Rotator Cuff Arthropathy
Andre Le Leu
Physiotherapy Clinical Specialist
Shoulder and Elbow Unit
Stanmore, UK
Contents
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Anatomy
Pathology
Sub-acromial Impingement Syndrome
Clinical Assessment
Treatment methodology
Anatomy
Anatomy
Acromium
Rotator interval
Supraspinatus
Posterior/
Superior
Zone
Infraspinatus
Corocoid
Teres minor
Subscapularis
Glenoid
NB: Subacromial Bursa not illustrated here but a critical element
Anterior
Zone
Biomechanical Considerations
Deltoid
Suprasp.
Infraspin
Subscap
Teres Minor
Cable Theory
subscap
Anterior Pillar
Teres Minor
LHBT
Supra/infra sp.
Posterior Pillar
Rotator Cuff Tendonopathy
40 yrs
50 yrs
60 yrs
80 yrs +
Intra-substance tears
Plasma enrichment
Surgical debridement
PHYSIOTHERAPY +++
‘Repetitive strain’ overuse
Biomechanical impingement
Angiogenesis
Up regulation of fibroblast activity
PHYSIOTHERAPY +++++++
Rotator cuff tears
Rehab
Surgery
GENTLE PHYSIOTHERAPY
Salvage ops
Tendon transfers
Constrained TSR
FUNCTIONAL REHAB
Rotator Cuff Examination
• No test is absolute and definitive
• Tests are merely a provocation symptoms
rather than a confirmation of diagnosis (Lewis,
2008)
• 90% of diagnoses are made from the patient
history (Malone, 2005)
Examination
• Look….
Postural alignment
Bony landmarks
Muscle bulk/atrophy
General (scars, limb perfusion etc)
• Feel….
Palpation (joint lines, muscle belly, ligaments/bursa)
• Move….
Active movement, passive movement, resistance
DO NOT FORGET NEUROVASULAR COMPONENTS / CLEARING TESTS
Special Tests
• Supraspinatus
– Jobes Test
90 degrees scaption
Internal rotation (thumb down)
Without resistance then with resistance
Pain and or weakness
Modification to start in thumbs up and run
resistance testing through range to include rotator
interval component.
- Initiation of Abduction testing
Arm by the patients side
Palpate the Humeral Head
Assess resisted abduction
Weakness, pain, superior translation of humeral head
are all indicative of a positive test
Subscapularis
• Gerber’s Lag sign
As above but the therapist positions the hand ways from the spine and the patient
must hold this position. (80% sensitivity for small tears)
• Gerber’s lift off test
Hand behind the back at 90 degrees elbow flexion
The patient must keep the arm away from the spine
The Therapist can add resistance
(90% sensitivity for weakness or pain)
• LaFosse belly press
Hand rests on belly with wrist at neutral away from the forearm
Held away from the body.
The patient pulls the entire arm into the stomach (watch for drop of elbow or wrist),
can also add therapist resistance to the outside of the elbow
Good for patients with restrictions to movement
Recruitment of P.major in 25% clouds the examination
Infraspinatus and Teres Minor
• Resisted testing
1. External rot lag sign (ERLS) with arm at waist the
therapist positions arm in full external rotation and the
lets go while the patients attempts to hold this position.
You can then add therapist resistance and required
looking for pain/weakness.
2. Patient Holds arms in 60 degrees scaption with elbows
at 90 degrees. Patient must resist internal rotation
movement against the therapist.
Pain and or weakness can be indicative of posterior cuff
insufficency.
Infraspinatus and Teres Minor
• Patte’s Test
90 degrees of abduction and external rotation, the patient must hold against
resistance.
Watch for correct scapulo-thoracic alignment
Can test eccentric control element
• Hornblowers Sign
Arm held in 90 degrees scaption with hand in front of the mouth (supination).
Patient must move the arm out into external rotation against gravity, however the
therapist can also look to add resistance.
• Hornblowers lag sign
Arm is positioned at 90 degrees in scaption with full external rotation by the
therapist. The Patient must the hold this position once the therapist lets the arm
go. A positive drop sign is indicative of a massive posterior cuff tear.
Biceps tendon
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Check for Popeye sign (rupture of LBHT)
Speeds test
Patient holds straight arm in supination at 90 degrees flexion and tries to elevate
the arm against the therapists resistance. Pain indicative of provocation.
90% Sensitivity and 15 % specificity (Malone 2005)
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LaFosse AERS test (abduction, ext rot, supination)
Arm is held at 90 degrees abduction and externally rotated with elbow at 90
degrees in pronation.
The Therapist provides resistance as the patient supinates the arm
Pain is indication of possible biceps irritation or SLAP tear
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Yergason’s test
– arm by side and elbow at 90 degrees, the therapist holds the patients hand and resists
the patient moving into supination while palpating the LHBT.
– Look for pain and or subluxation of tendon from bicepital groove
Shoulder Impingement Syndrome
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Extrinsic
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Acromial shape
ACJ pathology
Hypertrophied CA lig
Chronic Synovitis of Bursa
Secondary Instability (micro and gross)
Posterior capsule tightness
• Neurogenic
S/T dysrythmia
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Primary
Intrinsic
Hypovascularity
Age related degenerative changes
Overuse
Cuff weakness/fatigue/cuff rupture
Impingement Tests
• Neer’s Test
– Therapist stands behind the patient and stabilizes the scapular. The
holds the arm in ‘thumbs down’ in full elbow extension.
– The maneuver is to the elevate the arm into f.flexion
– Provocation of pain (80% specificity for bursa and cuff problems
Malone et al)
• Hawkins (Kennedy) Test
– Therapist holds he arm in the plane of the scapular with the elbow at
90 degrees.
– The hand is put into a thumbs down position and then the arm is
medially rotated, a positive test provokes pain/restriction of
movement (90% sensitivity, Malone et al)
Acromioclavicular joint
• Pain on palpation
• Pain at end range abduction, hand behind
back
• Scarf test
» Pain provocation with horizontal adduction
» NB restriction of movement may be due to posterior
capsular stiffness esp. if scapular is held in retraction
Innervation
• Suprascapular nerve
• Nerve to Subscapularis
• Axillary or Circumflex nerve
• Lateral Pectoral Nerve
• Autonomic Nervous System (LBHT)
Practical Session
• Basic Assessment
• Provocation Testing
• Where to Start Rehab?
Indications for
Shoulder Replacement Surgery
Indications for surgery
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Pain
Loss of function and ROM
Quality of life
Failed conservative management
Age related considerations
Indications for Primary TSR
Arthritic joint pathology
Neer Classification System for proximal humeral fractures
Pathology
AVN
Tumours
Infection
Types of Shoulder Prosthesis
• Fully constrained = For severe arthritis of the shoulder
and destruction of the rotator cuff. Basically a salvage
procedure.
• Semi constrained = To prevent superior subluxation of
the humeral prosthesis when the patient has joint
arthritis and rotator cuff insufficiency.
• Un Constrained =Joint arthritis with good rotator cuff
function.
• Surface replacement= one articular surface involved
Cemented or Uncemented?
Cemented
• Reduced pain reported
Uncemented
• Avoid loosening of parts
• Increased mobility
• Scope for revision in
younger person
• Active lifestyle
• Senior population
• Less physically demanding
lifestyle
• Extended recovery period
RNOH Philosophy
• Bone Stock & Rotator Cuff
– Good BS / good RC = unconstrained TSR
– Good BS / poor RC = Constrained
– Poor BS / good RC = CAD-CAM stem
– Poor BS / poor RC = CAD-CAM glenoid/stem
Surface Replacement
Unconstrained
Sulzar TSR – with
glenoid liner
(cemented)
Modular (no glenoid liner)
Cemented or uncemented
Glenoid screw and
Biomet Humeral
Component
Constrained
Reverse Delta-3
Constrained
Reverse Fixed Fulcrum (Bayley-Walker)
Constrained
CAD CAM
RNOH Rehabilitation guidelines
Weak and smooth shoulder
Stiff shoulder
Post operation immobilisation
Abduction pillow
polysling
Rehab Guidelines
All of this will vary according to the individual
Phase 1 – Initial Rehab
Optimise tissue healing (time specified)
Pain control
“SMOOTH AND WEAK”
Use of sling
No ER>neutral/20 degrees
A-A/Passive elevation<90 degrees
No active use of UL or strengthening
No HBB or cross body
Education
Milestones for next stage
Achieved time specific goals
For X-rays to show osseo-integration
Allowed ROM achieved
Reduced pain
Adequate scapula control
Early phase day 1 -6/52 exercise
Active assisted GHJ FF 90
ISOMETRIC IR IN NEUTRAL
ISOMETRIC ER IN NEUTRAL
Carer performing the exercise
Early phase day 1 -6/52 exercise
Start position with shoulder supported
Active assisted GHJ ER to neutral start…
Carer performing the exercise
End position of exercise
Phase 2 – Early Recovery (approx 6 weeks – 4 months)
Decrease sling use
Start light activity at waist level
Increase ROM
Optimise normal movement patterns
No exercises that increase pain
No active anti-gravity work until RC rehabilitated
Deltoid Programme for Constrained TSR
Milestones for next stage
No sling
Minimal pain
Passive ROM: elevation>90 and ER>30
RC stabilises within available ROM
Functional Triangle
Phase 3 – Late Recovery (approx 5 months – 12 months)
Increase strength and endurance to functional level required
No exercises that increase pain
No heavy lifting above shoulder level
Milestones for Discharge
Reduced pain from pre-op status
Achieved functional goals
Expected outcomes
Unconstrained – Light to moderate use at
waist, shoulder and above shoulder level
Constrained – Light use at waist level and
towards shoulder height if possible
May take 12-24 months to achieve
Rehabilitation Guidelines
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www.rnoh.nhs.uk
Follow link to CLINICAL SERVICES
Click on Physiotherapy
Click on SHOULDER AND ELBOW UNIT
Select Guideline for exercise information