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Clinical diagnosis for shoulder labrum vs. rotator cuff

Exit forum ID Forum Discussion Clinical diagnosis for shoulder labrum vs. rotator cuff

This topic contains 6 replies, has 4 voices, and was last updated by   Brandon Cohen DC, CSCS September 26, 2019 at 12:50 am.

Viewing 7 posts - 1 through 7 (of 7 total)
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  • #7991

    Brandon Cohen DC, CSCS
    Participant

      48 yr old male
      active crossfitter
      I have been working on managing his load for a long time, and he is compliant and trying to keep things to a minimum.
      Dx: Rotator cuff adhesion
      Shoulder joint pathology, likely labral tear

      We have done some treatment for his right shoulder. Range is near full with pinching in the superior shoulder.
      We have done 3 visits. First visit gave us sustained progress, but visits 2-3 produced reflex changes of full range of motion.

      We got the MRA.

      Findings are: Near complete tear of supraspinatus tendon. No discrete labral tear.

      I’m not super savy on reading Shoulder MR, but my question is how can I best clinically determine the difference between rotator cuff tears and labral tears?

      I was pretty confident it was labrum, but now I’m not sure at all. I suppose I could have left it at “tear in your shoulder, so we should get an MRI,” but I would like to have better certainty than that.

      Also, speed’s test and O’brien’s were both negative.

      Thanks team.

      #7992

      Doc Nina
      Participant

        Hey Brandon!
        Here are some hopefully helpful tips:

        So we are on the same page I suspected you did Speeds because the biceps tendon inserts into the labrum? and of course you did O’Brians because its commonly done for suspected labral pathology.

        Ortho’s for rotator cuff include: Apley (best one), Codmans sign, Mazion shoulder maneuver, and subacrombial push-button sign.

        Supraspinatus specific include subacormial push-button and impingement sign (which can also be for biceps).

        Symptoms:

        Labrum: If there was audible clicking, popping, a grinding sensation, pain moving the arm or lifting overhead then a labrum pathology was not outside the differential list.

        Rotator cuff: If there was more a dull ache deep in the shoulder with weakness, positive Apley test, pain that disturbs sleep especially laying on the affected shoulder would be more consistent with a rotator cuff pathology.

        Rotator cuff tendinitis: Tenderness in the front of the shoulder with pain at the midpoint of the arm is usually due to rotator cuff tendinitis.

        Pain induced mostly by activity, or made worse with activity is generally attributed to shoulder arthritis, but many patients with GH joint arthritis will have symptoms which would put labrum and rotator cuff pathology on the differential.

        You ordered the MRA, which was the right move, and it did reveal pathology, and no it was not the one you had suspected but you knew based on your clinical assessment and response to treatment that there was something else going on other than adhesion. You did the right thing in my opinion.

        Hope that helps!

        Cheers!
        Dr. Nina

        #7993

        Adam Holen D.C.

          What is the mechanism for pain at night with a rotator cuff tear (esp sleeping on that side)? That wouldn’t also apply for a joint problem (compression of the joint)? I’ve always thought it was more an indication of a joint problem vs. rotator cuff, so I need to shore that understanding up!

          As Dr. Nina mentioned, I usually look for the more obvious labral signs like clicking, catching, grinding, “popping” out of place, or protective weakness in certain positions/motions. Pain in multiple locations around the joint. Described as “deep” ache in the joint (difficult to identify exact location), sometimes sharp when loading the tear. I tend to lean more toward provocative motions the patient details vs orthopedic tests and test them passive, active, and resisted to gauge severity. Any previous history of trauma to the shoulder. Then try to balance the more ambiguous case details like age, load, and genetic durability. Although without the more “obvious” signs it seems difficult to differentiate a labrum tear outright vs. cartilage damage/arthritis.

          For rotator cuff tears, like 80%+ of them are SS, especially overuse and (age-related) degenerative. Pain or tenderness in the proximal bicep region, empty can test, oftentimes pain in the anterior/lateral delt with SA as the tendon is under load. For crossfitters I find lateral shoulder movements become progressively limited/more painful.

          That’s roughly how I differentiate based on sx location, quality, and provocative. However, I haven’t seen many/if any SS tears as the only thing that shows up on MRI/MRA, for someone like your patient (48 yo with high load). If this guy has/had adhesion and SS tear, would adhesion and high load be enough to degenerate one tissue (SS) in isolation of other shoulder pathologies like labrum or cartilage? If so, what’s the general likelihood of that?

          Sorry, I have more questions than answers for this one.

          #8024

          Brandon Cohen DC, CSCS
          Participant

            Taking a deeper look at this pateint, he has all the signs and symptoms of labral damage, but lacks a painful arc with ROM.

            He has pain is specific positions and very clear motions. Most provocative test is end range of shoulder flexion overhead, where he gets a pinch in the superior shoulder and feels “stuck.” This is clearly protective tension of some kind that I interpreted as protection of the labrum, and not the rotator cuff.

            Theoretically, a torn rotator cuff would disrupt the stability of the joint, and it could be jamming into itself at end range causing the same symptom.

            I don’t find Appley’s or many other orthos to be to helpful in this situation as his range of motion was 90% of shoulder abduction.

            There seems to be more overlap in symptoms of rotator cuff and labrum pathology than I realized, and will stick to the, “We need to get imaging to see what is wrong in the shoulder” kind of conversation.

            He has no pain at night, and only with loading, mostly overhead.

            Adam, The imaging doesn’t show any tendinosis so far as I can tell other than a bit on the SS tendon. I’m not super savvy on the shoulder MRIs and sometimes radiologist just put down what they think you want and not all the findings (grrrrrrrr), but the rest of the shoulder looks healthy to me.

            Damage to one tissue seems unlikely, but not impossible. Sometimes rare things happen. I spoke with him since, and he had two episodes of trauma in the past couple of years that could have produced a tear.

            Thank you for your help.

            #8049

            Doc Nina
            Participant

              Hey Brandon,
              If I am understanding your original post on this patient, the MR Arthrogram did NOT show labral pathology? MRAs are very sensitive and specific for diagnosing any labrum damage, and it would be unlikely for there to be something there if the radiologist indicated otherwise.

              If you would like you could share the MRI with me, I would need the whole study, through a drop box and I could give you my opinion. I just finished a radiology residency in Southern California, and did rounds with the MSK radiologists at the nations number one trauma center in LA. In our practice here I evaluate all imaging, but have not yet found that any labrum pathology is missed by the original radiologist.

              Further, I am confused as to why you think that orthos, such as Apley’s hold no value simply because the shoulder abduction test was 90% which if I understand Dr. Brady correctly means he can bring his biceps to touch his head bilaterally?

              In my radiology experience working with both MD and DC radiologists I do not agree that we tend to “include what we think you want” so much as we include what is most pertinent and of the most value, and then there are those of us who will include every single finding no matter how incidental or mundane it may be. But a labrum pathology is not something myself, or any other MSK radiologist would leave out if it was there.

              Feel free to contact me at drnina@barefootrehab.com if you would like me to take a look at the MRA.

              Cheers!
              Doc Nina

              #8056

              James Phipps

                Brandon,
                I would have handled this case just like you did. If you could predict the exact pathology present in the shoulder 100% of the time that would be impressive. So going with “you have a tear in the shoulder” seems like a better option to me. Even if you did a full can test and it produced pain over the supraspinatus tendon adding RC tendon deg/tear on your dx list… doesn’t mean you 100% only have a tendon tear. Half the time when these come back you have a little labral, RC, and bicep tendon involvement so I always tend to be more general.

                A patient who has reflex change with treatment, no adhesion, manages their load and still has pain needs imaging and it showed you exactly what you needed. Now you have an explanation for why he is still in pain. Lets say hypothetically you could do 50 orthopedic tests and know this guy only had a RC tear…that wouldn’t have changed your treatment plan at all.

                #8058

                Brandon Cohen DC, CSCS
                Participant

                  Nina-
                  Thanks for your response. I understand that MRAs are sensitive for labral pathology, which is the reason it was ordered in the first place. I understand that it would be unlikely that there was pathology that was missed, but sometimes it happens. I am quite comfortable reading lumbar spine MRI, and conservatively would guess that 30% of the time I see something that is relevant that is not in the report. In those cases I am very comfortable calling up the radiologist and asking them about what I think I see. We have a conversation and generally, the report will be amended as appropriate. Radiologists are doing their best, but sometimes miss something. Just as when I have observers in the office, or am working on passes at a seminar with Dr. Brady, Dr. Scharf, Dr. Lytle, and Dr. Notolli watching I am extra careful to do things as good as I possibly can. Radiologist are just other people that sometimes miss things. I am just not comfortable in my own ability to see labral tears to be confident in making that call. I am not terribly concerned in this case as he has a visible rotator cuff tear and will likely be getting surgery to repair it.

                  I’m sorry you understood that I said that orthos have no value. My purpose in doing tests in the office is to rule things out on my diagnostic list. If the tests don’t give me more information than I already have from other evaluations, I struggle to want to add other data points to my exam that will cloud the picture. Apley’s, and the other tests won’t really tell me more than SA, furthermore, based on the criteria outlined above for rotator cuff, he doesn’t have a rotator cuff tear. After getting the imaging it shows that he does.

                  At the end of the day, the case just violated my expectations. We all have cases that don’t make sense. I had a guy with 80% ROM of the shoulder and had complete tears of supra, infra, and subscap with retraction following a trauma 10 years before. Ortho didn’t want to touch it. It didn’t make any sense. He was super fortunate to have such great range, and no pain. No pain. Based on the ID tests for shoulder, and palpation, I knew he had tears and some issues, but didn’t imagine it was going to be that bad.

                  JJ-
                  Thanks Bro. Go Bills.

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