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Rotator-Cuff Failure
Frederick A. Matsen III, M.D.
This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinical recommendations.

A 63-year-old woman presents with a 2-year history of progressive weakness and discomfort in her right shoulder, especially when she puts dishes on the top shelf in her kitchen. She is otherwise healthy and has had no injuries. Her physician diagnosed “bursitis” and gave her four subacromial corticosteroid injections; the first two seemed to relieve her symptoms temporarily, but the last two were ineffective. Physical examination reveals some atrophy of the muscles of the right shoulder and weakness when her right arm is elevated. Magnetic resonance imaging (MRI) reveals a large defect in the rotator cuff. How should her case be managed?

The Cl inic a l Probl e m
From the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle. N Engl J Med 2008;358:2138-47.
Copyright © 2008 Massachusetts Medical Society.

The rotator cuff is a synthesis of the capsule of the glenohumeral joint with the tendons of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles (Fig. 1).1 The rotator-cuff mechanism precisely centers the humeral head by compressing it into the glenoid concavity. The individual muscles of the cuff help to provide strength in arm movement: the subscapularis in internal rotation, the supraspinatus in elevation, and the infraspinatus and teres minor in external rotation. Failure of the rotator-cuff tendons due to either tear or wear is the most common clinical problem of the shoulder, accounting for more than 4.5 million physician visits per year in the United States.2 Failure of the cuff tendon may result from a major injury, but more commonly it results from age-related attrition of the tendons, typically starting with the undersurface of the anterior aspect of the supraspinatus (Fig. 1 and 2 of the Supplementary Appendix, available with the full text of this article at www.nejm.org).3 Failure of the rotator cuff may progress to involve the full thickness of the tendinous insertions of the supraspinatus and then may extend to involve the infraspinatus and the subscapularis. The natural history of degenerative cuff-tendon failure is one of age-related progression.4 Imaging studies reveal that 30% of asymptomatic persons over 60 years of age5 and 65% of asymptomatic persons over 70 years of age6 have rotatorcuff defects. The rate of progression may be slow; patients with moderately symptomatic, massive rotator-cuff tears have been found to maintain satisfactory shoulder function for at least 4 years.7 Cuff defects are also more frequent in obese persons.8 Although corticosteroid injections have not been shown to increase the risk of cuff failure, there is evidence that injection of corticosteroids in and around tendons and ligaments can alter their collagen composition, strength, and ability to heal.9-11 Nicotine also may compromise the ability of tendons to heal and attach to bone.12

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S t r ategie s a nd E v idence
Evaluation

The clinical manifestations of full-thickness, degenerative rotator-cuff failure vary widely among patients (Table 1).13,14 Patients with acute, traumatic, full-thickness cuff tears may experience the sudden onset of weakness with elevation of the arm after an injury in which the arm has been forced to the side (e.g., during a fall while skiing with the arm out to the side or on catching a heavy falling object with the extended arm). Patients with chronic degenerative cuff defects may notice a gradual onset of shoulder weakness, often accompanied by pain and crepitus on active movement4; however, many degenerative rotator-cuff defects are asymptomatic.13,15 The examination of the shoulder should include observation for atrophy of the deltoid, supraspinatus, or infraspinatus or a combination of these muscles. Palpation at the anterior greater tuberosity may reveal a defect in the cuff–tendon attachment (Fig. 2A). Palpation below the acromion as the arm is rotated may reveal crepitance from the edges of the torn cuff (Fig. 2B). Pain or weakness on isometric testing of arm elevation suggests involvement of the supraspinatus (Fig. 2C). Pain or weakness on isometric testing of internal rotation suggests involvement of the subscapularis (Fig. 2D), and during external rotation pain or weakness suggests involvement of the infraspinatus (Fig. 2E). The range of passive motion may be limited in shoulders with cuff defects; the limitation of internal rotation on abduction is particularly common in partial-thickness rotator-cuff lesions (Fig. 2F). Because the cuff mechanism is the primary stabilizer of the shoulder, major cuff defects may be associated with instability in the anterior, posterior, or superior direction. In a severe form of instability known as anterosuperior escape, the humeral head slides out anteriorly on attempted elevation because of wear or surgical compromise of the coracoacromial arch.16,17 When the humeral head is no longer stabilized in the glenoid concavity, contraction of the deltoid muscle is ineffective in elevating of the arm away from the side, leading to a finding known as pseudoparalysis of the shoulder.16,17

B I

Figure 1. Anatomy of the Rotator Cuff. In this view of the rotator cuff from inside the joint, the ICM sectioned long head of the biceps is draped across RETAKE 1st AUTHOR Matsen 2nd the REG F FIGURE 1The subscapularis tendon (arrow) humeral head. 3rd approaches the humerus from the left, the supraspinaCASE TITLE Revised tus EMail (arrowhead) from the top to the 4-C of the biceps right Line SIZE (B),Enon the infraspinatus (I) from the right below the and ARTIST: mst H/T H/T 16p6 FILL Combo supraspinatus. The slip of supraspinatus forms a roof over the biceps tendon. PLEASE NOTE: AUTHOR,
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Plain films of the shoulder may show upward displacement of the humeral head relative to the glenoid and narrowing of the interval or even contact between the acromion and the humeral head in patients with chronic cuff failure. Plain imaging may also reveal an alternative cause of shoulder pain such as degenerative arthritis of the glenohumeral joint. Both MRI (Fig. 3) and ultrasonography (Fig. 4) may be useful in directly evaluating the status of the rotator-cuff tendons.18 In a study comparing the results of imaging with findings at arthroscopy, ultrasonography and MRI were each almost 90% accurate in diagnosing full-thickness and partial-thickness tears. The sensitivities and positive predictive values of both tests were high (97%), but the specificities were only modest (67%). In another study, which used open or arthroscopic operative findings as the gold standard, ultrasonography and MRI each correctly identified approximately 90% of full-

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History Physical Examination Pain on resisted elevation of the arm Weakness of the arm during elevation and possibly during external rotation, palpable defect in tendon insertion Weakness of the arm during elevation and possibly during external rotation Tuberosity fracture Normal findings Normal findings Plain-Film Radiographic Assessment MRI or Ultrasonographic Examination Findings Electromyographic Examination Normal findings
The

Table 1. Differential Diagnosis of Rotator-Cuff Lesions.

Diagnosis

Partial- thickness acute tear

Fall or sudden attempt to lift the arm, followed by pain

Thinning of tendon at insertion, with defect in the deep aspect of the tendon Full-thickness defect in cuff tendon

Full-thickness acute tear

Sudden loss of shoulder strength after a fall or sudden attempt to lift the arm

Normal findings

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Acute fracture of tuberosity

Sudden loss of shoulder strength after a definite injury

Tuberosity fracture

Normal findings

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Degenerative rotator-cuff failure

Insidious onset of shoulder weakness without major injury Severe weakness, anterior and superior movement of humeral head on attempted elevation of the arm Limited range of motion, especially in internal rotation of the abducted arm, external rotation, and when the patient reaches up the back Limited range of motion, especially during external rotation and elevation; boneon-bone crepitance

Weakness of the arm during Normal or narrowed space elevation and possibly durbetween humeral head ing external rotation, palpaand acromion ble defect in tendon insertion Superior displacement of humeral head relative to glenoid and acromion Normal findings

Full-thickness defect in cuff tendon or tendons; atrophy, fatty degeneration, or both of cuff musculature Supraspinatus and often infraspinatus tendons not visible Normal findings (contrastenhanced MRI may show obliteration of normal axillary recess)

Normal findings

of

Anterosuperior escape, pseudoparesis, or both

Inability to raise the arm away from the side

Normal findings

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Downloaded from www.nejm.org at HARVARD UNIVERSITY on January 7, 2009 . Copyright © 2008 Massachusetts Medical Society. All rights reserved. Joint-space narrowing, osteophytes, sclerosis Cuff tendons usually intact

Frozen shoulder

Shoulder pain and stiffness, often without an injury

Normal findings

Glenohumeral arthritis

Progressive onset of pain and stiffness

Normal findings

clinical pr actice

Calcific density in supraspinatus tendon near insertion

Normal findings on shoulder images, cervical spondylosis

Normal findings

Normal findings

Normal findings

thickness cuff defects, 70% of partial-thickness cuff defects, and 80% of normal tendons.19 Decisions regarding the need for imaging should be based on whether the results are likely to affect treatment. For example, because of the need for prompt repair of an acute full-thickness tear, an expedited ultrasound or MRI study is warranted in a patient who cannot raise his or her arm after a fall.20-22 However, imaging of the cuff tendon is unlikely to change the initial care of an elderly patient who has no history of an injury and who reports long-standing weakness, pain, and stiffness in the shoulder that are suggestive of degenerative cuff failure.
Treatment

Peripheral neuropathy

Suprascapular denervation

C5 or C6 findings

Normal findings

Normal findings

Pain above the shoulder, hand numbness, dysesthesia

Onset of weakness in suprascapular nerve distribution

Severe pain at rest, difficulty moving the arm

Pain and catching without weakness

Atraumatic onset of pain in nerve distribution, followed by weakness

The treatment of various types of rotator-cuff lesions is summarized in Table 2. Few randomized trials have compared the effectiveness of different approaches to the management of rotatorcuff lesions, and none have directly compared surgical with nonsurgical intervention. A Cochrane review of various common interventions for rotator-cuff lesions23 concluded that there were insufficient data to provide support for or refute their use.2 Most studies have been limited by the lack of a control group, the types of outcome data reported (which have rarely included assessment of both the subjective benefits to the patient and the objective assessment of the integrity of the rotator-cuff tendons), the lack of long-term follow-up of all prospectively enrolled patients, and the questionable generalizability of studies performed by expert surgeons in major centers to general practice.24 Therefore, the approach to the management of cuff lesions is largely based on clinical experience, an understanding of the anatomy, and the management of tendon failure at other sites, such as the hand and knee.
Acute Complete Tears

Local tenderness over supraCalcific density in supraspispinatus tendon insertion, natus tendon near inpain on elevation of the arm sertion

Shoulder and arm symptoms Normal findings on shoulexacerbated by turning the der films, cervical sponhead or leaning the head to dylosis the side, weakness, atrophy, loss of reflexes (often in C5 or C6 distribution)

Normal findings

Normal findings

Weakness of the supraspinatus and infraspinatus due to involvement of the suprascapular nerve

Crepitance on rotation of the arm

Weakness of supraspinatus, infraspinatus, or both

Normal findings

Spinoglenoid notch cyst (ganglion)

Acute calcific tendinitis

Brachial neuritis (Parsonage–Turner syndrome)

Cervical radiculopathy

Bursitis, subacromial abrasion

As is the case with the acute rupture of any major tendon, acute traumatic ruptures of the rotator cuff are best repaired as soon as possible, ideally within 6 weeks after injury.21,25-32 Prolonged observation and nonsurgical management allow the detached tendon to retract and resorb while the muscle atrophies.20-22,33,34
Partial-Thickness Rotator-Cuff Tendon Defects

In contrast to acute full-thickness cuff tears, acute partial-thickness or chronic partial-thickwww.nejm.org may 15, 2008

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A

Palpating cuff defect

B Crepitance

Patient motion

C Supraspinatus

Physician resistance

D Subscapularis

E Infraspinatus

Limited internal rotation

F

Limited internal rotation in abduction

COLOR FIGURE

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Figure 2 (facing page). Examination of a Patient with a Suspected Rotator-Cuff Injury. Defects in the rotator cuff often can be palpated just lateral to the acromion when the patient’s arm is at the side and slightly extended (Panel A). Gently rotating the arm can increase the sensitivity of this palpation. Roughness between the rotator cuff and the coracoacromial arch can be assessed by palpating the shoulder for crepitance while the patient’s arm is passively rotated (Panel B). The integrity of the supraspinatus attachment to the greater tuberosity of the humerus is examined by having the patient isometrically press up against resistance while the arm is held at 90 degrees of elevation and internal rotation (Panel C). A defect of the supraspinatus tendon can produce pain or weakness on this test. The integrity of the subscapularis attachment to the lesser tuberosity of the humerus is examined by having the patient isometrically rotate the arm inward toward the abdomen while the forearm is flexed to a 90-degree angle (Panel D). A defect of the subscapularis tendon can produce pain or weakness on this test. The integrity of the infraspinatus attachment to the greater tuberosity of the humerus is examined by having the patient isometrically rotate the arm outward against resistance while the arm is held at the side with the forearm pointing forward and flexed to a 90-degree angle (Panel E). A defect of the infraspinatus tendon can produce pain or weakness on this test. Limitation of internal rotation is a common manifestation of rotator-cuff injury (Panel F). The most sensitive test involves placing the arm of the supine patient at 90 degrees of abduction away from the side and measuring the degrees of internal rotation from the position with the forearm vertical (0 degrees of internal rotation).

D

T

H

Figure 3. Coronal MRI Scan of the Right Supraspinatus Tendon. The tendon has an articular-surface partial-thickness RETAKE 1st AUTHOR Matsen ICM defect (arrow). D denotes deltoid, H humoral head, and 2nd REG F FIGURE 3 T tendon. (Courtesy of Michael Richardson, Department 3rd CASE TITLE Revised of Radiology, University of Washington, Seattle.)
EMail Enon FILL

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ness cuff tears often improve with nonsurgical management because the part of the tendon remaining intact prevents retraction and muscle atrophy (see Fig. 1 and 2 of the Supplementary Appendix). A program of range-of-motion exercises may help resolve the stiffness in adduction across the body, in internal rotation up the patient’s back, and especially in internal rotation with the arm in abduction. Patients in whom the symptoms of a partial cuff tear are refractory to this stretching program may benefit from débridement of the lesion, smoothing of the humeroscapular motion interface, and curettage of the deep surface of the tendon attachment. In a series of patients who underwent débridement of partial-thickness defects of the rotator cuff without acromioplasty, the results were considered satisfactory by 87% of the patients.25,35

H

Figure 4. Coronal Ultrasonographic Image of the Left Supraspinatus Tendon. The tendon has a full-thickness defect (arrow). D denotes deltoid, H humoral head, and T tendon. (Courtesy of RETAKE 1st AUTHOR Matsen Michael Richardson, Department of Radiology, UniverICM 2nd sityREG Washington, Seattle.) of F FIGURE 4
CASE EMail

TITLE

3rd

nonsteroidal antiinflammatory NOTE: (NSAIDs) or AUTHOR, PLEASE drugs Figure has been redrawn and type has been reset. acetaminophen Please check carefully. activity modififor discomfort, cation, and gentle stretching and strengthening exercises for the muscles thatISSUE: 5-15-08 remain intact. AlJOB: 35820 though data are lacking from randomized trials assessing the benefits of exercise therapy for fullthickness, degenerative defects, case series and case reports have shown improvement in comfort and function with exercise.36 Chronic, Full-Thickness, Degenerative Tendon Defects In a Cochrane review of placebo-controlled, Most chronic, full-thickness, degenerative tendon randomized trials of the use of subacromial indefects are best managed without surgery. Non- jection of corticosteroids for rotator-cuff disease, n engl j med 358;20 www.nejm.org may 15, 2008

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Table 2. Treatment of Rotator-Cuff Lesions. Diagnosis Acute rotator-cuff tear Partial-thickness rotatorcuff lesion Degenerative rotator-cuff failure without arthritis Nonsurgical Management Usually not recommended in active persons Flexibility exercises to eliminate shoulder tightness, especially of the posterior capsule Flexibility exercises to restore range of motion, gentle progressive strengthening exercises to increase shoulder function Flexibility exercises to restore range of motion, gentle progressive strengthening exercises to increase shoulder function Flexibility exercises to restore range of motion, gentle progressive strengthening exercises to increase shoulder function Surgical Management Prompt surgical repair in active persons Surgical repair often not needed; smoothing of humeroscapular motion interface, cuff curettage, or both may be considered Surgical repair often not possible; surgical repair may be considered if quality and quantity of tissue are sufficient for durable repair — otherwise, smoothing of humeroscapular motion interface is considered Humeral hemiarthroplasty with careful preservation of coracoacromial arch Reverse total shoulder arthroplasty to provide necessary glenohumeral stability16

Arthritis of humeral head and chronic, massive rotator-cuff defect Anterosuperior escape, pseudoparesis, or both

some trials showed a modest benefit with this intervention; however, pooled results of three trials comparing subacromial corticosteroid injection with NSAIDs showed no significant benefit of injection. Overall, the authors concluded that the effects of subacromial corticosteroid injection for rotator-cuff disease appeared to be slight and not sustained.37 Another Cochrane review showed no evidence of a significant benefit of corticosteroid injection in patients with rotator-cuff tears.23 Because corticosteroid injections may adversely affect tendon quality and their benefit is uncertain, repeated use of injections is discouraged, except in cases in which surgery is not considered an option, the response to other nonsurgical interventions is inadequate, and there is a perceived improvement in symptoms with injection. Other approaches, such as electrotherapy, therapeutic ultrasonography, acupuncture, injection of hyaluronic acid, and shock-wave therapy, have also been used in patients with rotator-cuff failure, but these methods have not been rigorously studied, and the indications and benefits are unclear.23 If symptoms persist in spite of nonsurgical measures and the clinical evaluation suggests that the cuff is reparable, surgical repair can be considered. Factors that favor durable surgical reattachment of a detached rotator-cuff tendon include an age of less than 60 years, a traumatic onset of weakness, a short duration of symptoms (e.g.,