ROTATOR CUFF: ANATOMY, INJURIES AND CLINICAL

EVALUATION

DR MOHAMMAD SAJIDJR ORTHOPAEDICS (2nd SEM)

Shoulder joint anatomyBones and Joints

GlenohumeralAcromioclavicular

Glenohumeral joint

Shoulder Joint Anatomy cont.

•A ball-and-socket joint• Most mobile joint in the body and most frequently dislocated •Provides motion i.e. flexion, extension, abduction, adduction and circumduction

Shoulder Anatomy cont.

Glenoid

Humeral head

NEED FOR ROTATOR CUFF ???

The Rotator Cuff The flattened tendons of

Supraspinatus, Infraspinatus, Teres Minor and Subscapularis muscles fuse with the joint capsule to form the rotator cuff

Thus provides stability to the the humeral head centered on the glenoid regardless of the arm’s position in space

Generally work to depress the humeral head while powerful deltoid contracts

MUSCLE ORIGIN INSERTION NERVE ACTION COMMENT

1.Supraspinatus

Supraspinatus fossa (scapula)

Greater tuberosity (superior)

Suprascapular

Abduct arm (initiate),

Trapped in impingement #1 torn tendon (RC tear)

2.Infraspinatus

Infraspinatus fossa (scapula)

Greater tuberosity (middle)

Suprascapular

ER arm, stability

Weak ER: damage to nerve. lesion in notch

3.Teres Minor Lateral scapular

Greater tuberosity (inferior)

Axillary ER arm, stability

Dissection can damage circum-flex vessels

4.Subscapularis

Subscapular fossa (scapula)

Lesser tuberosity

Upper & Lower Subscapular

IR, adduct arm, stability

Can rupture in anterior dislocation

Rotator Cuff Injuries

Rotator cuff pathology is a common problem

Cadaver studies have reported tears in 30-50 % of specimens

Neer introduced the concept of continuum of impingement syndrome

Stage 1- edema and haemorrhage Stage 2- fibrosis and tendinitis Stage 3- bone spurs and tendon rupture

• Loss of continuity of rotator cuff can be described in several ways

• Acute and chronic• Traumatic and degenerative• Partial thickness ( less than

50% depth of tendon) and Full thickness

– Small (< 1cm)– Medium (1-3 cm)– Large (3-5 cm)– Massive (> 5 cm)

History Older patients – no history of

trauma, changes in collagen proteoglycan and water content associated with aging/ degeneration

Younger patients- high energy injury, repeated overuse

Pain ( typically in the night) Weakness Loss of active motion

Clinical Evaluation Inspection: atrophy, symmetry Palpation: greater tuberosity,

acromiaclavicular joint, bicipital groove, coracoid process, cuff tenderness

Range of motion: active, passive Strength: ER and elevation

power, lag Provocative: impingement sign,

arc of pain

Provocative Tests

1. Neer Impingement Test 2. Hawkins Kennedy Impingement Sign 3. Jobe / Empty Can Test4. Internal Rotation Resistance Stress Test5. Gerber Subcoracoid Impingement Test6. Jobe Apprehension Relocation Test7. Speed Test8. Yergason Supination Sign

Neer Impingement Test

Pain is elicited during forward flexion of the shoulder while keeping the arm in full pronation (thumb down). Pain with this manoeuvre is a sign of subacromial impingement

Hawkins Kennedy Impingement SignPain is elicited after first forward flexing the arm to 90º and then applying internal rotation. Pain with this manoeuver suggests subacromial impingement or rotator cuff tendonitis

Jobes Empty Can Test

•Patient is asked to abduct shoulder to 40 degrees, with 30 degrees forward flexion and full internal rotation (i.e. turned so that the thumb is pointing downward)

•Direct them to forward flex the shoulder, without resistance

•Repeat while offering resistance

•Shows weakness of supraspinatus

Internal Rotation Resistance Stress Test

•Performed in the seated position with the examiner positioned behind the patient•The arm is positioned in 90° of abduction in the coronal plane and approximately 80° of external rotation. •A manual isometric muscle test is performed for external rotation and then compared with one for internal rotation in the same position•If a patient has good strength in external rotation in this position and apparent weakness in internal rotation- the test is positive

Gerber Subcoracoid Impingement Test

                                                                                                                                            

•Useful in identifying shoulder impingement caused by impingement between the rotator cuff and the coracoid process•The patient is placed in the sitting position and the affected upper extremity is forward flexed 90 degrees and then adducted 15 to 20 degrees across the body to bring the lesser tuberosity of the humerus into contact with the coracoid process

Jobe Apprehension Relocation Test

The patient's arm is abducted to 90 degrees while the examiner externally rotates the arm and applies anterior pressure to the humerus

Speeds Test

•Speed's manoeuver is used to examine the proximal tendon of the long head of the biceps•The patient's elbow is flexed 20 to 30 degrees with the forearm in supination and the arm in about 60 degrees of flexion•The examiner resists forward flexion of the arm while palpating the patient's biceps tendon over the anterior aspect of the shoulder

Yergason Supination Sign

The patient's elbow is flexed to 90 degrees, and the examiner resists the patient's active attempts to supinate the arm and flex the elbow. Patients with rotator cuff tendonitis frequently have concomitant inflammation of the biceps tendon. The Yergason test is used to evaluate the biceps tendon

The tests described next are designed to assess rotator cuff integrity and fall into two types

1. Tests that determine whether a movement can be undertaken actively

2. Tests that determine whether a passive position can be maintained ( the lag signs)

Gerbers Lift Off Test

•Tests the integrity and function of subscapularis muscle•The arm is completely rotated internally and dorsum of the hand is placed against the lower back with the elbow flexed•If the patient is unable to lift the dorsum of the hand off the back against resistance indicates weakness or rupture of the muscle

Belly Press (Napolean) Test

•Patient presses the abdomen with the flat of the hand and attempts to keep the arm in maximal internal rotation•If the strength of the subscapularis is impaired, maximal internal rotation cannot be maintained, the patient feels weakness, and the elbow drops back •Or can only exercise abdominal pressure by a retropulsion of the arm and by bending the wrist

External Rotation Stress Test

•Patients arms by his or her side in neutral flexion and abduction, the shoulders are externally rotated 45 to 60 degrees•The examiner applies force against the dorsum of the hands, attempting to rotate the shoulders internally back to neutral while the patient is asked to resist•Pain and weakness

External Rotation Lag Sign

•The patient is asked to maintain the position of maximal external rotation actively as the examiner maintains support of the arm at the elbow•The sign is positive in case of a lag or angular drop

Drop Sign

•This test is performed by passively abducting the patient's shoulder, then observing as the patient slowly lowers the arm to the waist.•Often, the arm will drop to the side if the patient has a rotator cuff tear or infraspinatus dysfunction

Internal Rotation Lag Sign

Inability to hold hand away from the lumbar region in maximal internal rotation

Hornblower’s Sign (Patte Test)

Strength of the teres minor Abduct the patient’s arm to 90

degrees in the scapular plane Flex the elbow to 90 degrees,

and the patient is asked to laterally rotate the shoulder

A positive test occurs (patient raises elbow) with weakness and/or pain

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