CHAPTER 45 • ROTATOR CUFF PATHOLOGY 269- Posterosuperior glenoid impingement: This condi-
tion, as described by Walch (Walch et al, 1992), has
also been proposed as an etiology in occurring in
patients who play repetitive overhead sports such as
baseball, tennis, and swimming. Walch did not find
the anterior instability described by Jobe in his
patients, but rather noted an impingement of the
supraspinatus and infraspinatus tendons between the
posterosuperior glenoid labrum and the humeral head. - These internal impingement syndromes are character-
ized by partial tears of the articular surface of the rota-
tor cuff, in distinction to the external compression
described by Neer (McFarland et al, 1999).
•Whatever the etiology, weakness of the rotator cuff
results, especially the lower cuff, and superior humeral
head migration occurs. The humeral head then com-
presses the bursa and tendon into the acromion, lead-
ing to impingement. This causes more bursitis, more
tendinosis, and eventually more weakness. Often with
chronic injury, shoulder mechanics will change lead-
ing to abnormal scapulothoracic motion. Physical ther-
apy will need to include rehabilitation of the scapular
stabilizing musculature as well as the lower rotator
cuff muscles (Jobe and Moynes, 1982).
•Any subacromial changes, such as lateral hooking,
CA ligament calcification, or AC joint arthritis (infe-
rior spurs), will cause the condition to get worse and
will more likely need operative intervention than
when the acromion is flat. - Calcific tendinitis: The etiology of calcific tendinitis
remains unknown. Degenerative changes and relative
hypoxia has been suggested as possible explanations.
Conservative treatment similar to that for rotator cuff
syndrome is reported as successful in 60–90% of
patients (DePalma and Kruper, 1961; Harmon, 1958;
Moseley, 1963). Repetitive needling and injection of
local anesthetic has also been successful in relieving
symptoms and often disappearance of the calcified
mass. Infrequently, the patient’s symptoms will per-
sist and they will require operative intervention. The
mass is localized within the substance of the tendon
while viewing in the subacromial space. The calcified
substance is then evacuated and debrided. Some argue
that a repair of the tendon is not necessary, but the
surgeon should evaluate the cuff after debridement in
each case to determine if repair is necessary.
EXAMINATION (YAMAGUCHI
ET AL, 2001)
- Inspection should focus on normal alignment of chest
wall, shoulders, and clavicle. Have the patient perform
active range of motion (ROM) in forward flexion,
abduction, adduction, external rotation, and internal
rotation. Look from the back and front for asymmetric
motion or atrophy. Often patients will have a painful
arc of motion over 120°of elevation.
•Palpation of the AC and sternoclavicular(SC) joints,
the anterior and lateral acromion edges and the infra-
spinatus fossa. Tenderness at the AC joint should lead
you to further evaluation and treatment of AC joint
arthrosis. Cross-arm adduction is often painful with
AC arthrosis; however, this test is not very specific
and is often positive with rotator cuff syndrome.
•Palpation of the long head of the biceps tendon within
the bicipital groove is helpful to determine biceps
involvement.- Strength testing should involve the deltoid muscles,
biceps muscles, and triceps muscles. Although there is
no way to totally isolate each of the rotator cuff mus-
cles, the tests that have shown to be most specific are
as follows (Kelly et al, 1996):- Supraspinatus: Active elevation against resistance
with the elbow in extension and the arm elevated to
90 °and externally rotated to 45°. The hand should be
supinated to neutral as if holding a full can of soda. - Infraspinatus/teres minor: Active external rotation
with arm at the side and elbow flexed to 90°. - Subscapularis: Active internal rotation with elbow
flexed to 90°and hand placed behind the back. This
is often referred to as the Gerber lift-off test (Gerber,
Hersche, and Farron, 1996; Gerber and Krushell,
1991; Greis et al, 1996). In patients who are unable
to internally rotate their hand behind their back, a
belly press test or “Napoleon’s test” is performed.
Patient place their hands on their belly and press
hard into their abdomen while bringing their elbow
forward in the sagittal plane. Subscapularis tear or
dysfunction is indicated if they are unable to do this
maneuver and the elbow stays close to the side
(Warner, Allen, and Gerber, 1994).
- Supraspinatus: Active elevation against resistance
- Lag tests are also often used to detect rotator cuff
tears. The Hornblower’s sign, ER lag and IR lag tests
were described by Gerber and Hertel and are helpful
to determine subtle weakness (Gerber and Krushell,
1991; Hertel et al, 1996). - Special tests include the Neer impingement sign and
test and Hawkins’ sign.
1.Neer’s impingement sign is similar to the
supraspinatus testing described above, except the
arm is held in maximal internal rotation as if pour-
ing out a can of soda. This rotates the greater
tuberosity under the acromion to elicit a painful
response if the bursa or tendons are injured. A pos-
itive Neer’s test is when a subacromial injection of
local anesthetic relieves the pain elicited prior to
the injection (Neer, 1972; 1983).