Pathophysiology
Majority occur in the rotator crescent |
Rotator cable takes load majority, allowing the RC muscles to still function and keep humeral head in place |
A tear in the ant. cable creates a larger gap, increases cuff strain, and loses its stress shielding capabilities |
Mostly supraspinatus tendon |
If the tear enlarges (which it may not), only a minority enlarge >5mm in 3 years |
Prognosis
Clinically important change (reported by pt) in 12 weeks |
Up to 4-6 months (more severe cases) |
Special Populations to Consider
Diabetics |
Tear frequently, do not respond well to treatment |
Hypothyroidism |
Susceptible to develop muscle aches, tenderness and stiffness |
Metabolic syndrome |
Cluster of conditions that increase risk of diabetes |
Epidemiology
Older sports person with shoulder pain during activity. |
<40 generally trauma |
>60 generally degenerative |
40<x>60 either trauma or degenerative |
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Risk Factors for Progression
Tear size |
1-tendon tears may remain dormant while 2-tendon lesions are more likely to undergo structural deterioration |
Location |
Ant. RC cable tears have sig greater tear migration, decreased tendon stiffness, and increased regional tendon strain |
Types
Small |
up to 1cm |
Medium |
1-3 cm |
Large |
3-5 cm |
Massive |
>5cm |
Clinical Presentation
Pain with overhead activity (throwing, swimming, overhead shots with racket). <90 degrees usually pain free. |
Pain may present with abduction (painful arc) or IR behind back |
Scapular muscle weakness and dysfunction, tightness of the posterior capsule and other soft tissues and postural abnormalities |
Subjective Markers
MOI: Falling on outstretched hand, unexpected pushing or pulling, or during shoulder dislocation. |
Night pain. |
History of associated symptoms of instability (ex. recurrent subluxation or episodes of "dead arm") |
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Objective Assessment
Observation |
Muscle atrophy (infraspinatus may also mean suprascapular nerve injury) |
Palpation |
Tenderness over supraspinatus tendon to or at its insertion into the greater tuberosity of the humerus. |
AROM/PROM |
Painful arc btwn 70-120deg (AROM). IR reduced. |
Strength |
IR, ER (infraspinatus), and abd. (supraspinatus) may be reduced. Measure with the scapula accurately stabilized. |
Functional Tests |
throwing overhead |
Rehab
Exercise > over no treatment or placebo and did not differ in outcomes compared to surgery or multi-modal physio (Littlewood et al) |
Improving scapular stability, neuromuscular control of shoulder girdle and thoracic posture, "loosen" tight muscles |
Address altered shoulder complex kinematics (decreased SA strength, hyperactivity and early activity of upper traps, decreased activity and late activations of middle and lower traps) |
Examples: "low row", "lawnmover", "robbery" - stabilizing but not stressing GHJ |
Strengthening middle/lower traps, and RC muscles (starting w low load), ant. delt., and teres minor |
Exercise plan (Edwards, Ebert, Joss, Bhabra et al. 2016) |
Special Tests
Subscapularis |
Lift off, Belly Press, Belly-off sign, Bear Hug Test |
Supraspinatus and Infraspinatus |
External rotation lag sign, Jobe's, Drop arm test, Neer |
Teres minor |
Hornblower's sign |
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