Introduction
Accounting for more than 4.5 million visits to providers and approximately 40,000 surgical procedures annually in the United States, rotator cuff pathology is a common cause of shoulder pain (Martin & Martin, 2017; PubMed Health, 2017; Simons, Dixon, & Kruse, 2017). The incidence of rotator cuff pathology is estimated between 16% and 34%, which increases linearly with age, beginning in the third decade (Giai Via, De Cupis, Spoliti, & Oliva, 2013; Simons et al., 2017).
Mechanisms underlying rotator cuff pathology include acute, traumatic incidents such as a fall, as well as chronic, multifactorial issues related to repetitive activities that overload the shoulder, impingement, and tendon degeneration associated with normal aging (Giai Via et al., 2013; Martin & Martin, 2017; PubMed Health, 2017; Simons et al., 2017). Treatment options include both conservative and surgical management. Although there is a clear indication for surgery following traumatic rotator cuff tear, there is lacking consensus as to when surgery should be performed for those patients with chronic pain associated with tendon degeneration and tearing (Martin & Martin, 2017; Moosmayer et al., 2014; PubMed Health, 2017; Simons et al., 2017).
Case Presentation
A 56-year-old, right-hand-dominant woman presented with 3 weeks of acute-on-chronic left shoulder pain. She reported intermittent aches and pains for several years, but nothing to the extent of her presenting complaints.
Three weeks previous, she was attempting to lift groceries from the back of her car and felt a sudden, sharp pain of the lateral shoulder. The pain was so marked that she left the groceries in the car and went inside to check her shoulder. She did not note any swelling or discoloration. She took ibuprofen and applied ice. In following days, the shoulder continued to ache and bother her. There was gradual relief over the next week but then plateaued to a steady, mild ache. She reported continued sharp pains with any attempted lifting or reaching overhead.
Upon presentation was an alert, oriented, affect-appropriate female in no apparent distress. She postured with a left shoulder hike. There was no gross deformity, swelling, or discoloration. Tenderness to palpation was noted in the subacromial space, overlying the greater tuberosity. Passive range of motion was grossly equal. Active range of motion was pain-limited in abduction and forward flexion, with noted trapezius recruitment. Strength was also limited by pain, noted to be 4/5 with resisted abduction and external rotation. She performed coordinated opposition and was found to be distally neurovascularly intact. She displayed a positive empty can, lift off, and Hawkins, O'Brien, and Neer's tests with a negative drop arm.
Radiographs taken at the time of evaluation included anteroposterior, Grashey, and axial views (see Figure 1). These were evident for mild glenohumeral narrowing, with subtle inferior osteophyte formation, subacromial osteophyte formation, and chronic changes about the greater tuberosity. Given these findings, in association with the patient's mechanism of injury and physical examination findings, she was referred for magnetic resonance imaging (MRI) of the left shoulder (Martin & Martin, 2017; PubMed Health, 2017; Simons et al., 2017). The MRI (see Figure 2) was revealing for a partial tear of the supraspinatus, quantified as near 75% of the tendon width, at its insertion on the greater tuberosity. There was associated subacromial bursitis and mild cartilage thinning about the humeral head.
Management
Options discussed with the patient included continued use of oral nonsteroidal anti-inflammatory drugs and referral to physical therapy, trial of therapeutic intra-articular steroid injection, or referral to an orthopaedic shoulder surgeon to discuss further intervention (Martin & Martin, 2017; Moosmayer et al., 2014; PubMed Health, 2017; Simons et al., 2017). With the extent of tearing, as well as the acute nature of the injury, the common recommendation is for surgical intervention (Martin & Martin, 2017; Oh, Wolf, Hall, Levy, & Marx, 2007; Strauss et al., 2011). In discussing this with the patient, she verbalized hesitance and concerns about undergoing surgery, wishing to pursue other options for treatment.
Given the level of pain, yet understanding the risk of propagating the tear, she elected for an intra-articular steroid injection (Martin & Martin, 2017; PubMed Health, 2017; Simons et al., 2017). She noted significant relief in days following the injection and started a course of physical therapy the next week. Unfortunately, a couple weeks into therapy, her symptoms returned and was then referred to an orthopaedic shoulder surgeon for definitive management.
Surgical intervention for rotator cuff tears includes debridement, followed by grafting of the tendon back to bone using one of many available anchors and suturing techniques (Martin & Martin, 2017; PubMed Health, 2017; Simons et al., 2017). This is often accompanied by a subacromial decompression to eliminate osteophytes and free up space for the tendon to glide freely between the humeral head and acromion (Kukkonen et al., 2015; Martin & Martin, 2017; Oh et al., 2007; Strauss et al., 2017). Newer techniques, including the administration of platelet-rich plasma at the time of repair, are still under investigation, with mixed results noted in the literature (Giai Via et al., 2013; Martin & Martin, 2017).
Discussion
Rotator cuff pathology is a common underlying etiology for shoulder pain (Martin & Martin, 2017; PubMed Health, 2017; Simons et al., 2017). The advanced practice orthopaedic provider should be acquainted with concerning physical examination findings and special testing consistent with rotator cuff pathology. These findings, in conjunction with the patient's reported history, especially if noting an acute injury, should prompt one to order appropriate advanced imaging to evaluate extent of rotator cuff damage (Martin & Martin, 2017; PubMed, 2017; Simons et al., 2017). Confirmation of rotator cuff pathology should then be considered with the patient's age, hand dominance, functional demand level, including occupation, severity, and timeline of presenting symptoms, as well as patient expectations in deciding on the most appropriate treatment plan.
References