ROTATOR CUFF INJURIES

ROTATOR CUFF INJURIESDr. RAGHAVENDRA RAJU

INTRODUCTIONIn 1834, Smith - first description of a rupture of the rotator cuff tendon .Among most common causes of shoulder pain and instability.Incidence 5-40% with increasing with advancing age ( >40 years).Normal senescence process

Always no history of trauma2

ANATOMY SHOULDER JOINTFOUR ARTICULATIONSsternoclavicularacromioclavicularglenohumeralscapulothoracic

ANATOMY- ROTATOR CUFFMade up of 4 interrelated muscles arising from the scapula and attaching to the tuberosities of humerus.supraspinatus infraspinatus teres minor subscapularis

Long head of biceps functional part

ROTATOR CUFF MUCLES

BIG BALL AND SMALL SOCKET JOINT

Function of rotator cuff

The rotator cuff is the Dynamic stabilizer of the glenohumeral joint. Normal function of the shoulder is a balance between mobility and stability.

Function of rotator cuffStabilisers of shoulder mainly anterior and posterior cuff providing fixed fulcrum for concentric rotation of the humeral head.

Neutralises shearing forces of deltoid in early abduction.

Initiation of abduction.Rotation of shoulder.

ETIOLOGYIMPINGEMENT( MC )TRAUMAATTRITION - AGINGISCHEMIC TENDONLACK OF NUTRITION TO JOINTIATROGENIC

Different shapes of acromia (Biglianni et al) -anterior slope Type 1 - Flat ( 3 % of cuff tears)Type 2 - Curved (24 % of cuff tears)Type 3 - Hooked ( 73 % of cuff tears)

PATHOLOGYTorn Rotator Cuff

Can not Counterbalance the upward pull of the deltoid on the humerus

Not able to Hold the head of the humerus secure in the glenoid

AHD 45 yo

26Focused History QuestionsLocation of pain*Anterior Lateral SuperiorPosterior

Radiation of painRotator cuff problems often include pain radiating to upper armIf pain starts in neck and radiates to shoulder, consider cervical spine disease

26*LOCATION of pain: It is important to determine the exact site of the patient's pain, although shoulder pain is often poorly localized. Anterior biceps tendinopathy, acromioclavicular DJD, impingement syndrome, instability (subluxation/dislocation), labral tear, clavicle fracture, glenohumeral joint DJDLateral rotator cuff strain/tear, deltoid strainSuperior - subacromial bursitis, subdeltoid bursitis, AC joint separation or DJD, impingement syndrome, cervical spine DJDPosterior rotator cuff strain/tear, cervical spine DJD, cyst (suprascapular notch)

28Consider sources of referred pain

Cervical spine spondylolysis, arthritis, disc disease Cardiac - myocardial ischemia Diaphragmatic irritation Thoracic outlet syndromeGallbladder diseaseComplex regional pain syndrome (a.k.a, reflex sympathetic dystrophy)Focused History Questions

29Characteristics of pain

Focused History QuestionsNight pain when lying on affected side, muscle atrophyRotator cuff tear< 30 yoBiomechanical, inflammatory> 45 yo, Hx of traumaRotator cuff tear - 35% of ptsPainful arc (60-120abduction)Subacromial impingementPain > 120 abductionAcromioclavicular jointCatching, popping, clickingGH or AC joint arthritis, labral tear

30Focused History QuestionsHistory of instabilityGlenohumeral subluxation or dislocationAggravating factorsOverhead work, repetitive movements, sportsRelieving factors/treatments triedRest, immobility, medications, other treatmentsHistory of Prior Shoulder Problems or Surgeries

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31Physical Exam - General Develop a standard routine protocol. Alleviate the patient's fears.Adequate exposure. Compare shoulders.

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32Physical Exam StepsInspectionPalpationRange of motion (ROM)Strength testingSpecial tests

32*Inspection - Identify gross deformities or abnormalities evidence of trauma, muscle atrophy, erythema, AC joint swelling or asymmetryMuscle atrophy of either the supraspinatus or infraspinatus muscles is moderately predictive of rotator cuff tears in the elderly population, with a positive predictive value of 81%. This sign not useful if absent, with negative predictive value of 43%.PalpationNo studies have assessed role of palpation in evaluation of shoulder pain.Discerns A/C joint pathology from shoulder and neck

33InspectionSwelling, asymmetry, muscle atrophy, scars, ecchymosis and any venous distentionNote postureDeformities Scapular "winging" Atrophy - supraspinatus or infraspinatus - consider rotator cuff tear, suprascapular nerve entrapment or neuropathy.

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34PalpationSternoclavicular jointClavicleAcromioclavicular jointSubacromial bursaCoracoid processBicipital grooveGreater tuberosityLesser tuberosityScapula (spinatus muscles)

35Palpation of AC Joint Patient's arm at his/her sideNote swelling, pain, and gapping.

35To palpate the acromio-clavicular joint, find the "soft spot" at the back of the clavicle, anterior to that is the A-C joint.

36Palpation of Bicipital Groove Patient sitting, beginning with the arm straightPatient actively flexes biceps muscle while examiner provides supination and ERExaminer palpates the bicipital groove for pain

37Range of Motion (ROM)Evaluate active ROM If movement limited by pain, weakness, or tightness, assist passivelyLack of full ROM with active and passive exam is found in adhesive capsulitis and arthropathyEvaluate bilaterally for comparison

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Range of MotionMovementForward flexionExtension (behind back)AbductionAdductionExternal rotation* Internal rotation*Normal range18060180 (with palms up)045 (arm at side, elbow flexed)55 (arm at side, elbow flexed)

38*ER and IR can also be assessed with the Apley scratch tests

FLEXION( 180)EXTENSION( 4O)

ABDUCTION(180)ADDUCTION

EXTERNAL ROTATION(55)INTERNAL ROTATION(45)

Apley scratch test for ER/IR

Internal rotation and adductionReach for lower scapulaCompare bilaterally note level reachedExternal rotation and abductionReach for upper scapulaCompare bilaterally note level reached

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SPECIAL TESTS

IMPINGEMENT TESTS

NEERS SIGNPatient seated with arm at side, palm down (pronated)Examiner standingExaminer stabilizes scapula and raises the arm (between flexion and abduction)Positive test = pain

45*Neer's impingement sign is elicited when the patient's rotator cuff tendons are pinched under the coracoacromial arch. The test is performed by placing the arm in forced flexion with the arm pronated The scapula should be stabilized during the maneuver to prevent scapulothoracic motion. Pain with this maneuver is a sign of subacromial impingement.

NEERS TESTMost diagnostic testLA 10ml lignocaine into subacromial bursa>50% relief rotator cuff tendinitis or partial tear of bursal surface.Pain relief but weakness persists full thickness tearsNo relief - incorrect diagnosis or wrong injection

Hawkins Test Patient standingExaminer forward flexes shoulder to 90, then forcibly internally rotates the armPositive test = pain in area of superior GH joint or AC joint

47*The Hawkins' test is another commonly performed assessment of impingement. It is performed by forward flexing the patient's arm forward to 90 degrees while forcibly internally rotating the shoulder. The drives the greater tuberosity farther under the coracoacromial ligament, reproducing impingement pain. Pain with this maneuver suggests subacromial impingement or rotator cuff tendonitis. One study found Hawkins' test more sensitive for impingement than Neer's test.

Sensitivity/SpecificityNeer Impingement Sensitivity: 72%Specificity: 60%Hawkins-Kennedy Impingement Sensitivity: 79%Specificity: 59%

Hegedus. British J Sports Med, 2012.

SUPRASPINATUS

JOBS TEST OR EMPTY CAN TEST Jobe s isolation test or empty can test.

The patient is positioned sitting with arms straight out, elbows locked, thumbs down, and arm at 30 degrees (in scapular plane). The patient should attempt to abduct his arms against the examiner's resistance.

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Drop Arm Test

Method:patient abducts (or examiner passively abducts) arm and then slowly lowers it May be able to lower arm slowly to 90 (deltoid function)Arm will then drop to side if rotator cuff tear

Positive test: patient unable to lower arm further with controlIf able to hold at 90, pressure on wrist will cause arm to fall

51Drop Arm Test Purpose: This test indicates tears in the rotator cuff, primarily of the supraspinatus muscle.Method:The athlete abducts (or examiner passively abducts) the arm as far as possible and then slowly lowers it to 90.Patient slowly lowers arm to waistMay be able to lower arm slowly to 90 (this is mostly deltoid function)Arm will then drop to patients side if rotator cuff tear Findings: A positive sign is that the athlete will be unable to lower the arm further with control. If the athlete is able to hold the arm at 90, pressure on the wrist will cause the arm to fall.

INFRASPINATUS

DROP SIGNThe affected arm is held at 90 degrees of elevation in the scapular plane and at almost full external rotation with the elbow flexed at 90 degrees. The patient is asked to maintain this position actively as the examiner releases the wrist while supporting the elbow

SUBSCAPULARIS

LIFT OFF TESTThe Gerber lift-off test The shoulder is placed passively in internal rotation and slight extension by placing the hand 5-10 cm from the back with the palm facing outward and the elbow flexed at 90. The test is positive when the patient cannot hold this position, with the back of the hand hitting the patient's back.

BELLY PRESS TEST

patient presses the abdomen with the flat of the hand and attempts to keep the arm in maximal internal rotation.

OTHER TESTSEXTERNAL ROTATION LAG SIGN- SUPRASPINATUS AND INFRASPINATUS.EXTERNAL ROTATION STRESS TEST- INFRASPINATUS AND TERES MINOR.

Hegedus. British J Sports Med, 2012

Cochrane Database Review 2013 Hanchard, et al.Physicaltests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement.

33 studies involving 4002 shoulders

Cochrane Database Review 2013 Hanchard, et al.There is insufficient evidence upon which to base selection ofphysicaltests for shoulder impingements, and local lesions of bursa, tendon or labrum that may accompany impingement, in primary care. The large body of literature revealed extreme diversity in the performance and interpretation of tests, which hinders synthesis of the evidence and/or clinical applicability.

INVESTIGATIONSX RAYUSGCT SCANMRI

X RAYAP VIEW AXILLARY LATERAL VIEWSUPRASPINATUS OUTLET VIEW

X RAY AP VIEW ER AND IR VIEWS

The internal rotation view is for detecting Hill-Sachs lesions, and external rotation for the greater tuberosity and proximal humeral physis in skeletally immature patients. A true anteroposterior radiograph of the glenohumeral joint is forarticular cartilage of the glenoid and the humeral head.

AXILLARY VIEW

the anatomy of the glenoid rim, the acromion, the coracoid, and the proximal humerus.

SUPRASPINATUS OUTLET VIEW

UltrasoundCheap and quick to perform.Good definition of rotator cuff.Allows dynamic examination.Operator dependant.Findings:Nonvisualization of cuffLocalized absence DiscontinuityFocal abnormal echogenicity

MRIBest diagnostic aid.Defines site of cuff damage.Demonstrates fatty changes in muscle -poor quality cuff.Exact size, shape and location of tearNon-invasive

MRINormal cuffFull thickness tear

TREATMENTSEVERITY OF SYMPTOMS.AGE.ACTIVITY LEVEL.PATIENT REQUIREMENTS .

Conservative managementMcLaughlin in 1962 advanced reasons to avoid early repair25 % of cadavers had torn cuff -most of them were asymptomatic50 % of patients would recover comfortablyResults of early and late repair are similarRepair did not always permit anatomic restorationEarly diagnosis is difficult

NATURAL HISTORY IS UNPREDICTABLE

Review of literature indicates that success rate of nonoperative treatment ranges from 33% to 92%Bartolozzi et al (Clin orthop, 1994) reported 66-75% good or excellent results (mean follow up 20 months). Unfavorable prognostic factors wereTear> 1 cm2Symptoms > 1yrSignificant functional impairment

REST ACTIVITY MODIFICATIONNSAIDSPHYSIOTHERAPHY (streching and strenghtening exercises).INJECTION THERAPHY ( STEROID AND PRp)

Orthotherapy Term used by Michael Wirth (OCNA 1997)Interactive exchange between patient and orthopedic surgeon directed at creating exercise regimen that gradually improves motion and strength in shoulder girdle.Three phases:Phase 1- restore full, painless range of motion. Codman pendulum exercise followed by passive movements in all directionPhase 2- designed to strengthened remaining muscles of rotator cuff, deltoid & scapular musclesPhase 3- gradual reinstitution of normal activities including work, hobby and sport.

OPERATIVE TREATMENTONLY IF CONSERVATIVE TREATMENT FAILS. (ATLEAST 6 WEEKS)

Operative treatmentPatient selection:Samilson & Binder :Patient physiologically younger than 60 yrsClinically or arthrographically demonstrable full thickness cuff tear.Failure to improve on nonoperative management for minimum of 6 weeksNeed to use shoulder in overhead elevationFull passive range of motionAbility & willingness to cooperate

Poor prognostic factorsOld age group (physiological age >60 years)Long historyNo history of traumaSmokerMultiple steroid injectionDiffuse osteopeniaGrade 3 or less of external rotationUpward migration of humeral head.

Procedures Repair of tear open or arthroscopicTendon to tendon or tendon to boneArthroscopic debridement,SAD and acromioplasty with mini-open repair.

Technique of open repairApproach- 5 to 7 cm incision extending from lateral aspect of ant third of acromion to lateral tip of coracoid

Rotator cuff repair:Assess the nature of tearMobilisation Release of adhesionRelease of coracohumeral ligamentInterval slideSubscapularis tendon transferRepair tendon to tendon or tendon to bone(McLaughlin technique)

Mobilisation Release of capsule from labrumRelease of cuff tendons from coracoid

Transosseous repair

Advantages of open repairEasy to doNo special equipment requiredAllows direct visualization of cuff repair and acromioplastyGood long term follow-up

DisadvantagesDeltoid detachment requiredFalse positive studies (arthrogram 2%, MRI 10%) will lead to unnecessary open explorationUnrepairable tear will be opened.Significant intraarticular pathology will be missed

Arthroscopic repair of rotator cuffAdvantages :Lesser morbidityAbility to identify and treat other pathologyTruly outpatientAllows to address small undetected tearsPatient acceptance

Disadvantages :Technically difficultImplant cost-needs anchorIncreased OR timeHigh failure rate during learning curve

Arthroscopic assisted mini open repairLateral portal is expandedUseful for small & moderate shape tearsResults comparable to open repair

Post operative plan.ArthroscopicImmd active and passive ROMAvoid active abduction >60 degree for 3-4 wksThen electrical stimulation, resisting exercises for 3-4 mthsHigh demand activities within 4-6 mthsOpenProceed slowly (deltoid detached)Avoid active flexion or abduction for 4 wksRequires 1-2 additional months

Partial thickness tear Surgical options:Debridement aloneDebridement with arthroscopic subacromial decompressionOpen repair with acromioplastyArthroscopic repairArthroscopic subacromial decompression with mini open repair

Partial thickness tearBefore and after debridement

Arthroscopic SAD

Removal of inferior part of anterolateral acromionOpen SAD

No morbidity Genuine benefit

Arthroscopic

Arthroscopic rotator cuff repair

Irreparable tearsPre operative diagnosis

AHI