Group of muscles
The
rotator cuff
is a group of
muscles
and their
tendons
that act to stabilize the human
shoulder
and allow for its extensive
range of motion
. Of the seven
scapulohumeral muscles
, four make up the rotator cuff. The four muscles are:
Structure
[
edit
]
Muscles composing rotator cuff
[
edit
]
The supraspinatus muscle spreads out in a horizontal band to insert on the superior facet of the
greater tubercle
of the
humerus
. The greater tubercle projects as the most
lateral
structure of the
humeral head
.
Medial
to this, in turn, is the
lesser tubercle
of the humeral head. The subscapularis muscle
origin
is divided from the remainder of the rotator cuff origins as it is deep to the
scapula
.
The four
tendons
of these muscles converge to form the rotator cuff tendon. These tendinous
insertions
along with the
articular capsule
, the
coracohumeral ligament
, and the
glenohumeral ligament
complex, blend into a confluent sheet before insertion into the humeral tuberosities (i.e. greater and lesser tubercle).
[3]
The infraspinatus and teres minor fuse near their
musculotendinous junctions
, while the supraspinatus and subscapularis tendons join as a sheath that surrounds the
biceps
tendon at the entrance of the
bicipital groove
.
[3]
The supraspinatus is most commonly involved in a
rotator cuff tear
.
Function
[
edit
]
The rotator cuff muscles are important in shoulder movements and in maintaining
glenohumeral joint
(shoulder joint) stability.
[4]
These muscles arise from the
scapula
and connect to the head of the
humerus
, forming a cuff at the shoulder joint. They hold the head of the humerus in the small and shallow
glenoid fossa
of the scapula. The glenohumeral joint has been analogously described as a
golf ball
(head of the humerus) sitting on a
golf tee
(glenoid fossa).
[5]
During
abduction
of the arm, moving it outward and away from the trunk (torso), the rotator cuff compresses the glenohumeral joint, an action known as concavity compression, in order to allow the large
deltoid muscle
to further elevate the arm. In other words, without the rotator cuff, the humeral head would ride up partially out of the glenoid fossa, lessening the efficiency of the deltoid muscle. The anterior and posterior directions of the glenoid fossa are more susceptible to
shear force
perturbations as the glenoid fossa is not as deep relative to the superior and inferior directions. The rotator cuff's contributions to concavity compression and stability vary according to their stiffness and the direction of the force they apply upon the joint.
In addition to stabilizing the glenohumeral joint and controlling humeral head translation, the rotator cuff muscles also perform multiple functions, including abduction,
internal rotation
, and
external rotation
of the shoulder. The infraspinatus and subscapularis have significant roles in scapular plane shoulder abduction (
scaption
), generating forces that are two to three times greater than the force produced by the supraspinatus muscle.
[6]
However, the supraspinatus is more effective for general shoulder abduction because of its moment arm.
[7]
The anterior portion of the supraspinatus tendon is submitted to a significantly greater load and stress, and performs its main functional role.
[8]
Clinical significance
[
edit
]
Tear
[
edit
]
The tendons at the ends of the rotator cuff muscles can become torn, leading to
pain
and restricted movement of the arm. A torn rotator cuff can occur following trauma to the shoulder or it can occur through the "wear and tear" on tendons, most commonly the supraspinatus tendon found under the
acromion
.
Rotator cuff injuries are commonly associated with motions that require repeated overhead motions or forceful pulling motions. Such injuries are frequently sustained by athletes whose actions include making repetitive throws, athletes such as
handball players
,
baseball
pitchers
,
softball
pitchers
,
American football
players (especially
quarterbacks
),
firefighters
,
cheerleaders
, weightlifters (especially
powerlifters
due to extreme weights used in the
bench press
),
rugby
players,
volleyball
players (due to their swinging motions),
[
citation needed
]
water polo
players, rodeo
team ropers
,
shot put
throwers,
swimmers
,
boxers
,
kayakers
,
martial artists
,
fast bowlers
in cricket,
tennis
players (due to their service motion)
[
citation needed
]
and
tenpin bowlers
due to the repetitive swinging motion of the arm with the weight of a
bowling ball
. This type of injury also commonly affects
orchestra conductors
,
choral conductors
, and
drummers
(due, again, to swinging motions).
As progression increases after 4?6 weeks, active exercises are now implemented into the rehabilitation process. Active exercises allow an increase in strength and further range of motion by permitting the movement of the shoulder joint without the support of a physical therapist.
[9]
Active exercises include the Pendulum exercise, which is used to strengthen the Supraspinatus, Infraspinatus, and Subscapularis.
[9]
External rotation of the shoulder with the arm at a 90-degree angle is an additional exercise done to increase control and range of motion of the Infraspinatus and Teres minor muscles. Various active exercises are done for an additional 3?6 weeks as progress is based on an individual case-by-case basis.
[9]
At 8?12 weeks,
strength training
intensity will increase as free-weights and resistance bands will be implemented within the exercise prescription.
[6]
Impingement
[
edit
]
The accuracy of the physical examination is low.
[10]
The
Hawkins-Kennedy test
[11]
[12]
has a
sensitivity
of approximately 80% to 90% for detecting impingement. The infraspinatus and supraspinatus
[13]
tests have a
specificity
of 80% to 90%.
[10]
A common cause of shoulder pain in rotator cuff impingement syndrome is
tendinosis
, which is an age-related and most often
self-limiting
condition.
[14]
Studies show that there is moderate evidence that hypothermia (cold therapy) and exercise therapy used together are more effective than simply waiting for surgery and they suggest the best outcome for non-surgical treatment of subacromial impingement syndrome. The group of patients who participated in the exercise group were found to use significantly lower amounts of non-steroidal anti-inflammatory drugs (NSAIDS) and analgesics than the control group with no intervention.
[15]
Inflammation and fibrosis
[
edit
]
The rotator interval is a triangular space in the shoulder that is functionally reinforced externally by the
coracohumeral ligament
and internally by the
superior glenohumeral ligament
, and traversed by the intra-articular
biceps tendon
. On imaging, it is defined by the coracoid process at its base, the supraspinatus tendon superiorly and the subscapularis tendon inferiorly. Changes of
adhesive capsulitis
can be seen at this interval as
edema
and
fibrosis
. Pathology at the interval is also associated with glenohumeral and biceps instability.
[16]
Adhesive capsulitis or "frozen shoulder" is often secondary to rotator cuff injury due to post-surgical immobilization. Available treatment options include intra-articular corticosteroid injections to relieve pain in the short-term and electrotherapy, mobilizations, and home exercise programs for long-term pain relief.
[17]
Pain management
[
edit
]
Treatment for a rotator cuff tear can include rest, ice, physical therapy, and/or surgery.
[18]
A review of manual therapy and exercise treatments found inconclusive evidence as to whether these treatments were any better than placebo, however "High quality evidence from one
trial
suggested that manual
therapy
and exercise improved function only slightly more than
placebo
at 22 weeks, was little or no different to
placebo
in terms of other patient-important outcomes (e.g. overall pain), and was associated with relatively more frequent but mild adverse events."
[19]
The rotator cuff includes muscles such as the supraspinatus muscle, the
infraspinatus
muscle, the
teres minor muscle
and the
subscapularis muscle
. The upper arm consists of the
deltoids
,
biceps
, as well as the
triceps
. Steps must be taken and precautions need to be made in order for the rotator cuffs to heal properly following surgery while still maintaining function to prevent any deteriorating effects on the muscles. In the immediate postoperative period (within one week following surgery), pain can be treated with a standard ice wrap. There are also commercial devices available which not only cool the shoulder but also exert pressure on the shoulder ("compressive cryotherapy"). However, one study has shown no significant difference in postoperative pain when comparing these devices to a standard ice wrap.
[20]
Continuous passive motion
[
edit
]
Physiotherapy
can help manage the pain, but utilizing a program that involves continuous passive motion will reduce the pain even further.
Assisted passive motion
at a low intensity allows the tissues to be stretched slightly without damaging them
[21]
Continuous passive motion
improves the shoulder range and enables the subject to expand their range of motion without experiencing additional pain. Easing into the motions will allow the person to continue working those muscles to keep them from undergoing atrophy, while also still maintaining that minimum level of function where daily function is allowed. Doing these exercises will also prevent tears in the muscles that will impair daily function further.
[21]
Manual therapy
[
edit
]
A systematic review and
meta-analysis
study shows
manual therapy
may help to reduce pain for patient with Rotator cuff
tendiopathy
, based on low- to moderate-quality evidence. However, there is not strong evidence for improving function also.
[22]
Surgery
[
edit
]
Surgical approaches include
acromioplasty
(a part of the bone is removed to decrease pressure placed on the rotator cuff tendons), removal of a bursa that is inflamed or swollen, and
subacromial decompression
(the removal of tissue or bone that is damaged in order to allow more space for the tendons).
[23]
Surgery may be recommended for patients with an acute, traumatic rotator cuff tear resulting in substantial weakness.
[
citation needed
]
Surgery can be performed open or arthroscopically, although the arthroscopic approach has become much more popular.
[23]
If a surgical option is selected, the rehabilitation of the rotator cuff is necessary in order to regain maximum strength and range of motion within the shoulder joint.
[24]
Physical therapy
progresses through four stages, increasing movement throughout each phase. The tempo and intensity of the stages are solely reliant on the extent of the injury and the patient's activity necessities.
[25]
The first stage requires
immobilization
of the
shoulder joint
. The shoulder that is injured is placed in a sling and shoulder flexion or abduction of the arm is avoided for 4 to 6 weeks after surgery (Brewster, 1993). Avoiding movement of the shoulder joint allows the torn tendon to fully heal.
[24]
Once the
tendon
is entirely recovered, passive exercises can be implemented. Passive exercises of the shoulder are movements in which a physical therapist maintains the arm in a particular position, manipulating the rotator cuff without any effort by the patient.
[26]
These exercises are used to increase stability, strength and range of motion of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles within the rotator cuff.
[26]
Passive exercises include internal and external rotation of the shoulder joint, as well as flexion and extension of the shoulder.
[26]
A 2019 Cochrane Systematic Review found with a high degree of certainty that subacromial decompression surgery does not improve pain, function, or quality of life compared with a placebo surgery.
[23]
Orthotherapy exercises
[
edit
]
Patients that suffer from pain in the rotator cuff may consider utilizing
orthotherapy
into their daily lives. Orthotherapy is an exercise program that aims to restore the motion and strength of the shoulder muscles.
[27]
Patients can go through the three phases of orthotherapy to help manage pain and also recover their full range of motion in the rotator cuff. The first phase involves gentle stretches and passive all around movements, and people are advised not to go above 70 degrees of elevation to prevent any kind of further pain.
[27]
The second phase of this regimen requires patients to implement exercises to strengthen the muscles that are surrounding the rotator cuff muscles, combined with the passive exercises done in the first phase to keep on stretching the tissues without overexerting them. Exercises include
pushups
and shoulder shrugs, and after a couple of weeks of this, daily activities are gradually added to the patient's routine. This program does not require any sort of medication or surgery and can serve as a good alternative.
The rotator cuff and the upper muscles are responsible for many daily tasks that people do in their lives. A proper recovery needs to be maintained and achieved to prevent limiting movement, and can be done through simple movements.
Additional images
[
edit
]
-
Human shoulder joint, front view
-
Human shoulder joint, back view
-
Muscles on the dorsum of the scapula, and the triceps brachii
-
The scapular and circumflex arteries (posterior view)
-
Suprascapular and axillary nerves of right side, seen from behind
-
The suprascapular, axillary, and radial nerves
See also
[
edit
]
Frozen shoulder
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[
edit
]
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