seminar rotator cuff

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ROTATOR CUFF: ANATOMY, INJURIES AND CLINICAL EVALUATIONDR MOHAMMAD SAJIDJR ORTHOPAEDICS (2nd SEM)

Shoulder joint anatomy

Bones 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 CuffThe 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 arms position in space

Generally work to depress the humeral head while powerful deltoid contracts

MUSCLEORIGININSERTIONNERVEACTIONCOMMENT1.SupraspinatusSupraspinatus fossa (scapula)Greater tuberosity (superior)SuprascapularAbduct arm (initiate),Trapped in impingement #1 torn tendon (RC tear)2.InfraspinatusInfraspinatus fossa (scapula)Greater tuberosity (middle)SuprascapularER arm, stabilityWeak ER: damage to nerve. lesion in notch3.Teres MinorLateral scapularGreater tuberosity (inferior)AxillaryER arm, stabilityDissection can damage circum-flex vessels4.SubscapularisSubscapular fossa (scapula)Lesser tuberosityUpper & Lower SubscapularIR, adduct arm, stabilityCan rupture in anterior dislocation

Rotator Cuff InjuriesRotator cuff pathology is a common problemCadaver studies have reported tears in 30-50 % of specimensNeer introduced the concept of continuum of impingement syndromeStage 1- edema and haemorrhageStage 2- fibrosis and tendinitisStage 3- bone spurs and tendon rupture

Loss of continuity of rotator cuff can be described in several waysAcute and chronicTraumatic and degenerativePartial thickness ( less than 50% depth of tendon) and Full thicknessSmall (< 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 EvaluationInspection: atrophy, symmetryPalpation: greater tuberosity, acromiaclavicular joint, bicipital groove, coracoid process, cuff tendernessRange of motion: active, passive Strength: ER and elevation power, lag Provocative: impingement sign, arc of pain

Provocative Tests Neer Impingement Test Hawkins Kennedy Impingement Sign Jobe / Empty Can TestInternal Rotation Resistance Stress TestGerber Subcoracoid Impingement TestJobe Apprehension Relocation TestSpeed TestYergason 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 90 and then applying internal rotation. Pain with this manoeuver suggests subacromial impingement or rotator cuff tendonitis

Jobes Empty Can TestPatient 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 patientThe arm is positioned in 90 ofabduction 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 positionIf 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 processThe 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 TestThe patient's arm is abducted to 90 degrees while the examiner externally rotates the arm and applies anteriorpressure to the humerus

Speeds TestSpeed's manoeuver is used to examine the proximal tendon of the long head of the bicepsThe patient's elbow is flexed 20 to 30 degrees with the forearm in supination and the arm in about 60 degrees of flexionThe 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

Tests that determine whether a movement can be undertaken activelyTests that determine whether a passive position can be maintained ( the lag signs)

Gerbers Lift Off Test

Tests the integrity and function of subscapularis muscleThe arm is completely rotated internally and dorsum of the hand is placed against the lower back with the elbow flexedIf 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 rotationIf 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 degreesThe examiner applies force against the dorsum of the hands, attempting to rotate the shoulders internally back to neutral while the patient is asked to resistPain 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 elbowThe sign is positive in case of a lag or angular drop

Drop SignThis 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

Hornblowers Sign (Patte Test)Strength of the teres minorAbduct the patients arm to 90 degrees in the scapular planeFlex the elbow to 90 degrees, and the patient is asked to laterally rotate the shoulderA positive test occurs (patient raises elbow) with weakness and/or pain

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