CLICK HERE to download a PDF version of the transcript

Hi, my name is Jo Gibson and I'm an Upper Limb Rehabilitation Specialist. Those of you who've joined me before will know that I've had the privilege of working as a shoulder specialist since 1995, so helping people with shoulder pain and instability.

A physiotherapist has written in about an 84-year-old guy who's got a right massive rotator cuff tear of supraspinatus. As we know, massive cuff tears now tend to be thought of as two or more tendons, but are were previously referred to as tears of five centimetres or more or those retracted back to the glenoid neck. So, this guy's got a right, massive rotator cuff tear of supraspinatus and also a partial tear of subscapularis, which all started two months ago after he'd done some gardening work, which unless he fell over in the garden, sounds like more of an overload pathology than actually being causative for the tear and a previous supraspinatus partial tear 10 years ago. Obviously a long history of shoulder problems. Now, this guy was managed conservatively. But one of the conundrums is he has intermittent numbness along his right upper limb posteriorly and also down to the second, third and fourth fingers. He also has associated variable dull ache pain and says he's never completely pain free.

The numbness comes on especially with shoulder protraction, reaching but also doing things like pendure exercise and the physio comments there's no Gilliatt-Sumner hand or change of colour temperature or swelling of the arm or fingers which might be suggestive of Thoracic outlet syndrome. Reflexes were present, but a little bit dampened on that side, I think, compared to the other side. Now, importantly, this guy's been improving with the anterior deltoid program. So he's doing right shoulder active flexion and abduction almost to full range, which is phenomenal.

With mild discomfort, he's got functional strength, but poor under load, which is what you would expect with the injury and his age, but he continues to progress well with anterior deltoid program.

He's only in the fourth week of 12 weeks intended intervention. So to be honest, this guy's doing phenomenally well to have regained that movement and it suggests that he probably had an underlying tear and the overload or the excessive gardening is what's tipped things over the edge.

The first thing is to say he has made excellent progress in a short period of time and obviously achieving full functional range is great. The important thing in terms of these patients with massive cuff tears is just being clear about realistic expectations. Some patients can get phenomenal range, as this gentleman has, but often they don't regain true strength in those elevated positions.

So they can get there, they can move light objects, but if they try and sustain it or have a heavy load, then they often can't achieve that because the system can't quite compensate in those exposed positions. Now, the physio specific question was whether nerve conduction or imaging studies would be warranted, as they didn't see much information on the web regarding prevalence of persistent numbness after a rotator cuff full thickness tear. So, in an effort to answer that, there's obviously a very short answer, but let's have a look at symptoms radiating into the posterior arm and wrist hand and how that may help in terms of working out the way forward. Now, interestingly, Bayam et al. in 2016 and then a further paper in 2017 looked at pain mapping in people with shoulder pathology.

Now, we all know that shoulder pain location in isolation is not terribly useful and there's a lot of overlap with a lot of different shoulder pathologies. However, if we put pain together with our age, our mechanism of onset, what makes the pain worse, what makes it better and how it impacts sleep, then really that constitutes our subjective which is 80 percent of our decision making and of course any relevant general health or past medical history.

Now interestingly in those Bayam studies they found that half of the patients, so 50 percent of patients with symptomatic rotator cuff tears had dull pain which radiated below the elbow. They tended to have more sharp proximal pain but this radiating dull ache pain very much as this gentleman seems to describe so it's good that he hasn't got that proximal sharp pain anymore. Interestingly wrist and hand numbness was also reported in those studies but was more associated with a subacromial pain group than those who had a proven rotator cuff tear but it's not clear if those with subacromial pain had an underlying tear ruled out. Now interestingly, Gumina et al in 2014, so a little bit earlier than the Bayam study, but they referred to a Bayam, an earlier version of that study in 2011, where patients with massive rotator cuff tears had a much greater pain distribution than patients with medium and large tears.

Now, their pain levels were generally less serious, but they could have radiation in dermatomes consistent with C4, 5, 6, and C7, 8 and T1. So, very diffuse symptomology in associated with those massive rotated cuff tears. Now, of course, when we look at this particular patient, he's 84, and as we know in terms of cervical changes and cervical radiculopathy particularly, it's more common in men than women, which is probably one of the few things that it is when we look at the shoulder.

Now equally, if we look at papers like those of Katsura et al in 2019 the prevalence of associated cervical spine problems in an older age group with shoulder pain can be up to 50%. So it's incredibly common for people with shoulder pain, particularly with a long history, to have an associated cervical spine problem as well.

Now, to delve into this a little bit more and try and tease out the detail of what's going to be helpful in terms of investigations and any further imaging, a paper by Akai et al. in 2017 looked at 301 patients who had symptomatic rotator cuff tears. 224 of that cohort had large tears and 144 had massive tears.

Now in those massive rotator cuff tears, which I've teased out because that's what we're talking about this evening, 25 percent had an associated suprascapular nerve issue, so remember retraction of those massive cuff tears can actually cause traction to the suprascapular nerve, and of course protraction type movements could potentially aggravate that.

The only thing is suprascapular nerves rarely cause any distal sensory symptoms. It tends to be more proximal around the shoulder, both sensory and motor. In terms of these massive cuff tears in this Ohio paper, what they found interestingly that was 38 percent had cervical spondylotic amyotrophy, which is really weakness and wasting without sensory deficits.

So degenerative changes within the cervical spine contributed to muscle wasting, obviously not just located to the cuff but to other muscles too suggesting and highlighting the importance of a thorough neurological examination. Now they further looked at 82 cases of patients with massive cuff tears who had pseudoparalysis. And in that group, the prevalence of this cervical spondylitic amyotrophy was even higher. So 48 percent of patients and 20 percent had suprascapular nerve neuropathy.

So it's really common for massive rotator cuff tears to co-exist with cervical spine pathology. And also remember that facet joint OA is highly associated with generalised hand pain, so pain might not necessarily be dermatomal. So I guess the other thing is to consider when you have somebody had a previous history 10 years ago, I'm not clear about how many problems he's had in terms of symptoms in between times, but now he's presented with a massive cuff tear. We know patients have adaptive strategies where they often over use some of the cervical muscles at a higher level. Some of their prime mover muscles as a strategy to try and keep the shoulder functional and on the background of a neck that's already potentially stiff , you can see very easily how there's quite clearly the risk of having an associated cervical spine problem.

And given with this gentleman, it seems to be that he's never entirely pain free. That dull ache is always there. That lack of mechanical picture might then point more to the cervical spine than the relevance of that underlying cuff tear. So I guess that brings us full circle to say really the key in this case is doing a thorough clinical assessment of the cervical spine.

The physiotherapist comments that reflexes are dull and I'm assuming that's compared to the other side. Now of course we need to consider other potential neurological causes but assuming this is a peripheral issue, then of course looking at dermatomes and myotomes, is there a consistent pattern, consistent with cervical radiculopathy and or facet osteoarthritis?

Are there any other signs that might be concerning? It doesn't sound like it and let's remember this guy has a general trend of improvement. When you look at studies trying to rule in facet OA, then a combination of stiffness on palpation, tenderness on palpation and provocation with combined tests , such as extension, rotation or Spurling's again have been shown to be sensitive and specific as a combination.

In terms of looking at other things that we might use to try and rule in this potential cervical spine component in the absence of clear dermatomal or myotomal findings, then of course our upper limb tension test can also be useful. Remember if it's negative it doesn't rule it out but given that protraction there does seem to be a neural or a mechanical element that provokes symptoms and it's less likely to be anything to do with the suprascapular nerve because of that peripheral presentation, much more likely to be sensitisation and involvement of the cervical nerves.

We know also in cervical radiculopathy we hear about the Wayner's cluster which is, if there's stiffness to the same side, it would be unusual for an 84-year-old not to have some stiffness in his cervical spine, and that in itself can be a potential risk factor. Distraction, does it change symptoms? Spurling's again, does it provoke symptoms and upper limb tension? As a combination, those have been shown to be reliable in ruling in cervical radiculopathy.

So I think the key thing is to do a full neurological examination. We know there can be overlap in those dermatomal and myotomal patterns, but the key thing is, is there enough of a query there about that potential neural involvement that then nerve conduction studies in EMG would be a reasonable suggestion to differentiate between peripheral and cervical nerve, but also to rule in that potential cervical contribution. I guess from my point of view, the other big question is, have you had the opportunity to do anything to actually incorporate this gentleman's cervical spine in his treatment?

Has he got stiffness in his neck? Remember, if he was doing some repeated loading in the garden, that might have had as much effect on his cervical spine as on his shoulder. We know that in people with shoulder pain, and no evidence of any involvement of their cervical spine, that repeated movements can have a positive impact on pain sensitivity.

So in those with cervical involvement, it's no great surprise to know that repeated movements can be a very effective way of reducing sensitivity and those peripheral symptoms. Now in an 84-year-old, I'm sometimes a little bit cautious of doing things like retractions because they can be a little bit provocative in the first instance.

So non-weight bearing rotation or supported against the wall can be a really nice place to start away from the side of symptoms, and then gradually progress from there. So some little things to reflect on that I hope have helped to answer the question and hopefully some clinical reasoning there to help you tease out between the different potential causes.

But I think the most important thing to emphasise here that to have that much improvement at four weeks is phenomenal. And it may well be that just continuing to improve that shoulder function, you might then see an improvement in those peripheral symptoms. But I think for me the key thing is ruling in or ruling out that cervical spine and if you have evidence of frank neurology then absolutely those nerve conduction studies in EMG would be a useful way forward.

So thank you so much for the question. I'm going to try and keep these Facebook lives to 15 or 20 minutes because I know how busy everybody is. Some real key points to take away. David will post some links to some of the key papers if you want to read them and find out anything more.

And don't forget, if you haven't accessed our free assessment infographics, they're still available. Thank you so much to any of you who have joined us this evening.