1.
Presented by
Neelesh Kumar Choudhary
MPT ( Sports )
MGM MAHSI INDORE

2.
 In 1834, Smith - first description of a rupture of
rotator cuff tendon .
 Disease severity range from inflammation and
edema to irreparable ruptures .
 A rotator cuff tear is a common injury, especially
in sports like baseball or tennis, or in jobs like
painting or cleaning windows.
 Incidence 5-40% with increasing with advancing
age .
 Each year, almost 2 million people in the United
States visit their doctors because of rotator cuff
problem.

3.
 Shoulder is made up of three bones: upper arm
bone (humerus), shoulder blade (scapula), and
collarbone (clavicle)
 The shoulder joints are: the glenohumeral
joint, the acromioclavicular joint and
the sternoclavicular joint, Thesubacromial joint
and the scapulothoracic joint.
 The shoulder girdle reaches a large range of
motion.
 Made up of 4 interrelated muscles arising from
the scapula and attaching to the tuberosities .

4.
 Supraspinatus .
 Infraspinatus .
 Teres minor .
 Subscapularis .
 Long head of
biceps -function

5.
 Stabilisers of shoulder anterior and posterior
cuff providing fixed fulcrum for concentric
rotation of humeral head.
 During elevation of arm, rotator cuff compresses
the glenohumeral joint in order to allow
thelarge deltoid muscle to further elevate the
arm.
 Initiation of abduction.
 Rotation of shoulder .

6.
 The two main causes are acute injury or
chronic .
 Mechanisms can be extrinsic, intrinsic or a
combination of both.
 ACUTE INJURY - the stress needed will
be high, such as with a fall on the outstretched
arm .
 other injuries such as dislocation of the
shoulder or separation of the acromioclavicular
joint.

7.
 range from an inflammation of muscle without
any permanent damage, such as tendinitis .
 the force may be more modest, such as with a
sudden lift, with arm above the horizontal
position .
 CHRONIC INJURY - Chronic tears are
indicative of extended use in conjunction .
 other factors such as poor biomechanics or
muscular imbalance.
 Several factors contribute to degenerative, or
chronic, rotator cuff tears of which repetitive
stress is the most significant.

8.
 The stress such as overhead throwing, rowing,
and weightlifting.
 Many jobs that require frequent shoulder
movement such as lifting and overhead
movements also contribute.
 most common non-sports related injury and
which occurs when tendons of rotator cuff
muscles become irritated and inflamed while
passing through the subacromial space
beneath acromion.
 Repetitive impingement can inflame the
tendons and bursa.

9.
 EXTRINSIC FACTOR - Hooked, curved, and
laterally sloping acromia are strongly associated with
cuff tears and may cause damage through
direct traction on the tendon.
 Repetitive mechanical activities such as sports and
exercise may contribute to flattening and hooking of
the acromion.
 Cricket, bowling, swimming, tennis, baseball,
and kayaking are implicated.
 Environmental factors include age, shoulder
overuse, smoking, and medical conditions that
affect circulation or impair the inflammatory and
healing response,

10.
 Different shapes of acromia (Biglianni et al) –
anterior slope
 Type 1 - Flat ( 3 % of cuff tears)
 Type 2 - Curved (24 % of cuff tears)
 Type 3 - Hooked ( 73 % of cuff tears)

11.
 INTRINIC FACTOR - The principal is a
degenerative-microtrauma model, which
supposes that age-related tendon damage
compounded by chronic microtrauma results in
partial tendon tears that then develop into full
rotator cuff tears .
A flattened or hooked
acromion can
predispose a shoulder
to rotator cuff
impingement and
tearing.

12.
 Stiffness- more common with partial tears.
. Internal rotation with arm in abduction .
. Flexion External rotation .
 Pain or weakness - anterolaterally and superior
.
 severe pain at time of injury, pain at night .
 pain with overhead activities and weakness of
involved muscle .
 Hear clicking or popping when move arm .
 pain over deltoid muscle by abduction against
resistance – the impingement sign.

13.
 rotator cuff tears can be divided into 5
categories.
 Type A: supraspinatus & superior
subscapularis Tear .
 Type B: supraspinatus and entire
subscapularis tears .
 Type C: supraspinatus, superior subscapularis
& infraspinatus tears .
 Type D: supraspinatus & infraspinatus tears .
 Type E: supraspinatus, infraspinatus & teres
minor tear .

14.
commonly cited
classification system for
full- thickness rotator cuff
tears was developed by
Cofield (1982).
1. Small tear: less than 1
cm
2. Medium tear: 1–3 cm
3. Large tear: 3–5 cm
4. Massive tear: greater
than 5 cm.

15.
 rotator cuff tendinopathy and bursitis
(subacromial bursitis).
 Acromioclavicular injury .
 Subacromial Impingement .
 Osteoarthritis, Rheumatoid Arthritis .
 Shoulder Instability and Adhesive Capsulitis .
 Biceps Tendonitis , Calcific Tendonitis Shoulder ,
Glenohumeral ligament tears or sprain .
 Parsonage Turner Syndrome, Thoracic Outlet
Syndrome .

16.
 Therapist should check for yellow flags
for shoulder injuries:
 Passive coping tendencies .
 Depression .
 Fear Avoidance Beliefs .
 Pain Syndromes .
 Concurrent Psychological Illness .
 Worker’s Compensation .
 Lack of family/community Support .

17.
 X – RAY :
R C TEAR
R C T IMPINGMENT
acromiohumeral
space less than 6
mm ---- chronic
full thickness tear

18.
 M R I --
Exact size,
shape and
location of
tear

19.
 ULTRA SOUND -
RCT

20.
 Inspection .
 Palpation .
 Range of motion (ROM) .
 Strength testing .
 Special tests .
1. INSPECTION - Swelling, asymmetry, muscle
atrophy, scars, ecchymosis and any venous
distention.
 Scapular "winging" and Atrophy .

21.
2 . Palpation -
Sternoclavicular joint
RANG OF MOTION
Acromioclavicular joint
Subacromial bursa
Coracoid process
Bicipital groove
Greater tuberosity
Lesser tuberosity
Scapula (spinatus muscles)

22.
3. RANG OF MOTION –
 Evaluate active ROM
If movement limited by pain,
weakness, or tightness, assist
passively .
Lack of full ROM with active and
passive exam is found in adhesive
capsulitis and arthropathy .
 Evaluate bilaterally for comparison

23.
IMPINGMENT
 NEER TEST – Hawkins test:
Sensitivity - 80 %
Specificity - 56 %
Sensitivity - 88 %
Specificity - 30 %

24.
SUPRASPINATUS AND INFRASPINATUS
 EMPTY CAN TEST - DROP ARM
TEST -
SENSITIVITY – 73 %
SPECIFICITY – 77 %

25.
DROP SIGN
 The affected arm is held at 90 degrees of
elevation in the scapular plane and at almost full
external rotation with the elbow flexed at 90
degrees. The examiner releases the wrist while
supporting the elbow

26.
SUBSCAPULARIS
 LIFT OFF TEST - SENSITIVITY – 40 %
SPECIFICITY – 79 %

27.
INTERNAL ROTATION TEST
SENSITIVITY – 100
%
SPECIFICITY – 84
%

28.
 BELLY PRESS TEST –
SENSITIVITY – 40 %
SPECIFICITY – 97%

29.
BEAR HUG TEST
SENSITIVITY – 75 %
SPECIFICITY – 56%

30.
 non-surgical treatment may include non-
steroidal anti-inflammatory drugs and steroid
injections .
 Injection of a corticosteroid .
 RICE .
 local rest, application of cold or heat and
massage.
 pain relief with modalities (e.g. iontophoresis)
and help to maintain motion.

31.
 SURGICAL TREATMENT
 Open repair - 5 to 7 cm incision extending
from lateral aspect of ant third of acromion to
lateral tip of coracoid .
 ADVANTAGES OF OPEN REPAIR
Easy to do .
No special equipment required .
Allows direct visualization of cuff repair . and
acromioplasty .
Good long term follow-up .

32.
 DISADVANTAGES
Deltoid detachment required .
False positive studies (arthrogram 2%,
MRI 10%) will lead to unnecessary open
exploration .
Unrepairable tear will be opened.
Significant intraarticular pathology will
be missed .

33.
ARTHROSCOPIC REPAIR OF ROTATOR
CUFF
 Advantages : - Lesser morbidity .
Ability to identify and treat other pathology .
Allows to address small undetected tears .
Patient acceptance.
 Disadvantages :
Technically difficult
Implant cost-needs anchor
Increased OR time
High failure rate during learning curve

34.
PHASE I – ( 0 – 4 week )
 Soft tissue mobilization to surrounding tissues,
effleurage for edema .
 gentle PROM , pendulum exercises, squeeze ball.
 triceps and biceps training with Theraband,
 pulley passive flexion and scaption (scapular
plane) 0-60 degrees.
 isometric shoulder abduction, adduction,
extension and flexion with arm at side.
 scapular pinches every hour, neck stretches for
comfort.

35.
 PHASE II – ( WEEKS 4 – 8 )
 Continue soft tissue mobilization, passive range of
motion, gentle mobilizations Gr I/II to increase
range of motion.
 start mid-range of motion range of motion rotator
cuff external and internal rotations active and light
resistance exercises without shoulder elevation
and avoiding extreme end range of motion.
 At Week 6: add supine cane exercises.
 No overhead lifting.
 Full shoulder passive ROM - flexion, abduction,
external rotation and internal rotation .

36.
PHASE III ( 9 – 12 ) –
 Start progressive resistance exercises with
weights as tolerated.
 Continue to seek full shoulder range of motion in
all planes.
 Mobilization of the scapulothoracic joint and
submaximal strengthening of the scapular
stabilizers are indicated.
 This phase is the scapular protraction and
retraction resistance exercise.
 Increase the intensity of strength and functional
training for gradual return to activities and sports.

37.
 Upper limb plyometric exercises, known as
“jump training” or “plyos”, which for example
include a patient throwing and catching a
weighted ball against a wall, starting at shoulder
height and progressing gradually to overhead.
 It is thought that these exercises improve
neuromuscular control, strength, and
proprioception.

38.
 Regular shoulder exercises to maintain strength
and flexibility .
 Using proper form when lifting or moving heavy
weights .
 Resting the shoulder when experiencing pain .
 Application of cold packs and heat pads to a
painful, inflamed shoulder .
 Strengthening program to include the back and
shoulder girdle muscles as well as the chest,
shoulder and upper arm .
 Adequate rest periods in occupations that require
repetitive lifting and reaching .

39.
THANK
YOU