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
- Partial thickness (more painful)/ Full thickness
- Traumatic (Young patient, outcome good after surgery)/ Degenerative (r/o all other causes before cuff repair)
- Acute/Chronic
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
- Supraspinatus impingement and tendinitis
- Tears of rotator cuff
- Acute calcified tendinitis
- Bicep tendinitis and/or rupture
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
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
Repair should cover the footprint and should be tension free.
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.