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Rotator Cuff Tear: Treatment, Symptoms, and Diagnosis -Physioscare

Note: Incidence of rotator cuff tear, less than 70 years— 30 percent; 71-80 years—60 percent; more than 89 years— 70 percent.

Rotator Cuff Tear- www.physioscare,com
     Rotator Cuff Tear
About Rotator Cuff Tears 
The causes for rotator cuff tears, partial or full, are as follows: 
• Age > 40 years. 
• Occupations requiring repetitive and excessive overhead movements.
• Overhead sports and athletes like throwers, swimmers, tennis players, etc. 
• Degenerative etiology is the major cause. 
• Dislocation of shoulder joint in 40-60 years of age. 
• About 2/3rd cases are seen in male population.

Classification of Rotator Cuff Tears 
(According to American Arthroscopic Orthopedics) 
• Small tear (< 1 cm) 
• Medium tear (1-3 cm) 
• Large tears (3-5 cm).

Clinical Tests 
Special shoulder tests that are helpful in diagnosing rotational, cuff tears and the impingement syndrome, is the painful arc sign (It is 81% specific). There are innumerable other tests but is outside the scope of this book.

Interesting facts 
Do you know the clinical facts leading to the diagnosis of RCL tear? 
• Age > 40 years. 
• Previous history of minor trauma. 
• Degenerative changes on the X-rays. 
• Various clinical tests. How accurate are these tests? There are 91 percent sensitive and 75 percent specific. 

Pearl: Clinical tests are more accurate and cost effective than a battery of investigations in diagnosing an RCL.
  
Clinical Features 
All patients with impingement syndrome have similar clinical features like pain, swelling, limitation of shoulder movements, muscle atrophy (supraspinatus and infraspinatus), and tenderness over the greater tuberosity, etc. The following grades are described in anterior impingement syndrome. 

Grade I: This is common in young adults and athletes in the age group of 18-30 years. Due to overstress and repeated overhead activity, impingement occurs and supraspinatus is inflamed. The painful arc appears here.

Grade II: This is seen in age group of 40-45 years and may be due to supraspinatus tendinitis or
subacromial bursitis. The cause could be either overuse or degeneration and osteophyte formation.

Grade III: It is seen in patients over 45 years of age and may be due to occupational overuse, fall, and sudden increase in activity, atrophic degenerative changes in the cuff and rarely due to acute tear of the rotator cuff.

Investigations to Diagnose Rotator Cuff Lesions 
X-rays of the shoulder: This helps to detect bony avulsions, spurs, calcific deposits, sclerotic areas, etc. 

Arthrogram: Single contrast arthrogram is considered as the gold standard in diagnosing rotator cuff tears. 

Ultrasonography: This is highly reliable in diagnosing rotator cuff pathology with a sensitivity of 98 percent. 

MRI: This is also very accurate (81%) but expensive.

Mystifying facts about X-ray changes in Rotator Cuff Lesions 
• ↓ Subarachnoid space ↓ 6 mm. 
• Anterior spurring of ACM joint. 
• Humeral head degeneration. 
• Sclerotic inferior acromion (eyebrow sign). 
• Hooking of the acromion.

Management 

Conservative Treatment
It consists of heat, massage, NSAIDs, local infiltration of hydrocortisone, subacromial steroid injections, exercises both active and passive, temporary immobilization, etc. Ninety percent will recover with these measures.

Surgical Treatment 
Indications: Failure of conservative treatment for three months, if the patients are young and active, and if there is increasing loss of shoulder function, surgery is indicated.

Methods 
• Arthroscopic repair in small and partial tears. 
• Open methods in major tears

Depending upon the etiological factors, the following surgical techniques are described: Excision of adhesions and manipulation of shoulder, excision of calcium deposits, repair of incomplete tear, acromioplasty, acromionectomy for more disabling pain with normal range of movements, direct suture for complete rupture of rotator cuff, rotation and transposition of flap, free graft, etc. Results are good in 85-90 percent.

Differential Diagnosis of Impingement Syndrome 
• Frozen shoulder. 
• Cervical spondylosis. 
• ACM and shoulder joint arthritis
• Bursitis. 
• Snapping scapula.
• Suprascapular neuropathy.










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