Updated: 4/23/2018

Rotator Cuff Injury

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Questions
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Evidence
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Snapshot
  • A 50-year-old woman reports shoulder pain that has worsened over the past year. She states that she has difficulty sleeping at night on the right side and experiences significant pain in the right arm when reaching over her head. On physical exam, the empty can test is positive. She is referred for physical therapy and given ibuprofen for pain management.
Introduction
  • Clinical definition
    • injury to one or more of the rotator cuff muscles
      • injury is typically due to tear or tendinopathy
      • rotator cuff muscles, which are all innervated by C5 and C6, are the SITS 
        • Supraspinatus
          • innervation
            • suprascapular nerve
          • function
            • initial abduction of the arm (0-15°)
        • Infraspinatus
          • innervation
            • suprascapular nerve
          • function
            • lateral rotation of the arm
        • Teres minor
          • innervation
            • axillary nerve
          • function
            • adduction and lateral rotation of the arm
        • Subscapularis
          • innervation
            • upper and lower subscapular nerves
          • function
            • adduction and medial rotation of the arm
  • Epidemiology
    • incidence
      • the supraspinatus muscle is most commonly injured
    • demographics
      • adults
    • risk factors
      • older age
      • smoking
      • repetitive overhead reaching
  • Pathogenesis
    • acute avulsion injuries
      • typically following trauma
    • chronic degenerative tears
      • repetitive overhead motions
      • tendon weakening due to degenerative changes and chronic impingement
  • Associated conditions
    • biceps tendinopathy
    • osteoarthritis
  • Prognosis
    • re-tear may occur
Presentation
  • Symptoms
    • shoulder pain
      • exacerbated by
        • sleeping on the affected shoulder
        • reaching overhead
    • limited function of the shoulder
  • Physical exam
    • severe focal tenderness at the insertion of supraspinatus (anterolateral shoulder)
    • decreased active elevation with normal passive range of motion
    • Hawkins impingement test
      • passive internal rotation of the shoulder with the patient seated and elbow flexed 90°
      • test is positive if there is pain
    • Neer impingement test
      • passive elevation of the arm while internally rotated with the patient standing
      • test is positive if there is pain
    • painful arc sign
      • pain with active abduction between 60° and 120°
    • empty can test
      • patient with arm elevated to 90° with elbow extended and thumbs down
        • clinician applies a downward force on the arm while patient resists
      • test is positive if there is pain
      • 90% specificity for supraspinatous pathology
Imaging
  • Radiographs
    • indication
      • for all patients as initial imaging
    • finding
      • loss of subacromial space, due to upward migration of humeral head
  • Magnetic resonance imaging (MRI)
    • indications
      • if radiography is normal but there is suspicions for rotator cuff injury
      • not indicated for all patients
      • most accurate test
Studies
  • Making the diagnosis
    • most cases are clinically diagnosed
Differential
  • Adhesive capsulitis
    • distinguishing factor
      • active and passive range of motion are limited
Treatment
  • Conservative
    • physical therapy
      • indication
        • for all patients
  • Medical
    • nonsteroidal anti-inflammatory drugs (NSAIDs)
      • indications
        • for all patients
        • pain management
    • steroid injections
      • indication
        • for patients who fail NSAIDs as pain management
  • Operative
    • surgical repair
      • indications
        • for patients with complete tears
        • for patients who fail all other more conservative management of 3-6 months
Complications
  • Functional limitations
  • Adhesive capsulitis
 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

(M1.MK.5) A 53-year-old man presents to clinic with a six month history of shoulder pain that is especially bothersome at night. Over the weekend he "strained his shoulder" during a pick-up basketball game and reports an acute exacerbation of his pain symptoms. On exam, he complains of pain to palpation just below the acromion. You suspect he has torn his supraspinatus. If correct, which of these functional maneuvers would you expect to be deficient on physical exam? Review Topic

QID: 101942
1

Initiation of adduction

4%

(4/106)

2

External rotation

10%

(11/106)

3

Initiation of abduction

57%

(60/106)

4

Completion of abduction

22%

(23/106)

5

Internal rotation

7%

(7/106)

M1

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