Clinical assessment of the rotator cuff

Clinical assessment of the rotator cuff - Dave Copas

1. Dave%Copas%
Wrightington%
19
th
%August%2014%

2. Aims%%
! Basics%
! History%
! Examination%
! Inspection%
! Palpation%
! Cuff%Assessment%
! Demonstration%
! Summary%

3. Role%of%the%Cuff%
! Shoulder%Complex%comprises%30%muscles%
! RC%muscles%predominantly%STABILISERS%
! Do%contribute%to%movement%
! 3%muscles%coalesce%to%form%rotator%cuff%
! 4
th
%separated%by%rotator%interval%

5. Cons1tuent%parts%
! Supraspinatus%
! Initiator%of%abduction%
! Acts%throughout%abduction%arc%
! As%powerful%as%deltoid%
! Origin%–%%Supraspinous%fossa%of%scapular%
! Insertion%–%%upper%facet%of%Gt%Tuberosity%
! Nerve%supply%–%Suprascapular%nerve%
! Lies%in%scapular%plane%(30°%to%coronal%plane)%

6. Cons1tuent%Parts%
! Subscapularis%
! Main%internal%rotator%
! Largest%and%strongest%cuff%muscle%
! Origin%–%subscapular%fossa%(ant.%surface%of%scapula)%
! Insertion%–%Lesser%tuberosity%
! Nerve%supply%%U%Upper%and%Lower%subscapular%nerves%
(posterior%cord)%

7. Cons1tuent%Parts%
! Infraspinatus%and%Teres%Minor%
! Two%muscles%below%scapular%spine%%
! Both%external%rotators%
! Infraspinatus%%U%Acts%when%arm%is%neutral%
! Teres%minor%U%More%active%when%arm%abducted%to%90°%

8. Assessment%
! History%
! General% %%
! Age,%handedness,%occupation%%
! Pain%
! Location,%character,%night%pain,%onset%%
! Weakness%
! Traumatic%vs%degenerative,%intrinsic%vs%neuroUmusc%%
! Stiffness%
! Secondary%to%cuff%pathology%
! Functional%Deficit%
! Interference%with%work,%leisure%or%ADLs%

9. Assessment%
! Inspection%
! Proper%exposure%
! Symmetry%
! Deformity%
! Muscle%wasting%(more%obvious%if%infraspinatus%involved)%
! Scars%%

10. Assessment%
! Palpation%
! Limited%role%in%cuff%assessment%
! Muscle%bulk%
! “Rent%Test”%(Codman)%%
! Palpation%of%supraspinatus%tear%

11. Assessing%Supraspinatus%
! 12%tests%on%shoulderdoc!%
! Jobe’s%Test%
! Empty%Can%Test%–%Jobe%and%Moynes
1
%
! Abduct%90°%,%scapular%plane,%full%IR%and%resist%
! Full%Can%Test%–%Kelly
2
%
! %Abduct%90%,%scapular%plane,%45°%ER%and%resist%
! FCT%less%provocative%–%Less%weakness%due%to%pain%
! Itoi%–%143%shoulders%in%136%pt
3
%
! ECT%–%70%%accurate%
! FCT%–%75%%accurate%

13. Assessing%Supraspinatus%
! Codman’s%sign%(Drop%arm%sign)%
! Passive%abduction%
! Support%released%%
! Deltoid%contracts%%U%hunching%of%shoulders%
! Burkhead’s%thumb%up%%and%down%test%
! Potentially%useful%in%patients%with%Impingment%signs%
! Apleys’s%scratch%test%
! And%others.....%

14. Assessing%Subscapularis%
! Gerber’s%lift%off%test
4
%
! IR,%dorsum%of%hand%over%mid%lumbar%spine%and%raised%
! Evidence%%Greis%(1996)
5
%
! Subscap%heavily%involved%(70%%max%contraction)%
! Mid%lumbar%1/3%MORE%activity%than%LS%junction%
! Gerber%looked%at%100%pts,%%
! 8/9%with%MRCT%+ve%
! 12/16%with%isolated%subscap%tears%+ve%
! Conclude%if%full%IR%and%test%not%limited%by%pain%then%reliable%in%
diagnosing%subscap%dysfuntion%
! Internal%Rotation%Lag%Sign%(Hertel%1996)
6
%
! As%specific,%more%sensitive,%detects%partial%ruptures?%

16. Assessing%Subscapularis%
! Other%%variants%
! Belly%Press%Test%(Napoleon%sign)
7
%
! Belly%Off%Sign%(Scheibel%2005)
8
%
! Modified%Belly%Press%Test%(Bartsch%2010)
9
%
! DeBeer’s%Bear%Hug%Test
10
%
! Useful%in%patients%with%painful%shoulders%
! Helpful%in%detecting%tears%in%upper%part%of%subscap%
! Can%use%tensiometer%
! Pennock%et%al,%2011
11
%
! No%difference%between%above%test%
! Not%known%whether%different%parts%of%subscap%fire%in%each%
test%

18. Assessing%Infraspinatus%
! Drop%sign%(Bigliani%Et%al%1992)
12
%
! Full%ER,%arm%by%side,%inability%to%hold%position%
! External%Rotation%Lag%Sign%(Hertel%1996)
6
%
! As%above%but%arm%in%20°%elevation%in%scapular%plane%
! Hertel’s%“Drop%Sign”%as%above%but%elevated%to%90°%

20. Assessing%Teres%Minor%(or%MRCT)%
! Hornbower’s%Sign%
! Inability%to%ER%the%elevated%arm%
! The%Dropping%Sign%(Walch)
13
%
! 0°%abduction,%90°%elbow%flex,%45°%ER%
! Falls%to%0°%ER%when%released%
! Both%indicative%of%massive%cuff%tear%

22. Demonstra1on%%

23. Summary%
! Careful%History%and%Exam%vital%
! Systematic%%Approach%
! Develop%%a%system%
! Remember%the%neck%
! Consider%core%stability%assessment%
%
! It’s%what%makes%it%more%interesting%than%the%hip%or%the%
knee.%

25. References%
!!
1.  Delineation!of!diagnostic!criteria!and!a!rehabilitation!program!for!rotator!cuff!injuries!Jobe!FW,!Moynes!DR.!Am!J!Sports!Med.!1982;10:336!J9!
2. The!Manual!Muscle!Examination!for!Rotator!Cuff!Strength,!An!Electromyographic!Investigation!Bryan!T.!Kelly,!MD,!Warren!R.!Kadrmas,!MD,!
Kevin!P.!Speer,!MD!Am!J!Sports!Med!September!1996!vol.!24!no.!5!581J588!!
3. Which!is!More!Useful,!the!“Full!Can!Test”!or!the!“Empty!Can!Test,”!in!Detecting!the!Torn!Supraspinatus!Tendon?!Eiji!Itoi,!MD*,!Tadato!Kido,!MD,!
Akihisa!Sano,!MD,!Masakazu!Urayama,!MD!Kozo!Sato,!MD!Am!J!Sports!Med!January!1999!vol.!27!no.!1!65J68!!
4. Isolated!rupture!of!the!tendon!of!the!subscapularis!muscle.!Clinical!features!in!16!cases.!Gerber!C,!Krushell!RJ.!J!Bone!Joint!Surg!Br.!1991!May;73(3):
389J94.!
5. Validation!of!the!liftJoff!test!and!analysis!of!subscapularis!activity!during!maximal!internal!rotation.!Greis!PE,!Kuhn!JE,!Schultheis!J,!Hintermeister!
R,!Hawkins!R.!Am!J!Sports!Med.!1996!SepJOct;24(5):589J93!
6. Lag!signs!in!the!diagnosis!of!rotator!cuff!rupture.!Hertel!R,!Ballmer!FT,!Lambert!SM,!Gerber!Ch.!J!Shoulder!Elbow!Surg.!1996;!5(4):307J313!
7. Isolated!rupture!of!the!subscapularis!tendon.!Gerber!C,!Hersche!O,!Farron!A.!J!Bone!Joint!Surg!Am.!1996!Jul;78(7):1015J23.!
8. The!bellyJoff!sign:!a!new!clinical!diagnostic!sign!for!subscapularis!lesions.!Scheibel!M,!Magosch!P,!Pritsch!M,!Lichtenberg!S,!Habermeyer!P.!
Arthroscopy.!2005!Oct;21(10):1229J35!
9. Diagnostic!values!ofclinical!tests!for!!
subscapularis!lesions.!Bartsch!M,!Greiner!S,!Haas!NP,!Scheibel!M.!!Knee!Surg!Sports!Traumatol!Arthrosc!2010;18:1712–1717!
10. The!bearJhug!test:!a!new!and!sensitive!test!for!diagnosing!a!subscapularis!tear.!Barth!JR
1
,!Burkhart!SS,!De!Beer!JF.!Arthroscopy.!2006!Oct;22(10):
1076J84.!
11. The!Influence!of!Arm!and!Shoulder!Position!on!the!BearJHug,!BellyJPress,!and!LiftJOff!Tests:!An!Electromyographic!Study!Pennock!AT,!Pennington!
WW,!Torry!MR,!Decker!MJ,!Vaishnav!SB,!Provencher!MT,!Millett!PJ,!Hackett!TR.!Am!J!Sports!Med!November!2011!vol.!39!no.!11!2338J2346!
12. Operative!treatment!of!massive!rotator!cuff!tears:!long!term!results.!Bigliani!LU,!Cordasco!FA,!McIlveen!SJ!
,!Musso!ES.!JBoneJoint!SurgAm!1992;74:!1505–1515.!!
13. Walch!G,!Boulahia!A,!Calderone!S!and!Robinson!AH.!The!‘dropping’!and!‘hornblower’s’!signs!in!evaluation!of!rotatorJcuff!tears.!J!Bone!Joint!Surg!
1998,!80B:624J628.!!
!!