Peer Reviewed Article on Rotator Cuff Treatment Technologies
J Orthop Sci. 2013 Mar; xviii(2): 197–204.
Rotator cuff tear: physical test and conservative treatment
Eiji Itoi
Department of Orthopaedic Surgery, Tohoku University School of Medicine, Seiryo-machi, Aoba-ku, Sendai, 980-8574 Japan
Abstract
Rotator cuff tear is one of the near mutual shoulder diseases. It is interesting that some rotator cuff tears are symptomatic, whereas others are asymptomatic. Hurting is the near mutual symptom of patients with a tear. Even in patients with an asymptomatic tear, information technology may go symptomatic with an increase in tear size. Physical exam is extremely of import to evaluate the presence, location, and extent of a tear. It too helps united states to sympathize the mechanism of hurting. Conservative handling frequently works. Patients with well-preserved office of the supraspinatus and infraspinatus are the best candidates for conservative treatment. Afterwards a successful bourgeois treatment, the symptom once disappeared may come back again. This recurrence of symptoms is related to tear expansion. Those with loftier risk of tear expansion and those with less functional rotator gage muscles are less likely to respond to bourgeois treatment. They may need a surgical handling.
Prevalence of rotator gage tears
Rotator cuff tear is a common affliction. According to general population surveys, the prevalence of rotator gage tear is 25 % in those older than 50 years of age [ane] and twenty % in those older than 20 years of age [2]. The interesting thing is that only ane/3 of the tears cause pain and 2/3 are without pain. Merely xx % of those who have shoulder pain come up to the clinic, whereas the residue go to os setters or chiropractors, buy pain killers, or merely leave information technology alone [3]. This means that only i/15 of those with rotator gage tears come up to encounter us at the clinic. In other words, when we see i patient at our clinic with a symptomatic rotator cuff tear, in that location are 4 more patients with a symptomatic tear and 10 more than patients with an asymptomatic tear in the background.
Symptoms of rotator cuff tears
We evaluated the symptoms of patients with rotator gage tears when they first come to see us [4]. There were 157 patients who visited united states of america: 138 patients (87.9 %) came to the states because of pain; 17 (10.8 %) came to the states because of pain and muscle weakness less than manual muscle testing (MMT) grade 3 (off-white); 2 patients (1.three %) came to u.s.a. because of muscle weakness less than MMT course iii without pain. Nigh 99 % of patients with rotator cuff tears come to the clinic because of pain. In other words, controlling pain is the cardinal element of treatment. What causes pain in shoulders with rotator cuff tears? We oft feel that an injection of local anesthetics into the subacromial bursa decreases shoulder pain and increases shoulder strength [v]. Koike et al. [6] reported that the uptake of radioisotopes on bone scintigraphy increased in shoulders with a symptomatic tear compared to the contralateral intact shoulders. Inflammation seems to be one of the major causes of pain in shoulders with a rotator cuff tear. In fact, oral medication of anti-inflammatory non-steroidal drugs (NSAIDs) or intra-articular injection of corticosteroid is known to be constructive in reducing the pain. Although the conservative treatment does non promote the healing of a tear, it is effective in about of the cases because the major symptom is pain, which is ofttimes controllable by the conservative treatment.
Physical examination
Concrete examination starts with inspection. It is like shooting fish in a barrel to detect musculus atrophy of the infraspinatus viewing from the back of the patient because the infraspinatus is located just under the pare, whereas the supraspinatus is covered by the trapezius (Fig.ane). Atrophy of the shoulder muscles is a mutual finding in patients with rotator cuff tears. The position of the scapula is also important. If the parascapular muscles exercise not function well, the scapula is protracted and located abroad from the spinous processes. Adjacent, the scapular motility on the thorax is examined from the dorsum of the patient. The scapula rotates upwardly and down during arm elevation/depression. This smooth movement of the scapula on the thorax may have deteriorated because of subacromial impingement, and every bit a consequence, the medial boarder of the scapula may be prominent during arm depression in order to avoid the passing of the rotator cuff tendon underneath the acromion (Fig.ii). Palpation of the cuff tendon defect is a very useful examination. Codman [7] described this palpation technique in his textbook "The Shoulder." The tip of the finger is placed just inductive to the acromion to palpate the defect of the cuff tendon (Fig.iii). A tendon defect may be felt just inductive to the acromion with the shoulder in extension, and it disappears under the acromion with the shoulder in flexion. According to Wolf and Agrawal [8], the sensitivity and specificity of this palpating of the cuff tendon defect for the diagnosis of full-thickness rotator gage tears were 96 and 97 %, respectively, which were equivalent to the sensitivity and specificity of magnetic resonance imaging (MRI) or ultrasonography.
Cloudburst of the shoulder musculature. The right infraspinatus muscle is atrophic, and the infraspinous fossa is dented (arrow)
Winging of the scapula. The medial boarder of the right scapula (arrows) is prominent because of subacromial impingement
Palpation of a delle (defect) of the cuff tendon. A delle or defect of the tendon may be palpated simply anterior to the anterior margin of the acromion
During active or passive arm elevation, patients may feel shoulder pain because of subacromial impingement. Information technology is chosen "painful arc" if the pain appears during active arm elevation or depression. The hurting appears between 90° and 120° during arm elevation, and it appears between xc° and 30° during arm depression. On the other hand, if the pain appears during passive arm motility, it is called a positive "impingement sign." Two types of impingement sign are well known: the Neer [nine] (Fig.4) and the Hawkins and Kennedy [10] (Fig.v). Modifications of these signs are also possible (Figs.6, 7).
Neer impingement sign. While holding the scapula with one manus to avoid scapular rotation, apply elevation force to the arm that is in internal rotation. This procedure causes pain if there is a subacromial impingement
Hawkins impingement sign. With the arm in flexion, utilize internal rotation force, which causes pain if there is a subacromial impingement
Modified Neer sign. Applying summit force with the arm in external rotation is a modification of original Neer sign
Modified Hawkins sign. Keeping the arm in abduction, apply internal rotation force, which causes pain
For the purpose of identifying which tendon is ruptured, various location-specific physical examinations have been reported. A tear of the supraspinatus tendon tin can be detected past the empty-tin can exam (Fig.8) [11] or full-can test (Fig.9) [12]. The accuracy of the tests was the greatest when muscle weakness was interpreted every bit indicating a torn supraspinatus tendon in both the full-tin can test (75 % accurate) and the empty-tin test (70 % accurate) [13].
Supraspinatus examination (empty-can test). Utilize downward force to the arm in xc° scaption and in internal rotation (thumb downwards). If there is a supraspinatus tear, the patient cannot resist this force because of musculus weakness
Supraspinatus exam (total-tin test). Employ downward force with the arm in 90° scaption and in external rotation (pollex upward). If in that location is a supraspinatus tear, the patient cannot resist this force and the arm will exist depressed
The major external rotators of the shoulder are the infraspinatus and teres minor. Measuring the isometric forcefulness of external rotation with the arm at the side is commonly performed to detect a tear of the infraspinatus [fourteen]. A patient cannot keep the arm in external rotation at the side when a tear involves the major portion of the infraspinatus tendon. As a result, the forearm drops to the neutral rotation position, and this is called the "dropping sign," described past Neer [15] (Fig.10). Hertel et al. [sixteen] introduced an external rotation lag sign, which is like to the "dropping sign." If a tear is more than extensive and involves the teres minor, the external rotation forcefulness decreases with the arm in abduction, which leads to a positive hornblower'south sign (Fig.eleven) [17]. Walch et al. [17] reported that the hornblower's sign had a sensitivity of 100 % and a specificity of 93 % for the presence of phase 3 or stage 4 fatty degeneration of teres minor on the CT scan. On the other hand, the dropping sign had a 100 % sensitivity and specificity for the presence of stage iii or stage 4 fatty degeneration of the infraspinatus.
Dropping sign or external rotation lag sign. The patient is asked to keep the arm in external rotation. On the intact side (a), the patient can keep the arm in external rotation position when the examiner lets the arm go. On the involved side (b), the patient cannot go along the arm in external rotation, and the arm comes back to the neutral rotation afterward the examiner lets the arm become
Hornblower's sign. The patient is asked to bring the hands to the mouth. He tin can do it, just only with the elbow in a high position and the wrist in extension on the affected side (right arm). On the intact side (left arm), the patient can accomplish the mouth without bringing the elbow high
With a tear of the subscapularis, the internal rotation strength theoretically decreases, simply because of the other internal rotators such as the teres major, latissimus dorsi, and pectoralis major, it is difficult to evaluate a decrease in the internal rotation forcefulness with the arm in neutral rotation using the manual muscle test. The lift-off examination to detect a subscapularis tear was introduced by Gerber and Krushell [xviii] (Fig.12). Placing the hand backside the dorsum at the lumbar level, the shoulder is almost in full internal rotation, and the only internal rotator that functions in this position is the subscapularis. The patient is instructed to raise the manus off the back, performing a further internal rotation of the shoulder. Inability to hold the hand off the dorsum is indicative of subscapularis tearing. In cases with express motion of internal rotation, the belly printing examination is recommended (Fig.thirteen) [19].
Lift-off examination. A patient can lift off the hand from the back at the lumbar level with the intact subscapularis (a). If it is torn, the patient cannot elevator off the hand from the dorsum (b)
Belly-press test. With the intact subscapularis, a patient can press the belly with the mitt, wrist, and elbow straight (a). If the subscapularis is torn, the patient cannot keep the manus, wrist, and elbow straight to press the abdomen (b). Due to weakness, the patient flexes the wrist and brings the elbow astern in club to press the belly
Bourgeois handling
For the purpose of eliminating pain, we use oral NSAID medication, steroids or hyaluronic acid injections into the glenohumeral joint or subacromial bursa depending upon the site of the tear. Physical therapy such as heat, stretching, passive and active range of motion exercises, and musculus strengthening exercises are prescribed. Evaluation of any aberrant movement of the scapulothoracic motion is too of import. If at that place is whatsoever dyskinesis of the scapulothoracic move (scapular protraction), information technology needs to be corrected by physical therapy.
How effective is conservative treatment? The success charge per unit of conservative treatment ranges from 33 % [20] to 82 % [21] in the literature. In our first study [21], we retrospectively reviewed 62 shoulders of 54 patients with full-thickness tears who were followed up without surgery. The follow-upwards period averaged 3.four years. According to modified criteria of Wolfgang, 51 shoulders in 45 patients (82 %) were rated as satisfactory (excellent or expert). The patients with satisfactory results and unsatisfactory results amongst those observed more than 5 years were compared. The simply significant differences in the initial findings between the two groups were the agile abduction angle and the abduction strength: the patients with satisfactory results retained a good range of motion and forcefulness, whereas those with unsatisfactory results had a limited range and musculus weakness on initial exam. Conservative treatment affords satisfactory results when given to the patients with well-preserved motion and strength. The limitation of this study was that all surgical cases were excluded. In order to evaluate the efficacy of conservative handling, those who failed to respond to conservative treatment and eventually underwent surgical handling should be included as failure cases of conservative handling. In our next study [22], we prospectively treated 107 shoulders of 105 consecutive patients with total-thickness tears of the rotator gage. Nosotros performed conservative treatment for 6 months. If the shoulder symptoms disappeared or became mild plenty, the handling was discontinued. If the shoulder symptoms remained but the patients did non want to undergo surgery, conservative handling was continued. If the patients were not happy with their shoulder considering of remaining symptoms after 6 months of bourgeois handling, they underwent surgical handling with informed consent. The average age of the patients was 64 years (range 44–80 years). 3 patients underwent surgical handling. These iii patients were evaluated as failure cases of bourgeois treatment. At the time of follow-up, one patient was dead as the outcome of a cause other than the shoulder and one patient was missing. In total, nosotros followed 102 shoulders of 100 patients with an average follow-upwardly period of 32 (12–48) months. At the time of follow-upward, 50 % of them were totally hurting free, and 40 % had mild pain not requiring hurting killers. Regarding activities of daily living, 75 % of the patients said they felt no limitations in daily activities. In full, 75/100 (75 %) had good or excellent results according to the Shoulder Rating Score of the Japanese Orthopaedic Association. Calculation 3 surgical cases as failure cases, the success charge per unit was 73 % (75/103).
Kuhn et al. [23] reported a multicenter prospective cohort report. Every bit of May 2010, 396 patients with full thickness rotator cuff tears take been enrolled. They began a physical therapy program with or without an intraarticular injection depending upon the severity of symptoms. They returned for evaluation at half dozen and 12 weeks. At those visits, they could choose 1 of three outcomes: (1) cured (no follow-up scheduled), (ii) improved (connected therapy with scheduled reassessment in 6 weeks), or (3) not better (arthroscopic gage repair scheduled). Patients were contacted past telephone at 1 and two years. Overall, 10 % of the patients chose surgery subsequently half dozen weeks and another 10 % chose surgery within ii years. This made the success rate of conservative handling xc % at six weeks and lxxx % at ii years.
Considering these studies, conservative handling is idea to be constructive in 73–80 % of cases with total-thickness tears of the rotator cuff. A systematic review has shown that exercise has statistically and clinically significant effects on pain reduction and improving function, but not on the range of motion or forcefulness [24].
When nosotros perform conservative treatment, we should pay attention to two things: (ane) the responsiveness of patients to conservative treatment and (two) recurrence of symptoms. We know that conservative treatment is effective in 73–80 % of patients. If nosotros know who will respond well to bourgeois handling and who will not before initiating the treatment, it would be beneficial for both the doctors and patients considering we would not accept to waste not-responders' time. Also, the nowadays symptom might go away after conservative treatment, but could recur in the future. If the symptoms disappear later on the initial treatment merely come back repeatedly, the patient will not be happy. If we knew who had a good chance of recurrence, we could advise surgery for them.
Responders and non-responders
Nosotros performed a study to determine the physical and MRI findings characteristic of responders on the initial test by comparison those who responded well and those who responded poorly to bourgeois treatment [25]. This report included 123 shoulders of 118 patients with full-thickness rotator gage tears diagnosed past MRI. All patients were treated conservatively for at to the lowest degree three months. Clinical symptoms improved in 65 shoulders of 62 patients with conservative treatment (responders), but remained unchanged or aggravated in 58 shoulders of 56 patients who eventually underwent surgical repair (non-responders). The following parameters showed meaning differences: (1) impingement sign (positive in 30.7 % in the responders and 79.3 % in the non-responders); (ii) agile external rotation angle on physical test (52.ii° in the responders and 35.0° in the not-responders); (iii) integrity of the intramuscular tendon of the supraspinatus on MRI (58.iv % in the responders and 24.1 % in the non-responders showed an intact intramuscular tendon); (4) presence of supraspinatus muscle cloudburst on MRI (occupancy ratio was 78.0 % in the responders and 69.8 % in the non-responders). The success rate of conservative treatment was 92 % in patients with all of these iv factors and 5.2 % in those with none of these factors. These four factors seem to be useful in separating responders from non-responders before initiating handling.
Recurrence of symptoms
Symptoms may come up back again after the shoulder has become symptom free. Some asymptomatic tears become symptomatic. Yamaguchi et al. [26] followed upwardly 58 patients with asymptomatic tears using ultrasonography. Later on an boilerplate of two.8 years, 51 % of them became symptomatic. They constitute that there was a strong association between symptom appearances and tear size expansion. Mall et al. [27] prospectively monitored 195 patients with asymptomatic tears for pain development. With pain evolution, the size of a total-thickness tear increased significantly, with 18 % of the total-thickness tears showing an increase of more than than five mm, and 40 % of the partial-thickness tears progressed to a full-thickness tear. They concluded that pain development in shoulders with an asymptomatic tear was associated with an increase in tear size. Safran et al. [28] evaluated 61 total-thickness tears equal to or larger than 5 mm in 51 patients using ultrasonography. At an average follow-upwards period of 29 months, 49 % of the tears increased in size. There was a meaning correlation between the existence of pain and increase in tear size. These reports tell united states that the remnant or recurrent hurting is related to an increment in tear size.
What are the risk factors for tear propagation? According to Safran et al. [28], at that place were no correlations between the alter in tear size and age of the patients, sex, existence of a prior trauma, initial size of the tear, and bilateral tears. On the other mitt, Maman et al. [29] reported that factors that were associated with progression of a rotator cuff tear were an age of more than 60 years, a full-thickness tear, and fatty infiltration of the rotator cuff muscles. We evaluated the human relationship between the tear size and the degree of labor in 195 patients with rotator cuff tears (unpublished data). The tear size was significantly greater in heavy laborers (8.2 ± 1.vii cmii) than in medium (4.9 ± i.ane cm2) or sedentary laborers (4.two ± 1.5 cmtwo) (p = 0.0020). Vigorous use of the shoulder or traumatic event on the shoulder seems to be related to tear expansion. Smoking is known to be related to tear size: the greater the smoking index, the larger the tear [30, 31]. These factors need to be taken into consideration when performing conservative treatment. Farther studies to clarify the risk factors of tear expansion need to be undertaken.
Conflict of interest
The authors declare that they have no conflict of interest.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3607722/
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