Clinical assessment of the rotator cuff
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Clinical assessment of the rotator cuff - Dave Copas
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Clinical assessment of the rotator cuff
- 1. Dave Copas Wrightington 19th August 2014
- 2. Aims — Basics — History — Examination — Inspection — Palpation — Cuff Assessment — Demonstration — Summary
- 3. Role of the Cuff — Shoulder Complex comprises 30 muscles — RC muscles predominantly STABILISERS — Do contribute to movement — 3 muscles coalesce to form rotator cuff — 4th separated by rotator interval
- 5. Cons1tuent parts — Supraspinatus — Initiator of abduction — Acts throughout abduction arc — As powerful as deltoid — Origin – Supraspinous fossa of scapular — Insertion – upper facet of Gt Tuberosity — Nerve supply – Suprascapular nerve — Lies in scapular plane (30° to coronal plane)
- 6. Cons1tuent Parts — Subscapularis — Main internal rotator — Largest and strongest cuff muscle — Origin – subscapular fossa (ant. surface of scapula) — Insertion – Lesser tuberosity — Nerve supply -‐ Upper and Lower subscapular nerves (posterior cord)
- 7. Cons1tuent Parts — Infraspinatus and Teres Minor — Two muscles below scapular spine — Both external rotators — Infraspinatus -‐ Acts when arm is neutral — Teres minor -‐ More active when arm abducted to 90°
- 8. Assessment — History — General — Age, handedness, occupation — Pain — Location, character, night pain, onset — Weakness — Traumatic vs degenerative, intrinsic vs neuro-‐musc — Stiffness — Secondary to cuff pathology — Functional Deficit — Interference with work, leisure or ADLs
- 9. Assessment — Inspection — Proper exposure — Symmetry — Deformity — Muscle wasting (more obvious if infraspinatus involved) — Scars
- 10. Assessment — Palpation — Limited role in cuff assessment — Muscle bulk — “Rent Test” (Codman) — Palpation of supraspinatus tear
- 11. Assessing Supraspinatus — 12 tests on shoulderdoc! — Jobe’s Test — Empty Can Test – Jobe and Moynes1 — Abduct 90° , scapular plane, full IR and resist — Full Can Test – Kelly2 — Abduct 90 , scapular plane, 45° ER and resist — FCT less provocative – Less weakness due to pain — Itoi – 143 shoulders in 136 pt3 — ECT – 70% accurate — FCT – 75% accurate
- 13. Assessing Supraspinatus — Codman’s sign (Drop arm sign) — Passive abduction — Support released — Deltoid contracts -‐ hunching of shoulders — Burkhead’s thumb up and down test — Potentially useful in patients with Impingment signs — Apleys’s scratch test — And others.....
- 14. Assessing Subscapularis — Gerber’s lift off test4 — IR, dorsum of hand over mid lumbar spine and raised — Evidence Greis (1996)5 — Subscap heavily involved (70% max contraction) — Mid lumbar 1/3 MORE activity than LS junction — Gerber looked at 100 pts, — 8/9 with MRCT +ve — 12/16 with isolated subscap tears +ve — Conclude if full IR and test not limited by pain then reliable in diagnosing subscap dysfuntion — Internal Rotation Lag Sign (Hertel 1996)6 — As specific, more sensitive, detects partial ruptures?
- 16. Assessing Subscapularis — Other variants — Belly Press Test (Napoleon sign)7 — Belly Off Sign (Scheibel 2005)8 — Modified Belly Press Test (Bartsch 2010)9 — DeBeer’s Bear Hug Test10 — Useful in patients with painful shoulders — Helpful in detecting tears in upper part of subscap — Can use tensiometer — Pennock et al, 201111 — No difference between above test — Not known whether different parts of subscap fire in each test
- 18. Assessing Infraspinatus — Drop sign (Bigliani Et al 1992)12 — Full ER, arm by side, inability to hold position — External Rotation Lag Sign (Hertel 1996)6 — As above but arm in 20° elevation in scapular plane — Hertel’s “Drop Sign” as above but elevated to 90°
- 20. Assessing Teres Minor (or MRCT) — Hornbower’s Sign — Inability to ER the elevated arm — The Dropping Sign (Walch)13 — 0° abduction, 90° elbow flex, 45° ER — Falls to 0° ER when released — Both indicative of massive cuff tear
- 22. Demonstra1on
- 23. Summary — Careful History and Exam vital — Systematic Approach — Develop a system — Remember the neck — Consider core stability assessment — It’s what makes it more interesting than the hip or the knee.
- 25. References 1. Delineation of diagnostic criteria and a rehabilitation program for rotator cuff injuries Jobe FW, Moynes DR. Am J Sports Med. 1982;10:336 -‐9 2. The Manual Muscle Examination for Rotator Cuff Strength, An Electromyographic Investigation Bryan T. Kelly, MD, Warren R. Kadrmas, MD, Kevin P. Speer, MD Am J Sports Med September 1996 vol. 24 no. 5 581-‐588 3. Which is More Useful, the “Full Can Test” or the “Empty Can Test,” in Detecting the Torn Supraspinatus Tendon? Eiji Itoi, MD*, Tadato Kido, MD, Akihisa Sano, MD, Masakazu Urayama, MD Kozo Sato, MD Am J Sports Med January 1999 vol. 27 no. 1 65-‐68 4. Isolated rupture of the tendon of the subscapularis muscle. Clinical features in 16 cases. Gerber C, Krushell RJ. J Bone Joint Surg Br. 1991 May;73(3): 389-‐94. 5. Validation of the lift-‐off test and analysis of subscapularis activity during maximal internal rotation. Greis PE, Kuhn JE, Schultheis J, Hintermeister R, Hawkins R. Am J Sports Med. 1996 Sep-‐Oct;24(5):589-‐93 6. Lag signs in the diagnosis of rotator cuff rupture. Hertel R, Ballmer FT, Lambert SM, Gerber Ch. J Shoulder Elbow Surg. 1996; 5(4):307-‐313 7. Isolated rupture of the subscapularis tendon. Gerber C, Hersche O, Farron A. J Bone Joint Surg Am. 1996 Jul;78(7):1015-‐23. 8. The belly-‐off sign: a new clinical diagnostic sign for subscapularis lesions. Scheibel M, Magosch P, Pritsch M, Lichtenberg S, Habermeyer P. Arthroscopy. 2005 Oct;21(10):1229-‐35 9. Diagnostic values ofclinical tests for subscapularis lesions. Bartsch M, Greiner S, Haas NP, Scheibel M. Knee Surg Sports Traumatol Arthrosc 2010;18:1712–1717 10. The bear-‐hug test: a new and sensitive test for diagnosing a subscapularis tear. Barth JR1, Burkhart SS, De Beer JF. Arthroscopy. 2006 Oct;22(10): 1076-‐84. 11. The Influence of Arm and Shoulder Position on the Bear-‐Hug, Belly-‐Press, and Lift-‐Off Tests: An Electromyographic Study Pennock AT, Pennington WW, Torry MR, Decker MJ, Vaishnav SB, Provencher MT, Millett PJ, Hackett TR. Am J Sports Med November 2011 vol. 39 no. 11 2338-‐2346 12. Operative treatment of massive rotator cuff tears: long term results. Bigliani LU, Cordasco FA, McIlveen SJ , Musso ES. JBoneJoint SurgAm 1992;74: 1505–1515. 13. Walch G, Boulahia A, Calderone S and Robinson AH. The ‘dropping’ and ‘hornblower’s’ signs in evaluation of rotator-‐cuff tears. J Bone Joint Surg 1998, 80B:624-‐628.