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Home Providers & Professionals E-Guidelines Rotator Cuff Disease (Also known as Rotator Cuff Syndrome) | |||||||
E Guidelines A-Z Index A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
Entitlement Eligibility GuidelinesRotator Cuff Disease
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MPC | 01319 |
ICD-9 | 726.1 |
Rotator Cuff Disease is a disorder of the musculotendinous cuff surrounding the glenohumeral joint (see Anatomy and Physiology).
Please note: Entitlement should be granted for a chronic condition only. For VAC purposes, 'chronic' means that the condition has existed for at least 6 months. Signs and symptoms are generally expected to persist despite medical attention, although they may wax and wane over the 6 month period and thereafter.
A diagnosis from a qualified medical practitioner is required. Radiographic changes are dependant upon the stage of the disease, with most changes occurring in advanced stages. Standard x-rays may be routinely obtained to rule out other disease processes. Electromyography, arthrography, shoulder arthroscopy or MRI tests may be required.
For pension purposes, location must be specified as to right or left, and evidence of duration of a disability for at least 6 months should be provided.
Back to TopThe chief muscles producing glenohumeral joint motion are the deltoid, pectoralis major and minor, teres major, latissimus dorsi and those of the rotator cuff. All rotation comes through the glenohumeral joint. The predominant stability in this joint occurs from the centering effect provided by the musculotendinous or rotator cuff. The rotator cuff muscles consist of the subscapularis, the supraspinatus, the infraspinatus, and the teres minor.
The rotator cuff is regarded as having the following three functions:
The rotator cuff is usually covered by a thin film of bursal tissue, i.e. the subdeltoid or subacromial bursae. Factors that impact on the rotator cuff also impact on the bursae, and inflammation of both structures often occurs together.
Rotator Cuff Disease is a continuum of pathology starting with inflammatory changes in the subacromial bursa and rotator cuff tendons, which may continue on to become a rotator cuff tendon rupture or tear. The supraspinatus insertion into the greater tuberosity passes directly between the coracoacromial arch when the upper extremity is elevated to the overhead position. The area beneath the coracoacromial arch is known as the supraspinatus outlet. If the rotator cuff insertion impinges or abuts against the coracoacromial arch on a chronic basis, as may occur in overhead labourers, the structures in the supraspinatus outlet (i.e. the bursae, rotator cuff and biceps) may become inflamed. This cumulative soft tissue trauma can eventually result in pain and/or dysfunction and is called subacromial impingement.
Subacromial impingement has been classified into the following three stages:
The affected individual may have weakness, pain, and tenderness, and may have limited ranges of shoulder abduction and external rotation.
Pain is the most consistent symptom. It is generally present at the greater tuberosity and anterior acromion. It can extend into the deltoid muscle. It may also be referred to the elbow, chest wall, or trapezius muscle. Pain may also affect the acromioclavicular joint (AC joint), if the joint is arthritic or involved in the impingement process. Weakness and loss of function may be secondary to pain, or to stage 3 disease where a rotator cuff tear is present.
There may be tenderness at the greater tuberosity and anterior acromion, and at the AC joint and biceps tendon if the latter are involved in the impingement process. A positive arc-of-motion test may be present. Forward flexion of the shoulder to 90 degrees with internal rotation of the humerus, called Hawkins' impingement sign, reproduces pain. Muscle of the affected arm may be normal or mildly diminished. X-rays may show calcific deposits of the rotator cuff tendons.
It should be noted that while calcification of the rotator cuff is often seen in association with Rotator Cuff Disease, its role in the etiology of the disease is not known. Calcification is not felt to contribute to the development of Rotator Cuff Disease.
Back to TopThe timelines cited below are not binding. each case should be adjudicated on the evidence provided and its own merits.
For overuse to cause or aggravate Rotator Cuff Disease, the following should be evident*:
**The definitions and criteria apply to a normal joint. The total time per day or total number of days required to qualify as overuse may be less when the joint is abnormal or where other pertinent circumstances exist. To illustrate:
Overuse means high repetition and/or extreme posture of the soft tissues at or above the shoulder joint for a substantial part of the day prior to clinical onset or aggravation.
High repetition means actions performed more than 2 to 4 times a minute, of cycles less than 30 seconds.
Extreme posture means over half of range of movement of the shoulder joint.
Substantial part of the day means for a total of 2 hours or more per day.
Determination of a service-relationship for an overuse syndrome will generally depend on whether the overuse factors can be seen to have arisen out of or to be directly connected with the performance of military duties.
Repetition that causes or aggravates rotator cuff tendinitis involves cyclical flexion, extension, abduction, or rotation of the shoulder joint.
Occupations at risk for rotator cuff tendinitis include automobile exhaust system repair, plumbing, mechanical maintenance, construction work, factory and assembly line work, poultry processors, riveters, welders, mail carriers, telephone operators, grocery store checkers, garment workers, orchard workers, and dentists.
Activities at risk for rotator cuff tendinitis include baseball, weight lifting, racquet sports, and swimming freestyle, butterfly or backstroke.
Repetition that causes or aggravates subacromial bursitis includes repetitive use of the upper extremity with shoulder movement and, in particular, overhead work.
Repetition that causes or aggravates bicipital bursitis includes highly repetitive use requiring movement of the shoulder, and sustained shoulder postures, especially in flexion and abduction.
Occupations at risk for bicipital bursitis include assembly of heavy equipment, red-meat slaughterhouse work, farm work or harvesting, manufacturing, assembly line work, and grocery store checking.
For specific trauma to cause or aggravate Rotator Cuff Disease, the following should be evident:
Specific trauma is physical injury to the soft tissue around the shoulder joint occurring prior to onset or aggravation of Rotator Cuff Disease.
Overuse injuries of the rotator cuff may be caused or aggravated when individuals use their upper limbs to transfer body weight (e.g. from a wheelchair to a bed due to a permanent inability to use the lower limbs).
Spontaneous tear of the rotator cuff may occur in persons with Rheumatoid Arthritis or Systemic Lupus Erythematosus as part of the pathological process with invasion from underlying pannus.
Diabetes Mellitus has been shown to be epidemiologically significant; the cause is thought to be multifactorial.
Persons receiving maintenance hemodialysis can develop dialysis arthropathy as a complication of dialysis. The shoulder is the most common joint affected.
For hemodialysis treatment to cause or aggravate Rotator Cuff Disease, it should have occurred for a period of at least one year immediately prior to clinical onset or aggravation of Rotator Cuff Disease.
Suffering from excess laxity of the glenohumeral joint of the shoulder prior to clinical onset or aggravation
Excess laxity can result in at least partial dislocation and may result from, for example, shoulder dislocations, and weakness of muscles which stabilize the shoulder joint.
For excess laxity to cause or aggravate Rotator Cuff Disease, it should have occurred for a period of at least one year immediately prior to clinical onset or aggravation of Rotator Cuff Disease.
An 'anatomical narrowing of the subacromial space' is a narrowing between the acromion and upper end of the humerus. This may occur as the result of malunion following acromial or humeral greater tuberosity fractures or from osteophytes which project into the subacromial space.
For anatomical narrowing of the subacromial space to cause or aggravate Rotator Cuff Disease, it should have occurred for a continuous period of at least three months immediately prior to clinical onset or aggravation of Rotator Cuff Disease.
Medical Conditions Which are to be Included in Entitlement/Assessment
Any accompanying soft tissue pathology surrounding the glenohumeral joint including but not limited to:
Pathology of the acromioclavicular joint is excluded.