Rotator Cuff Tear

Synonyms

ICD-9 Codes

Musculotendinous cuff rupture

Rotator cuff rupture
Rotator cuff tendinitis

726.10
Rotator cuff syndrome NOS
727.61
Nontraumatic complete rupture
of rotator cuff

Definition
The rotator cuff is composed of four muscles: the supraspinatus,
the infraspinatus, the subscapularis, and the teres minor (see the
illustration on page 303). These muscles form a cover around
the head of the humerus and function to rotate the arm and
stabilize the humeral head against the glenoid.
Rotator cuff tears occur with acute injury, but most are the
result of age-related degeneration, chronic mechanical
impingement, and altered blood supply to the tendons. Tears
generally originate in the supraspinatus tendon and may progress
posteriorly and anteriorly (Figure 1). Full-thickness tears are
uncommon in individuals younger than 40 years but are present
in 25% of individuals older than 60 years. Most older people
with rotator cuff tears are asymptomatic or have only mild,
nondisabling symptoms.

Figure 1 Coronal oblique MRI

Clinical Symptoms
Patients often report chronic shoulder pain for several months
and a specific injury that triggered the onset of the pain. Night
pain and difficulty sleeping on the affected side are
characteristic. Common symptoms include weakness, catching,
and grating, especially when raising the arm overhead.

of the shoulder
demonstrates a rotator
cuff tear (arrows).

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840.4
Rotator cuff sprain

Tests
Physical Examination
The back of the shoulder may appear sunken, indicating atrophy
of the infraspinatus muscle following a long-standing cuff tear.
Passive range of motion is near normal, but active range of
motion may be limited. With large tears, the patient cannot raise
the arm when asked to do so but can only shrug, or hike, the
shoulder (Figure 2). The patient also cannot hold the arm
elevated when it is lifted by the examiner parallel to the floor.
Some patients, however, maintain remarkably good active
motion despite large cuff tears. As the patient raises the arm, a
grating sensation about the tip of the shoulder can be felt.
Tenderness to palpation over the greater tuberosity is usually
present as well.
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Figure 2 Atrophy of the supraspinatus and

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infraspinatus muscles and shoulder

shrug with attempted abduction.
(Reproduced with permission from
Rockwood CA Jr: Subluxations and
dislocations about the shoulder, in
Rockwood CA Jr, Green DP, eds:
Rockwood and Greens Fractures in
Adults, ed 2. Philadelphia, PA, JB
Lippincott, 1984, pp 722-805.)

Figure 3 A, Positioning of x-ray beam for the 30 caudal

tilt view. B, Radiograph shows a bone spur of

the inferior acromion. (Part A is adapted with
permission from Rockwood CA Jr, Matsen FA,
eds: The Shoulder. Philadelphia, PA, WB
Saunders, 1990.)

Diagnostic Tests
A 30 caudal tilt view will often show a spur projecting down
from the inferior surface of the acromion (Figure 3). Often a
coracoacromial arch view (outlet view) is needed to show a
hooked acromion, indicative of this spur (Figure 4). The
presence of a spur does not necessarily indicate a rotator cuff
tear, however. Soft-tissue imaging is necessary to confirm the
diagnosis. With large, long-standing tears, AP radiographs may
reveal a high-riding humerus relative to the glenoid, indicative
of rotator cuff arthropathy (Figure 5).
If the diagnosis is equivocal or if surgical treatment is being
considered, MRI is the imaging study of choice because it can
provide additional information on the status of the muscle and
on the size of full-thickness and some partial-thickness tears.
Ultrasonography, in experienced hands, also is useful and
accurate in evaluating the rotator cuff.

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Differential Diagnosis

Acromioclavicular joint arthritis (localized pain and

tenderness and preserved motion)
Cervical spondylosis (neck stiffness, absent biceps reflex,
sensory changes)
Frozen shoulder (restricted active and passive motion)
Glenohumeral joint arthritis (evidence of arthritis on
radiographs)
Impingement syndrome/cuff tendinitis (similar pain, but
preserved active motion)
Pancoast tumor (venous distention, pulmonary changes, or
bony metastases)
Thoracic outlet syndrome (ulnar nerve paresthesias, worse
with military brace position)

Figure 4 Outlet view demonstrates

a hooked acromion
(arrow).

Adverse Outcomes of the Disease

Treatment
Nonsurgical treatment includes NSAIDs, rehabilitation with
strengthening and stretching exercises (see page 250), and
avoiding overhead activities. Corticosteroid injections should be
used judiciously. The steroid injection may decrease
inflammation of an associated subacromial bursitis and provide
short-term pain relief, but it also weakens the tendon. Repeated
injections may ultimately accelerate propagation of the rotator
cuff tear. Therefore, patients should never receive more than two
or three subacromial injections. If they are not effective,
additional injections are unlikely to help.
In general, patients with significant symptoms and failed
rehabilitation over 3 to 6 months should be considered
candidates for surgery. One exception to this rule is the patient
who has an acute traumatic cuff tear, in which case rotator cuff
repair is best performed acutely or no later than within 6 weeks
of injury. If an acute tear is neglected longer than this, it may
propagate and become retracted and much harder to repair.
Another possible exception is a rotator cuff tear in a younger
patient (younger than 55 years). Tears can enlarge with time and
become more difficult to repair. Therefore, consideration should
be given to surgical repair in younger patients of working age
with repairable tears.
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Figure 5 AP view of shoulder

shows high-riding
humeral head (arrow),
indicative of rotator cuff
arthropathy.

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Loss of shoulder motion (especially the ability to lift the arm

overhead), chronic pain, and/or weakness in the affected arm is
possible. Long-standing large tears sometimes lead to joint
degeneration.

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Rehabilitation Prescription
The functional goal of rehabilitation for a patient with a rotator
cuff tear is to reduce pain, increase strength, increase the range
of motion of the involved shoulder, and restore function.
Stiffness of the glenohumeral joint and poor scapulothoracic
mobility may be present, secondary to a period of
immobilization. Rehabilitation should not involve forcing the
shoulder into passive or active elevation. It is very important to
avoid further damage to the rotator cuff. Instructions to the
patient regarding a home exercise program should emphasize
that the patient should experience no pain during or after the
exercises. The home exercise program (see page 315) begins
with light weights and high repetitions to increase range of
motion and progresses to heavier weights and fewer repetitions
to strengthen the rotator cuff and the scapula rotators. Active
elevation should be avoided.
Formal rehabilitation should be prescribed immediately for
athletes or if the patient does not progress on the home program.
Poor progress would include the presence of pain and/or
stiffness during or after the exercises. In addition, formal
rehabilitation is indicated when, upon reevaluation by the
physician in 3 to 4 weeks, muscle strength or range of motion
has not improved. The prescription should include an evaluation
of glenohumeral and scapula rotator muscle strength and
initiation of an appropriate strengthening program. Pain-relieving
modalities such as interferential current, ultrasound, or heat also
may help to prepare the soft tissues for mobilization and
strengthening.

Adverse Outcomes of Treatment

NSAIDs may cause gastric, renal, or hepatic complications.
Corticosteroid injections may result in a transient increase in
pain because of the injection itself and degeneration of cuff
tissue. Repair of large rotator cuff tears has a high incidence of
failure, though the dbridement alone may relieve persistent pain.

Referral Decisions/Red Flags

Failure of 6 weeks of nonsurgical treatment is an indication for
further evaluation.

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Home Exercise Program for Rotator Cuff Tear

Perform the exercises in the order listed.

Apply a bag of crushed ice or frozen peas to the shoulder for 20 minutes after performing both
exercises to prevent any further inflammation or pain.
You should not experience pain with any of the exercises. If pain or stiffness occurs that prevents
you from performing any of the exercises correctly, call your doctor.

Exercise Type

Number of
Repetitions/Sets

Muscle Group

Number of
Days per Week

Number of
Weeks

Trapezius
strengthening

Middle and posterior deltoid

Supraspinatus
Middle trapezius

20 repetitions/3 to 4 sets,
decreasing to 8 to
10 repetitions/3 to 4 sets as
weight is added, then
progressing to
15 repetitions/3 sets

3 to 5

3 to 4

Internal and
external rotation
at 90 or 45
elevation

Internal rotation:
Anterior deltoid
Pectoralis
Subscapularis
Latissimus
External rotation:
Posterior deltoid
Infraspinatus
Teres minor

20 repetitions/3 to 4 sets,
decreasing to 8 to
10 repetitions/3 to 4 sets as
weight is added, then
progressing to
15 repetitions/3 sets

3 to 5

3 to 4

Trapezius Strengthening

Stand next to a bench or chair with your

knee and hand (on the unaffected side)
resting on the bench. The other hand should
be at your side, palm facing the body.
As you lift the arm slowly, rotate the hand
to the thumb-up position, stopping when the
arm is parallel to the floor.
Slowly lower the arm to the original
position to a count of 5.
Begin with a light enough weight to allow 3
to 4 sets of 20 repetitions without pain.
Decrease the repetitions to 8 to 10 and add
no more than 2 to 3 pounds of weight so
that the last few repetitions are difficult but
pain free.
Progress to 3 sets of 15 repetitions at each
weight increment.
Perform the exercise 3 to 5 times per week,
continuing for 3 to 4 weeks.

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Internal and External Rotation

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Lie on your back on the floor or a bed.

Extend your arm straight out from the
shoulder and bend the elbow 90.
Keeping your elbow bent, slowly move your
arm in the arc shown in the illustration.
Change the angle of the arm to 45 if you
experience pain at 90.
Begin with a light enough weight to allow 3
to 4 sets of 20 repetitions without pain.
Decrease the repetitions to 8 to 10 and add
no more than 2 to 3 pounds of weight so
that the last few repetitions are difficult but
pain free.
Progress to 3 sets of 15 repetitions at each
weight increment, with maximum weight
approximately 5 to 7 pounds.
Perform the exercises 3 to 5 times per week,
continuing for 3 to 4 weeks.

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