Rotator Cuff Differential Diagnosis.
Last updated Wednesday, January 26, 2005
Introduction
Traditionally it is stated that rotator cuff tears must be
differentiated from cuff tendinitis and bursitis and that tests such as
arthrography or ultrasonography are necessary to make this distinction.About rotator cuff tear diagnosis Perhaps a more realistic view is that many of the symptoms often
attributed to tendinitis and bursitis are, in actuality, episodes of
acute fiber failure that are not clinically detected.
Patients with a frozen shoulder
demonstrate, by definition, a restricted range of passive motion with
normal glenohumeral radiographs. Patients with partial-thickness cuff
defects may similarly demonstrate motion restriction, whereas patients
with major full-thickness defects usually have a good range of passive
shoulder motion but may be limited in strength or range of active
motion. An arthrogram in the case of frozen shoulder shows a diminished
volume and obliteration of the normal recesses of the joint.
Snapping scapula may produce shoulder pain on elevation and a
catching sensation somewhat reminiscent of the subacromial snap of a
cuff tear. However, the latter can usually be elicited with the scapula
stabilized while the arm is rotated in the flexed and somewhat abducted
position. Scapular snapping usually arises from the superomedial corner
of the scapula, producing local discomfort, and is elicited on scapular
movement without glenohumeral motion.
Glenohumeral arthritis may also produce shoulder pain, weakness, and
catching. This diagnosis can be reliably differentiated from rotator
cuff disease by a careful history, physical examination, and
roentgenographic analysis (see figure 1).
Acromioclavicular arthritis may imitate cuff disease.
Characteristically, however, the shoulder is most painful with
cross-body movements and with activities requiring strong contraction
of the pectoralis major. Tenderness is commonly limited to the
acromioclavicular joint. Relief of pain on selective lidocaine
injection, and coned-down radiographs may help establish the diagnosis
of acromioclavicular arthritis.
Suprascapular neuropathy and cervical radiculopathy are common
imitators of cuff disease. The suprascapular nerve and the fifth and
sixth cervical nerve roots supply two of the most important cuff
muscles: the supra and infraspinatus. Thus, patients with involvement
of these structures may have lateral shoulder pain and lack strength of
elevation, and external rotation.
In the presence of weakness, the neurologic examination should test
the cutaneous distribution of the nerve roots from C5 to T1. The biceps
reflex and the triceps reflex help to screen C5/6 and C7/8,
respectively. The next component of the neurologic examination requires
recognition of the segmental innervation of joint motion: abduction C5,
adduction C6, 7, and 8. External rotation C5, internal rotation C6, 7
and 8. Elbow flexion C5 and 6, elbow extension C7 and 8. Wrist
extension and flexion C6 and 7. Finger flexion and extension C7 and 8.
Finger adduction/abduction T1.
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