ROTATOR CUFF TEAR
– Rotator cuff tear is common explanation for shoulder pain and impingement.
– structure tendon become swollen, hypercellular, and collagen matrix is disorganised .
– Apoptosis is increase in overuse tendinopathy.
✓ Complete or partial rupture of structure .
✓ Supraspinatus tendinitis.
✓ Subacromial bursities
✓ Bicipital tenosynovitis.
✓ Fracture of greater tuberosity.
✓ Intrinsic and extrinsic
✓ Tendinous fibers of structure undergo degenerative changes with advancing age.
• Mode of injury
✓ Fall on shoulder.
✓ Lifting or throwing heavy object with overhead action.
• Clinical features
✓ Pain in overhead activity, below 90° abduction pain-free.
✓ Associated symptom of instability /subluxation dead arm.
✓ Painful arc present.
• On examination
✓ Tenderness over Supraspinatus tendon.
✓ Reduced internal rotation.
✓ Impingement test is positive.
• Diagnostic testing
✓ Neer’s impingement sign.
AIM : Identify impingement of supraspinatus tendon or long head of biceps
PATIENT POSITION :Patient sitting and shoulder is passively internally rotated and fully abducted
POSITIVE SIGN : Reproduce symptoms of pain within shoulder region .
✓ Hawkins – kennedy sign
AIM : Identify impingement of rotator cuff.
PATIENT POSITION : Patient is sitting with arm flexed at 90 degree and elbow flexed to 90 degree; the examiner then stabilizes proximal to the elbow with their outside hand and with the other holds just proximal to the other holds just proximal to the patient’s wrist. Then passively move the arm into internal rotation.
POSITIVE SIGN : Pain in the sub -acromial space
✓ Investigation :
(1) Conservative treatment
– Heat , massage, NSAID’s , local infiltration of hydrocortisone, Subacromial steroid injection.
– Active and passive exercise.
– Temporary immobilization.
– Small and partial tear can be treated with conservative management.
(2) Surgical management.
– Surgery is indicated when there is failure of conservative management.
– Arthroscopic repair for small and partial tear.
– Open method in larger tears.
√ excision of adhesion and manipulation.
√ Excision of calcium deposits.
√ Direct suture.
(1) Preventive measures
–To avoid recurrance.
(a) sudden lifting of heavy weights should be avoided.
(b) Repeated compression of tendon should be avoided.
– Avoid strenous abduction and flexion.
(c) Extra care should be taken for people in age group prone for degenerative changes.
(d) PRE to strengthen the rotator cuff
– Strengthen all three components of rotator cuff like abductor, internal rotator , and external rotators.
(c) Avoid sports involving repeated movement of elevation without strengthening programme.
(2) Prevention of further damage
✓ Positioning during standing
– Hanging the arm for longer periods by side of the body puts constant strain on rotator cuff.
✓ Positioning during exercise
– Teach the patient to correct the position and actions so that ruptured tendon is not exposed to any further damage
– Shoulder movements like flexion and abduction against gravity and resistance is discontinued.
✓ Passive full ROM to avoid adhesive capsulities.
(3) Restoration of function
– Rest with proper support in sling.
– Elbow , forearm , wrist and hand movements should be encouraged.
– Ultrasound , cryotherapy and TENS can be used.
– Isometric contractions
– Transverse friction massage just below acromion
• Exercise program
(1) Relaxed passive movements
– In supine lying position , relaxed passive full range movements can be given for abductors and for flexors exercise can be done in side lying.
– Total relaxation and proper stabilization during abduction.
(2) Active or active assisted exercise
– initiate abduction, rotation, and flexion in gravity eliminated position.
– The arm is held in neutral position of rotation with the elbow in flexion is done in supine position .
– Stabilize just above the GH joint over shoulder girdle .
– Then abduction of arm is done by the patient.
– If patient is able to perform , lever arm is lengthened by elbow extension.
– Patient should perform movement without elevating shoulder girdle.
– If both the movements are not possible, Assisted abduction can be done.
(3) Resisted exercise
– Manual resistance can be given by using dumbells .
– start with minimum weight
– Controlled resisted program for rotator cuff is important because scapular muscles are called as ‘power house’ of shoulder movement.
• Differential diagnosis
– Frozen shoulder.
– Shoulder joint arthritis.
– Cervical spondylosis.
– Snapping scapula.