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====== Rotator Cuff Injuries ======

  * common and disabling early treatment prevents late complications

====== Clinical Findings ======

> Sambandam:
> 
> Progressive shoulder pain typically occurs around the anterolateral shoulder margin, lateral surface of the arm down to the elbow[70]. Night pain can occur in 83% patients while 41% may experience muscle weakness[71]. Local examination reveals disuse-related SSP and ISP MA. Among various tests, the empty can test is most sensitive (68.4%), drop arm and lift-off tests most specific (100%) and Neer test most accurate (75%) for RC tears overall[71].
> 
> For the SSP and ISP, the Jobe sign and the full can test have comparable accuracies[72]. High sensitivities (83% and 97%) and low specificities (23% and 5%) are reported with Hawkins sign and the painful arc test. Higher specificities (91% and 86%) have been observed with the external rotation lag sign (ERLS) and the drop-arm test (DAT) in diagnosing FTT. The sensitivity of lag tests reduces after subacromial lidocaine injection, while specificities of the Jobe, ERLS and DAT have been seen to improve[73]. A positive lift-off test is highly specific for diagnosing FTT and severe FI of SS[74]. No test in isolation however, is adequate for diagnosing an RC tear and a combination of tests improves the diagnostic yield[75].

====== Natural History ======

  * some patients asymptomatic, but can become symptomatic
  * PTT can become FTT
  * risk of late arthropathy and GH arthritis

====== Risk factors ======

===== Patient =====

  * Age is major risk factor
  * Smoking and family history
  * Female

===== Anatomical =====

  * Shape of the acromion: Flat, curved or hooked

====== Classification ======

==== Partial tears (Ellmann)

see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4686437/bin/WJO-6-902-g001.jpg

^Grade         ^1   ^2   ^3   ^
|Articular side|<1/4|<1/2|>1/2|
|Bursal side   |<1/4|<1/2|>1/2|

====== Investigation ======

  * US good sensitivity and specificity for PTT and FTT
  * MRI shows more detail and helps surgical planning. Also likely better for smaller tears

====== Treatment ======

  * nonsurgical
    * some conflicting results, but better results in more educated female with active abduction
    * ROM optimization, RC and scapular rotator strengthening; manage anterior/posterior capsular tightening
  * partial repair and/ or debridement
  * open or arthroscopic repair
  * reconstruction
  * arthroplasty

====== Outcomes ======

  * Is there a RCT comparing surgery to conservative? There a few and reviewed by [[https://doi.org/10.1016/j.jse.2017.09.032 | Piper]]. There was small statistical but not clinically important differences between the two groups at 1 year follow up in [[https://rdcu.be/cxwTI|Constant]] and VAS scores.

====== References ======

Piper, C. C., Hughes, A. J., Ma, Y., Wang, H., & Neviaser, A. S. (2018). Operative versus nonoperative treatment for the management of full-thickness rotator cuff tears: A systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery, 27(3), 572–576. https://doi.org/10.1016/j.jse.2017.09.032

Sambandam, S. N., Khanna, V., Gul, A., & Mounasamy, V. (2015). Rotator cuff tears: An evidence based approach. World Journal of Orthopedics, 6(11), 902–918. https://doi.org/10.5312/wjo.v6.i11.902

Ziegler, P., Kühle, L., Stöckle, U. et al. Evaluation of the Constant score: which is the method to assess the objective strength?. BMC Musculoskelet Disord 20, 403 (2019). https://doi.org/10.1186/s12891-019-2795-6

====== Meta-data ======

  * created 2021-09-10 in org-mode with Emacs 27.2 on HPX360 Windows 10 Edu. Most of initial notes from [[https://doi.org/10.5312/wjo.v6.i11.902|Sambandam]]
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