1. © Copyright Annals of Internal Medicine, 2015 Ann 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

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3. © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 162 (1): ITC1-1. in the clinic Rotator Cuff Disease

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

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

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

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

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

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

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

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

12. © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 162 (1): ITC1-1.  Extrinsic causes of shoulder pain  Apical lung cancer (Pancoast tumor)  Brachial neuritis (Parsonage-Turner syndrome)  Cervical radiculopathy  Fibromyalgia  Myocardial ischemia  Subdiaphragmatic process

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

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

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

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

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

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

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

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

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

22. © Copyright Annals of Internal Medicine, 2015 Ann Int Med. 162 (1): ITC1-1.  Open or arthroscopic surgical options  Acromioplasty  Decompression of the subacromial space  Repair of RC tears  Removal of calcium deposits

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

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