ROTATOR CUFF

DISORDERS
SALAMI OLUWASEYI O.

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 The supraspinatus, infraspinatus, teres
minor and subscapularis muscles constitute
the musculotendinous rotator cuff.
 All of them are involved in the rotation of

the shoulder joint except supraspinatus

which functions during the initial abduction
of the arm.
 Pathologic conditions include tendinitis,

partial- and full-thickness tears of the

supraspinatus and other rotator cuff
muscles, calcific tendinitis, and adhesive
capsulitis.
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 They are commoner in athletes and
incidence increases with age.
AETIOLOGY
 In the younger patient, especially the

athlete, repetitive overuse, muscle

imbalance and weakness, capsular
contractures, and coexistent glenohumeral
instability are potential causes.
 Abnormality of scapular rotation, because of

the functional interdependency of the

shoulder complex, can cause secondary
rotator cuff dysfunction and pain.
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 In middle-aged and older patients, primary
tendon degeneration as well as morphologic
alteration of the coracoacromial arch
including degeneration of the
acromioclavicular joint are the principal
causes of symptomatic rotator cuff
tendinopathy
 An increased incidence of tendinopathy has

been noted in patients with a type II or III

acromial configuration, as well as in those
with ununited acromial ossification centers.
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CLINICAL FEATURES
 Except in cases of an acute traumatic injury,
patients with rotator cuff tendinitis usually
describe an insidious onset of shoulder pain
located over the anterior superior aspect of the
shoulder.
 Pain occurs during or following overhead
activity and is relieved by rest.
 With progression, pain may occur at rest,
although usually it is less severe than that
associated with activity, and it may awaken
the patient at night 5
 A complaint of weakness or stiffness of the
shoulder may be elicited.
 Acute onset of pain in the absence of
significant trauma, coupled with marked pain
on attempted motion, raises the possibility of
acute calcific tendinitis, infection, or acute
brachial neuritis.
 A history of catching or popping can occur in
partial rotator cuff tears but more likely
indicates an internal derangement such as a
labral tear
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 PHYSICAL EXAMINATION
 Carefully examine the cervical spine, especially
in older patients, to rule out degenerative disc
disease with radicular symptoms.
 In longstanding rotator cuff disease, inspection
may reveal atrophy of the supraspinatus,
infraspinatus, and deltoid muscles, as well as
limited or asymmetric scapular rotation. Active
and passive forward flexion and abduction, as
well as internal and external rotation, may be
reduced, compared with the unaffected side.
Loss of internal rotation identifies posterior
capsular tightness.
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 Look for pain or weakness with manual muscle testing
of external rotation, abduction, and isolated
supraspinatus. Elicit the impingement sign by passive
elevation of the arm against the supraspinatus outlet,
which is fixed by your hand to limit rotation.
 Inability to initiate or maintain abduction suggests a
large tear of the rotator cuff. A smaller tear confined
to the supraspinatus may cause weakness only with
isolation of the supraspinatus (elevation of the arm,
internally rotated in the scapular plane).
 Marked weakness in external rotation suggests a tear
with posterior extension to include the infraspinatus.
Perform isolated testing of the external rotators of the
rotator cuff in the lateral decubitus position with the
elbow aligned with the thorax.
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 To test subscapularis function, have the
patient extend her arm and rotate it
internally as much as possible, which
positions the hand on the lumbar spine
region. Inability to lift the hand posteriorly
from the lumbar spine indicates weakness
of the subscapular (the lift-off test).

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 ADJUNCTIVE CLINICAL TESTING
 The most helpful diagnostic test is the injection of

local anesthetic into the subacromial bursa.

 After injection of approx. 10 ml of 1% lidocaine,

repeat the examination.

 If rotator cuff tendinitis or a partial tear of the

bursal surface is present, the injection will provide

a minimum of 50% and often nearly 100% relief of
symptoms.
 If no relief is obtained, the diagnosis is incorrect or

the injection has not been delivered into the bursa.

If there is a full-thickness rotator cuff tear, pain
will be significantly relieved, but some weakness
usually persists despite injection. 10
 IMAGING
 Obtain at least two perpendicular views for every
patient, consisting of an AP view of the glenohumeral
joint and a supraspinatus outlet view. The
supraspinatus outlet view is a lateral radiograph made
in the plane of the scapula with the x-ray beam
directed 10° inferiorly. On the AP view, nonspecific
changes such as sclerosis and cysts in the area of the
greater tuberosity and anatomic neck can be seen, as
well as a decreased interval (normal, 7–15 mm)
between the humeral head and the acromion, which
suggests a full-thickness tear of the cuff.
 Calcium deposits are usually apparent on a standard
AP view, but an AP view in external rotation may
better define the lesion. 11
 The outlet view defines any anterior
acromial spurs, CA ligament ossification, or
abnormal morphology of the acromion.
 Magnetic Resonance Imaging, Ultrasound,

and Arthrography can also be used.

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DIFFERENTIALS
 Glenohumeral instability
 Glenohumeral DJD, labral tears, and loose bodies
 Acromioclavicular joint DJD
 Adhesive capsulitis
 Suprascapular nerve entrapment
 Scapulothoracic dysfunction
 Brachial neuritis
 Cervical DJD
 Cervical radiculopathy
 Apical lung tumour
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TREATMENT
 Tendinitis, the most common manifestation of
rotator cuff disease, usually responds to modification
of activity or nonoperative treatment and typically
does not progress to frank tendon rupture.
 Nonsurgical treatment remains the standard initial

care for tendinitis & surgery is indicated for those

patients who fail to respond to nonoperative
measures.
 For active patients, once a torn rotator cuff is

diagnosed, surgical repair is recommended

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 A nonoperative regimen includes modalities
directed at decreasing pain, stretching and ROM
exercises, and a rotator-cuff-specific strengthening
program consisting of isometric and isotonic
exercises.
 Surgical techniques include:

i. subacromial decompression (open or

arthroscopic: standard treatment for patients
with rotator cuff tendinitis due to mechanical
impingement

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 Complications from arthroscopic and open
surgery for rotator cuff disorders include
retear or failure of cuff repair, infection,
stiffness, acromial fracture, deltoid injury,
and reflex sympathetic dystrophy.

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