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

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Series1

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

Latissimus dorsi

Levator Scapulae

Rhomboid

Supraspinatus

Infraspinatus

Teres Minor

Teres Major

Pectoral muscles

Pectoralis Major

Pectoralis Minor

Serratus Anterior

Long head of biceps (LHB) tendon

Biceps

Subscapularis

Latissimus Dorsi

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

rotator cuff (p<0.001) (J of Shoulder & Elbow surgery vol.4, issue 5, p376-383)

Acromiom type

Neer classification

of impingement

• Neer5 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 work-

related 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.