PAINFUL ARC SYNDROME AND

ROTATOR CUFF PATHOLOGY

ROTATOR CUFF MUSCLES SUPRASPINATUS

INFRASPINATUS

TERES MINOR

SUBSCAPULARIS

AND THEIR MUSCULOTENDINOUS ATTACHMENT

ROTATOR CUFF

ANATOMY subscapularis muscle is innervated by

the subscapular nerve and originates on the scapula. It inserts on the lesser tubercle of the humerus.

The supraspinatus and infraspinatus are both innervated by the suprascapular nerve, originate in the scapula, and insert on the greater tubercle.

The teres minor is innervated by the axillary nerve, originates on the scapula, and inserts on the greater tubercle.

subacromial space lies underneath the acromion, the coracoid process, the acromioclavicular joint, and the coracoacromial ligament. A bursa in the subacromial space provides lubrication for the rotator cuff.

FUNCTIONAL ANATOMY

The rotator cuff is the dynamic stabilizer of the glenohumeral joint. The static stabilizers are the capsule and the labrum complex, including the glenohumeral ligaments.

Without an intact rotator cuff, particularly during the first 60° of humeral elevation, the unopposed deltoid would cause cephalad migration of the humeral head, with resulting subacromial impingement.

ROTATOR CUFF PATHOLOGY Extrinsic factors include

a traumatic tear in tendons from a fall or accident.

Overuse injuries from repetitive lifting, pushing, pulling, or throwing are also extrinsic in nature.

INTRINSIC FACTORS

POOR BLOOD SUPPLY DEGENERATION WITH AGING CALCIFICATION OF TENDON

Rotator cuff dysfunction is typically a continuum of pathology ranging from tendinitis and bursitis, to partial tearing, to a complete tearing in one or more of the tendons.

These tears most commonly occur at the tenoperiosteal (tendon-to-bone) junction. Because this area has a relatively poor blood supply, injury to the tendon at this location is very unlikely to heal.

Additionally, the constant resting tension in the muscle-tendon unit, or muscle tone, pulls any detached fibers away from the bone, preventing their reattachment.

Finally, joint fluid from within the shoulder may seep into the tear gap and

prevent the normal healing processes from occurring

DISORDERS OF ROTATOR CUFF IMPINGEMENT

SYNDROME/SUPRASPINATUS TENDINITIS RUPTURES OF ROTATOR CUFF ADHESIVE CAPSULITIS CALCIFIC TENDINITIS

IMPINGEMENT SYNDROME

is a clinical SYNDROME which occurs when the tendons of the rotator cuff muscles mainly supraspinatus undergo repititive compression or rubbing under the coraco acromial arch.

This can result in pain, weakness and loss of movement at the shoulder syndrome

CAUSES bony structures such as subacromial

spurs (bony projections from the acromion), osteoarthritic spurs on the acromioclavicular joint, and variations in the shape of the acromion.

Thickenend or calcified coracoacromial ligament .

Loss of function of the rotator cuff muscles, due to injury or loss of strength, may cause the humerus to move superiorly, resulting in impingement.

Inflammation and subsequent thickening of the subacromial bursa may also cause impingement.[1]

SIGNS AND SYMPTOMS The range of motion at the shoulder

may be limited by pain. A painful arc of movement may be present during forward elevation of the arm from 60° to 120°.

Passive movement at the shoulder will appear painful when a downwards force is applied at the acromion but the pain will Cease once the downwards force is removed.[1]

DIAGNOSIS History and physical exam. Xrays of the shoulder can be used to

detect some joint pathology and variations in the bones, including acromioclavicular arthritis, variations in the acromion, and calcifcation.

Ultrasonography, arthrography and MRI can be used to detect rotator cuff muscle pathology

TREATMENTConservative treatment includes Rest NSAIDS PHYSIOTHERAPY

Therapeutic injections of corticosteroid and local anaesthetic may be used for persistent impingement syndrome.

Surgery may be done arthroscopically or as open surgery.

The impinging structures may be removed in surgery, and the subacromial space may be widened by resection of the distal clavicle and excision of osteophytes on the under-surface of the acromioclavicular joint.[2]

damaged rotator cuff muscles can be surgically repaired.

CUFF DISRUPTION Most patients with a pathological

condition of the rotator cuff have insidious onset of progressive pain and weakness, with concomitant loss of active motion.

TWO TYPES Full thickness tear Partial thickness tear

FULL THICKNESS TEAR Follow a long period of c/c tendinitis Spontaneously after a sprain or jerking

injury of shoulder

CLINICAL FEATURES Sudden pain and pt not able to abduct

the arm Active abduction is impossible even

when pain subsides or has been abolished by

Injection of local anaesthetic.

But once the arm is passively abducted pt can hold it up with deltoid(abduction paradox) and when the pt lowers it sideways it suddenly drops(drop arm sign)

PARTIAL THICKNESS TEAR

Partial-thickness tears usually are located on the articular surface of the supraspinatus near its insertion.

Pt can abduct actively once the pain has been abolished by local anaesthetic.

CONSERVATIVE MGMT Physiotherapy NSAIDS

OPERATIVE MGMT if it fails

OPERATIVE MGMT arthroscopic-assisted or

arthroscopic repair is appropriate for partial-thickness and small to medium full-thickness rotator cuff tears.

After standard repair, shoulder immobilized for 6 weeks followed by assisted exercises in flexion and external rotation to avoid adhesions, disuse atrophy, and disruption of the repairs.

Debridement and limited decompression.

to obtain and maintain the maximal range of passive glenohumeral flexion and rotation

ADHESIVE CAPSULITIS/FROZEN SHOULDER

contracted, thickened joint capsule that seemed to be drawn tightly around the humeral head with a relative absence of synovial fluid and chronic inflammatory changes within the subsynovial layer of the capsule.

Common in pts with

DM CERVICAL SPINE DISEASES HYPERTHYROIDISM TRAUMA INTRATHORACIC DISORDERS

PHASESI. PAINII. STIFFENINGIII. THAWING

Diagnostic tests in patients with a frozen shoulder (including plain film roentgenograms) usually are normal.

Treatment. self-limiting condition, lasting 12 to 18 months without long-term sequelae

Initial treatment is nonoperative, NSAIDS Transcutaneous electrical nerve stimulation

(TENS) and ultrasound PHYSIOTHERAPY –PENDULUM EXERCISES

CALCIFIC TENDINITIS

Cause-hypo vascularity Phase 1—Precalcification stage.:

fibrocartilagenous metaplasia Phase II—Calcific stage. During this

stage calcium is deposited into matrix vesicles, which are excreted by the cells and coalesce into larger calcium deposits. This stage can be exceedingly painful, and many patients seek treatment at this time

    Phase III—Postcalcific phase. Pain subsides markedly during this phase.

Nonoperative treatment usually includes physical therapy, exercises, antiinflammatory medications, and steroid injections.

OPERATIVE TREATMENT indications for operative treatment: (1)

symptom progression, (2) constant pain that interferes with activities of daily living, and (3)conservative therapy-failure

Aspiration and Needling of Calcified Deposits

Excision of Calcium Deposits

DIFFERENTIAL DIAGNOSIS-IN A CASE OF PAINFUL SHOULDER REFERRED PAIN SYNDROME-

SPONDYLOSIS,MEDIASTINAL PATHOLOGY

JOINT DISORDERS-ARTHRITIS

BONE LESIONS-INFNS,TUMOURS

ROTATOR CUFF DISORDER INSTABILITY-DISLOCATION,SUBLUXATION

NERVE INJURY-SUPRASCAPULAR NERVE ENTRAPMENT

EXAMINATIONS

HISTORY INSPECTION The shoulder, cervical region, and entire

upper extremity must be assessed-BONE & SOFT TISSUE.

The dominant side may be lower than the nondominant one. Observation of the soft tissues is directed first at the contours of the deltoid.

PALPATION

FROM ANTERIOR TO POSTERIOR-SOFT & BONY STRUCTURES PALPATED.

EXAMINER STANDS BEHIND THE PATIENT.

THE STRUCTURES ASSESED ARE THE STERNOCLAVICULAR JOINTS, SCM, COSTOCHONDRAL JOINTS, FIRST RIB & ACROMIOCLAVICULAR JOINTS.

SUPERIOR MIGRATION OF MEDIAL END OF CLAVICLE IS NOTED IN STERNOCLAVICULAR JOINT DISLOCATION.

STEP DEFORMITIES WITH SUPERIOR MIGRATION OF LATERAL END OF CLAVICLE SEEN IN ACROMIOCLAVICULAR JOINT DISLOCATION OR SUBLUXATION.

RANGE OF MOTIONBOTH ACTIVE & PASSIVE MOVEMENTS

ASSESED.NORMAL ROM-1) ABDUCTION (70 – 180)2) ADDUCTION (30 -45)3) EXTENSION (45 – 60)4) FLEXION (160 – 180)5) INTERNAL ROTATION(90 – 110)6) EXTERNAL ROTATION( 80 – 90)

The scapulohumeral rhythm is observed. If a painful arc (ie, pain or inability to abduct because of pain) is observed at 45-120°, a subacromial impingement syndrome is suggested.

If the pain is greater after 120°, when full elevation is reached, an acromioclavicular joint disorder is suggested.

If a reverse scapulohumeral rhythm (ie, an abduction initiated by the scapulothoracic joint rather than by the glenohumeral joint) is observed, a frozen shoulder is suggested.

IMPINGEMENT TESTS NEER IMPINGENENT TESTS

HAWKINS KENNEDY TESTS

YOCUM TESTS

NEER IMPINGEMENT TESTS With the examiner standing behind the

patient, the shoulder is passively flexed. When the result is positive, this test

produces pain caused by contact of the bursal side of the rotator cuff on the anterior third of the undersurface of the acromion and the coracoacromial ligament.

A positive test result suggests an anterosuperior impingement syndrome

THE HAWKINS-KENNEDY TEST With the examiner standing behind the patient,

the shoulder is flexed passively to 90°, followed by repeated internal rotation.

When the result is positive, this test produces pain caused by contact of the bursal side of the rotator cuff on the coracoacromial ligament and by contact between the articular surface of the tendon and the anterosuperior glenoid rim. Contact between the subscapularis tendon and the coracoid process is also observed.

A positive test result suggests an anterosuperior or an anterointernal impingement test.

THE YOCUM TEST

With the examiner standing behind the patient, the hand on the ipsilateral side of the examined shoulder is placed on the contralateral shoulder. The elevation of the elbow is resisted by the examiner.

When the result is positive, this test produces pain caused by contact of the bursal side of the cuff tendon with the coracoacromial ligament and possibly the undersurface of the acromioclavicular joint.

TOPOGRAPHIC TESTS

To identify the supraspinatus tendon Full-can test: The shoulder is placed at

90° of flexion and 45° of external humeral rotation (thumb pointing upward, as if someone is holding a full can right-side-up). Shoulder elevation is resisted. The test result is considered positive if it produces pain.

TO IDENTIFY THE INFRASPINATUS TENDON In the Patte test, the shoulder is placed

at 90° of abduction, in neutral rotation, and in the plane of the scapula. The examiner holds the elbow of the patient, and the external rotation is resisted. The test result is considered positive if it produces pain.

To identify the teres minor tendon, use the same tests used for the infraspinatus tendon

TO IDENTIFY THE SUBSCAPULAR TENDON, In the Gerber lift-off test, the shoulder

is placed passively in internal rotation and slight extension by placing the hand 5-10 cm from the back with the palm facing outward and the elbow flexed at 90°. The test result is positive when the patient cannot hold this position, with the back of the hand hitting the patient's back