), Asymptomatic Patient 

Patients presenting with MRI-evidence of PTTs or FTTs often present without any symptoms. The most recent American Academy of Orthopaedic Surgeons (AAOS) clinical practice guideline (CPG) summary reported the growing awareness of incidental RC pathology revealed via shoulder MRIs in asymptomatic patient populations. Although there is evidence of the increasing prevalence of RC disease in the aging population, there is no reliable evidence that surgical intervention prevents tear propagation or the development of clinical symptoms.  Thus, the committee recommended symptomatic management via nonoperative modalities alone.[rx]

Group 2: Partial-Thickness (PTT), Symptomatic Patients

Patients presenting with symptoms of EI/SIS in the absence of FTTs are first managed with nonoperative treatment modalities. There is no agreed-upon time interval of when is most appropriate to proceed with surgical intervention in this particular group of patients. The literature ranges from 3 months to 18 months. Surgical intervention should be individually tailored based on the patient’s symptoms, improvement with nonoperative modalities, and overall goals of the patient.[rx][rx]

Group 3: Chronic RC Tears, Symptomatic Patients

The AAOS CPG reported a “weak” recommendation grade secondary to limited available evidence in the literature comparing rotator cuff repair (RCR) to continued nonoperative treatment modalities in this subset of patients. Certainly, the overall clinical picture must be considered, and the treatment tailored to the individual patient in each scenario.[rx]

Nonoperative RCS Treatment Modalities

Physical therapy (PT)

• Physical therapy (PT) remains the mainstay of first-line treatment for RC tendonitis.  Even in the setting of PTTs, patients can still be managed with PT alone.
• PT modalities include aggressive RC and periscapular stabilizer strengthening programs, as well as ROM exercises.

Rest/Activity modifications

• Patients benefit from an initial period of rest from the exacerbating activity (occupation or sport), especially repetitive overhead activity and heavy lifting.

Surgical Management

RCS surgical techniques range from debridement, subacromial decompression (SAD), and/or acromioplasty to RC debridement and, when indicated, RC bursal- or articular-sided tear completion with RCR.  The latter will not be discussed in this review. Assuming no RC FTTs are present, the extent of surgical management for external impingement/SIS alone includes[rx][rx][rx]:

Subacromial decompression

• Extensive debridement of the subacromial space is beneficial in patients with persistent symptoms of EI/SIS after at least 4 to 6 months of failed nonoperative modalities.
• Comprehensive bursectomy allows for the thorough and more accurate evaluation of thehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4004132/ bursal side of the cuff itself.
• CAL debridement is recommended in the setting of substantial CAL fraying and/or calcification as this is considered an additional source of impingement.
• A meta-analysis of 9 studies comparing open versus arthroscopic procedures yielded equivalent surgical times, outcomes, and complication rates at 1-year follow-up; the arthroscopic cohort returned to work quicker compared to the open cohort.

Acromioplasty

• Shaving the undersurface of the acromion, especially in the setting of significant spurring, improves the environment surrounding the cuff and allows additional clearance distance between the acromion and cuff itself throughout mid-arc and terminal range of motion (ROM) and impingement positions.
• In the case of hooked acromion morphologies, care is taken to debride this area with a shaver, burr, or rasp to flatten the undersurface.
• The anterior extent of the acromioplasty is demarcated by the anterior deltoid origin. This area should be respected in the debridement process. The anteroinferior region of the acromion is a common site of spurring and causes impingement symptoms in these patients.

Os acromiale

• In the case of persistent symptoms, a two-stage procedure is often utilized. First, the os acromiale is fused using bone grafting-techniques, followed by a formal acromioplasty after healing is achieved.

Differential Diagnosis

The differential diagnosis for chronic shoulder pain includes several etiologies:

Impingement

• External/SIS
• Subcoracoid
• Calcific tendonitis
• Internal (including SLAP lesions, glenohumeral internal rotation deficit (GIRD), Little league shoulder, posterior labral tears)

Rotator Cuff (RC) Pathology

• Tendonitis (acute), tendinopathy (chronic or acute on chronic)
• Partial- versus full-thickness tears (PTTs versus FTTs)
• RCA

Degenerative

• Advanced DJD, often associated with RCA
• Glenohumeral arthritis
• Adhesive capsulitis
• Avascular necrosis (AVN)
• Scapulothoracic crepitus

Proximal Biceps

• Subluxation–often seen in association with SubSc injuries
• Tendonitis and tendinopathy

AC Joint Conditions

• AC separation
• Distal clavicle osteolysis
• AC arthritis

Instability

• Unidirectional instability–seen in association with an inciting event/dislocation (anterior, posterior, inferior)
• Multidirectional instability (MDI)
• Associated labral injuries/pathology

Neurovascular Conditions

• Suprascapular neuropathy – can be associated with paralabral cyst at the spinoglenoid notch
• Scapular winging–medial or lateral
• Brachial neuritis
• Thoracic outlet syndrome (TOS)
• Quadrilateral space syndrome

Other Conditions

• Scapulothoracic dyskinesia
• Os acromiale
• Muscle ruptures (pectoralis major, deltoid, latissimus dorsi)
• Fracture (acute injury or pain resulting from long-standing deformity, malunion, or nonunion)

Prognosis

The majority of patients with rotator cuff (RC) tendinopathy in the absence of FTTs improve with nonoperative management. The most recent AAOS CPGs touted a “moderate” recommendation grade for initial treatment of NSAIDs and/or exercises programs based on multiple level II studies in the literature

Complications

Complications associated with rotator cuff syndrome (RCS) are best broken down into nonoperative- versus operative-related complications:

Nonoperative Management

• Persistent pain/recurrent symptoms
• In the setting of PTTs, there is at least a theoretical risk of tear propagation, lack of healing, fatty infiltration, atrophy, and retraction.
  • Overall a controversial topic, a 2017 study analyzed independent risk factors for symptomatic RC tear progression over a 19-month period of nonoperatively managed shoulders; risk factors for tear progression included:
    • The initial presence of an FTT
    • Medium-sized cuff tears (1 to 3 cm)
    • Smoking
    • While PTTs were included in the study, the presence of a PTT was not a risk factor for cuff tear progression
• In the setting of chronic/atrophic tears, especially with RC tear propagation, degenerative joint disease and RCA ensue

Surgical Management

• Surgical treatment tends to be most effective in patients that have failed or reported persistent or worsening symptoms despite at least 4-6 months of exhaustive nonoperative treatment modalities
• The standard risks of surgery, including recurrent pain/symptoms, infection, stiffness, neurovascular injury, and risks associated with anesthetic use
• SAD/acromioplasty
  • Deltoid dysfunction: can occur secondary to failed deltoid repair following an open acromioplasty or excessive debridement during arthroscopy
  • Anterosuperior escape: occurs secondary to aggressive CAL release–the coracoacromial arch and suspensory system becomes compromised, and with CAL release in the setting of massive, retracted, and irreparable RC tears, the humeral head migrates superiorly and anteriorly to compromise patient functional outcomes

References

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3084009/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4295680/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4246390/
• https://www.ncbi.nlm.nih.gov/pubmed/15160255
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4246390/
• https://www.sciencedirect.com/topics/neuroscience/infraspinatus-muscle
• https://socratic.org/questions/what-is-infraspinatus-tendonitis
• http://www.prioryclinic.com/library/article/infraspinatus_tendinitis
• https://www.p2sportscare.com/articles/upper-extremity/infraspinatus-strain/
• https://www.p2sportscare.com/articles/upper-extremity/infraspinatus-strain/
• https://www.cancertherapyadvisor.com/home/decision-support-in-medicine/shoulder-and-elbow/

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3084009/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4295680/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4246390/
• https://www.ncbi.nlm.nih.gov/pubmed/15160255
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4246390/
• https://www.sciencedirect.com/topics/neuroscience/infraspinatus-muscle
• https://socratic.org/questions/what-is-infraspinatus-tendonitis
• http://www.prioryclinic.com/library/article/infraspinatus_tendinitis
• https://www.p2sportscare.com/articles/upper-extremity/infraspinatus-strain/
• https://www.p2sportscare.com/articles/upper-extremity/infraspinatus-strain/
• https://www.cancertherapyadvisor.com/home/decision-support-in-medicine/shoulder-and-elbow/

Generally, it is accepted that heat on soft tissue (muscles, tendons, ligaments) provides the following desirable therapeutic effects:

• Electromagnetic heat increases the extensibility of collagen tissues – Tissues heated to 45 degrees Celsius and then stretched exhibit a nonelastic residual elongation of about 0.5 to 0.9 percent that persists after the stretch is removed. This does not occur in these same tissues when stretched at normal tissue temperatures. Therefore 20 stretching sessions can produce a 10 to 18 percentage increase in the length of tissues heated and stretched.
  Stretching of tissue in the presence of heat would be especially valuable in working with ligaments, joint capsules, tendons, fascia, and synovium that have become scarred, thickened, or contracted. Such stretching at 45 degrees Celsius caused much less weakening in stretched tissues for a given elongation than a similar elongation produced at normal tissue temperatures.
  Experiments cited clearly showed low-force stretching could produce significant residual elongation when heat is applied together with stretching or range-of-motion exercises. This is safer than stretching tissues at normal tissue temperatures.
• Electromagnetic heat decreases joint stiffness –There was a 20 percent decrease in rheumatoid finger joint stiffness at 45 degrees Celsius (112 degrees Fahrenheit) as compared with 33 degrees Celsius (92 degrees Fahrenheit), which correlated perfectly to both subjective and objective observation of stiffness. Speculation has it that any stiffened joint and thickened connective tissues may respond in a similar fashion.
• Electromagnetic heat relieves muscle spasms – Muscle spasms have long been observed to be reduced through the use of heat, be they secondary to underlying skeletal, joint, or neuropathological conditions. This result is possibly produced by the combined effect of heat on both primary and secondary afferent nerves from spindle cells and from its effects on Golgi tendon organs. The results produced demonstrated their peak effect within the therapeutic temperature range obtainable with electromagnetic heat.
• Electromagnetic heat treatment leads to pain relief – Pain may be relieved via the reduction of attendant or secondary spasms. Pain is also at times related to ischemia (lack of blood supply) due to tension or spasm that can be improved by the hyperemia that heat-induced vasodilatation produces, thus breaking the feedback loop in which the ischemia leads to further spasm and then more pain.
  The heat has been shown to reduce pain sensation by direct action on both free-nerve endings in tissues and on peripheral nerves. In one dental study, repeated heat applications led finally to the abolishment of the whole nerve response responsible for pain arising from dental pulp.
  Localized electromagnetic therapy using lamps tuned to the 2 to 25-micron waveband is used for the treatment and relief of pain by over 40 reputable Chinese medical institutes.
• Electromagnetic heat increases blood flow – Heating muscles produces an increased blood flow level similar to that seen during exercise. Temperature elevation also produces an increased blood flow and dilation directly in capillaries, arterioles, and venules, probably through direct action on their smooth muscles. The release of bradykinin, released as a consequence of sweat-gland activity, also produces increased blood flow and vasodilatation.
• Electromagnetic heat assists in resolution of inflammatory infiltrate, edema and exudates Increased peripheral circulation provides the transport needed to help evacuate edema, which can help inflammation, decrease pain, and help speed healing.
• Electromagnetic heat affects soft tissue injury – Electromagnetic healing is now becoming leading-edge care for soft tissue injuries to promote both reliefs in chronic or intractable “permanent” cases and accelerated healing in newer injuries.

Exercise Physiotherapy

• Weighted pendulum exercise – Sit or stand holding a 5- to 10-pound weight in the hand of the affected shoulder. Use a hand weight or make one from a gallon container filled with water. Relax the shoulder, and allow the arm to hang straight down. Lean forward at a 20- to a 25-degree angle (if you’re standing, bend your knees slightly for a base of support), and swing your arm gently in a small circle, about one foot in diameter. Perform 10 circles in each direction, once or twice a day. As symptoms improve, you can make the circle wider — but never force it.
• Towel stretch – Grasp a dishtowel behind your back and hold it at a 45-degree angle. Use your good arm to gently pull the affected arm up toward the lower back. Do this stretch 10 to 20 times per day. You can also perform this exercise while holding the towel horizontally.
• Cross-body stretch – Sitting or standing, use the unaffected arm to lift the affected arm at the elbow and bring it up and across your body. Press gently, just above the elbow, to stretch the shoulder. Hold the stretch for 15 to 20 seconds. Do this exercise 10 to 20 times per day.
• Finger walk – Stand facing a wall at a distance of about three-quarters of an arm’s length away. With the affected arm, reach out and touch the wall at about waist level. Slowly walk your fingers up the wall, spider-like, as far as you comfortably can or until you raise your arm to shoulder level. Your fingers should be doing most of the work, not your shoulder muscles. Keep the elbow slightly bent. Slowly lower the arm — with the help of your good arm, if necessary. Perform this exercise 10 to 20 times a day. You can also try this exercise with the affected side facing the wall.
• Isometric muscle toning exercises – Heat and stretch your shoulder joint before doing these exercises. Use flexible rubber tubing, a bungee cord, or a large rubber band to provide resistance.

Associate

• Supraspinatus Tendonitis
• Subacromial Impingement
• Supraspinatus Tear

• https://www.ncbi.nlm.nih.gov/pubmed/3949834
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• https://onlinelibrary.wiley.com/doi/full/10.1111/imj.2_13829?af=R
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• https://www.jshoulderelbow.org/article/S1058-2746(10)00447-7/fulltext
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• https://journals.lww.com/clinorthop/Abstract
• https://www.americanjournalofsurgery.com/article/S0002-9610(38)91106-7/fulltext
• https://www.menshealth.com/fitness/a19531139/rupture-of-the-supraspinatus-tendon/
• https://link.springer.com/article/10.1007/s10195-013-0271-x
• https://radiopaedia.org/articles/rotator-cuff-tear
• http://www.aidmyrotatorcuff.com/rotator-cuff-tear/supraspinatus-tear-symptoms-and-recovery.php
• https://clinicaltrials.gov/ct2/show/NCT03171883
• https://www.amazon.com/Shoulder-Rupture-supraspinatus-lesions-subacromial/dp/B00085DK5O