Spontaneous Conditions: Rotator Cuff Degeneration

The management of rotator cuff degeneration will depend on the pathology:

Subacromial impingement (SAI)

Supraspinatus pathology accounts for >30% of all shoulder pathology, and 20% of over sixties have features of impingement of the supraspinatus beneath the acromion (Fig 1). Weak or absent Jobes test is the clinical sign. Ultrasound determines if a tear is present.

Perhaps the commonest presentation in shoulder clinics, impingement syndrome describes the clinical picture of pain on elevation of the arm, often with acute pain in mid-range. This is the classic painful arc and is caused by impingement of the supraspinatus, that has been attributed to entrapment of tissues between the humerus and acromion. Examination will reveal a painful arc in abduction and positive impingement tests.

Arthroscopic surgery (subacromial decompression) makes more space available by acromioplasty and has a dramatic effect (Fig 2).

Fig 1: MR showing the degenerative A-C joint impinging on the supraspinatus below (click on scan to enlarge)	Fig 2: Arthroscopic view of the supraspinatous tendon

Calcific tendonitis

Calcific tendonitis typically occurs in young to middle aged adults with no previous problem (Fig 3).

There is a sudden onset of excruciating pain, typically preventing sleep. This is due to leakage of calcium deposits from the supraspinatus tendon into the joint space.

In most cases, clinical symptoms will resolve spontaneously in 7-10 days.

In some cases the oedema is so severe that downward displacement of the humeral head occurs (Fig 4).

Fig 3: Calcific tendonitis (click x-ray to enlarge)	Fig 4: Calcific tendonitis with downward displacement of the humeral head (click x-ray to enlarge)

Other rotator cuff pathology

Tears to the subscapularis may be part of a Bankart lesion.

Tears to the infraspinatus are unusual but a direct fall onto a straight arm by the body can produce this.