1. Rotator Cuff Injuries

2. OBJECTIVES Anatomy of shoulder joint
Anatomy & Physiology of rotator cuff
Types of rotator cuff injuries
Signs and Symptoms
Diagnosed by
Treatments
Rehabilitation
Prevention

4. ROTATOR CUFF ANATOMY & PHYSIOLOGY
An anatomical term given to the group of muscles & their tendons.
The rotator cuff is made up of four muscles )SUPRASPINATUS
2)INFRASPINATUS )TERES MINOR ) SUBSCAPULARIS They help move and stabilize the shoulder joint

5. 1)STRAINS 2)TEARS 3)TENDINITIS
ROTATOR CUFF INJURIES
1)STRAINS 2)TEARS 3)TENDINITIS

6. WHAT ARE THE CAUSES ?????

8. CAUSES Acute injuries Chronic overuse Gradual aging
Incorrect shoulder moving techniques
Calcium deposition
Abnormalities in shoulder structure
Bursitis

9. SIGNS & SYMPTOMS
Pain in the shoulder or arm , especially with arm movement (reaching overhead, reaching behind your back, lifting, pulling or sleeping on the affected side.
Radiation of the pain to the upper, lateral arm
Pain at night
You may not be able to move your arm well, especially away from your body.
Your shoulder may feel weak, numb, or tingly.
Loss of shoulder range of motion
Inclination to keep your shoulder inactive
Lying or sleeping on the affected shoulder also can be painful

10. TEARS 2) Grade II 3) Grade III
Injuries to muscle-tendon units called as tears.
Can classified by the amount of damage to the muscle or tendon fibers ) Grade I
Strains involve stretching of the fibers without any tears.
2) Grade II
Injuries involve partial muscle or tendon tearing
3) Grade III
Injuries are defined as a complete tear of a muscle or tendon.

12. CHRONIC TEAR
Found among people in occupations or sports requiring excessive overhead activity (examples: painters, baseball pitchers)
Variations in the shoulder structure causing narrowing under the outer edge of the collarbone
Occur more often in a person's dominant arm
More commonly found among men older than 40 years
Pain usually worse at night and interferes with sleep
Worsening pain followed by gradual weakness
Decrease in ability to move the arm, especially out to the side
Able to use arm for most activities but unable to use the injured arm for activities that entail lifting the arm as high or higher than the shoulder to the front or side

13. ACUTE TEAR
Sudden tearing sensation followed by severe pain shooting through the arm
Motion limited by pain and muscle spasm
Acute pain from bleeding and muscle spasm (often goes away in a few days)
Point tenderness over the site of rupture
With large tears, inability to raise the arm out to the side, although this can be done with help

14. TENDINITIS Inflammation of tendons.
Degeneration (wearing out) of the muscles with age .
Repetitive trauma to the muscle by everyday movement of the shoulder.
More common in women aged years
Deep ache in the shoulder also felt on the outside upper arm
Point tenderness
Pain comes on gradually and becomes worse with lifting the arm to the side or turning it inward
May lead to a chronic tear

15. RED FLAGS Basket ball Net ball Baseball Hand ball Tennis Badminton
Football
Weight Lifting
Swimmers
Athletes
Painters
Carpenters

16. DIAGNOSIS Physical examination X-ray MRI Arthrogram
Ultra sound scanning

17. PHYSICAL EXAMINATION The physical examiner must detect the torn muscle by olating the muscle through manual testing.
External rotation - with elbow at right angles and held into side, turn the arm outwards as far as possible.
Internal rotation - with elbow held into side, raise arm as far as possible up patient's back.
Internal rotation with 90° forward flexion - support elbow and shoulder with elbow at right angles pointing vertically downwards and palm facing backwards, turn the forearm as far backwards as possible.
Forward flexion - start with arm at patient's side and lift arm forwards and upwards as far as possible.
Extension-with arm by the patient's side, lift the arm back wards as far as possible.
Abduction-with arm at patient's side, lift arm away from the body as far as possible, continuing past the horizontal by allowing the shoulder to externally rotate, bringing the hand behind the head.
Adduction-draw the arm across the anterior chest wall as far as possible.

18. Additional Tests
Drop-arm test Abduct the patient's shoulder to 90° and ask the patient to lower the arm slowly to the side in the same arc of movement. Severe pain or inability
of the patient to return the arm to the side slowly indicates a positive test result.A positive result indicates a rotator cuff tear.
Neer impingement test The shoulder is forcibly forward flexed and internally rotated, causing
the greater tuberosity to jam against the anterior inferior surface of the acromion. Pain reflects a positive test result and indicates an overuse
injury to the supraspinatus muscle and possibly to the biceps tendon
Hawkins-Kennedy impingement test With force internally rotate the shoulder. Pain indicates a positive test result and is due to supraspinatus tendon and greater tuberosity impingement
under the coracoacromial ligament and coracoid process.  
Apprehension test Abduct the arm 90° and fully externally rotate while placing anteriorly directed force on the posterior humeral head from behind. The patient becomes apprehensive and resists further motion if chronic anterior instability is present. 

19. TREATMENTS Rest Anti-inflammatory drugs Ice packs Slings Surgery
Physiotherapy

22. PHYSIOTHERAPY
Ensure an optimal outcome and reduce the likelihood of recurrence in all patients
with rotator cuff injuries.
soft tissue massage
electrotherapy (e.g. ultrasound, TENS etc)
stretches
joint mobilization
joint manipulation
ice or heat treatment
exercises to improve strength, flexibility, posture and scapula stability
correction of abnormal biomechanics or technique
education
postural taping
the use of a posture support
anti-inflammatory advice
activity modification advice
a gradual return to activity program

23. PHYSIOTHERAPY PRODUCTS
Some of the most commonly recommended products by physiotherapists to hasten healing and speed recovery in patients with shoulder impingement include:
Slings
Shoulder Supports
Ice Packs
Sports Tape (for postural taping)
Posture Supports
Resistance Band (for strengthening exercises)
TENS Machines (for pain relief)
Therapeutic Pillows

24. REHABILITATION
Maintain the strength in the muscles of the rotator cuff.
These muscles help control the stability of the shoulder joint. Strengthening these muscles can actually decrease the rotator cuff injuries.
Therapist can also evaluate your workstation or the way you use your body when you do your activities and suggest changes to avoid further problems

25. REHABILITATION
Rehabilitation is crucial to restore the rotator cuff strength. The length of recovery depends of the severity of the injury. Rehabilitation can be divided into three phases: : Use of non-steriodal antiflammatory agents, cryotherapy, protection of the injured tissue through the use of a sling or shoulder immobilizer. Exercises such as the pendulum can be performed. This is important for preservation of strength, which will speed recovery time. : In an overuse problem, this phase begins when pain diminishes. Range of motion is fully restored. Progressive resistive exercises are initiated to establish normal strength. Some examples of exercises are rotator cuff strengthening and strengthening of the scapular stabilizers. Restoration of strength and mobility of the shoulder is vital to allow for a successful return to sports. : To return an athlete to a level of full recovery and maximal performance, the exercises need to be tailored to the specific sport. For example, an interval throwing program is used for the throwing athlete.

26. Shoulder Exercises
Shoulder Pendulum: Let arm move in a circle clockwise, then counterclockwise by rocking body weight in a circular pattern. Repeat 5 times and complete 3 to 4 sessions per day.
Lay on stomach on a table or bed. Put your arm out shoulder level with your elbow bent to 90 degrees and your hand down. Keep your elbow bent and slowly raise your hand. Stop when your hand is level with your shoulder. Lower the hand slowly.

27. Shoulder Exercises Continued
Lie on your right side with a rolled-up towel under your right armpit. Stretch your right arm above your head. Keep your left arm at your side with your elbow bent to 90 degrees and the forearm resting against your chest, palm down. Roll your left shoulder out, raising the left forearm until it is level with your shoulder.
Shoulder Shrugs: scapular stabilizing exercise of retraction and elevation.

31. SAPULAR SQUEESES Lie on the back with your knees bent and feet flat.
arms should be straight out,15 to 30 cm away from the side of the body, with palms facing upward.
Keeping the low back flat against the ground, squeeze your shoulder blades downward and towards each other, towards the spine.
Do not shrug the shoulders and keep the neck relaxed.
Doer should feel the lower muscles between the shoulder blades contracting. Hold for five seconds and repeat 20 times.
Do this exercise two to three times per day.

32. OUTWARD ROTATION EXERCISE
Hold your elbows at 90 degrees, close to your sides; holding a towel between your torso and the inside of your elbow will cue you to keep your elbow by your side.
Hold one end of a rubber band in each hand and rotate the affected forearm outward two or three inches
Holding for five seconds

34. Prevention
Warm-up stretching and strengthening of the shoulder muscles.
The shoulder exercises for treatment are great for a general conditioning program.
When shoulder injury symptoms begin, early evaluation and treatment can prevent mild inflammation from becoming full blown rotator cuff impingement, or worse, a tear of the rotator cuff.
A program of twenty minutes a day of shoulder stretches and muscle strengthening exercises is recommended to increase performance and decrease injuries.

35. HOME PROGRAM

36. References
Geiger, Bill. “The cuff; If your shoulder hurts, don't shrug it off. shoulder pain can derail your chest and delt training. here's how to strengthen your rotator cuffs and prevent injury.(SPORTS MED).” Joe Weider’s Muscle & Fitness. Oct 2007 v68 i10 p241(3). Retrieved on March 15, < Kessenich, C. “Shoulder assessment for rotator cuff tear. Diagnostic tips.” The Journal for Nurse Practitioners Feb; 4(2): retrieved on Macrh 15, < Puffer, James C. Sports Medicine, 20 common problems. New York: McGraw-Hill , Wells, Ken. R. "Rotator cuff injury." The Gale Encyclopedia of Medicine. Ed. Jacqueline L. Longe. 3rd ed. Detroit: Gale, vols

37. THANK YOU