Rotator cuff injuries

Question 1

What are the 4 muscles of the rotator cuff and what do they do?

Answer 1

• Supraspinatus: abducts the arm before the deltoid
• Infraspinatus: external rotation
• Teres minor: adduction and external rotation
• Subscaprularis: Adduction and internal rotation

Question 2

What are the causes of subacromial impingement (supraspinatus tendonitis)?

Answer 2

• Swollen supraspinatus tendon (supraspinatus tendinopathy or subacromial bursitis)
• Reduced space between acromion and humeral head (osteophytes)
• 30% of cases follow trauma

Question 3

What are the symptoms of subacromial impingement (supraspinatus tendonitis)?

Answer 3

• Tenderness of over anterior acromion
• Painful arc between 60-120 degrees and 170-180 degrees (demonstrated by passive abduction then active adduction)
• Pain will radiate to upper arm
• May have painful spasms of trapezius

Question 4

What are the examination findings of subacromial impingement (supraspinatus tendonitis)?

Answer 4

• Active movement more painful than passive movement (causes more impingement)
• Positive empty can (jobes) test

Question 5

What are the investigations for subacromial impingement (supraspinatus tendonitis)?

Answer 5

• X-ray for bony involvement (may show degenerative changes)
• USS may show it
• MRI is definitive but only done in run up to surgery

Question 6

What is the management of mild to moderate subacromial impingement (supraspinatus tendonitis)?

Answer 6

• Rest
• Analgesia with paracetamol and NSAIDs
• Physio

Question 7

What is the treatment of severe subacromial impingement (supraspinatus tendonitis)?

Answer 7

• Corticosteroid injection in subacromial bursa
• Surgery (removal of osteophytes or acromioplasty)

Question 8

What is a tendinopathy?

Answer 8

Degenerative change in the structure of a tendon from well structured bundles of collagen to disarrayed fibrils with a larger ECM volume

Question 9

What are the common sites of tendinopathy?

Answer 9

• Supraspinatus (most common)
• Achilles
• Common flexor/extensor insertion of forearm
• Tibialis posterior
• Patellar tendon

Question 10

What is the difference between tendinitis and tendinopahty?

Answer 10

Tendinitis is inflammation whereas tendinopathy is collagen degeneration

Question 11

What does supraspinatus tendinopathy cause?

Answer 11

Painful arc syndorme

Question 12

How its supraspinatus tendinopathy resolved?

Answer 12

Time, physio and analgesia

Question 13

Causes of supraspinatus tear?

Answer 13

• When tendons are violently stretched (e.g. lifting something too heavy or falling on outstretched arm)
• More common in OA and RA

Question 14

What are the clinical features of a supraspinatus tear?

Answer 14

• Intense pain in shoulder that radiates down arm (pain is in first 60 degrees)
• Inability to abduct arm (can’t initiate movement)

Question 15

What are the examination findings for supraspinatus tear?

Answer 15

• Shoulder looked normal
• Tenderness below lateral margin of acromion
• Normal passive movement but no active abduction
• Positive drop arm and Jobes test

Question 16

How can Jobes test differentiate between supraspinatus tendonitis and suprapinatus tear?

Answer 16

• Pain with weakness = tear
• Pain without weakness = tendonitis

Question 17

Signs of infraspinatus or teres minor tear?

Answer 17

Pain and weakness on external rotation especially against resistance

Question 18

Signs of subscapularis tear?

Answer 18

Inability to lift hand of back in Gerber’s lift off test

Question 19

What imaging is used in rotator cuff tear?

Answer 19

USS (but MRI more sensitive)

Question 20

What is the management of rotator cuff tear?

Answer 20

• If can’t move muscle at all: refer urgently due to atrophy risk
• PRICE
• Surgery for younger patients (not done in RA or elderly)