Rotator cuff injuries

Pratigya Deuja-
Rotator cuff injuries- Definition, etiology, pathology, clinical features, clinical management, physiotherapy management

1. PRATIGYA DEUJA ROTATOR CUFF INJURIES

2. DEFINITION Commonest cause of pain around the shoulder, it is a disorder of the rotator cuff which sometimes referred as rotator cuff syndrome. Rotator cuff muscles :- Supraspinatus , Infraspinatus , Subscapularis and Teres minor. MECHANISM :- Fall or direct impact trauma :- Acute overload incident or develop gradually from degenerative process.

3. ROTATOR CUFF INJURY Fig:- Rotator cuff tears- Orthoinfo - AAOS

4. CAUSES Baseball players. By excessive force (lifting a very heavy object with the arm extended / trying to catch a heavy object as it falls). Typical RCI occurs to a middle aged person or older has an experienced problem of shoulder. Also occurs in injuries or condition such as arthritis, tendonitis or bursitis affect the shoulder joint. Pain and loss of mobility can result. Weak shoulder muscle. Poor posture Repetitive stress on the shoulder

5. SYMPTOMS Shoulder pain, usually when moving the shoulder or sleeping on it. Tenderness in shoulder weakness in shoulder Not being able to move the shoulder as much as normal (decrease ROM) Soreness in the shoulder Impossible to raise the arm or move it away from the side Instability Deformity

6. CLINICAL FEATURES Complain of pain with overhead activity such as throwing, swimming, overhead shots in racquet sports, activities undertaken <90° of abduction are usually pain free. Associated symptoms of instability such as recurrent subluxation or episodes of dead arm. Depends on the stage of disorder, age of the patient and vigorous of heading response.

7. 3 PATTERNS Subacute tendinitis (Vascular congestion, edema and hemorrhage leads painful arc syndrome) Chronic tendinitis (recurrent shoulder pain due to tendinitis and fibrosis) Cuff disruption (Recurrent pain, weakness and loss of movement)

8. PATHOLOGY It occurs due to repetitive compression or rubbing of the tendon (mainly supraspinatus ) When the arm is abducted the conjoint tendon slides under the coracromial arch. If the arm is held persistently in abduction and then moved to and fro in IR and ER (as in cleaning a window, painting a wall or polishing a flat surface. Rotator cuff may be compressed and irritated as it comes in contact with the anterior edge of the acromion process and the taut coracoacromial ligament. This attitude has been called the Impingement position, ( Abd , slight flx , IR)

9. OTHER FACTORS Repetitive Impingement :- RA Swelling of cuff Osteophytes on the anterior edge of the acromion Formation of bony edges Osteoarthritic Thickening of the AC joint

10. OTHER FACTORS Friction :- Localized edema and swelling 3 variation of acromial morphology Type I :- Flat Type II :- Curved Type III :- Hooked acromion Prolonged or repetitive impingement (older age) Minute tears can developed these may be followed by scarring , fibrocartilaginous , metaplasia or calcification in tendon

11. ON EXAMINATION Physical examination:- Therapist assist the full ROM of shoulder yet patient is unable to complete the same movements using their own strength. MRI scan:- To determine torn Special test:- Impingement:- Aim is to elicit pain while moving the greater tuberosity under the acromion .

12. ON EXAMINATION Hawkins kennedy test :- The shoulder is placed in 90° of forward flexion and then forcibly internally rotated. Resisted movement :- Empty can position (90 ° of abduction, 30°of horizontal flexion and full internal rotation) . This test may indicate supraspinatus abnormalities. Repeat with a retracted scapulae.

13. CLINICAL MANAGEMENT Anti- inflammatory drugs (ibuprofen) Steroid injection in the bursa, shoulder joint, around the tendons to reduce inflammation, pain and increase mobility of shoulder joint. If it is not successful, surgery may needed such as arthroplasty of shoulder, suturing, tendon repair etc.

14. PHYSIOTHERAPY MANAGEMENT Electro:- TENS Ice pack Hot pack Contrast bath Ultrasound

15. PHYSIOTHERAPY MANAGEMENT Exercise:- AROM RROM Stretching Wall slides Front cross over pulls Wand exercise Towel stretch Blade squeeze Back stretch Scapular squeeze Pendulum exercise Prone extension Pectoralis stretch Push up pulls Scaption Prone horizontal extension

16. PHYSIOTHERAPY MANAGEMENT PECTORALIS STRETCH PENDULAR EXERCISE

17. PHYSIOTHERAPY MANAGEMENT SHOUDER SQUEEZE SCAPTION

18. PHYSIOTHERAPY MANAGEMENT TOWEL STRETCH WAND EXERCISE

19. POST OPERATIVE MANAGEMENT Acute phase Tissue healing:- Rest :- Short term mobilization :- Modalities Decrease pain & inflammation:-NSAID, :- Corticosteroid :- Ultrasound :- cold compression

20. PHYSIOTHERAPY MANAGEMENT Re-establish ROM:- Pendulum exercise :- Manual capsular stretch :- Cross fiber massage :- T -pulleys, ropes or bars To decrease muscle atrophy :- Isometric exercise with arm below 90° of abduction and 90° of flexion. Scapular control:- Closed chain weight shifts with hands on table and shoulder flexed less than 60° and abducted less than 45°.

21. PHYSIOTHERPAY MANAGEMENT Maintain fitness in rest of kinetic chain Aerobic exercise :- Running, bicycling or stepping Anaerobic :- Agility drills Elbow and wrist :- Strengthening by Isometric exercises or rubber tubing Flexibility exercise Criteria for movement out of the acute phase Minimal pain, Kinetic chain integration, manual muscle strength, progression of tissue healing, PROM at 66%-75% of opposite side

22. PHYSIOTHERAPY MANAGEMENT 2) Recovery phase Normal ROM :- Active assisted motion above 90° of Abduction with hand :- AROM in IR and ER with scapula stabilized Scapular control :- Scapular PNF patterns. :- closed chain exercise at 90° of flexion, 90° abduction, scapular retraction/ protraction and elevation / depression :- Modified push –ups :- Ball catch and push exercise :- Dips ; clock , low row ,lawn mower

23. PHYSIOTHERAPY MANAGEMENT Upper extremity strength and strength balance :- GH PNF patterns :-Closed chain exercise at 90° of flexion then 90° of abduction :- Forearm curls ; isolated rotator cuff exercise :- light bench presses Normal shoulder Arthokinematics :- RoM with arm 90° of abduction :- Proprioceptive sensory feedback :- Open chain exercises – mild plyometric exercise

24. PHYSIOTHERAPY MANAGEMENT Normal kinetic chain and force generation :- Normalization of all inflexibilities throughout kinetic chain. :-Normal agonist –antagonist force couples in leg using squats, plyometric depth jumps. :- Trunk rotation exercise with medicine ball or tubing. :- Integrated exercise with leg and trunk stabilization, rotation , diagonal patterns from hip to shoulder and medicine ball throw. :- Rotator cuff strength 4⁺/5 or higher. :- Normal kinetic function.

25. PHYSIOTHERAPY MANAGEMENT 3) Functional phase Power and endurance in UE :- Diagonal and multiplanar motions with rubber tubing, light weights, small medicine balls and isokinetic machines. :- Plyometrics – wall push – ups, corner push – ups, weighted ball throws and tubing Increase multiple plane neuromuscular control :-Kinetic chain to generate and funnel the proper forces to and through the shoulder.

26. PHYSIOTHERAPY MANAGEMENT Rehabilitation :- Flexibility :- Strength :- Endurance Sport specific activity :- Functional progressions of throwing or serving :- Kinetic chain

27. REFRENCES Clinical orthopaedic rehab by S. BRENT Brontzman and Kevin E.WILK (second edition) Clinical sports medicine by P eter B rukner and Karim Khan ( third edition) P hysical M edicine and Rehabilitation by W alter R . Frontera Belmaire et al. Rehabilitation Management of Rotator Cuff Injuries in the Master Athelete (American college of sports medicine, 2019)