Shoulder Injuries are prevalent in our general population. The most common condition being a rotator cuff lesion. The general prevalence is 13% in people over 50, to more than 50% n persons over 80. However 2/3 of these lesions are asymptomatic. Approximately 54% of asymptomatic people over the age of 60 have rotator cuff lesions.
What is the rotator cuff?
The shoulder has 30 muscles. The muscles move and stabilize the shoulder. The rotator cuff muscles refer to 4 muscles:
• Teres Minoris
The tendons of these muscles come together to form the rotator cuff. These muscles support and stabilize the shoulder.
How do tears happen?
There are both extrinsic and intrinsic factors. Extrinsic factors include trauma, heavy lifting and forceful movements above shoulder height. Intrinsic factors include poor blood supply, degeneration with aging and calcific invasion of the tendons. Intrinsic factors include anatomical factors, such as acromial spurs, narrowing the available space for the tendons to move.
How does the examining doctor assess the shoulder?
The doctor has taken a comprehensive history of the onset and progress of the shoulder complaint. The doctor first inspects the shoulder to determine contour and wasting. The doctor then palpates the shoulder to detect areas of tenderness or deformity. The doctor then assesses range of shoulder motion in each plane of motion by first observing the examinee lift their arm forward, backward, sideways and in rotation. The doctor may also assess passive motion by assisting the examinee to move the shoulder to identify any additional movement. The doctor may then perform some specific testing to assess whether the tendons have become impinged. There may also be a requirement to assess stability of the shoulder with specific tests.
The doctor will review any investigations such as an ultrasound or MRI scans to further assess the anatomy.
How is the condition treated?
There may be a requirement for a period of modified activity, avoiding aggravating activities. Physical therapy, including specific exercises may be prescribed. In some cases a corticosteroid injection may be required to manage any swelling in the bursa above the tendons. This is a sac of fluid that lies between the tendons and the bone above (the acromion). In the majority of cases, recovery occurs with conservative management. Occasionally, a rotator cuff tear may require surgical management. This can include cases with high-grade tears (over half the thickness of the tendon) or cases with protracted recovery.
The literature has indicated some prognostic factors particularly for recovery after surgery. Twelve prognostic factors were associated with better recover including:
• Younger age
• Male gender
• Higher bone mineral density
• Absence of diabetes mellitus
• Greater preoperative shoulder range of movement
• Absence of obesity
• Smaller size of the cuff lesion
• Less displacement retraction of the cuff
• Less fatty infiltration
• No multiple tendon involvement
• No concomitant biceps involvement
• No concomitant (acromioclavicular) joint procedures
In cases with protracted recovery, the examining doctor will review the likelihood of further improvement and return to their previous function or any requirement for ongoing work restrictions. If the condition has stabilized, that is, reached maximum improvement, the doctor will assess permanent impairment.