The Rotator Cuff is a group of four muscles that play a significant role in movement of The Shoulder Girdle . The extensive range of motion available to the shoulder is in sacrifice of structural stability, for which the rotator cuff is able to compensate. The Supraspinatus , Subscapularis , Teres Minor and Infraspinatus all originate from varying locations before inserting onto the proximal Humerus . The term “cuff” refers to its reinforcing role of the Glenohumeral Joint as each associated muscle extends fibres that blend with the Glenohumeral Joint Capsule (SOURCE-6).
Bone :
together these bones form the following joints:
Muscle :
Nerve :
Collectively, the Rotator Cuff is responsible for two main functions:
Dynamic Stability- a primary function of the Rotator Cuff is to afford the highly-mobile Glenohumeral Joint stability in the absence of significant bony/ static stabilisers. Anticipatory forces produced by the Cuff actively move the Head of the Humerus to centralise and stabilise it against the Glenoid Fossa. Given the larger superficial muscles (such as Latissimus Dorsi , Deltoid , Pectoralis Major or Coracobrachialis ) produce movement, the Rotator Cuff must counter their individual translatory biases to maintain a centred Humeral Head (SOURCE-16). Relative to these more superficial muscles, the Rotator Cuff has little shear bias in any direction (SOURCE-22). The Rotator Cuff has displayed “pre-setting” activity fractions of a second prior to movement (SOURCE-17)
Controllers of the Arthrokinematics- During arm elevation, the cuff must counteract the superior pull of the Deltoid to prevent the Head of Humerus from impinging superiorly (SOURCE-36). For the Infraspinatus , Teres Minor and Subscapularis , this is achieved through their shared inferiorly directed pull on the Humeral Head (SOURCE-36). Uniquely, the Supraspinatus produces a compression force, stabilising the Humeral Head against the Glenoid Fossa (SOURCE-36).The anterior cuff ( Subscapularis ) and posterior cuff ( Infraspinatus and Teres Minor ) also form an antagonising force-coupling (SOURCE-37). Contraction of the anterior cuff causes an anterior glide/roll of the Humerus, while contraction of the posterior cuff causes an opposing posterior roll (SOURCE-36). The posterior cuff also contributes to GH Joint - External Rotation which during arm elevation allows the Greater Tubercle to adequately clear the Acromion by increasing subacromial clearance (SOURCE-38)
While the Glenohumeral Joint Capsule provides significant contributions at 0º and 90º GH Joint - Abduction , it appears to provide little stability at mid range (30º and 60º) which forces dynamic stabilisers such as the Rotator Cuff to increase their activity in compensation (SOURCE-7).
Rotator Cuff pathologies such as a Tendinopathy , Subacromial Impingement and Tears often occur concomitantly and at various stages predisposing or perpetuating one another (SOURCE-12). While many Rotator Cuff pathologies begin asymptomatic, ~20% are expected to become symptomatic within a three year period (SOURCE-15).Secondary Steatosis, Muscle Atrophy and traumatic Osteoarthritis are common sequelae that may follow chronic or severe rotator cuff pathology (SOURCE-21). There are several mechanisms by which the Rotator Cuff can be left vulnerable to injury through both insidious and traumatic onset:
Subacromial Impingement - Both primary and secondary impingement threaten the integrity of the Rotator Cuff through diverging mechanisms:
Primary Impingement- Hooked Acromion morphologies, Bony Spur formation and Subacromial Bursitis impose on the Rotator Cuff (SOURCE-2)
Secondary Impingement- perturbed arthrokinematics at the Glenohumeral Joint entrap the Rotator Cuff
In a positive feedback-loop the inflammatory cascade associated with Rotator Cuff Tendinopathy may also narrow the Subacromial Space by a reported 53-68% (SOURCE-24).
Coracoacromial Ligament - excessive or repetitive friction between the Rotator Cuff Tendons and the Coracoacromial Ligament can lead to degeneration of either structure (SOURCE-1). Variations in the CAL of more than one band are associated with a greater incidence of Rotator Cuff degeneration (SOURCE-2). Similarly, a shallower Bicipital Groove or shorter Lesser Tuberosity of Humerus potentiates pathology of the Subscapularis (SOURCE-13).
Muscle insufficiency is also of concern. Without adequate Supraspinatus force, the almost vertical pull of the Deltoid approximates the Humeral Head superiorly against the Coracoacromial Arch which may narrow the Subacromial Space and restrict GH Joint - Abduction .
Humeral Retroversion increases the functional GH Joint - External Rotation range in sacrifice of GH Joint - Internal Rotation which directly alters the length-tension relationship of the Rotator Cuff. Furthermore, these changes can lead to an adaptive thickening of the Posterior Glenohumeral Joint Capsule which can also perpetuate Rotator Cuff pathology (SOURCE-19).
FOOSH was the most common mechanism of traumatic injury and forced GH Joint - External Rotation with the arm in GH Joint - Abduction was also frequently reported. Given their nature, these mechanisms are more likely to produce Tears of greater severity and to affect the Subscapularis . The average age of those experiencing a traumatic Rotator Cuff Tear was almost half that of those experiencing non-traumatic tears (34.2 versus 54.1). The two most notable contributors to tissue healing are lesion size and patient age (SOURCE-15).
Excessive Scapulothoracic Joint - Upward Rotation during arm elevation is a common presentation and is thought to be a compensatory mechanism for insufficient Rotator Cuff action (SOURCE-12). Increased Anterior Scapular Tilting and Internal Rotation are also common (SOURCE-12). Additionally, in the presence of Rotator Cuff pathology, the Biceps Brachii have displayed increased activity suggesting further compensation (SOURCE-5).
In terms of Fascia l connections the Rotator Cuff belongs to several chains or lines. Restriction along either could result in Pain or dysfunction in the Rotator Cuff or vice versa:
Myofascial Chains - the proximal end of the Dorsal Arm Chain contains the Teres Minor and Infraspinatus
Fascial Lines - Collectively, the Rotator Cuff muscles belong to the Deep Back Arm Line . Individually, the Teres Major is included in the Superficial Front Arm Line , thus forming a crossover with the Deep Back Arm Line via the Scapula
A Peripheral Nerve Neuropathy could result in weakness, dysfunction or in severe instances atrophy of the Rotator Cuff muscle(s) it innervates:
Similarly, a Radiculopathy from predominately the C5 or C6 Nerve Roots may also result in Rotator Cuff dysfunction.
Aside from the aforementioned, Rotator Cuff pathology occurs more frequently in the following populations:
Athletes and Labourers, particularly those with substantial overhead work (SOURCE-15+19)
Surgery - following an excision of the Coracoacromial Ligament or Acromioplasty, the Rotator Cuff increases its working capacity by 25-30% to uphold normal mechanics of the Glenohumeral Joint (SOURCE-2)
Alcohol Consumption - excessive alcohol intake (~7-13 and 4-6 drinks per week for men and women respectively) a significant risk factor for occurrence and severity of Rotator Cuff Tears (SOURCE-23)
The Rotator Cuff is subject to is own pathologies and associated with many others. In non-traumatic instances Subacromial Impingement is described to predispose Rotator Cuff Tendinopathy and eventually Rotator Cuff Tear . Further its pathologic condition can be predisposed and maintained by many pathologies, including those discussed below:
Scapular Dyskinesis - Either a predisposing factor or sequela of a Rotator Cuff Tear or Tendinopathy is altered positioning and Motor Control of the Scapula (SOURCE-3). Scapular instability has been identified in as many as 68% of Rotator Cuff pathologies which may provide direction for treatment (SOURCE-12).
Subacromial Impingement - Decreased Scapulothoracic Joint - Upward Rotation with increased Anterior Scapular Tilting and Internal Rotation predisposes underlying soft-tissue to impingement (SOURCE-12). Further pathologically inflamed Rotator Cuff muscles could reduce the Subacromial Space.
Subacromial Bursitis - one hypothesis for the evolution of Subacromial Bursitis into Rotator Cuff pathologies attributes the formation of synovial folds, known asPlica. These Plica course through the Bursa and may increase friction of the Rotator Cuff (SOURCE-11)
Glenohumeral Instability - Rotator Cuff weakness was associated with anterior instability and recurrence (SOURCE-10). Conversely, the following factors were associated with acute traumatic posterior instability events:
Greater GH Joint - External Rotation Strength at 0º and 45º GH Joint - Abduction
Greater GH Joint - Internal Rotation Strength at 0º GH Joint - Abduction
Ratio of External to Internal Rotation at 45º GH Joint - Abduction
(SOURCE-9)
A consensus is yet to be established on whether greater Rotator Cuff Strength was a compensatory response to the instability or a contributing factor (SOURCE-9).
Adhesive Capsulitis - the conditions pathogenesis may be related to rotator cuff pathology (SOURCE-6)
Glenoid Retroversion - significantly associated with Rotator Cuff Tears (SOURCE-20).
Traumatic Osteoarthritis - a known sequela of Rotator Cuff Tears (SOURCE-21)
Shoulder Elevation with and without a clenched fist - Pain on movement that subsides once a clenched fist is added indicates a failure of the Rotator Cuff to adequately centre the Head of the Humerus within the Glenoid
Scapulohumeral Rhythm - Rotator Cuff pathologies may cause disturbances to Rhythm (SOURCE-12 (20,82)), particularly a reduction in Scapulothoracic Joint - Upward Rotation (SOURCE-12)
The following lists validated tests for evaluation of the Rotator Cuff:
General Pathology:
Rent Test - sensitivity 0.73-0.96, specificity 0.66-0.97
Dynamic Rotary Stability Test - evaluates RC ability to provide dynamic stability through multiple ranges
Painful Arc - sensitivity 0.67-0.75, specificity 0.47-0.61
Whipple Test - sensitivity 0.80, specificity: 0.33
Rotator Cuff Tear / Rupture:
Whipple Test - sensitivity: 1.00, specificity: 0.26
Drop Arm Test - sensitivity: 0.14-0.34, specificity: 0.77-0.87
For tests that evaluate individual Rotator Cuff muscles, see Shoulder - Special Tests or their respective pages.
As imaging findings alone do not consistently correlate with a patients symptoms and findings are often identified in asymptomatic shoulders, they should be complimented by physical examination before reaching a diagnosis and establishing a treatment protocol (SOURCE-28).
Radiographs (X-Rays)- generally the first line of imaging, used to determine presence of Acromial morphology or other related abnormalities such as Subchondral Cysts or a “notch” on the Greater Tuberosity or ligamentous calcification which may predispose impingement (SOURCE-29). X-Rays are also a reliable measure of theAcromiohumeral Interval, which quantifies the extent of impingement through determining the shortest distances between the inferior cortex of the Acromion and the peak of the Humeral Head (SOURCE-30). A distance of 7-14mm is considered normal, ≤ 7mm indicative of a large Rotator Cuff Tear and a distance smaller than 6mm indicates a chronic and complete tear of the Infraspinatus (SOURCE-30). The following views may be relevant (SOURCE-29+30+31+32+33):
AP view in the Scapula plane - also known asGrashey view, provides a (~20%) higher detection rate when compared to a conventional AP for the following conditions:
Osteophytes on the Greater Tuberosity of the Humerus or under the Acromion
Outlet view - reveals morphology of the Acromion, including bony spurs as well as ligamentous calcification and other causes of impingement
Axillary view - evaluates for Os Acromiale and rules out Dislocation in cases of trauma
When X-Ray findings are unremarkable, CT Scans and MRI’s may be indicated (SOURCE-33).
Ultrasonography (Ultrasound)- an accessible imaging modality with dynamic, real-time capabilities for the evaluation of Rotator Cuff pathology and Subacromial Impingement via certain metrics (SOURCE-28+29+34):
Rotator Cuff Pathology
“focal heterogenous hypoechogenicity”, or a localised portion of the tendon that has a dark and abnormal appearance, indicates the presence of a Rotator Cuff Tear . This may result from accumulated fluid within the cuff surface or its substance. Linear appearing echogenicity within the substance with or without muscle atrophy may also suggest a tear . A complete non-echogenic (black) gap extending the thickness of the tendon indicates a full tear, while in partial tears attachment is still visible
a decrease in tendon thickness was associated with Subacromial Impingement which is indicative of degenerative changes associated with chronicity
Bursa - the thickening of associated bursa as seen in Subacromial Bursitis is indicative of Subacromial Impingement. Similarly, an increased width of the Subdeltoid Bursa may be indicative of impingement. This Inflammation is visualised as an increase in anechoic fluid within the bursa
Subacromial Space - like other imaging modailities, the Acromiohumeral Inverval may be established with Ultrasounds to quantify impingement. A side-to-side differential of <2.1mm was considered normal.
AStandard I (transverse plane) Viewtaken approximately 15mm lateral of the Long Head of Biceps may be used to evaluate the rotator cuff, although this distance is subject to anatomical variation (SOURCE-34). AStandard II (longitudinal plane) Viewmay be used to determine the Acromiohumeral Interval with the Humerus neutrally rotated (SOURCE-34). Other views that may be relevant include Standard Auxiliary Views I, II and III (SOURCE-34). A downfall of this imaging modality is that accuracy is clinician dependent (SOURCE-34).
Magnetic Resonance Imaging MRI- can be used to evaluate the integrity of the Rotator Cuff , the presence of concomitant injuries such as Subacromial Bursitis or SLAP Lesions or associated morphologies (SOURCE-28+29+35). The following findings may be indicative of Rotator Cuff pathology (SOURCE-29):
T1-weighted images - an increased signal without tendon discontinuity indicates a partial- tear . On T1 and proton-density images an increased signal and loss of anatomic definition suggests Tendinitis
T2-weighted images - a signal increase with intra-tendinous focal defect suggests partial- tear . Conversely, Tendinitis may have moderate or decreased signal
Computed Tomography (CT) Scan- akin to MR-arthrography, used most often for the evaluation of Cartilage or the Glenoid Labrum (SOURCE-28). Typically reserved as a complement to other imaging modalities for the assessment of bony changes or when MRI’s are contraindicated (SOURCE-28).
The importance of an effective treatment protocol is highlighted by the fact that the self-healing rate of Rotator Cuff lesions negligible (SOURCE-21).
The following Stretching techniques can be used to restore length in the Rotator Cuff:Simple
Genie Stretch - rudimentary horizontal adduction stretch
Sleeper Stretch - greater emphasis on GH Joint - Internal Rotation
Sleeper Stretch MWM - internal rotation stretch combined with Humerus Mobilisation
Intermediate
Door Frame Shoulder Stretch ( Subscapularis variant) - self-guided anterior shoulder stretch with large Horizontal GH Joint - Abduction range
Door Frame Neck Stretch ( Supraspinatus variant)
Dowel External Rotation Stretch - self-guided GH Joint - External Rotation stretch with overpressure
Advanced
Shoulder Dislocates - mobility exercise that emphasises the greatest circumduction range possible
Swimmers Oblique Extensions - exercise that may be used to lengthen entire Lateral Line through large body-wide lateral-flexion range
Sleeper Stretch MWM - internal rotation stretch combined with Humerus Mobilisation
Restoring function of the Rotator Cuff is centred around ensuring the muscles are appropriately engaged, rather than increasing strength or hypertrophy. Many of these exercises are activation exercises that would be conducted before training or activities of daily living. 2-3 sets of 12-15 is typically sufficient with sets in excess of 20 repetitions increasing the likelihood of compensation from the Posterior Deltoid . Given the relationship between the Scapulothoracic Joint musculature and Rotator Cuff pathologies, improving activity in other stabilisers such as the often weak Serratus Anterior and Lower Trapezius may be indicated.Initial Phase:
Shoulder Sling - passive shoulder movement produced by asymptomatic side
Rotator Cuff Pendulums - oscillatory motion that afford a distracting glide to the Humeral Head
Prone Horizontal Abduction - rudimentary Scapulothoracic Joint - Retraction exercise
Band Pull-Apart - basic isotonic exercise for Scapular Retractors
Rotator Cuff Banded Rotations - light low range isotonic rotation exercises
Prone Shoulder External Rotations - adds gravity or light load to Apprehension Test position
Side-Lying Shoulder External Rotations - maximises effect of gravity against External Rotation with upper arm fixed against torso
Standing Shoulder External Rotations - incorporates upright torso posture
Pallof Press - low load horizontal push exercise that emphasises anti-rotation of Core
Banded Unilateral Lat Activations - activate lat, posteroinferior drawer on Humerus
Circumduction Row - isotonic exercise with variable load used to emphasise mid-to-lower Trapezius
Mid-Phase:
Face Pulls - bilateral isonotic horizontal pull exercise that emphasises GH Joint - External Rotation
Front Raises - isotonic GH Joint - Flexion exercise with many variations
Side Raises - isotonic GH Joint - Abduction exercise with many variations
Upright Row - weighted isotonic vertical pull exercise that emphasises Upper Trapezius
Farmers Carry - upperbody/ Core isometric exercise with perturbation of walking
Later Phase:
DB Hang Clean - unilateral clean progression, often performed explosively
Bottoms-Up Kettlebell Walk - typically isometric exercise for entire arm musculature with perturbation from walking
Suitcase Carry - unilateral farmers carry which emphasises crossbody functional patterns
DB Snatch - unilateral isotonic, explosive shoulder exercise with large overhead range
Lu Raises - large GH Joint - Abduction range with no Humerus rotation to promote Scapulothoracic Joint - Upward Rotation
Push Press - explosive overhead movement with large range that incorporates entire body
Kneeling Landmine Press - explosive Vertical Push exercise with a large overhead range
Split Stance Landmine Press - explosive unilateral, whole-body Vertical Push exercise
DB Snatch to Step-Up - wholebody DB Snatch variation that emphasises diagonal functional patterns
Rope Climb - pull-up variation with entire load bestowed on alternating arm
Bird-Dog Row - One Arm Row variation that emphasises Posterior Sling
All Rotator Cuff muscles can be treated directly and along the Fascial Lines / Myofascial Chains they belong to, particularly when hypertonicity is identified. For specific treatment techniques for each of the four Rotator Cuff muscles, see their individual pages:
Altered arthrokinematics at The Shoulder Girdle can hinder tone and functionality of Rotator Cuff muscles (as seen in Glenohumeral Instability ) or leave them vulnerable to mechanical injury (as seen in secondary Subacromial Impingement ). While treating the relevant soft tissues directly may improve said arthrokinematics, so too can mobilisations which in turn may improve Rotator Cuff dysfunction. Similarly, mobilisations of the Cervical Spine may be relevant in Radiculopathy derived Rotator Cuff symptoms.
Posterior Glide on Humerus - limited by Infraspinatus and Teres Minor
Anterior Glide on Humerus - limited by Subscapularis , advocated as a potential treatment for any stage of Rotator Cuff pathology by Maitland (SOURCE-18)
Humeral Compression with Rotation - used to treat residual Rotator Cuff pain associated with Subacromial compression (SOURCE-18)
All four Rotator Cuff Muscles are treatable with Dry Needling , with specific procedures discussed under their respective pages:
Additionally, the following muscles may disturb innervation of the Rotator Cuff through various mechanisms and are eligible to needle:
Middle Scalene - entrapment site for C5
Sternocleidomastoid - increased Forward Head Posture may increase chances of Radiculopathy
Subacromial Decompression (acromioplasty/ bursectomy) is a common surgical intervention for Rotator Cuff pathology and other causes of Subacromial Impingement that removes bone spurs from the anterolateral undersurface of the Acromion and inflamed Subacromial Bursa or other soft tissues with the aim of widening the space for traversing Tendons (SOURCE-25+26+27). Decompression may be achieved through an open approach, arthroscopic-assisted (mini-open) or arthroscopic only with the latter resulting in less morbidity and shorter recovery times (SOURCE-25). Despite being common, the use of this procedure remains controversial as it boasts no or negligible benefits for markers such as Pain , functionality and quality of life when compared to placebo surgery or exercise therapy (SOURCE-25+26+27). Additionally the lack of extra benefit comparing open decompression to arthroscopic decompression suggests the benefits of surgery may be attributed to either the placebo effect or post-operative physiotherapy (SOURCE-26).
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