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    Managing Rotator Cuff Tears in Young Patients

    The authors review the history, presentation, examination, imaging studies, and treatment of rotator cuff injuries in adolescents.

    Authors

    Filippo Familiari, MD, Alan Gonzalez-Zapata, MD, and Edward G McFarland, MD

    Disclosures

    No funding has been received in support of this study. The authors have no conflicts of interest to report.

    Introduction

    Muscles and tendons of the rotator cuff, like those elsewhere, show changes in morphology, histology, biomechanics, and integrity as the individual ages. Common wisdom suggests that “normal tendons do not tear.” This observation is supported by the fact that tendinosis usually does not make tendons susceptible to tearing until the fourth decade of life. [1] The incidence of tears of the Achilles tendon, patellar tendon, long head of the biceps, and rotator cuff increases linearly with age, [2,3] a relationship that is particularly applicable to rotator cuff abnormality.

    The increasing incidence of rotator cuff syndrome (abnormalities ranging from painful tendinosis to full-thickness tears of the tendons) is supported by epidemiologic, [4-10] cadaveric, [11,12] imaging, [13] and surgical studies. [14-19] Rotator cuff tears occur more commonly in middle-aged and older patients than in young patients; studies have shown that less than 1% of rotator cuff tears occur in patients less than 20 years old. [6,8]

    In patients age 30 years or younger, rotator cuff tendons are generally healthy, robust, and unless subjected to repetitive overhead activities, less likely to be the source of symptoms. [5] The number of recorded cases in adolescents is limited. [4,7,9,10]

    Despite varying reports of occurrences in “younger” patients, most rotator cuff abnormalities in patients less than 30 years old are painful tendinoses or partial-thickness rotator cuff tears; full-thickness rotator cuff tears in this age group are almost entirely the result of severe trauma. Partial-thickness tears in this population are very common in overhead athletes, but the exact mechanism of injury remains conjectural.

    Rotator cuff abnormality in adolescents and young adults less than 18 years old is even more uncommon. [4,6,9,10,20-33] However, it is important for any clinician treating patients of this age to realize that rotator cuff abnormality can occur in this population.

    The history, presentation, examination, imaging studies, and treatment of these injuries in adolescents are reviewed.

    History

    Because the rotator cuff tendons are typically stronger than apophyseal or epiphyseal attachments, it is most common for injuries in this area to be partial or complete bone avulsions or fractures, rather than rotator cuff tears. Usually, severe trauma is required to create rotator cuff tears in this population, and the lesions include bone and soft-tissue injury. However, repetitive activities such as throwing a baseball or casting a fishing line [31] can also cause bony avulsions.

    Rotator cuff avulsion injuries occur most commonly at the lesser tuberosity where the subscapularis tendon attaches. A common mechanism for these avulsions is an abducted, externally rotated arm, with or without a shoulder dislocation. Activities associated with lesser tuberosity avulsion include: (Table 1)

    • Wrestling
    • Falls
    • Ice hockey
    • Baseball

    Because adolescents with this injury are often told it is a “sprain” that will resolve with time, many consequently present late with stiffness, weakness, and pain.

    Avulsions of the supraspinatus are even rarer in adolescents; we found only 14 cases in the literature. [19,34] The most commonly reported mechanisms for this injury are: [19]

    • Impingement of the supraspinatus in abduction coupled with external rotation
    • Overhead activities
    • Overuse injuries

    As do patients with lesser tuberosity avulsions, patients with supraspinatus avulsions often present late because the diagnosis is missed or not considered in the differential diagnosis.

    Physical Examination

    If seen acutely, younger patients with rotator cuff injuries have substantial pain and loss of motion and function. A systematic evaluation is warranted, including:

    • Observation
    • Range of motion evaluation
    • Palpation
    • Rotator cuff testing

    These injuries can produce swelling but rarely ecchymosis. Acutely, the pain may cause the patient to have guarding and apprehension. Patients are most often neurologically intact, although some may complain of paresthesias and weakness. [10]

    Palpation and rotator cuff testing can help make the diagnosis. In the adolescent shoulder, rotator cuff injuries typically occur with fractures. Therefore, the patient will be tender on the lesser tuberosity or the greater tuberosity rather than on the top (acromioclavicular joint) or back (scapula fracture of the shoulder).

    Active and passive range of motion in the acutely injured adolescent will often be limited. Rotator cuff tendon testing should include resisted abduction as tolerated (Jobe test) [35] and resisted external rotation with the arm at the side.

    Tests of subscapularis tendon integrity include the lift-off test, [36] the lift-off lag sign, [37] the belly press, [38] and the “bear hug test.” [39] To our knowledge, there is no literature on the sensitivity and specificity of these tests for rotator cuff injury, but if they are positive, a high index of suspicion for these injuries should be considered.

    When evaluation is delayed, the diagnosis may be difficult because there is typically non-specific pain and loss of motion. In such cases, radiographs and additional imaging may be necessary for a definitive diagnosis.

    Imaging

    The diagnosis of a rotator cuff tear can often be made on conventional radiographs if the correct images are obtained. The standard trauma series for the shoulder should include anteroposterior views in internal and external rotation and an axillary view. Anteroposterior views are helpful for making the diagnosis of a greater tuberosity avulsion.

    Patients who present several weeks or months after the injury may exhibit heterotopic ossification in the tuberosity region or subacromial space. Axillary radiographs are necessary to make the diagnosis of lesser tuberosity fracture or avulsion. In some cases, a small sliver of bone may be all that is seen on the axillary radiograph.

    Magnetic resonance imaging can be helpful because it is very sensitive for edema in the bone and partial avulsions through the growth plate not seen with conventional radiographs. It is particularly helpful for overuse injuries in which there may be separation of the physis but no apparent bone avulsion.

    Treatment

    Rotator cuff lesions in adolescents are treated primarily according to the amount of displacement of the bone fragment, which is largely related to the mechanism of injury. Typically, overuse lesions do not have much displacement and can be treated non-operatively.

    However, traumatic lesions, which can involve large bony fragments, are usually best treated surgically with fragment reduction and internal fixation. Reduction can often be accomplished with suture fixation alone because the bone is often of high quality, which makes the use of proximal humeral plates or other hardware usually unnecessary.

    Chronic lesions may require more dissection, but most have been reported to be successfully treated without the use of hardware. [24,25,40] Good treatment outcomes have generally been reported, with most adolescents being able to return to their sports and activities with no limitations. Of the studies shown in Table 1, only one had an unsatisfactory outcome. [20]

    A review of the literature (Table 1) indicates that the average time to full recovery is 4.3 months (range, 3-6 months) after non-operative treatment and 7.5 months (range, 3-12 months) after surgical treatment. The average time to full recovery for patients with supraspinatus tears or bony avulsions was 8.8 months (range, 5-12 months).

    Table 1. Rotator Cuff Injuries in Adolescents

    Study

    Age at treatment

    Time from injury to diagnosis

    Mechanism of injury

    Tendon(s) involved

    Physical findings

    Treatment

    Time to recovery

    Results*

    LaBriola [22]

    20

    3 m

    During gymnastics, atraumatic

    Sub

    Superior tenderness; limited active abduction

    Op

    6

    Successful

    Shibuya [28]

    12

    4 d

    Fall with the arm externally rotated and extended

    Sub

    Anterior tenderness; range of motion limited

    Nonop

    6

    Successful

    White [33]

    12

    <10 d

    Climbing

    Sub

    Pain in abduction and external rotation; limited active internal rotation

    Op

    3

    Successful

    Ross [27]

    12

    12

    14 d

    N/A

    Fall in externally rotated and abducted position during wrestling

    Fall

    Sub

    Sub

    Anterior tenderness, pain with resisted internal rotation

    Anterior tenderness; pain with resisted abduction

    Nonop

    Nonop

    N/A

    N/A

    Successful

    Successful

    Kunkel [21]

    13

    1 y

    Forced internal rotation while playing baseball

    Sub

    Pain during abduction and external rotation; pain in internal rotation

    Op

    5

    Successful

    Itoi [6]

    15

    19

    19

    1 m

    2 w

    1 m

    Fall

    Fall

    Rugby

    Sup and infra

    Sup

    Sup

    Deltoid and infraspinatus atrophy

    Positive impingement sign in internal rotation with the arm in 90° abduction

    Painful arc

    Op

    Op

    Op

    12

    6

    6

    Satisfactory

    Successful

    Successful

    Klasson [20]

    19

    13

    6 y

    3 m

    Hockey

    Baseball

    Sub

    Sub

    Limited abduction and rotations

    Pain and apprehension in abduction and external rotation, and with resisted internal rotation

    Op

    Nonop

    11 m

    N/A

    Successful

    Un-satisfactory

    Le Huec [23]

    15

    2 y

    Volleyball

    Sub

    Pain and apprehension in abduction and external rotation, and with resisted internal rotation

    Op

    12

    Successful

    Paschal [9]

    14

    15

    14 m

    3 y

    Football

    During an assault

    Sub

    Sub

    Limited internal rotation; positive lift-off test

    Pain in abduction and external rotation; positive lift-off test

    Op

    Op

    12

    12

    Successful

    Successful

    Ogawa [25]

    12

    17

    13

    <6 m

    <6 m

    3 y

    NA

    NA

    NA

    Sub

    Sub

    Sub

    NA

    NA

    NA

    Nonop

    Op

    Nonop

    N/A

    N/A

    N/A

    Satisfactory

    Successful

    Successful

    Battaglia [4]

    13

    20 m

    Baseball

    Sup

    Pain with resisted external rotation; Positive sup stress test

    Op

    9

    Successful

    Sikka [29]

    14

    1 y

    Wrestling

    Sub

    Pain and weakness during resisted internal rotation

    Op

    6

    Successful

    Sugalski[30]

    15

    10 w

    Baseball

    Sub

    Pain and weakness during resisted internal rotation

    Nonop

    4.75

    Successful

    Tarkin [10]

    12

    14

    12

    14

    N/A

    N/A

    2 w

    2 y

    Skateboard and baseball

    Wrestling

    Baseball

    Hockey

    Sub

    Sub

    Sup

    Sup

    Positive belly-press test and Neer impingement sign

    Pain in abduction and external rotation

    Positive Hawkins and Neer impingement signs

    Tender anterior shoulder prominence and decreased external rotation strength

    Op

    Op

    Op

    Op

    6

    6

    12

    5

    Successful

    Successful

    Satisfactory

    Satisfactory

    Levine [24]

    14

    10 d

    Wrestling

    Sub

    Anterior tenderness, positive apprehension test, weakness during internal rotation

    Op

    4

    Successful

    Provance

    [26]

    13

    2 m

    Dodge ball

    Sub and biceps

    Pain with external rotation and abduction; positive lift off test

    Op

    11

    Successful

    Tosun [32]

    19

    33

    N/A

    3 d

    Traffic crash

    Fall after epileptic attack

    Sub

    Sub

    Pain on all active and passive movements

    Edema and tenderness to palpation over the anterior proximal humerus with restricted joint rotation

    Op

    Op

    3

    3

    Successful

    Successful

    Teixeira [31]

    14

    15 w

    Fly-fishing

    Sub

    Pain with internal rotation and resisted lift-off test, positive Neer and Kennedy-Hawkins impinge-ment sign, active compression test, Whipple test, crossed arm adduction

    Nonop

    3

    Successful

    Abbreviations: y = year; m = month; w =, week; d = day; N/A = not available; Sub = subscapularis; Sup = supraspinatus; Infra = infraspinatus; Op = operative; Nonop = non-operative. * Successful = return to previous level; Satisfactory = improvement without returning to previous level; Unsatisfactory = no improvement.

    Key Points

    • Rotator cuff tears in young patients are rare, but a high index of suspicion is necessary for making the diagnosis.
    • A comprehensive examination of the shoulder, including tests of the rotator cuff, should be done in young athletes with shoulder injuries.
    • Conventional radiographs are the best initial imaging study and should include an axillary view.
    • Magnetic resonance imaging can detect some lesions without apparent bone avulsions.
    • Lesions from repetitive motion can often be treated without surgery, whereas acute traumatic lesions with bone displacement may be best treated with surgery.

    Author Information

    Filippo Familiari, MD; Alan Gonzalez-Zapata, MD; and Edward G McFarland, MD, are from the Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland.

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