rotator cuff disorder

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Rotator cuff disorder

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 :Supraspinatus .Infraspinatus .Teres minor .Subscapularis .Rotator Cuff

actionNerve supply insertionoriginAbduction of the shoulder joint from 0-15 degreesSuprascapular nerve Top of greater tuberosity of humerus Med 2/3 of supraspinus fossa of the scapula supraspinatusExternal 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 FactorsReduce Vascular supply (significance)TendonitisBursitisBone spur Acromion rubs on the rotator cuff and bursa bursitis and tendonitis earlyrotator cuff tear over timeDegenerative changesAge relatedChange in proteoglycan and collagen content in symptomatic tendons

Pathophysiology

Impingement in which a tendon is squeezed and rubs against bone.Acromial spursType III acromion and decreased geometric area of the supraspinatus outletIncreased prevalance of symptomatic cuff diseaseCoracoacromial ligamentAC joint osteophytesCoracoid processPosterior superior glenoidPathophysiology

Extrinsic factorsRepetitive useTensile overloadMuscle fatigueMicrotrauma

Glenohumeral instabilityAccentuates abnormal loadingCan 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 fatigueAs rotator cuff fatigues, it no longer performs its 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 cuffRotator Cuff dysfunctionImpingement with motion

Impingement

Men = womenAny ageAche Activity relatedNight painTreatment from Weeks to monthsStarted after Too muchComputer useGardeningHeavy liftingTennisGolfThrowingfishing

Impingement

Impingement signsNeerPain with passive forward flexion while internally rotated

HawkinsPain 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 treatmentRelative restIceAnti-inflammatory medicationscortisone injectionPhysical 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 treatmentShotMedicineExercises/Posture Correction

Impingement

Cortisone Injectionprimary indication is difficulty sleeping70% improved with a single shot20% better with a second shotIf no better, Check MRIConsider 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 capsulitisCapsule surrounding shoulder ball and socket scars and shrink wraps itself inhibiting full motion and causing pain

Frozen Shoulder

Severe painFront of ShoulderconstantstiffGetting worseMay or may not know whyNo injuryShortly after minor injuryfollowing breast or heart surgery40 - 60 years oldWomen > MenThyroid diseaseDiabetesHeart diseaseWill Occur on Opposite Side 30% of Time

Frozen Shoulder

Three phasesInflammatoryFrozenDisabilityLoss of exernal rotationPassive and active motion lossNormal strength

Frozen Shoulder

Initial treatmentTime18+ months to spontaneous resolutionPain medicineCortisone injections2-3 StretchingMay help or worsenArthroscopic capsular release with manipulationIf not improved with initial conservative measuresCapsule and ligaments are partially excisedStretched to full motion while anesthetizedCortisone Injection

Frozen Shoulder

Arthroscopic capsular release with manipulationSling 2-4 weeks for comfort onlyImmediate motionImmediate therapy to maintain motionCapsulitis may grow right back without stretching

Frozen Shoulder

RareCalcium buildup inside tendon

Cortisone injectionArthroscopic removal

Calcific Tendonitis

Detachment of the tendon from the boneDoes not heal on ownAcute: single injury greater than thresholdChronic: long term overuse, wear and tear

Rotator Cuff Tear

historyInjury (25%)Pain without injury (75%)Loss of overhead or behind the back activity without painSymptomsPain: anterior superior shoulder or deltoid insertionRestNightactivity relatedWeakness or disabilityinstabilityRotator Cuff Tear

Exam findingsWeakness/PainActive motion loss/PainPassive motion maintained

Rotator Cuff Tear

Diagnosed withHistoryExamXraysMri (or ultrasound)

Rotator Cuff Tear

Full thickness

Partial thickness

Rotator Cuff Tear

Nonoperative cortisone injectionphysical therapyoral analgesicsTemporary reliefIt will get worse with time

Rotator Cuff Tear

Rotator Cuff TearArthroscopic rotator Cuff Repair

Sling 1 monthHealing 3 months98% with small tears50-85% with large tearsMaximum recovery 6 12 months

Rotator Cuff TearArthroscopic rotator Cuff Repair

Arthroscopic Rotator cuff tear Repair: predictors of successTear sizeSmall < 1.5 cmLarge >3 cmAge of TearMuscle and Tendon AtrophyPatient age

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