ACC Review: Issue 13 (October 2004) – Rotator cuff disorders: Part 1 – Diagnosis

Issue 13 October 2004

General points

  • Rotator cuff disorders are the most common source of shoulder pain in people over the age of 35years, ranging from tendinosis to a significant tear
  • Tendinosis usually develops from repetitive activity at or above shoulder height and is characterised by a painful arc due to impingement
  • Tears are usually a result of trauma. Full thickness and massive tears are characterised by weakness
  • If a significant rotator cuff tear is suspected, refer for diagnostic ultrasound
  • Active and physiologically young people with a full thickness tear require early specialist referral (within 4-6weeks)
  • Massive tears require immediate referral to a specialist for evaluation.

Background

Rotator cuff disorders are the most common source of shoulder pain in people over 35years of age. They range from mild strains to massive tears and are common in athletes, workers with repetitive overhead activities, and the elderly, due to years of use. Tears usually occur as a result of trauma.

The diagnosis of shoulder injuries is challenging as pathologies and their clinical manifestations vary widely with each person and more than one pathology may exist.

Recently ACC published a Guideline on the diagnosis and management of soft tissue shoulder injuries.1 The Guideline’s recommendations for the diagnosis of rotator cuff disorders associated with trauma are summarised below.

Clinical Diagnosis

The following are the commonly described trauma-related rotator cuff disorders:

  • Tendinosis – caused by collagen fibre failure (degeneration) due to ageing, vascular compromise, or microtrauma associated with repetitive activity at or above shoulder height.
  • Partial tears – occur on the bursal or articular side of the tendon. These are more common than full thickness tears.
  • Full thickness tears – extend through the full thickness of the tendon.
  • Massive tears - are large (>5 cm) involving 2 or more tendons (usually supraspinatus and infraspinatus or supraspinatus and subscapularis).

No clinical test or group of tests is both reliable and valid for diagnosing these tears. [DSR++] However, a recent study2 [D+] suggests that the supraspinatus test (Jobe’s test) may be useful in diagnosing large and massive tears. A clinical examination by a specialist may rule out, but is less effective at detecting, a rotator cuff tear. [DSR++]

Differential diagnosis

The differential diagnosis includes cervical spine and nerve disorders, inflammatory disorders and related shoulder disorders including acromioclavicular joint problems and calcific tendonitis. Labral tears and associated instability should be considered in younger people with a history of dislocation.

Specific Diagnosis

Tendinosis and partial tears

A painful arc is the classic clinical manifestation of impingement. Activity-related pain and night pain are also characteristic. Pain is typically felt around the lateral deltoid or point of the shoulder and may be referred to the elbow. Active movement may be limited, but full range passive movement can be achieved. Paradoxically, a younger person may be more symptomatic than an older person with a larger tear.

Full thickness and massive tears

The primary indicator for these tears is weakness in abduction and external rotation. Weakness of internal rotation, associated with significant trauma, suggests a major tear of the subscapularis.

Weakness from pain inhibition can be misleading. A subacromial injection of local anaesthetic may enable the cause of the weakness to be clarified.

These tears require early specialist referral (4-6weeks) in the active and physiologically young as surgery may be required to achieve optimal functional outcomes. With increasing age, full thickness tears may be asymptomatic, compatible with normal functional activity, and of little clinical significance. Tears may be present in greater than50% of those aged 70-80years.

Traumatic cuff tears in the older age groups are commonly associated with dislocation and usually require additional investigation.

Refer people with massive tears to a specialist immediately. A delay in repair may result in severe loss of function.

Imaging

  • Diagnostic ultrasound – this is a valid tool for diagnosing full thickness tears in a secondary care setting. [DSR++] There is no conclusive evidence for the validity of diagnostic ultrasound in the diagnosis of partial tears. [DSR++] Where there is a suspicion of a significant tear, referral for diagnostic ultrasound is recommended.
  • Magnetic resonance imaging (MRI) – this can rule out a full thickness tear, but the evidence for ruling in rotator cuff tears has yet to be established. [DSR++]

MR arthrography may be accurate in detecting full thickness tears, and more accurate than MRI and diagnostic ultrasound in detecting partial tears. [DSR++]

Summary

In active and young individuals, a full thickness tear requires early referral to a specialist to evaluate the need for surgery. For individuals with a massive tear, immediate specialist referral is recommended. Diagnostic ultrasound is recommended for a full thickness tear and on suspicion of a large or massive tear.

References

  1. Accident Compensation Corporation and New Zealand Guidelines Group. The Diagnosis and Management of Soft Tissue Shoulder Injuries and Related Disorders. Wellington: ACC, 2004.
  2. Holtby R, Razmjou H. Validity of the supraspinatus test as a single clinical test in diagnosing patients with rotator cuff pathology. Orthop & Sports Phys Ther 2004;34:194-200.

Evidence Scales (as in the Guide (1))

Single Diagnostic Studies

D+ Fair: One or two of the four criteria not met

(D++ Good, all four criteria met; D- Poor, no criteria met)

Diagnostic Systematic Reviews

DSR++ High quality meta-analysis or systematic review of diagnostic studies

(DSR+ Fair quality; DSR- Poor quality)

© ACC2004 • Printed October 2004