Rotator Cuff Tear

THE CLINICAL SYNDROME

Rotator cuff tears represents a common cause of shoulder pain and dysfunction encountered in clinical practice. A rotator cuff tear will frequently occur after seemingly minor trauma to the musculotendinous unit of the shoulder. However, in most cases, the pathology responsible for the tear is usually a long time in the making and the most often is the result of ongoing tendonitis. The rotator cuff is made up of the subscapularis, supraspinatus infraspinatus, and teres minor muscles and associated tendons. The function of the rotator cuff is to rotate the arm to help provide shoulder joint stability along the other muscle, tendons, and ligaments of the shoulder.

The supraspinatus and infraspinatus muscle tendons are particularly susceptible to the development of tendonitis for several reasons. First, the joint is subjected to a wide variety of motions that are often repetitive in nature. Second, the space in which the msuculotendinous unit functions is restricted by the coracoacromial arch, making impingement a likely possibility with extreme movements of he joint. Third, the blood supply to the musculotendinous unit is poor, making healing of microtrauma more difficult. All of these factors can contribute to tendontitis of one or more of the tendons of the shoulder joint. Calcium deposition around the tendon may occur if the inflammation continues, making subsequent treatment more difficult.

Bursitis often accompanies rotator cuff tears and may require specific treatment. In addition to the pain, patients suffering form rotator cuff tear will often experience a gradual decrease in functional ability with decreasing shoulder range of motion, making simple everyday tasks such as hair combing, fastening brassiere, or reaching overhead quiet difficult. With continued disuse, muscle wasting may occur and a frozen shoulder may develop.

SIGNS AND SYMPTOMS

The patient presenting with rotator cuff tear will frequently complain that he or she cannot lift the arm above the level of the shoulder without using the other arm to lift it. On physical examination, the patient will have weakness on external rotation if the infraspinatus is involved and weakness in abduction above the level of the shoulder if the supraspinatus is involved. Tenderness to palpation in the subacromial region is often present. Patients with partial rotator cuff tears will exhibit loss of the ability to smoothly reach overhead. Patients with complete tears will exhibit anterior migration of the humeral head as well as a complete inability to reach above the level of the shoulder. A positive drop arm test, which is the inability to hold the arm abducted at the level of the shoulder after the supported arm is released, will often be seen with complete tears of the rotator cuff. Moseley’s test for rotator cuff tear, which is performed by having the patient actively abduct the arm to 80 degrees and then adding gentle resistance, which will force the arm to drop if complete rotator cuff tear is present, will also be positive. Passive range of motion of the shoulder is normal, but activate range of motion is limited. The pain of rotator cuff tear is constant and severe and is made worse with abduction and external rotation of the shoulder. Significant sleep disturbance is often reported. The patient may attempt to splint the inflamed subscapularis tendon by limiting medial rotation of the humerus.

Inability to elevate the arm above the level of the shoulder is the hallmark of rotator cuff disturbance.

TREATMENT

Initial treatment of the pain and functional disability associated with rotator cuff tear should include a combination of the nonsteroidal anti-inflammatory drugs or cyclooxygenase-2 inhibitors and physical therapy. The local application of heat and cold may also be beneficial. For patients who do not respond to these treatment modalities, the following injection technique may be a reasonable next step before surgical intervention.

Injection for rotator cuff tear is carried out by placing the patient in the supine position and preparing with antiseptic solution the skin overlying the superior shoulder, acromion, and distal clavicle.

This injection technique is extremely effective in the treatment of pain secondary to the rotator cuff tears. This technique is not a substitute for surgery but can be used to palliate the pain of partial tears or in patients with complete tears in whom surgery is not contemplated. Coexistent bursitis and arthritis may also contribute to shoulder pain and may require additional treatment with a more localized injection of local anesthetic and methylprednisolone acetate steroid. This technique is a safe procedure if careful attention is paid to the clinically relevant anatomy in the areas to be injected. Care must be taken to use sterile technique to avoid infection, as well as universal precautions to avoid risk to the operator. The use of physical modalities including local heat as well as gentle range of motion exercise should be introduced several days after the patient undergoes this injection technique for shoulder pain. Vigorous exercise should be avoided because they will exacerbate the patient’s symptomatology and may lead to complete tendon rupture. Simple analgesics and nonsteroidal anti-inflammatory drugs may be used concurrently with this injection technique. It should be noted that partial tears may be amenable to arthroscopic or minimal incision surgery and the clinician should not wait until the tear is complete before obtaining orthopedic consultation.

Low intensity laser therapy as well as a coordinated wellness program is also effective in treating this disorder.

Low Intensity Laser Therapy (LILT)

The low intensity Laser (LILT) sends photons (light) into the injured tissues and can penetrate two to three inches to treat affected areas. It uses a natural enhancement of the cellular machinery that can and has been dynamically measured in published studies to promote healing without burning affected tissue .Once the photons find the injured tissues, they stimulate and energize the cells to repair and strengthen at a remarkable rate. The treatment does not hurt, takes about 30 minutes and is very cost advantageous.

Wellness Program

A wellness program whichindividualizes treatment for age, performance and function has been shown in pilot studies to improve the overall health and well being of the individuals evaluated. A well conceived dietary and supplementary regimen based on scientific age –related decline in certain necessary compounds can improve quality of life, correct the ravages of hormone imbalance, balance critical neurotransmitter function without resorting to powerful drugs for depression that often have unfavorable side-effect profiles and restore vitality and youth in daily exercise routines. Furthermore, when wellness products are utilized with success, individuals often seek less costly interventions including unnecessary surgeries and narcotic options to treat pain. For more information go to www.drpwellness.com.