Shoulder Pain Management

Rotator Cuff Tears

Rotator cuff injuries are much more common in adult and senior patients because muscle and tendon tissues of the rotator cuff are less elastic and hence more susceptible to injuries. Damage often occurs during everyday activities. In younger more active -patients, rotator cuff injuries are usually caused by traumatic injury or demanding use of the shoulder.^1-5

Key Observations
• Rotator cuff tears are more frequent in adult and senior patients
• Pain is the most common symptom
• A complete tear may cause shoulder immobility

Pain is the most common symptom of a rotator cuff tear, and is often felt over the outside of the shoulder and upper arm in the deltoid region. Patients may describe the pain as generalized discomfort exacerbated by specific movements. Loss of motion may indicate the severity of the rotator cuff tear, and the patient also may complain of crepitus, catching and stiffness.

For incomplete tears, pain will be the most prominent symptom followed by decreased strength. For complete tears, the patient will likely be unable to move the shoulder through some normal motions. Diagnosis can be made by a physical examination where the specific muscles that form the rotator cuff can be isolated and tested.

Clinical Clues
• Painful shoulder in adult or senior patients
• Trauma may be the cause
• Persistent weakness and loss of motion
• MRI showing rotator cuff tear

Physical Findings

In every patient, the examination should include inspection, palpation, range of motion, strength testing, neurologic assessment and the performances of special shoulder tests. The cervical spine and distal portions of the upper extremity should also be examined. Inspection should include these features: scars, color, edema, deformities, muscle atrophy, and asymmetry. Palpate the bony and soft tissue structures, noting any areas of tenderness. Assess active and passive range of motion, noting provoked pain and loss of motion.^1,2

If a rotator cuff tear or subacromial impingement is suspected, then try to reproduce the patient’s symptoms with specific tests. The Neer and Hawkins tests will cause pain in patients with subacromial impingement (Fig. 1). Both tests bring the greater tuberosity, the biceps tendon and the rotator cuff under the coracoacromial arch to reproduce pain.^2,6

Figure 1A: The Neer impingement sign is elicited by standing behind the patient and passively elevating the arm in the scapular plane while stabilizing the scapula. A positive test generally elicits pain in the 50-130 degree range of forward elevation. B: Hawkins sign – modification of the Neer sign. This test is performed by placing the arm in 90 degrees of forward flexion, with the elbow flexed 90 degrees. The examiner then passively internally rotates the arm maximally. A positive test is signified by production of pain.

Neer and Hawkins Tests

Neer impingement sign is elicited by standing behind the patient and passively elevating the arm in the scapular plane while stabilizing the scapula. A positive test generally elicits pain in the 50-130 degree range of forward elevation.

The Hawkins sign (modification of the Neer sign) test is performed by placing the arm in 90 degrees of forward flexion, with the elbow flexed 90 degrees. The examiner then passively internally rotates the arm maximally. A positive test is signified by production of pain.

Patients with full-thickness tears may show weakness during specific muscle tests, may show a difference between active and passive range of motion, and may have muscle atrophy if the tear is chronic. In range of motion testing, patients with tears will initially shrug their affected shoulder when trying to abduct their arm. Shrugging uses scapulothoracic motion to compensate for the damaged cuff (Fig. 2).²

Figure 2: This patient is attempting to abduct his left arm. Notice how the shoulder is shrugged and the trunk is leaning to the right. This is a mechanism of compensation used by patients with rotator cuff tears to make up for a lack of rotator cuff strength with attempted abduction of the arm.

Pain and weakness during the active compression test indicates supraspinatus involvement.² (Fig. 3). The external rotators of the shoulder should also be tested for weakness or rupture during the physical examination. Persons with large cuff tears that involve multiple tendons will be unable to externally rotate their arm (Fig. 4).^1-3,7

Figure 3: Active compression test (O'Brien test). This test is performed by having the patient place his or her arm forward, flexed to 90 degrees with 10 degrees of horizontal adduction and internal rotation (thumb down). A positive test is signified by pain on top of the shoulder when the arm is pushed in a downward direction, which is lessened when the test is repeated with the arm in external rotation (thumb up). Patients may also note weakness with this test as compared with that on the normal side.⁸

Figure 4: This patient demonstrates weakness with external rotation on his left side as compared with the right. Note that the patient is barely able to externally rotate past neutral on the left, while on the right he can actively externally rotate to approximately 45 degrees. This should lead the clinician to suspect a tear of the posterior rotator cuff.

A second test for the integrity of the external rotators is the external rotation lag sign. Place the arm at the side of the patient with the elbow bent to 90 degrees and the arm passively externally rotated, then release the arm. If it drifts back into internal rotation, the external rotators are likely weakened (Fig. 5). The hornblower’s sign, the inability to actively externally rotate the abducted arm, provides similar information (Fig. 6).

Figure 5: This patient, with a massive tear involving the posterior rotator cuff, can be passively externally rotated. When the arm is let go, it falls back into internal rotation, demonstrating severe weakness.⁹

Figure 6: Hornblower's sign. In this patient, notice that the right arm must be elevated higher than the left to reach the mouth since active external rotation is impaired.⁹

Weakness of the subscapularis tendon can be identified by the abdominal compression test (Fig. 7). The test assesses the strength of internal rotation. Have the patient place the hand of the affected side on the abdomen and press against the abdomen with elbows in front of the torso. If the subscapularis is torn, the patient cannot press the abdomen and the elbow drops behind the torso.^2,10

Figure 7: Positive abdominal compression test. The right elbow falls back when the patient tries to compress his abdomen. Notice that the left side is normal.¹¹

If subacromial impingement is suspected, inject the subacromial bursa with lidocaine, and test the strength of the rotator cuff musculature after several minutes (Fig. 8). Persistent weakness in the absence of pain is diagnostic for compromised cuff integrity.

Figure 8: Subacromial injection. This injection is performed from the back by using the posterolateral border of the acromion as a landmark. The injection is placed into the subacromial space by advancing the needle directly under the acromion anteriorly and slightly medially. In exceptionally large individuals, the needle must be long enough to reach the anterior one third of the subacromial area because the pathology exists anteriorly. Alternatively, lateral and anterior injection techniques can be used in injecting the subacromial space.¹²

Confounding Sources of Pain
• Septic shoulder
• Brachial plexus injury
• Avascular necrosis of the humeral head
• Acromioclavicular separation
• Gout
• Calcific tendonitis
• Adhesive capsulitis
• Neurologic injuries (C5-C6) caused by repetitive trauma
• Ganglion cyst of the shoulder
• Referred pain of cardiac, pulmonary or visceral origin
• Soft tissue or bone tumor
• Symptomatic os acromiale

Clinical Course

The clinical course for rotator cuff tears is variable with factors such as age, size of the lesion, duration of the tear, patient needs, patient expectations and persistence of symptoms. The rotator cuff tear itself may not heal, and most small tears are associated with minimal functional disability. Those associated with persistent symptoms may require surgical intervention.

If surgery is necessary, recovery time depends on the surgical method used, the level of strength before the operation and the severity of the rotator cuff tear. A period of shoulder immobilization will be needed for wound healing. Physical therapy will be necessary. Begin gently, followed by more active lifting with the arm. Physical therapy will become more intense in an effort to strengthen the rotator cuff muscles after a few months. Complete recovery may require 4 to 6 months.^1-3,5,7

Know When to Refer
• Patient not responding to conservative treatment after 4 to 6 months
• Patient employment requires overhead use
• Glenohumeral instability
• Acute full-thickness rotator cuff tear
• Any full-thickness rotator cuff tear in a patient <50 years of age
• Acute exacerbation of a chronic rotator cuff tear with sudden loss of forward elevation
• Recalcitrant adhesive capsulitis

The ICD9 codes for rotator cuff conditions are:

• 840.4 Rotator cuff (capsule) sprain
• 726.10 Disorders of bursae and tendons in shoulder region, unspecified
• 727.61 Complete rupture of rotator cuff

The reimbursement information contained on this site is provided for your informational purposes only and represents no statement, promise, or guarantee by DePuy Orthopaedics, Inc. concerning levels of reimbursement, payment or charge. Similarly, all billing codes and revenue codes mentioned above are supplied for information purposes only and represent no statement, promise or guarantee by DePuy Orthopaedics, Inc. that these codes will be appropriate or that reimbursement will be made.

References