ROTATOR CUFF INJURIES - WITH FULL DESCRIPTION OF TESTS FOR SHOULDER EXAMINATION

1. Dept of Orthopaedics , J.N. Medical
College and
Dr. Prabhakar Kore Hospital and MRC,
Belgaum

2. INTRODUCTION
• In 1834, Smith – first described
rupture of the rotator cuff tendon
• It is among most common causes of
shoulder pain and instability
• Disease severity range from
inflammation and edema to
irreparable ruptures
• Incidence 5-40% with increasing with
advancing age ( >40 years)

3. ANATOMY- ROTATOR CUFF
• Made 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

4. Subscapularis
Origin Subscapular fossa of scapula
Insertion Lesser tuberosity of humerus
Action Internal rotation and adduction of the
arm
Nerve Supply Upper and lower subscapular nerves
(C5, C6 and C7)
Blood Supply Subscapular artery
Anterior Chest Wall

5. Posterior Chest Wall
Supraspinatus
Origin Supraspinous fossa of scapula
Insertion Superior facet on greater tuberosity
of humerus
Action Abduction of arm
Nerve Supply Suprascapular nerve (C4, C5 and C6)
Blood Supply Suprascapular artery

6. Posterior Chest Wall
Infraspinatus
Origin Infraspinous fossa of scapula
Insertion Middle facet on greater tuberosity of
humerus
Action Externally rotates arm
Nerve Supply Suprascapular nerve (C5 and C6)
Blood Supply Suprascapular and circumflex scapular
arteries

8. Function of rotator cuff
• The rotator cuff is the Dynamic
stabilizer of the glenohumeral
joint.
• Stabilisers of shoulder mainly
anterior and posterior cuff
provide fixed fulcrum for
concentric rotation of the
humeral head.
• Neutralises shearing forces of
deltoid in early abduction.
• Initiation of abduction.
•

9. Rotator Cuff Disorders
• Impingement -
– Tendonitis / Tendinosis / Bursitis /
Tendon Entrapment
• Rotator Cuff Tears
• Calcific Tendonitis

10. ETIOLOGY
• IMPINGEMENT( MC ) - Subacromial Impingement syndrome
• High velocity trauma
• Microtrauma (overuse, athletic) caused by repetitive movement in
Occupational or Sports activities. – Weightlifting, Tennis & Badminton,
Baseball, Softball, Hockey
• AGING (Age >40 years)
• ISCHEMIC TENDON
• IATROGENIC
Rotator Cuff Tear
• Working Conditions – long hours of Computer usage stresses
your neck and shoulders, Carpenters, Painters, Electrician -
who also use repetitive motions, have an increased risk of
injury.

11. Pathophysiology
The extrinsic hypothesis :
– Repeated impingement of rotator cuff tendon
against different structures of the glenohumeral
joint .
– Three distinct impingement syndromes
• Anterosuperior impingement syndrome
• Posterosuperior impingement syndrome
• Anterointernal impingement syndrome

12. Antero-Superior impingement
syndrome
• Impingement beneath the Coracoacromial arch
• Supraspinatus tendon insertion to the greater
tuberosity and the bicipital groove must pass
beneath the arch with forward flexion of the
shoulder, especially if internally rotated, causing
an impingement
• Patient with cuff tear are more likely to have
curved or hooked acromion (Toivonen DA et al
1995,Tuite et al1995)

13. 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)

14. Postero-Superior impingement syndrome
• Impingement between the articular side of the
supraspinatus tendon and the Posterosuperior edge of the
Glenoid cavity
• With the shoulder held at 120° of abduction, retropulsion,
and in extreme external rotation (similar to the late
cocking phase in throwers), the labrum moves away from
the glenoid and the glenoid rim comes in contact with the
deep surface of the tendon, producing repeated
microtrauma and leading to partial tears

15. Antero-Internal impingement
syndrome
• Gerber (1985) - impingement of the cuff in the
Coracohumeral interval
• When the shoulder is held in flexion and internal
rotation, the coracohumeral distance is reduced
from 8.6 mm when the arm is at the side to 6.7
mm
• Subcoracoid impingement can be idiopathic (eg,
large coracoid tip), iatrogenic or following a
fracture (eg. humeral head or neck fracture)

16. Neer‘s stages:
• Stage 1- Edema and Hemorrhage.
– Age <25 year
• Stage 2- Fibrosis and Tendinosis.
– Age 25-40 years
• Stage 3 - Bone spurs and Tendon rupture.
– Age>40 years

17. Cuff Disease Progression
Bursitis
Tendinosis
Impingement
Calcific Tendonosis
Oedema
Hemorrhage
Partial Tears Spurs
Full Thickness
Tears
Cuff tear
Arthritis

18. The intrinsic hypothesis
• Progressive age-related degeneration of the tendon
• “The critical zone” (Codman) -articular surface of
the tendon, near its insertion on the greater
tuberosity
• ? hypovascularity in critical zone
• Rathbun et al stated -relative avascularity of the
cuff is position-dependent and observed a poor
filling only when the shoulder is in adduction

19. PATHOLOGY
Torn 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
Stage I, AHI is normal (>6 mm).
Stage II, decrease in AHI (<5 mm)
starts. AHI - acromiohumeral interval

20. Leads to abutement of humeral head
against acromion
stage III, coracoacromial arch
acetabularization (Concave
deformity of under surface of
Acromion)with the decrease of
AHI (<5 mm)

21. Stage 4a - Narrowing & Arthritis
of Gleno-Humeral Joint Space
Stage 5 of Cuff tear
arthropathy with collapse of
humerus head because of
the osteonecrosis.
If the acetabularization is present
then stage becomes Stage -4b

22. Hamada and Fukuda Stages of
Cuff Arthropathy

23. CLASSIFICATION
1. DURATION – ACUTE OR CHRONIC
2. DEGREE OF TEAR- PARTIAL OR FULL THICKNESS
TEAR.
3. ETIOLOGY- TRAUMATIC OR DEGENERATIVE.
4. BASED ON SIZE OF TEAR
SIZE OF TEAR DEGREE
<1 cm SMALL
1- 3 cms MEDIUM
3-5cms LARGE
>5 cms MASSIVE

24. • ELLMANS CLASSIFICATION
1.ARTICULAR
2.BURSAL
3.INTERSTITIAL

26. Crescent Reverse ‘L’ ‘L’ Shaped
Trapezoidal Massive tear
Full Thickness Tear

27. SYMPTOMS
• Pain and weakness on the antero-lateral
aspect of the shoulder
– May radiate to deltoid insertion
– Pain during racquet sports and activities involving throwing
– Aggravated by use of arm in overhead position or flexion
– Associated crepitus, clicking, clunking or grinding sensation
– Shoulder pain worsens at night
• Stiffness
• Cannot lie affected side.

28. 28
Characteristics of pain
Night pain when lying on affected
side, muscle atrophy
Rotator cuff tear
< 30 yo Biomechanical, inflammatory
> 45 yo, Hx of trauma Rotator cuff tear - 35% of pts
Painful arc (60-120°abduction) Subacromial impingement
Pain > 120° abduction Acromioclavicular joint
Catching, popping, clicking GH or AC joint arthritis, labral
tear

30. Mechanism of Injury
– Helps predict injured structure
Example: Fall directly onto anterior/superior of
shoulder  AC joint injury
Example: Arm forcefully abducted and
externally rotated  subluxation or anterior
dislocation
Example: If chronic pain, note activity that
triggers pain, such as the cocking phase of
throwing or the pull-through phase of
swimming

31. 31
Physical Exam- Inspection
• Swelling, asymmetry, muscle atrophy,
scars, ecchymosis and any venous
distention
• Note posture
• Deformities
– Scapular "winging"
– Atrophy - supraspinatus or infraspinatus -
consider rotator cuff tear, suprascapular
nerve entrapment or neuropathy.

32. 32
Palpation
• Sternoclavicular joint
• Clavicle
• Acromioclavicular joint
• Subacromial bursa
• Coracoid process
• Bicipital groove
• Greater tuberosity
• Lesser tuberosity
• Scapula

33. Range of Motion
Movement
Forward flexion -
Extension -
Abduction -
Adduction -
External rotation -
Internal rotation -
Normal range
180°
60°
180°
45°
45°
55°
EXTERNAL
ROTATION
INTERNAL
ROTATION

34. SPECIAL TESTS - Subscapularis
• Bear Hug Sensitivity 60% Specificity 100%
• Belly Press Napolean Sensitivity 40% Specificity 97.9%
• Lift off Sensitivity 17.6% Specificity 91.7%
• Internal Rotation Resistance test at Maximal
Abduction (IRRTM) 76.5% sensitivity

35. “Lift off test/ Gerber’s test”
• Patient standing with hand
behind back with the
dorsum of the hand at
lumbar level. The hand is
lift off the back by
increasing internal rotation
of the humerus and
extension at the shoulder.
• Inability = subscapularis
tear/ dysfunction

36. • If the patient’s hand is passively Internally
rotated as far as possible & the pt. is asked to
hold the position, it will be found that the hand
moves toward the back (medial rotation “spring
back” or lag test) because subscapularis cannot
hold the position due to weakness or pain.
• Also called Modified Lift Off Test
Internal Rotation Lag Sign

38. Bear Hug Test
• The patients hand is placed on the opposite shoulder
with the elbow anterior to the body. The examiner
then applies an ER force while the patient attempts
to maintain the hand on the shoulder
• Postive Test: Patient cannot hold the hand against
the shoulder as examiner applies an ER force.
• Indicates: Subscapularis tear.

39. Supraspinatus
• Hug Up Test 94% sensitivity, 76% specificity
• Empty Can 84% sensitivity 74% specificity
• Full Can 74% sensitivity 81% specificity
• Lag Signs
The examiner pushed the patient's elbow
downward with an inferiorly directed
force applied perpendicular to the elbow
while asking the patient to resist the
pressure.
+ve test if weakness or pain –
Supraspinatus Tear

40. JOBE’S TEST OR EMPTY CAN TEST
Shoulder is placed at 90° of
abduction and 30° of flexion with
elbows locked, thumbs down.
The patient should attempt to abduct
his arms against resistance.
Test is positive if pain is noted and
it indicates FTT Suprapinatus

41. The Full Can test
– Shoulder is placed at 90° of flexion and 45° of
external humeral rotation (thumb pointing
upward, like someone holding a full can)
– Shoulder elevation is resisted.
– Test is positive if it produces pain.

42. Painfull Arc
Supraspinatus –
FTT or Tendinitis

43. EXTERNAL ROTATION STRESS TEST
or The Infraspinatus Test
– The shoulder is positioned at 0°
of elevation (elbows against the
waist flexed at 90°) and
shoulder external rotation is
resisted.
– The test is positive if it produces
pain.
Infraspinatus
Infraspinatus &
Teres Minor

44. Supraspinatus &
Infraspinatus

45. Drop Arm (Codman's) 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 control
– Indicates FTT Infraspinatus

46. Hornblower’s Sign (Patte Test)
•Abduct the patient’s arm to 90 degrees in
the scapular plane
•Flex the elbow to 90 degrees, and the
patient is asked to laterally rotate the
shoulder
•A positive test occurs (patient raises
elbow) with weakness and/or pain
Teres Minor

47. Impingement Tests
 Neer's impingement sign is
elicited when the patient's rotator
cuff tendons are pinched under the
coracoacromial arch
 Pain is elicited during forward
flexion of the shoulder while
keeping the arm in full pronation
(thumb down). The scapula should
be stabilized during the maneuver
to prevent scapulothoracic motion
 Pain with this manoeuvre is a sign
of subacromial impingement

48. NEERS’ TEST
– Most diagnostic test
– LA 10ml lignocaine into subacromial bursa
– >50% relief – rotator cuff tendinitis or partial tear of
bursal surface.
– Pain relief but weakness persists FTT Supraspinatus
– No relief - Other condition.

49. Hawkins Kennedy Test
•Examiner forward flexes shoulder to
90°, then forcibly internally rotates the
arm
•The drives the greater tuberosity further
under the coracoacromial ligament,
reproducing impingement pain.
•Pain with this maneuver suggests
Subacromial impingement or Rotator
cuff tendonitis.

52. Speed’s Test
( Biceps or Straight-Arm Test )
• The examiner resists shoulder forward flexion by the
patient while the patient's forearm is Supinated & the
elbow is extended.
• + test: pain in the bicipital groove & is indicative of
Bicipital Paratenonitis or Tendinosis.

53. Yergason’s Test
• Pt's elbow flexed to 90° & forearm is pronated, patient
attempts to supinate against
• + test: pain in the bicipital groove indicate Bicipital
Paratenonitis or Tendinosis.

54. X-ray
• AP for AHI (Normal >7 mms)
<5mms - poor prognosis.
• Y-lateral for shape of acromion
• Axillary glenoid rim, acromion, coracoid, and
proximal humerus.
• AP in Abd for rotator cuff dysfunction
• Internal rotation view - detecting Hill-Sachs lesions
• External rotation view -greater tuberosity and
proximal humeral physis
INVESTIGATIONS

55. Radiographic features
• Subchondral sclerosis of humeral head
• Flattening of the greater tuberosity
• Sclerosis of the acromion - sourcil sign
• Calcifications located in the presumed
area of rotator cuff tendon
• Acromion spurs
• Acromion type 2 and 3.
subchondral sclerosis of humeral head

56. • acromiohumeral space less
than 6 mm chronic full
thickness tear
Bony spur on the inferior
surface of the acromion

57. Arthrogram
Presence of contrast medium in the
subdeltoid-subacromial bursa
signs the presence of a complete
rotator cuff tear.
Channel between the articular
capsule and the subacromial-
subdeltoid bursa in a complete
rotator cuff tear.
 Invasive

58. Ultrasound
• Cheap and quick to perform.
• Good definition of rotator cuff.
• Allows dynamic examination. Check integrity of Cuff
repair within 1 year of surgery
• Guided injections
• Operator dependant.
• Findings:
– Discontinuity
– Focal abnormal echogenicity

59. MRI
• Best diagnostic aid
• Non-invasive
• Assess Cross sectional anatomy of Bone and Joint
• Exact size, shape and location of tear
• Pre-operatively to assess for Muscle Wasting and
Fatty atrophy
Full thickness tear

60. Differential diagnosis
• Adhesive Capsulitis or Frozen Shoulder
• Bicipital Tendinitis
• Cervival Disc Disease
• Acromio-Clavicular or Gleno-Humeral Arthritis
• Rheumatoid Arthritis
• Thoracic Outlet Syndrome
• Ishchaemic Heart Disease

61. TREATMENT
• SEVERITY OF SYMPTOMS.
• AGE.
• ACTIVITY LEVEL.
• PATIENT REQUIREMENTS .

62. Conservative management
• REST
• ACTIVITY MODIFICATION
• NSAIDS
• PHYSIOTHERAPHY (streching and
strenghtening exercises).
• INJECTION THERAPHY ( STEROID AND
PRP)

63. SUBACROMIAL
CORTICOSTEROID INJECTIONS
• Needle entry is just under acromion from anterolateral
• Benefits: - short-term benefit in reducing pain and
increasing ROM
• Risks:
- decreased tendon strength and risk of tendon rupture
- subcutaneous atrophy
- effects on articular cartilage
- may have detrimental effects on results of
subsequent repair

64. Orthotherapy
• 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 direction
– Phase 2 - designed to Strengthened remaining muscles
of rotator cuff, deltoid & scapular muscles
– Phase 3 - gradual Reinstitution of normal activities
including work and sports.

65. Operative treatment
• Patient selection:
• Samilson & Binder :
– Patient younger than 60 yrs
– Full thickness cuff tear
– Failure to improve on Non-operative management for
6 weeks
– Need to use shoulder in Overhead elevation
– Need Full passive range of motion
– Ability & willingness to cooperate

66. Poor prognostic factors
• Old age group (physiological age >60 years)
• Long history
• No history of trauma
• Smoker
• Multiple steroid injection
• Diffuse osteopenia
• Compromised tendon vascularity
• Large / Massive tear
• Fatty Atrophy / Muscle Wasting
• Grade 3 or less of external rotation
• Upward migration of humeral head.

67. Operative treatment
• Open or Arthroscopic
• Arthroscopic debridement, SAD and acromioplasty with
mini-open repair.
• Types of repair
– trans osseous anchors
– single double row
• Large tears – graft
• Replacement

68. Technique of open repair
• Approach- 5 to 7 cm incision extending
from lateral aspect of ant third of acromion
to lateral tip of coracoid

69. Sub-Acromial decompression
– Coracoacromial ligament release
– Anterior acromioplasty
– Modified acromioclavicular arthroplasty

70. Rotator cuff repair
– Assess the nature of tear
– Mobilisation –
• Release of adhesion
• Release of coracohumeral ligament
• Subscapularis tendon transfer
– Repair – tendon to tendon or tendon to bone
(McLaughlin technique)
– Double Row has better biomechanical characteristics-
decreased gap formation and higher load to failure

71. Transosseous
repair

72. Advantages
of open repair
 Easy to do
 No special equipment
required
 Allows direct
visualization of cuff repair
and acromioplasty
Disadvantages
 Deltoid detachment required
 False positive studies
(arthrogram 2%, MRI 10%) will
lead to unnecessary open
exploration
 Unrepairable tear will be
opened.
 Significant intraarticular
pathology will be missed

73. Arthroscopic rotator cuff repair

74. Portals

75. Anchor sutures
Side to side repair

76. Arthroscopic repair of rotator cuff
 Advantages :
 Lesser morbidity
 Ability to identify and
treat other pathology
 Truly outpatient
 Allows to address small
undetected tears
 Disadvantages :
 Technically difficult
 Implant cost-needs
anchor

77. Arthroscopic assisted mini open repair
• Lateral portal is expanded
• Useful for small &
moderate shape tears
• Results comparable to
open repair
• Avoid opening patients
with false positive studies
and unrepairable defects
• Allows for arthroscopic
correction of
intraarticular pathology

78. Post operative plan.
• Arthroscopic
– Immediate active and passive ROM
– Avoid active abduction >60 degree for 3-4 wks
– Then electrical stimulation, resisting exercises for
3-4 mths
– High demand activities within 4-6 mths
• Open
– Proceed slowly (deltoid detached)
– Avoid active flexion or abduction for 4 wks
– Requires 1-2 additional months

79. Partial thickness tear
• Surgical options:
– Debridement alone for <50% Thickness Tear
– Debridement with arthroscopic subacromial
decompression for Bursal lesions with type 2 or 3
acromions
– Excision and repair for >50% Thickness Tear
– Arthroscopic or Open repair with acromioplasty

80. Irrepairable tears- Treatment options
• Debridement
• Tendon transposition
– Subscapularis
– Infraspinatus
• Muscle transfer
• Partial repair
• Allograft substitution

81. Debridement
• Indication
– >60 years
– good external rotation
– good flexion
– good relief with subacromial LA injection
• Excise all frayed margin and tissue.
• Do not excise coraco-acromial ligament as it cause
antero- superior translation of humeral head.
• Minimal debridement of acromion.

82. Muscle transfers
• Main indication- symptomatic rotator cuff defect
that has low probability of repair
• Two parameters are used
– Static subluxation of humeral head
– Degree of degeneration and atrophy of rotator cuff
muscles
• Transfers for substitution of individual muscle
– Subscapularis -Trapezius (acromial portion), pectoralis
major, pectoralis minor
– Supraspinatus – Trapezius (acromial portion), Deltoid
– Infraspinatus – Latissimus dorsi, Teres major

83. Latissimus Dorsi Transfer
• Described by Gerber in 1992
• Indication
– Irreparable rotator cuff tear involving
• Supraspinatus
• Infraspinatus
– With Functioning subscapularis and deltoid.

84. Complications of rotator cuff repair
• Retear or failure of repair
• Adhesions
• Rotator cuff arthropathy
• Long head of biceps tendon rupture
• Anteroposterior instability
• Fracture of acromion
• Denervation of deltoid
• Injury to suprascapular nerve
• Greater tuberosity fracture
• Stiffness – frozen shoulder
• Reflex sympathetic dystrophy

85. Conclusion
• Non operative management remains the
standard initial care.
• Surgery in selective active individuals.
• Advantage of Arthroscopy is.
- early mobilization and decreased morbidity.
• Treatment according to patients functional
needs.