Rotator Cuff Injuries

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

ROTATOR CUFF ANATOMY & PHYSIOLOGY An anatomical term given to the group of muscles & their tendons. The rotator cuff is made up of four muscles. 1)SUPRASPINATUS 2)INFRASPINATUS 3)TERES MINOR 4) SUBSCAPULARIS They help move and stabilize the shoulder joint

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

WHAT ARE THE CAUSES ?????

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

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

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. 1) 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.

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

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

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 35-50 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

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

DIAGNOSIS Physical examination X-ray MRI Arthrogram Ultra sound scanning

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.

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. 

TREATMENTS Rest Anti-inflammatory drugs Ice packs Slings Surgery Physiotherapy

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

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

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

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.

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.

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.

 

 

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.

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

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.

HOME PROGRAM

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, 2008. < http://galenet.galegroup.com.libproxy.cc.stonybrook.edu/servlet/ Kessenich, C. “Shoulder assessment for rotator cuff tear. Diagnostic tips.” The Journal for Nurse Practitioners. 2008 Feb; 4(2): 142-3 retrieved on Macrh 15, 2008. < http://web.ebscohost.com.ezproxy.hsclib.sunysb.edu/ehost/detail?vid=4&hid=5&sid=a45885a2-b787-48bb-9bde-81d5b2e35ab1%40sessionmgr3 Puffer, James C. Sports Medicine, 20 common problems. New York: McGraw-Hill , 2002. Wells, Ken. R. "Rotator cuff injury." The Gale Encyclopedia of Medicine. Ed. Jacqueline L. Longe. 3rd ed. Detroit: Gale, 2006. 5 vols. http://www.stoneclinic.com/rotator_cuff.htm Http://ravenstd.com/wp-content/uploads/2007/12/rotator-cuff-diagram.jpg http://medicalimages.allrefer.com/large/rotator-cuff-muscles.jpg

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