ROTATOR CUFF INJURY – TENDINOPATHY
Functions of Rotator cuff
- depression of humeral head into glenoid fossa – as deltoid force humeral head superiorly in abduction
- supraspinatus – abduction
- subscapularis – internal rotation
- infraspinatus and teres minor – external rotation
- circumferential reinforcement of glenohumeral joint and joint compression ( static stabilization)
Saha's concept
- prime movers – deltoid and pect. Major
- prime steerers – rotator cuff muscles
Pathogenesis
- Extrinsic factors
- Primary ( impingement syndrome)
- acromion shape ( Bigilani and Morrison classification)
- os acromiale
- a/c joint pathology
- bursitis
- coracoacromial ligament hypertrophy
- exostosis of greater tuberosity
- Secondary
- instability
- post capsule tightness
- abnormal muscular or neurological control of cuff
- Intrinsic factors
- over use
- insufficient blood supply
- critical zone – 1cm proximal to rotator cuff insertion – water shed area between osseous and tendinous vessel supply
Neer Classification of Rotator cuff tendinopathy ( impingement syndrome)
Stage
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Age
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Pathology
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Clinical course
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I
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<25
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Edema and hemorrhage – microscopic tear
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Reversible
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II
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25 - 40
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Fibrosis and tendinitis – microscopic to partial
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Recurrent pain with activity
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III
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>40
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Complete tear – small, medium, large, massive
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Progressive disability
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Classifications of Rotator cuff tears
- a/c – after trauma : c/c – after 3 months
- complete – communicates with bursa and joints
- 4types – largest diameter based – can be retracted or non retracted
- small <1cm
- medium 1-3 cm
- large 3-5 cm
- massive 5cm
- incomplete – tears with no communication
- bursal tears
- intratendinous tears
- joint side tears
- traumatic and degenerative
- tendinitis
- primary
- intrinsic tendon degeneration
- secondary
- structural – acromial spur, os acromiale
- dynamic – glenohumeral instability, capsular contracture, muscle imbalance, over use
- calcific tendinitis
- acute
- chronic
Clinical evaluation
- pain – anterior superior aspect of shoulder - overhead activities – painful arc 60 – 120o – progressive – h/o specific injury
- crepitus – sub acromial
- weakness – abduction, rotation ( IR>ER)
- decrease in activities
- muscle atrophy – reduced ROM
- inability to initiate or maintain the abduction – large tear of cuff
- Neer impingement sign – stabilize scapula – forced elevation of humerus – greater tuberosity impinges against acromion
- Neer impingement test – 10ml lignocaine into subacromial bursa – repeat the sign
- Jove supraspinatus test (empty can position) – 90o abduction – 30ohorizontal flexion – full IR
- Hawkins Kennedy test – 900 forward flexion – forcible IR
- rule out DJD with radicular symptoms in old people
- X ray
- AP view
- subchondral cysts – sclerosis of greater tuberosity and edge of acromion
- OA of AC jt., glenohumeral jt.
- Calcific tendinitis
- decreased interval between humeral head and acromion – full thickness tear
- Axillary lateral view
- to diagnose os acromiale
- 3 centers of ossification – pre , meso, meta
- bony Bankart's lesion
- Supraspinatus outlet view
- lateral view - in plane of scapula – beam directed 5-10o caudal
- for sub acromial space
- acromial variants and abnormalities
- coracoacromial ligament calcification
- Caudal tilt view
- AP – beam tilted 300 caudal
- better for viewing antero inferior projection of acromion
- USG
- moderate to large complete tears – not small or partial tears
- MRI
- gold standard – sub acromial fluid, osteophytes, a/c joint arthropathy, signal changes in cuff
Differential Diagnosis
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Management
- Non surgical
- initial care of tendinitis
- NSAIDS
- alleviating the pain by ice, heat, ultrasound, electrical stimulation, TENS
- Physiotherapy exercises
- increase depresser effect of rotator cuff or humeral head – isometric and isotonic exercises
- stretching and ROM exercises
- avoid overhead activities – rest
- local subacromial steroid injection - <2 injections – 40ml methyl prednisolone – not in full thickness tear
- natural h/o – do not heal with physiotherapy – remain symptomatic with use – enlarge with time leading to cuff tear arthropathy
- Surgical
- Decompression (Acromioplasty)
- open
- arthroscopic
- Rotator cuff repair
- open repair
- mini open repair
- arthroscopic cuff repair
Acromioplasty (Neer's principle)
- coraco acromial ligament release not resection
- removal of acromion anterior to the anterior border of clavicle
- removal of distal 1-1.5cm of clavicle – if significant OA found
- gold standard, established results
- deltoid detachment, longer rehabilitation, weakness esp. deltoid – cons
Arthroscopic decompression
- avoids deltoid detachment
- glenohumeral pathology can be evaluated
- cosmetic
- earlier restoration of movements
- technically demanding, inadequate resection – cons
Cuff repair
- open repair – done by detaching deltoid insertion
- mini open – arthroscopic subacromial decompression – repair of cuff through deltoid splitting approach
- arthroscopic – exclusively arthroscopic
Treatment algorithm
Pathology
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Treatment
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Sub acromial bursitis
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Arthroscopic bursectomy
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Worn coracoacromial ligament
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Arthroscopic bursectomy - ligament excision
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Partial cuff tear
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Arthroscopic bursectomy - ligament excision - acromioplasty - cuff debridement
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Small/ medium full thickness tear
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Mini open cuff repair
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Large cuff tear
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Open acromioplasty – cuff repair – coracoacromial ligament preservation
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After treatment
- repair – shoulder immobilization / abduction restriction – 6 wks
- removed for assisted exercises in flexion and ER – to avoid adhesion, disuse therapy, disruption of the repair
- repair weakest at 3wks
- isometric exercises of ER – 6wks
- active motion - 12 wks
Rotator cuff tear arthropathy
- end stage rotator cuff disease
Etiology
- normal humeral head depression in supraspinatus in lost
- unopposed pull leads to shearing forces across glenoid
- articular cartilage can not resist the shearing force – degenerative changes follows
- cartilage and bone atrophy – due to loss of fluid pressure – also due to loss of quality of chemical content of synovial fluid
X ray
- Sourcil sign – erosion of inferior surface of acromion – due to humeral head articulation with it
- inferior humeral osteophytes
- loss of glenohumeral joint space
Treatment
- humeral head replacement + coracoacromial arch maintenance – hemiarthroplasty is preferred to total – shear forces lead to glenoid wear
- reverse total shoulder arthroplasty – glenoid resurfaced with a ball – humeral head replaced with articular socket – requires a functioning deltoid
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