Rotator cuff tearMANAGEMENT

SHOULDER & CLAVICLE · 12 SECTIONS

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252 items

☷ Legend

01Approach to the Critical Patient/attcp27

Triage and limb threat

›Triage priorities

›Concurrent shoulder dislocation concern

›Immediate reduction pathway if confirmed

›Open injury over shoulder concern

›Open fracture pathway and antibiotics

›Neurovascular compromise

›Axillary nerve sensory loss over lateral deltoid

›Distal pulses and capillary refill

Immediate imaging and escalation

›Time critical diagnostics

›Shoulder radiographs before reduction attempt if stable

›AP view

›Scapular Y view

›Post reduction radiographs if dislocation reduced

›AP view

›Axillary view if tolerated

Analgesia safety and monitoring

›Pain control and sedation readiness

›Non opioid analgesia first line when possible

›Acetaminophen and NSAID if no contraindication

›Opioid titration if severe pain

›Reassessment after each dose

›Procedural sedation pathway if reduction required

›Capnography use reduces adverse respiratory events ACEP Level B

Key decision points

›Early red flags that change pathway

›Pseudoparalysis after trauma

›Urgent shoulder specialist referral for suspected acute full thickness tear

›Older patient after traumatic anterior dislocation

›High prevalence of associated cuff tear and early imaging recommended

02History/hx22

Mechanism and timeline

›Injury context

›Acute traumatic mechanism

›Fall on outstretched hand

›Direct blow or traction injury

›Time since injury

›Time since any reduction attempt

›Prior shoulder instability

›Prior dislocations or subluxations

Symptom pattern and function

›Functional impact

›Immediate weakness and inability to abduct

›Pseudoparalysis definition inability to actively elevate despite passive range preserved

›Night pain

›Sleep disruption

›Mechanical symptoms

›Clicking or catching

Risk modifiers

›Baseline risks

›Age over 40 years

›Increased probability of cuff tear after traumatic dislocation

›Anticoagulant use

›Expanding hematoma concern

›Prior rotator cuff disease

›Prior imaging or injections

03Physical Exam/exam27

Inspection and palpation

›Shoulder overview

›Deformity consistent with dislocation

›Loss of deltoid contour

›Ecchymosis and swelling

›Proximal arm hematoma

›Greater tuberosity tenderness

›Occult fracture concern

Range of motion and strength

›Rotator cuff focused findings

›Active abduction limitation

›Pseudoparalysis

›External rotation weakness

›Infraspinatus involvement

›Positive drop arm sign

›Suggests full thickness supraspinatus tear

Neurovascular

›Neurovascular exam

›Axillary nerve function

›Deltoid contraction

›Sensation over lateral deltoid

›Distal motor and sensory

›Radial median ulnar screening

›Perfusion

›Radial pulse and capillary refill

PITFALLS

›Common misses

›Missed cuff tear after dislocation in older patient

›Weakness reassessment after pain control and reduction

›Overcalling tear when pain inhibits effort

›Repeat strength testing after analgesia

04Differential Diagnosis/ddx19

Shoulder trauma differentials

›Alternative diagnoses

›Anterior glenohumeral dislocation ICD-10 S43.01

›Rotator cuff tear as associated injury

›Proximal humerus fracture ICD-10 S42.2

›Greater tuberosity fracture mimic

›Acromioclavicular separation ICD-10 S43.1

›Pain localized to AC joint

Neurologic and tendon mimics

›Mimics of weakness

›Axillary nerve neuropraxia ICD-10 S44.3

›Sensory loss over lateral deltoid

›Cervical radiculopathy ICD-10 M54.12

›Neck pain or dermatomal symptoms

›Biceps tendon rupture ICD-10 S46.1

›Popeye deformity

Non traumatic differentials

›Atraumatic considerations

›Calcific tendinitis ICD-10 M75.3

›Acute severe pain without trauma

›Septic arthritis ICD-10 M00.9

›Fever and severe pain with minimal motion

05Laboratory Tests/lt17

Labs when uncomplicated isolated tear

›Usually not indicated

›No routine labs for isolated suspected cuff tear

›Pain control and imaging focused pathway

Labs when infection or systemic illness concern

›Infection screen

›White blood cell count for septic arthritis concern

›Limited sensitivity early disease

›CRP for inflammatory or septic concern

›Trend value over single value

›Blood cultures if febrile and septic concern

›Before antibiotics if feasible

Labs for procedural sedation or operative pathway

›Sedation and surgery readiness

›Glucose for diabetes or altered mental status

›Hypoglycemia exclusion

›Pregnancy test when applicable

›Imaging and medication selection implications

›INR and platelet count if anticoagulants or bleeding risk

›Hematoma and procedural risk

06Diagnostic Tests/dt32

Scoring Systems

›Functional and severity tools

›ASES score for baseline function tracking

›Use in follow up and rehab response

›Constant Murley score for outcome tracking

›Use in specialist clinics

›Pain and function documentation anchors

›Active forward elevation degrees

›External rotation strength grade

Radiographs

›X ray indications and views

›Trauma series

›AP shoulder

›Scapular Y

›Axillary view if tolerated

›Dislocation and fracture exclusion

›Greater tuberosity avulsion

›Hill Sachs and bony Bankart if dislocation

›Normal X ray does not exclude cuff tear

›Proceed to ultrasound or MRI if high suspicion

MRI

›MRI role

›Full thickness tear confirmation and retraction assessment

›Surgical planning value

›Pseudoparalysis after trauma

›Urgent imaging pathway

›MRI performance high for full thickness tears per ACR evidence based criteria

›Use when ultrasound expertise limited

›CT role

›Occult fracture suspicion despite negative X ray

›Greater tuberosity or glenoid fracture

›Preoperative bony anatomy when fracture dislocation pattern

›Surgical planning support

›Not first line for isolated soft tissue tear

›Prefer ultrasound or MRI per ACR criteria

07Disposition/dispo17

Discharge vs urgent referral

›Disposition framework

›Discharge with expedited outpatient imaging and follow up

›Preserved active elevation

›Pain controlled with oral meds

›Urgent shoulder specialist referral

›Suspected acute full thickness tear after trauma

›Pseudoparalysis

›ED ortho consultation or transfer

›Associated dislocation not reducible

›Neurovascular deficit not resolving

Follow up timing

›Follow up targets

›Suspected acute traumatic tear

›Specialist evaluation ideally next available clinic per BESS BOA pathway statement

›Post dislocation with weakness in older patient

›Early ultrasound or MRI recommended by BESS BOA pathway

›Physical therapy initiation window

›After fracture and dislocation excluded and pain controlled

08Treatment/t12

Symptom control and definitive care

›Nonoperative initial care

›Relative rest and activity modification

›Avoid overhead lifting

›Early range of motion as tolerated

›Prevent stiffness risk

›Physical therapy

›Scapular stabilizers and rotator cuff strengthening progression

›Surgical pathway triggers

›Acute traumatic full thickness tear with functional deficit

›Early surgical consultation supported in specialty pathways

›Massive tear with pseudoparalysis

›Time sensitive repair consideration

09Special Populations/sp21

Pregnancy

›Pregnancy considerations

›Imaging selection

›Ultrasound preferred when feasible

›MRI without gadolinium preferred if advanced imaging needed

›Analgesia choices

›Acetaminophen preferred

›NSAID avoidance in later pregnancy per obstetric guidance

Geriatric

›Older adult considerations

›Higher likelihood of cuff tear after dislocation

›Weakness reassessment after reduction and analgesia

›Higher stiffness risk

›Earlier mobilization and PT emphasis

›Polypharmacy and delirium risk with opioids

›Lowest effective dose strategy

Pediatrics

›Pediatric considerations

›Traumatic cuff tear uncommon

›Consider physeal injury and avulsion fractures

›Imaging priorities

›Radiographs to exclude fracture and physeal injury

›Referral triggers

›Persistent weakness or suspected avulsion requires specialist evaluation

10Background/b25

Epidemiology

›Frequency and risk patterns

›Rotator cuff tear common cause of shoulder pain

›Incidence increases with age

›Traumatic anterior dislocation association

›Meaningful proportion of patients over 40 years have associated cuff tear per BESS BOA pathway

›Acute traumatic tears often full thickness

›Higher surgical consideration than degenerative tears

Pathophysiology

›Injury mechanism

›Tendon failure under eccentric load

›Supraspinatus most commonly involved

›Tear morphology

›Full thickness vs partial thickness

›Retraction and muscle atrophy affect reparability

›Pain and weakness drivers

›Loss of force couple and humeral head centering

Therapeutic Considerations

›Treatment rationale

›Early identification of acute traumatic full thickness tear

›Potentially better repair biology than chronic tears per AAOS guidance context

›Imaging selection

›Ultrasound effective with expertise

›MRI for tear size and retraction per ACR criteria

›Corticosteroid injection timing

›Short term pain relief option in selected cases with specialist guidance

›Rehabilitation emphasis

›Stiffness prevention and scapular mechanics

11Patient Discharge Instructions/pdi21

Copy discharge instructions

›Discharge instructions

›Sling use for comfort

›Remove several times daily for gentle elbow wrist hand motion

›Activity restrictions

›No heavy lifting

›Avoid overhead reaching until cleared

›Pain control plan

›Acetaminophen as directed

›NSAID as directed if safe

›Ice and elevation

›Ice 15 to 20 minutes at a time

›Sleep with shoulder supported

›Follow up plan

›Shoulder specialist or sports medicine within 1 to 2 weeks for suspected traumatic tear

›Earlier follow up if severe weakness or pseudoparalysis

›Return to ED now

›New numbness over lateral shoulder

›Hand becomes cold pale or weak

›Worsening pain not controlled with meds

›Fever or redness if any wound

›New visible deformity suggesting dislocation

12References/r12

Guidelines and key sources

›Evidence sources

›AAOS Clinical Practice Guideline Management of Rotator Cuff Injuries 2025 update

›AAOS press release summary of updated guideline Aug 28 2025

›AAOS Clinical Practice Guideline Management of Rotator Cuff Injuries 2019

›Prior guideline baseline for management recommendations

›ACR Appropriateness Criteria Acute Shoulder Pain 2025

›Evidence based imaging selection for acute shoulder pain and suspected cuff tear

›BESS BOA Patient Care Pathways Traumatic anterior shoulder instability 2015

›Urgent referral recommendation for acute traumatic rotator cuff tear

›ACEP Clinical Policy Procedural Sedation and Analgesia in the Emergency Department 2014

›Capnography recommendation Level B

›Internal project instructions source :contentReference[oaicite:0]{index=0}

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed March 6, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.