Rotator cuff - Wikipedia, the free encyclopedia

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Rotator cuff

Rotator cuff

Muscles on the dorsum of the scapula, and theTriceps brachii.

The scapular and circumflex arteries.

From Wikipedia, the free encyclopedia

In anatomy, the rotator cuff (sometimesincorrectly called a "rotator cup", "rotor cuff", orrotary cup [1]) is a group of muscles and theirtendons that act to stabilize the shoulder. The fourmuscles of the rotator cuff are over half of theseven scapulohumeral muscles.

Contents [hide]

1 Function2 Muscles comprising rotator cuff3 Injuries

3.1 Rotator cuff tear3.2 Rotator cuff impingement3.3 Treatment

3.3.1 Reduce pain and swelling3.3.2 Posture and sleeping positions3.3.3 Strengthening3.3.4 Non-Operative Treatment3.3.5 Surgery

3.3.5.1 Surgery for the Rotator Cuff3.3.6 Rehab

4 Imaging4.1 Shoulder imaging4.2 Conventional x-rays

4.2.1 a.-p.-projection 40° posterior obliqueafter Grashey4.2.2 Transaxillary projection4.2.3 Y-projection

4.3 Ultrasound4.4 MRI

4.4.1 Magic angle artifact4.4.2 MRA

5 Additional images6 See also7 References

The rotator cuff muscles are important in shoulder movements and in maintaining glenohumeraljoint (shoulder joint) stability.[2] These muscles arise from the scapula and connect to the head ofthe humerus, forming a cuff at the shoulder joint. They hold the head of the humerus in the small

Function [edit]

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Rotator cuff - Wikipedia, the free encyclopedia

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and shallow glenoid fossa of the scapula. The glenohumeral joint has been analogously describedas a golf ball (head of the humerus) sitting on a golf tee (glenoid fossa).[3]

During abduction of the arm, moving it outward and away from the trunk, the rotator cuffcompresses the glenohumeral joint, a term known as concavity compression, in order to allow thelarge deltoid muscle to further elevate the arm. In other words, without the rotator cuff, thehumeral head would ride up partially out of the glenoid fossa, lessening the efficiency of thedeltoid muscle. The anterior and posterior directions of the glenoid fossa are more susceptible toshear force perturbations as the glenoid fossa is not as deep relative to the superior and inferiordirections. The rotator cuff's contributions to concavity compression and stability vary according totheir stiffness and the direction of the force they apply upon the joint.

Despite stabilizing the glenohumeral joint and controlling humeral head translation, the rotator cuffmuscles also perform multiple functions, including abduction, internal rotation, and externalrotation of the shoulder. The infraspinatus and subscapularis have significant roles in scapularplane shoulder abduction (scaption), generating forces that are two to three times greater thanthe force produced by the supraspinatus muscle.[4] However, the supraspinatus is more effectivefor general shoulder abduction because of its moment arm.[5] The anterior portion of thesupraspinatus tendon is submitted to significantly greater load and stress, and performs itsmainfunctional role.[6]

Muscle Origin onscapula

Attachment onhumerus

Function Innervation

Supraspinatusmuscle

supraspinousfossa

superior and middle facetof the greater tuberosity

abducts thearm

Suprascapular nerve(C5)

Infraspinatusmuscle

infraspinousfossa

posterior facet of thegreater tuberosity

externallyrotates the arm

Suprascapular nerve(C5-C6)

Teres minormuscle

middle half oflateral border

inferior facet of thegreater tuberosity

externallyrotates the arm

Axillary nerve (C5)

Subscapularismuscle

subscapularfossa

lesser tuberosity (60%) orhumeral neck (40%)

internallyrotates thehumerus

Upper and Lowersubscapular nerve (C5-C6)

The supraspinatus muscle fans out in a horizontal band to insert on the superior and middlefacets of the greater tubercle. The greater tubercle projects as the most lateral structure of thehumeral head. Medial to this, in turn, is the lesser tuberosity of the humeral head. Thesubscapularis muscle origin is divided from the remainder of the rotator cuff origins as it is deepto the scapula.

Main article: Rotator cuff tear

The tendons at the ends of the rotator cuff muscles can become torn, leading to pain andrestricted movement of the arm. A torn rotator cuff can occur following a trauma to the shoulder orit can occur through the "wear and tear" on tendons, most commonly the supraspinatus tendonfound under the acromion.

Rotator cuff injuries are commonly associated with motions that require repeated overhead

Muscles comprising rotator cuff [edit]

Injuries [edit]

Rotator cuff tear [edit]

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motions or forceful pulling motions. Such injuries are frequently sustained by athletes whoseactions include making repetitive throws, athletes such as cheerleaders, baseball pitchers, softballpitchers, American football players (especially quarterbacks), weightlifters, especially powerliftersdue to extreme weights used in the bench press, rugby players, volleyball players (due to theirswinging motions)[citation needed], water polo players, rodeo team ropers, shot put throwers (due tousing poor technique)[citation needed], swimmers, boxers, kayakers, western martial artists, fastbowlers in cricket, tennis players (due to their service motion)[citation needed] and tenpin bowlersdue to the repetitive swinging motion of the arm with the weight of a bowling ball.

This type of injury also commonly affects orchestra conductors, choral conductors, and drummers(due, again, to swinging motions).

Main article: Impingement syndrome

A systematic review of relevant research found that the accuracy of the physical examination islow.[7] The Hawkins-Kennedy test[8][9] has a sensitivity of approximately 80% to 90% fordetecting impingement. The infraspinatus and supraspinatus[10] tests have a specificity of 80% to90%.[7]

As with all muscle injuries, R.I.C.E. is an initial response to injury recommended by healthproviders:

Rest means ceasing movement of the affected area.Icing uses ice to reduce inflammation.Compression limits the swelling.Elevation involves placing the area higher to reduce inflammation and swelling.

Cold compression therapy shoulder wraps facilitate the icing and compression of an otherwisedifficult body area to ice and compress.

Depending on severity of symptoms, further imaging with radiograph, or MRI may be warranted tosee if surgery or an underlying bone injury exists.

Postures and sleeping positions may be modified to provide relief. But as your shoulder begins toheal, sleeping positions may vary considerably.[11]

The rotator cuff can be strengthened to rehabilitate shoulder injuries, and prevent future ones.There are different exercises to target the individual rotator cuff muscles.

Description Beginning End

The most effective is the side-lying externalrotation, which activates the supraspinatus,subscapularis, infraspinatus and teresminor.

Lie on a bench sideways, with the affectedarm next to the side and flexed about 90degrees at the elbow. Rotate the upper armoutward, keeping the elbow flexed and the

Rotator cuff impingement [edit]

Treatment [edit]

Reduce pain and swelling [edit]

Posture and sleeping positions [edit]

Strengthening [edit]

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arm close to the body, until the lower arm isperpendicular to the ceiling (see picture).For added resistance, use a dumbbell. Paceat two seconds out and four seconds back.

This is an excellent all-around shoulderexercise.

The propped external rotator targets theinfraspinatus and teres minor.

Sit perpendicular to the dumbell with armflexed at 90 degrees at the elbow, and theforearm resting parallel on the dumbell.Raise the dumbbell up until the forearmpoints up. Slowly lower the dumbbell andrepeat, exercising both arms.

The posterior deltoid also aids in externalrotation. Like the posterior deltoid, both theinfraspinatus and teres minor also contributeto transverse extension of the shoulder,such as during a bent over row to thechest. They can be trained in this waybesides isolating the external rotationaction.

The lateral raise with internal rotation(LRIR) primarily targets the supraspinatus.

Grasping a dumbbell in each hand,internally rotate the arms so that thethumbs point towards the floor whenextended (as if emptying a drink into a bin).Raise the arms sideways, keeping thethumbs pointing downwards, until thedumbbells are just below the shoulders.

This exercise is sometimes called a lateralraise.

Strengthening the rotator cuff allows for increased loads in a variety of exercises. Whenweightlifters are unable to increase the weight they can lift on a pushing exercise (such as thebench press or military press) for an extended period of time, strengthening the rotator cuff canoften allow them to begin making gains again. It also prevents future injuries to the glenohumeraljoint, balancing the often-dominant internal rotators with stronger external rotators. Finally,exercising the rotator cuff can lead to improved posture, as without exercise to the externalrotator, the internal rotators can see a shortening, leading to tightness. This often manifests itselfas rounded shoulders.

Non-Operative Treatment [edit]

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Non-operative treatment is often the first line of treatment for rotator cuff injuries. If the tendonsare strained or torn less than 50%, they respond well to an aggressive non-operative approach.Non-operative measures can include physical therapy, oral or injected medications, biologicaugmentation such as PRP, ultrasound therapy, dry needling, and other modalities. It will oftentake 3 months to recover with non-operative measures.

Even for full thickness rotator cuff tears, conservative care (i.e., non-surgical treatment) outcomesare usually reasonably good.[12] However, many patients still suffer disability and pain despitenon-surgical therapies. For massive tears of the rotator cuff, surgery has shown durable outcomeson 10 year follow-up.[13] However, the same study demonstrated ongoing and progressive fattyatrophy and repeat tears of the rotator cuff. Shen has shown that MRI evidence of fatty atrophy inthe rotator cuff prior to surgery is predicative of a poor surgical outcome.[14] If the rotator cuff iscompletely torn, surgery is usually required to reattach the tendon to the bone.[15]

Surgery for the rotator cuff can be for complete tears, or partial tears/strains that fail to get better.If a torn rotator cuff goes untreated for too long, it may become un-repairable and so shoulderpain should not be ignored. Surgery often consists of removing damaged tissue and repairing thegood tissue back to the bone. Bone spurs and inflammation (bursitis) is also removed to try toprevent re-tears. all arthroscopic rotator cuff repairs can fix most tears through 4-5 smallincisions. On occasion a patch needs to be placed on the rotator cuff tendons which requires alarger incision. Many times, the biceps tendon is damaged with rotator cuff tears and may alsorequire biceps tenodesis surgery at the same time.

The rehab for rotator cuff surgery falls into three basic categories; some damage to the tendonswith surgery consisting of debridement, removing spurs and cleaning out inflammation, tearsrequiring repair with excellent quality tendon tissue, and tears requiring repair with poor qualitytendon tissue. The first category, rehab consists of early active and passive range of motionexercises focused on maintaining range of motion for 4 weeks and then strengthening and returnto sports from weeks 4-8. Repaired tendons with excellent quality will begin full passive motionearly, start active motion from weeks 4-8, strengthening from 8-12 and return to sports after 3–4months. Repairs with poor tissue quality will have no motion early on, start passive motion after2–4 weeks, active at 6–8 weeks, strengthening at 4 months and return to sports at 6 months.Your doctor will guide you through the rehabilitation process.

There are several ways to depict the structures of the shoulder, which consist of muscles,tendons, bones, cartilage and soft tissue. When deciding which medical imaging technique shouldbe used, there are a couple of factors that need to be taken into account. Firstly, one has toconsider the suspected clinical diagnosis. Together with the knowledge of the advantages andlimitations of the various medical imaging techniques ( i.e. conventional radiography, ultrasound,computer tomography and magnetic resonance), one has to make an informed decision whichtechnique would best suit the specific situation.Hodler et al. recommend to start scanning with conventional x-rays taken from at least twoplanes, since this method gives a wide first impression and even has the chance of exposing anyfrequent shoulder pathologies, i.e. decompensated rotator cuff tears, tendinitis calcarea,

Surgery [edit]

Surgery for the Rotator Cuff [edit]

Rehab [edit]

Imaging [edit]

Shoulder imaging [edit]

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dislocations, fractures, usures and/or osteophytes. Furthermore, x-rays are required for theplanning of an optimal CT or MR image.[16]

Conventional x-rays and ultrasonography are the primary tools used to confirm a diagnosis ofinjuries sustained to the rotator cuff. For extended clinical questions, imaging through MagneticResonance with or without intraarticular contrast agent is indicated.The conventional invasive arthrography is now-a-days being replaced by the non-invasive MRIand US and is used as an imaging reserve for patients who are contraindicated for MRI, forexample pacemaker-carriers with an unclear and unsure ultrasonography.[17]

The scapula should be positioned parallel to the x-rayfilm. The body has to be rotated about 30 to 45 degreestowards the shoulder to be imaged, and the standing orsitting patient lets the arm hang.This method allows the diagnostician to judge:[17]

The joint gap and the vertical alignment towards thesocket.

The humerus head should be aligned in the neutralposition and external rotation in a way towards thesocket, that a fictive continuous line can be seen. Thisline is called Bandi line, otherwise known as theMénard-Shenton line. A discontinuous line alludes to acranial decentralization of the humerus head.[18]

The arm should be abduced 80 to 100 degrees at aprecise defined scapular or frontal plane.This method allows the diagnostician to judge:[17]

The horizontal alignment of the humerus head inrespect to the socket, and the lateral clavicle inrespect to the acromion.Lesions of the anterior and posterior socket borderor of the tuberculum minus.The eventual non-closure of the acromial apophysis.The coraco-humeral interval

The lateral contour of the shoulder should be positionedin front of the film in a way that the longitudinal axis ofthe scapula continues parallel to the path of the rays.This method allows the diagnostician to judge:[17]

The horizontal centralization of the humerus headand socket.The osseous margins of the coraco-acromial archand hence the supraspinatus outlet canal.The shape of the acromion

Conventional x-rays [edit]

a.-p.-projection 40° posterior oblique after Grashey [edit]

CR. shoulder x-ray, a.p.

Transaxillary projection [edit]

Transaxillary conventional radiography

Y-projection [edit]

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This Y-projection can be traced back to Wijnblath’s1933 published cavitas-en-face projection.[19]

It must be pointed out that this projection has a lowtolerance for errors and accordingly needs properexecution.[17]

There are several solid advantages of ultrasound. It isrelatively cheap, does not emit any radiation, isaccessible, is capable of visualizing tissue function inreal time and allows to the performing of provocativemaneuvers in order to replicate the patient’s pain.[20]

Those apparent benefits have helped ultrasoundbecome a common initial choice for assessing tendonsand soft tissues. Limitations include, for example, thehigh degree of operator dependence and the inability todefine pathologies in bones. One also has to have anextensive anatomical knowledge of the examined regionand keep an open mind to normal variations andartifacts created during the scan.[21]

Although musculoskeletal ultrasound training, likemedical training in general, is a lifelong process, Kissinet al. suggest that rheumatologists who taughtthemselves how to manipulate ultrasound can use it justas well as international musculo-skeletal ultrasoundexperts to diagnose common rheumatic conditions.[22]

After the introduction of high-frequency transducers inthe mid-eighties, ultrasound has become a conventional tool for taking accurate and preciseimages of the shoulder to support diagnosis.[23][24][25][26][27]

Adequate for the examination are high-resolution, high-frequency transducers with a transmissionfrequency of 5, 7.5 and 10 MHz. To improve the focus on structures close to the skin anadditional „water start-up length“ is advisable. During the examination the patient is asked to beseated, the affected arm is then adducted and the elbow is bent to 90 degrees. Slow andcautious passive lateral and/or medial rotations have the effect of being able to visualize differentsections of the shoulder. In order to also demonstrate those parts which are hidden under theacromion in the neutral position, a maximum medial rotation with hyperextension behind the backis required.[28]

To avoid the different tendon echogenicities caused by different instrument settings, Middletoncompared the tendon’s echogenicity with that of the deltoid muscle, which is still lege artis.[29][30]

Usually the echogenicity compared to the deltoid muscle is homogeneous intensified withoutdorsal echo extinction. Variability with reduced or intensified[31] echo has also been found inhealthy tendons. Bilateral comparison is very helpful when distinguishing and setting boundaries

Transaxillary projection. Schematicdrawing. After "Orthopedic radiology: apractical approach; Adam Greenspan; ISBN0-7817-1589-X, 9780781715898"

Y-projection conventional radiography

Ultrasound [edit]

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between physiological variants and a possible pathological finding. Degenerative changes at therotator cuff often are found on both sides of the body.[32] Consequently unilateral differencesrather point to a pathological source and bilateral changes rather to a physiological variation.[33]

In addition, a dynamic examination can help to differentiate between an ultrasound artifact and areal pathology.[34]

To accurately evaluate the echogenicity of an ultrasound, one has to take into account thephysical laws of reflection, absorption and dispersion. It is at all times important to acknowledgethat the structures in the joint of the shoulder are not aligned in the transversal, coronal or sagittalplane, and that therefore during imaging of the shoulder the transducer head has to be holdperpendicularly or parallel to the structures of interest. Otherwise the appearing echogenicity maynot be evaluated.[35]

Orientation-aid for the longitudinal plane:As an aid to orientation, it is advisable to begin the examination with the delineation of theacromion, as it is easy to palpate and it has an identifiable echo extinction. To adjust thelongitudinal plane image the way it is known in the x-rays and the physical examination, theacromion has to be visible at the image border.[35]

Orientation-aid for the transversal plane:Again it is advantageous to start above the acromion and then move the transducer to thehumerus. The acromion echo extinction disappears and the wheel-like figure with almostconcentric projection of the deltoid muscle, supraspinatus muscle tendon and humeral head-outline turns up as soon as the transducer is directed perpendicularly and parallel to the acromionedge. Using the anterior transversal plane one can depict the intraarticular part of the long headof the biceps brachii muscle. Additionally one can use the posterior transversal plane to depict theintersection of the infraspinatus muscle tendon and the posterior edge of the fossa.[35]

usual longitudinal front visionusual

longitudinalback vision

usualtransversalside vision

supraspinatustendon

acromion of the left shoulder in the left half of theimage and vice versa. (In order to explore the entiretendon the examiner must move the transducer fromventral to dorsal perpendicular at the acromion axis.Either through a maximal medial rotation or anaccording position of the transducer it is possible tosee the supra- infraspinatus tendon intersection.)

ventral rightshoulder inthe right halfof the imageand viceversa.

infraspinatustendon

scapula spineof the rightshoulder inthe left half ofthe imageand viceversa.

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Orthopedics established early the MRI as the tool of choice for joint- and soft tissue-imaging,because its non-invasiveness, the lack of radiation exposure, multi planar slicing possibilities andthe high soft tissue contrast.[36]

The MR Imaging should provide joint details to the treating orthopedist, to help him diagnose anddecide the next appropriate therapeutic step. To examine the shoulder, the patient is lying andthe concerned arm is in lateral rotation. For signal detection it is recommended to use a surface-coil. To find pathologies of the rotator cuff in the basic diagnostic investigation, T2-weightedsequences with fat-suppression or STIR sequences have proven value. In general, theexamination should occur in the following three main planes: axial, oblique coronal andsagittal.[37]

Most morphological changes and injuries are sustained to the supraspinatus tendon. Traumaticrotator cuff changes are often located antero-superior, meanwhile degenerative changes morelikely are supero-posterior.[38]

Tendons are predominantly composed of dense collagen fiber bundles. Because of their extremeshort T2-relaxation time they appear typically signal-weak, respectively, dark. Degenerativechanges, inflammations and also partial and complete tears cause loss of the original tendonstructure. Fatty deposits, mucous degeneration and hemorrhages lead to an increasedintratendinal T1-image. Edema formations, inflammatory changes and ruptures increase thesignals in a T2-weighted image.[37]

Erickson et al. noticed and described a typical artifactand gave the phenomenon the name „magic angle“.The „magic angle“ describes a changed T2-relaxationtime depending on the spatial orientation of the tissueto the main magnetic field. If parts of the tendon arelocated at the area of the magic angle at 55 degrees tothe main magnetic field, their T2-relaxation time getsinfluenced and the signal heavily intensified. Unluckilythese artifacts occupy similar areas where clinicalrelevant pathologies are found. To avoid a wrongdiagnosis it is recommended to exclude thisphenomenon in a case of doubt through a heavy T2-weighted sequence or an additional fat-suppression ata proton weighted sequence.[39]

While using MRI, true lesions at the rotator intervalregion between the parts of the supraspinatus andsubscapularis are all but impossible to distinguish fromnormal synovium and capsule.[40]

In 1999, Weishaupt D. et al. reached through tworeaders a significant better visibility of pully lesions atthe rotator interval and the expected location of thereflection pulley of the long biceps and subscapularistendon on parasagittal (reader1/reader2 sensitivity:

Longitudinal ultra sonographyof the supraspinatus tendon

Transversal ultra sonographyof the supraspinatus tendon

MRI [edit]

Magic angle artifact [edit]

MRA [edit]

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86%/100%; specificity: 90%/70%) and axial(reader1/reader2 sensitivity: 86%/93%; specificity:90%/80%) MRA images.[41]

When examining the rotator cuff, the MRA has a coupleof advantages compared to the native MRI. Through afat suppressed T2-weighted spin echo, MRA canreproduce an extreme high fat-water-contrast, whichhelps to detect water-deposits with better damagediagnosis in structurally changed collagen fiberbundles.[42]

MRI. Magic angle artifact.Additional images [edit]

Diagram of the humanshoulder joint

Suprascapular and axillarynerves of right side, seenfrom behind.

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Shoulder problems

This article needs additional citations for verification.Relevant discussion may be found on the talk page. Pleasehelp improve this article by adding citations to reliable sources.Unsourced material may be challenged and removed. (June

2008)

1. ^ Tnation article Push-Ups, Face Pulls, and Shrugs ...for Strong and Healthy Shoulders! by BillHartman and Mike Robertson: The rotator cuff, of course. (Or for those of you from Indiana, thatwould be your "rotary cup").

2. ^ Morag Y, Jacobson JA, Miller B, De Maeseneer M, Girish G, Jamadar D (2006). "MR imaging ofrotator cuff injury: what the clinician needs to know". Radiographics 26 (4): 1045–65.doi:10.1148/rg.264055087 . PMID 16844931 .

3. ^ "Khazzam et al. American Journal of Orthopedics - Open Shoulder Stabilization Using bone blocktechnique for treatment of chronic glenohumeral instability associated with glenoid deficiency." .American Journal of Orthopedics. July, 2009.

4. ^ Escamilla RF, Yamashiro K, Paulos L, Andrews JR. Shoulder muscle activity and function incommon shoulder rehabilitation exercises. Sports Med 2009; 39:663-85.

5. ^ Arend CF. Ultrasound of the Shoulder. Master Medical Books, 2013. Free chapter on anatomy andfunction of rotator cuff muscles available at ShoulderUS.com

6. ^ ItoiE, Berglund LJ, Grabowski JJ, et al. Tensile properties of the supraspinatustendon. J OrthopRes 1995; 13:578-84.

7. ^ a b Hegedus EJ, Goode A, Campbell S, et al. (February 2008). "Physical examination tests of theshoulder: a systematic review with meta-analysis of individual tests". British Journal of SportsMedicine 42 (2): 80–92. doi:10.1136/bjsm.2007.038406 . PMID 17720798 .

8. ^ ShoulderDoc.co.uk Shoulder and Elbow Surgery. "Hawkins-Kennedy Test" . Retrieved 2007-09-12. (video)

9. ^ Brukner P, Khan K, Kibler WB. "Chapter 14: Shoulder Pain" . Retrieved 2007-08-30.10. ^ ShoulderDoc.co.uk Shoulder and Elbow Surgery. "Empty Can/Full Can Test" . Retrieved 2007-

09-12. (video)11. ^ Maschi, PT, DPT, CSCS, Robert. "Chapter 40 Rotator Cuff Repair: Arthroscopic and Open" .

Unknown. p. 449. Retrieved 2010-04-28.12. ^ Baydar M, Akalin E, El O, et al. (April 2009). "The efficacy of conservative treatment in patients

with full-thickness rotator cuff tears". Rheumatology International 29 (6): 623–8.doi:10.1007/s00296-008-0733-2 . PMID 18850322 .

13. ^ Zumstein MA, Jost B, Hempel J, Hodler J, Gerber C (November 2008). "The clinical and structurallong-term results of open repair of massive tears of the rotator cuff". The Journal of Bone and JointSurgery. American Volume 90 (11): 2423–31. doi:10.2106/JBJS.G.00677 . PMID 18978411 .

The suprascapular, axillary,and radial nerves.

See also [edit]

References [edit]

Rotator cuff - Wikipedia, the free encyclopedia

http://en.wikipedia.org/wiki/Rotator_cuff#Strengthening[10/12/2013 11:24:02 PM]

14. ^ Shen PH, Lien SB, Shen HC, Lee CH, Wu SS, Lin LC (2008). "Long-term functional outcomesafter repair of rotator cuff tears correlated with atrophy of the supraspinatus muscles on magneticresonance images". Journal of Shoulder and Elbow Surgery 17 (1 Suppl): 1S–7S.doi:10.1016/j.jse.2007.04.014 . PMID 17931908 .

15. ^ Matsen, Frederick A.; Winston J. Warme (19 August 2008). "Repair of Rotator Cuff Tears: Surgeryfor shoulders with torn rotator cuff tendons can lessen shoulder pain and improve function withoutacromioplasty" . University of Washington School of Medicine. Retrieved 5 July 2009.

16. ^ Hodler J et al.. Gelenkdiagnostik mit bildgebenden Verfahren. Stuttgart [etc.]. G. Thieme. 1992.ISBN 3-13-780501-5

17. ^ a b c d e Hedtmann A et al.. Imaging in evaluating rotator cuff tears. Orthopade. 2007Sep;36(9):796-809. - (http://www.springerlink.com/content/26l346817932h383/ )

18. ^ Bandi W (1981) Die Läsion der Rotatorenmanschette. Helv Chir Acta 48:537-54919. ^ Wijnbladh H (1933) Zur Röntgendiagnose von Schulterluxationen. Chirurg 5:70220. ^ Arend CF. Ultrasound of the Shoulder. Porto Alegre: Master Medical Books; 2013. Free access to

sample chapter on ultrasound technique to evaluate rotator cuff disorders at ShoulderUS.com .21. ^ Broadhurst NA. Musculoskeletal ultrasound - used to best advantage. Aust Fam Physician. 2007

Jun;36(6):430-2. - free article(http://www.racgp.org.au/afp/200706/200706broadhurst.pdf )22. ^ Kissin et al.. Self-directed learning of basic musculo-skeletal ultrasound among rheumatologists in

the United States. Arthritis Care Res (Hoboken). 2010 Feb;62(2):155-60 -(http://www3.interscience.wiley.com/journal/123236784/abstract )

23. ^ Allen GM, Wilson DJ, Eur J Ultrasound. 2001 Oct;14(1):3-9. Review -(http://linkinghub.elsevier.com/retrieve/pii/S0929826601001409 )

24. ^ Middleton WD, Edelstein G, et al. Sonographic detection of rotator cuff tears. Ajr American Journalof Roentgenology. 1985a;144(2):349–53. freearticle(http://www.ajronline.org/cgi/reprint/144/2/349 )

25. ^ Middleton WD, Reinus WR, et al. Ultrasonographic evaluation of the rotator cuff and bicepstendon. Journal of Bone and Joint Surgery American Volume. 1986;68(3):440–50.

26. ^ Crass JR, Craig EV, et al. Ultrasonography of rotator cuff tears: a review of 500 diagnostic studies.Jcu J Clin Ultrasound. 1988;16(5):313–27.

27. ^ Mack LA, Gannon MK, et al. Sonographic evaluation of the rotator cuff. Accuracy in patientswithout prior surgery. Clinical Orthopaedics and Related Research. 1988a;234:21–7.

28. ^ Thelen M. et al.. Radiologische Diagnostik der Verletzungen von Knochen und Gelenken. Stuttgart[etc.]. Georg Thieme. 1993. ISBN 3-13-778701-7

29. ^ Middleton WD. et al.. Ultrasonography of the rotator cuff: technique and normal anatomy. JUltrasound Med.. 1984 Dec;3(12):549-51

30. ^ Middleton WD. et al.. Pitfalls of rotator cuff sonography. AJR AM J Roentgenol. 1986Mar;146(3):555-60 @Katthagen BD. et al.. Schultersonographie. Stuttgart. ISBN 3-13-719401-6 -free article(http://www.ajronline.org/cgi/reprint/146/3/555 )

31. ^ crass 1984 @Katthagen BD. et al.. Schultersonographie. Stuttgart. ISBN 3-13-719401-632. ^ Arend CF. Top ten pitfalls to avoid when performing musculoskeletal sonography: What you

should know before entering the examination room. Eur J Radiol. 2013 Mar 7. pii: S0720-048X(13)00057-0. doi: 10.1016/j.ejrad.2013.01.022. Epub ahead of print

33. ^ Middleton WD. et al.. Pitfalls of rotator cuff sonography. AJR AM J Roentgenol. 1986Mar;146(3):555-60

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Rotator cuff - Wikipedia, the free encyclopedia

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List of muscles of upper limbs (TA A04.6, GA 4.432)

Shoulderdeltoid · rotator cuff (supraspinatus, infraspinatus, teres minor, subscapularis) ·teres major

fascia: deltoid fascia · supraspinous fascia · infraspinous fascia

Arm(compartments)

anterior coracobrachialis · biceps brachii · brachialis

posterior triceps brachii · anconeus · articularis cubiti

fasciaaxillary sheath · axillary fascia · brachial fascia · intermuscular septa

(lateral, medial)

other spaces (quadrangular space, triangular space, triangular interval)

Forearm

anterior

superficial: pronator teres · palmaris longus · flexor carpi radialis ·flexor carpi ulnaris · flexor digitorum superficialis

deep: pronator quadratus · flexor digitorum profundus ·

flexor pollicis longus

posterior

superficial: mobile wad (brachioradialis, extensor carpi radialis longus andbrevis) · extensor digitorum · extensor digiti minimi · extensor carpi ulnaris

deep: supinator · anatomical snuff box (abductor pollicis longus,

extensor pollicis brevis, extensor pollicis longus) · extensor indicis

fasciabicipital aponeurosis · common tendons (extensor, flexor) ·

antebrachial fascia

other cubital tunnel

Hand

lateral volarthenar (opponens pollicis, flexor pollicis brevis,

abductor pollicis brevis) · adductor pollicis

medial volarhypothenar (opponens digiti minimi, flexor digiti minimi brevis,

abductor digiti minimi) · palmaris brevis

intermediate lumbrical · interossei (dorsal, palmar)

fasciaposterior: extensor retinaculum · extensor expansion

anterior: flexor retinaculum · palmar aponeurosis

M: MUS, DF+DRCT anat (h/n, u, t/d, a/p,l)/phys/devp/hist

noco (m, s, c)/cong(d)/tumr, sysi/epon, injr

proc, drug (M1A/3)

Categories: Rotor cuff Shoulder Upper limb anatomy

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