2.  SUPRASPINATUS
 INFRASPINATUS
 TERES MINOR
 SUBSCAPULARIS
 AND THEIR MUSCULOTENDINOUS
ATTACHMENT

4.  subscapularis muscle is innervated by the
subscapular nerve and originates on the
scapula. It inserts on the lesser tubercle of
the humerus.
 The supraspinatus and infraspinatus are both
innervated by the suprascapular nerve,
originate in the scapula, and insert on the
greater tubercle.

5.  The teres minor is innervated by the axillary nerve,
originates on the scapula, and inserts on the
greater tubercle.
 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.

6.  The rotator cuff is the dynamic stabilizer of the
glenohumeral joint. The static stabilizers are the
capsule and the labrum complex, including the
glenohumeral ligaments.
 Without an intact rotator cuff, particularly during the
first 60° of humeral elevation, the unopposed deltoid
would cause cephalad migration of the humeral head,
with resulting subacromial impingement.

7.  Extrinsic factors include
 a traumatic tear in tendons from a fall or
accident.
 Overuse injuries from repetitive lifting,
pushing, pulling, or throwing are also
extrinsic in nature.

8.  INTRINSIC FACTORS
 POOR BLOOD SUPPLY
 DEGENERATION WITH AGING
 CALCIFICATION OF TENDON

9.  Rotator cuff dysfunction is typically a continuum of
pathology ranging from tendinitis and bursitis, to
partial tearing, to a complete tearing in one or
more of the tendons.
 These tears most commonly occur at the
tenoperiosteal (tendon-to-bone) junction. Because
this area has a relatively poor blood supply, injury
to the tendon at this location is very unlikely to
heal.

10.  Additionally, the constant resting tension in
the muscle-tendon unit, or muscle tone,
pulls any detached fibers away from the
bone, preventing their reattachment.
 Finally, joint fluid from within the shoulder
may seep into the tear gap and prevent the
normal healing processes from occurring

11.  IMPINGEMENT SYNDROME/SUPRASPINATUS
TENDINITIS
 RUPTURES OF ROTATOR CUFF
 ADHESIVE CAPSULITIS
 CALCIFIC TENDINITIS

12.  is a clinical SYNDROME which occurs when
the tendons of the rotator cuff muscles
mainly supraspinatus undergo repititive
compression or rubbing under the coraco
acromial arch.
 This can result in pain, weakness and loss of
movement at the shoulder syndrome

13.  bony structures such as subacromial spurs
(bony projections from the acromion),
osteoarthritic spurs on the acromioclavicular
joint, and variations in the shape of the
acromion.
 Thickenend or calcified coracoacromial
ligament .

14.  Loss of function of the rotator cuff
muscles, due to injury or loss of strength,
may cause the humerus to move
superiorly, resulting in impingement.
 Inflammation and subsequent thickening of
the subacromial bursa may also cause
impingement.[1]

15.  The range of motion at the shoulder may be
limited by pain. A painful arc of movement
may be present during forward elevation of
the arm from 60° to 120°.
 Passive movement at the shoulder will
appear painful when a downwards force is
applied at the acromion but the pain will
Cease once the downwards force is
removed.[1]

16.  History and physical exam.
 Xrays of the shoulder can be used to
detect some joint pathology and variations in
the bones, including acromioclavicular
arthritis, variations in the acromion, and
calcifcation.
 Ultrasonography, arthrography and MRI can
be used to detect rotator cuff muscle
pathology

17. Conservative treatment includes
 Rest
 NSAIDS
 PHYSIOTHERAPY
 Therapeutic injections of corticosteroid and
local anaesthetic may be used for persistent
impingement syndrome.

18.  Surgery may be done arthroscopically or as
open surgery.
 The impinging structures may be removed in
surgery, and the subacromial space may be
widened by resection of the distal clavicle
and excision of osteophytes on the under-
surface of the acromioclavicular joint.[2]
 damaged rotator cuff muscles can be
surgically repaired.

19.  Most patients with a pathological condition
of the rotator cuff have insidious onset of
progressive pain and weakness, with
concomitant loss of active motion.
TWO TYPES
 Full thickness tear
 Partial thickness tear

20.  Follow a long period of c/c tendinitis
 Spontaneously after a sprain or jerking injury
of shoulder
CLINICAL FEATURES
 Sudden pain and pt not able to abduct the
arm
 Active abduction is impossible even when
pain subsides or has been abolished by

21.  Injection of local anaesthetic.
 But once the arm is passively abducted pt
can hold it up with deltoid(abduction
paradox) and when the pt lowers it sideways
it suddenly drops(drop arm sign)

22.  Partial-thickness tears usually are located on the
articular surface of the supraspinatus near its
insertion.
 Pt can abduct actively once the pain has been
abolished by local anaesthetic.

23.  Physiotherapy
 NSAIDS
 OPERATIVE MGMT if it fails

24.  arthroscopic-assisted or arthroscopic
repair is appropriate for partial-thickness
and small to medium full-thickness rotator
cuff tears.
 After standard repair, shoulder immobilized
for 6 weeks followed by assisted exercises in
flexion and external rotation to avoid
adhesions, disuse atrophy, and disruption of
the repairs.

25. Debridement and limited decompression.
 to obtain and maintain the maximal range of
passive glenohumeral flexion and rotation

26.  contracted, thickened joint capsule that
seemed to be drawn tightly around the
humeral head with a relative absence of
synovial fluid and chronic inflammatory
changes within the subsynovial layer of the
capsule.

27. Common in pts with
 DM
 CERVICAL SPINE DISEASES
 HYPERTHYROIDISM
 TRAUMA
 INTRATHORACIC DISORDERS

28. I. PAIN
II. STIFFENING
III. THAWING

29.  Diagnostic tests in patients with a frozen shoulder
(including plain film roentgenograms) usually are
normal.
 Treatment. self-limiting condition, lasting 12 to 18
months without long-term sequelae
Initial treatment is nonoperative,
 NSAIDS
 Transcutaneous electrical nerve stimulation (TENS)
and ultrasound
 PHYSIOTHERAPY –PENDULUM EXERCISES

30.  Cause-hypo vascularity
 Phase 1—Precalcification stage.:
fibrocartilagenous metaplasia
 Phase II—Calcific stage. During this stage
calcium is deposited into matrix vesicles,
which are excreted by the cells and coalesce
into larger calcium deposits. This stage can
be exceedingly painful, and many patients
seek treatment at this time

31.  Phase III—Postcalcific phase. Pain subsides
markedly during this phase.
 Nonoperative treatment usually includes
physical therapy, exercises, antiinflammatory
medications, and steroid injections.

32.  indications for operative treatment: (1)
symptom progression, (2) constant pain that
interferes with activities of daily living, and
(3)conservative therapy-failure
 Aspiration and Needling of Calcified Deposits
 Excision of Calcium Deposits

33.  REFERRED PAIN SYNDROME-SPONDYLOSIS,MEDIASTINAL
PATHOLOGY
 JOINT DISORDERS-ARTHRITIS
 BONE LESIONS-INFNS,TUMOURS
 ROTATOR CUFF DISORDER
 INSTABILITY-DISLOCATION,SUBLUXATION
 NERVE INJURY-SUPRASCAPULAR NERVE ENTRAPMENT

34.  HISTORY
 INSPECTION
 The shoulder, cervical region, and entire
upper extremity must be assessed-BONE &
SOFT TISSUE.
 The dominant side may be lower than the
nondominant one. Observation of the soft
tissues is directed first at the contours of the
deltoid.

35.  FROM ANTERIOR TO POSTERIOR-SOFT & BONY
STRUCTURES PALPATED.
 EXAMINER STANDS BEHIND THE PATIENT.
 THE STRUCTURES ASSESED ARE THE
STERNOCLAVICULAR JOINTS, SCM,
COSTOCHONDRAL JOINTS, FIRST RIB &
ACROMIOCLAVICULAR JOINTS.

36.  SUPERIOR MIGRATION OF MEDIAL END OF
CLAVICLE IS NOTED IN STERNOCLAVICULAR
JOINT DISLOCATION.
 STEP DEFORMITIES WITH SUPERIOR
MIGRATION OF LATERAL END OF CLAVICLE
SEEN IN ACROMIOCLAVICULAR JOINT
DISLOCATION OR SUBLUXATION.

37. BOTH ACTIVE & PASSIVE MOVEMENTS ASSESED.
NORMAL ROM-
1) ABDUCTION (70 – 180)
2) ADDUCTION (30 -45)
3) EXTENSION (45 – 60)
4) FLEXION (160 – 180)
5) INTERNAL ROTATION(90 – 110)
6) EXTERNAL ROTATION( 80 – 90)

38.  The scapulohumeral rhythm is observed. If a painful
arc (ie, pain or inability to abduct because of pain)
is observed at 45-120°, a subacromial
impingement syndrome is suggested.
 If the pain is greater after 120°, when full
elevation is reached, an acromioclavicular joint
disorder is suggested.

39.  If a reverse scapulohumeral rhythm (ie, an
abduction initiated by the scapulothoracic
joint rather than by the glenohumeral joint)
is observed, a frozen shoulder is suggested.

40.  NEER IMPINGENENT TESTS
 HAWKINS KENNEDY TESTS
 YOCUM TESTS

41. With the examiner standing behind the
patient, the shoulder is passively flexed.
 When the result is positive, this test
produces pain caused by contact of the
bursal side of the rotator cuff on the anterior
third of the undersurface of the acromion
and the coracoacromial ligament.
 A positive test result suggests an
anterosuperior impingement syndrome

42.  With the examiner standing behind the patient, the
shoulder is flexed passively to 90°, followed by
repeated internal rotation.
 When the result is positive, this test produces pain
caused by contact of the bursal side of the rotator cuff
on the coracoacromial ligament and by contact between
the articular surface of the tendon and the
anterosuperior glenoid rim. Contact between the
subscapularis tendon and the coracoid process is also
observed.
 A positive test result suggests an anterosuperior or an
anterointernal impingement test.

43.  With the examiner standing behind the
patient, the hand on the ipsilateral side of
the examined shoulder is placed on the
contralateral shoulder. The elevation of the
elbow is resisted by the examiner.
 When the result is positive, this test
produces pain caused by contact of the
bursal side of the cuff tendon with the
coracoacromial ligament and possibly the
undersurface of the acromioclavicular joint.

44.  To identify the supraspinatus tendon
 Full-can test: The shoulder is placed at 90°
of flexion and 45° of external humeral
rotation (thumb pointing upward, as if
someone is holding a full can right-side-up).
Shoulder elevation is resisted. The test result
is considered positive if it produces pain.

45.  In the Patte test, the shoulder is placed at
90° of abduction, in neutral rotation, and in
the plane of the scapula. The examiner holds
the elbow of the patient, and the external
rotation is resisted. The test result is
considered positive if it produces pain.
 To identify the teres minor tendon, use the
same tests used for the infraspinatus tendon

46.  In the Gerber lift-off test, the shoulder is
placed passively in internal rotation and
slight extension by placing the hand 5-10 cm
from the back with the palm facing outward
and the elbow flexed at 90°. The test result
is positive when the patient cannot hold this
position, with the back of the hand hitting
the patient's back