Rotator Cuff History and Physical Exam

Symptoms and Pain Location and Character

With this foundation of understanding, the clinician proceeds with eliciting the history of present illness beginning with the location and character of pain and symptoms. The classically described location of rotator cuff pain is the anterolateral shoulder. Often, patients describe the pain as radiating down the humerus. Rotator cuff pain is also often experienced within the distribution of the subacromial space, which patients may outline with their palm when describing the location of the pain. Although the character of the pain is commonly described as aching, it may be phrased in many different ways. Two studies have attempted to characterize the nature and location of pain in rotator cuffs. Itoi et al. asked patients to localize their pain to six regions around the shoulder: anterior, lateral, posterior, superior, central, and distal. They found that shoulders with rotator cuff tears most commonly had anterior and lateral shoulder pain. Motion-related pain in the setting of rotator cuff tear was most often reported anteriorly and laterally whereas night pain associated with rotator cuff tear was most often anterior or central. Similarly, a study of 287 patients with operatively treated posterolateral cuff tears uniformly reported pain localized to the anterolateral shoulder in a C5 distribution without pain beyond the elbow. In this study, women with rotator cuff tears experienced significantly more pain and all patients with massive cuff tears had less intense but more geographically diffuse pain.

Night pain is a very typical and common symptom, with patients report aching lateral shoulder pain often worsening at night, resulting in disturbed or wakeful sleep secondary to pain or discomfort with sleeping on the symptomatic limb. Of a cohort of patients reported by van Kampen et al., 83% experienced night pain, with weakness being reported in addition in 41% of patients. Similarly, in a report on 54 patients with rotator cuff tear, Walch et al. report the most common presenting symptoms as night pain, disturbed sleep, and an inability to sleep on the affected side, with greater than 55% reporting loss of strength or rapid onset of fatigue. Another report by Nakajima et al. demonstrated similar symptoms, as patients with rotator cuff tears were significantly more likely to have difficulty sleeping and have difficulty lifting 3.6 kg to shoulder level.

Although patients may present classically as described earlier, rotator cuff disease does not always present in isolation. For this exact reason, it remains important to understand the location of each patient’s pain as localization to the anterior, superior, or posterior shoulder may point to other or additional pathology of the biceps tendon, acromioclavicular joint, or cervical spine, respectively, and will require more detailed examination and history. For instance, a history of any associated neck pain or pain radiating below the elbow should always be elicited, as this is a strong indicator of primary or concomitant cervical pathology. Similarly, patients should always be questioned regarding numbness or tingling or hand function, because although these can result from shoulder pathology, they more frequently result from cervical pathology and distal compressive neuropathies. These common conditions can also be present in the setting of symptomatic cuff pathology.

In completing the patient’s discussion of pain and symptoms, it is important to ascertain what activities or conditions exacerbate their pain and symptoms. Patients with rotator cuff pathology most frequently have pain exacerbated by raising the arm into abduction with a painful arc from approximately 30 to 120 degrees of abduction in the scapular plane. Activities of daily living that commonly exacerbate patient’s pain include reaching for objects at or above shoulder level, such as a cup in a cupboard, or reaching for something behind them such as an object in the back seat of a car.

History of Trauma

Determining the exact onset of shoulder pain and the exact duration of symptoms is also immensely helpful. Any notable “pop” or bruising about the shoulder can be suggestive of a long head biceps tendon rupture. Patients presenting with this history should be examined for development of asymmetry and questioned regarding cramping or weakness. A strong correlation exists between a history of a trauma and rotator cuff tears. For this reason, it is important to question the patient regarding a history of falls, fracture, and/or dislocations. It is also useful to inquire as to the presence of symptoms prior to the trauma and how they differ from their current presenting symptoms. In this regard, both small and large studies have demonstrated the relationship of trauma and rotator cuff tears. Of patients with a history of shoulder trauma without radiographic evidence of fracture or dislocation presenting to a European Emergency Department, 32% were persistently painful at a 1-year telephone follow-up, and 34% of those with persistent pain were found to have a rotator cuff tear on follow-up exam accounting for 9% of the initial population. In a larger study by Robinson et al., 34% of 3633 patients with a traumatic anterior shoulder dislocation were diagnosed with either a rotator cuff tear or greater tuberosity fracture. Female patients older than 60 were found to have the highest rate of rotator cuff tear. The magnitude of the correlation between antecedent trauma and rotator cuff tears has also been shown to increase with increasing age. In a study by Sorensen et al., 58% of patients presenting for clinical and ultrasound exam after soft tissue injury to the shoulder were diagnosed with a rotator cuff tear. Importantly, the prevalence of both partial- and full-thickness tears was greater than 50% in those older than 50, and the prevalence of full-thickness tears alone was 50% in both groups of patients aged 50–59 and 60–69 years.

Chronicity and Duration of Symptoms

The clinician must establish the duration and chronicity of symptoms. Multiple studies on the natural history of symptomatic rotator cuff tears treated nonoperatively have shown evidence of rotator cuff tear progression with time. For instance, an investigation by Safran et al. highlights the importance of both the intensity and chronicity of symptoms. Fifty-one patients under the age of 60 with symptomatic full-thickness rotator cuff tears less than 5 mm in size were treated nonoperatively and followed clinically with exam and ultrasound. After a mean follow-up of 29 months, 49% of tears had progressed on ultrasound. In this instance, there was a significant relationship between new or increasing pain leading up to the time of tear progression in these patients, whereas patients without progression remained with stable symptoms. This is also true of those with asymptomatic tears. Mall et al. followed a cohort of 195 patients with asymptomatic rotator cuff tears for 2 years with clinical exam and ultrasound. Throughout this time period, 44 patients developed new pain. Of patients with new-onset pain, 40% progressed from a partial-thickness to a full-thickness tear, and 18% of full-thickness tears increased by greater than 5 mm. This was significantly greater than the progression seen in a comparative group of 55 patients who remained pain-free. These findings are corroborated by Maman et al., who showed increasing rates of cuff tear progression with the length of follow-up in symptomatic cuff tears. Patients followed for greater than 18 months had a 48% rate of progression. This risk of progression was shown to be higher with increasing age, as 54% of patients greater than 60 years of age progressed compared with only 17% of younger patients. The risk for tear progression with time has also been linked to tear size. Keener et al. prospectively evaluated a cohort of 218 patients for 5 years. Over the duration of follow-up, 48% of shoulders had tear progression at a median follow-up time of 2.8 years. Tear progression correlated with tear size with 66% of full-thickness tears progressing, compared with 44% of partial-thickness tears and 18% of controls. They also again noted an important relationship between new-onset pain and tear progression with new pain developing in 50% of full-thickness tears, 48% of partial-thickness tears, and 28% of controls. Understanding tear progression as a function of time and changing symptomatology informs discussion of treatment outcomes. There is an additional body of evidence highlighting the relationship of long follow-up duration increasing cuff atrophy, fatty infiltration, and retraction. Most notably, a small series evaluating nonoperative management of minimally symptomatic massive repairable cuff tears by Zingg et al. demonstrated that 50% of these tears had become irreparable at 4 years of follow-up. Thus, symptom duration, understood within the spectrum of cuff disease, may directly relate to treatment options.

Age

Age truly is a very important factor to consider with patients on initial evaluation. Advanced age has been linked specifically to poor rotator cuff healing. Furthermore, with advancing age, patients develop more comorbid conditions that need to be considered and managed in the perioperative period. Rotator cuff pathology increases with age. The landmark study by Yamaguchi et al. performed ultrasound examinations on 588 patients presenting for unilateral shoulder pain. They demonstrated an increasing prevalence of rotator cuff tears with increasing age. The average age of patients with bilateral cuff tears was 67.8 years, unilateral cuff tears 58.7 years, and no cuff tearing 48.7 years. Similarly, postmenopausal women have been shown to have a near threefold higher prevalence of asymptomatic rotator cuff tears (8.9%) than premenopausal women (3.1%). Thus age can be a critical clue that the rotator cuff may be the source of a patient’s pain. However, because rotator cuff pathology becomes so common with advancing age, it can mislead the surgeon from cervical radicular pain and other pathologies that may be the actual source of a patient’s complaints.

Sex, Hand Dominance, and Occupation

Sex, hand dominance, and occupation have also been linked to rotator cuff disease. Conflicting evidence exists for correlations with sex. A study by Castoldi et al. evaluating the diagnostic accuracy of external rotation signs found a higher rate of symptomatic rotator cuff tears in female patients. In direct contrast, a study of a Japanese mountain population by Yamamoto et al. showed a higher prevalence in men (40.3% vs. 31.6%). This same study also demonstrated a higher rate of rotator cuff tears in the dominant arm and in those who are heavy laborers compared with those who only perform light labor. This relationship with heavy labor and rotator cuff disease has long been suggested. An investigation by Seidler et al. demonstrated a dose-dependent relationship between cumulative overhead work and symptomatic supraspinatus tears. They also demonstrated an independent dose-response relationship between carrying heavy loads and rotator cuff tears. Finally, they were able to show an association of vibration-type labor (e.g., jackhammer and heavy machinery) with cuff tears but were unable to demonstrate a dose-dependent effect of this type of labor. Certainly, these associations suggest a “wear and tear” aspect to rotator cuff tear etiology.

Smoking

Baumgarten et al. showed a dose- and time-dependent relationship between smoking and rotator cuff tears in patients evaluated with ultrasound for unilateral atraumatic shoulder pain. Similarly, Carbone et al. noted a significantly larger proportion of patients with intraoperatively graded type II (Southern California Orthopaedic Institute [SCOI] classification) or greater rotator cuff tears to have a positive preoperative smoking history. Meanwhile, other studies have noted the harmful effects of smoking on rotator cuff healing and vascularity. Lundgreen et al. performed histologic evaluation of torn rotator cuffs treated operatively and showed increased apoptotic cell density, decreased tenocyte number, increased proliferative changes, and longer symptom duration. Bishop et al. performed a systematic review of 13 studies with more than 16,172 patients and more than 6081 smokers. They concluded that smokers were more likely to report shoulder pain and dysfunction and were far more likely to suffer from impingement symptoms. Rotator cuff disease was found to be associated with a history of smoking. Furthermore, they noted a positive correlation between rotator cuff disease severity and smoking history.

Obesity

Obesity, not unlike smoking, is also not without its negative health effects. A growing body of orthopedic literature across all subspecialty areas highlights these negative effects. There is a growing body of literature linking obesity to higher rates of cuff tears and shoulder surgery. Wendelboe et al., in a case-control study, demonstrated that men and women with body mass index (BMI) >30 were significantly more likely to have surgery for rotator cuff pathology. The highest odds ratios were in those men and women with BMI >35, with odds ratios to have shoulder surgery of 3.1 and 3.5, respectively, compared with normal weight controls. A case-control study by Gumina et al. demonstrated similar results, with patients with BMI >30 having higher odds ratios for the presence of a rotator cuff tear. There was also a statistically significant relationship between increasing BMI and body fat percentage with rotator cuff tear severity. It remains unknown whether obesity results in high arm weight and more strain on the cuff or whether obesity has direct metabolic effects on the rotator cuff.

Diabetes and Hyperlipidemia

Although perhaps multifactorial, there is also strong evidence that diabetes and hyperlipidemia are strongly correlated with rotator cuff disease. A study by Lin et al. evaluated the hazard ratio for developing rotator cuff disease in nearly 500,000 people in a large Taiwanese population study. They showed an increased hazard ratio of developing rotator cuff disease in the presence of diabetes with or without insulin treatment. They also demonstrated an increased hazard ratio for developing rotator cuff disease with hyperlipidemia with or without the use of statins. The study did demonstrate that, although still elevated from the normal population, statin treatment did significantly lower the risk of developing rotator cuff disease among those with hyperlipidemia. In a similar study, Jeong et al. demonstrated a higher prevalence of full-thickness rotator cuff tears in both smokers and diabetics. It is important to also ensure that patients have adequate glucose control given the growing body of literature suggesting the increased risk for operative complications in the setting of an elevated hemoglobin A1c. Multiple studies have suggested diabetes as a risk factor for failure after rotator cuff repair. In a basic science animal study, Bedi et al. demonstrated impaired healing of a rat rotator cuff model in a group of diabetic mice with a hemoglobin A1c of 10.7 compared with 6 in the normal mouse group. Certainly this suggests a metabolic aspect to the etiology of rotator cuff tears.

Family History

Much research has been done regarding the genetics and familial predilection of rotator cuff disease. Dabija et al. performed a systematic review of seven studies. They identified four studies examining the existence of a familial predisposition to rotator cuff disease and three studies analyzing the genetics of rotator cuff disease. They concluded that siblings of patients with rotator cuff tears were more likely to develop symptomatic, progressive full-thickness cuff tears. The work of Tashjian et al. was also included in their review. Tashjian et al. analyzed a large population database of 3091 patients with a diagnosis of rotator cuff disease specifically looking to discover a link between family history and rotator cuff disease. In analyzing a subcohort of 652 patients diagnosed with rotator cuff disease before 40 years of age, they found first-, second-, and third-degree relatives to be at a significantly higher risk of developing rotator cuff disease. These data are suggestive of a genetic etiology to rotator cuff tears.

Previous Therapies

It is also paramount to document all treatments patients have undergone to date, and the clinical response to these treatments. Typical treatments include activity modification, physical therapy, narcotics, antiinflammatories, corticosteroid injections, and prior surgeries. These certainly guide treatment going forward, although they may not be particularly helpful in diagnosis.