Rotatory cuff syndrome & Scapular Dyskinesia

Dr. Manoj Kumar ParidaDr. Manoj Kumar Parida
DNB OrthopedicsDNB Orthopedics
Apollo HospitalsApollo Hospitals
BhubaneswarBhubaneswar
Scapular Dyskinesia &Scapular Dyskinesia &
Rotator Cuff SyndromeRotator Cuff Syndrome

Questions in DNB TheoryQuestions in DNB Theory
 What is Scapular Dyskinesia , in role ofWhat is Scapular Dyskinesia , in role of
Impingement syndrome (2016)?Impingement syndrome (2016)?
 Describe Anatomy of Subacromial space.Describe Anatomy of Subacromial space.
What is rotator cuff disease? Discuss itsWhat is rotator cuff disease? Discuss its
pathogenesis and management(2008).pathogenesis and management(2008).
 Rotator cuff injury in sportsmen (2013)Rotator cuff injury in sportsmen (2013)

What is Scapular DyskinesisWhat is Scapular Dyskinesis
 Alteration in the normal static or dynamic position or motionAlteration in the normal static or dynamic position or motion
of the scapula during coupled scapulohumeral movements.”of the scapula during coupled scapulohumeral movements.”
 Alters the scapulohumeral rhythmAlters the scapulohumeral rhythm
 Scapular dyskinesis identified in (Warner, 1992):Scapular dyskinesis identified in (Warner, 1992):
 68% of RC problems68% of RC problems
 100% of GH instability100% of GH instability

Classification Of ScapularClassification Of Scapular
DyskinesisDyskinesis
Type 1 - Infero-medial scapular border
prominence
This becomes more evident in the cocking
position of overhead sports.
It is often associated with tightness at the
anterior side of the shoulder (in flexibility of the
pectoralis major/ minor muscles) and weakness
of the lower trapezius and serratus anterior
muscles.
Posterior tipping of the scapula is responsible
for functional narrowing of the subacromial space
during the overhead motion, leading to pain in
the abduction/externally rotated position.
This is often noticed in the early stages of
shoulder disorders.

Classification Of ScapularClassification Of Scapular
DyskinesisDyskinesis
Type 2 - Medial border prominence
This pattern is winging of the entire
medial border of the scapula at rest.
It becomes more prominent in the
cocking position and after repetitive
elevation of the upper extremity. It is
caused by fatigue of the scapula
stabilising muscles (trapezius and
rhomboids).
Type 3 - supero-medial border
prominence
This type of dyskinesis is displayed as
a prominence of the superior medial
border of the scapula and often
associated with impingement and
rotator cuff injury.

Causes Of Scapular DyskinesiaCauses Of Scapular Dyskinesia
1. Shortening of pec minor, short
head of biceps brachii Result in
anterior tilt + protraction of
scapula
2. GH IR deficit Creates “windup”
of scapula on thorax with arm
in IR or ABD
3. Poor Patterning
-Serratus activation/strength
-loss of posterior tilt/upward
rotation

Causes Of Scapular DyskinesiaCauses Of Scapular Dyskinesia
Bony
thoracic kyphosis, clavicular #
(non-union), shortened
clavicular malunion
Joint
High grade AC instability, AC
arthrosis/instability, GH jt
internal derangement
Neurologic
Cervical radiculopathy, nerve
palsy (long thoracic n, spinal
acc n)

Identification of ScapularIdentification of Scapular
DyskinesiaDyskinesia
 Observation: SICK posture (Burkhart, 2003)
 Scapular malposition
 Inferior medial border prominence
 Coracoid pain and malposition
 Dyskinesis of scapular movement

Tests for Scapular DyskinesisTests for Scapular Dyskinesis
 Scapular Retraction Test (SRT)
 Scapular Assistance Test (SAT)
 Lateral Scapular Slide Test
 Wall pushups

Scapular Retraction Test (SRT)Scapular Retraction Test (SRT)
Baseline AROM and pain is evaluated.
 This test is positive if pain is reduced as the
therapist assists active elevation by applying a
posterior tilt and external rotation motion to the
scapula.
This application may be used in conjunction with
other tests such as Neer's, Hawkin's-Kennedy, and
Jobe's relocation.

Scapular Assistance Test (SAT)Scapular Assistance Test (SAT)
Baseline AROM and pain is evaluated.
The therapist then applies an assist to scapular
dynamics.
This test is positive if ROM is increased or pain is
reduced as the therapist manually assists scapular
upward rotation during active UE elevation.

Lateral scapular Slide testLateral scapular Slide test
(LSST)(LSST)
Measurements are taken from spine of scapulae to T2/T3,
Inferior angle of scapulae to T7/T9 and superior angle of
scapulae to T2.
The measurements are taken in 3 positions,
(A) sitting/standing with arms resting on the side,
(B) Hands on the waist, Thumbs Posteriorly (45 abduction),
(C) 90 degrees abduction and maximal internal
rotation.
Measurement should not vary more than 1 to 1.5 cm, more
the 1.5 cm difference significant.

Isometric Scapular Pinch testIsometric Scapular Pinch test
Patient in standing position and is asked to
actively squeeze or retract the scapulae
together as hard as possible.
Normal Response: An individual able to hold
the squeeze or 15 to 20 sec without any
burning pain or noticeable weakness.
Positive: Burning pain present. Watch for:
patient relaxing the contraction.

Wall Push – Ups TestWall Push – Ups Test
 Patient performs wall pushups for 15 to 20
times.
Weakness of scapular muscles (mainly
serratus anterior) or winging usually shows
up with 5 to 10 pushups.
For stronger or younger population, perform
the test on floor.

Pectoralis Minor TightnessPectoralis Minor Tightness
 Supine :
Distance from
posterior
acromion to
table
 Normal : < 1cm
Difference

Role of Scapula Dyskinasia inRole of Scapula Dyskinasia in
Impingement SyndromeImpingement Syndrome
 Scapula Dyskinasia highly associated with impingement syndrome by
altering the scapula position at rest and dynamic position, characterized
by loss of acromian upward rotation and laberal injury,
 This position creates scapula protracted which decrease the
subacromial space and rotatory cuff strength.
 Scapula Dyskinasia increase upper trapezious muscle activity and
decrease seratous anterior activation. This results in lack of acromial
elevation and posterior tilt.
 The pectoralis minor muscle shortened in length leads to tightness of
muscle , scapular protraction at rest and doesn’t allow scapula posterior
tilt or External rotation of upper arm motion predisposing to
impingement syndrome.

Rotator Cuff SyndromeRotator Cuff Syndrome
Rotator cuff syndrome group of
disorder such as :
1. Rotator cuff Tear
2. Supra Spinatus Impingement
3. Calcific Tendinitis
4. Bicep Tendinitis / Rupture

1. Rotator Cuff1. Rotator Cuff
Anatomy:Anatomy:
 Rotator Cuff made up ofRotator Cuff made up of
lateral portion of infralateral portion of infra
spinatous , supra spinatous,spinatous , supra spinatous,
subscapularies , teres minorsubscapularies , teres minor
and the their tendon insertedand the their tendon inserted
into the greater tuberosity ofinto the greater tuberosity of
the humerusthe humerus
 The Rotator cuff passThe Rotator cuff pass
beneath the coracoacromialbeneath the coracoacromial
as from which it is separatedas from which it is separated
from sub acromial bursae.

Anatomy contd.Anatomy contd.
M 0 I F NS
SS SS GT AB C5
IS IS GT ER C 5-6
TM LBS GT ER C5
SS SS LT IR C 5-6

 Blood Supply:Blood Supply:
 The major Artery supply to RCThe major Artery supply to RC
derived from ascending branch ofderived from ascending branch of
anterior humoral circumflex artery,anterior humoral circumflex artery,
acroarmial branch ofacroarmial branch of
Thoracoacromial Artery as well asThoracoacromial Artery as well as
suprascapular and posteriorsuprascapular and posterior
circumflux Artery.circumflux Artery.
 Most cadaver study haveMost cadaver study have
demonstrated that Hypovascular areademonstrated that Hypovascular area
within the critical zone ( at thewithin the critical zone ( at the
insertion of GT).insertion of GT).
 Most recent study demonstrates thatMost recent study demonstrates that
hypovascularity has a significant rolehypovascularity has a significant role
in degeneration of ageing tendon.in degeneration of ageing tendon.

Subacromial spaceSubacromial space
The subacromial space is the area between CA arch and the
humeral head.
The rotator cuff tendons run through this space, a bursa (fluid
filled sac) lying above these tendons reduces friction between
them and the acromium during overhead activities.
The subacromial space is only 10mm.
Regardless of the patho-anatomical etiology, most shoulder
injuries involve a disruption in the delicate subacromial space
(SAS).
Once this space is altered the structures (joint capsule,
articular cartilage, rotator cuff, biceps tendon, bursa) have
increased risk for damage and misuse.
This also leads to subsequent changes in muscle length-
tension relationships, arthrokinematics, and motor patterns.

 Imp functions:Imp functions:
 Counter balance the upward pull of the deltoid on the humerus.Counter balance the upward pull of the deltoid on the humerus.
 Hold the head of the humerus in the glenoid cavity.Hold the head of the humerus in the glenoid cavity.
 Externally rotate the shoulder which is important during armExternally rotate the shoulder which is important during arm
elevation.elevation.
 Stabilize the shoulder mainly anterior (subscapularies)and posteriorStabilize the shoulder mainly anterior (subscapularies)and posterior
cuff (infraspinatus,teresminor), provide fixed fulcrum to concentriccuff (infraspinatus,teresminor), provide fixed fulcrum to concentric
rotation of humerus head.rotation of humerus head.
 Initiation of abductionInitiation of abduction

Rotator Cuff TearRotator Cuff Tear
 RC Tear definedRC Tear defined
as tear of one oras tear of one or
more of themore of the
tendon of the fourtendon of the four
rotator cuffrotator cuff
muscles ofmuscles of
shoulder.shoulder.

Rotator Cuff TearRotator Cuff Tear
CausesCauses
 Usually < 40 yrsUsually < 40 yrs
 High Velocity TraumaHigh Velocity Trauma
 Repeated Micro traumaRepeated Micro trauma
(Overuse, Atheletic)(Overuse, Atheletic)
 Sports Related InjurySports Related Injury
 TraumaticTraumatic..  Non-TraumaticNon-Traumatic..
 Age > 40 yrsAge > 40 yrs
 Degenerative (Painter,electrician)Degenerative (Painter,electrician)
 Inflammatory disease like calcificInflammatory disease like calcific
tendinitis/RA /crystal inducedtendinitis/RA /crystal induced
arthropathyarthropathy
 Scapulo humoral neuro muscularScapulo humoral neuro muscular
dysfunctiondysfunction
 Shoulder instabilityShoulder instability
 Entrapment SyndromeEntrapment Syndrome

PathophysiologyPathophysiology
 Anterosuperior
impingement
 Posterosuperior
impingement
 Anterointernal impingement
 ExtrinsicExtrinsic  IntrinsicIntrinsic..
 Age-related degeneration of the
tendon.
 The critical zone -articular surface of
the tendon, near its insertion on the
GT
 Rathbun et al -relative avascularity of
the cuff is position-dependent and
observed a poor filling only when the
shoulder is in adduction

 ANTEROSUPERIOR IMPINGEMENTANTEROSUPERIOR IMPINGEMENT
 It is d/t deep surface tear of subscapalaris andIt is d/t deep surface tear of subscapalaris and
impingement occur in humeral head and anterior glenoidimpingement occur in humeral head and anterior glenoid
rimrim
 Provocative test-Provocative test-
 Foreward flexion of arm and IR -painForeward flexion of arm and IR -pain

 POSTEROSUPERIOR IMPINGEMENTPOSTEROSUPERIOR IMPINGEMENT
 SS and IS Impingement between GT AND posterior glenoid rim .SS and IS Impingement between GT AND posterior glenoid rim .
 PROVACATIVE TEST-arm ABD AND ER-PAIN.PROVACATIVE TEST-arm ABD AND ER-PAIN.
 ANTEROINTERNAL IMPINGEMENTANTEROINTERNAL IMPINGEMENT
 Gerber (1985) - impingement of the cuff in the coracohumeral interval whenGerber (1985) - impingement of the cuff in the coracohumeral interval when
the shoulder is held in flexion and internal rotation, the coraco humeralthe shoulder is held in flexion and internal rotation, the coraco humeral
distance is reduced from 8.6 mmdistance is reduced from 8.6 mm
 Subcoracoid impingement can be idiopathic(eg, large coracoid tip), iatrogenicSubcoracoid impingement can be idiopathic(eg, large coracoid tip), iatrogenic
or following a fracture (eg, humeral head or neck fracture)or following a fracture (eg, humeral head or neck fracture)

Clinical FeauturesClinical Feautures
 Pain on the lateral surface of shoulder radiatePain on the lateral surface of shoulder radiate
distally to the deltoid insertion.distally to the deltoid insertion.
 Pain usually in nightPain usually in night
 Stiffness is more common in partial tearStiffness is more common in partial tear
 Pain may also localized to the ant. Aspect ofPain may also localized to the ant. Aspect of
acromianacromian
 Progressive pain and weakness with loss ofProgressive pain and weakness with loss of
active motionactive motion
 Pt. would have felt or heard a pop.Pt. would have felt or heard a pop.

ClassificationClassification
A.A. Acute and ChronicAcute and Chronic
B.B. Partial Thickness tear and Full Thickness tearPartial Thickness tear and Full Thickness tear
C.C. Traumatic and Non TraumaticTraumatic and Non Traumatic
Partial Thickness Tear classified byPartial Thickness Tear classified by Ellman’sEllman’s StagingStaging
Grade 1 – Tear upto ¼ th thicknessGrade 1 – Tear upto ¼ th thickness
Grade 2 – Tear upto ¼ th to ½Grade 2 – Tear upto ¼ th to ½
Grade 3 – More than ½Grade 3 – More than ½
Full Thickness TearFull Thickness Tear CofieldCofield ClassificationClassification
Small - < 1cmSmall - < 1cm
Medium – 1 to < 3cmMedium – 1 to < 3cm
Large – 3 to < 5cmLarge – 3 to < 5cm
Massive – > 5cmMassive – > 5cm

InvestigationInvestigation
XRAY:XRAY:
 Sclerosis of acromian – Sourcil signSclerosis of acromian – Sourcil sign
 Sclerosis of humeral headSclerosis of humeral head
 Flattening of GTFlattening of GT
 Acromial spurAcromial spur
 Calcification of RC TendonCalcification of RC Tendon
 Reduce joint spaceReduce joint space
MRI :MRI :
 T2 image – presence of fluid in subacromial spaceT2 image – presence of fluid in subacromial space
 T1 image – Loss of subacromial fat planeT1 image – Loss of subacromial fat plane
 Discontinuity of tendonDiscontinuity of tendon
 Size of tearSize of tear
 Retraction of tendonRetraction of tendon
 Irregularity of glenoid labrumIrregularity of glenoid labrum
 Fatty infiltrationFatty infiltration

Investigation contd.Investigation contd.
Fatty Infiltration classified into five stages according to MRI or CT byFatty Infiltration classified into five stages according to MRI or CT by GoutallierGoutallier
et alet al
Grade 0 – No fat within the muscleGrade 0 – No fat within the muscle
Grade 1 – Occassionally fatty streak within the muscleGrade 1 – Occassionally fatty streak within the muscle
Grade 2 – Fat < 50% infiltration within the MuscleGrade 2 – Fat < 50% infiltration within the Muscle
Grade 3 – Fat infiltration 50% within the muscleGrade 3 – Fat infiltration 50% within the muscle
Grade 4 – Fat more than 50% within the muscleGrade 4 – Fat more than 50% within the muscle
USG –USG –
Partial or full thickness tearPartial or full thickness tear
Visualization of rotator cuff pathologyVisualization of rotator cuff pathology
Arthrogram –Arthrogram –
Good diagnosis of complete Rotator cuff tearGood diagnosis of complete Rotator cuff tear
Cost effectiveCost effective
InvasiveInvasive
Size of tear cannot be determinedSize of tear cannot be determined

TreatmentTreatment
Indications:Indications:
 Pt. with chronic RC tearPt. with chronic RC tear
 Limited to 1 tendonLimited to 1 tendon
 Age > 60 and less activeAge > 60 and less active
 Co-morbidies conditionCo-morbidies condition
 Inactive lifestyleInactive lifestyle
 Pt. not willing for surgery.Pt. not willing for surgery.
 ConservativeConservative..  OperativeOperative
Indications:Indications:
 Full thickness tearFull thickness tear
 Conservative treatment failureConservative treatment failure
 Need to use shoulder overheadNeed to use shoulder overhead
elevationelevation
 Pt. < 60 yrsPt. < 60 yrs
 To achieve full passive range ofTo achieve full passive range of
motionmotion

Conservative TreatmentConservative Treatment
 Mc Laughlin in 1962 reason to avoid early repair.Mc Laughlin in 1962 reason to avoid early repair.
 25 % of cadaver head torn cuff most of them asymptotic25 % of cadaver head torn cuff most of them asymptotic
 50% pt. would recover conservatively50% pt. would recover conservatively
 Result of early and late repair are same.Result of early and late repair are same.
 Repair did not always permit anatomical restoration.Repair did not always permit anatomical restoration.
 Early diagnosis is difficultEarly diagnosis is difficult
 Conservative T/t:Conservative T/t:
Physical TherapyPhysical Therapy
Gentle progressive strechingGentle progressive streching
Analgesic , TENS, Exercise, avoid abduction,Analgesic , TENS, Exercise, avoid abduction,
Intra articular steroid or oral steroidIntra articular steroid or oral steroid

Surgical TreatmentSurgical Treatment
Partial Thickness Tear ( < 50
% of articular or bursal
surface
Arthroscopic
decompression /
Debridement or repair with
acromioplasty
Partial Thickness Tear ( >
50% of articular or bursal
surface)
Arthroscopic
decompression /
Debridement or repair with
acromioplasty
Small to medium tear (< 3cm
, one tendon)
Arthroscopic repair
Large massive tear ( 3 to 5
cm / 2 – 3 tendon)
Open or arthroscopic repair
with muscle transfer ,
debridment
Massive retracted irreparable
with intra articular pathology
Open reverse to shoulder
replacement

Physical TestPhysical Test
 Supraspinatus – Empty Can TestSupraspinatus – Empty Can Test
 90 deg. Abduction and 30 deg. Forward flexion, IR,90 deg. Abduction and 30 deg. Forward flexion, IR,
thumb towards the floor -> apply downward pressurethumb towards the floor -> apply downward pressure
both the arms against resistanceboth the arms against resistance
 InfraspinatusInfraspinatus
 Arm close to the body and elbow 90 deg. Flexion –Arm close to the body and elbow 90 deg. Flexion –
ER against resistanceER against resistance
 Subscapularies – Lift of TestSubscapularies – Lift of Test
 Teresminor – Patte Test (Horn Blower Sign)Teresminor – Patte Test (Horn Blower Sign)
 Arm 90 deg. And elbow 90 deg. In the suprascapularArm 90 deg. And elbow 90 deg. In the suprascapular
plane – ER against resistanceplane – ER against resistance

2. Supraspinatus2. Supraspinatus
ImpingementImpingement
 Supraspinatus injury is painful disorder which is thoughtSupraspinatus injury is painful disorder which is thought
to be arised from repeatative compressive / rubbing ofto be arised from repeatative compressive / rubbing of
the tendon under the CA arch.the tendon under the CA arch.
 Pathalogy: Abduction of armPathalogy: Abduction of arm
SS Tendon, Compress and irritated as itSS Tendon, Compress and irritated as it
contact with ant. Edge of Acromiancontact with ant. Edge of Acromian
process.process.
Site of Impingement ‘Critical Area’ 1cm prox.Site of Impingement ‘Critical Area’ 1cm prox.
To GT.To GT.

Clinical FeaturesClinical Features
 Pain usually at nightPain usually at night
 StiffnessStiffness
 WeaknessWeakness
 Loss of movementLoss of movement

ClassificationClassification
 Deposition of Hydroxy apitate in critical zone.Deposition of Hydroxy apitate in critical zone.
 Local IschemiaLocal Ischemia
 Fibro cartilage metaplasiaFibro cartilage metaplasia
 Deposition of CrystalDeposition of Crystal
 Calcification alone not painful when florideCalcification alone not painful when floride
vascular reaction produce swelling of tendon.vascular reaction produce swelling of tendon.
 30 – 50 yrs aching pain30 – 50 yrs aching pain
 Xray – wooly appearanceXray – wooly appearance
 Treatment : NSAID , CS, ESWT, AspirationTreatment : NSAID , CS, ESWT, Aspiration
 Arthroscopically milk out toothpaste likeArthroscopically milk out toothpaste like
depositiondeposition
 AcuteAcute..  ChronicChronic
 AsymtomaticAsymtomatic
 incidental findingincidental finding
on xrayon xray
 UsuallyUsually
associated withassociated with
SS ImpingementSS Impingement
3. Calcification of Rotator3. Calcification of Rotator
CuffCuff

 Long heads of BicepLong heads of Bicep
 Usually together with RC ImpingementUsually together with RC Impingement
 Young PeopleYoung People
 Tenderness localized to Bicipital groupTenderness localized to Bicipital group
 Speed TestSpeed Test
 T/t. – Rest, hot compression, cs injection ,Refractory cases, ArthroscopicT/t. – Rest, hot compression, cs injection ,Refractory cases, Arthroscopic
decompression, Bicep tenotomy, Bicep Tenodesisdecompression, Bicep tenotomy, Bicep Tenodesis
 BICEP RUPTURE:BICEP RUPTURE:
 Long head of bicep usually RC disruptionLong head of bicep usually RC disruption
 50 yrs50 yrs
 Snap while lifting heavy objectsSnap while lifting heavy objects
 Lump lower part of the armLump lower part of the arm
 T/t – Anterior Acromioplasty at the same time distal tendon can be sutured to theT/t – Anterior Acromioplasty at the same time distal tendon can be sutured to the
bicipetal groovebicipetal groove
 Post of light splint with elbow flexed for 4 weeksPost of light splint with elbow flexed for 4 weeks
4. Bicep Tendinitis / Rupture4. Bicep Tendinitis / Rupture

Rotatory cuff syndrome & Scapular Dyskinesia

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