Rotator Cuff Syndrome

in the shoulder classification system where are SAPS/RC syndrome fall?

pain and muscle power deficits

extrinsic factors attributing to rotator cuff pathology

heavy labor

trauma

smoking

subacromial issues

intrinsic factors attributing to rotator cuff pathology

age

higher BMI

diabetes

prevalence rate of RC injury associated with age

increase risk/likelihood with increased age

Codman's Critical Zone

area about 1.5 cm from the supraspinatus tendon insertion on the greater tubercle.

poor blood supply (hypovascularity) --> Degeneration over time, poor healing, more likely to develop tears which is why many supraspinatus tears occur in this location

this theory is inconsistent though and hypovascularity does not fully explain rotator cuff pathology

Vascularity of small tears vs large tears

Small tears → increased vascularity (active healing response).

Large/chronic tears → decreased vascularity (failed healing response)

Take home message: Role of Vascularity in the Intrinsic Mechanism of Symptomatic RC Tendinopathy

Blood supply is one factor in rotator cuff tendinopathy, but it interacts with other factors like aging, mechanical loading, degeneration, and tendon biology rather than acting alone

pathogenesis of RC injury in throwing athletes

repetitive activity --> weakness and fatigue of RC --> overload of passive structures --> laxity --> eccentric overload of RC OR subluxation --> inflammation OR impingement respectively

age of onset for rotator cuff injuries

majority > 45

ruptures can occur in active young healthy individuals but more of a traumatic onset

incidence of rotator cuff injury

men > women

manual laborers > sedentary

dominant arm > non-dominant

risk factors for rotator cuff injury

smoking

repeated steroid injections

systemic disease (RA, gout, neurogenic disorders)

traumatic rotator cuff tears MOI

suddenly in more active individuals

traumatic event (FOOSH)

examination findings for a traumatic rotator cuff tear

AROM more limited than PROM

pain and weakness with resisted tests

attritional rotator cuff tear clinical presentation

Age: >50

Lateral shoulder/arm pain

Visible atrophy

Pain at night

Weakness

Pseudoparesis/ pseudoparalysis

attritional rotator cuff tear examination findings

PROM maintained but AROM limited

development of abd weakness (+ drop arm test)

altered scapulohumeral rhythm

resisted/special tests for rotator cuff involvement

supraspinatus - full vs. empty can

infraspinatus - lag sign at 20

teres minor - lag sign at 90

subscapularis - belly press, lift off

test item cluster for full thickness tear - Park

painful arc - + if pain or catching between 60-120 degrees

infraspinatus muscle test - + with pain, weakness, or lag

drop arm sign - + with pain or arm drop

3/3 and age > 60 --> likelihood ratio of 28

is there a single clinical test for diagnosing rotator cuff tears?

no but combining factors like older age and + Neer improves likelihood of making correct diagnosis, although accuracy remains relatively low

Predictors of rotator cuff tear

ER strength ratio (affected vs unaffected)

male sex

+ lift off

+ empty can test

rotator cuff imaging options

standard x-ray

arthrogram (MRA)

MRI with or without contrast

ultrasound

arthroscopy

difference between MRA and MRI with contrast

MRA - contrast injected DIRECTLY in joint space

MRI - contrast injected into vein in arm

what may you see on standard x-ray if someone has an atraumatic "attritional"?

superior migration of humeral head

degenerative changes in GH joint margins, humeral head and inferior aspect of acromion

what are our treatment options for rotator cuff tears?

1. non-operative (success dependent on integrity of remaining cuff)

2. surgical intervention

3. decompression w/o repair (very rare)

types of tears: timing

acute

subacute

chronic

types of tears: location

Tendon

Musculotendinous junction

Muscle or avulsion from bone

types of tears: direction

longitudinal

transverse

longitudinal tears

Tear parallel to tendon and muscle fibers

Less weakness and disability

LONGITUDINAL = LESS

transverse tear

perpendicular to tendon and muscle fibers

greater weakness, retraction of muscle fibers, increased fatty infiltration and muscle atrophy

seen in chronic tears

types of tears: thickness

full

partial

full-thickness tears

Extends completely through articular to bursal surface

partial-thickness tears

Articular sided - 2-3x more common

Bursal sided

size of tears

small: 0-1 cm

medium: 1-3 cm

large: 3-5 cm

massive: >5 cm

what is the most common site for full thickness tears?

posterosuperior rotator cuff

what is the most common rotator cuff to be torn?

supraspinatus followed by infraspinatus

cuff tear patterns

crescent - ant/post

u-shape - med/lat

L/reverse L

massive, contracted

what cuff tear pattern has the best prognosis?

crescent followed by u-shape

tear characteristics associated with impaired healing

Longer duration (i.e. older tears)

Transverse (vs. longitudinal)

Greater amounts of retraction

Increased muscle atrophy & fatty infiltration

comorbidities associated with increased risk of impaired healing

elevated cholesterol

DM

obesity

so what should we do with management of small to medium tears?

strong evidence for PT + operative treatment

scapular control assessment: normal

Scapula stable during first 30-60deg of humeral elevation, then smoothly and continuously rotates upward during elevation and downwards during arm lowering

scapular control assessment: dysrhythmia

Scapula demonstrates premature or delayed upward rotation, non-smooth stuttering, or rapid downward rotation during arm lowering

what causes scapular dysrhythmia

inadequate force couple at ST joint

scapular control assessment: winging

Displacement of medial or inferior border of scapula off rib cage often due to injury to long thoracic nerve

goals of conservative management for rotator cuff injuries

1. restore ROM

2. maximize RC and scapular function

3. address functional impairments

rotator cuff exercises

infraspinatus and teres minor: s/l ER at neutral

supraspinatus: prone horizontal abd at 100 degrees w/ full ER

Jobe's 4 - Early Intervention

1. sidelying ER

2. prone shoulder extension

3. prone horizontal abd

4. prone 90/90 ER with retraction

supraspinatus test

test strength with full can and empty can - should be less pain with full can

if finding is pain - not great

if finding is weakness - better

what does the drop arm test evaluate

full thickness rotator cuff tear

drop arm procedure

With patient sitting or standing, shoulder is passively placed in 90° or > of abduction.

Examiner then removes arm support

positive drop arm test

uncontrolled drop of arm

belly press for subscapularis procedure

Patient in seated or standing with elbow flexed to 90

degrees and the palm of the hand on the upper

abdomen, just below xyphoid process. Patient is

asked to press palm of hand against abdomen,

through shoulder IR.

positive belly press

compensation through wrist flexion, shoulder

abduction, or shoulder extension, would result in elbow

dropping below the trunk

subscapularis lift off test procedure

Patient is standing or seated

Examiner will bring the shoulder into maximal IR and place the arm behind back.

Examiner then extends the arm into 20° of extension while maintaining 90° of elbow flexion

positive lift off test

presence of a lag or a drop of the arm when released by examiner