Definition

The rotator cuff is composed of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles and tendons

(Figs.
16.1 and 16.2).

These four muscles originate from the scapula and transition into their respective tendons prior to
insertion. The rotator cuff is responsible for abduction (supraspinatus),external rotation (infraspinatus and teres
minor), andinternal rotation (subscapularis) of the arm. In addition,it puts compressive forces on the humeral head,
increases joint contact pressure, and centers the humeral head on the glenoid. Each tendon is composed of relatively
avascular col-lagen fibers, so the rotator cuff tendons are the sites of rota-tor cuff injuries. Because the tendons are
relatively avascular,their capacity to heal spontaneously is minimal, resulting in
chronic and recurrent symptomatology. The supraspinatus tendon is most commonly involved in rotator cuff
disease.
Rotator cuff disease is a spectrum of disorders that includes subacromial or subdeltoid bursal pathology, rotator cuff
tendinopathy, and partial- and full-thickness rotator cuff tears.
The term “impingement lesions” was coined by Charles Neer II to describe the impingement of the supraspinatus
tendon under the acromion, coracoacromial ligament, and acromio-clavicular joint. The fibrotic changes seen in
rotator cuff tendons and subacromial bursa are caused by repeated episodes of inflammation ; in addition,
fibroblastic hyperplasia of tendons (tendinosis) can occur secondary to degeneration from the aging process. In
chronic rotator cuff tendinopathy, the muscles of the rotator cuff and surrounding scapulothoracic stabilizers may
become weak by disuse. Shoulder pain is the third most common musculoskeletal complaint (behind back and knee
pain) in the United States. The prevalence of shoulder pain ranges from 14% to 34% ; each year approximately 1%
of the population 45 years and older present with shoulder pain to primary care settings. In the United States the
direct healthcare expenses attributable to shoulder disorders was estimated to be $7 billion in 2000. Rotator cuff
disorders are the underlying problems in 65% to 70% of patients with shoulder pain.

Symptoms
Patients usually present with shoulder pain, weakness, and loss of range of motion resulting in impaired shoulder
function. Pain may occur with internal and external rotation and may affect daily self-care activities. The patient can
be awoken by pain in the shoulder,which impairs sleep.

Physical Examination
The shoulder examination is approached systematically in every patient. It includes inspection, palpation, range of
motion, muscle strength testing, and performance of special tests of the shoulder as clinically indicated.

Inspection
The shoulder should be carefully inspected from the anterior,lateral, and posterior positions. Comparison with the
Contralateral shoulder can be useful. During inspection, assessment of asymmetry of upper body posture, atrophy of
The supraspinatus and infraspinatus muscles, scapular winging, and abnormal scapulothoracic rhythm during
shoulder elevation are performed.
FIG. 16.1 Anatomy of the anterior rotator cuff. a, Supraspinatus tendon; b, subscapularis tendon; c,long head of
biceps brachii tendon; d, long head of biceps brachii tendon sheath; e,greater tuberosity of the humerus; f, acromion;
g, coracoid; h, supraspinatus muscle; i, subscapularisnmuscle.

FIG. 16.2 Anatomy of the posterior rotator cuff. a, Supraspinatus

tendon; b, infraspinatus tendon; c, teres minor tendon; d, greater tuberosity; e, acromion; f, infraspinatus muscle; g,
teres minor muscle.

Palpation
Tenderness should be evaluated at the greater tuberosity, subacromial bursa, long head of the biceps located in
bicipital groove, and acromioclavicular (AC) joint. Muscle atrophy can be assessed by feeling for the loss of muscle
bulk and comparison with the contralateral side.

Range of Motion
Total active and passive range of motion in all planes and scapulohumeral rhythm should be evaluated ( Fig. 16.3).
Forward flexion is performed by asking the patient to raise the arm in front of him or her as high as possible with the
thumb pointing upward. Maximal total elevation occurs in the plane of the scapula, which lies approximately 30
degrees forward of the coronal plane. The impingement syndrome associated with rotator cuff injuries tends to cause
pain with elevation between 60 and 120 degrees (painful arc), when the rotator cuff tendons are compressed against
the anterior acromion and coracoacromial ligament. Abduction is assessed by raising the arm at the side as high as
possible while the scapula is held down by the examiner. Glenohumeral external rotation can be assessed at 0
degrees in abduction with 90 degrees of elbow flexion and neutral supination-pronation position of forearm. At 90
degrees of glenohumeral abduction, with 90 degrees of elbow flexion and neutral supination-pronation position of
forearm, the external and internal rotation can be measured by moving the forearm upward and downward as much
as possible. Internal rotation can also be evaluated by documenting the highest level the patient can reach on his or
her back with the dorsum of the thumb. It is helpful to memorize some important bony landmarks: T7 corresponds
to the inferior border of scapula and L4 levels at the top of the iliac crest.

Strength
Muscle strength testing should be done isolating the relevant individual muscles. The precise way to test muscle
Strength can be performed by using a commercially Available device that measures strength in kilograms or pounds,
Such as a portable handheld dynamometer (Fig.16.4). The patient should be notified that he or she is supposed to
push into the device as hard as possible while the examiner resists his or her limb movement. Once the examiner
matches the patient’s resistance so that the isometric contraction is achieved, the patient is asked to keep pushing
while maintaining the position for 5 seconds.When the 5-second period is up, the examiner can read the numeric
value of muscle strength. All measurements should be performed twice on each arm, with a 10 second rest between
repetitions. The numeric readings are then averaged for each arm and evaluated for symmetry. To measure external
rotation exerted by infraspinatus, the patient is instructed to hold the arm in neutral rotation, elbow at 90 degrees of
flexion and thumb directed upward. The dynamometer is placed on the dorsal surface of the distal forearm just
proximal to the ulnar styloid process. Abduction exerted by supraspinatus is measured by placing the dynamometers
on the distal arm at the lat- eral humeral epicondyle while the patient is instructed to hold the shoulder at 90 degrees
of abduction and 45 degrees of horizontal abduction, elbow fully extended and palms facing down. Internal rotation
is exerted predominantly by subscapularis. The patient firstly holds the arm at 90 degrees of forward flexion and
elbow at 90 degrees.

FIG. 16.3 Range of motion testing. (A) Forward flexion. (B) Isolated abduction. (C) External rotation in neutral. (D)
External rotation in abduction.
of flexion. The examiner places the dynamometer on the patient’s hand with one hand and supports the patient’s
olecranon process with the other hand to ensure only internal rotation moment, and no adduction moment, is
produced.

Special Tests
Special tests in general are more applicable to rotator cuff tears. Tests for impingement are described later, and the
remaining tests are described in Chapter 17 (Table 16.1).

Functional Limitations
Patients with rotator cuff tendinopathy complain of limi- tations in the performance of overhead activities, such as
throwing a baseball and painting a ceiling, particularly greater than 90 degrees of abduction. Pain may also occur
with internal and external rotation and may affect daily self-care activities. Women typically have difficulty hooking
their bra in back. Work activities, such as filing, hammering overhead, and lifting, can be affected.

Diagnostic Studies
Imaging studies may be used to confirm the clinician’s diagnosis and to eliminate other possible pathologic
processes.Plain films Can be useful to Assess for fractures, osteoarthritis, and dislocation. The anteroposterior view
With internal and external rotation, West Point axillary view, true anteroposterior, and Y views are usually obtained.
Calcification can be visualized in plain film in calcified tendinitis of rotator cuff.Magnetic resonance imaging is the
study of choice when a patient is not progressing with conservative management or to rule out an alternative
pathologic process (e.g., rotator cuff tear). In tendinopathy, magnetic resonance imaging will demonstrate an
increased T2-weighted signal within the substanc of the tendon. Electrodiagnostic studies can be ordered to exclude
alternative diagnoses as well (e.g., cervical radiculopathy). Ultrasound can also be used in the diagnosis of rotator
cuff tendinopathy. Rotator cuff tendinopathy is shown as heterogeneous hypoechoic thickening of the tendon
without obvious fibrillar disruption.

FIG. 16.4 Strength testing by using a dynamometer. (A) External rotation. (B) Abduction. (C) Internal rotation.
Treatment
Nonoperative treatment is recommended for rotator cuff tendinopathy, which includes physical therapy, and several
modalities such as acupuncture, iontophoresis, phonophoresis, transcutaneous electrical nerve stimulation, pulsed
electromagnetic field, and ultrasound are also available. Other nonoperative treatments such as corticosteroid
injections, topical glyceryl trinitrate, and nonsteroidal anti-inflammatory drugs (NSAIDs) are aimed at symptomatic
relief. There are five basic phases of nonoperative treatment (Table16.2). These phases often overlap and can be
progressed as rapidly as tolerated, but each should be performed for optimal recovery.

Initial
Both oral and topical medications can provide pain relief and help participation in exercise programs. Most
commonly used oral medications in rotator cuff disease include NSAIDs, selective cyclooxygenase 2 (COX-2)
inhibitor, And acetaminophen COX-2 inhibitor, in comparison tononselective NSAIDs, has been shown to provide
similar improvements in pain and function with noninferior cardiovascular safety and significantly less
gastroenterologic and renal adverse effects. The efficacy of topical NSAIDs and glyceryl trinitrate in pain reduction
in rotator cuff disease has been proven in several clinical studies. The topical NSAIDs, in the form of patch, foam,
gel, or spray, showed no difference in pain reduction compared with systemic NSAIDs and systemic adverse effects
compared with placebo.

Rehabilitation
Rehabilitation of rotator cuff disorders mainly consists of physical therapy and manual exercise therapy. A
rehabilitation prescription should include the number of sets, repetitions, and an intensity at which the specific
exercise should be performed. Rehabilitation therapy focuses on restoring normal motion and strength to the
shoulder complex, as well as to decrease pain and improve the overall function without surgery. A physical therapy
program should be individualized to address the patient’s specific impairments to accomplish these goals. The basic
phases of nonoperative management of rotator cuff disorders consist of: range of motion and pain control,
flexibility, and strengthening and advanced strengthening. Physical therapy may include treatments such as shoulder
stretches, strengthening exercises to the scapular stabilizers and rotator cuff, proprioceptive exercises, joint
mobilization techniques, soft tissue mobilization techniques, and modalities to help control pain and inflammation.

Range of Motion and Pain Control

During the early stage of rehabilitation, controlling pain and inflammation is important so that the involved tissue
may begin to heal, enabling the patient to progress towards an active rehabilitation program. Physical therapy
treatment may consist of soft tissue mobilization, passive range of motion, and joint mobilizations to the shoulder to
improve mobility and decrease pain in the joint and surrounding tissues. Furthermore, both the cervical spine and
thoracic spine should be assessed for soft tissue or joint restrictions. Treatment techniques such as stretches and
mobilization techniques may be used because these structures play an important role in the overall mobility of the
shoulder complex. The primary goal of this phase is to decrease pain and inflammation to improve mobility and
function. There is insufficient evidence to support the use of physical modalities such as electrical stimulation and
low-level.
FIG. 16.5 Neer sign for impingement syndrome.

laser therapy in the treatment of rotator cuff disorders, and therefore they are not recommended. On the other hand,
cryotherapy has been shown to be effective in pain management and controlling inflammation and may be used in
the treatment of rotator cuff disorders. Ultrasound can be considered in calcific tendinosis because it has been shown
to resolve the calcification and is associated with short-term symptom relief.

Flexibility and Strengthening

Restoring range of motion to the shoulder complex by performing active assisted range of motion exercises such as
wand or cane exercises, as well as pulley exercises, may be used at this time. A continued focus on restoring passive
Range of motion through soft tissue mobilizations, as well as joint mobilizations, may also be performed during this
phase. Gentle shoulder stretches should be introduced to stretch those structures that have become tight and guarded
Due to pain and inflammation. Shoulder self-stretching
Should focus on the posterior capsule, posterior cuff, and the pectoralis minor muscles. A tight posterior capsule
can lead to anterior or superior migration of the humeral head. which in turn, can result in impingement. It is also
important to stretch the pectoralis minor muscle as well. Its attachment to the coracoid process on the scapula can
cause the scapula to tilt anteriorly, which can lead to muscle imbalances of the lower trapezius and decrease the
subacromial space. Strengthening of the scapular muscles should be performed with a focus on middle trapezius,
lower trapezius, and serratus anterior muscle groups because they play an important role in controlling the scapula
and to normalize scapular mechanics. Strengthening of the rotator cuff mus- culature may begin during this phase as
well. Positioning the arm at 30 degrees of abduction to perform internal rotation and external rotation prevents the
“wringing out” effect on the supraspinatus tendon, and it facilitates blood flow to the tendon. The wringing out
effect is caused by the humeral head compressing on the articular side of the supraspinatus tendon while the arm is
at 0 degrees of adduction. Empty can exercise with the thumb down and shoulder internally rotated should be
avoided because this exercise may cause subacromial impingement. Full can exercises with the thumb up can be
performed because this position recruits the supraspinatus better and it is more of a functional position. There are
many types of ways to strengthen the scapular stabilizers and the rotator cuff musculature.

Advanced Strengthening
Advanced strengthening of the rotator cuff and the scapular stabilizers should be the focus during the later stages of
rehabilitation. Both proprioceptive training and functional rehabilitation may be incorporated during this phase as
well. Proprioceptive training is important in retraining the neurologic control of the strengthened muscle groups.
Exercises may include both closed chain (e.g. exercises done with the hand in contact with a fixed object) and open
chain exercises (e.g. exercises done where the hand is free to move). Functional rehabilitation activities should be
geared toward specific activities the patient would like to return to, such as work-related tasks, sport-specific
activities, or household activities.

Procedures
An injection of lidocaine and corticosteroid is often performed for pain relief. The evidence for the use of
corticosteroid injections in rotator cuff disorders is variable. It is difficult to predict a patient’s response to
corticosteroid injection, and the failure rate of this procedure was reported around 40%. Percutaneous tenotomy can
be performed under ultrasound guidance. The needle is localized and placed in and out of the tendon to create small
perforations within the damaged tendon. This stimulates the healing response through the inflammatory cascade,
enhancing tendon repair. It has been proven safe but not superior to ultrasound-guided subacromial corticosteroid
injection. Ultrasound-guided percutaneous needle lavage was reported as a safe and cost-effective procedure to
reduce pain and calcification in calcified tendinitis. in addition, numerous studies supported the use of
extracorporeal shock wave therapy to improve pain and range of motion (ROM) in rotator
cuff tendinopathy. The advent of novel regenerative medicine strategies has shown its promise in treating
tendinopathy. Plateletrich plasma (PRP), obtained by gentle centrifugation of whole blood, has been proposed an
effective means of facilitating healing of injured tendons because it is rich in platelet-derived growth factors,
transforming growth factors, vascular endothelial growth factor, and epithelial growth factor. Current clinical studies
evaluating efficacy of PRP are complicated by considerable heterogeneity of tendinopathies, different PRP
preparation techniques, and variations in the composition of PRP. Therefore we are lacking convincing data to
conclude on its clinical efficacy. Low-leveled evidence exists showing the benefit of PRP
in alleviating pain and improving function for patients with lateral epicondyle extensor tendinopathy and patellar
tendinopathy. Few studies reported the therapeutic outcome of PRP in rotator cuff tendinopathy. In a randomized
controlled trial of 40 patients, no difference was found between saline and PRP injection at 1 year. In contrast, it
was reported by another group that PRP achieved a moderate (>50%) improvement in pain syndrome in 81% of
patients with rotator cuff tendinopathy refractory to conventional treatments.

Technology
There is no specific technology for the treatment or rehabilitation of this condition.

Surgery
Surgery is generally not indicated in the treatment of rotatorcuff tendinopathy unless patients are refractory to
treatment and have symptoms for a prolonged period of time. Surgical procedures include arthroscopic or open
acromioplasty to alleviate the outlet stenosis. Débridement of the tendon and subacromial decompression can also
be performed.
Potential Disease Complications
Rotator cuff tendinopathy may progress to a rotator cuff tear, although the clinical implications of this progression
are unclear. With prolonged impairment in motion and strength and subtle instability, hooking of the acromion can
develop. Adhesive capsulitis may develop with chronic pain and decreased shoulder movement as well.

Potential Treatment Complications

There are minimal possible complications from nonoperative treatment of rotator cuff tendinopathy.
Because NSAIDs are used frequently, one must remain vigilant to their potential side effects (e.g., gastritis,
ulcers, renal impairment, bronchospasm). Injections may cause rupture of the diseased tendon.

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