Referat

ROTATOR CUFF SYNDROME

Arranged by:

Esti Rahmawati Suryaningrum G0007064

Tutor:

dr. Tangkas Sibarani, SpOT, FICS

Clinical Department of Orthopaedic & Traumatology Sebelas Maret University

Hospital of Dr. Moewardi/ Orthopaedic Hospital of Prof. Dr. Soeharso

Surakarta

2012

LEGALY SHEET

Referat entitled “Rotator Cuff Syndrome” is arranged to fulfill the

requirement of clinical department of Orthopaedic & Traumatology Sebelas Maret

University Hospital of Dr. Moewardi/Orthopaedic Hospital of Prof. Dr. Soeharso, by:

Esti Rahmawati Suryaningrum G0007064

Has been approved by the referat tutor of the Orthopaedic Hospital of Prof.

Dr. Soeharso on May, 2012.

Tutor

dr. Tangkas Sibarani, SpOT, FICS

ROTATOR CUFF SYNDROME

DEFINITION

Rotator cuff syndrome is damage to the rotator cuff, is a part of the shoulder.

The rotator cuff is a group of four muscles that sit around the shoulder joint in a cuff-

like pattern. The rotator cuff attaches from the scapula, or shoulder blade, to the

humerus, or arm bone, and it functions to pull the arm into the shoulder socket,

stabilizing the arm, so that overhead movements can be performed.

Rotator cuff syndrome is a disorder most frequently diagnosed in those whose

work involves repeated or sustained raising of the upper arms more than 30° over

horizontal. Such repetitive motion irritates the muscles and tendons by putting

pressure against the bone at the top of the shoulder blade. When the arm is raised

repeatedly, front edge of the shoulder blade (acromion) can rub across the rotator cuff

(impingement syndrome or painful arc syndrome). If rotator cuff injuries are

diagnosed early, causes can be identified and effective treatments implemented,

thereby preventing further injury or deterioration.

INCIDENCE AND PREVALENCE

Shoulder pain is the third most common musculoskeletal disorder; estimates of

all shoulder disorders are 10 per 1,000 population, with a peak incidence of 25 per

1,000 population aged 42 to 46 years. Among those age 60 years or older, 21% were

found to have shoulder syndromes, most of which were attributable to the rotator cuff

(Roy). Nevertheless, the actual incidence of rotator cuff syndrome is uncertain since

about 34% of the population may have a torn rotator cuff but no pain (Roy).

RISK FACTOR

Workers at risk for rotator cuff syndrome are those required to repeatedly

move heavy weights over their heads, such as painters, welders, plate workers, and

slaughterhouse workers. This syndrome also has been reported in sewing machine

operators. It can occur in athletes who engage in sports such as swimming, tennis,

weightlifting, and baseball in which the arm is repeatedly raised over the head.

Younger individuals are more likely to experience rotator cuff syndrome as a result of

trauma, overuse, shoulder (glenohumeral) joint instability, or muscle imbalance. In

older individuals, the syndrome is more commonly related to chronic wear and

shoulder degeneration. Rotator cuff syndrome is most common in the dominant arm.

ANATOMY OF ROTATOR CUFF

The "cuff" is actually a group of four muscles and their tendons that work as a

unit to hold the bones of the shoulder together, allowing individuals to lift their arms

and reach overhead. Repetitive motion and overuse, along with individual variations

in the anatomy of the shoulder and trauma can lead to rotator cuff injuries.

The rotator cuff is the sheath of conjoint tendons which run over the top of the

shoulder capsule and inserts into the greater tuberosity of the humerus

the tendons are those of the short muscles of the shoulder - supraspinatus,

infraspinatus, teres minor and subscapularis

the cuff is covered anteriorly by the coracoacromial arch with the subacromial

bursa in between

the main role of the cuff is to stabilise the humeral head within the glenoid,

particularly when the arm is flexed or abducted by the deltoid muscle.

MuscleOrigin on scapula

Attachment on humerus

Function

Innervation

subscapularis muscle

subscapular fossa

lesser tuberosity (60%) or humeral neck (40%)

internally rotates the humerus

subscapular nerve (C5-6)

supraspinatus muscle

supraspinous fossa

inserts on the middle facet of the greater tuberosity

abduction of the arm

suprascapular nerve (C5)

infraspinatus muscle

infraspinous fossa

inserts posterior facet of theon the greater tuberosity

externally rotates the arm

suprascapular nerve (C5-6)

teres minor muscle

middle half of the lateral border

inserts on the inferior facet of the greater tuberosity

externally rotates the arm

axillary nerve (C5)

The subacromial space lies underneath the acromion, the coracoid process, the

acromioclavicular joint and the coracoacromial ligament. A bursa in the subacromial

space provides lubrication for the rotator cuff.

Supraspinatus is the cuff tendon most liable to injury. It is the most exposed of

the tendons - running over the top of the shoulder under the anterior edge of the

acromion and the adjacent acromioclavicular joint - and also has a relatively poor

arterial blood supply near to it's insertion into the greater tuberosity. Consequently,

`supraspinatus' is often used synonymously with `rotator cuff' when describing lesions

of this area.

the rotator cuff is the dynamic stabilizer of the glenohumeral joint

o the static stabilizers are the capsule and the labrum complex, including

the glenohumeral ligaments

o although the rotator cuff muscles generate torque, they also depress the

humeral head

o the deltoid abducts the shoulder

o without an intact rotator cuff, particularly during the first 60 degrees of

humeral elevation, the unopposed deltoid would cause cephalad

migration of the humeral head, with resulting subacromial

impingement of the rotator cuff

in patients with large rotator cuff tears, the humeral head is

poorly depressed and can migrate cephalad during active

elevation of the arm. This migration is sometimes evident even

on plain radiographs

the space between the undersurface of the acromion and the superior

aspect of the humeral head is called the impingement interval

this space is normally narrow and is maximally narrow when the

arm is abducted. Any condition that further narrows this space can

cause impingement

CLASIFICATION

Rotator cuff syndrome is divided into three stages of severity. In stage I,

swelling (edema) and/or bleeding (hemorrhage) occurs. Stage I is frequently

associated with an overuse injury. At this stage, the syndrome can either be reversed

or it can progress. In stage II, there is inflammation of the tendon (tendinitis) and

development of scar tissue (fibrosis). Stage III frequently involves a tendon rupture or

muscle tear and often represents years of fibrosis and tendinitis.

Stage I rotator cuff syndrome is found most often in individuals under age 25;

stage II occurs most often in individuals between 25 and 40; stage III occurs mainly in

individuals over age 50 (Quintana). Men develop rotator cuff syndrome twice as often

as women, possibly because of work activities as noted above. The syndrome occurs

independently of race, ethnicity, or geographic location.

DIAGNOSIS

History: A complete medical history, including the individual's occupation and

recreational activities will be taken. A good description of the shoulder pain including

the onset, timing, location, radiation, quality of pain, aggravating and alleviation

factors, presence of associated symptoms, and association with any activities helps to

diagnose rotator cuff syndrome. The individual frequently reports aching pain in the

shoulder or referred pain along the outside upper arm. The pain worsens when the arm

is lifted overhead and at night. Other symptoms may include weakness and reduced

range of motion. The onset of symptoms is often gradual. The first

dysfunction/symptom to arise is pain. When weak, the rotator cuff can no longer

handle the load of raising (abduction) and flexing the arm. Reaching for a glass in the

cupboard

Reaching to switch on a light

Putting on a seatbelt

Washing one's hair

Driving (steering) with the affected arm

Physical exam: Examination of the shoulder begins with a thorough

inspection for any deformities, scars, edema, or decrease in muscle bulk (atrophy).

Next, the entire shoulder joint and all of its muscle groups are palpated for tenderness.

Both active and passive range of motion are determined by rotating the individual’s

arm through different planes, noting any decrease in range of motion and any pain.

The pain may be more intense with certain movements or when pressure is applied; it

can disappear with other movements. There may be a grating, clicking or cracking

sound (crepitus) in the shoulder. Muscle strength testing and neurological testing

should be performed. Special maneuvers during the physical examination (such as the

Neer impingement, Hawkins-Kennedy impingement, drop-arm, apprehension, and

relocation tests) may be helpful. A thorough exam includes evaluation of the cervical

spine along with both arms and shoulders.

Tests: X-rays (Anteroposterior view, axillary view, supraspinatus view) are an

essential component of evaluation to rule out calcium deposits in the joint, and bone

or joint diseases. If symptoms do not improve following 3 to 6 weeks of conservative

therapy, other advanced imaging modalities may prove helpful, especially in

diagnosing suspected rotator cuff tears. MRI detects a wide spectrum of rotator cuff

disease, including degeneration and partial to complete tears. It can also reveal soft

tissue abnormalities, and proves especially valuable in tracking postoperative healing.

Ultrasonography proves useful in diagnosing moderately large rotator cuff tears and

evaluating other cuff disease. Widespread use of arthrography has decreased with the

advent of MRI, but it remains useful in individuals for whom MRI is contraindicated

(e.g., those with a pacemaker, cerebral aneurysm clip, or recent cardiac stent).

Arthrography involves injection of contrast media into the glenohumeral joint

followed by plain x-rays. Observed leakage of contrast material into the subacromial

or subdeltoid spaces following injection indicates a full-thickness rotator cuff tear.

Other diagnostic tests for rotator cuff syndrome are bone scintigraphy and CT scan,

often with contrast media (CT-arthrography). Electromyography (EMG) and nerve

conduction velocity studies (NCVs) may be helpful if neurologic involvement is

suspected.

TREATMENT

During the acute phase of rotator cuff syndrome, conservative treatment

consists of rest and activity modification, ice, and the use of (NSAIDs). The goals are

to decrease inflammation and pain and restore normal shoulder function. Activities

causing the pain should be resumed gradually when pain is gone. Sometimes a

cortisone injection into the space above the rotator cuff tendon (subacromial

corticosteroid injection) helps relieve swelling and inflammation. Application of ice

to the tender area for 15 minutes 3 to 4 times a day also is helpful as is a supervised

program of stretching and strengthening exercises to increase range-of-motion.

Recovery of function should be stressed. An on-going home exercise program is

essential to help prevent recurrence. Surgery may be considered for those individuals

who show no improvement after 3 months of aggressive therapy or who continue to

be bothered by weakness.

Indications for surgery vary but should take into consideration an individual’s

age, type and severity of tear (partial to full-thickness muscle tears), duration of

symptoms, and willingness and ability to comply with postoperative therapy. The

main goals of surgery are improved strength, increased function, and pain relief.

Chronic rotator cuff syndrome with severe impingement may be treated by cutting

into the shoulder and repairing the bone and/or tendon and/or the muscle (arthroscopic

acromioplasty). Rotator cuff surgery is done to repair a torn rotator cuff. Bone spurs

or calcium deposits causing impingement may be removed at the same time. Surgery

must be followed by physical therapy to improve strength and range-of-motion

followed by an on-going home exercise program.

PROGNOSIS

Recovery often depends on the stage of the syndrome and the age of the

individual. Some individuals whose rotator cuff syndrome is caused by repetitive

above-the-shoulder lifting may recover completely if the repetitive work is stopped

and an aggressive, nonsurgical treatment plan (i.e., ice, strengthening, and range-of-

motion exercises) is followed. Success rates with such conservative treatment range

from 33% to 90%, with longer recovery times noted in older individuals (Quintana).

Surgical outcomes often depend on the willingness and ability of an individual to

participate actively in postoperative physical therapy and home exercise. The reported

success rate for surgery to treat torn rotator cuffs is between 77% and 95% ("Shoulder

Rotator"; Quintana). In many individuals who resume overhead work or other activity

that initially caused the problem, recurrent episodes may continue despite appropriate

acute treatment. These individuals need to alter their work or recreational activities.

REHABILITATION

Rotator cuff syndrome represents a chronic shoulder impingement syndrome.

The early goals of rehabilitation for rotator cuff syndrome are to decrease pain and

inflammation and to reduce the stress on the irritated tendon and/or tissues (Morrison,

"Shoulder Impingement"; Rubin). In conjunction with pharmacological management,

individuals are instructed in the use of cold treatments to the shoulder to decrease

inflammation. Reduction of stress to the irritated tissue(s) is often achieved through

education, ergonomic adjustments, and/or work modifications aimed at reducing the

offending activities, which often include repetitive movements or sustained positions

where the elbow is raised above the shoulder level. Stiffness may be prevented by

passive range of motion exercises conducted during supervised rehabilitation and a

home exercise program (Ludewig).

Rehabilitation also aims to reduce the stress on the irritated tendon and/or

tissues by improving strength and flexibility around the shoulder (Morrison,

"Shoulder Impingement"; Rubin). The strengthening is usually aimed at the shoulder

girdle musculature (Morrison, "Non-Operative Treatment"; Morrison, "Shoulder

Impingement"; Rubin). Flexibility exercises vary, based on the physical examination

findings. Some evidence from randomized controlled trials suggests that manual

therapy in conjunction with a program of strengthening and stretching is more

beneficial than strengthening and stretching alone (Bang). Throughout rehabilitation,

exercise intensity and duration should be increased until full functional ability is

regained (Rubin).

While many individuals respond well to the conservative management of

rotator cuff syndrome, surgical intervention may be required.

COMPLICATIONS

The main complication of rotator cuff syndrome occurs when rotator cuff tears

go undiagnosed. Symptoms will persist until the rotator cuff is repaired surgically.

Another complication results from inadequate treatment. If the shoulder is

immobilized in a sling, the individual can develop "frozen shoulder" (adhesive

capsulitis). Conditions such as a rotator cuff tear or impingement syndrome may also

lead to decreased range of motion in the shoulder. An estimated 4% of rotator cuff

ruptures result in joint disease (arthropathy) of the shoulder (Quintana). Proper care,

whether conservative or surgical, and appropriate follow-up lessen the likelihood of

joint disease and other long-term consequences of rotator cuff syndrome.

REFERENCES

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