rotator cuff injuries IN DAY TO DAYLIFE .pptx

rotator cuff injuries IN DAY TO DAYLIFE IN SPORTS PERSONS

1. ROTATOR CUFF INJURIES MODERATORS: Dr.T.VENKATESHWAR RAO PROFESSOR & H.O.D Dr.J.VENKATESHWARLU ASSO. PROFESSOR Dr.VENKAT LAKAVATH ASST. PROFESSOR Dr.VENKATA SWAMY ASST.PROFESSOR PRESENTED BY PRAMOD KUMAR PG IN MS(ORTHO ) KMC/MGM

2. ANATOMY Four muscles around shoulder form rotator cuff which compress the humeral head into glenod These are 1.sura spinatus 2,infra spinatus 3.teres minor 4.subscapularis

3. Disorders of the rotator cuff commonly affect patients older than 40 years of age. It represents a spectrum of disorders ranging from rotator cuff tendinopathy to a partial- or full-thickness tear of the rotator cuff. Rotator Cuff Injuries

4. Tendinitis: Tendons in rotator cuff can become inflamed due to overuse or overload, especially in athletes who perform a lot of overhead activities. In some people, the space where the rotator cuff resides can be narrowed due to the shape of different shoulder bones, including the outside end of the collarbone or shoulder blade. . Strain or tear : Left untreated, tendinitis can weaken a tendon and lead to chronic tendon degeneration or to a tendon tear. Stress from overuse also can cause a shoulder tendon or muscle to tear.

5. Causes Causes include intrinsic and extrinsic factors. The intrinsic factor is early degenerative changes that are typically observed in the “watershed” region of the supraspinatus tendon (area with diminished blood supply). Extrinsic factors include a thickened coracoacromial ligament, an inflamed subacromial bursa, and a hook-shaped acromion .

6. Repetitive stress: Repetitive overhead movement of arms can stress rotator cuff muscles and tendons, causing inflammation and eventually tearing. This occurs often in athletes, especially baseball pitchers and tennis players. It's also common among people in the building trades, such as painters and carpenters Impingement: Falls or incorrect throwing techniques or arm movements and weak shoulder muscles may cause the arm bone to move up and trap the tendon. This may also happen in persons who over-train or have a sudden change in arm or shoulder activity.

7. Normal wear and tear: The rotator cuff tendons can degenerate due to ages (starting around the a ge of 40) . This can cause a breakdown of fibrous protein (collagen) in the cuff's tendons and muscles. Calcium deposits: Calcium may deposit in the tendons due to decreased oxygen and poor blood supply. These deposits may cause irritation and inflammation

8. Poor posture: space where the rotator cuff muscles reside can become smaller. This can allow a muscle or tendon to become pinched under shoulder bones especially during overhead activities, such as throwing. Falling: Using arm to break a fall or falling on arm can bruise or tear a rotator cuff tendon or muscle. Lifting or Pulling: Lifting an object that's too heavy, or doing so improperly (especially overhead) can strain or tear tendons or muscles. Pulling something, such as an archery bow of too heavy poundage, may cause an injury.

9. Rotator Cuff Tear Loss of continuity of the rotator cuff can be described in several ways, including acute and chronic, partial or full thickness, and traumatic or degenerative

10. Partial thickness tears Location- articular,anterstetial and bursal Grade 1- <3mmdeep Grade2- 3to 6mm deep Grade3- >6mm deep

11. Complete cuff tears Bateman classification Grade 1- tear <1 cm after debridement Grade 2- tear 1-3cm after debridement Grade 3- tear 3-5cmafter debridement Grade 4-global tear,no cuff left

12. Ellman and Gartsman classification 1.crescent 2.reverse L 3.L shaped 4.trapezoidal 5.massive tear

13. Topographic classification Hebermeyer Sector A-anterior sub scapularis tendon,long head of bisceps,rotator interval Sector B-central superior lesion Supraspinatus tendon Sector C-posterior lesion Infra spinatus and teres minor

14. Chronic tears can be classified based on the percentage of fatty infiltration of the muscle belly as seen on MRI . Goutallier et al. proposed five stages of fatty degeneration. Stage 0, corresponds to a completely normal muscle, without any fatty streak; in stage 1, the muscle contains some fatty streaks; in stage 2, the fatty infiltration is important, but there is still more muscle than fat; in stage 3, there is as much fat as muscle; and in stage 4, more fat than muscle is present

15. ACUTE A ripping of one or more of the tendons Result when a sudden eccentric force applied to the rotator cuff resulting in failure of the tendon. Uncommon under the age of 40 but strains do occur. In the population over 40 years of age most commonly supraspinatus tears occur and less commonly infraspinatus tears. Tears in the subscapularis tendon are uncommon and are often the result of a shoulder dislocation.

16. Common in sports such as: Baseball Tennis Football Weight Lifting Skiing Swimming

17. Symptoms Pain in the shoulder or arm , especially with arm movement (reaching overhead, reaching behind back, lifting, pulling or sleeping on the affected side. Radiation of the pain to the upper, lateral arm Pain at night pt may not be able to move arm well, especially away from body. shoulder may feel weak, numb, or tingly. Loss of shoulder range of motion Inclination to keep shoulder inactive Lying or sleeping on the affected shoulder also can be painful

18. SIGNS Examination often demonstrates tenderness along the lateral acromion or the lateral aspect of the proximal humerus . Abduction in the 70° to 120° arc increases pain, which can be decreased by moving the arm into internal rotation

19. 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.

20. 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 acromian . Pain reflects a positive test result and indicates an overuse injury to the supraspinatus muscle and possibly to the biceps tendon

21. 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.  

22. Lift-off Test Gerber and Krushell described the lift-off test for detection of an isolated rupture of the subscapularis tendon . With the patient seated or standing, the arm is internally rotated, and the dorsum of the hand is placed against the lower back. If the patient is unable to lift the dorsum of the hand off the back, the test is positive.

23. Belly Press Test. In this test, the patient presses the abdomen with the flat of the hand and attempts to keep the arm in maximal internal rotation. If active internal rotation is strong, the elbow does not drop backward, meaning it remains in front of the trunk. If the strength of the subscapularis is impaired, maximal internal rotation cannot be maintained, the patient feels weakness, and the elbow drops back behind the trunk. The patient exerts pressure on the abdomen by extending the shoulder, rather than by internally rotating it.

24. External Rotation Stress Test The external rotation stress test is intended to test the integrity of the external rotators of the shoulder, specifically the infraspinatus and the teres minor With the patient's arms by his or her side in neutral flexion and abduction, the shoulders are externally rotated 45 to 60 degrees. The examiner applies force against the dorsum of the hands, attempting to rotate the shoulders internally back to neutral while the patient is asked to resist. Pain and weakness suggest inflammation or tearing of the infraspinatus or the teres minor or both.

25. Shoulder Impingement Syndrome :   - impingement syndrome describes pain in subacromial space when the humerus is elevated or internally rotated ;     - during humeral flexion, the supraspinatus tendon and bursa become entrapped between the anteroinferior cor ner of the acromion (and CA ligament) and the greater tuberosity ;     - this syndrome is thought to precipitate attritional changes in the rotator cuff, leading to rotator cuff tear             - once the supraspinatus (and infraspinatus ) tendon is disrupted there will often be further impingement                   and irritation which can lead to biceps tendonitis and subsequent rupture ;

26. SHOULDER IMPINGEMENT SYNDROME

27. Developmental Stages of Impingement Syndrome Stage 1 : Edema and Hemorrhage Typical age of patient—<25 years old Differential diagnosis—subluxation, acromioclavicular joint arthritis Clinical course—reversible Treatment—conservative

28. Stage 2 : Fibrosis and Tendinitis Typical age of patient—25 to 40 years old Differential diagnosis—frozen shoulder, calcium deposits Clinical course—recurrent pain with activity Treatment—consider bursectomy or division of coracoacromial ligament

29. Stage 3 : Bone Spurs and Tendon Rupture Typical age of patient—>40 years old Differential diagnosis—cervical radiculitis , neoplasm Clinical course—progressive disability Treatment—anterior acromioplasty , rotator cuff repair

30. Diagnosis physical examination. X rays Arthrogram - painful afterwards. MRI

31. Arthrogram : A test done by injecting dye into the shoulder joint and then taking x-rays. Areas where the dye leaks out indicate a tear in the tendons. Imaging (MRI) Scan: A special radiological test that uses magnetic waves to create pictures of an area, including bones, muscles, and tendons. Ultrasound: An ultrasound is a test that looks inside your body. Sound waves are used to show pictures of muscles and tissues . Diagnosis Continued

32. Treatment Initial Care: Treatment will depend on symptoms and the duration. limit activity on affected shoulder to decrease stress on the tendon. This may help prevent further damage, decrease pain, and promote tendon heal. primary treatment is resting the shoulder and, for minor tears and inflammation, applying ice packs. may need to wear a sling to keep the shoulder to prevent from moving. Medicines: Anti-inflammatory medications may also be prescribed. Assoon as pain decreases, physical therapy is usually started to help regain normal motion. .

33. Surgical management The primary goal of surgical management of rotator cuff tears is pain relief, and this is accomplished with predictable results. Improvement of function is a secondary but important consideration. Functional improvement is not as predictable as pain relief and depends on the age of the patient, the age and size of the tear (which suggests the quality of the tissue and the condition of the muscle), and the postoperative rehabilitation program.

34. In chronic rotator cuff injury pts attempt a short course of conservative treatment (approximately 6 weeks). If there is a positive response, the nonoperative approach may be continued, but if there is no improvement, we proceed to surgery to minimize the atrophy of the rotator cuff musculature. Surgery is appropriate for an acute rotator cuff injury in a young patient or in an older patient (60 to 70 years old) with a defined injury who suddenly is unable to rotate the arm externally against resistance. In these patients usually have an excellent return of strength and function

35. Surgical management 1.acromioplasty-if tear less than 3mm 2.open or arthroscopic repair of rotator cuff->3mm Soft tissue mobilization procedures-for massive irrepairable tears

36. OPEN ANTERIOR ACROMIOPLASTY

37. Make the incision from lateral to the anterior acromion toward the coracoid and just lateral to it . Split the deltoid between anterior and middle part Deltoid origin elevated from acromian with periosteum Anterior extent of aromian to be removed

38. Rotator cuff repair The goals of mobilization are 1)to obtain tissue of adequate strength at the site at prone for injury 2) without damage to innervation and without compromise of deltoid function 3) to decompress the subacromial space to prevent further mechanical impingement on repaired cuff tissue

39. The initial step is a side-to-side tendon repair that results in “marginal convergence” toward the greater tuberosity, which decreases the strain at the free margin of the rotator cuff tear, enhancing the mechanics of the construct . A combination of the tendon-to-tendon repair with tendon-to-bone repair can result in a functional rotator cuff.

40. Cordasco and Bigliani identified five factors that improved results of operative treatment of large and massive rotator cuff tears: 1. Adequate subacromial decompression 2. Maintaining the integrity of the deltoid origin 3. Mobilizing torn tendons and performing an interval slide when indicated 4. Repairing tendons to bone 5. Carefully supervising and staging postoperative rehabilitation

41. McLaughlin McLaughlin described suturing the tendon to a trough in bone at whatever point it could be advanced onto the humeral head. This may be more proximal (approximately 2 cm) through the anterior neck area. Although this repair allows a watertight closure, the mechanical advantage of the muscle-tendon unit is lost with this much proximal advancement

42. MCLAUGHLIN PROCEDURE

43. TENDON TRANSFERS Tendon transfers for the treatment of irreparable rotator cuff tears may involve transfer of rotator cuff tendons or other muscle-tendon units . Cofield described subscapularis tendon transposition to fill large gaps in the supraspinatus insertion . The flap is created by separating the outer portion of the subscapularis from the inner capsular portion. It is detached from the lesser tuberosity and mobilized superiorly to cover the humeral head. This repair results in great tension in abduc-tion and external rotation and disrupts the subscapularis force couple, which could prove detrimental to shoulder function

44. For anterosuperior tears involving the subscapularis and the supraspinatus, transfer of the pectoralis major is useful. For posterosuperior tears involving the infraspinatus and supraspinatus , the latissimus dorsi has been transferred. with irreparable full-thickness tears of at least two complete tendons managed with latissimus dorsi transfer. This transfer is best used with an intact subscapularis tendon.

45. free grafts (autologous or autogenous ), such as the intrinsic portion of the biceps and fascia lata , or synthetics to replace deficient rotator cuff tendon. . The disadvantages of the material are the potential for foreign body reaction to synthetics and tissue rejection. Such materials do not replace the atrophic and weakened rotator cuff musculature present with chronic massive tears

46. Rotator Cuff Tear Arthropathy End-stage rotator cuff disease leads to an entity known as rotator cuff arthropathy . Normal humeral head depression of the supraspinatus is lost, and the unopposed deltoid pull leads to shearing forces across the glenoid . Articular cartilage is poorly suited to resist shearing-type forces, and degenerative changes ensue . Neer also postulated that nutritional factors contributed to the process owing to loss of fluid pressure and the accompanying reduction in the quality of the chemical content of the synovial fluid leading to cartilage and bone atrophy

47. . Radiographic findings include the sourcil sign (erosion of the inferior acromial surface as the humeral head “articulates” against the undersurface of the acromion ), superior humeral head osteophytes , and loss of glenohumeral joint space.

48. ROTATOR CUFF ARTHROPATHY

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