Diagnosis
History
Most individuals with acute tears will describe an athletic injury, fall, or an attempt to break a fall by grabbing a rail. Those with a chronic tear will describe increasing pain and difficulty using the shoulder. Activity, especially overhead reaching, often increases shoulder pain. Individuals may report pain at night with inability to sleep on the affected shoulder. There may be shoulder weakness and the inability or limited ability to raise (abduct) their arm.
Physical Exam
Examination of the shoulder begins with a thorough inspection for any deformities, scars, edema, or decrease in muscle bulk (atrophy). Next, the entire shoulder joint and all of its muscle groups are palpated for tenderness. Both active and passive range of motion are determined by rotating the individual's arm through different planes, noting any decrease in range of motion and any pain. A tear is indicated when an individual cannot raise his or her arm away from their side toward the ear (abduction) or when the arm is raised by someone else, cannot hold the position. Pain may be more intense with certain movements or when pressure is applied. There may be a grating, clicking or cracking sound (crepitus) in the shoulder. Muscle strength testing and neurological testing should be performed. Special maneuvers during the physical examination (such as the Neer impingement, Hawkins-Kennedy impingement, drop-arm, apprehension, and relocation tests) may be helpful. A thorough exam includes evaluation of the cervical spine to detect any underlying pathologic changes.
Tests
Plain x-rays are not diagnostic for rotator cuff tears but will show abnormalities in the bones, and shoulder structures, as well as inflammation and calcification of the shoulder bursa (calcific tendinitis). Magnetic resonance imaging (MRI) is used most often to detect a tear. Arthrography, or computed tomography (CT) scan, often with contrast media (CT-arthrography), may be helpful in certain circumstances. Widespread use of arthrography has decreased but remains useful in individuals for whom MRI is contraindicated (e.g., those with a pacemaker, cerebral aneurysm clip, or recent cardiac stent). Arthrography involves injection of contrast media into the glenohumeral joint followed by plain x-rays. Observed leakage of contrast material into the subacromial or subdeltoid spaces following injection indicates a full-thickness rotator cuff tear. Ultrasonography is used in some facilities, although differentiating a partial and full thickness tear may depend on the skill of the sonographer and may not be as accurate as other tests. A minimally invasive surgical procedure in which a special lighted microscope and tools are inserted through several incisions in the skin to look inside the shoulder joint (diagnostic arthroscopy) is occasionally done to evaluate the rotator cuff and shoulder mechanics, especially on acute tears in athletes.
Treatment
The goals of treatment are pain relief and improved shoulder function. Partial tears that do not cause significant or progressive shoulder weakness can be treated conservatively with rest, ice, and the use of nonsteroidal anti-inflammatory drugs (NSAIDs). In some circumstances, corticosteroid is injected into the space above the rotator cuff tendon (subacromial corticosteroid injection). Physical therapy helps increase rotator cuff muscle strength, stabilize the shoulder blade (scapula), and increase range of motion. Use of heat on an inflamed or torn tendon may increase pain and worsen the situation. Although nonoperative treatment will not repair the tear, it often achieves the goals of pain relief and partial restoration of function. Disadvantages are that the individual may need to decrease his or her activity level, there may be no improvement in strength, and the tear may increase in size over time.
Complete tears and tears that cause marked weakness or interfere with daily activities in younger adults are repaired surgically, either arthroscopically or with open surgery (open rotator cuff repair). Rotator cuff surgery may be performed under regional or general anesthesia. Partial tears are sometimes cleaned (debrided) arthroscopically to remove the inflamed tissue and ragged edges of the tear. Treatment in older individuals is based on overall health, weakness of the rotator cuff muscles, pain, and impact on activities of daily living including work. Otherwise, a complete tear in an elderly individual is treated conservatively or with simpler procedures such as arthroscopic debridement and subacromial decompression. Large tears (greater than 3 cm) may be inoperable and are usually treated nonoperatively. Rotator cuff surgery may be performed as an inpatient or outpatient, depending on the specific procedure used.
See the original guideline document for information on prognosis and differential diagnoses.
Rehabilitation
Acute Phase: The early goals of rehabilitation in the acute phase of a rotator cuff tear are to decrease pain and inflammation, to reduce the stress on the torn tendon(s), and to prevent the development of joint stiffness, which can severely complicate recovery.
In conjunction with pharmacological management, the individual will be instructed in the use of cold treatments to the shoulder to decrease inflammation. Reduction of stress to the healing tendon(s) is often achieved through education, ergonomic adjustments, and/or work modifications aimed at reducing painful activities. Such activities often include positions in which the elbow is raised above the level of the shoulder, and should be avoided. Stiffness may be prevented by passive range of motion exercises conducted during supervised rehabilitation and a home exercise program.
Healing Phase: As the pain and inflammation ease, treatment aims at improving strength and flexibility to the shoulder without irritating the healing tendon(s). The strengthening exercises begin with scapular muscles. These are important muscles for normal shoulder function, and the exercises can usually be performed without excessively stressing the healing tendon(s). Gentle stretching exercises may be initiated, avoiding stress on the healing tendon(s). As the tendon heals, strengthening exercises are added, as indicated.
Chronic Phase: The goal of rehabilitation in this phase is to restore pain-free function. Strengthening exercises emphasize all muscles of the shoulder area. Flexibility exercises and manual therapy are incorporated within the available range of motion. Individuals who are not able to regain function or control pain may be evaluated for surgery.
If managed operatively, see Rotator Cuff Repair.
Frequency of Rehabilitation Visits
| Nonsurgical (Acute Phase) |
Physical or Occupational Therapist |
Up to 16 visits within 8 weeks |
| Surgical (Acute Phase) |
Physical or Occupational Therapist |
Up to 24 visits within 12 weeks |
Rehabilitation Disclaimer: The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.
See the original guideline document for information about comorbid conditions, complications, and factors influencing duration.
Length of Disability
Disability may be permanent for individuals who do heavy work or repetitive overhead work.
Surgical Treatment, Arthroscopic Rotator Cuff Repair
| Duration in Days |
| Job Class |
Minimum |
Optimum |
Maximum |
| Sedentary Work |
7 |
10 |
21 |
| Light Work |
7 |
10 |
42 |
| Medium Work |
28 |
42 |
70 |
| Heavy Work |
56 |
84 |
112 |
| Very Heavy Work |
70 |
112 |
140 |
Surgical Treatment, Open Rotator Cuff Repair
| Duration in Days |
| Job Class |
Minimum |
Optimum |
Maximum |
| Sedentary Work |
7 |
14 |
70 |
| Light Work |
7 |
21 |
84 |
| Medium Work |
28 |
84 |
140 |
| Heavy Work |
56 |
98 |
140 |
| Very Heavy Work |
70 |
112 |
154 |
Medical Treatment, Rotator Cuff Tear
| Duration in Days |
| Job Class |
Minimum |
Optimum |
Maximum |
| Sedentary Work |
0 |
3 |
4 |
| Light Work |
0 |
3 |
7 |
| Medium Work |
14 |
21 |
42 |
| Heavy Work |
28 |
42 |
84 |
| Very Heavy Work |
28 |
42 |
84 |
Return to Work (Restrictions/Accommodations)
Limiting use of the affected shoulder or avoiding use completely may be necessary. Reaching and arm use above shoulder level should be avoided. The arm and hand can be used at the individual's side for activities that do not require lifting, pushing, or carrying. These restrictions may become permanent. An ergonomic evaluation of the workplace may be necessary. Changing job duties, sharing or alternating tasks, working at a reduced rate, taking more frequent rest breaks, and limiting the time and frequency of repetitive activities are important accommodations. Work site modifications can include forearm rests for individuals who use computer keyboards frequently, headsets for those who answer telephones, and alterations such that repetitive activities are performed with the arms in a lower level of elevation.
Recovery from surgical repair is the most restrictive, with no use of the arm and shoulder for up to 2 months, followed by a gradual increase in allowed activities. Some individuals will never regain full range of motion or strength in the affected arm. Depending on job duties, individuals may require permanent reassignment, which may necessitate retraining. Use of prescription painkillers (analgesics) and other medications can affect dexterity and alertness. Use of these medications may require review of drug policies.
Failure to Recover
If an individual fails to recover within the maximum duration expectancy period, the reader may wish to reference the following questions to assist in better understanding the specifics of an individual's medical case.
Regarding Diagnosis
- Does individual have any risk factors for a rotator cuff tear (those who perform overhead work, certain athletes, those who have impingement syndrome, instability of the glenohumeral joint, or congenital abnormalities of the shoulder)?
- Did individual fall?
- Did individual experience associated shoulder weakness or inability to raise his or her arm?
- Did individual have any positive findings on exam, such as muscle atrophy, or impaired range of motion?
- Has the diagnosis been confirmed by imaging studies (i.e., MRI, CT scan, arthroscopy)?
- If diagnosis was uncertain, were other conditions with similar symptoms ruled out (i.e., painful arc syndrome, impingement syndrome, rotator cuff tendinitis, biceps tendinitis, and subacromial bursitis)?
Regarding Treatment
- Has individual responded favorably to conservative treatment of rest, ice, NSAIDs, and physical therapy? If not, have steroid injections been tried?
- Did it become necessary to repair the tear surgically?
Regarding Prognosis
- Is individual active in physical therapy? Does individual follow a home exercise program?
- Is individual's employer able to accommodate necessary restrictions?
- Is affected shoulder on the dominant or nondominant side?
- Does individual have any other conditions, such as shoulder dislocation or other shoulder injuries, osteoarthritis, rheumatoid arthritis, diabetes, or osteoporosis that could affect recovery?
- Has individual experienced any complications that could affect recovery and prognosis?
