Rotator cuff
pathologies
Dechasa Imiru (BSc, Msc PT)
Physiotherapy Department
Jimma University
April, 2023
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Rotator cuff muscles
• Structurally;
– The tendons are broad
– Their tendons measure approximately 5cm’s in width
• Functionally;
– Holds the head of humerus into the glenoid socket
– They form a cuff encapsulating the articular surface of
the top of the humerus
– Allow shoulder movements (Rotations and abduction)
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Picture of the rotator cuff muscles
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Rotator cuff disorders
 Rotator cuff injuries are one of the most common causes
of shoulder pain across all ages and activity levels
 Involves any type of irritation or damage to the rotator
cuff muscles or tendons
 This can be caused from;
 traumatic injury (falling on an outreached arm), lifting, or
repetitive arm activities, such as throwing or placing an item
on a shelf
 The incidence of rotator cuff disorder increases with age
and is most frequently due to degeneration of the
tendon, rather than injury from sports or trauma
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Rotator cuff disorders
 Rotator cuff disorders can be described commonly as;
– Tendinosis,
– Tendinitis
– Partial thickness tears,
– Full thickness tears
– Massive tears
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Tendinitis vs. Tendinosis
Tendinitis
 Is the inflammation of the tendon and results from
micro-tears that happen when the musculotendinous
unit is acutely overloaded with a tensile force that is too
heavy and/or too sudden.
Tendinosis
 Is a degeneration of the tendon’s collagen in response to
chronic overuse; when overuse is continued without
giving the tendon time to heal and rest, such as with
repetitive strain injury, tendinosis results.
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Rotator cuff disorders
 Partial thickness tears can occur on the articular
side of the rotator cuff and do not extend through
the full thickness of the tendon
 Full thickness tears extend through the full
thickness of the tendon
 Massive tears might involve 2 or more tendons
(eg. supraspinatus and infraspinatus)
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Rotator cuff disorders
1. Tendinitis:
– Happen due to overuse or overload, especially in
athletes,
– The space where the rotator cuff resides can be
narrowed due to the shape of different shoulder bones
2. Bursitis:
– It inflammation of the fluid-filled sac/bursa between
shoulder joint and;
– Because of this rotator cuff tendons can become irritated
and inflamed
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Rotator cuff disorders
 Though found to be more common in older
populations,
– But no discrimination occur in males and females of all ages
 Due to the aging process,
– the muscle and tendon tissues of the rotator cuff loses
elasticity,
– become more susceptible to injury, and are more frequently
damaged while performing everyday activities
 In younger patients, these disorder are typically due to
unusually high demand of the shoulders or a traumatic
injury
 NOTE: Most tears involved the supraspinatus muscle
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Pathophysiology
 Intrinsic Factors
 Vascular supply/ Hypo vascularity
 The vascularity of the rotator cuff muscle-tendon unit
appears to decrease with time,
 These may explain rotator cuff tears in the elderly
 Several studies have also suggested that;
 rotator cuff injury may reflect an age-related thinning,
degeneration, and weakening of the cuff tissue
Note: A tendon has 5-7 times less blood supply than a muscle
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Pathophysiology
Extrinsic factors/ Acromial morphology
–Decreased area of the subacromial
space, because of;
 Type III acromion morphology
 AC joint osteophytes
 Coracoid process spur
 Corocoacriomial ligament
 Note: reported that 80% of patients presenting with
rotator cuff tears had type III acromiom (Bigliani et al
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1986)
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History
 Generally, a patient with rotator cuff injury will
experience;
 Anterolateral pain with shoulder motion,
particularly overhead movement
 Night pain also is a common symptom
 Patients will also commonly describe weakness in
the shoulder, most often with overhead activities
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History continued …
 A patient may describe 1 of 3 possible scenarios
with respect to the onset of pain:
1. A gradual onset of symptoms in the case
spontaneous onset
2. An acute or traumatic onset (often seen with a
rotator cuff tear, especially in the younger patient),
or
3. An acute on- chronic presentation, in which the
patient experiences low-grade progressive pain that
is exacerbated by a more recent event
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Physical Exam
 The physical examination should
evaluate;
– Shoulder range of motion,
– Tenderness to palpation,
– Strength, and
– Stability
– Provocative test: impingement sign
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Special test
Impingement signs
NEER SIGN (ear)
– Shoulder internally rotated.
– Examiner forward flexes the
patient’s arm, pushing the
supraspinatus against the
anteroinferior acromion, with
increased shoulder pain
signifying rotator cuff
inflammation or tear
– Sens-75%, Spec-47.5%
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Special test
Impingement testing
HAWKIN'S TEST
 Pt’s humerus is elevated to
90 degrees and forcibly
internally rotated, pushing
the supraspinatus against the
anteroinferior acromion
 Test is positive if pain elicited
 Sens-91.7%, Spec-44.3%
 Neer + Hawkin’s yields Sens70.8%, Spec-50.8%
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Special test
Subscaplularis
–Lift off test:
 Push examiner's hand
away from 'hand behind
back position'
 Internal rotation lag
sign: inability to hold
hand away from back
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 Test subscapularis
 Belly Press
 Pt press palm of ipsilateral hand into belly
 Examiner assess strength of IR
• Bear Hug test
 Pt places palm of ipsilateral hand on the contralateral
shoulder
 Pt then resists anterior translation of the palm
 Weakness is a positive test
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Special test
• Supraspinatus
Jobe's Test:
• Arm abducted
diagonally, thumb
pointing down .
• Resist elevation of
the arm
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Special tests
• Infraspinatus
• Resisted ER with arm by
side activates both infra
and Teres minor, therefore
not specific
• Place arm by side, flex
elbow 90 degrees, ER 45
degrees and resist
external rotation of arm.
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– Mostly infraspinatus is
under tension
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Special test
• Teres minor
– 90 degree shoulder abduction, elbow
90º, resisted ER
– This position will activate more the
teres minor
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Special Tests:
Biceps Tendon
 Biceps Tendon Tests
– Speed’s Test
– Yergason’s Test
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Special Tests: Biceps Tendon
 Speed’s Test
– Test for long head of biceps
tendon
– Pt flexes to 90 degrees with
palm/thumb up
– Pt resists downward force
applied by examiner to palm
of patient
– Positive test is pain in the
bicipital groove/SLAP
– Sens-68.5%, Spec-55.5%
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Special Tests: Biceps Tendon…
 Yergason’s Test
 Test for long head of biceps tendon
 Elbow flexed to 90 degrees and
pronated
 Examiner then resists the pt.'s
active supination
 Pain over the bicipital groove OR
tendon subluxation out of groove is
a positive test
 Sens-37%, Spec-86.1%
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Test continued…
• AC joint testing
Horizontal adduction
• forced cross body
adduction in 90ºflexion,
pain at the extreme of
motion indicative of ACJ
pathology
• Manual stress to ACJ
• Direct application of the
pressure to the AC
joint/pixston’s test/
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Diagnosis
• Diagnosis is usually made after a through
history & physical examination
• X-rays
• Ultrasound scans
• Magnetic resonance imaging (MRI) is preferred
to determine tendon tears
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Differential Diagnosis
– Rotator Cuff Tendinitis (specifically what??)
– Rotator Cuff Tear (partial vs. full thickness)
– Impingement syndrome
– ACJ disorder
– Adhesive Capsulitis
– GHJ Arthritis
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Treatment
• Analgesics/ NSAID are preferable initially
• Physiotherapy intervention
• Surgical intervention;
• reserved for significantly symptomatic patients who have
failed conservative management after 6 months
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Non-Operative Treatment
Medication:
 Non steroidal anti-inflammatory drugs (NSAIDs) is
recommended
Physiotherapy:
 Avoiding or modifying activities that elicit discomfort
 Regain full, pain-free ROM
 Strengthen all rotator cuff muscles

- Isometrics, followed by isotonic with theraband
 Strengthen shoulder girdle muscles
 Note: Approximately 90% of patients with rotator cuff
impingement, tendonitis, or bursitis respond to these nonoperative measures
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Effect of non operative mangt.
 The patient will generally experience a reduction
in pain and symptoms within 2 to 6 weeks,
 but recovery to full strength and activity levels
may take 3 up to 6 months
 In some cases, a modification in activity level
may be permanent
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When is surgery required
• Determining when rotator cuff tears require surgery considers
multiple factors, including;
– Patient’s requirements and expectations,
– Failed conservative management
• presence of significant pain and dysfunction after six
months of conservative treatment
– Repeated dislocation of an unstable joint
– The presence of a complete tear
– Significant or progressive weakness
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Surgical Options
• Several effective procedures are available for repair;
– Open repair,
– The mini-open repair, and
– arthroscopic repair
+/- subacromial decompression
• In more severe cases;
– Open surgery may involve tissue transfer of a tendon graft
– Shoulder joint replacement is also a consideration for
extreme cases
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Surgical complications
– Postoperative shoulder stiffness
– Minor (loss of motion and infection)
– Major (nerve damage, tendon re-tear and muscle
detachment)
– Repair failure
• Note: In approximately 80 % of procedures performed, patients
experience positive results,
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Post operative rehab
• Physiotherapy;
– Immobilizing of the shoulder for 2 to 4 weeks
using a sling
• Pendulum exercises can be performed
– Passive range of motion exercise, initiated soon
after surgery,
– Progress into strengthening and range of motion
exercises for 6 to 12 weeks
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Protection measures
• Do regular shoulder stretches & shoulder strengthening
programs can help prevent a recurrence or actual injury
• Take frequent breaks at work from job activities
requiring repetitive arm and shoulder motions
• Rest the shoulder regularly during sports that require
repetitive arm use
• Apply appropriate ice and heat therapies to reduce
shoulder pain and inflammation
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Case study
• A classic example of repetitive use injury involves a 19year old female who began swimming competitively at an
early age.
• During a typical swim practice, Olivia (age 16) became
aware of pain and a clicking/grinding sensation in her
right shoulder.
• Worried about telling her coach that she was in pain, she
continued to push through believing that it would just go
away.
• After two months of chronic pain, she conceded and saw
a physical therapist for evaluation. Olivia’s diagnosis was
a rotator cuff tear
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Cont …
• Given the option of surgery or conservative
treatment, she elected to take the conservative
track in an attempt to heal naturally with rest
and functional rehabilitation therapy.
• Olivia continued to swim while attending physical
therapy sessions, but the discomfort was still too
great and ultimately stopped swimming
completely.
• The combination of rest, activity modification,
and physical therapy resulted in the elimination
of pain and symptoms.
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Cont …
• She will admit that she is not consistent
with preventative practices, and has
difficulty with lifting heavy objects and
overhead motions.
• It has taken almost three years, but Olivia
has regained 90% of her functional levels
and avoided surgery
• (Schane, Olivia “Patient Interview”).
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Subacromial
impingement syndrome
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What is impingement Syndrome:
• A syndrome in which soft tissue is entrapped
or impinged between two hard (bone) tissue
structures with resultant inflammation, pain,
and dysfunction.
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Anatomy of the subacromial
• The subacromial space is formed by:
– Superior aspect of the humeral head
– Under surface of the acromion
– Acromioclavicular joint
– Coracoid process and
– Coracoacromial ligament
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Subacromial space
• The width of the subacromial space can be
influenced by the shape of the acromion
• (Type I-III, described by Bigliani, 1997),
• The coracoid process, and
• The variable thickness of the coracoacromial
ligament.
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Acromion shape
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Impingement
• Impingement syndrome was originally
described by Neer (1972):
• As mechanical impingement of the
supraspinatus and the long head of the
biceps tendon underneath the acromial
arch
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Incidence
• SAIS is the a common disorder of the shoulder
• Accounting 44-65% of all complaints of
shoulder pain
• SAIS is the primary underlying problem or a
justifying factor in many rotator cuff disorders
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Impingement syndrome
Tendon and bursa pathology:
• Inflammation of the tendons or bursa of the
subacromial space
• Inflammation will cause a decrease in the
volume of the subacromial space
• Potentially leading to increased compression
of the tissues against the borders of the
subacromial space
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Structural causes
• Morphology of the acromion process
• Presence of osteophytes on the inferior
aspect of the acromion or ACJ
A thickened coracoacromial lig.
• Another possible cause of encroachment
into the subacromial space
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An other cause
• Excessive superior and anterior
humeral head translations can
decrease the size of the subacromial
space
–E.g. Rotator cuff weakness
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Clinical presentations
• Pain is the primary complaint
• Pain is usually described as sharp pain at
the lateral aspect of the upper arm or in
the periacromial area
• Pain is usually related to activity, in
particular to elevation of the arm
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Pain full arc
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Neer classification of SAIS into three
stages
Stage I: Edema and/or hemorrhage
• Generally occurs in patients < 25 years of age
• Frequently associated with an overuse injury
• Generally, at this stage the syndrome is
reversible with conservative management
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Cont …
Stage II
• More advanced and tends to occur in patients
25 to 40 years of age
• Represents a progression from acute edema
and hemorrhage to fibrosis and tendinitis of the
rotator cuff
• Irreversible tendon changes are evident
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Cont …
Stage III
• Generally occurs in patients over 50
years of age
• Frequently involves a tendon rupture
or tear
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Assessment
History:
– Occupation, location, nature and behavior of
symptoms
Observation:
– Symmetry of the shoulders
– Position of scapula
– Posture and muscle contours
– Signs of inflammation, such as swelling or redness
Palpation:
– Note warmth, tenderness, deformity, and crepitus
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Cont …
• Usually AROM is more painful than
PROM
• Isometric muscle tests for strength
and provocation of pain
–(E.g. abduction, internal and external
rotation)
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Impingement Tests
• Impingement tests are designed to
approximate the greater tubercle of the
humerus and the acromion, thereby
compressing the subacromial structures.
– Neer impingement test
– Hawkins impingement test
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Imaging
• Radiographic study of the
supraspinatus outlet
• US
• MRI
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Treatments
• All subacromial impingement are
initially treated non-operatively
Principles of treatment initially are:
– Reduce pain and inflammation,
– Maintain joint movement
– Muscle control, and prevent muscle weakness
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Cont …
• The patient should be instructed to rest from
provocative activity
• Perform all activities in front of the shoulder and
below shoulder level
• Take anti-inflammatory medicine, in conjunction
with anti-inflammatory modalities including
cryotherapy, and ultrasound
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Cont…
• Conservative treatment should last at least
within 3 months
• Sometimes depending on the severity of the
conditions the treatment may last in 6 months
to 1 year
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Home exercise advice
• Sleeping advice on the non affected side
• Performing exercises in pain-free range
• 3 sets of 5-20 repetitions is recommended
(ER, IR and Ext) below shoulder level
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ER (below shoulder)
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IR (below shoulder)
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Extension
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Criteria for the next stage of exercises
• If there is no discomfort at rest,
• good tolerance of the above program
• Ability of passing 3 sets of 20 repetitions
without feeling pain or fatigue
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Three sets of 10 rep. with progression to 20
rep.
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Cont …
• Stretching exercises for the shoulder
throughout the rehabilitation phase
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Any
Questions
Comments
????
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