Tue . 20 Jul 2020
TR | RU | UK | KK | BE |

Rotator cuff tear

rotator cuff tear, rotator cuff tear symptoms
A rotator cuff tear is a tear of one or more of the tendons of the four rotator cuff muscles of the shoulder A rotator cuff 'injury' can include any type of irritation or overuse of those muscles or tendons,1 and is among the most common conditions affecting the shoulder2

The tendons of the rotator cuff, not the muscles, are most commonly involved, and of the four, the supraspinatus is most frequently affected, as it passes below the acromion The role of the supraspinatus is to resist downward motion The supraspinatus resists downward motion while the shoulder is relaxed as well as when carrying weight3 Such a tear usually occurs at its point of insertion onto the humeral head at the greater tubercle4 Even though the supraspinatus is the most commonly injured muscle of the four muscles in the rotator cuff, the other three muscles that comprise the rotator cuff, the infraspinatus, teres minor, and subscapularis, may also be injured3

The cuff is responsible for stabilizing the glenohumeral joint, abducting, externally rotating, and internally rotating the humerus When shoulder trauma occurs, these functions can be compromised Because individuals are highly dependent on the shoulder for many activities, overuse of the muscles can lead to tears, the vast majority again occurring in the supraspinatus tendon

Contents

  • 1 Signs and symptoms
  • 2 Risk factors
  • 3 Mechanisms of injury
    • 31 Acute tears
    • 32 Chronic tears
    • 33 Extrinsic factors
    • 34 Intrinsic factors
  • 4 Pathophysiology
    • 41 Classification
    • 42 Surgical considerations
  • 5 Diagnosis
    • 51 Symptoms
    • 52 Signs
    • 53 MRI
    • 54 Ultrasound
    • 55 Projectional radiography
    • 56 In-office testing
  • 6 Prevention
    • 61 Size
    • 62 Position
    • 63 Stretching
    • 64 Muscle groups
  • 7 Treatment
    • 71 Non-operative treatment
    • 72 Surgery
    • 73 Rehabilitation
  • 8 Prognosis
  • 9 Epidemiology
    • 91 Incidence
    • 92 Prevalence
  • 10 Complications
  • 11 References
  • 12 External links

Signs and symptomsedit

Many rotator cuff tears are asymptomatic They are known to increase in frequency with age2 and the most common cause is age-related degeneration and, less frequently, sports injuries or trauma4 Both partial and full thickness tears have been found on post mortem and MRI studies in those without any history of shoulder pain or symptoms However, the most common presentation is shoulder pain or discomfort This may occur with activity, particularly shoulder activity above the horizontal position, but may also be present at rest in bed Pain-restricted movement above the horizontal position may be present, as well as weakness with shoulder flexion and abduction56

Risk factorsedit

Risk factors of rotator cuff tears

Some risk factors of experiencing a rotator cuff tear cannot be changed: age, body mass index, and height Recurrent lifting and overhead motions are at risk for rotator cuff tears People who have jobs that involve overhead work, such as carpenters, painters, custodians and servers are at risk of also experiencing a rotator cuff tear7 People who play sports that involve overhead motions, such as swimming, volleyball, baseball, tennis, and American football quarterbacks, are at a greater risk of experiencing a rotator cuff tear Generally, the incidence of rotator cuff tears or injuries increases by age 89 while corticosteroid injection for pain relief increases the risk of tendon tear and delays tendon healing10

Mechanisms of injuryedit

The two main causes are injury acute and degeneration chronic and cumulative, and the mechanisms involved can be either extrinsic or intrinsic or, probably most commonly, a combination of both11

Acute tearsedit

The amount of stress needed to tear a rotator cuff tendon acutely will depend on the underlying condition of the tendon prior to the stress In the case of a healthy tendon, the stress needed will be high, such as a fall on the outstretched arm This stress may occur coincidentally with other injuries such as a dislocation of the shoulder, or separation of the acromioclavicular joint In the case of a tendon with pre-existing degeneration, the force may be surprisingly modest, such as a sudden lift, particularly with the arm above the horizontal position11 This is a common occurrence with rear seated passengers in a motor vehicle collision, regardless of speed

Chronic tearsedit

Chronic tears are indicative of extended use in conjunction with other factors such as poor biomechanics or muscular imbalance Ultimately, most are the result of wear that occurs slowly over time as a natural part of aging They are more common in the dominant arm, but a tear in one shoulder signals an increased risk of a tear in the opposing shoulder Several factors contribute to degenerative, or chronic, rotator cuff tears of which repetitive stress is the most significant This stress consists of repeating the same shoulder motions frequently, such as overhead throwing, rowing, and weightlifting Many jobs that require frequent shoulder movement such as lifting and overhead movements also contribute

Another factor in older populations is impairment of blood supply With age, circulation to the rotator cuff tendons decreases, impairing natural ability to repair, ultimately leading to, or contributing to, tears

The final common factor is impingement syndrome, the most common non-sports related injury and which occurs when the tendons of the rotator cuff muscles become irritated and inflamed while passing through the subacromial space beneath the acromion This relatively small space becomes even smaller when the arm is raised in a forward or upward position Repetitive impingement can inflame the tendons and bursa, resulting in the syndrome1213

Extrinsic factorsedit

Well-documented anatomical factors include the morphologic characteristics of the acromion Hooked, curved, and laterally sloping acromia are strongly associated with cuff tears and may cause tractional damage to the tendon14 Conversely, flat acromia may have an insignificant involvement in cuff disease and consequently may be best treated conservatively The development of these different acromial shapes is likely both genetic and acquired In the latter case, only age has been positively correlated with progression from flat to curved or hooked14 The nature of mechanical activities, such as sports involving the shoulder, along with frequency and intensity of such sports, may be responsible for the adverse development Sports such as bowling in cricket, swimming, tennis, baseball, and kayaking, are most frequently implicated However, a progression to a hooked acromion may simply be an adaptation to an already damaged, poorly balanced rotator cuff that is creating increasing stress on the coracoacromial arch14 Other anatomical factors that may have significance include os acromiale and acromial spurs Environmental factors implicated include increasing age, shoulder overuse, smoking, and any medical condition that affects circulation or impairs the inflammatory and healing response, such as diabetes mellitus14

Intrinsic factorsedit

Intrinsic factors refer to injury mechanisms that occur within the rotator cuff itself The principal is a degenerative-microtrauma model, which supposes that age-related tendon damage compounded by chronic microtrauma results in partial tendon tears that then develop into full rotator cuff tears14 As a result of repetitive microtrauma in the setting of a degenerative rotator cuff tendon, inflammatory mediators alter the local environment, and oxidative stress induces tenocyte apoptosis causing further rotator cuff tendon degeneration14 A neural theory also exists that suggests neural overstimulation leads to the recruitment of inflammatory cells and may also contribute to tendon degeneration14

Pathophysiologyedit

The shoulder joint is made up of three bones: the shoulder blade scapula, the collarbone clavicle and the upper arm bone humerus Further information: Shoulder

The shoulder is a complex mechanism involving bones, ligaments, joints, muscles, and tendons

Classificationedit

MRI of normal shoulder intratendinous signal MRI of rotator cuff full-thickness tear

Tears of the rotator cuff tendon are described as partial or full thickness, and full thickness with complete detachment of the tendons from bone

  • Partial-thickness tears often appear as fraying of an intact tendon
  • Full-thickness tears are "through-and-through" These tears can be small pinpoint, larger buttonhole, or involve the majority of the tendon where it still remains substantially attached to the humeral head and thus maintains function
  • Full-thickness tears may also involve complete detachment of the tendons from the humeral head and may result in significantly impaired shoulder motion and function

Shoulder pain is variable and may not be proportional to the size of the tear

Surgical considerationsedit

Neer promoted the concept of three stages of rotator cuff disease15 Stage I, according to Neer, occurred in those younger than 25 years and involved edema and hemorrhage of the tendon and bursa Stage II involved tendinitis and fibrosis of the rotator cuff in 25- to 40-year-olds Stage III involved tearing of the rotator cuff partial or full thickness and occurred in those older than 40 years16 For surgical purposes, tears are also described by location, size or area, and depth16 Further subclasses include the acromiohumeral distance, acromial shape, fatty infiltration or degeneration of muscles, muscle atrophy, tendon retraction, vascular proliferation, chondroid metaplasia, and calcification Again, in surgical planning, age-related degeneration of thinning and disorientation of the collagen fibers, myxoid degeneration, and hyaline degeneration are considered14

However, for simplicity, tears are sometimes classified based on the trauma that caused the injury:

  • Acute, as a result of a sudden, powerful movement which might include falling onto an outstretched hand at speed, making a sudden thrust with a paddle in kayaking, or following a powerful pitch/throw
  • Subacute, arising in similar situations but occurring in one of the five layers of the shoulder anatomy
  • Chronic, developing over time, and usually occurring at or near the tendon as a result of the tendon rubbing against the overlying bone, and usually associated with an impingement syndrome

Diagnosisedit

A complete tear of the supraspinatus resulting in a shift upwards of the head of the humerus

Diagnosis is based upon physical assessment and history, including description of previous activities and acute or chronic symptoms A systematic, physical examination of the shoulder comprises inspection, palpation, range of motion, provocative tests to reproduce the symptoms, neurological examination, and strength testing17 The shoulder should also be examined for tenderness and deformity Since pain arising from the neck is frequently 'referred' to the shoulder, the examination should include an assessment of the cervical spine looking for evidence suggestive of a pinched nerve, osteoarthritis, or rheumatoid arthritis

Diagnostic modalities, dependent on circumstances, include X-ray, MRI, MR arthrography, double-contrast arthrography, and ultrasound Although MR arthrography is currently considered the gold standard, ultrasound may be most cost-effective18 Usually, a tear will be undetected by X-ray, although bone spurs, which can impinge upon the rotator cuff tendons, may be visible19 Such spurs suggest chronic severe rotator cuff disease Double-contrast arthrography involves injecting contrast dye into the shoulder joint to detect leakage out of the injured rotator cuff20 and its value is influenced by the experience of the operator The most common diagnostic tool is magnetic resonance imaging MRI, which can sometimes indicate the size of the tear, as well as its location within the tendon Furthermore, MRI enables the detection or exclusion of complete rotator cuff tears with reasonable accuracy and is also suitable to diagnose other pathologies of the shoulder joint21

The logical use of diagnostic tests is an important component of effective clinical practice22

Clinical judgement, rather than over reliance on MRI or any other modality, is strongly advised in determining the cause of shoulder pain, or planning its treatment, since rotator cuff tears are also found in some without pain or symptoms The role of X-ray, MRI, and ultrasound, is adjunctive to clinical assessment and serves to confirm a diagnosis provisionally made by a thorough history and physical examination Over-reliance on imaging may potentially lead to overtreatment or distraction from the true underlying problem23

Symptomsedit

Symptoms may occur immediately after trauma acute or develop over time chronic

Acute injury is less frequent than chronic disease, but may follow bouts of forcefully raising the arm against resistance, as occurs in weightlifting, for example24 In addition, falling forcefully on the shoulder can cause acute symptoms These traumatic tears predominantly affect the supraspinatus tendon or the rotator interval21 and symptoms include severe pain that radiates through the arm, and limited range of motion, specifically during abduction of the shoulder25 Chronic tears occur among individuals who constantly participate in overhead activities, such as pitching or swimming, but can also develop from shoulder tendinitis or rotator cuff disease Symptoms arising from chronic tears include sporadic worsening of pain, debilitation, and atrophy of the muscles, noticeable pain during rest, crackling sensations crepitus when moving the shoulder, and inability to move or lift the arm sufficiently, especially during abduction and flexion motions2425

Pain in the anterolateral aspect of the shoulder is not specific to the shoulder,26 and may arise from, and be referred from, the neck, heart or gut

Patient history will often include pain or ache over the front and outer aspect of the shoulder, pain aggravated by leaning on the elbow and pushing upwards on the shoulder such as leaning on the armrest of a reclining chair, intolerance of overhead activity, pain at night when lying directly on the affected shoulder, pain when reaching forward eg unable to lift a gallon of milk from the refrigerator Weakness may be reported, but is often masked by pain and is usually found only through examination With longer-standing pain, the shoulder is favored and gradually loss of motion and weakness may develop, which, due to pain and guarding, are often unrecognized by the patient and only brought to attention during examination

Primary shoulder problems may cause pain over the deltoid muscle intensified by abduction against resistance - the impingement sign This signifies pain arising from the rotator cuff, but cannot distinguish between inflammation, strain, or tear Patients may report that they are unable to reach upwards to brush their hair or to lift a food can from an overhead shelf

Signsedit

It has been suggested that no single physical examination test distinguishes reliably between bursitis, partial-thickness, and full-thickness tears27 On the contrary, a combination of tests seems to provide the most accurate diagnosis For impingement, these tests include the Hawkins-Kennedy impingement sign in which the examiner medially rotates the patient's flexed arm, forcing the supraspinatus tendon against the coracoacromial ligament and so producing pain if the test is positive27 a positive painful arc sign, and weakness in external rotation with the arm at the side For the diagnosis of full-thickness rotator cuff tear, the best combination appears to include once more the painful arc and weakness in external rotation, and in addition, the drop arm sign27 This test is also known as Codman's test The arm is raised to the side to 90° by the examiner The patient then attempts to look to lower the arm back to neutral, palm down If the arm drops suddenly or pain is experienced, the test is considered positive

MRIedit

Magnetic resonance imaging MRI and ultrasound28 are comparable in efficacy and helpful in diagnosis although both have a false positive rate of 15 - 20%29 MRI can reliably detect most full-thickness tears although very small pinpoint tears may be missed In such situations, an MRI combined with an injection of contrast material, an MR-arthrogram, may help to confirm the diagnosis It should be realized that a normal MRI cannot fully rule out a small tear a false negative while partial-thickness tears are not as reliably detected30 While MRI is sensitive in identifying tendon degeneration tendinopathy, it may not reliably distinguish between a degenerative tendon and a partially torn tendon Again, magnetic resonance arthrography can improve the differentiation30 An overall sensitivity of 91% 9% false negative rate has been reported indicating that magnetic resonance arthrography is reliable in the detection of partial-thickness rotator cuff tears30 However, its routine use is not advised, since it involves entering the joint with a needle with potential risk of infection Consequently, the test is reserved for cases in which the diagnosis remains unclear

Ultrasoundedit

Musculoskeletal ultrasound has been advocated by experienced practitioners, avoiding the radiation of X-ray and the expense of MRI while demonstrating comparable accuracy to MRI for identifying and measuring the size of full-thickness and partial-thickness rotator cuff tears31 This modality can also reveal the presence of other conditions that may mimic rotator cuff tear at clinical examination, including tendinosis, calcific tendinitis, subacromial subdeltoid bursitis, greater tuberosity fracture, and adhesive capsulitis32 However, MRI provides more information about adjacent structures in the shoulder such as the capsule, glenoid labrum muscles and bone and these factors should be considered in each case when selecting the appropriate study

Projectional radiographyedit

Projectional radiograph showing a high-riding humeral head

X-ray projectional radiography cannot directly reveal tears of the rotator cuff, a 'soft tissue', and consequently, normal X-rays cannot exclude a damaged cuff However, indirect evidence of pathology may be seen in instances where one or more of the tendons have undergone degenerative calcification calcific tendinitis The humeral head may migrate upwards high-riding humeral head secondary to tears of the infraspinatus, or combined tears of the supraspinatus and infraspinatus33 Prolonged contact between a high-riding humeral head and the acromion above it, may lead to X-rays findings of wear on the humeral head and acromion and secondary degenerative arthritis of the glenohumeral joint the ball and socket joint of the shoulder, called cuff arthropathy, may follow32 Incidental X-ray findings of bone spurs at the adjacent acromioclavicular joint may show a bone spur growing from the outer edge of the clavicle downwards towards the rotator cuff Spurs may also be seen on the underside of the acromion, once thought to cause direct fraying of the rotator cuff from contact friction, a concept currently regarded as controversial

In-office testingedit

As part of clinical decision-making, a simple, minimally invasive, in-office procedure may be performed, the rotator cuff impingement test A small amount of a local anesthetic and an injectable corticosteroid are injected into the subacromial space to block pain and to provide anti-inflammatory relief If pain disappears and shoulder function remains good, no further testing is pursued The test helps to confirm that the pain arises from the shoulder primarily rather than referred from the neck, heart, or gut

If pain is relieved, the test is considered positive for rotator-cuff impingement, of which tendinitis and bursitis are major causes However, partial rotator-cuff tears may also demonstrate good pain relief, so a positive response cannot rule out a partial rotator-cuff tear However, with demonstration of good, pain-free function, treatment will not change, so the test is useful in helping to avoid overtesting or unnecessary surgery

Preventionedit

Long-term overuse/abuse of the shoulder joint is generally thought to limit range of motion and productivity due to daily wear and tear of the muscles, and many public web sites offer preventive advice See external links The recommendations usually include:

  • regular shoulder exercises to maintain strength and flexibility
  • using proper form when lifting or moving heavy weights
  • resting the shoulder when experiencing pain
  • application of cold packs and heat pads to a painful, inflamed shoulder
  • strengthening program to include the back and shoulder girdle muscles as well as the chest, shoulder and upper arm
  • adequate rest periods in occupations that require repetitive lifting and reaching

Sizeedit

According to a study which measured tendon length against the size of the injured rotator cuff, researchers learned that as rotator cuff tendons decrease in length, the average rotator cuff tear severity is proportionally decreased, as well 34 This shows that larger individuals are more likely to suffer from a severe rotator cuff tear if they do not tighten the shoulder muscles around the joint

Positionedit

Another study observed 12 different positions of movements and their relative correlation with injuries occurred during those movements The evidence shows that putting the arm in a neutral position relieves tension on all ligaments and tendons35

Stretchingedit

One article observed the influence of stretching techniques on preventative methods of shoulder injuries Increased velocity of exercise increases injury, but beginning a fast-movement exercise with a slow stretch may cause muscle/tendon attachment to become more resistant to tearing36

Muscle groupsedit

When exercising, exercising the shoulder as a whole and not one or two muscle groups is also found to be imperative When the shoulder muscle is exercised in all directions, such as external rotation, flexion, and extension, or vertical abduction, it is less likely to suffer from a tear of the tendon37

Treatmentedit

Weightlifting physical therapy exercise

Those suspected of having a rotator cuff tear are potentially candidates for either operative or non-operative treatment However, any individual may move from one group to the other based on clinical response and findings on repeated examination

No evidence of benefit is seen from early rather than delayed surgery, and many with partial tears and some with complete tears will respond to nonoperative management38 Consequently, many recommend initial, nonsurgical management However, early surgical treatment may be considered in significant >1 cm-15 cm acute tears or in young patients with full-thickness tears who have a significant risk for the development of irreparable rotator cuff changes39

Finally, a review of more than 150 published papers in 2010 concluded that no solid evidence indicated rotator-cuff surgery benefited patients more than nonoperative management, adding to management and treatment controversies404142

Non-operative treatmentedit

Ice pack

Those with pain but reasonably maintained function are suitable for nonoperative management This includes oral medications that provide pain relief such as anti-inflammatory agents, topical pain relievers such as cold packs, and if warranted, subacromial corticosteroid/local anesthetic injection43 An alternative to injection is iontophoresis, a battery-powered patch which "drives" the medication to the target tissue A sling may be offered for short-term comfort, with the understanding that undesirable shoulder stiffness can develop with prolonged immobilization Early physical therapy may afford pain relief with modalities eg iontophoresis and help to maintain motion Ultrasound treatment is not efficaciouscitation needed As pain decreases, strength deficiencies and biomechanical errors can be corrected

A conservative physical therapy program begins with preliminary rest and restriction from engaging in activities which gave rise to symptoms Normally, inflammation can usually be controlled within one to two weeks, using a nonsteroidal anti-inflammatory drug and subacromial steroid injections to decrease inflammation, to the point that pain has been significantly decreased to make stretching tolerable43 After this short period, rapid stiffening and an increase in pain can result if sufficient stretching has not been implemented

A gentle, passive range-of-motion program should be started to help prevent stiffness and maintain range of motion during this resting period Exercises, for the anterior, inferior, and posterior shoulder, should be part of this program43 Codman exercises giant, pudding-stirring, to "permit the patient to abduct the arm by gravity, the supraspinatus remains relaxed, and no fulcrum is required" are widely used The use of NSAIDs, hot and cold packs, and physical therapy modalities, such as ultrasound, phonophoresis, or iontophoresis, can be instituted during this stretching period, if effective43 Corticosteroid injections are recommended two to three months apart with a maximum of three injections Multiple injections four or more have been shown to compromise the results of rotator cuff surgery which result in weakening of the tendon43 However, before any rotator cuff strengthening can be started, the shoulder must have a full range of motion

After a full, painless range of motion is achieved, the patient may advance to a gentle strengthening program Rockwood44 coined the term orthotherapy to describe this program which is aimed at creating an exercise regimen that initially gently improves motion, then gradually improves strength in the shoulder girdle43 Each patient is given a home therapy kit, which includes elastic bands of six different colors and strengths, a pulley set, and a three-piece, one-meter-long stick43 The program is customized, fitting the needs of the individual and altering when necessary Participants are asked to use their exercise program whether at home, work, or traveling

Several instances occur in which nonoperative treatment would not be suggested:

  • 20 to 30-year-old active patient with an acute tear and severe functional deficit from a specific event43
  • 30 to 50-year-old patient with an acute rotator cuff tear secondary to a specific event43
  • a highly competitive athlete who is primarily involved in overhead or throwing sports

These patients may need to be treated operatively because rotator cuff repair is necessary for restoration of the normal strength required to return to the preoperative, competitive level of function43 Finally, those who do not respond to, or are unsatisfied with, conservative treatment should seek a surgical opinion

Surgeryedit

The three general surgical approaches are arthroscopic, mini open, and open-surgical repair24 In the recent past, small tears were treated arthroscopically, while larger tears would usually require an open procedure Advances in arthroscopy now allow arthroscopic repair of even the largest tears, and arthroscopic techniques are now required to mobilize many retracted tears The results match open surgical techniques, while permitting a more thorough evaluation of the shoulder at time of surgery, increasing the diagnostic value of the procedure, as other conditions may simultaneously cause shoulder pain Arthroscopic surgery also allows for shorter recovery time24 although significant differences in postoperative pain or pain medication use apparently are not seen between arthroscopic- and open-surgical patients45

Even for full-thickness rotator cuff tears, conservative care ie, nonsurgical treatment outcomes are usually reasonably good46 However, many patients still suffer disability and pain despite nonsurgical therapies For massive tears of the rotator cuff, surgery has shown durable outcomes on 10-year follow-up47 However, the same study demonstrated ongoing and progressive fatty atrophy and repeat tears of the rotator cuff MRI evidence of fatty atrophy in the rotator cuff prior to surgery is predicative of a poor surgical outcome48 If the rotator cuff is completely torn, surgery is usually required to reattach the tendon to the bone49

If a significant bone spur is present, any of the approaches may include an acromioplasty, a subacromial decompression, as part of the procedure50 Subacromial decompression, removal of a small portion of the acromion that overlies the rotator cuff, aims to relieve pressure on the rotator cuff in certain conditions and promote healing and recovery20 Although subacromial decompression may be beneficial in the management of partial and full-thickness tear repair, it does not repair the tear itself and arthroscopic decompression has more recently been combined with "mini-open" repair of the rotator cuff, allowing for the repair of the cuff without disruption of the deltoid origin51 The results of decompression alone tend to degrade with time, but the combination of repair and decompression appears to be more enduring52

Repair of a complete, full-thickness tear involves tissue suture The method currently in favor is to place an anchor in the bone at the natural attachment site, with resuture of torn tendon to the anchor If tissue quality is poor, mesh collagen, Artelon, or other degradable material may be used to reinforce the repair Repair can be performed through an open incision, again requiring detachment of a portion of the deltoid, while a mini-open technique approaches the tear through a deltoid-splitting approach The latter may cause less injury to muscle and produce better results52 Contemporary techniques now use an all arthroscopic approach Recovery can take as long as three–six months, with a sling being worn for the first one–six weeks53

In a small minority of cases where extensive arthritis has developed, an option is shoulder joint replacement arthroplasty

Rehabilitationedit

Rehabilitation after surgery consists of three stages First, the arm is immobilized so that the muscle can heal Second, when appropriate, a therapist assists with passive exercises to regain range of motion Third, the arm is gradually exercised actively, with a goal of regaining and enhancing strength54 Yoshitsugu Takeda and his team have recently studied rotator cuff injuries and rehab exercises that target the supraspinatus As mentioned earlier, the supraspinatus muscle is the muscle and tendon within the rotator cuff that is most often injured In order to rehab the supraspinatus and combat future injuries in the rotator cuff, Takeda’s team has concluded that the empty can and full can exercises are most effective at isolating and strengthening the supraspinatus55

Following arthroscopic rotator-cuff repair surgery, patients undergo rehabilitation to regain shoulder function Orthopaedic surgeons stress that physical therapy is crucial to healing56 Exercises decrease shoulder pain, strengthen the joint, and improve the arm's range of motion Therapists, in conjunction with the surgeon, design workout regimens in accordance with individuals' needs and risk factors

Traditionally, patients have been advised to immobilize their shoulders for six weeks before doing rehabilitation However, the appropriate timing and intensity of therapy are subject to debate Regardless, most surgeons advocate to remain in the sling for at least six weeks Some authorities advocate early, aggressive rehab They favor the use of passive motion, which allows a patient to move the shoulder without physical effort Alternatively, some authorities argue that therapy should be started later and carried out more cautiously Theoretically, that gives tissues time to heal; though there is conflicting data regarding the benefits of early immobilization A study of rats suggested that it improved the strength of surgical repairs, while research on rabbits produced contrary evidence Patients, especially those recovering from large rotator cuff tears, are prone to developing new tears Rehabbing too soon or too strenuously might increase the risk of retear or failure to heal However, no research has proven a link between early therapy and the incidence of re-tears In some studies, patients who received earlier and more aggressive therapy reported reduced shoulder pain, less stiffness and better range of motion56 Other research has shown that accelerated rehab results in better shoulder function Ross et al note that, despite the findings, "no definitive consensus exists supporting a clinical difference" between the two methods of rehab

There is consensus amongst orthopaedic surgeons and physical therapists regarding rotator cuff repair rehabilitation protocols The timing and duration of treatments and exercises are based on biologic and biomedical factors involving the rotator cuff For approximately two to three weeks following surgery, a patient experiences shoulder pain and swelling; no major therapeutic measures are instituted in this window other than oral pain medicine and ice All in all, those patients at risk of failure, should undergo a more conservative approach to rehabilitations

That is followed by the "proliferative" and "maturation and remodeling" phases of healing, which ensues for the following six to ten weeks The effect of active or passive motion during any of the phases is unclear, due to conflicting information and a shortage of clinical evidence Gentle physical therapy guided motion is instituted at this phase, only to prevent stiffness of the shoulder; the rotator cuff remains fragile At three months after surgery, physical therapy intervention changes substantially to focus on scapular mobilization and stretching of the glenohumeral joint Once full passive motion is regained at usually about four to four and a half months after surgery strengthening exercises are the focus The strengthening focuses on the rotator cuff and the upper back/scapular stabilizers Typically at about six months after surgery, most patients have made a majority of the gains

The objective in repairing a rotator cuff is to enable the patient to regain full function Surgeons and therapists analyze outcomes in several ways Based on their examinations of patients, they compile scores on tests; some examples are those created by the University of California at Los Angeles and the American Shoulder and Elbow Surgeons Other outcome measures include the Constant score; the Simple Shoulder Test; and the Disabilities of the Arm, Shoulder and Hand score The tests assess a patient's range of motion and the degree of shoulder function

Due to the conflicting information about the relative benefits of rehab conducted early or later, an individualized approach is necessary The timing and nature of therapeutic activities are adjusted according to patients' ages, the tissue integrity of their rotator cuff repairs and other factors Special considerations are appropriate for those who have suffered multiple tears

Prognosisedit

While people with rotator cuff tears may not have any noticeable symptoms, studies have shown that over time 40% will have enlargement of the tear over a five-year period Of those whose tears enlarge, 20% have no symptoms while 80% eventually develop symptoms57

There is no irrefutable evidence that rotator cuff surgery benefits patients more than non-surgical management41 and a percentage of patients never regain full range of motion after surgery58

Epidemiological studies strongly support a relationship between age and cuff tear prevalence In a recent study the frequency of such tears increased from 13% in the youngest group aged 50–59 y to 20% aged 60–69 y, 31% aged 70–79 y, and 51% in the oldest group aged 80–89 y14 This high rate of tear prevalence in asymptomatic individuals suggests that rotator cuff tears could be considered a "normal" process of aging rather than a result of an apparent pathological process

Epidemiologyedit

Incidenceedit

A rotator cuff tear can be caused by the weakening of the rotator cuff tendons This weakening can be caused by age or how often the rotator cuff is used Adults over the age of 60 are more susceptible to a rotator cuff tear According to a study in the Journal of Orthopaedic Surgery and Traumatology the frequency of rotator cuff tears can increase with age The study shows the participants that were the ages of 70–90 years old had a rate of rotator cuff tears that were 1 to 5 The participants who were 90+ years old the frequency of a rotator cuff tear jumped to 1 to 3 This study shows that with an increase in age there is also an increase in the probability of a rotator cuff tear59

Prevalenceedit

Prevalence of Rotator Cuff Tears

According to a study in the Journal of Orthopaedics the prevalence of a rotator cuff tear was considerably greater in males than in females within the ages of 50–60 years old, within the ages of 70–80 years old there wasn’t much difference in prevalence The data of this study showed that the prevalence of a rotator cuff tear in the general population is 221% 60 Yamamoto et al performed a medical examination on 683 people whom live in a mountain village The purpose of this study was to determine the prevalence of a rotator cuff tear among a population Yamamoto found that among the mountain village population, rotator cuff tears were present in 207% of the village population In both of these studies we see that the percentages of the prevalence of a rotator cuff tear are very close in number so these numbers show us the prevalence of rotator cuff tears in the general population59

In an autopsy study of rotator cuff tears, the incidence of partial tears was 28%, and of complete rupture 30% Frequently, tears occurred on both sides and the frequency increased with age The frequency was also higher in females61 Other cadaver studies have noted intratendinous tears to be more frequent 72% than bursal-sided 24% or articular-sided tears 36%62 However, clinically, articular-sided tears are found to be 2 to 3 times more common than bursal-sided tears and among a population of young athletes, articular-sided tears constituted 91% of all partial-thickness tears62

Complicationsedit

Patients usually regain function in their shoulders, and experience less pain, following surgery For some, however, the joint continues to hurt Weakness and a limited range of motion also may persist Those who report such symptoms frequently are diagnosed with failed rotator cuff syndrome

According to an article published by the American Academy of Orthopaedic Surgeons, arthroscopic procedures produce "satisfactory results" more than 90 percent of the time Dr Eric J Strauss and the other authors 56 wrote that 6-8 percent of patients have "incompetent" rotator cuffs, because their repaired tendons either fail to heal or develop additional tears In some cases, the symptoms are due to cervical spine disease, featuring neck pain that radiates into the shoulder; suprascapular neuropathy, a nerve disorder; subacromial impingement, common in athletes and others who make repetitive overhead movements; or arthritis Superior labral anterior-posterior lesions produce pain similar to that of rotator cuff tears

Those most prone to failed rotator cuff syndrome are patients 65 years of age or older; and those with large, sustained tears Smokers, diabetes sufferers, patients with muscle atrophy and/or fatty infiltration, and those who do not follow postoperative-care recommendations also are at greater risk

Doctors examine patients and conduct imaging tests to identify the causes of continued discomfort Depending upon the diagnosis, several treatment alternatives are available They include revision repair, nonanatomic repair, tendon transfer and arthroplasty When possible, surgeons make tension-free repairs in which they use grafted tissues rather than stitching to reconnect tendon segments This can result in a complete repair Other options are a partial repair, and reconstruction involving a bridge of biologic or synthetic substances Partial repairs typically are performed on patients with retracted cuff tears

Two methods of promoting rotator cuff healing are injecting patients' own stem cells or other growth factors into the site of the repair, and installing scaffolds natural or artificial supports that maintain tissue contour The results of using PRP platelet rich plasma to augment the healing of rotator cuff repair at the time of surgery, although intellectually interesting, does not seem to demonstrate a statistically significant clinical difference Biceps tenotomy and tendonesis are treatment alternatives for patients with rotator cuff tears as well as bicep tendon lesions Tendonesis, which may be performed as an arthroscopic or open procedure, generally restores strength and function Tenotomy is a shorter surgery, requiring less rehabilitation, that doctors tend to recommended for older patients

Tendon transfers are prescribed for young, active cuff-tear patients who experience weakness and decreased range of motion, but little pain The technique is not considered appropriate for older people, or those with pre-operative stiffness or nerve injuries People diagnosed with glenohumeral arthritis and rotator cuff anthropathy often undergo hemiarthroplasty, which entails replacement of the humerus portion of the shoulder joint Elderly patients with recurring cuff tears and degenerative glenohumeral arthritis sometimes receive total shoulder arthroplasty replacement Another surgery, reverse total shoulder arthroplasty, is effective for others

Referencesedit

  1. ^ "Rotator cuff injury Definition - Diseases and Conditions" Mayo Clinic 2014-02-19 Retrieved 2014-08-03 
  2. ^ a b Williams GR, Rockwood CA, Bigliani LU, Iannotti JP, Stanwood W December 2004 "Rotator cuff tears: why do we repair them" The Journal of Bone and Joint Surgery American Volume 86–A 12: 2764–76 PMID 15590865 
  3. ^ a b Saladin, Kenneth S "Anatomy & Physiology" McGraw Hill, nd Web 04 Oct 2016
  4. ^ a b "Your Orthopaedic Connection: Rotator Cuff Tears and Treatment Options" 
  5. ^ Harris JD, Pedroza A, Jones GL, The MOON Multicenter Orthopedic Outcomes Network Shoulder Group Nov 2011 "Predictors of Pain and Function in Patients With Symptomatic, Atraumatic Full-Thickness Rotator Cuff Tears: A Time-Zero Analysis of a Prospective Patient Cohort Enrolled in a Structured Physical Therapy Program" Am J Sports Med 40 2: 359–66 PMC 3632074  PMID 22095706 doi:101177/0363546511426003 CS1 maint: Multiple names: authors list link
  6. ^ Factor D, Dale B Apr 2014 "CURRENT CONCEPTS OF ROTATOR CUFF TENDINOPATHY" Int J Sports Phys Ther 9 2: 274–88 PMC 4004132  PMID 24790788 
  7. ^ Sliverstein B; Welp E; Nelson N; Kalat J 1998 "Claims incidence of work-related disorders of upper extremities: Washington state 1987-1995" American Journal of Public Health 88 12: 1827–1833 PMC 1509055  PMID 9842381 doi:102105/ajph88121827 
  8. ^ Teunis, Teun; Lubberts, Bart; Reilly, Brian T; Ring, David December 2014 "A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age" Journal of Shoulder and Elbow Surgery 23 12: 1913–1921 ISSN 1532-6500 PMID 25441568 doi:101016/jjse201408001 
  9. ^ Mohamadi, Amin; Chan, Jimmy J; Claessen, Femke M A P; Ring, David; Chen, Neal C January 2017 "Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis" Clinical Orthopaedics and Related Research 475 1: 232–243 ISSN 1528-1132 PMC 5174041  PMID 27469590 doi:101007/s11999-016-5002-1 
  10. ^ Dean, Benjamin John Floyd; Lostis, Emilie; Oakley, Thomas; Rombach, Ines; Morrey, Mark E; Carr, Andrew J February 2014 "The risks and benefits of glucocorticoid treatment for tendinopathy: a systematic review of the effects of local glucocorticoid on tendon" Seminars in Arthritis and Rheumatism 43 4: 570–576 ISSN 1532-866X PMID 24074644 doi:101016/jsemarthrit201308006 
  11. ^ a b Via AG, Cupis MD, Spoliti M, Oliva F Apr–Jun 2013 "Clinical and biological aspects of rotator cuff tears" Muscles Ligaments Tendons J 3 2: 70–9 PMC 3711705  PMID 23888289 doi:1011138/mltj/201332070 
  12. ^ "Rotator Cuff Tears-OrthoInfo - AAOS" Orthoinfoaaosorg 2011-05-01 Retrieved 2014-08-03 
  13. ^ "Mechanisms-Rotator Cuff" Biomedbrownedu 2004-02-05 Retrieved 2014-08-03 
  14. ^ a b c d e f g h i Nho SJ, Yadav H, Shindle MK, Macgillivray JD May 2008 "Rotator cuff degeneration: etiology and pathogenesis" Am J Sports Med 36 5: 987–93 PMID 18413681 doi:101177/0363546508317344 
  15. ^ Neer CS 2nd, Craig EV, Fukuda H Dec 1983 "Cuff-tear arthropathy" J Bone Joint Surg Am 65 9: 1232–44 PMID 6654936 CS1 maint: Multiple names: authors list link
  16. ^ a b Wolf BR, Dunn WR, Wright RW June 2007 "Indications for repair of full-thickness rotator cuff tears" Am J Sports Med 35 6: 1007–16 PMID 17337723 doi:101177/0363546506295079 
  17. ^ Marreez, YM; Forman, MD; Brown, SR May 2013 "Physical examination of the shoulder joint-Part I: Supraspinatus rotator cuff muscle clinical testing" Osteopathic Family Physician 5 3: 128–134 doi:101016/josfp201301005 
  18. ^ Arend CF Ultrasound of the Shoulder Master Medical Books, 2013 Free chapter on ultrasound evaluation of rotator cuff disorders available at ShoulderUScom
  19. ^ "Rotator Cuff Tears and Injuries" Webmdcom Retrieved 2014-08-03 
  20. ^ a b "Rotator Cuff Disease Symptoms, Causes, Treatment - What are symptoms of rotator cuff disease" MedicineNet 2012-09-14 Retrieved 2014-08-03 
  21. ^ a b Gückel C, Nidecker A November 1997 "Diagnosis of tears in rotator-cuff-injuries" Eur J Radiol 25 3: 168–76 PMID 9430826 doi:101016/s0720-048x9701171-6 
  22. ^ Sox, Harold C 1988 Medical decision making Boston: Butterworths ISBN 0-409-90091-5 page needed
  23. ^ Bernstein J 1 September 1997 "Decision analysis" The Journal of Bone and Joint Surgery American Volume 79 9: 1404–14 PMID 9314406 
  24. ^ a b c d "Rotator Cuff Tears-OrthoInfo - AAOS" Orthoinfoaaosorg 2011-05-01 Retrieved 2014-08-03 
  25. ^ a b August 2, 2014 2014-03-27 "Rotator Cuff Injury: Click for Surgery Info and Healing Time" Emedicinehealthcom Retrieved 2014-08-03 
  26. ^ McFarland EG, Selhi HS, Keyurapan E 1 February 2006 "Clinical evaluation of impingement: what to do and what works" The Journal of Bone and Joint Surgery American Volume 88 2: 432–41 PMID 16475277 
  27. ^ a b c Park HB, Yokota A, Gill HS, El Rassi G, McFarland EG July 2005 "Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome" The Journal of Bone and Joint Surgery 87 7: 1446–55 PMID 15995110 doi:102106/JBJSD02335 
  28. ^ Jacobson JA Sep 2009 "Musculoskeletal ultrasound: focused impact on MRI" Am J Roentgenol 193 3: 619–27 PMID 19696273 doi:102214/AJR092841 
  29. ^ Lenza M1, Buchbinder R, Takwoingi Y, Johnston RV, Hanchard NC, Faloppa F Sep 24, 2013 "Magnetic resonance imaging, magnetic resonance arthrography and ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered" Cochrane Database Syst Rev 9 doi:101002/14651858CD009020pub2 CS1 maint: Multiple names: authors list link
  30. ^ a b c Stetson WB, Phillips T, Deutsch A 2005 "The use of magnetic resonance arthrography to detect partial-thickness rotator cuff tears" The Journal of Bone and Joint Surgery American Volume 87 Suppl 2 suppl_2: 81–8 PMID 16326727 doi:102106/JBJSE00509 
  31. ^ Teefey SA, Rubin DA, Middleton WD, Hildebolt CF, Leibold RA, Yamaguchi K April 2004 "Detection and quantification of rotator cuff tears Comparison of ultrasonographic, magnetic resonance imaging, and arthroscopic findings in seventy-one consecutive cases" The Journal of Bone and Joint Surgery American Volume 86–A 4: 708–16 PMID 15069134 
  32. ^ a b Moosikasuwan JB, Miller TT, Burke BJ 2005 "Rotator cuff tears: clinical, radiographic, and US findings" Radiographics 25 6: 1591–607 PMID 16284137 doi:101148/rg256045203 
  33. ^ Keener, Jay D; Wei, Anthony S; Kim, H Mike; Steger-May, Karen; Yamaguchi, Ken 2009 "Proximal Humeral Migration in Shoulders with Symptomatic and Asymptomatic Rotator Cuff Tears" The Journal of Bone and Joint Surgery-American Volume 91 6: 1405–1413 ISSN 0021-9355 doi:102106/JBJSH00854 
  34. ^ Kim, Kyung Cheon, Hyun Dae Shin, Bo Kun Kim, Soo Min Cha, and Jun Yeong Park "Changes in Tendon Length with Increasing Rotator Cuff Tear Size" Knee Surgery, Sports Traumatology, Arthroscopy 206 2012: 1022-026 Print
  35. ^ Howe, C, P Huber, F M Wolf, and F Matsen "Differential Suture Loading in an Experimental Rotator Cuff Repair" The American Journal of Sports Medicine 372 2009: 324-29 Print
  36. ^ Zumstein, Matthias A, Eric Frey, Brigitte Von Rechenberg, Robert Frigg, Christian Gerber, and Dominik C Meyer "Device for Lengthening of a Musculotendinous Unit by Direct Continuous Traction in the Sheep" BMC Veterinary Research 81 2012: 50 Print
  37. ^ Andarawis-Puri, N, E T Ricchetti, and L J Soslowsky "Interaction Between the Supraspinatus and Infraspinatus Tendons: Effect of Anterior Supraspinatus Tendon Full-Thickness Tears on Infraspinatus Tendon Strain" The American Journal of Sports Medicine 379 2009: 1831-839 Print
  38. ^ "Rotator Cuff Tears" American Academy of Orthopaedic Surgeons There is no evidence of better results from surgery performed near the time of injury versus later on For this reason, many doctors first recommend nonsurgical management of rotator cuff tears 
  39. ^ Tashjian RZ October 2012 "Epidemiology, natural history, and indications for treatment of rotator cuff tears" Clin Sports Med 31 4: 589–604 PMID 23040548 doi:101016/jcsm201207001 
  40. ^ "Shoulder Rotator Cuff Surgery Research Review: Does Surgery work Better than No Surgery" Centeno-Schultz Clinic You might think that with about 40,000 shoulder rotator cuff tear repair surgeries performed in the United States each year, that there was solid medical evidence supporting that this type of shoulder surgery was effective However, a recent published review by Agency for Healthcare Research and Quality looked at more than 150 published papers and concluded that there was no solid evidence that rotator cuff surgery benefited patients more than no surgery 
  41. ^ a b Jennifer C Seida, MPH; Claire LeBlanc, MD; Janine R Schouten, BSc; Shima S Mousavi, MD; Lisa Hartling, PhD; Ben Vandermeer, MSc; Lisa Tjosvold, MLIS; and David M Sheps, MD, MSc 2010-08-17 "Systematic Review: Nonoperative and Operative Treatments for Rotator Cuff Tears" Annals of Internal Medicine 153 4: 246–55 PMID 20621893 doi:107326/0003-4819-153-4-201008170-00263 CS1 maint: Uses authors parameter link
  42. ^ Comparative Effectiveness of Nonoperative and Operative Treatments for Rotator Cuff Tears: Executive Summary Rockville, Md: Agency for Healthcare Research and Quality, 2010
  43. ^ a b c d e f g h i j Mantone J K; Burkhead W Z; Noonan J Jr 2000 "Nonoperative Treatment of Rotator Cuff Tears" Orthopedic Clinics of North America 31 2: 295–311 PMID 10736398 doi:101016/s0030-58980570149-8 
  44. ^ Rockwood C A Jr; Wirth M A; Basamania C 1997 "Nonoperative Management of Full-Thickness Tears of the Rotator Cuff" Orthopedic Clinics of North America 28: 1 doi:101016/s0030-58980570264-9 
  45. ^ Williams, GR Jr; Kraeutler, MJ; Zmistowski, B; Fenlin, JM Jr September 2014 "No difference in postoperative pain after arthroscopic versus open rotator cuff repair" Clin Orthop Relat Res 472 9: 2759–65 PMC 4117892  PMID 24912870 doi:101007/s11999-014-3715-6 
  46. ^ Baydar M; Akalin E; El O; et al April 2009 "The efficacy of conservative treatment in patients with full-thickness rotator cuff tears" Rheumatology International 29 6: 623–8 PMID 18850322 doi:101007/s00296-008-0733-2 
  47. ^ Zumstein MA, Jost B, Hempel J, Hodler J, Gerber C November 2008 "The clinical and structural long-term results of open repair of massive tears of the rotator cuff" The Journal of Bone and Joint Surgery American Volume 90 11: 2423–31 PMID 18978411 doi:102106/JBJSG00677 
  48. ^ Shen PH, Lien SB, Shen HC, Lee CH, Wu SS, Lin LC 2008 "Long-term functional outcomes after repair of rotator cuff tears correlated with atrophy of the supraspinatus muscles on magnetic resonance images" Journal of Shoulder and Elbow Surgery 17 1 Suppl: 1S–7S PMID 17931908 doi:101016/jjse200704014 
  49. ^ Matsen, Frederick A; Winston J Warme 19 August 2008 "Repair of Rotator Cuff Tears: Surgery for shoulders with torn rotator cuff tendons can lessen shoulder pain and improve function without acromioplasty" University of Washington School of Medicine Retrieved 5 July 2009 
  50. ^ "Rotator cuff injury Definition - Diseases and Conditions" Mayo Clinic 2014-02-19 Retrieved 2014-08-03 
  51. ^ Norberg FB, Field LD, Savoie FH 2000 "Repair of the rotator cuff Mini-open and arthroscopic repairs" Clinics in sports medicine 19 1: 77–99 PMID 10652666 doi:101016/s0278-59190570297-0 
  52. ^ a b Lyons P; Orwin J 1998 "Rotator cuff tendinopathy and subacromial impingement syndrome" Medicine & Science in Sports & Exercise 30 4: 12–17 doi:101097/00005768-199804001-00003 
  53. ^ "Rotator cuff repair" MedlinePlus Retrieved 2009-09-29 
  54. ^ "Rotator Cuff Tears: Surgical Treatment Options" orthoinfoaaosorg 2012 Retrieved May 3, 2012 
  55. ^ Takeda Y; et al 2002 "The most effective exercise for strengthening the supraspinatus muscle evaluation by magnetic resonance imaging" The American journal of sports medicine 30 3: 374–381 CS1 maint: Explicit use of et al link
  56. ^ a b c Strauss; et al 2012 "Management of Failed Arthroscopic Rotator Cuff Repair" JAAOS 20 5: 301–309 doi:105435/jaaos-20-05-301 
  57. ^ Tempelhof S, Rupp S, Seil R 1999 "Age-related prevalence of rotator cuff tears in asymptomatic shoulders" Journal of Shoulder and Elbow Surgery 8 4: 296–9 PMID 10471998 doi:101016/S1058-27469990148-9 
  58. ^ Chung SW, Huong CB, Kim SH, Oh JH February 2013 "Shoulder stiffness after rotator cuff repair: risk factors and influence on outcome" Arthroscopy 29 2: 290–300 PMID 23290184 doi:101016/jarthro201208023 
  59. ^ a b Yamamoto A, Takagishi K, Osawa T; et al 2010 "Prevalence and risk factors of a rotator cuff tear in the general population" J Shoulder Elbow Surg 19: 116–120 CS1 maint: Explicit use of et al linkCS1 maint: Multiple names: authors list link
  60. ^ Minagawa H, Yamamoto N, Abe H 2013 "Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: From mass-screening in one village" Journal of Orthopaedic 10 1: 8–12 doi:101016/jjor201301008 
  61. ^ Jerosch J, Müller T, Castro W 1991 "The incidence of rotator cuff rupture An anatomic study" Acta Orthop Belg 57 2: 124–9 PMID 1872155 
  62. ^ a b Matava M J; Purcell D B; Rudzki J R 2005 "Partial-Thickness Rotator Cuff Tears" Am J Sports Med 33 9: 1405–1417 PMID 16127127 doi:101177/0363546505280213 
  • This article contains text from the public domain document "Questions and Answers about Shoulder Problems", NIH Publication No 01-4865, available from URL http://wwwniamsnihgov/hi/topics/shoulderprobs/shoulderqahtm

External linksedit

  • Rotator Cuff Arend CF Ultrasound of the Shoulder Master Medical Books, 2013
  • Rotator Cuff Tears Wheeless' Textbook of Orthopedics A description of rotator cuff tears from Wheeless'
  • Partial tears of the rotator cuff Albrecht J Partial tears of the rotator cuff - What to do
  • Prevention of rotator cuff disorders - WebMD
  • Prevention of rotator cuff injury - Mayo Clinic

rotator cuff tear, rotator cuff tear arthropathy, rotator cuff tear exercises, rotator cuff tear icd 10, rotator cuff tear mri images, rotator cuff tear pictures, rotator cuff tear surgery, rotator cuff tear symptoms, rotator cuff tear test, rotator cuff tear treatment


Rotator cuff tear Information about

Rotator cuff tear


  • user icon

    Rotator cuff tear beatiful post thanks!

    29.10.2014


Rotator cuff tear
Rotator cuff tear
Rotator cuff tear viewing the topic.
Rotator cuff tear what, Rotator cuff tear who, Rotator cuff tear explanation

There are excerpts from wikipedia on this article and video

Random Posts

Modern philosophy

Modern philosophy

Modern philosophy is a branch of philosophy that originated in Western Europe in the 17th century, a...
Tim Shadbolt

Tim Shadbolt

Timothy Richard "Tim" Shadbolt born 19 February 1947 is a New Zealand politician He is the Mayor of ...
HK Express

HK Express

Andrew Cowen Deputy CEO Website wwwhkexpresscom HK Express Traditional Chinese 香港快運航空...
List of shrinking cities in the United States

List of shrinking cities in the United States

The following municipalities in the United States have lost at least 20% of their population, from a...