acute rotator cuff tear

see also:

• orthopaedics in the ED
• the painful shoulder
• references:
  • BMJ 2017
  • Austin Health guidelines (pdf)
  • Western Health Phong Tran's website

• acute shoulder rotator cuff tears can result in significant pain and disability
• these should be managed more acutely than the more subacute/chronic rotator cuff syndrome conditions
• 3 main groups:
  • 1: acute trauma without shoulder dislocation
    • ~2/3rds of those with red flags will have an acute tear, 1/3rd will have a complete tear
    • generally in those under 40yrs
    • accounts for 5% of tears
  • 2: acute trauma with anterior shoulder dislocation:
    • ~50% of patients with dislocated shoulder aged over 40yrs will have an acute tear
    • extreme forces at any age with large cuff tear maybe associated nerve injury
  • 3. impingement tears
    • no Hx of trauma, usually in those over 40yrs
    • impingement signs may be present - Neer's , Hawkin's

• red flags which suggest a tear:
  • trauma with acute painful shoulder, a normal Xray and inability to actively abduct greater than 90deg (this is particularly sensitive if pain is not the limiting factor)
• generally cannot sleep on affected shoulder
• may have pain down arm or chest wall
• tenderness over anterolateral edge of acromion or biceps tendon (faces anteriorly at 5-10° of IR)
• painful arc from 70-120°

• Shoulder XRs to exclude fractures and dislocations
  • should include 3 views:
    • True AP Glenohumeral Joint (Grashey View)
    • Scapula Lateral (Neer View)
      • Axillary Lateral
• simple analgesia, sling, physiotherapy
• if suspected, and pain not settling within 1-2 weeks:
  • arrange USS or MRI scan (sensitivity of 100% and specificity of 95%) within 1-2wks of injury and if present, early surgery within 1 month of injury appears to be preferable and thus referral to an orthopaedic surgeon at the 2 week mark is optimal, once imaging has been obtained and confirmed the tear
    • partial thickness tears generally can be managed without surgery but many will progress in size and rpt USS in 6-12 months is advisable in those with ongoing symptoms
    • full thickness acute tears generally should be considered for surgery within 1 month
      • 60-80% have a satisfactory outcome and improvement continues over 2 yrs
      • poorer outcomes are more likely in those over 60yrs, large tears, and neglected tears