Rotator Cuff Injuries and Their Management

Submitted By:

Aishwarya Patil
Roll no.
Enrollment no.

Project Submitted to

Apollo College Of Physiotherapy

Anjora, Durg (C.G.)

In partial fulfillment of requirements for the degree of

Bachelor of Physiotherapy

Under the guidance of:

Dr. Suraj. K.Nanda, Professor, Apollo College of Physiotherapy.

 DECLARATION BY THE CANDIDATE

I, hereby declare that this Project entitled, “Rotator Cuff Injuries and Their
Management.” is a bonafide and Project work carried out by me,under the guidance
of Dr. Suraj. K. Nanda, Professor, at Apollo College of Physiotherapy.

Date: Signature of the Candidate:

Place: Name:

CERTIFICATE BY THE GUIDE

This is to certify that the project entitled, “Rotator Cuff Injuries and Their
Management.” is a bonafide and Project work done by Aishwarya Patil in partial
fulfillment for the degree of Bachelor of Physiotherapy.

Date: Signature of the Guide:

Place: Name:
Designation:

ENDORSEMENT BY THE PRINCIPAL

This is to certify that the project entitled, “Rotator Cuff Injuries and Their
Management.” is a bonafide and Project work done by Aishwarya Patil, under the
guidance of Dr. Suraj. K. Nanda, Professor, at Apollo College of Physiotherapy.

Signature of the Principal

 ACKOWLEDGEMENTS:

THIS PAGE IS INTENTIONALY LEFT BLANK TO BE AUTHORED AT A LATER

DATE.
 INDEX

S. LIST OF CONTENTS PAGE

NO. NO.
1 INTRODUCTION
2 RELEVANT ANATOMY OF:
SHOULDER COMPLEX AND ROTATOR CUFF
MUSCULATURE.
3 RELEVANT BIOMECHANICS OF:
SHOULDER JOINT AND ROTATOR CUFF
MUSCULATURE IN MOBILITY AND STABILITY.
4 ROTATOR CUFF LESIONS:
1. EPIDEMIOLGY/PREVALENCE.
2. ETIOLOGY/MODE OF INJURY.
3. PATHOPHYSIOLOGY/MECHANISM OF INJURY.
4. CLASSIFICATION.
5. DIAGNOSIS.
6.MANAGEMENT.
5 CLINICAL CASES.
6 OUTCOME MEASUREMENT.
7 CONCLUSIONS
8 REFERENCES
LIST OF ABBREVIATONS USED
LIST OF FIGURES
 INTRODUCTION

Rotator Cuff Injuries, are one of the leading causes of shoulder pain and upper limb
instability, worldwide. If left untreated, shoulder problems and pain can lead to
significant disability, limitations in activity and restrict participation in major life
areas such as work and employment, education, community and social life.

In 1837, John Gregory Smith first described a shoulder lesion, with characteristics
similar to a Rotator Cuff Injury, during a cadaveric dissection at the Hunterian Theatre
of Anatomy, which got published in the London Medical Gazette. Post this, another
valuable progress was made by Meyer in 1924, followed by Codman in 1934 who
summarized and compiled his observations of the musculotendinous cuff of the
shoulder and it's various traumatic and atraumatic (degenerative) conditions.
Beginning 10 years after the publication of Codman's book and for the next 20 years
McLaughlin wrote on the etiology of cuff tears and their management. Post Codman's
studies, various other clinicians such as Mclaughlin, Asherman, Lindblom, Palmer,
Petterson and others elaborated on diverse Rotaror Cuff Lesions.

The Rotator Cuff mainly attaches on the Shoulder Complex, and acts on
Glenohumeral Joint. The Shoulder Complex consists of:
• Sternoclavicular Joint (SC Joint).
• Acromioclavicular Joint (AC Joint) .
• Glenohumeral Joint (GH Joint) .
• Scapulothoracic Joint (ST Joint) .

Fig. 1. Anatomy of Shoulder Complex.

 • Out of these, the first three ( The SC Joint, AC Joint and GH Joint) are
anatomical articulations and the last two, (The ST Joint and the
Coracoclavicular joint) are functional articulations. The Rotator Cuff
Musculature chiefly, produces the movements of the GH Joint. It also greatly
influences Upper Limb mobility and stability.

The Glenohumeral Joint which is the primary mobile joint of the Shoulder Complex,
is a Synovial Joint of Ball and Socket variety with the Glenoid fossa of the Scapula
acting as the socket and the Head of the Humerus acting as the ball. This
configuration provides, less bony/static stability as opposed to a true Ball and Socket
joint, for example as in Hip Joint.

The following are some salient features of the Glenohumeral Joint:

• The Glenohumeral Joint is a Synovial joint, of Ball and Socket variety. It is a

Diarthroial, Multi-axial joint that allows 3 Degrees of Freedom, Flexion-
Extension, Abduction-Adduction, External Rotation-Internal Rotation.

• The articular surfaces of Glenohumeral joint are formed by: Humeral head
forming the Convex surface/Ball and Glenoid fossa forming the Concave
surface/Socket of the joint. Both these structures are covered with articular
cartilage, that is avascular, aneural, and alymphatic. Articular Cartilage is
highlighted in the below figure.

Fig. 2. Articular cartilage, on Articular surfaces on glenohumeral joint

• The Glenoid Fossa of scapula, is surrounded by an accessory structure, known
as The Glenoid Labrum, which is also attached to its periphery. The primary
function of the Glenoid Labrum is to enhance the concavity of the Glenoid
Fossa. The central part of the Labrum is composed of tighly packed
connective tissue covered by a fine mesh-like superficial tissue composed of
fibrocartilage, at its attachment near the periphery of the Glenoid Fossa. It's
structure annd commposition allows the Glenohumeral Joint a great extent of
mobility and stability, by allow in the Humeral Head to translate within its
enclosure. Apart from it,this structure also protect the bony periphery of the
Glenoid Fossa, decrease Joint Friction and Joint Reaction Forces and to
function as a landmark for attachment for various soft tissue structures.

Fig. 3 Glenoid Fossa and Glenoid Fossa.

• The Glenohumeral Joint is covered by a capsule, that is large, loose and covers
the joint in its entirety. The structure of the Capsule allows the Humeral Head
to translate freely in the Glenoid Fossa. It is taut superiorly and slack
anteriorly and inferiorly with the arm dependent at the side. The capsule
tightens when the humerus is abducted and laterally rotated, making this the
close-packed position for the glenohumeral joint.
 Fig. 4 Glenohumeral Joint Capsule.

The glenohumeral joint capsule covers, twice the amount of surface area as
compared to that of humeral head. Its loose structure, allows for free intra-
articular movements of the humeral head on the glenoid fossa.

• Th Glenohumeral Joint, is held together by various ligaments, that are

responsible for the joint integrity and static as well as dynamic stability. The
Glenohumeral Joint is held together by the following Ligaments :

S. Name of the Ligament Functions

No.
1 Glenohumeral Ligaments: Attaches Glenoid Fossa and Humeral
Divided into; Head.
-Superior Glenohumeral
Ligament -Limits external rotation and inferior
translation of humeral head.
-Middle Glenohumeral Ligament -Limits external rotation and anterior
translation of humeral head.
-Inferior Glenohumeral -Limits external rotation and
Ligament anteriosuperior translation of humeral
head (anterior band);
Limits internal rotation and anterior
translation (posterior portion).
2 Coracohumeral Ligament: Together both bands limit inferior and
Further divided into the posterior translation of humeral head
following; support weight of resting arm against
gravity.

-Anterior Band -Limits extension

-Posterior Band -Limits flexion
3 Transverse Humeral Ligament. Keeps tendon of long head of biceps in
bicipital groove.
4 Coracoacromial Ligament. Limits superior translation of humeral
head.

Fig. 5. Glenohumeral Joint ligaments

 • The Glenohumeral Joint consists of the following bursae (Synovial fluid filled
sacs), that acts as a cushion between tendons and other joint structures. There
are following bursae in Glenohumeral joint:

S. No. Bursae Functions

1 Subscapular Bursa. (Located between
subscapularis tendon and the
scapula.)
2 Subacromial/Subdeltoid Bursa. (Lies
between Deltoid muscle and Joint
capsule, in the superolateral aspect of
the Joint, just superficial to
Supraspinatus tendon)
It reduces wear and tear on
subscapularis tendon during
movement at the shoulder joint,
particularly in internal rotation.
Reduces friction underneath deltoid
muscle, allowing an increased range of
motion. This bursa, excluding anatomic
variants, does not usually communicate
with shoulder joint itself.

3 Subcoracoid Bursa. (Located Reduces friction between

anteriorly, to subscapularis and
inferior to Coracoid process.)
4 Infraspinatus Bursa. (Located
between infraspinatus tendon and
joint capsule.)
Coracobrachialis, Short head of
Biceps brachii and Subscapularis.
Facilitates, internal and external
rotation.
Reduces wear and tear on
infraspinatus tendon, during
movement especially external
rotation.

Fig.6. Bursae of Glenohumeral Joint.

• The Shoulder joints consists of a structure known as The Coracoacromial

Arch, formed by Coracoid process, Acromion proces and Coracoacromial
ligament. This is an osseo-ligamentous vault that covers the humeral head and
encloses a space within which the subacromial bursa, rotator cuff tendons and
the long head of biceps brachii thereby protecting these structures from trauma
and superior dislocation of the humeral head.

Fig. 7. Coracoacromial Arch.

Fig.8 Contents around and under the Coracoaromial Arch.

• Neurovascular Supply of Shoulder Joint consists of the following:

 1. -Vascular Supply: -Anterior circumflex humeral vessels, Posterior
circumflex humeral vessels, Suprascapular vessels, Subscapular vessels and
their respective Veins.

2. -Nervous Supply: Nerve branches from Brachial plexus, i.e.

Axillary nerve, Musculocutaneous nerve, Suprascapular nerve,
Subscapular nerve and Lateral Pectoral nerve.

• The Glenohumeral Joint produces the following movements:

S. Movements at Muscles producing the Range of Motion

No. Glenohumeral Joint
1 Flexion
2 Extension
3 Adduction
4 Abduction
Movement
Pectoralis major, Deltoid 0°-180°
(anterior fibres), assisted
by Coracobrachialis and
Biceps brachii.
Deltoid (posterior fibres), 0°-60°
Latissimus dorsi assisted
by Teres major, Long head
of Triceps brachii,
Pectoralis
Major(Sternocostal Part).
Pectoralis major, 30°
Latissimus dorsi,
Subscapularis, Long head
of Biceps brachii, Short
head of Triceps brachii,
assisted by Teres major
and Coracobrachialis.
Supraspinatus- 0°-15° 0°-180°
Deltoid (middle fibres)-
15°-90°
Serratus anterior and
Trapezius-90°-180°

5 Internal Rotation Anterior fibres of deltoid, 0°-90°

Teres major,
Subscapularis, Pectoralis
major and the Latissimus
dorsi.
6 External Rotation Posterior fibres of the 0°-90°
Deltoid, Infraspinatus and
Teres minor.
 Apart from these, Circumduction, a combination of all movements also takes place
that involves all muscles that participate in the above movements.

Fig.9. Movements of Glenohumeral Joint.

• Musculature of Glenohumeral joint, is classified into 2 basic groups, that are

Extrinsic Muscles and Intrinsic Muscles.

Extrinsic Muscles involve the muscles that arise from, the Thorax and attach to the
Shoulder Girdle.
Example: Trapezius, Latissimus dorsi, Levator scapulae and Rhomboids (Rhomboid
major and Rhomboid minor)

Intrinsic Muscles involve the muscles that arise from, the bones of shoulder girdle and
attach there itself.
Example: Deltoid, Teres major, The Four rotator cuff muscles (Suprapinatus,
Infraspinatus, Teres minor, Subscapularis), Biceps brachii and Triceps Brachii.
 Here, we shall be discussing the various Rotator cuff muscles and their functional
parts, alongside its anatomy, biomechanics, various lesions and their management,
along with various clinical case discussions.
ROTATOR CUFF ANATOMY:

The Shoulder Joint, is one of the most mobile joints of the body and for it to hold such
a mantle, its movements need to be of full range and power. The glenohumeral joint
allows for 6 movements namely, Flexion, Extension, Abduction, Adduction, External
Rotation, Internal Rotation and Circumduction. For these to happen smoothly, few
key factors for the smooth motion of the glenohumeral joint are as follows:

• Articular Congruence of Glenohumeral Joint

• Bony Architecture of Shoulder Complex.
• Musculature of Shoulder Complex.

The first two are parts of the bony components of the shoulder complex. The last one,
namely Musculature of Shoulder Complex is composed of the Intrinsic Muscles of the
Shoulder Joint, which include The Deltoid, Teres major, The Four rotator cuff muscles
(Suprapinatus, Infraspinatus, Teres minor, Subscapularis), Biceps brachii and Triceps
Brachii, and even out of these The Rotator Cuff muscles play an extremely important
role in the healthy and ideal biomechanics of the shoulder joint.

The Rotator Cuff muscles, are a musculotendinous cuff-like structure formed by the
flattened tendinous attachments of the Rotator Cuff muscles. This cuff-like structure
blends with the Capsule of the glenohumeral joint and provides it stability, by
attatching to the humeral head in an almost circimferential manner, all around the
joint except inferiorly.

The tendons of these muscles are nonlinear, viscoelastic, and heterogeneous. A major
component of these tendons is collagen, which creates a matrix providing
extensibility. The transition point of a tendon to bone insertion can be broken down
into the following four zones: tendon mid-substance, fibrocartilage, calcified
fibrocartilage, and bone. This cuff of flattened tendinous attachments help in the
static and dynamic stabilization of the shoulder joint. The glenohumeral joint capsule
is thin and lax for allowing a wide range of movements and needs more reinforcement
which is provided by the rotator cuff muscles.

These four muscles form an integral part of the Intrinsic Musculature of the shoulder
joint, which may also be abbreviated as “SITS” for convinience in future mentions.
This group of four muscles, acts primarily on the glenohumeral joint to produce its
movements as well as to provide stabilization in movement as well as in static states.

Anatomicallly though, the so-called musculotendinous cuff is formed by only three

muscles, namely the Suprapinatus, Infraspinatus, Teres minor as they attach close to
each other on proximal humerus. The fourth Rotator cuff muscle, which is The
Subscapularis attaches on another landmark and is joined to the rest of the cuff via a
structure known as The Rotator cuff interval. The attachment of these muscles provide
an infinite variety of moments to rotate the humerus and to oppose unwanted
components of the forces from other muscle groups.
 The long head of biceps brachii tendon may be considered a functional part of the
rotator cuff. It attaches to the supraglenoid tubercle of the scapula, runs between
subscapularis and the supraspinatus, and exits the shoulder through the bicipital
groove under the transverse humeral ligament, attaching to its muscle in the proximal
arm.

The Rotator Cuff is comprised of the following muscles :

• Suprapinatus.
• Infraspinatus.
• Teres Minor.
• Subscapularis.
 DESCRIPTION OF ROTATOR CUFF MUSCLES:

 SUPRASPINATUS:

• The Supraspinatus, is the first muscle of the Rotator Cuff muscle group. This
muscle, is a relatively small muscle runs from the superior part of dorsal
surface of the, underneath the accromion process to the proximal part of the
Humerus, in a posterolateral direction.

• Supraspinatus lies deep to the trapezius muscle and superior to the spine of the
scapula and infraspinatus muscle. The tendon of supraspinatus is separated
from the coracoacromial ligament, thecromion and the deltoid muscle by the
subacromial bursa.attachment at proximal humerus forms superior part of the
Rotator cuff.

• Approximately 70% of the muscle fibers attach to the intramuscular tendon,

whereas 30% attach directly to the extra muscular tendon.

• ORIGIN: The Supraspinatus muscle, originates from the medial two-thirds of

Supraspinous fossa of scapula and the deep fascia that covers it.

• INSERTION: On the most superior facet on the greater tuberosity of the

humerus, blending with the superior part of the glenohumeral joint capsule.

• NERVOUS SUPPLY: Suprascapular Nerve, arising from C5 & C6 roots, from

superior trunk of the brachial plexus.

• VASCULAR SUPPLY AND LYMPHATIC DRAINAGE: Suprascapular artery

and dorsal scapular artery a branch of the thyrocervical trunk of subclavian
artery. Venous drainage is conveyed by the corresponding veins which
accompany the arteries and drain into subclavian vein.

• ACTION: The Supraspinatus muscle, abducts the arm upto 15° as an Agonist
, and pulls head of the humerus medially towards glenonid fossa. It
independently prevents excessive inferior translation of head of the humerus.
Along wih this, Supraspinatus also acts as a synergist to Deltoid in
abduction,when shoulder is adducted. Supraspinatus, apart from its mobility
function, also helps to stabilize the shoulder joint by keeping the head of the
humerus medially against the glenoid fossa of scapula. With this, the
Supraspinatus, provides an upward anchor-like force to resist the inferior
gravitational forces placed across the shoulder joint due to the downward pull
from the weight of upper limb. Recent studies have shown, that the
Supraspinatus muscle has two bellies rather than the previously believed ,one
anterior and the other posterior. The structure of the anterior belly was
fusiform in nature,and was seen to be originating purely in the supraspinous
fossa and foms around 60% of the muscle bulk of the supraspinatus muscle.
The anterior belly contained an internal tendon which forms a tendinous core
into which muscle fibers insert. The internal tendon thickened into a tubular
 structure as it became extra-muscular. The tendon from the anterior belly
supplies 40% of overall width of the external tendon. The structure of the
posterior belly was found to be of unippennate nature, which would be
inadequate for bearing large amounts of foece sustained by shoulder
musculature. It has a strap-like structure and was seen to be arising from
spinous process of scapula and neck of glenoid.Both bellies fuse and attach to
thee aforementioned site at humeral head.

THE SUPRASPINATUS MUSCLE:

Fig.10.Supraspinatus Muscle
 INFRASPINATUS:
• The Infraspinatus muscle, is a component of the Rotator cuff musculature. It
lies inferior to the Supraspinatus muscle. It is a thick, triangular muscle,
inhabiting the inferior part of the dorsal surface of the scapula. It is of
mesodermal origin and is composed of cross-striated muscles.
• With Teres minor muscle, Infraspinatus forms the posterolateral part of the
Rotator cuff. Like its superior countepart, The Supraspinatus, Infraspinatus
lies deep to various muscles such as Trapezius, some parts of Deltoid muscle
and Lattisimus dorsi. Due to their anatomical proximity, The Supraspinatus
anad The Infraspinatus muscles are considered together as a functional unit. It
arises superior to Tere minor and Teres major muscles.
• The infraspinatus muscle (fibres), runs almost parallel to Teres major and
Teres minor muscle and is separated from them by a fascia. Like all Rotator
cuff muscles, Infraspinatus also has both mobility and stabillity functions, in
both unloaded and loaded conditions.
• ORIGIN: Infraspinatus arises from medial two-thirds of the infraspinatus
fossa, with its tendinous attachments arising from the ridges of the fossa.
Along with these two osteological landmarks this muscle also originates from
the infraspinatus fascia. From these origin points, the muscle fibres converge.
• INSERTION: The converged muscle fibres of Infraspinatus which teads over
to the superolateral part of the dorsal surface of the scapula and posterior part
of the glenohumeral joint capsule and attaches to the middle facet on the
greater tuberosity of the proximal humerus.
• NERVE SUPPLY: The infraspinatus muscle is supplied by the Suprascapular
nerve, with root values of (C5-C6). It arises from superior trunk of the
Brachial Plexus to descend laterally to supply Supraspinatus and Infraspinatus.
• VASCULAR SUPPLY AND LYMPHATIC DRAINAGE: Infraspinatus
recieves arterial supply from Suprascapular and Circumflex scapular arteries
arisng from Subclavian and Axillary arteries respectively. Lymphatic drainage
is primarily done by the Subscapular, Pectoral, and Humeral nodes which
drain into Central Axillary nodes, which inturn drain into Subclavian
lymphatic trunk.
• ACTION: The Infraspinatus muscle acts primarily on the humeral head, by
acting as its primary external/lateral rotator of the shoulder joint. This action is
also important in pre-loading the upper extremity, in extension and lateral
rotation of shoulder joint for overhead activity and for the smooth
decelerattion of the upper limb during powerful overhead movements.
Apart from this, Infraspinatus and other Rotator cuff muscles, holds the
humeral head in the glenoid fossa by applying compressive forces o n the
humeral head. and prevent shoulder instability with additionallly reinforcing
the glenohumeral joint capsule. With the Subscapularis, Infraspinatus balances
the anterior-posterior force balance. Threfore if rotator cuff muscles are
deficient (tear/tendinopathy), humeral head gets elevatea partially against
glenoid fossa, decreasing efficiency of the deltoid muscle's abduction range.
The Infraspinatus is synergistic with the Teres minor muscle.
Lastly, ths muscle also acts on scapula as it allows Scaption (Abduction in
scapular plane); which is important for the complete mobility of the shoulder
complex.

THE INFRASPINATUS MUSCLE:

Fig. 11 Infraspinatus Muscle.

 TERES MINOR:
• The Teres minor muscle, is the third component of the Rotator cuff group of
muscles. It is a fusiform muscle having a narrow, elogated muscle. It is an
intrinsic muscle of the Shoulder complex. Teres minor lies superficial to the
Long head of Triceps brachii, snugly between Trapeius and Deltoid muscles.
Trapezius covers Teres minor medially and Deltoid covers it from the
superolateral aspect.
• Teres minor, lies inferior to Infraspinatus and superior to Teres major. It also
forms the borders of two intermuscular spaces, namely The Quadrangular
space and the Triangular space which are essential for the passage of various
neurovascular structures, such as axillary nerve ans circumflex humeral
arteries. Its fibres, along with Infraspinatus and Teres major have an oblique
orientation, upwards and laterally towards the humeral head.
• Sometimes, the Teres minor and Infraspinatus muscles, may not be separated
at all and are fused, working as a joint component in shoulder movements.
• ORIGIN: The Teres major muscle, originates on the dorsal surface of scapula,
on the upper two-thirds of lateral border of scapula by two heads, between
which there exists a ridge for the passage of circumflex scapular artery, from
where these two heads fuse to form a single belly and traverse superolaterally
to its attachment.
• INSERTION: Teres minor, attaches to the Greater Tuberosity of the proximal
humerus, from where it blends into the glenohumeral joint capsule. The
superior fibres of the muscle formsa short tendon, inserting on the greater
tuberosity of humerus. The inferior fibres, insert on the proximal humeral
shaft, near origin of lateral head of triceps brachii.
• INNERVATION: Teres minor is innervated by the posterior branch of the
Axilary nerve (C5,C6), which arises from the posterior cord of the brachial
plexus.
• VASCULAR SUPPLY AND LYMPHATIC DRAINAGE: Teres minor is
supplied by subscapular artery, circumflex scapular artery and posterior
circumflex humeral artery, all of which arise from the terminal part of the
Axillary artery.
• ACTION: The Teres minor muscle, as a component of the Rotator cuff, has a
dual function, comprising of both stability and mobility of the glenohumeral
joint.
For the stability component, Teres minor along with other components of
rotator cuff muscle holds the head of the humerus against the glenoid fossa,
whilst reinforcing the capsule of the glenohumeral joint by the virtue of its
attachment on the humeral head and preventing posterior dislocation of
shoulder. It also abducts scapula when humerus is stablized.
For the mobility component, Teres minor muscle is primarily responsible for
External/Lateral Rotation of the glenohumeral joint, in collaboration with the
Infraspinatus and posterior Deltoid.
• It also produces: Adduction (with Latissimus dorsi and Pectoralis major) and
 Extension (with posterior Deltoid) of glenohumeral joint
With all above functions Teres minor being an external rotator of shoulder
joint acts as an antagonist to the medial rotators of the shoulder. This
important, for when the shoulder is abducted and externally rotated, Ters
minor is critical in stabilizing the shoulder during medial rotation to prevent
anterior dislocation of the humerus by preventing excessive anterior translation
of the humeral head and avoiding strain on anterior soft tissue sturctures.

THE TERES MINOR MUSCLE:

Fig. 12 Teres minor Muscle

 SUBSCAPULARIS:
• The subscsapularis muscle, is a powerful triangular muscle located on the
costal/ventral surface of the scapula. Its the largest muscle of the Rotator cuff
muscle group, spanning across the whole of subscapular fossa. The
Subscapularis is a wide, fleshy and flat muscle, that lies on the posterolateral
aspect of the thorax.
• It is the only internal rotator of the 4 rotator cuff muscles. Although other
internal rotators of the shoulder exist (pectoralis major, teres major, and
latissimus dorsi), subscapularis remains one of the most important, as it purely
originates from scapula and attaches to humerus.
The muscle derives its name from the virtue of its location, i.e.
"Subscapularis" with "Sub-" meaning underneath and "scapularis" meaning
the Scapula. Thererfore Subscapularis means the muscle that originates under
the scapula bone.

• Subscapularis' tendinous bands are scattered evenly around the medial part of
the muscle belly, which condense superolaterally into a flat tendon in the
superior two-thirds, whereas the inferior third is muscular and not tendinous.

• ORIGIN: Subscapularis, originates from the Subscapular fossa on the costal

surface of Scapula, specifically medial and inferior two-thirds of the groove on
the lateral border of scapula.

• INSERTION: From its origin, the muscle belly transitions into a flat tendon
that traverses superolaterally and majority fibres attach to lesser tuberosity of
humerus and some fibers attach to the medial lip of the bicipital groove and to
the greater tuberosity of the humerus. As the subscapularis tendon reaches the
humeral head, it fuses with tendon of Teres major.

• INNERVATION: Subscapularis is supplied by the upper and lower branches of

the Subscapular nerve, which arises from the posterior cord of Brachial
plexus.

• VASCULAR SUPPLY AND LYMPHATIC DRAINAGE: Subscapularis is

supplied by branches of the Subclavian artery, namely the The Axillary artery
(continuation of Subclavian artery) and The Subscapular artery (continuation
of the Axillary artery).

• ACTION: Subscapularis, is the only medial/internal rotator in the Rotator cuff

musculature out of the four muscles. It also assists Latissimus dorsi and
Posterior Deltoid in extension of the Shoulder joint.

The Subscapularis, due to its unique course, will rotate the head of the
humerus towards the midline, into the glenoid fossa. It also adducts the
shoulder upto a lesser extent. These two movements are essential for arm
swing, during gait.

The Subscapularis also enhances co-ordination between different mobility

components of shoulder complex.
As with the rest of thr Rotator cuff muscles the Subscapularis is extremely important
for the stabilization of the glenohumeral joint by:
(a.) Holding the head of humerus against the glenoid fossa.
(b.) Stabillizing Shoulder joint when shoulder joint is active.
(c.) Counteracting forces from to avoid instability.

THE SUBSCAPULARIS

Fig.13. Subscapularis M uscle

Apart from the four rotator cuff muscles, other muscles of upper limb also
functionally assist the rotator cuff in both static and dynamic states, while they
may be loaded or unloaded.
• Biceps brachii and Triceps brachii, are especially important in glenohumeral
joint stabilization. The long head of biceps brachii, keeps the humeral head in
the glenoid fossa while the shoulder is in motion by the virtue of its origin at
 the supraglenoid tuberosity. The long head and short head of biceps brachii
provides the glenohumeral joint stability in flexion and abduction. Biceps
brachii is important for shoulder stabilization in elevation especially if other
muscles are compromised. Triceps brachii, by its long head, in abduction,
steadies the head of humerus in the glenoid fossa and stabilizes it in weight
bearing states.
• The Deltoid muscle, can initiate and execute full abduction range of motion
when the supraspinatus is compromised albeit with less strength.
• Teres major and Latissimus dorsi increase strength of the shoulder muscle in
pulling activities when the shoulder is extended and/or adducted against
resistance.
These muscles, either act in synergy with the rotator cuff or stabilize the
shoulder while the rotator cuff is in action.
BIOMECHANICS OF THE SHOULDER JOINT AND ROTATOR
CUFF MUSCULATURE:
 Introduction:
• The glenohumeral joint, is a diarthroidal ball and socket joint. It allows three
degrees of freedom, namely Flexion-Extension, Adduction-Abduction and
External (lateral) rotation and Internal (medial) rotation.

Fig. 14. Shoulder joint-degrees of freedom.

• Resting/neutral position: Anatomical position.

Fig. 15. Shoulder joint-resting position.

• Loose-packed position: 55° Abduction and 30° Horizontal adduction.

Fig. 16. Glenohumeral joint-Loose packed position.

• Closed-packed position: Abduction and External rotation.

Fig.17. Glenohumeral joint-Closed packed position.

  Kinematics of the Glenohumeral joint:
Consists of the intra-articular and extra-articular motions, namely
Arthrokinematics and Osteokinematics.

(a).Arthrokinematics: These are the movements, taking place between the two
joint surfaces namely the glenoid fossa and the humeral head, in accordance
with the concave-convex rule meaning the convex joint surface (humeral
head) moves in opposite direction to that of the distal segment (humeral shaft).
(b).Osteokinematics: These are the movements, taking place between the distal
end of the joint, namely the distal end of the humerus.

The following arthrokinematic and osteokinematic motions are seen in the shoulder
joint:

S.NO. OSTEOKINE ARTHROKINEMATICS PLANE AXES

-MATICS
1 Flexion Humeral head, glides Saggital Mediolater-
posterolaterally in the glenoid plane. al axis.
fossa.
2 Extension Humeral head, glides Saggital Mediolater-
anteromedially in the glenoid plane. al axis
fossa.
3 Abduction. Humeral head, glides inferiorly Frontal A-P axis.
in the glenoid fossa. plane.
4 Adduction. Humeral Head, glides superiorly Frontal A-P axis.
in the glenoid fossa. plane.
5 Internal Humeral head, glides Transverse Vertical
Rotation. posterolaterally in the glenoid plane. axis.
fossa.
6 External Humeral head, glides Transverse Vertical
Rotation. anteromedially in the glenoid plane. axis.
fossa.

Arthrokinematic movements, as they occur intra-articular fine-tune the range of

motion for the distal segment to move throughout the range.
If due to some pathologies, the arthrokinematic movements get compromised, it
results in the compromise of the osteokinematic movement s well, because the if the
arthrokinematic clearance is not present, the this discrepance translates into the
osteokinematics as well.
One of the best examples of this is the adhseive capsulitis of the shoulder,in that due
to various pathologies the arthrokinematic movements get compromised leading to the
hinderance in the shoulder joint range of motion.
The physiotherapy managment of it is joint mobilization, which also work on the
principle of joint play movements, to increase the overall range of motion in the
shoulder joint.

Fig. 18. Movements at shoulder joint.

Various muscles producing movement at the glenohumeral joint are:

1. Flexion: Pectoralis major, Deltoid (anterior fibres), assisted by
Coracobrachialis and Biceps brachii.

2. Extension: Deltoid (posterior fibres), Latissimus dorsi assisted by Teres major,

Long head of Triceps brachii, Pectoralis Major(Sternocostal Part).

3. Abduction: Supraspinatus- 0°-15°, Deltoid (middle fibres)-15°-90°, Serratus

anterior and Trapezius-90°-180°.

4. Adduction: Pectoralis major, Latissimus dorsi, Subscapularis, Long head of

Biceps brachii, Short head of Triceps brachii, assisted by Teres major and
Coracobrachialis.

5. Internal Rotation: Anterior fibres of deltoid, Teres major, Subscapularis,

Pectoralis major and the Latissimus dorsi.

6. External Rotation: Posterior fibres of the Deltoid, Infraspinatus and Teres

minor.
 Stability of the shoulder joint:
This may be divided in to two parts for the ease of understanding, which are:
(1.) Static Stability
(2.) Dynamic Stability

 Static Stability: The shoulder has the greatest range of motion of any joint in
the human body and has three degrees of freedom of motion (anterior-
posterior/superior-inferior/medial-lateral translation and
flexion-extension/external-internal rotation/abduction-adduction). Due to this
large range of motion, however, it is predisposed to instability. Static stability
is mostly provided by bony, capsulolabral, and ligamentous components
Static stablity may be divided into two instances, namely static stability in
unloaded arm and static stability in loaded arm.

Static stability in unloaded arm: For this, mere bony structure is insufficient
albeit it has a role in joint stabilization. The glenoid fossa, has a slight upward
tilt. Apart from this the following factors are responsible for static stabilization
of the glenohumeral joint, which are as follows:
(a.) Passive tension of the glenohumeral joint capsule.
(b.) Intra-articular negative pressure produced by the joint capsule.
(c.) Capsular attachments of the glenohumeral joint ligaments (suprior
glenohumeral ligament) and coracohumeral ligament.
(d.) To counteract the caudal translation force on the humerus a strong
crainially directed force is required to prevent inferior instability which is
provided by the passive tension in the deltoid, supraspinatus, and the long
heads of the biceps brachii and triceps brachii muscles.

Fig. 19. Static stabilization of the unloaded arm.

 Static stability in loaded arm: For loaded arm all above mechanismss are
rendered inadequate, and in their place the Supraspinatus muscle, an integral
component of Rotator cuff musculature steps up for stabilization, by the virtue
of its superior attachment.

Fig. 19. Static stabilization of loaded arm by Supraspinatus muscle

When the upper limb is not loaded, the only stabilization factors needed are
the ones that are passive in their contribution as the arm is stationary and does
not need any muscular support. This function may simply be done by the static
elements present in the joint, which are the participating bones and soft tissue
structures.

 Dynamic Stability: Provided primarily by the muscular components., namely

the deltoid, the rotator cuff and the biceps brachii.
1. Dynamic stabilization provided by Deltoid muscle: The deltoid muscle,
by the virtue of it location superior to the glenohumeral joint, superiorly
helps in stabilizing the glenohumeral joint. The majority of its contaction
force, causes the superior translation of the humeral head.
Apart from this, the deltoid produces two components of force, one
parallel and the other perpendicular. The parallel component produces a
shear force that holds the humeral head superiorly, and the perpendicular
component assists in abduction of the glenohumeral joint.
With all this being said, the deltoid functions weaker in absence of a
synergistically acting force, and the large superiorly present force will
cause the humeral head to impact upon the coracoacromial arch. The
following is the force distribution of the deltoid muscle:
 Fig. 20. Dynamic stabilization by the Detoid muscle by binary force component.

2. Dynamic stabilization provided by Rotator cuff muscles: The rotator cuff

muscles, for glenohumeral joint stabilization, divide into two components,
which are the Infraspinatus, Teres minor and Subscapularis that function
together and the Supraspinatus muscle acting in isolation.
The infraspinatus, teres minor and subscapularis have a similar line of pull
and in collaboration with each other and produce two components: a
rotatory component and translatory component. The rotatory component,
while rotating the humerus also compresses the humeral head into the
glenoid fossa. The translatory component however, produces an inferior
translatory force that counteracts the superior translating force produced
by the deltoid. The forces produced by the deltoid and the three rotator
cuff muscles, form a force couple that stabilizes the shoulder joint and
causes the humeral head to be in optimum amount of rotation
The supraspinatus muscle, also produces two force components, a rotatory
translatory and a translatory compnent. It produces a strong superiorly
translating force, given its attachment site. It is more compressive in
action and can abduct the shoudler independently.
3. Dynamic stabilization provided by the Long head of biceps brachii: By
the virtue of its attachment at supraglenoid tuberosity reinforces, superior
stability by tightening the superior structures namely superior labrum and
superior glenohumeral ligament.
Its action may also be influenced by the changes in position of shoulder
and elbow.
Fig. 21. Line of action of the rotator cuff muscles (infraspinatus, teres minor and subscapularis)

Fig. 22. Line of action of the supraspinatus muscle.

 The shoulder joint is the most mobile joint of the body, upto the extent
that it needs various stanilizing mechanisms. This stabilization also comes
at a cost, which is the excessive wear and tear. Some of which include the
following:
• Rotator Cuff Tendinopathies and/or tears.
• Supraspinatus impingement under coracoacromial arch.
• Acromioclavicular joint degenerative changes.
• Bicipital tendonitis.
• Recurrent shoulder instability.
For the full range function of glenohumeral joint, the integrated function of the
shoulder complex, meaning all joints of the shoulder complex should work in
complete harmony so that smooth function is achieved.
ROTATOR CUFF LESIONS AND THEIR MANAGEMENT:

● INTRODUCTION:
The rotator cuff is formed by the flattened tendons of the four muscles, namely
Supraspinatus, Infrspinatus, Teres minor and Subscapularis. These muscles,
near their insertion get flat and broad and attach onto the glenohumeral joint
capsule. The tendons are approximately, 4-5 centimeters long, and encapsulate
the humeral head.
First ever case of rotator cuff disease was described by Smith in 1834 and ever
since that various anatomists and clinicians, like Charles Neer for
impingement and Codman for rotator cuff weakness. Rotator cuff lesions are
variable in their severity, ranging from mere inflammation and edema in the
tendons to irrepairable ruptures.
Like severity, the causes for rotator cuff injuries can vary a lot. Rotator cuff
lesions are one of the leading causes of shoulder pain and disability, causing
significant pain and dysfunction.
With increasing age, the prevalance of rotator cuff injuries has also risen.
Although, it can be argued that the prevalance is just a part of normal
senescence process and may be avoidable if proper measures are taken.
However rotator cuff injuires have also risen in younger population as a result
of trauma.
Majority patients can be asymtomatic or have mild symptoms that may be
managed by a wide array of therapeutic modalites. Treatment can be
nonoperative or operative depending on the chronicity of symptoms, severity
of the tear, degree of muscle fatty atrophy, patient age and patient activity
demands.
Rotator cuff syndrome can affect a person’s quality of life. If left untreated,
shoulder problems and pain can lead to significant disability, limitations in
activity and restrict participation in major life areas such as work and
employment, education, community, social and civic life.
In the workplace, the rotator cuff poses significant challenges for clinicians
and employers, like clinical classification/diagnosis, determination of
contribution of physical and psychological working conditions to the
development of rotator cuff syndrome and the design of appropriate treatment
and prevention program. During recovery from rotator cuff syndrome there
will typically be a limited period of time where some activities and
participation in home, work and community are restricted.
Rotator cuff pathologies, may be callled as rotator cuff syndrome. The Rotator
cuff syndrome includes a wide variety of lesions, likeshoulder impingement
syndrome (SIS), subacromial impingement syndrome (SAIS), subacromial
bursitis, rotator cuff tendonitis and rotator cuff tears (partial or full-thickness)
etc.
Rotator cuff lesions have also been seen as a leading cause of shoulder
problems in athletes and sportspersons worldwide, being second only to ACL
injuries in the list of injuries/conditions leading to deconditioning and athletes
quitting their respective sports. These have been seen in boxing, basketball,
badminton, shortput, volleyball etc. Players.
Post-op rotator cuff complications also pose a number of problems for the
patients, as without proper management they lead to significant disability,
especially in athletes as the duration of them being unabalr to practice/train
increases. This causes general body deconditioning, loss of form and skills and
loss of confidence
In the non-athlete population rotator cuff lesions are huge source of problems
especially in the senile population as they undergo rotator cuff tears very fast
and a lott of the times, they cause sever pain and dysfunction.

The following discussion entails, in detail regarding various lesions of rotator

cuff lesions, their etiology, pathophysiology, clinical features and
management.
DEFINITIONS/TERMINOLOGIES IN RELATION TO ROTATOR
CUFF LESIONS:

The spectrum of rotator cuff lesions, includes the following:

● Rotator cuff Tendinopathy: Disease/degenerative changes in the tendon(s) of

the rotator cuff as a result of acute injuries/chronic overuse/age related
intrinsic rotator cuff degenration.

● Shoulder Impingement Syndrome: This is the compression and/or mechanical

abrasion of the rotator cuff tendon(s), predominantly seen woth the
supraspinatus tendon. Impingement causes mechanical irritation of the rotator
cuff tendons. This mechanical compression may also include the irritaation of
the bursae, known as Bursitis. Subacromial bursitis is most commonly seen.
The impingement may be externam or internal.

▪ External Impingement: A term used synonymously with SIS. External

impingement (EI) encompasses etiologies of external compressive
sources (i.e., the acromion), leading to subacromial bursitis and bursal-
sided injuries to the RC.

▪ Internal impingement: Common in overhead-throwing athletes such as

baseball pitchers and javelin throwers. Impingement occurs at the
posterior/lateral articular side of the cuff as it abuts the
posterior/superior glenoid rim and labrum when the shoulder is in
maximum abduction and external rotation (i.e., the "late cocking"
phase of throwing) The term "thrower's shoulder" refers to a common
set of anatomic adaptive changes that occur over time in this subset of
athletes.These adaptive changes include but are not limited to
increased humeral retroversion and posterior capsular tightness.
Glenohumeral internal rotation deficit (GIRD) is a condition resulting
from these anatomic adaptations, and GIRD is known to predispose the
thrower's shoulder to internal impingement.

● Painful arc Syndrome: Pain in shoulder and upper arm region amidst of
glenohumeral abduction range, which decreases at extremes of the range, Seen
mostly due to supraspinatus tendon damage.

● Rotator Cuff Tears: An injury to the tendon(s) of rotator cuff musculature, as a

result of trauma (trivial or severe) leading to disrruption of the continuity of
the tendon(s) leading to a rupture/tear in the substance of the tendon.
● Rotator Cuff Syndrome: A term used to describe disease process where
tendinopathy and impingement are ongoing simultaneously.

● Calcific Rotator Cuff Tendonitis: Rotator cuff calcific tendinitis is a very

common condition caused by the presence of calcific deposits in the rotator
cuff or in the subacromial-subdeltoid bursa when calcification spreads around
the tendons.

Injury to the rotator cuff may arise from a single traumatic event (e.g. fall or
direct impact trauma), an acute overload incident or develop gradually from
degenerative processes.
In degenerative rotator cuff syndrome, it is possible for the underlying
processes to be occurring over time with limited or no symptoms, but an
incident (such as a posture which uses the end of range motion of the shoulder
or sudden increase in load upon the tendon) can precipitate pain from the
degenerative tendon. This event may also include an episode of sustaining
trivial trauma leading to damage in an already degenerated tendon.
NATURAL HISTORY AND PREVALANCE OF ROTATOR CUFF
LESIONS:

● Studies have shown a relationship between age and rotator cuff injury
prevalance. In rotator cuff lesions seen in younger age are mostly traumatic,
whereas in older males, age>65 the rotator cuff lesions seen are mostly
degenrative. There is also a predisposition seen in menopausal women,
age>55. Rotator cuff weakness is also seen in pregnant women.

● Rotator cuff lesions were also seen in subjects who were frequently indulging
in cigarette smoking and other forms of tobacco consumption, alcohol
consumption and drug abuse. Other causes seen were fibrofatty infiltration and
weakness seen in the tendons, as a result of deconditioning.

● People who had undergone operative proceduresof either rotator cuff or other
procedures which needed access through the shoulder and did not follow the
post-op care recommendations also showed greater frequency of rotator cuff
weakness.

● Population with repetitive overhead motions and frequent overhead lifiting

were also seen to have an inclination towards having a possible rotator cuff
injury. This group of population included:
(a). Service providers such as- carpenters, painters, servers, masons, factory
workers etc.
(b). Athletes participating in sports such as Striking sports ( badminton,
tennis,squash, batting in cricket and baseball volley ball etc), Combat sports
( boxing, muay-thai, mixed martial arts, judo, karate etc.) andThrowing sports
( bowling in cricket, pitching in baseball, goal-keeping in football, rugby, shot
put javelin throw etc.). All these sports cause the shoulder to undergo a huge
amount of stress in a position that causes trauma and degeneration to the
structures of the shoulder joint.

● Comorbidities of rotator cuff tears are hormone-related gynecologic diseases,

autoimmune pathologies, rheumatoid arthritis and type 1 diabetes mellitus.
● A lot of major rotator cuff lesions, i.e. Rotator cuff tears, were seen to be
asymptomatic in majority of studies over 60-65 years of age. Ths could be due
to the decrease in the tendon matrix with age, as a result of degeneration
causing intracellular processes.
● Major rotator cuff lesions were also seen in indivisuals who did not undergo
primary management of minor rotator cuff injuries.
● There has also been seen a familal history factor, but that has been limited to
indivisuals of a family adapting a similar profession.
Fig. 23. Professions involving repeated overhead motion
Fig. 24. Sports involving high intensity trauma to shoulder.
 ETIOLOGY OF ROTATOR CUFF LESION AND ITS
CLASSIFICATION:

● CLASSIFICATION OF ROTATOR CUFF INJURIES:

1. On the basis of etiology: Rotator cuff lesions are classified into two groups:
(a). Atraumatic: Lesions sustained by already diseased and degenrated, weak
soft tissues of the shoulder causing damage.
(b). Traumatic: Lesions sustained by the soft tissue structures of shoulder as a
result of severe, acute trauma to the shoulder. This may also be seen when the
shoulder sustains regular microtrauma in sports and/or activites of daily life.

2. Conventional Classification of Rotator Cuff Muscle Strain:

(a). Grade 1 strains: Injuries in the rotator cuff occur when the fibers of the
muscles or tendons are stretched beyond their capacity.
(b). Grade 2 strains: Injuries in the rotator cuff occur when the fibers of the
muscles or tendons are strained too far and partially tear.
(c). Grade 3 strains: Injuries in the rotator cuff occur when the fibers of the
muscles or tendons completely tear.

3. Collin's Classification of Rotator Cuff Tears:

(a). Type A: supraspinatus & superior subscapularis tears.
(b). Type B: supraspinatus and entire subscapularis tears.
(c). Type C: supraspinatus, superior subscapularis & infraspinatus tears.
(d). Type D: supraspinatus & infraspinatus tears.
(e). Type E: supraspinatus, infraspinatus & teres minor tear.

Fig. 25. Collin's classification of rotator cuff tears.

4. Neer's Classification of Rotator Cuff Disease:
Stage I: Edema, hemorrhage (patient usually <25 yearsof age).
Stage II: Tendinitis/bursitis and fibrosis (patient usually 25 to 40 years of age).
Stage III. Bone spurs and tendon rupture (patient usually> 40 years of age)

Fig. 25. Neer's classification of Rotator Cuff Disease.

5. Jobe's Classification of Impinement in Athletes:

(a). Group-1: Pure impingement with no instability.
(b). Group-2: Primary instability with capsular and labral injury with
secondary impingement which can be internal impingement or subacromial.
(c). Group-3: Primary instability because of generalised ligamentous laxity
with secondary impingement.
(d). Group-4: Pure instability and no impingement.
● ETIOLOGY OF ROTATOR CUFF INJURIES:

On the basis of vivo and cadeveric studies, following etiological factors are
seen:
(A). Traumatic Rotator Cuff Lesions: These include the following causative
factors:
1) Falls: A lot of rotator cuff lesions are seen post fall on outstretched hand. Such
a fall, transmits high intensity traumatic forces onto the rotator cuff
musculature, causing direct trauma to it and starting the inflammatory cascade.
Such falls are seen in- road traffic accidents, minor factory accidents, sports
related falls.

2) Sudden pushing/pulling forces during activities: Sudden exposure of high

velocity tensile/compressive forces on the rotator cuff musculature like during
sports in catching/throwing, sudden overhead activity as in factory work,
lifting or pulling an object that is too heavy like pulling bowstring of a bow
that's too tight or lifting too much weight during deadlifts/owerlifting or heavy
poundage.

3) Chronic and repetitive microtrauma: Such overuse injuries are seen after
sustaining repeated forces, in a position that is not to favourable for therottor
cuff muscles as it causes them to be vulnerable and in a condtion where they
have to bear a lot of damaging forces. Such injuries are seen in people who
workin masonry, painting, carpentry etc.

4) Trivial trauma sustained by an already weak and damaged muscle: In this

causative factor, we have an already damaged and weak muscle and/or its
tendons that undergo a minimal/trivial amount of trauma that otherwise would
not have damaged a healthy muscle/tendon but because the soft tissue in
question is already weakened it cannot sustain the minimal trauma and gets
injured. This is commonly seen in patients with age>45 years, as after that age
tendon matrix starts getting deficient in collagen.

5) Post-traumatic states: This is most frequently seen post shoulder joint

dislocation or in fractures of the shoulder girdle, as it can result in either
rotator cuff weakness or a tear in rotator cuff tendons that can be of full
thickness or partial thickness.

6) Iatrogenic Trauma: Trauma sustained by the shoulder during medical

procedures for example: posterolateral thoracotomy, mastectomy/radical
mastectomy, intra-articular injections, hydrodilatation of shoulder joint for
adhesive capsulitis.
Fig. 26. Various mechanisms of Rotator cuff injuries.
 (B).Atraumatic Rotator Cuff Lesions: These include the following causative
factors:
1) Degenerative Conditions: These are either caused due to age related changes
i.e. Loss of collagen from tendon matrix that worsen as a result of activities of
daily life that cause repetitve trauma onto the rotator cuff muscles. Examples
include people employed for a long time in construction work, heavy
machinery and electricals, homemakers in their activities of daily life,
painters, carpeters, older athletes etc.

2) Impingement Syndrome: The mechanical compression and abrasion of the

supraspinatus tendon, under the coracoacromial arch while elevation of the
arm. This causes growth of bony spurs on the under-surface of acromion
causing further mechanical damage to the supraspinatus tendon. This may or
may not include the subacromial bursa. Impingement could be of degenerative
origin (bony spurs due to osteoartitic changes), post-traumatic origin or
developmental origin (changes in the shape of acromion).

3) Developmental Causes: This includes the diffrent variations seen in the

sturucture of acromion. These include:
• Variation in different shapes of Acromion:

Fig. 27. Variations of acromial structure.

Out of all these on radiological studies, it was revealed that types- 2, 3, and 4 were
seen toh have the most instances of subcromial impingement as their structure
reduced the subacromial space.
• Os Acromiale:
This is a variation in the structure of acromion wherein there is an unfused accessory
center of ossification of the acromion of the scapula. These are relatively common and
asymptomatic.
Although they have been seen to increase the risk of subacromial impingement as the
unfused segment tends to tilt forward causnig subacromial impingement.
 Fig. 28. Types of Os acromiale.

4) Inflammatory Conditions: These include calcific tendinitis of the rotator cuff,

rheumatoid arthrits of the shoulder, crystal induced arthropathy of gout or
pseudo-gout.

Fig. 29. Calcific tendinitis of the rotator cuff.

Fig. 30. Rheumatoid arthitis of glenohumeral joint.

Fig. 31. Crystal arthropathy of the shoulder.

5) Iatrogenic damage to shoulder musculature during prodecures, like
posterolateral thoracotomy, mastectomy/radical mastectomy, intra-articular
injections, maipulations etc.
6) Chronic shoulder instability, as seen in recurrent shoulder dislocation post trau
or post neurological disordersike stroke or spinal cord injury.
MECHANISM OF LESIONS OF ROTATOR CUFF LESIONS:

The spectrum of rotator cuff injuries is a wide one. It includes lesions like:
● Rotator cuff tendinitis.
● Shoulder impingement syndrome.
● Rotator cuff tears.

● Rotator Cuff Tendinitis: This includes, the inflammation of the rotator cuff
tendon post acute trauma sustained by the soft tissues of shoulder.
Post sustaining the trauma, there is tearing of muscle fibres, followed by
rupture of micro blood vessels and bleeding.

Bleeding is folllowed by inflammatory cascade in the injured tissues.

Manifestaton of Clinical features of Rotator cuff sprain.

Healing by fibrosis

• This type of lesion is usually, mild to moderate in severity and usually resolves
without much complications. Most commonly seen after acute sports injuries
and/or sudden jerky movements performed.

• Acute rotator cuff tendinitis, produces the classic symptoms of shoulder pain,
probable local erythema and warmth accompanied by palpable swelling, pain
movement of shoulder due to the ongoing inflammatory processes.

• As this lesion, at the maximum is of moderate severity, it will notcause

debilitating consequences to the shoulder, however if this type of lesion is
sustained regularly by the tissues, it may transition into Chroni rotator cuff
tendinopathy.

• Histopathologically, it shows disrruption of tendon matrix, blood clots from

the micro blood vessel rupture, leucocyte and throbocyte infiltration with
inflammation and edema.
• When such trauma is repeatedly sustained by the rotator cuff muscles, the
condition may progress to Chronic rotator cuff tendinopathy.

• Chronic rotator cuff tendinopathy, is a result of recurrent rotator cuff tendon

injuries, causing acute on chronic tendinitis with icreasing levels of tendinosis.

• Its histopathology shows: apoptotic tenocytes, disrruption of tendon matrix,

hypovascularity, decreased collagen quantity and presence of degenerative
changes in the substance of the tendon.

• If the injury is recurrent and has transgressed to chronic, there also can be
calcium deposition in tendons causing calcific tendinitis of the rotator cuff
tendons as a result of prolonged inflammatory process undergoing in the
tendon substance.

Fig. 32. Rotator cuff tendinitis.

• The following are some illustrations detaling rotator cuff tendinitis:

 Fig. 33. Acute rotator cuff tendinitis.

Fig. 34. Chronic rotator cuff tendinopathy.

 Fig. 35. Calcific rotator cuff tendinits.

● Shoulder Impingement Syndrome: Impingement causes mechanical irritation

of the rotator cuff tendon(s), usually beneath a joint structure. This causes
hemmorhage and inflammation with edema in the tendons.

• Supraspinatus is the most commonly involved muscle, due to its sperior site of
attachment, that comes directly under the coracoacromial arch. This may also
include a bursa, which is most frequently the subacromial bursa, causing
subacromial bursitits.

• Shoulder complex is greatly affected by impingement syndrome from

excessive overhead activities. It is huge debilitating factor in athletes and
persons with frequent overhead activities. Impingement with Rotator cuff
tendinitis, is on of the most common overuse conditions seen in athletes

• For the pathophysiology of Shoulder impingement synrdrome, two widely

known mechanisms are studies, which are:

(a.) Extrinsic Mechanism: Repeated impingement of rotator cuff tendons

against different structures of glenohumeral joint, leading to shoulder
pathologies and temporary disability.

In this, three impingement syndromes have been identified:

 1. Anterosuperior impingement: Impingement bet*ween, supraspinatus tendon
and the coracoacromial arch, where the acromion is of curved/hooked type.
This causes the subacromial space to decrease drastically on forward flexion
of the shoulder, accompanied by internal rotataion, which, causes the
reproduction of symptoms.

2. Posterosuperior Impingement: Impingement between, articular side of

supraspinatus tendon and posterosuperior edge of the glenoid margin.
In this the subacromial space, decreases when the shoulder is abducted to
120°, with external rotation and retropulsion. This causes the glenoid labrum
to move away from the glenoid rim which then impinges with the suprasinatus
tendon, causing repeated microtrauma and the partial rupture of the
supraspinatus tendon.

3. Antero-internal Impingement: Impingement of the rotator cuff tendons

within the coracohumeral space. The coracohumeral space is smallest, when
the shoulder is in forward flexion, accompanied by internal rotation causes the
reproduction of symptoms.

(b). Intrinsic Mechanism: This mainly focuses on the progressive age related
wear and tear seen in rotator cuff tendons.
Codman described a hypovascularized area, on the articular side of the
tendons. However, this zone was position dependentcand was shown to have
a little filling in glenohumeral abduction.
Apart from this, other intrinsic factors seen are: overuse/repetitve trauma, joint
instability, muscular imbalance and labral injuriees.

● Rotator Cuff Tears: Rotator cuff tears can be caused, either due to repetitive
trauma to an already weakened tendon or due to an acute high velocity trauma
to a healthy tendon.
Following is the pathogenesis for rotator cuff tears:

Repetitve trauma sustained by the tendons of rotator cuff.

Leading to tear of Rotator Cuff.

 Torn rotator cuff, is unable to provide a downwards directing force, causing
uninhibited superior translation of the humeral head.

Causing abutment of the humeral head against the acromion, which if left unchecked
causes deformity of the acromion known as Acetabulization,

With superior translation, the humeral head also starts moving medially toward the
glenoid fossa, thereby decreasing the joint space and commencing arthritic processes.

Due to already torn tendons, and excessive superior translation of the humeral head
causing constant trauma to it, the humeral head starts collapsing

The above pathogenetic frocess, is known as the Hamada and Fukuda stages of
Rotator cuff arthopathy.

Fig. 36. Hamada and Fukuda stages of Rotator cuff tear induced arthropathy.
Fig. 37. Classification of Partial thickness rotator cuff tear, according to tendon surface.

Fig. 38. Classification of Full thickness rotator cuff tears, according to morphology
 DIAGNOSIS OF ROTATOR CUFF LESIONS:

The diagnosis of rotator cuff lesions can be done under the following sub-headings:

● Clinical features.
● Physical examination.
● Investigations.
● Differential diagnosis.

● Clinical features:
1. Shoulder pain, with positive history of a traumatic event/repetitive overuse
injury.
◦ Localized to anterior / lateral aspect of the shoulder, with referred pain
down the upper arm (lateral aspect).
◦ Painful shoulder range of motion, Painful arc of movement in abduction
(degrees vary - generally between 60° to 120° ), Pain in overhead reaching
out activities. Painful external rotation / internal rotation / Abduction.

Fig. 39. Painful arc syndrome.

 ◦ Associated symptoms such as crepitus/clicking/clunking/grinding
sensation.

◦ All these symptoms worsen at night.

2. Muscle weakness in the shoulder joint (particularly in abduction in mid-range,

external rotation and overhead activities.)
3. Palpable swelling in the shoulder area, with all characteristic features such as
erythema, tenderness/pain on palpation and warmth on touching (warmth only
seen in acute traumatic tear)

4. Patient complaints of shoulder instability.

5. Patient cannot lie on the affected site while sleeping/lying down.

6. Patient feels numb or tingles in the affected arm.

7. Patient, tries to keep the affected arm inactive and supported.

8. Patient reports of sleep disturbances especially at nigght due to shoulder pain.

9. Patient usually belongs to the population, susceptible for rotator cuff injuries.

10. Often times, patient reports that the affected upper limb is their dominant one.

11. Functional impairments (difficulty lifting, pushing, overhead movements and

movements with hand behind the back ). These signs result mainly from a loss
of the superior stability of the glenohumeral joint because of dysfunction of
the rotator cuff muscles.

➔ Physical examination:
 Demographic data (name, age, gender, occupation).
 History:
➔ Past medical history:
Co-morbidities (diabetes / hypertension / smoking)
Prior shoulder pain / cervical pain.
Any past trauma sustained on the shoulder, especially on the affected side,
 as to have an inkling regarding the patient's complaints.
➔ Present Medical History:
Onset of symptoms, acute or gradual. Helps in understanding mode of
injury, whether it was traumatic or degenertive.
Mechanism of injury, whether it was a fall/sports/recurreent ADL tat
caused the condition.
Pain history:
Site- Anterolateral Shoulder.
Onset- Acute (indicating injury) / Gradual (indicating degeneration) .
Character- Dull (chronic degeneration) / Sharp, Throbbing (acute)
Radiation of pain- Upto lateral arm (Deltoid insertion)
Associated symptoms- Numbness, Tingling sensation in the arm.
Time/Duration of pain- Pain more at night.
Exacerbating factors- Overhead activities in ADL's, Sports etc.
Relieving factors- Rest, pain medcation.
Severity- Taken on NPRS (Numerical Pain Rating System.), out of 10.

➔ Chief Complaints: As described by the patient.

 Inspection: This is the process of visual inspection of the exposed, affected

part of the patient. This includes the following:
➔ Postural evaluation: Studies have shown that with rotator cuff injuries,
protruded shouders are seen frequently.
➔ Limb attitude: Affected side shoulder is dropped. Patient supports the affected
arm, with the other arm.

➔ Presence of: Swelling, Asymmetry, Scars, Skin discolouration etc. For

recognition of any signs of injury, seen in rotator cuff tear with shoulder
dislocation.

➔ Presence of: Any deformity in proximity to the shoulder (examples- scapular

winging, step deformity of shoulder, flat shoulder), or any muscle atrophy
(atrophy of deltoid post axillary nerve injury). These are usually not seen in
rotator cuff injuries.
 Palpation: Deep palpation of the humeral head at attachments of the rotator
cuff, reveals tenderness / pain.
➔ If the injury is acute, there may be temperature changes of the skin, i.e. The
surface if the skin above the affected area would be warmer than unaffected
area.
➔ On palpation, swelling will be appreciated which may be of the following:
-Bloody, tense,warm- In acute rotator cuff tear
-Acute swellling seen soon post inury- In acute rotator cuff tendinitis..
➔ -On palpation, crepitus may be felt, which is indicative of calcified rotator
cuff tear / arthritic changes in shoulder complex / fracture in shoulder
complex.

 Examination: This includes the following sub-headings:

➔ Range of motion: Bilateral evaluation for active and passive range of motion,
will be examined for any range limitation by pain / weakness / tighness /
mechanical obstruction.
Painful active range of abduction and extenal rotation indicates rotator cuff
tendinitis.
Presence of a painful arc in the entireity of the abduction range, indicates
shoulder impingement syndrome.
If the patient is unable to initiate / control / hold movements it maybe an
indicator of the patient having a rotator cuff tear.
 Muscle power testing shows: If patient is able to initiate and hold
movements, the muscle power may be checked. This is done on the MMT-
MRC scale.
Examination reveals, rotator cuff muscle weakness.

 Resisted Isometric Contractions: Painful.

 Special Tests: The following special tests are perfomed for confirmation of
Rotator cuff lesions and their exact type.
1. Drop arm test: To identify tear and/or full rupture of rotator cuff.
Patient position: Sitting, with shoulder passively abducted to 120°. Patient is
then instructed to lower their arm slowly as to bring the arm to their side.
If the patient is unable to do so, test is positive for full/partial rotator cuff
rupture.

2. Empty can test: To identify tear and/or impingement of supraspinatus tendon

or a possible suprscapular nerve neuropathy.
Patient position: Sitting, with shoulder in 90° elevation in scapular plane with
shoulder fully internally rotated with the thumbs facing down. Then the patient
is asked to patient resists downward pressure exerted by the examiner at the
patients elbow.
If patient feels any pain and/or weakness, the test is considered positive for
supraspinatus impingement or weakness.
The above procedure may also be done with the thumbs facing upward and the
test would yield the same results albeit with less specificity.
3. Resisted external rotation: For Infraspinatus and Teres minor tendon integrity
and to identify suprascapular nerve neuropathy.
Patient position: Patient is seated and is asked to flex their elbows upto 90°
and then is asked to externally rotate both their shoulders against resistance for
bilateral comparison.

If patient is unable to do they may have infraspinatus/teres minor weakness or

tendinitis.

4. Horn blower's Test: To test for teres minor and infraspinatus pathology.
Patient position: Sitting, with the shoulder in 90° abduction and 90° external
rotation and is asked to hold this position.
If the patient is unable to hold the position, they may have infraspinatus/teres
minor pathology.
5. Lift off test: To identify tear/weakness of subscapularis muscle and scapular
instability.
Patient position: Sitting, with the patients's dorsum of the hand against the
mid-lumbar spine, by internally rotating the shoulder. Patient is then asked to
lift the hand off from their back, against so indicate resistance provided by
examiner.
Inability to do so, indicates subscapularis rupture or scapular dysfunction.

6. Belly press test: To identify tear/weakness of subscapularis muscle, if patient

cannot internally rotate their shoulder behind their back.
Patient position: Sitting, patient is asked to place the palm of their hand on
their belly, and are asked to press it with resistance provided by the examiner.
If patient is unable to perform the test it also indicates subscapularis
weakness.
7. Neer's sign: To identify impingement of supraspinatus.
Patient position: Sitting, the examiner stabilizes the patient's scapula with one
hand, while passively flexing the arm while it is internally rotated.
If the patient reports pain in this position, then the result of the test is
considered to be positive.
8. Hawkins-Kennedy Test: To identify rotator cuff impingement.
Patient position: Sitting, with shoulder and elbow flexed upto 90° . The
examiner then stabilizes the proximal elbow with one hand and with the other,
grasps patient's proximal wrist and moves the shoulder gently into internal
rotation.
If patient feels pain in subacromial region test is positive for rotator cuff
impingement.

9. Posterior Internal Impingement Test: To identify impingement between rotator

cuff and greater tuberosity of humerus or posterior glenoid and labrum.
Patient position: Supine, with shoulder in 90° abduction, maximum external
rotation and 20° horizontal adduction. If patient feels pain in posterior
shoulder, the test is positive for posterior internal impingement.
 Investigations:
A) Laborartory Investigations: These include the following investigations.
• Complete blood count ( Hb analysis, TLC, DLC, BT, CT) for major pso-
traumatic cases.
• Complete lipid profile for connfirmatio of hypelipidemia.
• Complete urine profile for uric acid levels.
• Blood glucose profile ( Random/Fasting blood sugar, Hba1C analysis)
• RA factor for rheumatoid arthritis.
• HLA-B27 for ankylosing spondilytis.
• C- reactive protien and ESR for confirming infflammatory process.

B) Radiological Investigations:
• X-Rays: The following views are essential for rotator cuff lesion visualization:
1. AP view for visualization of normal Acromiohumeral Interval (normal-7
mms and less than indicates poor recovery.
2. Y-Lateral for clinical visualization of the acromion.
3. AP view in Abduction for clear visualizaton of rotator cuff dysfunction.
X-ray evaluation shows-sclerosis and collapse of humeral head, sclerosis of
the acromion and the coracoid, clear visualization of calcified rotator cuff
tendinitis and acromial bony spurs.
Various X-ray findings are as follows:
• Ultrasonography: This one of the best and cheapest visualization modality. It
also allows dynamic examination, is non-invasive and can be done quickly as
opposed to other modalities.

Findings show discontinuity of the soft tissues and focal abnormal

echogenicity.
• Maagnetic Resonanace Imaging (MRI): This is the clearest imaging modalties
by far. It shows the clearest demarcations of lesions of the rotator cuff.
It vividly demonstrates fibrofatty changes in the tissue matrix and is a reliable
indicator the health of rotator cuff. It also shows clear location and
morphology of the tear with being non-invasive. But MRI, is an expensive
modality and not everyone can afford it.
T1 images show- Loss of subacromial fat plane, Subacromial bone spur
formation, Discontinuation of the tendon and tear morphology.
T2 images show- Presence of fluid in subacromial space.
● Differential Diagnoses:

1. Adhesive capsulitis / frozen shoulder.

2. Bicipital tendinitis.
3. Cervical disc lesions causing radiculopathy.
4. Arthritis of glenohumeral joint and /or acromioclavicular joint.
5. Rheumatoid arthritis/Gout or pseudogout.
6. Thoracic outlet syndrome.
7. Fractures of shoulder girdle.
 MANAGEMENT OF ROTATOR CUFF LESIONS:

The management of rotator cuff lesions depends upon the following factors:

● Severity of lesion.
● Age of the patient.
● Requirements of the patient
● Level of activity.

On the above factors, the route of management may be decide which could be either