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So um hello again, my name is uh George Contos. Uh I am an consultant at West Apple Hospital. I work with uh Mr Dunn and MS Young. I was asked today to give a presentation about the rotator cuff. Um It's a broad kind of presentation, but I will try to focus on three major aspects of the rotator cuff. That would be the anatomy, the uh clinical assessment and finally, the management uh do we all know the rotator cuff muscles? Can someone name the little calf muscles for me? Yeah. Supraspinal, the infraspinous tea is minor and subscapularis. Yeah. So these are the um the muscles of the rotator cuff, which are basically anatomically speaking, if we start with the subcapital uh which is in the front of the shoulder and anatomically, the origin of the subscapularis is from the subscapular fossa and it attaches on uh the lesser tuberosity. Um Yeah. Next, next slide. Next. Yeah, thanks. Next one going on the top of the shoulder is the supraspinatus. The origin of um the supraspinatus is the supraspinal fossa of the scapula as the name suggests and it passes above uh the shoulder above the glenohumeral joint and it attaches onto the greater tuberosity of note, although it's part of the rotator, calf uh muscles. Uh it is not a rotator. Yeah. Next light similarly going to the back of the shoulder. Now, there is uh the infraspinatus which is uh originating from the infraspinous force of the scapula and again, attaches next to the supraspinatus on the great breast. Yeah, your next slide, please. Yeah. Uh last but not least in the way and usually forgotten when you ask people how many calf muscles we have is a that is minor which is uh in the back and at the bottom of the shoulder and it originates from the lateral border of the scapula and inserts again lower in the credit tuberosity below the infraspinous tendon. So that's roughly the anatomic um uh location of the rotator cuff, uh tendons um moving on. Um There are five layers but basically uh uh the rotator calf uh tendon is consisted of, you probably have to know those five layers. Um which the first layer, the the most outer one is the uh is is uh fibers from the co humeral ligament, which is around one millimeter in thickness. Then moving on more towards the joint. There is a 3 to 5 millimeter tendon fibers uh followed by 45 degree tendon fibers. Again of the fourth layer, there is a connective tissue and then you have the joint capsule. You don't have to remember probably the thickness of its leg uh separately. But um overall probably you have to remember the uh thickness of the rotator cuff, which is more or less 1.2 centimeters. And this is important in a way, uh because that dictates what kind of treatment we're gonna give to your patient, especially when you are in inside the shoulder and you're looking at the tone tendon. Is it clear? Yeah. Yeah. Next, the rough anatomy about the blood supply of the rotator cuff. There are branches of the subscapular, suprascapular and humeral circum arteries, especially the posterior circum arteries. But uh also the arterial circuplex artery and they usually run between the second and the third layer. As previously seen on uh the picture, uh the bile side tends to have more blood supply than the articular side. And also there is a zone of reduced vascularity which is very close to the lateral portion of the supraspinatus insertion. And that's again important to know when uh tears happen in this area. Usually they never heal, moving on. And one name, the nurse applying with innervation, the uh rotator cuff, no ear, anyone else? What inner ways the supraspinatus then was the nerve the in the supraspinatus is the, the supra an infraspinous, but they are invaded by the same nerve. The suprascapular nerve which is uh a branch of the superior tr of the brachial plexus. The subscapular is innervated that's easily remembered by the subscapular nerve which is part of the posterior cord of the brachial plexus and the that is minor, which it can be forgotten again. Um As in terms of what nerve innervate is. It, it's given fibers of nerves from the axillary nerve, which is again part of the posterior cord of the brachial plexus. So we need to know the innervation to the separate uh muscles and tendons of the rotator cuff. So this is basically the ro anatomic um uh bullet points that you should be aware of when it comes to the rotator cuff. Uh moving on. Um I would like to talk about briefly about biomechanics. What does really the rotator cuff do? Let's see. Who, who did I ask? Is there anyone apart from that can ask this question, what do you think the rotator cuff does? What is function? What is it, what its purpose on? What is its purpose in the shoulder keeps the um glenohumeral joint or en located and, and it's um involved in movement of the shoulder. So, um exactly apart from moving the shoulder around, it basically contributes greatly to the stability of the glenohumeral joint. And the way it does, it is basically with two ways. Um one there is concavity compression. So there are compression forces that hold the humeral head into the socket into the glenoid and that is provided by the rotator cuff. And then um the, the, the trigger word, the key word here and the, the key phrase is force couples of the shoulder. So basically, when we're talking about force couples, but of um uh in the shoulder, we meaning that the two muscles, two tendons, which are basically designed to do the opposite function from one to the other. And that as a result creates a stable axis or even better said a stable Crum of rotation. And that is the way how the shoulder moves around. If you look at the coronal plane, these uh muscles are usually the, the lower part of the subscapularis and in the back is the lower part of the Intrasinus and, and the ter spinal uh if you look uh on the axial point, uh these these forces have been dictated by deltoid. Can you hear me? Yeah, yeah, but they deal it and again, the um uh rotator cuff uh muscles and, and the way they work, they work opposing one another in order to hold the head concentrically into the glenoid. Is that, is that clear? Next? Next, please? Um When we're talking about the rotator cuff, uh sometimes or if not more of most, most of the time I, I used to do the same mistake. Um I was looking at um separate conditions, separate conditions such as a rotator cuff, tear calci, uh subac impeachment, um and even rotator graph arthropathy. But the thing that the things that we know about the rotator cuff is that this is a combination of conditions which might actually be coexisting or going through stages until you actually develop a arthropathy. And they might be happening even at the same time in the same shoulder. And these ones as as seen on uh the slide, we're talking about a continuum of conditions which include the subacromial and subarach pi calci tendinitis, rotator cuff test, and rotator cuff arthropathy. So basically, we, when we want to describe pathologies in in in the rotator cuff, we name it as rotator cuff disease. Then we have to find exactly what is happening in the different stages. Uh next slide. So, subacromial basement, most of you, you will know that this is because of the reduced space between the humeral head and the acromion. Um So the tendon can be actually irritated by the top part of the acromion, especially whenever someone is trying to attack the shoulder that causes irritation to the tendon causes inflammation of the bursa, which reduces the uh strangulates in a way the tendon causes and more inflammation goes into a vicious cycle and that causes pain and, and reduce function of the shoulder. Next slide, calcific tendinitis. We're all aware of calcific tennis of people presenting themselves even to the emergency department with extreme pain, especially during the night time, which is quite debilitating to have an x-ray done. And suddenly you see these white spots which correlate with um uh the rotator cuff tendons. Next, a rotator cuff tears. It's part of the um spectrum of the disease of related disease. And on this MRI scan, you can see the white bit on the lateral side of the insertion of the grade tuberosity. There is a rotator cuff tear there. Next, the end stage of the disease is the rotator cuff arthropathy. What happens is if you remember that we just discussed about the uh the stable axis of rotation about the force couples about the um uh concavity compression that keeps the shoulder stable into the joint when these forces are not there, this is what happens. This is the result of altered biomechanics of the shoulder. Any questions so far? OK. Moving on, there are different theories of um of injury. We're not in a way even today, we're not really sure why certain individuals in their lives will, will develop rotator cuff disease. There is the um exclusion theory described face by bii and uh basically what he said is that depending on the type of the acromion, there might be impeachment of the supraspinatus tendon. And as you can see in the type one acromion which is mo it gives more space under the tendon. Usually there's no impeachment. And as you go on the right hand side, you'll see that the acromion changes its shape, it's becoming like a hook. So when we're talking about the type three, let's say acromion that severely impe the uh impinges the uh supra tendon causing um subac impeachment pain and it might actually lead to a full spectrum of disease. Yeah. Next, there is another type of impeachment which is um, the internal impeachment described by Waltz uh in 1991. Basically, this is more usually seen in overhead uh throwing athletes like uh pitches in, in uh baseball. I don't play cricket. So I wouldn't know if that's the case with the um in, in UK as well, but I'm suspecting just in from the movement, it would be basically the tendon is a trap in that movement. When you do abduction and rotation, you entrap the tendon uh under the acromion and that can cause again, symptoms of impeachment in professional athletes. Yeah. Then there is the increasing theory of uh the disease and basically that is related to the, the strength of the rotator cuff, which in this particular case is not as strong and it is age related as we age, especially after the age of 40 45. We will all start developing um weaker rotator cuff tendons. It's, it is also seems to be sex related. Uh male individuals tend to develop more often um rotator cuff disease. Some people have also um uh advised that this might be because of uh increased type I collagen. So all these steroids are, are, are been um um given to the public, but we don't actually have um a reason why a rotator cuff disease happens. We, we, we're not really sure why this happens. All these are theories, right. Do you want to continue with the clinical examination? Do you want, do you have any questions about the things we just discussed so far? Ok. So we'll do the clinical examination. We do a tenminute break and, and do the management after that. Is that all right with everyone? Yeah. Right. So I suggest um there are many tests to um, to test the rotator cuff, many tests. Uh I suggest for your exam and, and for your practice, you should learn one for every tendon. So um can someone tell me what, what is being tested on this photograph? These photographs cream Super spa. Sorry, I didn't hear that for the belly. It stops capitis. So on the left hand side, this is the of test and on the right hand side is the the belly press test. Uh basically on the left hand side, if the patient can actually pull his arm away from his back and hold it there under the pressure, that means that the subcapital is intact if he or she cannot do that, that means that it's a torn subcapital. The same thing with the with the belly press. Uh When you do a belly press with intact subscapularis, you can bring your shoulders in in the front when you're missing the subscapularis or is torn. You cannot. Yeah. Next side, can someone else told me, tell me if anyone has seen the test and what the test is, not him someone else. It's a jobs test for supraspinatus. Yes. And how do you do it? How do you examine, uh, in, uh, sus a job? What, what is the, so, um, should ab B, um, with, uh, uh, not full 90 degree, I think it's about 80 degrees, I think. Um, and then with the, uh, with the, uh, uh, thumbs facing downwards and resisted, resistant movement, uh, resisted, uh, it is, it is around 30 to 60 degrees abducted. And why would you turn the thumbs down on this test? Uh is to isolate the supraspinatus I think specifically. Very good. Correct. Yeah. So that's the job. Job says that that's what I'm using and, and I think it's easy and very, very easily reproducible, right? Um Next slide, please. Can someone else tell me what are we testing here? We've eliminated probably two out of four. So um is who else is in the line? Let see. Mm Anyone else is testing external rotation? It's infraspinatus infraspinatus, correct. Basically, you um ask the patient to hold their arms very close to the body and you can test both sides at the same time and uh uh basically pick up a te a torn tendon or an injured tendon on this test. And uh yeah, next one has there was in the test. Um It's just the hornblower stuff. Yes. And what, what, how you do it and what are you testing? Uh So it's um it's uh abduction of the abduction of the shoulder up to 90 degrees external rotation of the uh of the arm. And uh what you're testing for is whether they maintain the external rotation. And uh that test for is m Yes. Yes. Exactly. Exactly. That and the, and the lady on the right, what's wrong with her? She's unable to maintain the external rotation. So, uh her arm uh drops basically even if she can maintain abduction. Yes. So they fell in when they want to raise their mouth. They, they just keep uh the shoulder in the rotation. And what else is wrong with the lady on the left? I'm not sure left side. She's not, she's not lifting your shoulder at all. Does she? Oh with the left uh left shoulder? Yes. Yes. So when, when, when you go to the exam, you make sure you see the patient holistically, right? You just, you don't look at the shoulder only right. Yes. Hold on. But generally speaking, these, these things that you, you can um easily read and reproduce in your clinics uh with your patients. And then as I said, stick with one test for every, every uh tendon. Um Yeah, symptoms of um of the rotator cuff disease. Um obviously pain, especially when someone is trying to lift up their shoulders. I usually ask my patients uh can you reach the top self elderly patients or, you know, can you, can you pass your back and you can you do your bra yourself in, in, in female individuals. Um Obviously there is acute pain when there's acute trauma and weakness after that. So it's really easy to establish diagnosis and pseudoparalysis. What, what is pseudoparalysis? Uh I don't know everyone but I can ask is, is s uh logged in. Yeah, I am. Uh I think it's um when they get significant pain and the rotator cuff becomes unbalanced, they, they become stiff and they sort of lose the function of the shoulder. So, pseudo pseudoparalysis in a way, it is the inability to move the shoulder as you see on the individual on, on, on the left picture, on the male individual, on the left picture regarding his left shoulder because there is no basically supraspinatus being able to lift the shoulder to initiate a a reduction. Uh And this is not due to a neurological problem. It's clearly because the uh rotator cuff is, is dysfunctioning. Um So patients can present like this as um in your clinic and, and it's very easy to pick up this one once you remove um uh the shirt from the patient and ask them to move the shoulders, right? Um I'm gonna stop here for now. Do you have any questions anything that you want to ask? Can I ask about the testing of the rotator cuff? Yeah. Yeah. So specifically what are the possible interpretations of the supraspinatus test as an example. I've had a case, for example, where they get a bit of a lag, a bit of weakness to begin with pain. But then as you move through the arc of movement, they get some resistance. So does this imply there's inflammation or does it imply there's a a what, where was the pain at? At what uh point of the range of motion did you get pain from the patient? It in the position for the uh jobs test. It was at the beginning of the movement, they would get pain, there would be a lag and some weakness to begin with. But then they would get uh resistance, uh you know, a few degrees down the line. So they would normally get resistance. The, the higher they would lift up the shoulder because that means that most likely they del to it would be taken over if you're not doing it correctly. So there's a chance that the test might not have been done correctly. That's why you were getting um um sort of like resistance as they were lift it higher. Not, not because of you. Maybe the patient was cheating if that makes sense. So you need to make sure that they maintain internal rotation of the shoulder to eliminate the uh the use of the um of the deltoid. So my interpretation would be if I was to see it, I would just wanted to make sure that the patient keeps their arm with a uh uh thumb pointing down if that makes sense. So the possible outcomes of the test are either weakness or nor normal power, possible results of the test if it makes sense. Um If, if you do it correctly and you isolated uh the the deltoid, if there is a torn tendon, it would at least be at the best case scenario, weak or worst case scenario, weak and painful. So either weakness or pain separately or both of them at the same time. Yeah, thanks. And anyone else, any other questions? Right. Um How uh specific and and sensitive are these tests? How much do you rely on these tests for um actual diagnosis or is imaging the the sort of the gold standard? So we we will get to that, you will get to that. Um it is a combination of things. So for me to send someone for imaging and what type of imaging that would be, I'm relying a lot on the clinical examination, sometimes I agree it's difficult to examine these patients, especially when they present the acute phase because they're really painful and you don't really know what's going on. But, but once you are able to examine them, I think if I although it's a different joint, uh it's similar thing as you, when you examine a knee, when you do a Lachman's test in the knee after injury and it s lax and you know that the, the AC L is gone and then you need confirmation. Uh from the MRI scan. So most of the times you will know what to expect on the scan. So the scan will not give you diagnostic information whether a tendon is torn or not. If that makes sense, it will just give you the size, it will just give you uh information about fat infiltration. It will give you information most likely about the type of tear, how many tendons are involved, this type of information. But, but you would know when you're testing a shoulder from your examination, whether a tendon is gone or not. Uh So I, I rely, um, I rely on my clinical examination first and, and, and usually, so I'm not saying I'm 100% always in my diagnosis. Usually I pick up the tunnel with a stone. The thing that you cannot pick up is how bad the tear is. Uh huh. Yes, that makes sense. Yeah. What function I saw you. Um, what function arthros surgery most influence post it is that the question for, for me, uh, Abi cause that's probably for, um, for next week I think we're doing for another two weeks time we're doing about arthroplasty. Uh Oh, no worries anyone else uh regarding the uh, the rotator cuff uh, so far. Ok. Do you want, do you want to take 10 minute break and come back? Yeah. Shall we reconvene at uh 2 50? Yeah. Yeah. Yeah, that's fine. Perfect. OK. Thank you. All right.