Rotator Cuff Syndrome

5/4/2019 Rotator Cuff Syndrome - MDGuidelines
Rotator Cuff Syndrome
Contributors
Contributors to the ACOEM Shoulder Disorders Guideline
Related Terms
Adhesive Capsulitis
Impingement Syndrome
Painful Arc Syndrome
Rotator Cuff Tear
Rotator Cuff Tendonitis
Supraspinatus Syndrome
Work ows
ACOEM Guidelines for Care of Acute and Subacute Shoulder Disorders
Initial Evaluation of Shoulder Disorders
Initial and Follow-up Management of Shoulder Disorders
Evaluation of Slow-to-Recover Patients with Shoulder Disorders (>4 Weeks)
Surgical Considerations for Shoulder Instability, Complete Rotator Cuff Tear, or Impingement Syndrome
Further Management of Shoulder Disorders
Overview
The shoulder is the most mobile of all the joints in the body. To attain this level of mobility, the shoulder
must sacri ce stability, in the form of less ligamentous attachments and bony stability. The shoulder,
therefore, is primarily stabilized by the rotator cuff muscles. The rotator cuff comprises four muscles — the
subscapularis, the supraspinatus, the infraspinatus and the teres minor — and their musculotendinous
attachments. The tendons that are linked to these four muscles attach to the humerus and fuse together to
form the rotator cuff.
If the rotator complex weakens in any capacity (such as from injury, deconditioning, or aging), the less able
the muscles will be to pull the arm rmly into the shoulder socket or joint. Therefore as the joint becomes
less stable, the humeral head can move around in the joint more easily. With increasing instability, several
dysfunctions and concomitant symptoms can arise (pain in the shoulder). Almost always, the rst
dysfunction or symptom to arise is pain. When the muscles are weak, the rotator cuff can no longer handle
the load of raising (abduction) and exing the arm. Examples of the movements that elicit pain include
putting on a seatbelt; washing one's hair; reaching for a glass in the cupboard; rolling over onto the shoulder
in bed; reaching to switch on a light, and driving (turning or steering) with the affected arm.
https://www.mdguidelines.com/mda/rotator-cuff-syndrome 1/12
The pain is also felt in a very distinct area, one that is classic for rotator cuff syndrome — the front of the
shoulder. This may be similar to the presentation for other shoulder conditions such as impingement, frozen
shoulder, rotator cuff tear biceps tendon tear and/or osteoarthritis.
There is some overlap with this diagnosis and the other conditions listed above. Some authors believe that
rotator cuff syndrome re ects instability in the shoulder due to muscle imbalance or weakness and that
rotator cuff tear is the nal common pathway (Ramsey).
Repetitive motion along with individual variations in the anatomy of the shoulder and trauma can lead to
rotator cuff injuries. Rotator cuff syndrome is a disorder most frequently diagnosed in those whose work
involves repeated or sustained raising of the upper arms more than 30° over horizontal. Such repetitive
motion may irritate the muscles and tendons by putting pressure against the bone at the top of the shoulder
blade. When the arm is raised repeatedly, front edge of the shoulder blade (acromion) can rub across the
rotator cuff (impingement syndrome or painful arc syndrome). If rotator cuff injuries are diagnosed early,
causes can be identi ed and effective treatments implemented, thereby preventing further injury or
deterioration.
Rotator cuff impingement syndrome is divided into three stages of severity. In stage I, swelling (edema)
and/or bleeding (hemorrhage) occurs. Stage I is frequently associated with an overuse injury. At this stage,
the syndrome can either be reversed or it can progress. In stage II, there is in ammation of the tendon
(tendinitis) and development of scar tissue ( brosis). Stage III frequently involves a tendon rupture or
muscle tear and often represents years of brosis and tendinitis.
Length of Disability
+ Medical treatment, rotator cuff syndrome.
JOB CLASS  MINIMUM OPTIMUM MAXIMUM
Sedentary 0 3 4
Light 0 3 7
Medium 14 21 42
Heavy 28 42 84
Very Heavy 28 42 84
+ Surgical treatment, arthroscopic rotator cuff repair.
Sedentary 7 10 21
Light 7 10 42
Medium 28 42 70
Heavy 56 84 112
Very Heavy 70 112 140
+ Surgical treatment, open rotator cuff repair.

Sedentary 7 14 70
Light 7 21 84
Medium 28 84 112
Heavy 56 98 140
Very Heavy 70 112 154
Factors In uencing Duration

Factors that may in uence disability include the individual’s age, occupation, and overall health, the severity
of symptoms, whether one or both shoulders are affected, whether the dominant or nondominant arm is
involved, whether the individual must perform overhead work, and whether the individual can be assigned a
job where full mobility of one shoulder is not needed.
Causation and Known Risk Factors

Risk factors for rotator-cuff related disorders are not well de ned. There are no large prospective cohort
studies that include physical examinations and detailed job-related physical exposure measurements to
compare, contrast, or quantify purported job-related physical factor risks (Hegmann).
The prevalence varies depending on the inclusion criteria. Studies suggest excessive cumulative daily loads
contribute to work-related shoulder conditions and that shoulder-arm pain seems related to psychological
factors (Melhorn, "Disease and Injury Causation").
Symptoms of rotator cuff syndrome often occur with repeated lifting of heavy weights over the head (e.g.,
painters, welders, plate workers, and slaughterhouse workers). However, this syndrome also has been
reported in sewing machine operators. It can occur in athletes who engage in sports such as swimming,
tennis, weightlifting, and baseball in which the arm is repeatedly raised over the head. Younger individuals
are more likely to experience rotator cuff syndrome as a result of trauma, overuse, shoulder (glenohumeral)
joint instability, or muscle imbalance. In older individuals, the syndrome is more commonly related to chronic
wear and shoulder degeneration. Rotator cuff syndrome is most common in the dominant arm.
Stage I rotator cuff syndrome is found most often in individuals under age 25; stage II occurs most often in
individuals between 25 and 40; stage III occurs mainly in individuals over age 50 (Quintana). Men develop
rotator cuff syndrome twice as often as women, possibly because of work activities as noted above. The
syndrome occurs independently of race, ethnicity, or geographic location.
Risk Factors
Risk factors for rotator-cuff related disorders are not well de ned. There are no large prospective cohort
studies that include physical examinations and detailed job physical exposure measurements to compare,
contrast, or quantify purported job physical factor risks. There also are no quality studies of bursitis and few
of impingement syndrome.
Rotator cuff disorders are not characterized by frank in ammation; however, in ammatory mediators may be
present in rotator cuff tear, tendinitis and impingement patients. These include increased: interleukin-1,(319-
321) interleukin-6,(321) tumor necrosis factor-alpha,(319, 321) basic broblast growth factor,(319)
transforming growth factor,(319) metalloproteinases,(321) CD2-positive T-lymphocytes,(322) tenascin-C,
(323) substance P(324) and vascular endothelial growth factor.(325) It is not known whether these factors
precede or are a consequence of the disease processes. Associations have been found between severity of
musculoskeletal disorders (MSDs) and in ammatory mediators.(326)
Some factors increase risk for shoulder pain, rotator cuff related disease, and atherosclerosis,(24, 70)
including obesity,(65, 66, 68-70, 310) smoking,(26, 65, 71-73, 327, 328) hypercholesterolemia,(329) and
diabetes mellitus.(67, 310, 330) These factors may be reduced with active exercise.(68) Genetic factors are
also reported risks.(269, 331)
Degenerative processes tend to occur in both shoulders(99). Risk factors reported for degenerative
processes include heredity,(331) ankylosing spondylitis,(335) rheumatoid arthritis, crystal diseases (gout,
pseudogout, hydroxyapatite), trauma,(91) and sports activities.(72)
Prevalence / Incidence
Shoulder pain is the third most common musculoskeletal disorder; estimates of all shoulder disorders are
10 per 1,000 population, with a peak incidence of 25 per 1,000 population aged 42 to 46 years. Among those
age 60 years or older, 21% were found to have shoulder syndromes, most of which were attributable to the
rotator cuff (Roy). Nevertheless, the actual incidence of rotator cuff syndrome is uncertain since about 34%
of the population may have a torn rotator cuff but no pain (Roy).
Work Relatedness
Shoulder tendinitis was found to be elevated in a cross-sectional study of shipyard welders(287) and
another study of shipyard plate workers.(288) However, both studies were limited by retrospective methods
without adjustments for potential confounders. EMG evidence of supraspinatus fatigue was found with
overhead shipyard welding.(289) A small case-control study of shoulder tendinitis cases found elevated
risks among those with hand use at or above the shoulder.(290) Another case-control study which measured
job physical factors found elevated risks among those with frequent activity and abduction or forward
exion more than 60º;(252) another found force to be associated with increased risk.(283) A moderately
large cross-sectional study reported 5-fold increased risks for a composite of multiple shoulder disorders
(rotator cuff tendinosis, frozen shoulder, acromioclavicular and glenohumeral degenerative joint disease)
among those with using high force or high repetition.(291) Other cross-sectional studies found elevated
risks of rotator cuff syndrome among sewing machine operators,(249) grocery checkers,(292) and sh
processing workers.(134) A population-based registry study of shery workers found elevated risks for
rotator cuff syndrome.(293) A cross sectional study from a retrospective cohort found elevated risks of
shoulder impingement syndrome among meat processing workers.(284) Another large cross sectional study
that included ergonomic assessments found high force and repetition to be associated factors of up to 3- to
4-fold magnitudes.(294) Workers with higher force requirements appear to have increased risk of shoulder
tendinosis and rotator cuff tears when identi ed in large administrative databases.(6, 295)
One prospective cohort study suggested high-hand force was associated with an increased risk of rotator
cuff tendinosis.(27, 66, 296) However, not all data support that supposition.(67, 91) High force and high
repetition, and repetition alone(297) are reported risk factors.(97, 298) Other data suggest working with the
hands above the shoulder is a risk factor(67) and another suggested long duration of shoulder exion.(66)
However, these results are not consistent among studies. Other studies have not found elevated risks of
shoulder tendinitis, including one of assembly line packers(299) and others of manufacturing workers,(300)
sewing machine workers,(300) heavy work,(301) bricklayers,(72) rockblasters,(72) and data entry workers.[1]
(302) A prospective cohort study to evaluate risks of shoulder postures found large within-group variance in
exposures and an inability to detect postural risks for shoulder disorders.(303) Unaccustomed use is
believed to be a risk factor, particularly involving forceful use that the individual does not normally perform.

Psychosocial factors have been associated with the presentation of rotator cuff tendinitis, including self
perception of poor health.(26, 304, 305) However, most studies of psychosocial factors evaluated combined
neck-shoulder disorders or shoulder girdle pain. These studies found risks that included stress,(26, 219) job
demand,(96, 218, 256, 306, 307) high distress,(218, 308) high psychological demand,(309, 310) low job
control,(66, 71, 96, 218) job strain,(236, 260, 274) low social support,(26, 218, 311) job dissatisfaction,(311,
312) depressive symptoms,(313) low job security,(66, 96) smoking,(26, 73) living alone with children,(26) low
socioeconomic status,(304) and work organizational issues.(314) Risks of disability were higher among
foreign-born workers and women in a Swedish population-based prospective cohort study.(315) Reduction
in risk of shoulder and neck pain has been reported with regular leisure time physical activity.(316) However,
another study suggested inconclusive evidence of the relationship between physical capacity and risk of
shoulder pain.(317) A Finnish study reported increased risk of early retirement, particularly among those
with heavy physical work combined with low cardiorespiratory tness.(318)
Diagnosis
Initial Assessment
Patients are clinically diagnosed based on their history and physical examination. Additional tests are
frequently performed on initial evaluation for more severe presentations, but often are not required in mild
cases. X-ray is recommended and may be needed of both shoulders, particularly if there is a bilateral injury
or need for comparison with the unaffected shoulder. Other studies are often helpful, including MRI,
especially for evaluation of potential rotator cuff tears or SLAP tears.
Diagnostic Criteria
Patients with rotator cuff tendinoses have varying clinical presentations, thus there are no consensus
diagnostic criteria that have proven effective. Patients generally have gradual onset, non-radiating
glenohumeral joint pain. There are no distal paraesthesias. Rotator cuff tears may present with either acute
or gradual onset pain. Impingement signs are often positive.
History
A complete medical history, including the individual's occupation and recreational activities will be taken. A
good description of the shoulder pain including the onset, timing, location, radiation, quality of pain,
aggravating and alleviation factors, presence of associated symptoms, and association with any activities
helps to diagnose rotator cuff syndrome. The key is that the initial pain is felt only in the front of the
shoulder. Over time the individual may report aching pain in the shoulder or referred pain along the outside
upper arm. The pain often worsens when the arm is lifted overhead and at night. Other symptoms may
include weakness and reduced range of motion. The onset of symptoms is often gradual.
Physical Examination
Examination of the shoulder begins with a thorough inspection for any deformities, scars, edema, or
decrease in muscle bulk (atrophy). Next, the entire shoulder joint and all of its muscle groups are palpated
for tenderness. Both active and passive range of motion is determined by rotating the individual's arm
through different planes, noting any decrease in range of motion and any pain. The pain may be more
intense with certain movements or when pressure is applied; it can disappear with other movements. There
may be a grating, clicking or cracking sound (crepitus) in the shoulder. Muscle strength testing and
neurological testing should be performed. Special maneuvers during the physical examination (such as the
Neer impingement, Hawkins-Kennedy impingement, drop-arm, apprehension, and relocation tests) may be
helpful. A thorough exam includes evaluation of the cervical spine along with both arms and shoulders.
Medical History Questionnaire

ACOEM Medical History Questionnaire for Shoulder Disorders
Tests
X-rays (anteroposterior view, axillary view, supraspinatus view) are an essential component of evaluation to
rule out calcium deposits in the joint, and bone or joint diseases. If symptoms do not improve following 3 to
6 weeks of conservative therapy, other advanced imaging modalities may prove helpful, especially in
diagnosing suspected rotator cuff tears. MRI detects a wide spectrum of rotator cuff disease, including
degeneration and partial to complete tears. It can also reveal soft tissue abnormalities, and proves
especially valuable in tracking postoperative healing. Ultrasonography proves useful in diagnosing
moderately large rotator cuff tears and evaluating other cuff disease. Widespread use of arthrography has
decreased with the advent of MRI, but it remains useful in individuals for whom MRI is contraindicated (e.g.,
those with a pacemaker, cerebral aneurysm clip, or recent cardiac stent). Arthrography involves injection of
contrast media into the glenohumeral joint followed by plain x-rays. Observed leakage of contrast material
into the subacromial or subdeltoid spaces following injection indicates a full-thickness rotator cuff tear.
Other diagnostic tests for rotator cuff syndrome are bone scintigraphy and CT scan, often with contrast
media (CT-arthrography). Electromyography (EMG) and nerve conduction velocity studies (NCVs) may be
helpful if neurologic involvement is suspected.
GO TO DART
Treatment
During the acute phase of rotator cuff syndrome, conservative treatment consists of rest and activity
modi cation, ice, and the use of (NSAIDs). The goals are to decrease in ammation and pain and restore
normal shoulder function. Activities causing the pain should be resumed gradually when pain is gone.
Sometimes a cortisone injection into the space above the rotator cuff tendon (subacromial corticosteroid
injection) helps relieve swelling and in ammation. Application of ice to the tender area for 15 minutes 3 to 4
times a day also is helpful as is a supervised program of stretching and strengthening exercises to increase
range-of-motion. Recovery of function should be stressed. An on-going home exercise program is essential
to help prevent recurrence. Surgery may be considered for those individuals who show no improvement after
3 months of aggressive therapy or who continue to be bothered by weakness. The decision to perform
surgery would be based on progression of condition from “syndrome” to perhaps impingement, rotator cuff
tear, or frozen shoulder.
Indications for surgery vary but should take into consideration an individual’s age, type and severity of tear
(partial to full-thickness muscle tears), duration of symptoms, and willingness and ability to comply with
postoperative therapy. The main goals of surgery are improved strength, increased function, and pain relief.
Chronic rotator cuff syndrome with severe impingement may be treated by cutting into the shoulder and
repairing the bone and/or tendon and/or the muscle (arthroscopic acromioplasty). Rotator cuff surgery is
done to repair a torn rotator cuff. (See Rotator Cuff Repair topic.) Bone spurs or calcium deposits causing
impingement may be removed at the same time. Surgery must be followed by physical therapy to improve
strength and range-of-motion followed by an on-going home exercise program.
GO TO DART
Prognosis
Recovery often depends on the stage of the syndrome and the age of the individual. Some individuals whose
rotator cuff syndrome is caused by repetitive above-the-shoulder lifting may recover completely if the
repetitive work is stopped and an aggressive, nonsurgical treatment plan (i.e., ice, strengthening, and range-
of-motion exercises) is followed. Success rates with such conservative treatment range from 33% to 90%,
with longer recovery times noted in older individuals (Quintana). Surgical outcomes often depend on the
willingness and ability of an individual to participate actively in postoperative physical therapy and home
exercise. The reported success rate for surgery to treat torn rotator cuffs is between 77% and 95%
("Shoulder Rotator"; Quintana). In many individuals who resume overhead work or other activity that initially
caused the problem, recurrent episodes may continue despite appropriate acute treatment. These
individuals need to alter their work or recreational activities.
The outcome for impingement syndrome (which may be similar to rotator cuff syndrome) is usually good to
excellent dependent on age and job activities (Melhorn) However, durations will be longer if the following
factors are identi ed: awkward posture (hand over shoulder), high forceful effort, high job demand, and
limited decision making by patient are predictors of chronic shoulder pain at work (Herin).
Length of disability, like disability durations are dependent on the cause for the rotator cuff syndrome (such
as impingement), the treatment provided, and the job activities required. The disability durations are also
affected by the age of the patient and their physical condition (capacity) prior to the onset of their rotator
cuff syndrome (Talmage, "Work Ability and Return to Work").
Differential Diagnosis
Acromioclavicular injury
Adhesive capsulitis
Avascular necrosis
Cervical disc disease
Cervical radiculopathy
Cervical spondylosis
Cervical strain
Fibromyalgia
Myocardial infarction (MI)
Myopathy
Osteoarthritis
Rheumatoid arthritis
Ruptured tendon
Shoulder dislocation
Suprascapular nerve entrapment
Thoracic outlet syndrome
Rehabilitation
Rotator cuff syndrome represents a precursor to a shoulder impingement syndrome and possible
progression to rotator cuff tear. The early goals of rehabilitation for rotator cuff syndrome are to decrease
pain and in ammation and to reduce the stress on the irritated tendon and/or tissues (Morrison, "Shoulder
Impingement"; Rubin). In conjunction with pharmacological management, individuals are instructed in the
use of cold treatments to the shoulder to decrease in ammation. Reduction of stress to the irritated
tissue(s) is often achieved through education, ergonomic adjustments, and/or work modi cations aimed at
reducing the offending activities, which often include repetitive movements or sustained positions where the
elbow is raised above the shoulder level. Posture must also be addressed as thoracic kyphosis can
contribute to shoulder impingement.
As with other tendinopathies there are several phases of therapy. After pain and in ammation is controlled
and work modi cations made, range of motion and strengthening should be addressed. Stiffness may be
prevented by passive range of motion exercises conducted during supervised rehabilitation and a home
exercise program (Ludewig). Posterior capsule stretching is recommended to restore normal mobility of the
glenohumeral joint and help reduce impingement. Strengthening should initially address scapulothoracic
stabilizers, then progress to eccentric strengthening of scapulothoracic and rotator cuff muscles (Morrison,
"Non-Operative Treatment"; Morrison, "Shoulder Impingement"; Rubin). Proprioception is then emphasized
with eventual progression to open chain activities and then task- or sport-speci c skills (Bowen).
Some evidence from randomized controlled trials suggests that manual therapy in conjunction with a
program of strengthening and stretching is more bene cial than strengthening and stretching alone (Bang).
Throughout rehabilitation, exercise intensity and duration should be increased until full functional ability is
regained (Rubin).
While many individuals respond well to the conservative management of rotator cuff syndrome, surgical
intervention may be required.
Frequency of Rehabilitation Visits

Classi cation Specialist Visits
Surgical Physical or Occupational Therapist Up to 16 visits within 8 weeks
Nonsurgical Physical or Occupational Therapist Up to 8 visits within 8 weeks
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It
provides a framework based on the duration of tissue healing time and standard clinical practice.
Comorbidities
Diabetes mellitus
Osteoarthritis
Osteoporosis
Tendon tears
Trauma to the shoulder
Complications
The main complication of rotator cuff syndrome occurs when rotator cuff tears go undiagnosed. Symptoms
will persist until the rotator cuff is repaired surgically. Another complication results from inadequate
treatment. If the shoulder is immobilized in a sling, the individual can develop "frozen shoulder" (adhesive
capsulitis). Conditions such as a rotator cuff tear or impingement syndrome may also lead to decreased
range of motion in the shoulder. An estimated 4% of rotator cuff ruptures result in joint disease (arthropathy)
of the shoulder (Quintana). Proper care, whether conservative or surgical, and appropriate follow-up lessen
the likelihood of joint disease and other long-term consequences of rotator cuff syndrome.
Ability to Work
Aggravating activities need to be avoided or limited until symptoms have improved or been relieved. During
early treatment, the individual should limit or not lift, carry, push, or pull heavy objects. Individuals should
limit or refrain from using the arm for above-the-shoulder activities. These guides rarely become permanent.
An ergonomic evaluation of the workplace may be helpful. A change in job duties, sharing or alternating
tasks, a reduced work rate, more frequent rest breaks, and limits on the time and frequency of repetitive
activities may be reasonable accommodations. Worksite modi cations may include using forearm rests for
individuals who frequently use computer keyboards, headsets for those who answer telephones, and
modi cations to reduce repetitive activities that involve raising the arms overhead. For example, using a
single step for a short-statured individual that can be removed for a taller individual may be a reasonable
accommodation. Individual attention and education can encourage recognition and avoidance of
aggravating activities, awareness of shoulder mechanics and early signs of rotator cuff syndrome, and use
of proper warm-up techniques (Talmage, "Work Ability and Return to Work", Table 12-1).
Risk
Reinjury is possible, but most individuals are on modi ed work.
Capacity
Capacity is dependent on age and physical conditioning before the onset of symptoms. Young and well-
conditioned individuals often return to work activities sooner and with less recurrence than older individuals,
those in poor physical condition, or those with reduced endurance (Talmage, "Work Ability and Return to
Work").
Tolerance
Tolerance of shoulder discomfort is typically the limiting factor with shoulder impingement. Non-surgical
treatment will often result in improvement over a prolonged period of time (Melhorn). The ability to work
through the pain is unique to each individual. Education can modify tolerance.
Accommodations
Most individuals will get better with time and therapy. An employer’s willingness to make accommodations
allows the individual time to recover. Older individuals may require more time. Tolerance and
accommodation determine the nal ability to return to work. Modi cations to the workplace or modi cations
to the job task may allow many individual to return to modi ed work.
Maximum Medical Improvement

This topic refers to pain in the rotator cuff. If no speci c diagnosis is available, MMI should occur at 30 days
after therapy and stable function.
If surgery is required, see "Rotator Cuff Repair" and "Rotator Cuff Tear."
Failure to Recover
If an individual fails to recover within the expected maximum duration period, the reader may wish to
consider the following questions to better understand the speci cs of an individual's medical case.
Regarding Diagnosis
Does individual have symptoms of rotator cuff syndrome, such as aching pain in the shoulder, especially
with reaching overhead?
Does individual have an occupation that requires lifting heavy weights overhead?
Was a good description of the pain obtained?

Has individual had adequate testing to establish the diagnosis?
Have conditions with similar symptoms been ruled out?
Regarding Treatment
Did individual respond to conservative treatment?
Was a cortisone injection administered?
Was surgery necessary? Was it successful?
Regarding Prognosis
Has individual stopped overhead work, repetitive lifting, and carrying?
Has individual actively participated in the physical therapy?
Does individual follow a home exercise program?
Does individual have any conditions that may affect recovery?
Did any complications arise?
Hospital Costs
The following hospitalization statistics are derived from the 2016 Nationwide Inpatient Sample (NIS),
provided by the Healthcare Cost and Utilization Project (HCUP). The 2016 NIS provides all-payer data
(including persons covered by Medicare, Medicaid, private insurance, and the uninsured) on approximately 7
million inpatient stays from about 4,500 hospitals; this approximates a 20-percent strati ed sample of
discharges from U.S. community hospitals.
Hospitalization statistics are presented by ICD-10-CM and Diagnosis Related Groups (DRGs). DRGs were
established by the Centers for Medicare and Medicaid Services as a patient classi cation scheme to
account for the severity of illness, prognosis, treatment di culty, need for intervention, and resource
intensity.
Hospital Charges in USD represents the median amount hospitals charge for an entire hospital stay. This
amount does not include professional (MD) fees. Charges do not necessarily represent actual
reimbursement.
+ M75.101 - Unspeci ed rotator cuff tear or rupture of right shoulder, not speci ed
as traumatic
DRG Length Medicare Private Other

of / Payer
Stay Medicaid
Major joint & limb reattachment proc of upper extremity with 1 $65,828 $66,292 -
CC/MCC
Tendonitis, myositis & bursitis without MCC 2 $30,854 - -
*Inpatient statistics were only calculated if at least 100 records per group were present in the 2016
NIS
This site displays data obtainable in 2018 (the year that HCUP released its 2016 NIS data base).
Follow-Up Care
Patients with rotator cuff tendinopathies usually require follow-up appointments, particularly if they are
undergoing active treatment(s), need assistance with advancing a course of exercises, and/or require
signi cant work limitations that need frequent adjustments. Frequencies of appointments may also be
greater when more workplace limitations are required and job demands are greater. Patients with rotator
cuff tears who undergo surgical repair may require at least several weeks to a few months of post-operative
rehabilitation. Patients with rotator cuff tears managed non-operatively (generally small tears and/or with
minimal or short-duration impairment and/or with other comorbid conditions) may require longer duration
limitations and slower recovery may occur. In those cases, the patient may require therapy on a prolonged
basis in order to recover as much function as possible.
Post-operative rehabilitation has been empirically derived and has emphasized a graded return to normal
function. It is generally believed that earlier advancement of exibility, strengthening, and conditioning
exercises results in faster recovery(826); however, initiating rehabilitation early in the healing process has
also been thought to increase potential for failure of surgical repairs such as rotator cuff repairs and has
provided some caution regarding early use of exercise. Initial emphasis is on both protecting the repair and
regaining shoulder motion. The usual progression is passive range of motion (self-assisted which some
consider to be active assisted), isometrics (about 6 weeks post-op), and progressive resisted exercises
(after 12 weeks). There are multiple variables that affect the timing of exercises after shoulder surgery.
These include the procedure performed, pre-operative physical condition, age, and patient compliance. (827)
See the post-operative section for impingement syndrome and tendinoses for general recommendations.
These recommendations should be adapted to the more extensive surgery for rotator cuff tears and
therefore slower initial recovery.
References
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General
Mercier, L. R. "Rotator Cuff Syndrome." Ferri's Clinical Advisor 2009. Ed. Fred Ferri. Philadelphia: Mosby,
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Rotator Cuff Syndrome - MDGuidelines

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Rotator Cuff Syndrome - MDGuidelines

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5/4/2019 Rotator Cuff Syndrome - MDGuidelines

JOB CLASS  MINIMUM OPTIMUM MAXIMUM

+ Surgical treatment, arthroscopic rotator cuff repair.

JOB CLASS  MINIMUM OPTIMUM MAXIMUM

Very Heavy 70 112 140

+ Surgical treatment, open rotator cuff repair.

JOB CLASS  MINIMUM OPTIMUM MAXIMUM

Very Heavy 70 112 154

Factors In uencing Duration

Causation and Known Risk Factors

Medical History Questionnaire

Frequency of Rehabilitation Visits

Surgical Physical or Occupational Therapist Up to 16 visits within 8 weeks

Nonsurgical Physical or Occupational Therapist Up to 8 visits within 8 weeks

Maximum Medical Improvement

Was a good description of the pain obtained?

DRG Length Medicare Private Other

Tendonitis, myositis & bursitis without MCC 2 $30,854 - -

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