The document provides a comprehensive overview of rotator cuff injuries, including definitions, types, epidemiology, risk factors, and management strategies. It outlines the categories of rotator cuff tears, their clinical presentation, diagnostic procedures, and the role of both medical and physiotherapy management. The document emphasizes the importance of understanding the injury's etiology, symptoms, and rehabilitation techniques to enhance recovery.

1. ROTATOR CUFF INJURY
By: Okeowo Similoluwa

2. OUTLINE
• Introduction/Definition
• Categories of rotator cuff injury
• Epidemiology & risk factors
• Etiology
• Clinical presentation
• Differential diagnosis
• Diagnosis

3. OUTLINE (CONT)
• Special tests
• Outcome measures
• Medical management
• Physiotherapy management

4. INTRODUCTION
A rotator cuff injury occurs when at least two tendons are completely torn. Next to the
number of tendons which are torn, at least one of the tendons must be retracted beyond the
top of the head of the humerus. Severity of the tear is expressed by the number of tendons
which are torn and sometimes the size of the tear.
There are three main joints of the shoulder girdle: the glenohumeral joint,
the acromioclavicular joint and the sternoclavicular joint. The shoulder girdle reaches a
large range of motion. Because of this large range of motion, the shoulder girdle is less
stable.The limited passive stability indicates that the primary source of joint stability must
be balanced by muscle control.

5. INTRODUCTION
The rotator cuff muscles provides this stability.
NOTE : There are four rotator cuff muscles:
● Subscapularis,
● Teres Minor,
● Supraspinatus and I
● Infraspinatus.
During shoulder abduction the rotator cuff muscles act together to stabilize the humeral
head within the glenoid cavity in a process known as concavity compression.

6. INTRODUCTION (CONTINUE )

7. INTRODUCTION (CONT)

8. CATEGORIES OF ROTATOR CUFF INJURY
Rotator cuff tears can be categorized into 5 types (A-E)
• Type A: supraspinatus and superior subscapularis tears
• Type B: supraspinatus and entire subscapularis tears
• Type C: supraspinatus , superior subscapularis and infraspinatus tears
• Type D: supraspinatus and infraspinatus tears
• Type E: supraspinatus, infraspinatus and teres minor tears

9. CATEGORIES OF ROTATOR CUFF INJURY
(CONT)

10. CATEGORIES OF ROTATOR CUFF INJURY
(CONT)
There are a number of classification systems that are used to describe the
size, location and shape of rotator cuff tears. Most commonly, tears are
described as partial- or full-thickness. A commonly cited classification
system for full- thickness rotator cuff tears was developed by Cofield
(1982). The classification system is:
1. Small tear: less than 1 cm
2. Medium tear: 1–3 cm
3. Large tear: 3–5 cm
4. Massive tear: greater than 5 cm.

11. EPIDEMIOLOGY & RISK FACTORS
Rotator cuff injury is extremely common, affecting between 6.8% and 22.4% of the population over
age 40. Tear prevalence, size, likelihood of progression, and retear rates after surgical repair are all
related to increasing age.
Risk factors :
• Age: The risk of rotator cuff tears increases with age because joints, ligaments and tendons
degenerate as people age.
• Sex: Men are more likely to have rotator cuff tears than women.
• Family history: A family history of rotator cuff tears can increase the risk.
• Hand dominance: Tears are more likely to affect the dominant arm.
• Smoking: Smoking can increase the risk of rotator cuff tears.
• Other health conditions: Diabetes, hypertension, and high cholesterol can increase the risk of
rotator cuff tears by causing vascular insufficiency which is associated with degenerative rotator
cuff disease.
• Trauma: A history of trauma can increase the risk of rotator cuff tears.
• Heavy labor: Heavy labor can increase the risk of rotator cuff tear

12. ETIOLOGY
• Rotator cuff tears can be caused by degenerative changes, repetitive micro traumas,
severe traumatic injuries, atraumatic injuries and secondary dysfunctions.
Traumatic injury to the rotator cuff can be caused by falling on an outstretched hand,
by an unexpected force when pushing or pulling, or during shoulder dislocation.
Normal age-related muscle deterioration and excessive repetitive motions are
examples of atraumatic causes.
• Extrinsic factors such as subacromial and internal impingement, tensile overload
and repetitive stress can lead to a higher risk of rotator cuff tears.
Intrinsic factors such as poor vascularity, alterations in material properties, matrix
composition and aging are also involved.
Smoking and inflammation of the joint capsule (frozen shoulder) can also lead to a
higher risk for a rotator cuff tear.

13. CLINICAL PRESENTATION
The location of the tear has an important influence on the possible dysfunctions.
Individuals with a rotator cuff tear may suffer from:
• severe pain at time of injury
• pain at night
• pain with overhead activities
• positive painful arc sign
• weakness of involved muscle
• shoulder stiffness.
Individuals with a tear of the supraspinatus may complain of tenderness over the greater
tuberosity, pain located in the anterior shoulder and symptoms radiating down the arm.

14. CLINICAL PRESENTATION (CONT)

15. CLINICAL PRESENTATION (CONT)

16. CLINICAL PRESENTATION (CONT)

17. CLINICAL PRESENTATION (CONT)

18. DIFFERENTIAL DIAGNOSIS
• Rotator cuff tendinopathy
• Subacromial Impingement
• Osteoarthritis, Rheumatoid Arthritis
• Shoulder Instability
• Subscapular nerve entrapment
• Scapulothoracic bursitis
• Adhesive Capsulitis
• Biceps Tendonitis
• Calcific Tendonitis Shoulder
• Parsonage Turner Syndrome, Thoracic Outlet Syndrome
• Glenohumeral ligament tears or sprains

19. DIAGNOSIS/EXAMINATION
Many factors are considered in diagnosing rotator cuff tears. Subjective history including mechanism of injury, activities
that aggravate or ease pain, current limitations to function and physical examination findings. Additionally, diagnostic
imaging is used to make the diagnosis.
Diagnosis is based on:
1. History
2. Clinical examination: active and passive range of motion, strength tests and rotator cuff tests
3. X- rays (to exclude sclerosis and osteophyte formation on the acromion)
4. MRI and ultrasound
5. IMPT (isokinetic muscle performance test): to estimate the functional status of the rotator cuff muscles.

20. SPECIAL TESTS
Tests for subscapularis
• Lift-off test and Passive Lift Off Test
• Belly Press
• Belly-off sign
• Bear Hug Test

21. SPECIAL TESTS (CONT )
Tests for Supraspinatus and infraspinatus
• External rotation lag sign: 0° and 90°
• Jobe’s test
• Drop arm test
• Neer test
Test for Teres minor
• Hornblower’s Sign

22. OUTCOME MEASURES
Commonly used shoulder outcome measures include:
• Penn Shoulder Score (PSS)
PSS is used to measure outcome of patients with various shoulder disorders. It’s a 100-point question
• Shoulder Pain and Disability Index: The SPADI is created to measure pain and disabilities associated
with shoulder pathology in patients with shoulder pain of musculoskeletal, neurogenic or undetermined
origin. There are 2 domains, pain and disability, with 13 items. Pain contains 5 items and activities
contain 8 items. Every item is scored on a visual analogue scale, ranging from 0 (no pain/no difficulty)
to 10 (the worst pain imaginable/so difficult that help is required).
• Simple Shoulder Test (SST):The SST is a function scale with 12 items, used to assess improvement in
shoulder function after treatment interventions and to check the patient’s ability to tolerate or perform
12 activities of daily living. The scores range from 0 to 100 and are reported as the percentage of items
that were answered.
Note: Your own clinical judgment will be necessary to determine the most useful measure in your clinical
setting.

23. MEDICAL MANAGEMENT
There are three types of surgical treatments to repair rotator cuff tears.
• Open repair: A traditional open surgical incision is often required for large or complex tears.
• Arthroscopic Repair :An optical scope and small instruments are inserted through small puncture
wounds instead of through a larger incision. The operation can be carried out under visual control
via a video display.
• Mini-Open repair: New techniques and instruments allow surgeons to perform a complete
recovery of the rotator cuff through a small incision of generally 4 to 6 cm.
The operative treatment is done mostly arthroscopically which is less invasive than open/mini-open
surgery and leaves only a few small scars. The rehabilitation can start faster and the patient has less
pain during recovery.

24. PHYSIOTHERAPY MANAGEMENT
• Soft tissue massage: Improves flexibility in muscles and ligaments
• Stretching exercises: Helps decrease shoulder stiffness and improve function
• Strengthening exercises: Helps you regain strength in your shoulder muscles
• Electrotherapies: Can include transcutaneous electrical stimulation (TENS) and
iontophoresis
• Taping: Can improve range of motion and muscle strength
• Exercise programs: Can include progressive resistive strengthening, proprioception training,
and sport-specific exercises.

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