Rotator Cuff

 The rotator cuff is a group of tendons and muscles in the shoulder,

connecting the upper arm (humerus) to the shoulder blade (scapula).
 rotator cuff tendons provide stability to the shoulder; the muscles allow
the shoulder to rotate.

The muscles in the rotator cuff include:

Teres minor
Infraspinatus
Supraspinatus
Subscapularis
 Eachmuscle of the rotator cuff inserts at the
scapula, and has a tendon that attaches to
the humerus. Together, the tendons and
other tissues form a cuff around the
humerus.
Rotator Cuff Problems

1. Rotator cuff tear

2. Rotator cuff tendinitis
I. Rotator cuff tendinitis refers to irritation of these tendons and
inflammation of the bursa (a normally smooth layer) lining
these tendons.
 Thetendons of the rotator cuff pass underneath a
bony area on their way to attaching the top part of
the arm bone.

 When these tendons become inflamed, they can become

frayed over this area during shoulder movements.
Sometimes, a bone spur narrows the space even more.

 Rotator
cuff tendinitis is also called impingement
syndrome.
Causes of Tendinitis
 Keeping the arm in the same position for long periods, such as
doing computer work or hairstyling
 Sleeping on the same arm each night
 Playing sports requiring the arm to be moved overhead
repeatedly such as in tennis, baseball (particularly pitching),
swimming, and lifting weights overhead
 Working with the arm overhead for many hours or days, such
as in painting and carpentry
 Poor posture over many years
 Aging
Signs and symptoms
 Early on, pain is mild and occurs with overhead activities and
lifting your arm to the side.
 Activities include brushing your hair, reaching for objects on
shelves, or playing an overhead sport.
 Pain is more likely in the front of the shoulder and may travel
to the side of the arm.
 The pain always stops before the elbow. If the pain goes
down the arm to the elbow and hand, this may indicate a
pinched nerve in the neck.
 There may also be pain when you lower the shoulder from a
raised position.
 Over time, there may be pain at rest or at
night, such as when lying on the affected
shoulder. You may have weakness and loss of
motion when raising the arm above your head.
 Your shoulder can feel stiff with lifting or
movement.
 It may become more difficult to place the arm
behind your back.
II. A Rotator cuff tear occurs when one of the tendons is
torn from the bone from overuse or injury.
May occur in two ways:
A sudden acute tear may happen when you fall on your
arm while it is stretched out. Or it can occur after a
sudden, jerking motion when you try to lift something
heavy.

A chronic tear of the rotator cuff tendon occurs slowly

over time. It is more likely when you have chronic
tendinitis or impingement syndrome. At some point, the
tendon wears down and tears.
 Types of Tear

1. Partial tear - occurs when a tear does not completely sever

the attachments to the bone.

2. Complete, full thickness tear - means that the tear goes all
the way through the tendon.
- complete tears, the tendon has come off (detached)
from where it was attached to the bone.
- This kind of tear does not heal on its own.
Signs and symptoms
 Right after the injury, you will likely have weakness of the shoulder and
arm.
 It may be hard to move your shoulder or raise your arm above the
shoulder.
 You may also feel snapping when trying to move the arm.
 With a chronic tear, you often do not notice when it began. This is
because symptoms of pain, weakness, and stiffness or loss of motion
worsen slowly over time.
*Rotator cuff tendon tears often cause pain at night. The pain may even
wake you. During the day, the pain is more tolerable, and usually only
hurts with certain movements.
Exams and Tests
 Physical examination - reveal tenderness over the shoulder.

 X-rays - shoulder may show a bone spur or change in the

position of the shoulder.

Other test
- ultrasound test
- MRI
Treatment

For Tendinitis
 Ice packs applied 20 minutes at a time, 3 to 4 times a day to
the shoulder
 Taking medicines, such as ibuprofen and naproxen, to help
reduce swelling and pain
 Avoiding or reducing activities that cause or worsen your
symptoms
 Physical therapy to stretch and strengthen the shoulder muscles
 Medicine (corticosteroid) injected into the shoulder to reduce
pain and swelling
 Surgery (arthroscopy) to remove inflamed tissue and part of the
bone over the rotator cuff to relieve pressure on the tendons
For Tear
 Rest and physical therapy may help with a partial tear if
you do not normally place a lot of demand on your shoulder.

 Surgery to repair the tendon may be needed if the rotator

cuff has a complete tear.
 Surgery may also be needed if the symptoms do not get better
with other treatment.
 Large tears may need open surgery (surgery with a larger
incision) to repair the torn tendon.
Reference

 https://medlineplus.gov/ency/article/000438.htm
Supraspinatus Tendinitis
Background

 Supraspinatus tendonitis is often associated with

shoulder impingement syndrome.
 The common belief is that impingement of the
supraspinatus tendon leads to supraspinatus
tendonitis (inflammation of the
supraspinatus/rotator cuff tendon and/or the
contiguous peritendinous soft tissues),
Epidemiology

 Supraspinatus tendonitis is a common cause of

shoulder pain in athletes whose sports involve
throwing and overhead motions.
Signs and symptoms

 Sudden onset of sharp pain in the shoulder with

tearing sensation
 Gradual increase in shoulder pain with overhead
activities
 Pain Usually lateral, superior, anterior shoulder;
occasionally referred to deltoid region
Causes

Extrinsic causes
 Primary impingement
 Increased subacromial loading
 Trauma (direct macrotrauma or repetitive
microtrauma)
 Overhead activity (athletic and nonathletic)
Secondary impingement
 Rotator cuff overload/soft tissue imbalance
 Eccentric muscle overload
 Glenohumeral laxity/instability
 Long head of the biceps tendon
laxity/weakness
 Glenoid labral lesions
 Muscle imbalance
Treatment

 period of active rest, eliminating any activity that

may cause an increase in symptoms.
 Range-of-motion exercises may include pendulum
exercises
 Joint mobilization
 Strengthening excercises
Modalities
 cryotherapy
 Ultrasound
 transcutaneous electrical nerve
stimulation
Medication

 NSAIDs
Complications

 Ifrotator cuff tendonitis is not diagnosed

and treated promptly and correctly, it can
progress to rotator cuff degeneration and
eventual tear. Other complications may
include progression to adhesive capsulitis,
cuff tear arthropathy, and reflex
sympathetic dystrophy
Prevention
 Primary prevention should be considered an
integral part of the treatment of rotator cuff
tendonitis. Educating patients at risk can
circumvent the development of rotator cuff
tendonitis. Athletes, particularly those involved in
throwing and sports involving overhead actions,
and laborers with repetitive shoulder stress
should be instructed in proper warm-up
techniques, specific strengthening techniques,
and warning signs of early impingement.
Reference

Medscape
Bicipital Tendinitis
 Biceps tendinitis is an inflammation or
irritation of the upper biceps tendon. Also
called the long head of the biceps tendon,
this strong, cord-like structure connects the
biceps muscle to the bones in the shoulder.
Cause
 Bicipital tendinitis frequently occurs from overuse
syndromes of the shoulder, which are fairly common in
overhead athletes such as baseball pitchers,
swimmers, gymnasts, racquet sport enthusiasts (eg,
tennis players), and rowing/kayak athletes.
 Trauma may occur because of direct injury to the
biceps tendon when the arm is passed into excessive
abduction and external rotation.
Symptoms

 Pain or tenderness in the front of the shoulder,

which worsens with overhead lifting or activity
 Pain or achiness that moves down the upper arm
bone
 An occasional snapping sound or sensation in the
shoulder
Physical Examination
During the examination, assess the shoulder for range of
motion, strength, and signs of shoulder instability. In addition,
may press over the area where the biceps tendon attaches to
the shoulder. Patients with tendinitis will have tenderness and
swelling in this area.
Imaging Tests
 X-rays
 Magnetic resonance imaging (MRI)
 Ultrasound
Treatment

Nonsurgical Treatment
 Rest
 Ice
 Nonsteroidal anti-inflammatory medicines
 Steroid injections
 Physical therapy ( Rehabilitation Program )
Rehabilitation Program
(Acute Phase)
 The initial goals of the acute phase of treatment
for bicipital tendinitis are to reduce inflammation
and swelling. Patients should restrict over-the-
shoulder movements, reaching, and lifting.
Physical Therapy
 Ice pack
 NSAID’s
 TENS or Ultrasound
Recovery Phase

Physical Therapy
 Physicaltherapy and rehabilitation are
directed toward restoring the integrity and
strength of the dynamic and static
stabilizers of the shoulder joint while
restoring the affected shoulder's ROM,
which is critical for most athletes.
 The goal of the recovery phase is to achieve and
maintain full and painless ROM.
 Weighted, pendulum stretch exercises are combined
with isometric toning. These exercises are
recommended 3 times per week throughout the
recovery phase. Passive stretching with ROM exercises
removes residual shoulder stiffness. The uninvolved
shoulder can be used as a standard comparison to
achieve symmetric ROM.
Maintenance Phase

Physical Therapy
 The maintenance phase concentrates on the patient developing
increased strength and endurance on the affected side. This phase can
begin as soon as patient discomfort is effectively controlled and should
continue for at least 3 weeks after the pain has completely resolved.
When performing strengthening exercises, it is safer for the individual
to start out with low tension, followed by a gradual increase in force,
because flare-ups can occur.
 The patient continues isotonic and isokinetic stretching
and is allowed limited participation in sports activities.
Monitor the patient and adjust his/her activities as
progress allows. Note: Conditioning and proper throwing
techniques are important for certain athletes because
improper mechanics may result in tissue fatigue and
damage.
 Surgical Treatment
 Arthroscopy
 Acromionectomy
 Biceps tenodesis
Reference:

 orthoinfo.aaos.com
 emedicine.medscape.com
Frozen shoulder
Frozen shoulder

 Also known as Adhesive Capsulitis

 It is an extremely painful condition in
which the shoulder is completely or
partially unmovable (stiff).
 Occurs in about 2% of the general
population
 Commonly affects people between 40-
60 years old
 Occurs in women more often than men
Three stages of development

 Freezing
pain increases with movement and is
often worse at night. There is a
progressive loss of motion with
increasing pain. This stage lasts
approximately 2-9 months.
 Frozen phase
pain begins to diminish, however, the range of
motion is now much more limited, as much as
50% less than in the other arm. This stage may
last 4-12 months.
Thawing phase
the condition may begin to
resolve. Most patients eperience a
gradual restoration of motion over
the net 12-42 months
Cause

 Diabetes
 Immobilization
 Other diseases
hypothroidism, hyperthyroidism, PD, and
cardiac diseases
Symptoms

 Painfrom frozen shoulder is usually dull or

aching. It is typically worse early in the
course of the disease and when you move
the arm. The pain is located over the outer
shoulder area and sometime the upper arm.
Tests

 X-rays
 MRI
Treatment

 Nonsurgical treatment
 NSAIDs
 Steroid injection
 Physical therapy

o Surgical treatment
 Manipulation under anesthesia
 Shoulder athroscopy
References

 Orthoinfo.aaos.org
 https://www.shoulderdoc.co.uk
Recurrent Dislocation of Shoulder/ Chronic
Shoulder Instability
Chronic Shoulder Instability

 Shoulder instability occurs when the head of the upper

arm bone is forced out of the shoulder socket.

 This can happen as a result of a sudden injury or from

overuse.

 Once a shoulder has dislocated, it is vulnerable to repeat

episodes. When the shoulder is loose and slips out of place
repeatedly, it is called chronic shoulder instability.
Description

 Shoulder dislocations can be partial, with the ball of the

upper arm coming just partially out of the socket, this is
called a subluxation.

 A complete dislocation means the ball comes all the way

out of the socket.
Causes

1. Shoulder Dislocation

2. Repetitive Strain

3. Multidirectional Instability
Shoulder Dislocation

 Severe injury, or trauma, is often the cause of an initial shoulder

dislocation.
 When the head of the humerus dislocates, the socket bone (glenoid)
and the ligaments in the front of the shoulder are often injured.
 The labrum — the cartilage rim around the edge of the glenoid — may
also tear. This is commonly called a Bankart lesion. A severe first
dislocation can lead to continued dislocations, giving out, or a feeling
of instability.
Repetitive Strain

 Most of these patients have looser ligaments in

their shoulders.
 This increased looseness is sometimes just their
normal anatomy. Sometimes, it is the result of
repetitive overhead motion.
Multidirectional Instability

 the shoulder can become unstable without a history of

injury or repetitive strain.
 the shoulder may feel loose or dislocate in multiple
directions, meaning the ball may dislocate out the front,
out the back, or out the bottom of the shoulder.
 These patients have naturally loose ligaments throughout
the body and may be "double-jointed."
Symptoms

 Pain caused by shoulder injury

 Repeated shoulder dislocations
 Repeated instances of the shoulder giving out
 A persistent sensation of the shoulder feeling loose,
slipping in and out of the joint, or just "hanging there"
Treatment

 often first treated with nonsurgical options.

 If these options do not relieve the pain and
instability, surgery may be needed.
Nonsurgical Treatment

 Activity modification. You must make some changes in your

lifestyle and avoid activities that aggravate your symptoms.

 Non-steroidal anti-inflammatory medication. Drugs like

aspirin and ibuprofen reduce pain and swelling.

 Physical therapy. Strengthening shoulder muscles and working

on shoulder control can increase stability. Your therapist will
design a home exercise program for your shoulder.
Surgical Treatment

Bankart lesions can be surgically repaired. Sutures and

anchors are used to reattach the ligament to the bone.
 Arthroscopy
 Open Surgery
 Rehabilitation. After surgery, your shoulder may be immobilized
temporarily with a sling.
 When the sling is removed, exercises to rehabilitate the ligaments will
be started. These will improve the range of motion in your shoulder and
prevent scarring as the ligaments heal. Exercises to strengthen your
shoulder will gradually be added to your rehabilitation plan.
Reference

 http://orthoinfo.aaos.org/topic.cfm?topic=a00529
Thank you 
Group 5