Traumatic Tendon Problems of the Shoulder

Essentials

• Distinguish between acute shoulder symptoms starting after a strain, wrench or fall and symptoms starting without prior trauma Non-Traumatic Tendon Problems of the Shoulder.
• Exclude bone injury by taking a plain x-ray.
• Refer patients with clinical findings suggestive of significant rotator cuff rupture (affecting shoulder function) and with normal x-ray findings to specialized care at an early stage.

Prevalence and incidence

• Asymptomatic rotator cuff ruptures are very common Non-Traumatic Tendon Problems of the Shoulder.
• Patients seeking treatment for shoulder injury who cannot lift their upper arm normally but are not found to have any bone injury relatively often have rotator cuff rupture 3 4.
  • Rotator cuff ruptures are rare in people below the age of 40 but in the above circumstances as many as 50% of people over 50 are found to have a rupture.
  • The annual incidence of rotator cuff ruptures following trauma is estimated at 23-25/100 000 in people aged 40-75 years 3.
• It is difficult to distinguish between genuine traumatic ruptures and degenerative ruptures by imaging.
  • A rupture seen in MRI after a traumatic event may represent
    • an old rotator cuff rupture that has previously been asymptomatic
    • a genuine fresh rupture or
    • a rupture that has become more extensive due to the trauma.
  • Most degenerative ruptures occur in the area of the supraspinatus tendon.

Symptoms

• Symptoms begin suddenly after a traumatic event.
• Pain is often the predominant symptom but in significant rotator cuff rupture, there is also shoulder dysfunction.
• Typically, normal muscle strength is momentarily lost (pseudoparesis or pseudoparalysis) immediately after shoulder injury. The range of motion tested immediately after trauma may be restricted and muscle strength affected even in the absence of tissue injury.
  • If there is no structural injury, muscle paresis should resolve within 1-2 weeks.
• Shoulder pain after trauma is a highly unspecific symptom (may be due to bruising or strain themselves) and it has not been shown to be correlated with the extent of rotator cuff rupture, for instance.
  • But a rotator cuff tear typically causes pain, nocturnal aching and a feeling of weakness in the shoulder area.

Workup

Treatment and criteria for referral

• Symptomatic treatment should be provided immediately after the trauma.
  • Cold bag, analgesics and encouragement to use the upper limb normally as far as the pain allows
• If there is weakness of external rotation or of the subscapular muscle, refer the patient to an orthopaedist.
  • If no weakness can be detected at first but pain continues and raising of the upper arm may not be normal, the patient should be re-examined in 3-4 weeks.
• If pain continues for more than 4 weeks from the trauma but the rotational strength is good, consider the possibility of capsulitis / frozen shoulder, in particular Frozen Shoulder. If there is nothing suggestive of this, refer the patient to an orthopaedist.
• Record in the referral any willingness of the patient to have surgery.
  • Shoulder surgery requires good cooperation and good commitment to treatment after surgery.
• Do not hesitate to refer the patient to a physiotherapist to mobilize the shoulder.
• If clear changes due to osteoarthritis or cuff arthropathy can be seen on x-ray (pictures 4 5), treatment is mainly conservative Non-Traumatic Tendon Problems of the Shoulder. If no clear improvement can be seen in (6-)12 months, refer the patient to an orthopaedist for assessment for endoprosthetic surgery.