October 31, 2024

The rotator cuff reinforces the joint capsule except at the rotator interval (area between the anterior part of the supraspinatus and upper border of subscapularis)

The most vulnerable area of tendon failure are deep fibers ( glenohumeral joint side) which is on the insertion of tuberosities

Rotator cuff disruption

Classifications

  1. Partial thickness (more painful)/ Full thickness
  2. Traumatic (Young patient, outcome good after surgery)/ Degenerative (r/o all other causes before cuff repair)
  3. Acute/Chronic
Rotator cuff anatomy
Rotator cuff anatomy

Teres minor inserts at the lower facet of GT

Infraspinatous inserts at the middle facet of GT

Supraspinatous inserts at the upper border of GT

Subscapularis inserted on LT

Musculo-tendinous cuff passes beneath coraco-acromion arch and both are separated by sub-acromion bursa

Rotator cuff syndrome

Conditions That come under rotator cuff syndrome

Impingement syndrome, Supraspinatus tendinitis, and Cuff disruption

Rotator cuff impingement is a painful disorder that is thought to arise from repetitive compression and rubbing of the tendon ( mainly supraspinatus) under the coracoacromial arch

Significantly, the site of impingement is also the ‘critical area’ of dismished vascularity in the supraspinatous tendon about 1 cm proximal to its insertion to GT.

Development of impingement

Extrinsic factors:

  • Spurs
  • OA
  • Laterally sloping acromion

Intrinsic factors:

  • Tendon degenerative
  • Due to high sulfated GAGs
  • Changes in collagen composition with loading

Biglani and Morrison Classification of acromiom

Type I: Flat

Type II: Curved

Type III: Hooked (most frequently associated with impingement)

Pattern of progress

A. Sub-acute tendinitis:- Painful arc syndrome, Due to vascular congestion, microscopic hemorrhage, and edema

B. Chronic tendinitis:- Due to tendinitis and fibrosis

C. Cuff disruption:- Due to tears

Diagnosis

See also: Shoulder examinations

Shoulder Examination Summary
Shoulder Examination Summary

Imaging

X-Ray

AP view shows cyst on GT suggests Rotator Cuff Disease

The undersurface of the acromion, Sclerosed (Sourcil or eyebrow sign) suggests chronic loading of rotator cuff

Axillary view

Os acromiale: Noted

Supraspinatous outlet view shoes Sub-acromial space and coraco-acromion arch

Any bony spurs

Acromion morphology

Large tears are characterized by upwards displacement of the humeral head

Cuff tear arthropathy

Humeral head losses prominence of tuberosity (become round and femoralized)

The coracoid acromion and glenoid may form a deep spherical socket which is called acetabularized

USG

Arthrography is the accurate method to defect full thickness tear

MRI is the Gold standard, quality of cuff, fatty infiltration, and retraction of cuff

Treatment Options

Non-operative treatment

  • NSAIDs
  • Physiotherapy
  • Heat application
  • Activity modification
Partial Tear management
Partial Tear management

Repair should cover the footprint and should be tension free.

Full thickness tear management
Full thickness tear management

Give satisfactory results with conservative treatment who had well-preserved motion and strengthed

Contraindication to surgery

Any concomitant stiffness secondary to adhesive capsulitis

Sub- Acromial decompression consists of

  • Anterior acromioplasty
  • Release of CAL (coracoacromial ligament)
  • Acromioclavicular osteophytes resection ( if needed)

After sub-acromial decompression, retracted edges of the cuff should be evaluated for mobility in the anteroposterior and medial-lateral directions. This decided cuff can be placed back in the footprint of the humerus.

In the cresent shape tear

Retracted edge pulled laterally after releasing adhesion inside and outside and repaired to bone bed by double row sutures (medial and lateral row of suturing) which decrease tension in primary repair, and increase the surface area of tendon-bone healing.

Classifications

Summary of management of tears
Summary of management of tears