Rotator cuff ppt
- 1. ROTATOR CUFF PRESENTED BY ; Mijin Mathew
- 2. ANATOMY OF ROTATOR CUFF ◈ Made up of 4 interrelated muscles arising from the scapula and attaching to the tuberosities of humerus 1. SUPRASPINATUS 2. INFRASPINATUS 3. TERES MINOR 4. SUBSCAPULARIS
- 3. Supraspinatus muscle ◈ Origin: Medial 2/3 of supraspinous fossa of scapula ◈ Insertion: Top of greater tuberosity of humerus ◈ Arterial supply : Suprascapular artery ◈ Nerve supply: Suprascapular nerve (c4,c5,c6) ◈ Action: Abduction of shoulder joint from 0 to 15 degree
- 4. Infraspinatus muscle ◈ Origin: Medial 2/3 of infraspinous fossa of scapula ◈ Insertion: Middle impression of greater tuberosity of humerus ◈ Arterial supply : Suprascapular and circumflex scapular artery ◈ Nerve supply: Suprascapular nerve (c5,c6) ◈ Action: External rotations of shoulder joint
- 5. TERES MINOR ◈ Origin: upper 1/3 of dorsal aspect of lateral border of scapula ◈ Insertion: lower impression of greater tuberosity ◈ Arterial supply : Subscapular and circumflex scapular artery ◈ Nerve supply: Axillary nerve (c5,c6) ◈ Action : Adduction and external rotation of shoulder joint
- 6. subscapularis ◈ Origin : Medial 2/3 of the subscapular fossa ◈ Insertion : Lesser tuberosity of humerus ◈ Arterial supply : Subscapularis artery ◈ Nerve supply : Upper and lower subscapular nerve (c5,c6,c7) ◈ Action : Adduction and internal rotation of shoulder joint
- 7. function ◈ Although contraction of the individual muscles that make up the rotator cuff exerts a rotational pull on the proximal end of the humerus, the main function of the conjoint structure is to draw the head of the humerus firmly into the glenoid socket and stabilize it there when the deltoid muscle contracts and abducts the arm
- 8. ROTATOR CUFF DISORDERS ◈ Patients with rotator cuff tendinitis experience pain and weakness on active abduction and those with a severe tear of the cuff are unable to initiate abduction but can hold the arm abducted once it has been raised aloft by the examiner. ◈ The commonest cause of pain around the shoulder is a disorder of the rotator cuff. This is sometimes referred to rather loosely as ‘rotator cuff syndrome’
- 9. ROTATOR CUFF SYNDROME ◈ which comprises at least four conditions with distinct clinical features and natural history: 1. Supraspinatus impingement syndrome and tendinitis 2. Tears of the rotator cuff 3. Acute calcific tendinitis 4. Biceps tendinitis and/or rupture
- 10. COMMON COMPLAINTS ◈ In all these conditions the patient is likely to complain of pain and/or weakness during certain movements of the shoulder. Pain may have started recently, sometimes quite suddenly, after a particular type of exertion ◈ The patient may know precisely which movements now reignite the pain and which to avoid, providing a valuable clue to its origin. ◈ Rotator cuff pain typically appears over the front and lateral aspect of the shoulder during activities with the arm abducted and medially rotated, but it may be present even with the arm at rest. Tenderness is felt at the anterior edge of the acromion.
- 11. IMPINGEMENT SYNDROME ◈ Rotator cuff impingement syndrome is a painful disorder which is thought to arise from repetitive compression or rubbing of the tendons (mainly supraspinatus) under the coracoacromial arch ◈ If the arm is held persistently in abduction and then moved to and Fro in internal and external rotation (as in cleaning a window, painting a wall or polishing a flat surface) the rotator cuff may be compressed and irritated as it comes in contact with the anterior edge of the acromion process and the taut coracoacromial ligament.
- 12. ACROMIAL morphology ◈ In 1986, Bigliani and Morrison described three variations of acromial morphology. ◈ Type I is flat (3% Of cuff tear) ◈ type II curved(24% of cuff tear) ◈ type III the hooked acromion(73% of cuff tear) ◈ They suggested that the type III variety was most frequently associated with impingement and rotator cuff tears.
- 13. Clinical features ◈ Subsequent progress depends on the stage of the disorder, the age of the patient and the vigour of the healing response. Three patterns are encountered: 1. Subacute tendinitis : The ‘painful arc syndrome’, due to vascular congestion, microscopic haemorrhage and oedema. 2. Chronic tendinitis : Recurrent shoulder pain due to tendinitis and fibrosis. 3. Cuff disruption : Recurrent pain, weakness and loss of movement due to tears in the rotator cuff.
- 14. SUBACUTE TENDINITIES ◈ The patient develops anterior shoulder pain after vigorous or unaccustomed activity, e.g. competitive swimming or a weekend of house decorating. The shoulder looks normal but is acutely tender along the anterior edge of the acromion.
- 15. CHRONICTENDINITIES ◈ The patient, usually aged between 40 and 50, gives a history of recurrent attacks of tendinitis, the pain settling down with rest or anti-inflammatory treatment, only to recur when more demanding activities are resumed. ◈ Characteristically pain is worse at night; the patient cannot lie on the affected side and often finds it more comfortable to sit up out of bed. Pain and slight stiffness of the shoulder may restrict even simple activities such as hair grooming or dressing. ◈ A disturbing feature is coarse crepitation or palpable snapping over the rotator cuff when the shoulder is passively rotated; this may signify a partial tear or marked fibrosis of the cuff. Small, unsuspected tears are quite often found during arthroscopy or operation.
- 16. Cuff disruption ◈ The most advanced stage of the disorder is progressive fibrosis and disruption of the cuff, resulting in either a partial or full thickness tear. The patient is usually aged over 45 and gives a history of refractory shoulder pain with increasing stiffness and weakness.
- 17. TEST FOR CUFF IMPINGEMENT PAIN ◈ The painful arc: On active abduction scapulohumeral rhythm is disturbed and pain is aggravated ◈ As the arm traverses an arc between 60 and 120 degrees. Repeating the movement with the arm in full external rotation may be much easier for the patient and relatively painless.
- 18. NEER IMPINGEMENT SIGN & TEST ◈ Neer’s impingement sign: The scapula is stabilized with one hand while with the other hand the examiner raises the affected arm to the full extent in passive flexion, abduction and internal rotation, thus bringing the greater tuberosity directly under the coracoacromial arch. The test is positive when pain, located to the subacromial space or anterior edge of acromion, is elicited by this manoeuvre. ◈ Neer’s test for impingement: If the previous manoeuvre is positive, it may be repeated after injecting 10 mL of 1 % lignocaine into the subacromial space; if the pain is abolished (or significantly reduced), this will help to confirm the diagnosis.
- 19. Hawkins–Kennedy test ◈ Hawkins–Kennedy test (Hawkins and Kennedy, 1980): The patient’s arm is placed in 90 degrees forward flexion with the elbow also flexed to 90 degrees. The examiner then stabilizes the upper arm with one hand while using the other hand to internally rotate the arm fully. Pain around the anterolateral aspect of the shoulder is noted as a positive test. As with the Neer’s sign, this test is highly sensitive but weakly specific
- 20. Test for isolated weakness ◈ Supraspinatus “empty can test” ◈ Infraspinatus – resisted external rotation ◈ Subscapularis “the lift off test”
- 21. Imaging for rotator cuff disorder ◈ X-ray examination : X-rays are usually normal in the early stages of the cuff dysfunction, but with chronic tendinitis there may be erosion, sclerosis or cyst formation at the site of cuff insertion on the greater tuberosity. ◈ In chronic cases the caudal tilt view may show roughening or overgrowth of the anterior edge of the acromion, thinning of the acromion process and upward displacement of the humeral head. ◈ Osteoarthritis of the acromioclavicular joint is common in older patients and in late cases the glenohumeral joint also may show features of osteoarthritis. Sometimes there is calcification of the supraspinatus, but this is usually coincidental and not the cause of pain
- 22. Supraspinatus tendinitis – X-ray of the shoulder showing a typical thin band of sclerosis at the insertion of supraspinatus and narrowing of the subacromial space. The rest of the joint looks normal X-ray at a later stage showing upward displacement of the humeral head due to a large cuff rupture. There is almost complete loss of the subacromial space, and osteoarthritis of the glenohumeral joint.
- 23. MAGNETIC RESONANCE IMAGING ◈ Magnetic resonance imaging : MRI effectively demonstrates the structures around the shoulder and give valuable ancillary information (regarding lesions of the glenoid labrum, joint capsule or surrounding muscle or bone). However, it should be remembered that up to a third of asymptomatic individuals have abnormalities of the rotator cuff on MRI ◈ Changes on MRI need to be correlated with the clinical examination
- 24. Ultrasonography ◈ Ultrasonography : Ultrasonography has comparable accuracy with MRI for identifying and measuring the size of full thickness and partial thickness rotator cuff tears ◈ It has the disadvantage that it cannot identify the quality of the remaining muscle as well as MRI and cannot always be accurate in predicting the reparability of the tendons.
- 25. MRI showing thickening of the supraspinatus and erosion at its insertion; the acromioclavicular joint is swollen and clearly abnormal Rotator cuff tear – MRI High signal on MRI, indicating a full-thickness tear of the rotator cuff.
- 26. TREATMENT CONCERVATIVE TREATMENT ◈ Uncomplicated impingement syndrome (or tendinitis) is often self- limiting and symptoms settle down once the aggravating activity is eliminated. ◈ Patients should be taught ways of avoiding the ‘impingement position’ ◈ Physiotherapy, including ultrasound and active exercises in the ‘position of freedom’, may tide the patient over the painful healing phase. ◈ A short course of non-steroidal anti-inflammatory tablets sometimes brings relief.
- 27. If all these methods fail, and before disability becomes marked, the patient should be given one or two injections of depot corticosteroid into the subacromial space. In most cases this will relieve the pain, and it is then important to persevere with protective modifications of shoulder activity for at least 6 months. Healing is slow, and a hasty return to full activity will often precipitate further attacks of tendinitis.
- 28. Indications of SURGICALTREATMENT ◈ The indications for surgical treatment are essentially clinical; the presence of a cuff tear does not necessarily call for an operation. ◈ Provided the patient has a useful range of movement, adequate strength and well-controlled pain, non- operative measures are adequate. ◈ If symptoms do not subside after 3 months of conservative treatment, or if they recur persistently after each period of treatment, an operation is advisable.
- 29. ◈ The indication is more pressing if there are signs of a partial rotator cuff tear and in particular if there is good clinical evidence of a full thickness tear in a younger patient. ◈ The object is to decompress the rotator cuff by excising the coracoacromial ligament, undercutting the anterior part of the acromion process and, if necessary, reducing any bony excrescences at the acromioclavicular joint
- 30. Surgical treatment ◈ Four methods: 1. OPEN ACROMIOPLASTY 2. ARTHEROSCOPIC ACRIMIOPLASTY 3. OPEN REPAIR OF ROTATOR CUFF 4. ARTHEROSCOPIC ROTATOR CUFF REPAIR
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