Rotator cuff disorder

Presented by Aser mohamed kamal

Physiotherapist

Describe anatomy of rotator cuff muscles. ROTATOR CUFF FUNCTION ETIOLOGY CLINICAL DIAGNOSIS INVESTIGATION OUTLINE OF MANAGEMENT

Objectives

an anatomical term given to the group of muscles & their tendons that act to stabilize the shoulder.

These muscles are :1. Supraspinatus .2. Infraspinatus .3. Teres minor .4. Subscapularis .

Rotator Cuff

action Nerve supply

insertion origin

Abduction of the shoulder joint from 0-15 degrees

Suprascapular nerve

Top of greater

tuberosity of humerus

Med 2/3 of supraspinus fossa of the

scapula

supraspinatus

External rotation of shoulder

joint

Suprascapular nerve

Middle impression of greater tuberosity

of humerus

Med 2/3 of infraspinus fossa of the

scapula

Infraspinatus

Adduction and external rotation of shoulder

joint

Axillary nerve

Lower impression of greater tuberosity

of humerus

Upper 1/3 of dorsal

aspect of lat border of scapula

Teres minor

Adduction and internal rotation of shoulder

joint

Upper and lower

subscapular nerve

Lesser tuberosity

of the humerus

Med 2/3 of the

subscapular fossa of the

scapula

Subscapularis

the subacromial space

hold the head of the humerus in the small and shallow glenoid fossa of the scapula. During elevation of the arm, the rotator cuff compresses the glenohumeral joint in order to allow the large deltoid muscle to further elevate the arm. In other words, without the rotator cuff,

the humeral head would ride up partially out of the glenoid fossa and the efficiency of the deltoid muscle would be much less.

Function of Rotator Cuff

injury to 1 or more of the 4 muscles in the shoulder. This shoulder injury may come on suddenly and be associated with a specific injury such as a fall (acute), or it may be something that gets progressively worse over time with activity that aggravates the muscle(s) (chronic).

can range from an inflammation of the muscle without any permanent damage, such as tendinitis, to a complete or partial tear of the muscle that might require surgery to fix it

ETIOLOGY

Intrinsic Factors◦ Reduce Vascular supply (significance)◦ “Tendonitis”◦ “Bursitis”• “Bone spur” Acromion rubs on the rotator cuff and

bursa • bursitis and tendonitis early• rotator cuff tear over time◦ Degenerative changes

Age related Change in proteoglycan and collagen content in

symptomatic tendons

Pathophysiology

◦ Impingement in which a tendon is squeezed and rubs against bone. Acromial spurs

Type III acromion and decreased geometric area of the supraspinatus outlet Increased prevalance of symptomatic

cuff disease Coracoacromial ligament AC joint osteophytes Coracoid process Posterior superior glenoid

Pathophysiology

Extrinsic factors◦ Repetitive use

Tensile overload Muscle fatigue Microtrauma

◦ Glenohumeral instability Accentuates abnormal loading Can lead to internal impingement

Pathophysiology

As larger muscles fatigue, the posterior capsule and rotator cuff play a larger role in decelerating the arm.

Leads to tensile overload and fatigue As rotator cuff fatigues, it no longer

performs it’s role in keeping the humeral head centered.

This leads to superior migration of the humeral head and impingement.

This leads to pain and muscle inhibition…. ……and the cycles repeats itself

Impingement

Pain and/or

fatigue of cuff

Rotator Cuff

dysfunction

Impingement with motion

Impingement

Men = women Any age Ache Activity related Night pain Treatment from Weeks to months• Started after Too much…• Computer use• Gardening• Heavy lifting• Tennis• Golf• Throwing• fishing

Impingement

• Impingement signs• Neer

• Pain with passive forward flexion while internally rotated

• Hawkins• Pain with passive internal

rotation while abducted 90 degrees

Impingement

Diagnose with history, physical exam, xrays, and a likely successful result with conservative treatment

Impingement

Initial treatment• Relative rest• Ice• Anti-inflammatory medications• cortisone injection• Physical therapy:

1.electoro therapy (U.S, faradic ,ir ) 2.passive and active ROM

3.stretching ex 4.muscle energy techniques

5.trigger points realease 6.posture correction

Impingement

• 90% successful with non-operative treatment Shot Medicine Exercises/Posture Correction

Impingement

Cortisone Injection• primary indication is difficulty sleeping

70% improved with a single shot 20% better with a second shot If no better, Check MRI

• Consider arthroscopic subacromial decompression if symptoms persist

Impingement

• Arthroscopic subacromial decompression

• 30 minute day surgery

• General anesthesia and a nerve block/pain pump

• Sling 2-4 weeks

• No restrictions

• Begin rehab exercises immediately

• 2-3 months to feel better

Impingement

As a result of microtrauma and inflammation.

Capsule tightens and can no longer accommodate humeral head as it rotates.

Leads to obligatory anterior-superior migration of humeral head.

Reduces subacromial space

Posterior Capsular Tightness

Adhesive capsulitis◦ Capsule surrounding shoulder ball and socket

scars and “shrink wraps” itself inhibiting full motion and causing pain

Frozen Shoulder

• Severe pain Front of Shoulder

• constant• stiff• Getting worse• May or may not know why• No injury• Shortly after minor injury• following breast or heart surgery

40 - 60 years old Women > Men Thyroid disease Diabetes Heart disease Will Occur on Opposite Side 30% of Time

Frozen Shoulder

Three phases• Inflammatory• Frozen• Disability

Loss of exernal rotation Passive and active motion loss Normal strength

Frozen Shoulder

Initial treatment• Time

18+ months to spontaneous resolution• Pain medicine• Cortisone injections

2-3 • Stretching

May help or worsen Arthroscopic capsular release with manipulation• If not improved with initial conservative measures• Capsule and ligaments are partially excised• Stretched to full motion while anesthetized• Cortisone Injection

Frozen Shoulder

Arthroscopic capsular release with manipulation• Sling 2-4 weeks for comfort only• Immediate motion• Immediate therapy to maintain motion• Capsulitis may grow right back without stretching

Frozen Shoulder

• Rare• Calcium buildup inside tendon

• Cortisone injection• Arthroscopic removal

Calcific Tendonitis

Detachment of the tendon from the bone

Does not heal on own Acute: single injury greater than

threshold Chronic: long term overuse, wear and

tear

Rotator Cuff Tear

history• Injury (25%)• Pain without injury (75%)• Loss of overhead or behind the back activity

without pain Symptoms• Pain: anterior superior shoulder or deltoid insertion

Rest Night activity related

• Weakness or disability• instability

Rotator Cuff Tear

Exam findings• Weakness/Pain• Active motion loss/Pain• Passive motion maintained

Rotator Cuff Tear

Diagnosed with• History• Exam• Xrays• Mri (or ultrasound)

Rotator Cuff Tear

Full thickness

Partial thickness

Rotator Cuff Tear

Nonoperative • cortisone injection• physical therapy• oral analgesics

Temporary relief It will get worse with time

Rotator Cuff Tear

Rotator Cuff TearArthroscopic rotator Cuff Repair

• Sling 1 month• Healing 3 months• 98% with small tears• 50-85% with large tears

• Maximum recovery 6 – 12 months

Rotator Cuff TearArthroscopic rotator Cuff Repair

• Arthroscopic Rotator cuff tear Repair: predictors of success• Tear size• Small < 1.5 cm• Large >3 cm

• Age of Tear• Muscle and Tendon Atrophy

• Patient age• <62 years

• Tobacco usage

Rotator Cuff TearArthroscopic rotator Cuff Repair

Rotator Cuff TearArthroscopic Allograft Cuff Augmentation