Rotator cuff injury

1. ROTATOR CUFF TEAR

2. END POINT DIAGNOSIS
• End point diagnosis:
• Rotator cuff tear
• It could be this
• Tendinitis
• Labral tear
• Impingement
• Adhesive capsulitis
• Referred shoulder pain from other sources

3. Rotator cuff anatomy

4. Anatomy
• The rotator cuff is a group of muscles in the shoulder that
allow a wide range of movement while maintaining the
stability of the glenohumeral joint.
• The rotator cuff includes the following muscles:
• Subscapularis
• Infraspinatus
• Teres minor
• Supraspinatus
• A helpful mnemonic to remember these muscles is "SITS".

5. Anatomy
• The glenohumeral joint is a ball and socket joint and comprises
a large spherical humeral head and a small glenoid cavity.
• This anatomy makes the joint highly mobile, however, really
unstable.
• Stabilization in the shoulder is provided collectively by the
non-contractile tissue of the glenohumeral joint (static
stabilizers) such as the capsule, the labrum, the negative
intraarticular pressure, and the glenohumeral ligaments; and
the contractile tissues (dynamic stabilizers) such as the rotator
cuff muscles and the long head of the biceps brachii.

6. Structure and Function
• The primary biomechanical role of the rotator cuff is to stabilize the
glenohumeral joint by compressing the humeral head against the
glenoid.
• These four muscles arise from the scapula and insert into the
humerus.
• Subscapularis: Medial (internal) rotation of the shoulder
• Supraspinatus: Abduction of the arm
• Necessary for the initial 0 to 15 degrees of shoulder abduction motion
• The deltoid muscle abducts the arm beyond 15 degrees
• Infraspinatus: Lateral (external) rotation of the shoulder
• Teres Minor: Lateral (external) rotation of the shoulder

7. Rotator cuff function
• the primary function of the rotator cuff is to provide dynamic
stability by balancing the force couples about the glenohumeral
joint in both the coronal and transverse plane.
• coronal plane
• the inferior rotator cuff (infraspinatus, teres minor, subscapularis) functions
to balance the superior moment created by the deltoid
• transverse plane
• the anterior cuff (subscapularis) functions to balance the posterior moment
created by the posterior cuff (infraspinatus and teres minor)
• this maintains a stable fulcrum for glenohumeral motion.
• the goal of treatment in rotator cuff tears is to restore this
equilibrium in all planes.

8. Blood Supply and Nerve
• The suprascapular artery supplies the supraspinatus and
infraspinatus muscles.
• The subscapular artery is the largest branch of the axillary artery. It
gives vascular supply to the subscapularis muscle.
• The posterior circumflex humeral artery originates from the third
part of the axillary artery in the axilla. It enters the posterior
scapular region through the quadrangular space (accompanied by
the axillary nerve) and supplies the teres minor muscle.
• The subscapular nerve (upper and lower branches) innervates
the subscapularis muscle.
• The suprascapular nerve innervates the infraspinatus and
supraspinatus
• The axillary nerve innervates teres minor

9. Mechanism of injury
• chronic degenerative tear ( intrinsic degeneration is the primary
etiology)
• older patients, involves the SIT (supraspinatus, infraspinatus, teres minor)
chronic impingement
• typically starts on the bursal surface or within the tendon
• acute avulsion injuries
• younger patients following a fall
• acute SIT in patients > 40 yrs with a shoulder dislocation
• full thickness rotator cuff tears  throwing athletes
• iatrogenic injuries
• due to failure of surgical repair
• often seen in repair failure of the subscapularis tendon following open
anterior shoulder surgery.

10. Classification

11. Risk Factors
• Age : most common > 40
• Poor posture  forward-shoulder posture  muscle or
tendon become irritated and inflamed when throw or perform
overhead activities
• Weak shoulder muscles  abductors and external rotators
• Repetitive overhead lifting
• Athelete : tennis, baseball pitchers
• Occupation : painters, carpenters, others who do overhead work
• Traumatic injury: falls or other shoulder injury

12. Symptoms
• pain
• typically insidious onset of pain exacerbated by overhead activities
• pain located in deltoid region
• night pain, which is a poor indicator for nonoperative management
• can have acute pain and weakness with an traumatic tear
• weakness
• loss of active ROM with greater or intact passive ROM

14. Strength Testing: Supraspinatus
• Supraspinatus: abduction (with deltoid)
• Empty Beer can Test
• Arm to 90o, forward flexion to 30o, internal rotation of hand with thumbs down,
push up against resistance

15. Strength Testing: Teres
minor/infraspinatus
• Teres minor/infraspinatus: external rotation
• External rotation against resistance

16. Strength Testing: Subscapularis
• Subscapularis: internal rotation
• Internal rotation against resistance

17. Other tests

18. AC Injury: Cross-Arm Test
• Pull arm across body (thereby compressing the AC joint)
• look for pain at the AC joint not just general shoulder pain

19. Impingement Tests: Neer’s Test
• Forward flexion with arm internally rotated

20. Impingement Tests: Hawkins Test
• Arm at 90o, 30o of forward flexion, bend elbow and take from
external rotation to internal rotation

21. Other Special Tests: O’Brien’s Test
• Labrum tears
• Arm at 90o, flexed at 90o, bring arm across midline and then up
against resistance
• Internally rotated (thumb down)-> if pain, labrum tear
• Externally rotated (thumb up) -> if pain, biceps pathology

22. Other Special Tests: Speed’s Test
• Biceps injury
• Grab hand as if handshake and do resisted supination, look for pain

23. Other Special Tests: Apprehension Test
• Shoulder stability (for recurrent dislocators)
• patient supine, arm abducted 90o, elbow flexed to 90o, external
rotation to 90o -> patient will feel pressure at the humerus
• If you push down on the humeral head, will decrease pain and increase
stability

24. Algorithm

25. Imaging

26. Radiographs
• views
• true AP, AP in internal/external rotation, axillary
• outlet view to assess acromion
• findings
• calcific tendonitis
• calcification in the coracohumeral ligament
• cystic changes in greater tuberosity
• proximal migration of humerus seen with chronic RCT
(acromiohumeral interval <7 mm)
• Type III (hooked) acromion

28. Arthrogram
• indications
• not commonly used in isolation; used when MRI contraindicated
• findings
• rotator cuff tear present if dye leaks from glenohumeral joint into
subacromial joint
• MR arthrogram may improve sensitivity and specificity

30. MRI
• indications
• diagnostic standard for rotator cuff pathology
• obtain when suspicion for pain or weakness attributable to a rotator cuff
tear
• findings
• important to evaluate muscle quality
• size, shape, and degree of retraction of tear
• degree of muscle fatty atrophy (best seen on sagittal image)
• medial biceps tendon subluxation
• indicative of a subscapularis tear
• cyst in humeral head on MRI seen in almost all patients with chronic RCT
• tangent sign
• failure of the supraspinatus to cross a line drawn between the superior borders of
the scapular spine and coracoid process on a sagittal MRI slice

32. Ultrasound
• indications
• suspicion of rotator cuff pathology
• need for dynamic examination
• advantages include
• allows for dynamic testing
• inexpensive
• readily available at most centers
• disadvantages include
• highly user dependent
• limited ability to evaluate other intraarticular pathology

34. Treatment

35. Treatment considerations
• activity and age of patient
• mechanism of tear (degenerative or traumatic avulsion)
• characteristics of tear (size, depth, retraction, muscle atrophy)
• partial thickness tears vs. complete tear
• articular sided (PASTA lesion) vs. bursal sided
• bursal sided tears treated more aggressively

36. Nonoperative
• physical therapy, NSAIDS, subacromial corticosteroid injections
• first line of treatment for most tears
• partial tears often can be managed with therapy
• technique
• avoidance of overhead activities
• physical therapy with aggressive rotator cuff and scapular-stabilizer
strengthening over a 3-6 month treatment course
• subacromial injections if impingement thought to be major cause of
symptoms

37. Operative
• subacromial decompression and rotator cuff debridement alone
• Indications: select patients with a low-grade partial articular sided rotator
cuff tear
• rotator cuff repair (arthroscopic or mini-open)
• acute full-thickness tears
• bursal-sided tears >3 mm (>25%) in depth
• release remaining tendon and debride degenerative tissue
• partial articular-side tears>50% can be treated with tear completion and
repair
• Partial articular-side tears <50% treated with debridement alone
• PASTA with >7mm of exposed bony footprint between the articular surface
and intact tendon represents significant (>50%) cuff tear (must have at least
25% healthy bursal sided tissue)

38. Operative
• Tendon transfer
• Superior capsular reconstruction
• Reverse total shoulder arthroplasty

39. Frozen Shoulder

40. Definition
Adhesive capsulitis (AC), is also
known as frozen shoulder an
insidious painful condition of the
shoulder persisting more than 3
months.
This inflammatory condition that
causes fibrosis of the glenohumeral
joint capsule is accompanied by
gradually progressive stiffness and
significant restriction of range of
motion (typically external rotation).

41. Etiology
The etiology of frozen shoulder is not yet fully understood. However, some
plausible risk factors have been identified:
Diabetes mellitus (with a prevalence up to 20%)
Stroke
Thyroid disorder

42. Etiology
Shoulder injury
Dupuytren disease
Parkinson disease
Cancer
Complex regional pain syndrome

43. Epidemiology
Adhesive capsulitis occurs
in up to 5%. Females are 4
times more often affected
than men, while the non-
dominant shoulder is more
prone to be affected

44. Pathophysiology
Frozen shoulder is usually described as fibrotic, inflammatory
contracture of the rotator interval, capsule, and ligaments.
However, the development of AC remains not fully understood.
Although disagreements exist, the most recognized pathology
is cytokine-mediated synovial inflammation with fibroblastic
proliferation based on arthroscopic observations.
Additional findings include adhesions around the rotator
interval caused by increased collagen and nodular band
formation.

45. Pathophysiology
The structure usually affected first is the coracohumeral ligament the
roof of the rotator cuff interval.
Contraction of the coracohumeral ligament limits external rotation of the
arm, which is usually first affected in early AC.
In advanced stages, thickening and contraction of the glenohumeral joint
capsule develop, further limiting the range of motion in all directions

46. Staging
Gradual restriction of passive shoulder motion
characterizes a natural course of AC.
The development is commonly described as
progressing through 3 overlapping phases (4
stages classification can also be found in the
literature).
However, from a practical point of view, we
recommended using 2-stage scheme: early and
developed frozen shoulder.

47. Treatment
In patients with refractory cases of frozen shoulder who do not improve after 6 months of non-operative treatment, more aggressive
treatments such as capsular hydrodilatation (stretching the joint capsule by the saline injectate pressure), manipulation under
anesthesia (tearing of the contracted capsule), and arthroscopic capsular release (particularly in the rotator interval) can be
considered.
Non Operative include (Oral NSAIDS, Oral Corticosteroid, Injection)
The majority of treatment options for AC are non-operative and include pharmacological management and physical therapy.

48. Treatment

49. Treatment

50. Impingement Syndrome
Describes a condition in which the supraspinatus and bursa are
pinched as they pass between the head of humerus (greater
tuberosity) and the lateral aspect of the acromion

51. Risk factors
Age: over 40 years
Overhead activities
Bursitis and supraspinatus tendinitis
Acromial shape: type II & III acromion
AC arthritis or AC joint osteophytes may result in impingement and mechanical irritation to the
rotator cuff tendons

53. Risk factors
Age (middle and older age; 40-85y)
Activity (overhead e.g. lifting, swimming, tennis).
Acromial shape.
Posterior shoulder capsule stiffness.
Rotator cuff weakness.

54. Symptoms
◦ Pain in the acromial area when the arm is flexed and internally rotated Inability to
use the overhead position.
◦ The pain may result from subacromial bursitis or rotator cuff tendinitis
◦ Pain when sleeping on the affected side..
◦ Pain will often become worse at night, as the subacromial bursa becomes hyperemic
after a day of activity
◦ Decreased range of motion especially abduction
◦ Weakness

55. Differential diagnosis
Rotator cuff tears
Calcific tendinitis
Biceps tendinitis
Cervical radiculopathy
Acromioclavicular arthritis
Glenohumeral instability
Degeneration of the glenohumeral joint.

56. Physical examination
Atrophy of rotator cuff muscles.
Decreased range of motion (esp. internal rotation & adduction)
Weakness in flexion and external rotation.
Pain on resisted abduction and external rotation.
Pain on “impingement tests”..

57. Impingement tests
Neer’s impingement test:
passive elevation of the internally rotated arm in the sagittal plane (shoulder forward flexion).
Hawkins’ impingement test:
with the elbow flexed to 90 degrees, the shoulder passively flexed to 90 degrees and internally
rotated.

58. NEER’S TEST HAWKINS TEST

59. Radiological findings
 Plain X-rays:
 Acromial spurs
 AC joint osteophytes
 Subacromial sclerosis
 Greater tuberosity cyst
 MRI:
 To confirm the diagnosis and rule out rotator cuff tear

61. Supraspinatous outlet view
Type of acromion:
I flat
II round
III hooked

62. Management
Conservative treatment:
◦ Always start with it
Operative:
◦ Indicated when conservative measures fail

63. Conservative treatment
Avoid painful and overhead activities
Physiotherapy:
1. Stretching and range of motion exercises
2. Strengthening exercises
 NSAIDs
 Steroid injection into the subacromial space

64. Operative treatment
 The goal of surgery is to remove the impingement and create more subacromial space for the rotator
cuff
 Indicated if there is no improvement after 6 months of conservative treatment
 The anterolateral edge of the acromion is removed
 Open (called: Acromioplasty) or arthroscopic technique (called subacromial decompression)
 Success rate 70-90%

65. Make a 12-14 cm long skin incision between the
coracoid process and the proximal humeral
shaft. The shape of the skin incision can be
straight or curved depending on surgeon’s
preference.
For an arthroplasty for degenerative diseases, a
rather vertical incision may be preferred (dashed
line).
Skin Incision

66. Expose the deltopectoral groove with the
cephalic vein. These structures can be identified
by:
The course of the muscle fibers
The cephalic vein itself
Fat tissue surrounding the vein
If in doubt, look for the deltopectoral groove at
the proximal and/or distal end of the skin
incision. (The sulcus is slightly more pronounced
and in cases of revision surgery less scarred.)
Exposure of the superficial Fascia

67. Retract the cephalic vein laterally or medially,
and open along the groove. If retracted laterally,
the anatomical drainage of blood from the
deltoid muscle is respected but it is at risk of
damage by retractors during surgery. In any
case, the cephalic vein should be preserved to
reduce the surgical edema of the limb.
Failure to find the deltopectoral groove can lead
to difficulty in dissection of the deltoid and
possibly to denervation of the anterior portion
of the deltoid.
Bluntly dissect between and under the deltoid
and pectoralis muscles down to expose the
clavipectoral fascia.
Dissection down to the deltopectoral groove

68. Identify the coracoid process and the conjoined
tendon.
Incise the clavipectoral fascia lateral to the
conjoined tendon and inferior the
coracoacromial ligament.
Exposure of the deep layers

69. Retract the deltoid muscle laterally using a delta
(modified Hohmann) retractor and the conjoined
tendon medially using a Langenbeck retractor.
Expose the proximal humerus and confirm the
anatomical landmarks (subscapularis tendon, lesser
tuberosity, bicipital groove with the biceps tendon
and the greater tuberosity). Evaluate the fracture
morphology. Hemorrhagic bursa tissue has to be
resected if needed.
Distally, expose the pectoralis major.
Pitfall: Be aware of retractor positioning (Roux or
Hohmann retractor) to prevent iatrogenic damage
of the axillary nerve.
Exposure of the deep layers

70. Pitfall: The musculocutaneous nerve enters the
coracobrachialis muscle as close as 2.5 cm distal to
the tip of the coracoid. Retractors placed under the
conjoined tendon can cause neurapraxia;
therefore, vigorous retraction must be avoided
Using an additional delta retractor might be helpful
to increase exposure of the proximal humerus.
Exposure may be increased additionally by partially
releasing the insertions of deltoid and/or pectoralis
major.
Shoulder abduction decreases tension on the
deltoid, and makes it easier to retract laterally.
Exposure of the deep layers

71. Intraarticular Exposure
There are several ways to expose the intraarticular aspect
of the glenohumeral joint:
• Incision of the rotator interval
• Opening through the fracture (dislocation of the lesser
tuberosity fragment)
• Tenotomy of the subscapularis tendon

72. Identify the course of the long head of the biceps
and the upper border of the subscapularis tendon.
Incise the rotator interval just at the upper border
of the subscapularis tendon towards the coracoid
process. It might be helpful to perform a tenotomy
of the long head of the biceps close to the labrum
and to remove the intraarticular portion of the
biceps. This window creates a nice view to the
anterosuperior parts of the humerus. It does not
violate the function of the rotator cuff.
Pitfall: In fractures of the proximal humerus which
consist of an anterior fragment one should take
care to analyze the fracture pattern. If the anterior
fragment consists of the lesser tuberosity, the
bicipital groove and the anterior part of the greater
tuberosity, it is strongly recommended to use a
supraspinatus split in line of the fracture instead of
the incision of the rotator interval.
Incision of the rotator interval

73. In fractures of the proximal humerus which
consist of a lesser tuberosity fragment, it might
be beneficial to open up the joint through the
fracture between the greater and lesser
tuberosity. Take care that the extension of the
vertical fracture line between the tuberosities
typically runs into the supraspinatus tendon and
not into the rotator interval. Therefore, a split of
the supraspinatus tendon is necessary to
preserve the anterior insertion of the
supraspinatus tendon.
Opening through the fracture

74. Satisfactory reduction of anatomical neck
fractures may sometimes require an anterior
shoulder arthrotomy.
The subscapularis tendon is identified and
divided vertically lateral to the
musculotendinous junction in line of the
anatomical neck.
Tenotomy of the subscapularis tendon

75. Reflect the subscapularis from the underlying
joint capsule and enter the joint through a
vertical capsulotomy, medial to the lateral stump
of the subscapularis.
Tenotomy of the subscapularis tendon

76. If difficulty is encountered in trying to expose
the axillary nerve, for example in a revision
procedure following a previous attempt at
fixation, it may be helpful to develop the course
of the axillary nerve starting from unoperated
tissues. This may be facilitated by reflecting the
conjoined tendon from the tip of the coracoid,
or with a small coracoid osteotomy.
Tenotomy of the conjoined tendon/osteotomy of
the tip of the coracoid process

77. Irrigate the wound. Placement of a drain
underneath the deltoid muscle might be
considered.
Close the deltopectoral groove, the
subcutaneous tissues and the skin.
Wound closure

78. COMPLICATIONS
• Early
• Pneumothorax (intraop)
• Deltoid detachment
• Nerve injury
• Repair failure
• Infection
• Late
• Stiffness
• Recurrence
• AC pain

79. Thank you