The Rotator cuff Dr Tom Lieng June 2011
Content 1. Anatomy 2. Rotator cuff pathology 3. Treatment of rotator cuff injury 4. Prognosis 5. Other common shoulder conditions:adhesive capsulitis 6. Acromio-clavicular joint arthritis 7. SLAP tear
Incidence of injuries in 2009 900 800 700 600 500 400 300 Series1 200 100 0
Shoulder muscles Back muscles: in 3 groups 1. Superficial: trapezius, latissimus dorsi 2. Deep : levator scapulae, rhomboids, serratus anterior 3. Intrinsic: deltoid, supraspinatus, infraspinatus, teres minor, teres major, subscapularis Pectoral muscles: Pectoralis major/minor, subclavius, serratus anterior
Shoulder muscles Trapezius Deltoid Levator Scapulae Supraspinatus Infraspinatus Teres Minor Teres Major Latissimus dorsi Rhomboid
Pectoral muscles Long head of biceps (LHB) tendon Pectoralis Major Subscapularis Pectoralis Minor Latissimus Dorsi Biceps Serratus Anterior
Rotator cuff Rotates and elevates the shoulder joint 4 muscles: Supraspinatus Elevates Infraspinatus - External rotation Subscapularis Internal rotation Teres Minor - External rotation
Rotator cuff
Rotator Cuffs
What is a rotator cuff injury? Rotator cuff injury is bruising and tearing of the rotator cuff (usually the supraspinatus tendon). It is caused by repetitive abducting (lifting) of the arm causing impingement of the tendon onto the roof of the joint (a-c joint). Incidence increases with age. Congenital factor with acromion variation 40% of population will suffer from rotator cuff pain
Ultrasound view-normal
Ultrasound view-abnormal
MRI view-normal
MRI view-abnormal
Facts on Rotator cuff tear 13% of 50-59yo has tear without pain 51% of >85yo has tear without pain (J Shoulder Elbow Surg. 1999 Jul-Aug;8(4):296-9) Complete supraspinatus tears may occur in up to 20% >32 yrs. >40 years, approximately 30% of patients will have cuff tears, and >50yo, approximately 40% of people will have cuff tears >60 yrs, 80% of patients will have cuff tears (Clifford R. Wheeless, III, MD)
Testing the Supraspinatus tendon Apley s Scratch test-scratching the opposite scapula Empty can test-internally rotated arm at 90 degrees abducted- 89% sensitivity Hawkins test-abducting the arm with elbow flexed in forward flexion 85% sensitivity Jobe test-pushing down on the abducted arm 85% sensitivity
Apley s scratch test Apley s scratch test test for range of motion
Empty can test
Jobe test
Hawkins test
Has this man got a rotator cuff tear?
Acromiom variation Plain XR Standard views are anteroposterior, trans-scapular lateral and an axillary view. The supraspinatus outlet view (Neer 1987) is a lateral radiograph of the erect scapula with a downward (caudal) tilt of 10 degrees, and this can help assess acromial morphology. Bigliani classified acromial morphology as: Type I straight 17% Type II curved 43% Type III hooked 40% -89% of type III acromions had tearing of the (J of Shoulder & Elbow surgery vol.4, issue 5, p376-383) rotator cuff (p<0.001)
Acromiom type
Neer classification of impingement Neer 5 divided impingement syndrome into three stages. Stage I involves edema and/or hemorrhage. This stage generally occurs in patients less than 25 years of age and is frequently associated with an overuse injury. Generally, at this stage the syndrome is reversible. Stage II is more advanced and tends to occur in patients 25 to 40 years of age. The pathologic changes that are now evident show fibrosis as well as irreversible tendon changes. Stage III generally occurs in patients over 50 years of age and frequently involves a tendon rupture or tear. Stage III is largely a process of attrition and the culmination of fibrosis and tendinosis that have been present for many years
Natural history of RCT Sher et al 1995-MRI study of ASYMPTOMATIC shoulders: 19-39yo 4% partial, 0% complete RCT 40-60yo 24% partial, 4% complete RCT >60yo 26% partial, 28% complete RCT
Treatment-physiotherapy Physiotherapy is the first line of treatment. Suggest treatment for 3 months. Aim at stretching/mobilising the capsule and strengthening the posterior shoulder Strengthening of the infraspinatus and the teres minor leads to a downward effect on the humerus away from the coraco-acromial ligament
Treatment-cortisone injection Injection is now usually under u/s guidance to the subacromial space. Aim to reduce inflammation and pain. Is NOT aimed to improve healing. Surgical study finds that rotator cuff tendons are more likely to be weaker in those who had injections.?role in complete tear Best for younger patients with bursitis.
Surgical outcome Patient satisfaction is rated excellent and good for 93 to 97% of patients after arthroscopic rotator cuff repair in recent studies from Flurin et al in Arthroscopy 2007, Burns and Snyder in Journal of Shoulder and Elbow Surgery (JSES) 2008, and Charosset et al in American Journal of Sports Medicine (AJSM) 2007. Success measures of patient satisfaction after rotator cuff repair depend upon age. Looking specifically at patients over 62 years of age, 87% had good to excellent results in a study by Grondel and Savoie in JSES2004. Whereas, 100% of patients less than 40 years old had pain relief and 95% had improved function after arthroscopic single row repair in Krishnan Arthroscopy 2008. Sugaya in Arthroscopy 2005 reported a retear rate of 25% for patients repaired with a single row of anchors, but that rate was lowered to 10% for those patients who had a dual row arthroscopic rotator cuff repair
Surgical view of a double anchor
A-C joint arthritis A-C joint arthritis can be due to an old injury or age-related wear and tear not considered a workrelated condition.
Adhesive capsulitis Adhesive capsulitis is a condition of unknown cause not work-related
SLAP tear Throwing injuries caused by pushing of the arm onto the superior/anterior margin of glenohumeral joint.
SLAP tear SLAP tear is a sporting injury. Not considered a work-related condition.