© copyright annals of internal medicine, 2015 ann int med. 162 (1): itc1-1. * for best viewing:...

© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (1): ITC1-1.

* For Best Viewing:

Open in Slide Show Mode Click on icon or

From the View menu, select the Slide Show option

* To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide


Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets constitutes copyright infringement.


in the clinic

Rotator Cuff Disease


Rotator cuff

Supraspinatus, infraspinatus, subscapularis, and teres minor muscles

Envelop shoulder joint, facilitate movement & dynamic stabilization throughout its large range of motion

“Rotator cuff disease” = umbrella term

Includes RC tendinopathy or tendinitis; tears of the cuff muscles, impingement syndrome, calcific tendinitis, and subacromial bursitis

Calcific tendinitis: uncommon form of RC disease

Excludes adhesive capsulitis, other disorders of glenohumeral joint


What are the risk factors for rotator cuff disease?

Increasing age

Obesity

Smoking

Diabetes mellitus

Genetics

Various anatomical factors

Occupational and sporting activities

Sports with frequent overhead activity (throwing)

Orchestral musicians


Are there measures that can prevent rotator cuff disease or its recurrence?

Interventions that reduce excessive overhead activity

Interventions that reduce loading of the shoulder in the abducted position

Exercises that improve flexibility and strengthen muscles


CLINICAL BOTTOM LINE: Prevention...

Most common cause of shoulder pain in primary care Prevalence increases with age, but frequently asymptomatic

or self-limiting Risk factors include occupational or sporting activities that

require repetitive overhead use of the arms Risk reduction includes shoulder-strengthening exercises and

workplace interventions


What symptoms are suggestive of rotator cuff disease?

Nontraumatic onset (except with acute traumatic tears)

Pain in upper arm near the deltoid insertion

Pain exacerbated by overhead activity

Pain worse at night, particularly if lying on affected side

Weakness or loss of function may occur


What physical findings and maneuvers during the examination are helpful?

Standard shoulder exam should include:

Adequate exposure of the shoulder girdle

Careful visual inspection from the front, back, and side

Atrophy of infraspinatus (positive likelihood ratio of 2.0)

Look for patterns of muscle wasting suggestive of underlying neurologic disease

Palpate bony structures of the shoulder for tenderness, swelling, and deformity

Test active and passive ranges of motion of the shoulder in all planes and compare with contralateral shoulder


Physical exam maneuvers to test for RC disorders

Painful arc test

Drop-arm test

Hawkins test

Empty can test

Resisted external rotation

Internal rotation lag test

Injecting short-acting local anesthetic into subacromial space sometimes recommended to confirm RC as source of pain


What other conditions should clinicians consider during evaluation?

Intrinsic causes of shoulder pain

Acromioclavicular osteoarthritis

Adhesive capsulitis

Amyloidosis

Avascular necrosis

Biceps tendinopathy

Crystal arthritis

Glenohumeral osteoarthritis

Inflammatory arthritis

Paget disease of bone

Polymyalgia rheumatica

Primary and metastatic tumors

Septic arthritis

Superior labrum anterior to posterior tears and labral lesions

Sternoclavicular osteoarthritis


Extrinsic causes of shoulder pain

Apical lung cancer (Pancoast tumor)

Brachial neuritis (Parsonage-Turner syndrome)

Cervical radiculopathy

Fibromyalgia

Myocardial ischemia

Subdiaphragmatic process


What is the role of imaging studies?

Reserve for when:

Patients present with atypical clinical features

There is doubt about the diagnosis and the results of the investigations would alter management

A decision to consider surgery has been made

Available imaging investigations

Plain radiographs

Ultrasonography

MRI


When should clinicians consider referring the patient to a surgical or nonsurgical specialist?

Patients have atypical clinical features or diagnostic uncertainty persists

Refer to rheumatologist orthopedic surgeon, or another specialist, according to the clinical circumstances

Patients have severe symptoms that do not respond to conservative measures

Refer to orthopedic surgeon

Especially if symptoms interfere with occupational tasks or athletic pursuits


CLINICAL BOTTOM LINE: Diagnosis...

Thorough history and examination: fundamental to diagnosis Exclude intrinsic or extrinsic causes of pain Physical examination maneuvers may improve accuracy of

the clinical assessment Imaging is usually not required

Use rarely alters management in primary care May increase risk for overtreatment


How should clinicians manage patients with rotator cuff disease?

Nonsurgical therapy is the cornerstone of management

Tailor initial conservative management plan to individual

Patient education regarding the diagnosis and prognosis

Advice on activity modification and self-management

Early management may also include

Analgesic drugs

NSAIDs

Glucocorticoid injections


Which analgesics should clinicians prescribe first? Simple analgesics on an as-needed basis

Such as acetaminophen (paracetamol)

Low-risk, first-line approach

If simple analgesia ineffective, consider NSAIDs

Balance potential benefits with known potential GI, renal, and cardiovascular risks

Be cautious about combining acetaminophen with NSAIDs

Use of opioids is discouraged

Short course of short-acting oral opioid may be considered if pain persists and interferes with function or sleep

Ongoing requirement for opioids should prompt referral


When should clinicians consider glucocorticoid injections?

When pain interferes with sleep or function despite adequate analgesia

Glucocorticoids usually mixed with local anesthetic and injected into the subacromial space

Procedure takes only a few minutes

Simple to learn

Requires no special equipment

Does not require a sterile field

Can be performed in an office setting

Low risk for infection and other complications

Safe with warfarin anticoagulation therapy if the INR <3


What is the role of physical therapy?

May reduce symptoms and improve function

Recommend when simple measures have failed

Common interventions evaluated in trials: Scapular stability training and progressive RC strengthening

Resistance exercise effective both in supervised setting and in home

Little evidence is available on the use of joint mobilization techniques as a lone intervention

Combination of mobilization + exercise may be superior to exercise alone

Role of exercise therapy in large RC tears is uncertain


What is the role of other treatments?

Extracorporeal shock wave therapy

Existing evidence does not support use in the absence of calcium deposits

Consider if patients have calcific RC tendinitis

Acupuncture

Consider as auxiliary treatment in patients with persistent pain

High-quality evidence on efficacy and safety is lacking

Platelet-rich plasma injections: evidence doesn’t support

Suprascapular nerve block: may be useful for pain relief


What is the role of surgical management?

Reserve for when nonsurgical treatment has failed

Refer to surgeon if there is progressive weakness or if symptoms are severe and persistent after 3 to 6 months of nonsurgical management

Before referral, consider relative risks and benefits for the individual patient

Early surgery is sometimes appropriate

May be considered when prompt repair minimizes disruption to occupational or sporting activities


Open or arthroscopic surgical options

Acromioplasty

Decompression of the subacromial space

Repair of RC tears

Removal of calcium deposits


How should clinicians follow patients with rotator cuff disease?

Most patients only need follow up if symptoms persist

In this case, repeated evaluation appropriate at 4 to 8 weeks

Additional or atypical symptoms or signs should prompt further investigation or specialist referral

May indicate an alternative diagnosis

If symptoms persist after 3 to 6 months of conservative treatment

Refer to a specialist


CLINICAL BOTTOM LINE: Treatment... Initial management should be conservative

Activity modification Simple analgesics and NSAIDs if required Physical therapy and exercise programs

Subacromial glucocorticoid injections For patients with persistent or severe pain

Surgery Younger patients with acute, functionally significant tears Older patients in whom active nonsurgical treatment failed

© copyright annals of internal medicine, 2015 ann int med. 162 (1): itc1-1. * for best viewing:...

Documents

slide slide

muscles slide

ann int

clinic slide sets

copyright infringement

entire slide set

acp copyright notice

cuff muscles