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© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
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© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
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© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
in the clinic
Rotator Cuff Disease
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
Rotator cuff
Supraspinatus, infraspinatus, subscapularis, and teres minor muscles
Envelop shoulder joint, facilitate movement & dynamic stabilization throughout its large range of motion
“Rotator cuff disease” = umbrella term
Includes RC tendinopathy or tendinitis; tears of the cuff muscles, impingement syndrome, calcific tendinitis, and subacromial bursitis
Calcific tendinitis: uncommon form of RC disease
Excludes adhesive capsulitis, other disorders of glenohumeral joint
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
What are the risk factors for rotator cuff disease?
Increasing age
Obesity
Smoking
Diabetes mellitus
Genetics
Various anatomical factors
Occupational and sporting activities
Sports with frequent overhead activity (throwing)
Orchestral musicians
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
Are there measures that can prevent rotator cuff disease or its recurrence?
Interventions that reduce excessive overhead activity
Interventions that reduce loading of the shoulder in the abducted position
Exercises that improve flexibility and strengthen muscles
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
CLINICAL BOTTOM LINE: Prevention...
Most common cause of shoulder pain in primary care Prevalence increases with age, but frequently asymptomatic
or self-limiting Risk factors include occupational or sporting activities that
require repetitive overhead use of the arms Risk reduction includes shoulder-strengthening exercises and
workplace interventions
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
What symptoms are suggestive of rotator cuff disease?
Nontraumatic onset (except with acute traumatic tears)
Pain in upper arm near the deltoid insertion
Pain exacerbated by overhead activity
Pain worse at night, particularly if lying on affected side
Weakness or loss of function may occur
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
What physical findings and maneuvers during the examination are helpful?
Standard shoulder exam should include:
Adequate exposure of the shoulder girdle
Careful visual inspection from the front, back, and side
Atrophy of infraspinatus (positive likelihood ratio of 2.0)
Look for patterns of muscle wasting suggestive of underlying neurologic disease
Palpate bony structures of the shoulder for tenderness, swelling, and deformity
Test active and passive ranges of motion of the shoulder in all planes and compare with contralateral shoulder
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
Physical exam maneuvers to test for RC disorders
Painful arc test
Drop-arm test
Hawkins test
Empty can test
Resisted external rotation
Internal rotation lag test
Injecting short-acting local anesthetic into subacromial space sometimes recommended to confirm RC as source of pain
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
What other conditions should clinicians consider during evaluation?
Intrinsic causes of shoulder pain
Acromioclavicular osteoarthritis
Adhesive capsulitis
Amyloidosis
Avascular necrosis
Biceps tendinopathy
Crystal arthritis
Glenohumeral osteoarthritis
Inflammatory arthritis
Paget disease of bone
Polymyalgia rheumatica
Primary and metastatic tumors
Septic arthritis
Superior labrum anterior to posterior tears and labral lesions
Sternoclavicular osteoarthritis
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
Extrinsic causes of shoulder pain
Apical lung cancer (Pancoast tumor)
Brachial neuritis (Parsonage-Turner syndrome)
Cervical radiculopathy
Fibromyalgia
Myocardial ischemia
Subdiaphragmatic process
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
What is the role of imaging studies?
Reserve for when:
Patients present with atypical clinical features
There is doubt about the diagnosis and the results of the investigations would alter management
A decision to consider surgery has been made
Available imaging investigations
Plain radiographs
Ultrasonography
MRI
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
When should clinicians consider referring the patient to a surgical or nonsurgical specialist?
Patients have atypical clinical features or diagnostic uncertainty persists
Refer to rheumatologist orthopedic surgeon, or another specialist, according to the clinical circumstances
Patients have severe symptoms that do not respond to conservative measures
Refer to orthopedic surgeon
Especially if symptoms interfere with occupational tasks or athletic pursuits
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
CLINICAL BOTTOM LINE: Diagnosis...
Thorough history and examination: fundamental to diagnosis Exclude intrinsic or extrinsic causes of pain Physical examination maneuvers may improve accuracy of
the clinical assessment Imaging is usually not required
Use rarely alters management in primary care May increase risk for overtreatment
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
How should clinicians manage patients with rotator cuff disease?
Nonsurgical therapy is the cornerstone of management
Tailor initial conservative management plan to individual
Patient education regarding the diagnosis and prognosis
Advice on activity modification and self-management
Early management may also include
Analgesic drugs
NSAIDs
Glucocorticoid injections
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
Which analgesics should clinicians prescribe first? Simple analgesics on an as-needed basis
Such as acetaminophen (paracetamol)
Low-risk, first-line approach
If simple analgesia ineffective, consider NSAIDs
Balance potential benefits with known potential GI, renal, and cardiovascular risks
Be cautious about combining acetaminophen with NSAIDs
Use of opioids is discouraged
Short course of short-acting oral opioid may be considered if pain persists and interferes with function or sleep
Ongoing requirement for opioids should prompt referral
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
When should clinicians consider glucocorticoid injections?
When pain interferes with sleep or function despite adequate analgesia
Glucocorticoids usually mixed with local anesthetic and injected into the subacromial space
Procedure takes only a few minutes
Simple to learn
Requires no special equipment
Does not require a sterile field
Can be performed in an office setting
Low risk for infection and other complications
Safe with warfarin anticoagulation therapy if the INR <3
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
What is the role of physical therapy?
May reduce symptoms and improve function
Recommend when simple measures have failed
Common interventions evaluated in trials: Scapular stability training and progressive RC strengthening
Resistance exercise effective both in supervised setting and in home
Little evidence is available on the use of joint mobilization techniques as a lone intervention
Combination of mobilization + exercise may be superior to exercise alone
Role of exercise therapy in large RC tears is uncertain
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
What is the role of other treatments?
Extracorporeal shock wave therapy
Existing evidence does not support use in the absence of calcium deposits
Consider if patients have calcific RC tendinitis
Acupuncture
Consider as auxiliary treatment in patients with persistent pain
High-quality evidence on efficacy and safety is lacking
Platelet-rich plasma injections: evidence doesn’t support
Suprascapular nerve block: may be useful for pain relief
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
What is the role of surgical management?
Reserve for when nonsurgical treatment has failed
Refer to surgeon if there is progressive weakness or if symptoms are severe and persistent after 3 to 6 months of nonsurgical management
Before referral, consider relative risks and benefits for the individual patient
Early surgery is sometimes appropriate
May be considered when prompt repair minimizes disruption to occupational or sporting activities
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
Open or arthroscopic surgical options
Acromioplasty
Decompression of the subacromial space
Repair of RC tears
Removal of calcium deposits
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
How should clinicians follow patients with rotator cuff disease?
Most patients only need follow up if symptoms persist
In this case, repeated evaluation appropriate at 4 to 8 weeks
Additional or atypical symptoms or signs should prompt further investigation or specialist referral
May indicate an alternative diagnosis
If symptoms persist after 3 to 6 months of conservative treatment
Refer to a specialist
© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.
CLINICAL BOTTOM LINE: Treatment... Initial management should be conservative
Activity modification Simple analgesics and NSAIDs if required Physical therapy and exercise programs
Subacromial glucocorticoid injections For patients with persistent or severe pain
Surgery Younger patients with acute, functionally significant tears Older patients in whom active nonsurgical treatment failed