Rotator cuff injury

ROTATOR CUFF INJURY
PRESENTED BY:- PUSHPENDRA YADUVANSHI
ASST. PROF. & HEAD
DEPARTMENT OF PHYSIOTHERAPY,
CAREER POINT UNIVERSITY KOTA

Rotator cuff tears are tears of one or more of the four
tendons of the rotator cuff muscles.
 A rotator cuff injury can include any type of irritation or
damage to the rotator cuff muscles or tendons.
Rotator cuff tears are among the most common conditions
affecting the shoulder.

Of the four tendons, the supraspinatus is most
frequently torn as it passes below the acromion;
the tear usually occurs at its point of insertion
onto the humeral head at the greater tuberosity.

The shoulder joint is made up of three bones:
The shoulder blade (Scapula),
The collarbone (Clavicle) and
The upper arm bone (Humerus).
The shoulder is a complex mechanism of intertwining
bones, ligaments, joints, muscles, and tendons:

Bone is living tissue that makes up the body's skeleton
providing shape and support.
The bones that form the shoulder are the
 Clavicle
 Humerus,scapula
 Glenoid fossa
 Acromion
 Coracoid processe

 These 2 bones create a ball-and-socket joint.
 Also known as the glenohumeral joint. that give
the shoulder its wide range of motion
 In order for this joint to be operational ligaments,
muscles, and tendons help support the bone;
keeping it in place.

 Ligaments and joints are formed from
the connection between two bones that
are adjacent.
 Examples of both ligaments and joints
are represented by the glenohumeral,
acromiclavicular, and sternoclavicular
regions.

The major muscle groups of the rotator cuff are
the:-
Supraspinatus
Subscapularis
 Infraspinatus
 Teres minor

The cuff plays two main roles: it stabilizes the
glenohumeral joint and rotates the humerus outward.
 The cuff centers the humeral head in the glenoid cavity via
passive effects and, more importantly, via active
multidirectional effects.
 In other words, the cuff prevents upward migration of the
humeral head caused by the pull of the deltoid muscle at the
beginning of arm elevation.
 Furthermore, two cuff muscles, the infraspinatus and the
teres minor, are the only muscles that ensure external
rotation of the arm.

 The four tendons of these muscles converge to
from the rotator cuff tendon.
 Supraspinatus
 Subscapularis
 Infraspinatus
 Teres minor

Tears of the rotator cuff tendon are described as
 partial thickness tears,
full thickness tears and
full thickness tears with complete detachment of the
tendons from bone.
•Partial thickness tears often appear as fraying of an
intact tendon.

•Full thickness tears are through-and-through tears.
These can be small pin-point tears or larger button
hole tears or tears involving the majority of the
tendon where the tendon still remains substantially
attached to the humeral head and thus maintains
function.

Shoulder pain is variable and does not always
correspond to the size of the tear.
For surgical purposes classifying the tendon
further is needed in order to determine the
correct repair strategy.
Neer generalized the concept of rotator cuff
disease in 3 stages.

Stage I occurs in those younger than 25 years and involves
edema and hemorrhage of the tendon and bursa.
Stage II involves tendinitis and fibrosis of the rotator cuff in 25-
to 40-year-olds.
Stage III involves tearing of the rotator cuff (partial or full-
thickness) and occurs in those older than 40 years. Before surgery
every aspect of the shoulder needs to be taken into account.

Therefore, it has further been described depending on the
tear location (articular, bursal, complete),
size or area (in mm2),
 depth (grade 1, <3 mm deep; grade 2, 3–6 mm deep; grade
3, >6 mm deep).
 And still further measurements are taken to classify the
acromiohumeral distance, acromial shape, fatty infiltration or
degeneration of muscles, muscle atrophy, tendon retraction,
vascular proliferation, chondroid metaplasia, and calcification.

Age-related degeneration of thinning and
 disorientation of the collagen fibers,
 myxoid degeneration
 hyaline degeneration also need to be taken into
consideration before a surgery plan is implemented.

Tears are also sometimes classified as
acute,
 subacute, and
 chronic based on the trauma that caused the injury:
•Acute tends to happen as a result of a sudden, powerful
movement. This might include falling over onto an
outstretched hand at speed, making a sudden thrust
with the paddle in kayaking, or following a powerful
pitch/throw.

•Subacute arises in similar situations to acute
•Chronic develops over a period of time, usual occurs at or
near the tendon (as a result of the tendon rubbing against the
overlying bone), and is usually associated with an
impingement syndrome.

WHEN TO CALL THE DOCTOR
 If shoulder pain lasts more than 2 days
 If shoulder problems (pain) do not allow you to work
 If you are unable to reach overhead to get an item in a
cabinet above shoulder level, for example
 If you are unable to play a certain sport such as baseball or
engage in an activity such as swimming

WHEN TO GO TO THE HOSPITAL
 For any acute injury in which you are unable
to move the injured shoulder as well as the
uninjured shoulder, seek emergency medical
care.

MODE OF INJURY
 A fall on the shoulder
 An attempt at lifting a heavy object
 Throwing heavy objects with over head
action

CAUSES
 Shoulder
 Non Shoulder

SHOULDER
 Direct problem to Shoulder joint
 Frozen Shoulder
 Tendinitis of rotator cuff
 Bicipital Tendinitis
 Dislocation around Shoulder

NON SHOULDER
 Dibetes
 CVD
 RSD
 A complication of colles’#

Diagnosis is based upon
a physical assessment and a detailed history of the
patient
 including descriptions of previously participated
activities
 acute or chronic symptoms experienced.
 The physical examination of a shoulder deals with a
systematic approach constituting inspection, palpation,
range of motion, strength testing, and neurological
testing.

Common medical studies used in diagnosing a
rotator cuff tear include
 X-ray
 MRI
 ultrasound techniques.

 These Acute symptoms include severe pain that
radiates through the arm
tenderness at the site of injury
 and limited range of motion, specifically during abduction
motions of the shoulder.

 Symptoms that persist as a result of a chronic
rotator cuff tears are
 Sporadic worsening of pain
 Debilitation and atrophy of the muscles
 Noticeable pain during rest
 Crackling sensations when moving the shoulder,
and inability to move or lift the arm sufficiently,
especially during abduction and flexion motions.

Pain in the anterolateral aspect of the shoulder can be
due to many causes, symptoms may reflect pathology
outside of the shoulder which cause referred pain to
the shoulder from sites such as the neck, heart or gut.

Symptoms of a rotator cuff tear may advance instantly
after a trauma (acute) or develop gradually, yet
persistently over time (chronic).
Acute injuries are not as frequent as chronic rotator cuff
disease. Acute tears occur following bouts of forcefully
raising the arm against resistance, which are evident
during weight lifting.
In addition, falling forcefully on the shoulder can elicit
acute symptoms.

Patient history will often include
pain or ache over the front and outer aspect of the
shoulder,
pain aggravated by leaning on the elbow and pushing
upwards on the shoulder (such as leaning on the armrest of
a reclining chair),
intolerance to overhead activity,
pain at night when lying directly on the affected shoulder,
pain when reaching forward (e.g. unable to lift a gallon of
milk from the refrigerator).

Weakness may be reported.
With longer standing pain, the shoulder is favored and
gradually loss of motion and weakness may develop which,
due to pain and guarding are often missed by the patient
and are only brought out during the examination.

Primary shoulder problems may cause pain over the deltoid
muscle that is made worse by abduction against resistance,
called the impingement sign.
 Impingement reflects pain arising from the rotator cuff but
cannot distinguish between inflammation, strain, or tear.
 Patients may report their experience with the impingement
sign when they report that they are unable to reach upwards
to brush their hair or to reach in front to lift a can of beans up
from an overhead shelf.

1. FORWARD ELEVATION (MAXIMUM
ARM-TRUNK ANGLE)
2. ABDUCTION (NOTE CLASSIC PAINFUL
ARC)

3. EXTERNAL ROTATION (ARM
COMFORTABLY AT SIDE)
4. EXTERNAL ROTATION (ARM AT 90
DEGREE ABDUCTION)

5. INTERNAL ROTATION (HIGHEST POSTERIOR
ANATOMY REACHED WITH THUMB)
6. IMPINGEMENT I (PASSIVE FORWARD
ELEVATION IN SLIGHT INTERNAL ROTATION)

7. IMPINGEMENT II (PASSIVE ABDUCTION
90 DEGREE EXTERNAL ROTATION)
8. IMPINGEMENT III (PASSIVE ABDUCTION
90 DEGREE INTERNAL ROTATION)

9. IMPINGEMENT IV (PASSIVE
ADDUCTION: CROSSOVER) 10. FORWARD FLEXION

11. EXTERNAL ROTATION (ARM COMFORTABLY AT
SIDE--TERES MINOR/INFRASPINATUS)
12. INTERNAL ROTATION (ARM
COMFORTABLY AT SIDE--SUBSCAPULARIS)

 X-RAY
 MRI
 ULTRASOUND

 X-rays cannot directly reveal tears of the rotator cuff as the
tendon is made of soft tissue and not bone.
 Normal x-rays cannot rule out a torn or damaged rotator
cuff.
Large tears of the rotator cuff may allow the humeral head
to migrate upwards ( high riding humeral head) and this can
be seen on x-ray.

 Prolonged contact between a high riding humeral
head and the acromion above it, may lead to x-
rays findings of wear on the humeral head and
the acromion and secondary degenerative
arthritis of the glenohumeral joint(the ball and
socket joint of the shoulder) may ensuecalled
cuff arthropathy.

MRI
Magnetic resonance imaging (MRI) or ultrasound are
comparable to examine the rotator cuff.
The MRI can reliably detect most full thickness tears,
although very small pin point tears can be missed.
If a small pin point tear is suspected, an MRI combined with
an injection of contrast material, called an MR-arthrogram
may help to confirm the diagnosis.

 MRI of normal shoulder
intratendinous signal

 The MRI is sensitive in identifying tendon degeneration
(tendinopathy), however, the MRI may not be able to
reliably distinguish between a degenerative tendon and a
partially torn tendon.
Magnetic resonance arthrography can improve the
differentiation of rotator cuff degeneration from partial
or complete rotator cuff tears.

 The MRI provides more
information about
adjacent structures in
the shoulder such as the
capsule, glenoid labrum
muscles and bone. These
are factors to be
considered in each case
when selecting the
appropriate study.

Ultrasound
Ultrasound studies have also been reported as a means of
identifying rotator cuff tears.
Unlike x-rays which require exposure to radiation and MRI
studies which are costly, ultrasound studies have been
advocated as an alternative, when read by experienced
clinicians.

Ultrasound can also reveal the presence of other conditions
that may mimic rotator cuff tear at clinical examination,
including tendinosis
calcific tendinitis
subacromial subdeltoid bursitis
greater tuberosity fracture
 and adhesive capsulitis

Patients suspected of having a rotator cuff tear are divided
into two treatment groups
non-operative treatment
operative

Non-operative treatment
Patients with pain and maintenance of reasonable function
are generally treated for pain relief at first.
Non-operative treatment of shoulder pain thought to be
related to the rotator cuff, or a tear of the rotator cuff,
includes:
oral medications that provide pain relief such as anti-
inflammatory medications
topical pain relievers such as cold packs
subacromial cortisone/local anesthetic injection

 Iontophoresis
A sling may be offered for comfort for a day or two, with the
awareness that the shoulder can become stiff with prolonged
immobilization, which is to be avoided.
 Early physical therapy may afford pain relief with modalities
(ex. iontophoresis) and help to maintain motion.
 Ultrasound treatment
As pain decreases, strength deficiencies and biomechanical
errors can be corrected.
 Home exercises may be obtained

Each patient is given a home therapy kit, which includes
elastic bands of six different colors and strength.
The program is customized to each individual patient, fitting
the needs of the patient and altering when necessary.
 Patients are asked to do all their home exercise program on
their own whether that be at home, at work, or when
traveling.

INVASIVE TREATMENT
Rotator cuff tear surgical procedure
If conservative treatments have yielded poor results, surgery
is considered to repair the torn tendons.

There are several surgical options for treatment of a rotator
cuff tear.
The exact type of surgery may depend on factors including
the degree of tendon disruption,
 location of the tear,
patients preferred activities, and
presence or absence of bone spurs that may be contributing
to the tear.

The three general approaches of
 surgical repairs are
 arthroscopic repair,
 mini-open repair, and
 open surgical repair.
 In the recent past small tears were treated
arthroscopically, while larger tears would usually
require an open procedure.

 Arthroscopic surgery allows for a shorter recovery time and
predictably less pain in the first few days following the
procedure than does open surgery.
arthroscopic repair, open repair (6–10 cm incision), or mini-
open repair (3–5 cm incision) will often include an
acromioplasty, a subacromial decompression, as part of the
procedures. Subacromial decompression consists of removal
of a small portion of the bone (acromion) that overlies the
rotator cuff, hoping to relieve pressure on the rotator cuff in
certain conditions and promote healing and recovery.

Although subacromial decompression may be beneficial to
partial and full thickness tears, this procedure does not
consists of physically repairing the tears. The repair can be
performed through an open incision, again requiring
detachment of a portion of the deltoid.
The mini-open technique approaches the tear through
a deltoid splitting approach.
This seemingly causes less damage to the deltoid
muscle and may produce better results.

Modern techniques now use an all arthroscopic
approach.
Surgical recovery can take as long as
3–6 months, with a sling being worn for the first 1–6
weeks.

Rotator cuff injury

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