Evaluation of the Weak Shoulder.

Last updated Thursday, February 10, 2005

Figure 1 - Age distribution of patients presenting for evaluation of full thickness rotator cuff defects

Figure 2 - Functional impairment from rotator cuff tears

History

Typical history

A typical history for degenerative cuff fiber failure in an older individual reveals an insidious onset of weakness of flexion and external rotation, perhaps punctuated by episodes of "bursitis" or "tendonitis." Failure of weakened tendon tissue may not produce much in the way of pain, bleeding, or swelling. The shoulder may have been treated with steroid injections with some relief of discomfort but without improvement in strength. More acute incremental losses of strength from tear propagation may follow lifting or falls.

A greater injury is required to tear the cuff of individuals at the younger end of the age distribution. A history of sudden eccentric loading, such as trying to support a falling load or trying to cushion a fall with the arm, is commonly given by younger patients with cuff tears. Traumatic glenohumeral dislocations in individuals over the age of 40 have a strong association with rotator cuff tears. These traumatic cuff tears may also involve the subscapularis, producing weakness in internal rotation.

Characteristic elements of the history of other common causes of shoulder weakness include:

1. long thoracic nerve palsy: posterior protrusion of the scapula on attempts to elevate the arm;
2. cervical radiculopathy: pain on top of the shoulder with radiation down the arm below the deltoid tubercle, weakness of the biceps, diminished biceps reflex and sensory changes on the lateral forearm;
3. suprascapular neuropathy from brachial neuritis: acute onset of pain lasting several weeks followed by profound weakness of external rotation;
4. suprascapular neuropathy from traction: external rotation weakness following an injury in which the shoulder was forced down and the neck forced to the opposite side (may be part of a full Erb's palsy); and
5. suprascapular neuropathy from compression/entrapment: insidious onset of external rotator weakness. Facioscapulohumeral muscular dystrophy is suggested by the atraumatic onset of bilateral symmetrical weakness of the scapular musculature.

The Simple Shoulder Test provides a set of data for characterizing some functional impairment from rotator cuff tears. It is evident that sleeping on the affected side, placing the hand behind the head, lifting eight pounds, and throwing overhand are particularly compromised by cuff tears.

Substantial information bearing on the reparability of a rotator cuff defect can also be determined from the history. Acute tears in younger, healthy individuals without prior shoulder disease are likely to be repairable. Long-standing tears associated with major weakness in older patients carry a poor prognosis. The prognosis for a durable repair is even worse if the history reveals local or systemic steroids, smoking, or difficulties in healing previous injuries or surgeries. The surgeon can also determine preoperatively the patient's goals and functional expectations for surgical treatment to see whether these are reasonable in view of the likely prognosis.

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