Shoulder / Arm

Rotator Cuff Syndromes

Definition

Rotator cuff syndromes of the glenohumeral joint are a collective name for disorders of the shoulder, such as tendinopathies, rotator cuff lesions (tears), and sometimes the impingement syndrome. They are one of the most frequent shoulder complaints encountered in general practice.

Aetiology

The cause of rotator cuff syndromes is not clear. Intrinsic degeneration of the rotator cuff tendons due to vascular insufficiency, together with repetitive micro-traumata, are seen as a possible cause.

Segmental dysfunction of the cervical spine and cervicothoracic junction can play a role in the clinical picture. Therefore, in addition to the evaluation of shoulder function, it is very important to examine the cervical spine as well.

Signs and symptoms

The complaint pattern is characterised by increasing shoulder pain after each time it takes a load. Nocturnal pain and the inability to sleep on the affected shoulder point in the direction of an inflammation.

Furthermore, the complaint pattern is dependent on the precise cause. Thus, impingement can present in a painful arc, while pain, weakness and atrophy are characteristic of a tear in the rotator cuff.

The location and radiation pattern of the pain can provide information on whether it is caused by a primary pathology of the shoulder, or that it is located outside the shoulder.

In particular, in non-traumatic shoulder pain with an abnormal natural course, other serious diseases, such as generalised joint pain, fever, malaise, weight loss, dyspnoea and angina pectoris, should be explored. Most importantly, a pancoast tumour must be excluded.

Diagnostics

Physical Examination

Examination of the shoulder in rotator cuff syndromes:

Three groups of shoulder tests are important in examination of the shoulder: 1. active and passive shoulder abduction; 2. active and passive shoulder external rotation; and 3. active and passive horizontal shoulder adduction. Serious shoulder pathology, presenting as brachialgia, can be diagnosed by means of these tests.

In addition, it is important to perform passive shoulder abduction in external rotation. Passive abduction should be performed as often as possible in the frontal plane.

As far as a tear is concerned, restricted active and passive external rotation is the most characteristic motion restriction in rotator cuff syndromes.

DISORDER

Passive External Rotation restriction

Active Abduction restriction

in

Neutral Position Arm

Passive Abduction restriction

in

External Rotation Position Arm

Passive Horizontal Abduction External Rotation

Osteoarthritis Glenohumeral Joint

+++

+++

+++

+

Capsulitis Glenohumeral Joint

+++

+++

+++

+

Rotator Cuff Syndrome

++

+++

+++

+

Osteoarthritis Acromioclavicular Joint

-

+++

+++

+++

Degenerative Disorder Subacromial Space (calcification)

-

+++

-

-

Additional Somatic Diagnostics

  • In the initial phase of uncomplicated shoulder complaints, no imaging techniques and laboratory examinations are indicated.
  • If systemic diseases or other serious conditions are suspected in shoulder pain, blood tests are indicated (CRP, Hb, BSE, rheumatoid factors).
  • A bone scan is indicated when metastases or primary tumours are suspected.

The diagnostic value of MRI and ultrasound in rotator cuff syndromes still has to be established.  These imaging techniques can demonstrate 'full thickness tears', however they are less accurate for partial tears.

Additional Psycho-cognitive Diagnostics

  • RAND-36 (quality of life)
  • VAS Pain (maximal, minimal, actual, average/week)
  • PCS (catastrophising)
  • HADS (fear and depression)

Multidisciplinary Treatment

Whether or not somatic treatment is indicated is based on the pain diagnosis.  Based on the findings of the pain questionnaires, additional diagnostics and/or multidisciplinary treatment consisting of various non-somatic treatments may be necessary.

Non-somatic Treatment

Somatic Treatment

Pharmacological treatment:

Other Treatments

Interventional Pain Treatment