See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/340779302

Anatomy, Rotator Cuff

Article · March 2020

CITATIONS READS
8 3,657

3 authors, including:

Antonio Madrazo-Ibarra Matthew Varacallo

Hospital for Special Surgery Penn Highlands Healthcare System
15 PUBLICATIONS 39 CITATIONS 231 PUBLICATIONS 2,642 CITATIONS

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Antonio Madrazo-Ibarra on 20 April 2020.

The user has requested enhancement of the downloaded file.

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.

Anatomy, Rotator Cuff

Authors

Smita Maruvada; Antonio Madrazo-Ibarra1; Matthew Varacallo2.

Affiliations
1 Universidad Panamericana
2 Department of Orthopaedic Surgery, University of Kentucky School of Medicine

Last Update: March 29, 2020.

Introduction
The rotator cuff is a group of muscles in the shoulder that allow a wide range of movement while maintaining the
stability of the glenohumeral joint. The rotator cuff includes the following muscles[1][2][3]:

Subscapularis

Infraspinatus

Supraspinatus

Teres minor

A helpful mnemonic to remember these muscles is "SITS."

The glenohumeral joint is a ball and socket joint and comprises a large spherical humeral head and a small glenoid
cavity. This anatomy makes the joint highly mobile, however, really unstable. Stabilization in the shoulder is provided
collectively by the non-contractile tissue of the glenohumeral joint (static stabilizers) such as the capsule, the labrum,
the negative intraarticular pressure and the glenohumeral ligaments; and the contractile tissues (dynamic stabilizers)
such as the rotator cuff and the long head of the biceps brachii.

Structure and Function

The primary biomechanical role of the rotator cuff is to stabilize the glenohumeral joint by compressing the humeral
head against the glenoid. These four muscles arise from the scapula and insert into the humerus. The tendons of the
rotator cuff muscles blend with the joint capsule and form a musculotendinous collar that surrounds the posterior,
superior, and anterior aspects of the joint, leaving the inferior aspect unprotected. This arrangement is an important
factor since most of the shoulder luxations occur because the humerus slides inferiorly through the unprotected part of
the joint. During arm movements, the rotator muscles contract and prevent the sliding of the head of the humerus,
allowing full range of motion and providing stability.

Additionally, rotator cuff muscles help in the mobility of the shoulder joint by facilitating abduction, medial rotation,
and lateral rotation.

Subscapularis: Medial (internal) rotation of the shoulder

Supraspinatus: Abduction of the arm

Necessary for the initial 0 to 15 degrees of shoulder abduction motion

The deltoid muscle abducts the arm beyond 15 degrees

Infraspinatus: Lateral (external) rotation of the shoulder

 Teres Minor: Lateral (external) rotation of the shoulder

During the physical examination, each muscle can undergo independent evaluation based on the specific movement of
each muscle.

Embryology
Mesoderm gives rise to the muscles and ligaments in the body.

Blood Supply and Lymphatics

The vascular supply to the rotator cuff muscles is mainly via the suprascapular artery, the subscapular artery, and the
posterior circumflex humeral artery.

The suprascapular artery is a branch of the thyrocervical trunk (a major branch of the subclavian artery) and
originates at the base of the neck. It enters the posterior scapular region superior to the suprascapular foramen (the
nerve passes through the foramen) and supplies the supraspinatus and infraspinatus muscles.

The subscapular artery is the largest branch of the axillary artery. It originates from the third part of the axillary
artery, follows the inferior margin of the subscapularis muscle, and then divides into the circumflex scapular artery and
the thoracodorsal artery. It gives vascular supply to the subscapularis muscle.

The posterior circumflex humeral artery originates from the third part of the axillary artery in the axilla. It enters the
posterior scapular region through the quadrangular space (accompanied by the axillary nerve) and supplies the teres
minor muscle.

All lymphatics from the upper limb drain into lymph nodes in the axilla.

Nerves
The subscapular nerve (upper and lower branches) innervates the subscapularis muscle.

Originate from the posterior cord of the brachial plexus

C5, C6, C7

The suprascapular nerve innervates the infraspinatus and supraspinatus

Originates from the superior trunk of the brachial plexus

Passes through the suprascapular foramen

C5 and C6

The axillary nerve innervates teres minor

Originates from the posterior cord of the brachial plexus

Passes through the quadrangular space into the posterior scapula region

C5 and C6

Muscles
The subscapularis is the largest component of the posterior wall of the axilla. It prevents the anterior dislocation of the
humerus during abduction and medially rotates the humerus. A large bursa separates the muscle from the neck of the
scapula.[4]

Origin: subscapular fossa of the scapula

 Insertion: lesser tubercle of the humerus

The supraspinatus muscle is the only muscle of the rotator cuff that is not a rotator of the humerus.

Origin: supraspinous fossa of the scapula

Passes above the glenohumeral joint

Insertion: greater tuberosity of the humerus

The infraspinatus is a powerful lateral rotator of the humerus. The tendon of this muscle is sometimes separated from
the capsule of the glenohumeral joint by a bursa.

Origin: infraspinous fossa of the scapula

Insertion: greater tuberosity of the humerus, immediately below the supraspinatus.

The teres minor is a narrow and long muscle entirely covered by the deltoid, hardly differentiated from the
infraspinatus.

Origin: lateral border of the scapula (below the infraglenoid tubercle)

Insertion: greater tuberosity of the humerus, below the infraspinatus tendon.

Clinical Significance
Physical Examination[5]

Rotator cuff muscles can undergo independent evaluation when the patient presents with rotator cuff syndrome
(explained ahead).

Supraspinatus muscle: The evaluation of this muscle is with the Jobe's test or commonly known as the "empty
can" test. It is done with a 90 degrees abduction and internal rotation (thumb pointing to the floor) of the arm
while pressing down on the arm. Positive, if painful or weak.

Infraspinatus muscle: Evaluation of this muscle is via lateral rotation against resistance with the elbow flexed
and the arm in neutral abduction/adduction position. Positive, if painful or weak.

Teres minor muscle: This muscle's evaluation is with the hornblower's test, done with the arm at 90 degrees
abduction, the elbow flexed (90 degrees), and doing a lateral rotation against resistance. Positive, if painful or
weak.

Subscapularis muscle: Evaluating this muscle uses the "lift-off" and the "bear hug" test. In the lift-off test, the
patient brings the hands around the back to the lumbar region with the palms facing outward. The test is positive
if the patient is unable to lift the hands away from the back. On the Bear hug test, the patient places the
ipsilateral pal on the opposite deltoid and tries to resist the examiner pulling it away anteriorly. Positive, if
painful or weak.

Rotator Cuff Syndrome [1][6][7][8]

Rotator cuff syndrome (RCS) describes a spectrum of clinical pathology ranging from minor injuries such as acute
rotator cuff tendinitis to advanced/chronic rotator cuff tendinopathy and degenerative conditions.

Rotator cuff injuries represent a common cause of shoulder pain. The rotator cuff tendons, particularly the
supraspinatus tendon, are uniquely susceptible to the compressive forces of subacromial impingement. Improper
athletic technique, poor posture, poor conditioning, and failure of the subacromial bursa to protect the supporting
tendons results in a progressive injury from acute inflammation, to calcification, to degenerative thinning, and finally
to a tendon tear.

Rotator cuff (RC) tendonitis/tendinosis

Acute or chronic tendinopathic conditions that result from a vulnerable environment for the RC secondary to repetitive
eccentric forces and predisposing anatomical/mechanical risk factors.

Shoulder impingement

A clinical term often used nonspecifically to describe patients experiencing pain/symptoms with overhead activities. It
is best to subdivide shoulder impingement into internal and external conditions:

Internal impingement[9]: 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.

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. [10]

History and Physical for RCS

The primary complaint is shoulder pain localized on the lateral aspect. It worsens with overhead activities, and patients
often describe a painful arc during flexion and abduction at 60 degrees to 120 degrees and report pain at night due to
lying on the same side. The presentation can be acute or chronic in onset. Young patients usually have an acute
presentation because of a recent traumatic event or significant overexertion (e.g., lifting a heavy box). The function is
often significantly impaired. Older patients or patients with repetitive overhead activities present chronically, and the
loss of strength and function occurs gradually. The range of motion is normal, with positive provocative tests like
Hawkins. Neer test rules in impingement syndrome. The drop arm test is confirmatory. If weakness is present on
shoulder abduction, a rotator cuff tear should be suspected (MRI is the best test for diagnosis of rotator cuff tear).

Treatment for RCS [11]

American Academy of Orthopedic Surgeons (AAOS) suggests patients with rotator cuff problems without tears can be
treated conservatively with exercise and NSAIDs. The patient must understand to limit overhead activities and to use
ice packs or heating pads. Proper physical therapy effectively treats most patients without subacromial decompression.
No difference in outcome has been reported for surgery over physical therapy in several trials. Subacromial injection
with steroids showed a short-term benefit in some trials and may improve a patient's compliance with physical therapy.
Surgical consultation merits consideration if symptoms do not improve three months after conservative management.
Arthroscopic acromioplasty may be a topic to discuss with the patient.

Partial- versus Full-Thickness Rotator Cuff Tears

Etiologies and underlying causes are known to be multifactorial. Degeneration, impingement, and tension overload due
to trauma may all lead to rotator cuff tears. Most often, the tears initially begin as partial tears of the supraspinatus
tendon. Eventually, they can progress to full-thickness tears to include all the four muscles.
It primarily presents in middle-aged to older patients. Repetitive overhead activities are commonly the reason for
younger athletes.

History and Physical

Pain and weakness are the presenting symptoms. Pain is prominent over the lateral deltoid, worsens with overhead
activities, and by lying on the side at night. The absence of pain, however, does not exclude the diagnosis because a
chunk of patients may also be asymptomatic. In fact, partial thickness tears cause more pain and disability than full-
thickness tears. Painful arc test, drop arm test, and weakness in the external rotation is the most common observations
on physical examination.

X-rays are usually normal and can help in diagnosing large rotator cuff tears if imaging shows humeral migration over
the glenoid, and the patient has a symptomatic shoulder.

MRI can provide a degree of muscle tear, tendon retraction, and muscle atrophy, which is critical in planning for
rotator cuff repair.

Treatment

Conservative treatment with NSAIDs, and most importantly, physical therapy, should be the first attempt at therapy.
Surgical treatment with arthroscopy is done in cases of both acute or chronic full-thickness tears since delay can result
in significant muscle atrophy, tendon retraction, and poorer surgical results.

Questions
To access free multiple choice questions on this topic, click here.

References
1. Varacallo M, Mair SD. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Dec 11, 2019. Rotator
Cuff Syndrome. [PubMed: 30285401]
2. Varacallo M, Mair SD. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Dec 11, 2019. Rotator
Cuff Tendonitis. [PubMed: 30335303]
3. Cowan PT, Varacallo M. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Dec 6, 2018. Anatomy,
Back, Scapula. [PubMed: 30285370]
4. Vosloo M, Keough N, De Beer MA. The clinical anatomy of the insertion of the rotator cuff tendons. Eur J Orthop
Surg Traumatol. 2017 Apr;27(3):359-366. [PubMed: 28204962]
5. Hippensteel KJ, Brophy R, Smith MV, Wright RW. A Comprehensive Review of Physical Examination Tests of the
Cervical Spine, Scapula, and Rotator Cuff. J Am Acad Orthop Surg. 2019 Jun 01;27(11):385-394. [PubMed:
30383577]
6. Wolff AB, Sethi P, Sutton KM, Covey AS, Magit DP, Medvecky M. Partial-thickness rotator cuff tears. J Am Acad
Orthop Surg. 2006 Dec;14(13):715-25. [PubMed: 17148619]
7. Inderhaug E, Kalsvik M, Kollevold KH, Hegna J, Solheim E. Long-term results after surgical treatment of
subacromial pain syndrome with or without rotator cuff tear. J Orthop. 2018 Sep;15(3):757-760. [PMC free article:
PMC6014565] [PubMed: 29946199]
8. Harrison AK, Flatow EL. Subacromial impingement syndrome. J Am Acad Orthop Surg. 2011 Nov;19(11):701-8.
[PubMed: 22052646]
9. Gelber JD, Soloff L, Schickendantz MS. The Thrower's Shoulder. J Am Acad Orthop Surg. 2018 Mar
15;26(6):204-213. [PubMed: 29443703]
10. Farfaras S, Sernert N, Rostgard Christensen L, Hallström EK, Kartus JT. Subacromial Decompression Yields a
Better Clinical Outcome Than Therapy Alone: A Prospective Randomized Study of Patients With a Minimum 10-
Year Follow-up. Am J Sports Med. 2018 May;46(6):1397-1407. [PubMed: 29543510]
11. Tashjian RZ. AAOS clinical practice guideline: optimizing the management of rotator cuff problems. J Am Acad
Orthop Surg. 2011 Jun;19(6):380-3. [PubMed: 21628649]
View publication stats

Figures

Muscles and Fascia of the Shoulder, Supraspinatus, Scapula, Humerus, Deltoid, Infraspinatus, Teres minor and
major, Latissimus Dorsi, Triceps brachii,. Contributed by Gray's Anatomy Plates

Copyright © 2020, StatPearls Publishing LLC.

This book is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/),
which permits use, duplication, adaptation, distribution, and reproduction in any medium or format, as long as you give appropriate credit to the original
author(s) and the source, a link is provided to the Creative Commons license, and any changes made are indicated.

Bookshelf ID: NBK441844 PMID: 28722874