1. PRATIGYA DEUJA
ROTATOR CUFF
INJURIES

2. DEFINITION
 Commonest cause of pain around the shoulder, it is a
disorder of the rotator cuff which sometimes
referred as rotator cuff syndrome.
 Rotator cuff muscles :- Supraspinatus, Infraspinatus,
Subscapularis and Teres minor.
MECHANISM
:- Fall or direct impact trauma
:- Acute overload incident or develop gradually from
degenerative process.

3. ROTATOR CUFF INJURY
Fig:- Rotator cuff tears-
Orthoinfo- AAOS

4. CAUSES
 Baseball players.
 By excessive force (lifting a very heavy object with the
arm extended / trying to catch a heavy object as it falls).
 Typical RCI occurs to a middle aged person or older has
an experienced problem of shoulder.
 Also occurs in injuries or condition such as arthritis,
tendonitis or bursitis affect the shoulder joint.
 Pain and loss of mobility can result.
 Weak shoulder muscle.
 Poor posture
 Repetitive stress on the shoulder

5. SYMPTOMS
1) Shoulder pain, usually when moving the shoulder or
sleeping on it.
2) Tenderness in shoulder
3) weakness in shoulder
4) Not being able to move the shoulder as much as
normal (decrease ROM)
5) Soreness in the shoulder
6) Impossible to raise the arm or move it away from
the side
7) Instability
8) Deformity

6. CLINICAL FEATURES
Complain of pain with overhead activity such as
throwing, swimming, overhead shots in racquet sports,
activities undertaken <90° of abduction are usually pain
free.
Associated symptoms of instability such as recurrent
subluxation or episodes of dead arm.
Depends on the stage of disorder, age of the patient
and vigorous of heading response.

7. 3 PATTERNS
1) Subacute tendinitis (Vascular congestion, edema and
hemorrhage leads painful arc syndrome)
2) Chronic tendinitis (recurrent shoulder pain due to
tendinitis and fibrosis)
3) Cuff disruption (Recurrent pain, weakness and loss of
movement)

8. PATHOLOGY
 It occurs due to repetitive compression or rubbing of the
tendon (mainly supraspinatus)
 When the arm is abducted the conjoint tendon slides
under the coracromial arch.
 If the arm is held persistently in abduction and then
moved to and fro in IR and ER (as in cleaning a window,
painting a wall or polishing a flat surface.
 Rotator cuff may be compressed and irritated as it
comes in contact with the anterior edge of the acromion
process and the taut coracoacromial ligament. This
attitude has been called the Impingement position,
(Abd, slight flx, IR)

9. OTHER FACTORS
 Repetitive Impingement :-
o RA
o Swelling of cuff
o Osteophytes on the anterior edge of the
acromion
o Formation of bony edges
o Osteoarthritic
o Thickening of the AC joint

10. OTHER FACTORS
 Friction :- Localized edema and swelling
 3 variation of acromial morphology
 Type I :- Flat
 Type II :- Curved
 Type III :- Hooked acromion
 Prolonged or repetitive impingement (older age)
Minute tears can developed these may be followed by
scarring , fibrocartilaginous, metaplasia or
calcification in tendon

11. ON EXAMINATION
Physical examination:- Therapist assist the full ROM of
shoulder yet patient is unable to complete the same
movements using their own strength.
 MRI scan:- To determine torn
Special test:-
Impingement:- Aim is to elicit pain while moving the
greater tuberosity under the acromion.

12. ON EXAMINATION
 Hawkins kennedy test :- The shoulder is placed in
90° of forward flexion and then forcibly internally
rotated.
 Resisted movement :- Empty can position (90° of
abduction, 30°of horizontal flexion and full internal
rotation) . This test may indicate supraspinatus
abnormalities. Repeat with a retracted scapulae.

13. CLINICAL MANAGEMENT
 Anti- inflammatory drugs (ibuprofen)
 Steroid injection in the bursa, shoulder joint, around the
tendons to reduce inflammation, pain and increase
mobility of shoulder joint.
 If it is not successful, surgery may needed such as
arthroplasty of shoulder, suturing, tendon repair etc.

14. PHYSIOTHERAPY
MANAGEMENT
 Electro:-
 TENS
 Ice pack
 Hot pack
 Contrast bath
 Ultrasound

15. PHYSIOTHERAPY
MANAGEMENT
 Exercise:-
 AROM
 RROM
 Stretching
 Wall slides
 Front cross over
pulls
 Wand exercise
 Towel stretch
 Blade squeeze
Back stretch
Scapular squeeze
Pendulum exercise
Prone extension
Pectoralis stretch
Push up pulls
Scaption
Prone horizontal
extension

16. PHYSIOTHERAPY
MANAGEMENT
PECTORALIS STRETCH PENDULAR EXERCISE

17. PHYSIOTHERAPY
MANAGEMENT
SHOUDER SQUEEZE SCAPTION

18. PHYSIOTHERAPY
MANAGEMENT
TOWEL STRETCH WAND EXERCISE

19. POST OPERATIVE
MANAGEMENT
1) Acute phase
 Tissue healing:- Rest
:- Short term mobilization
:- Modalities
 Decrease pain & inflammation:-NSAID,
:- Corticosteroid
:- Ultrasound
:- cold compression

20. PHYSIOTHERAPY
MANAGEMENT
 Re-establish ROM:- Pendulum exercise
:- Manual capsular stretch
:- Cross fiber massage
:- T -pulleys, ropes or bars
 To decrease muscle atrophy :- Isometric exercise with
arm below 90° of abduction and 90° of flexion.
 Scapular control:- Closed chain weight shifts with hands
on table and shoulder flexed less than 60° and abducted
less than 45°.

21. PHYSIOTHERPAY
MANAGEMENT
 Maintain fitness in rest of kinetic chain
o Aerobic exercise :- Running, bicycling or stepping
o Anaerobic :- Agility drills
o Elbow and wrist :- Strengthening by Isometric
exercises or rubber tubing
o Flexibility exercise
 Criteria for movement out of the acute phase
o Minimal pain, Kinetic chain integration, manual
muscle strength, progression of tissue healing,
PROM at 66%-75% of opposite side

22. PHYSIOTHERAPY
MANAGEMENT
2) Recovery phase
 Normal ROM
:- Active assisted motion above 90° of Abduction with hand
:- AROM in IR and ER with scapula stabilized
 Scapular control
:- Scapular PNF patterns.
:- closed chain exercise at 90° of flexion, 90° abduction,
scapular retraction/ protraction and elevation / depression
:- Modified push –ups
:- Ball catch and push exercise
:- Dips ; clock , low row ,lawn mower

23. PHYSIOTHERAPY
MANAGEMENT
Upper extremity strength and strength balance
:- GH PNF patterns
:-Closed chain exercise at 90° of flexion then 90° of
abduction
:- Forearm curls ; isolated rotator cuff exercise
:- light bench presses
Normal shoulder Arthokinematics
:- RoM with arm 90° of abduction
:- Proprioceptive sensory feedback
:- Open chain exercises – mild plyometric exercise

24. PHYSIOTHERAPY
MANAGEMENT
 Normal kinetic chain and force generation
:- Normalization of all inflexibilities throughout kinetic
chain.
:-Normal agonist –antagonist force couples in leg using
squats, plyometric depth jumps.
:- Trunk rotation exercise with medicine ball or tubing.
:- Integrated exercise with leg and trunk stabilization,
rotation , diagonal patterns from hip to shoulder and
medicine ball throw.
:- Rotator cuff strength 4⁺/5 or higher.
:- Normal kinetic function.

25. PHYSIOTHERAPY
MANAGEMENT
3) Functional phase
 Power and endurance in UE
:- Diagonal and multiplanar motions with rubber tubing,
light weights, small medicine balls and isokinetic
machines.
:-Plyometrics – wall push – ups, corner push – ups,
weighted ball throws and tubing
 Increase multiple plane neuromuscular control
:-Kinetic chain to generate and funnel the proper forces
to and through the shoulder.

26. PHYSIOTHERAPY
MANAGEMENT
Rehabilitation
:- Flexibility
:- Strength
:- Endurance
 Sport specific activity
:- Functional progressions of throwing or serving
:- Kinetic chain

27. REFRENCES
 Clinical orthopaedic rehab by S. BRENT Brontzman
and Kevin E.WILK (second edition)
 Clinical sports medicine by Peter Brukner and Karim
Khan ( third edition)
 Physical Medicine and Rehabilitation by Walter R.
Frontera
 Belmaire et al. Rehabilitation Management of
Rotator Cuff Injuries in the Master Athelete
(American college of sports medicine, 2019)