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So um hello again, my name is uh George Costopoulos. Uh I am an, a consultant at West Apple Hospital. I work with uh Mr Dunn and my, 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 muscles? Can someone name the cuff muscles for me? Yeah. Supraspinatus, infraspinatus steer 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 subcapillaris, uh which is in the front of the shoulder and anatomically, the origin of the subscapularis is from the subscapular fossa and it touches 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 supraspinous fossa of the scapula as the name suggests and it passes above uh the shoulder above the glenohumeral joint and it attaches onto the graded tuberosity of. No, although it's part of the rotator cuff 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 breast. Yeah. Put your next slide, please. Yeah, I last but not least in the way and usually forgotten when you ask people how many calf muscle we have is a tens 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 great tuberosity below the infraspinatus tendon. So that's that the anatomic um uh location of the rotator cuff uh tendons um moving on. Um There are five layers that basically uh uh the rotator cuff uh tendon is consisted of, you probably have to know those five layers um which the first layer of the the most outer one is the uh is is fibers from the correct 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, on the fourth leg, there is a connective tissue and then you have a joint capsule. You don't have to remember probably the thickness of each layer. 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, an at me about the blood supply of the rotator cuff. There are branches of the subscapular, suprascapular and humeral circumflex arteries, especially the posterior circumflex arteries, but uh also the arterial circumflex artery and they usually run between the second and the third layer as previously seen on uh the picture. Uh the beside 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 up in this area. Usually they never heal. Moving on. Can anyone name the nurse applying with innervation? The uh rotator cuff, no ear, anyone else? What raise the supers then was the never the invasin is the the sins and infraspinal but they are invaded by the same nerve. The suprascapular nerve, which is uh a branch of the superior trunk of the brachial plexus, the subscapularis innervated. That's easy to remember by the subscapular nerve, which is part of the posterior core of the brachial plexus and the there is minor which it can be forgotten again. Um As in terms of what nerve innervated it is 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 r 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 Kalim that can ask this question? What do you think the does, what is function? What is it, what is purpose on? What is its purpose in the shoulder keeps the um cleaner humeral joint or, and located and uh and it's um involved in movement of the shoulder. So, uh exactly apart from moving the shoulder around, it basically contributes greatly to the stability of the gal 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 keyword here and the, the key phrase is force couples of the shoulder. So basically, when we're talking about four couples 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 set a stable fulcrum 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 subcapillaris and in the back is the lower part of the Intrasinus and, and the terrace minor. 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 it d 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 constantly 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 mo of most, most of the time II used to do the same mistake. Um I was looking at um separate conditions, separate conditions plus such as a calcific adenitis uh subac impeachment um and even rotator cuff, 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 cat arthropathy. And it might be happening even at the same time in the same shoulder. And these ones are as seen on uh the slide, we're talking about a continuum of conditions which include the subacromial and Sardo easement, cal tendinitis, rotator cuff test, and rotator cuff, arthropathy. So basically, we when we want to describe pathology in in in the rotator cuff, we name it as rotator cuff disease, then we have to find exactly what is happening in different stages. Uh next slide. So subacromial replacement, 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 the way the tendon causes and more inflammation goes into a vicious cycle and that it causes pain and and reduced function of the shoulder. Next slide, calcific tendinitis. We're all aware of calcitic adenitis 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 the disease. And on this MRI scan you can see the white bit on the lateral side of the insertion of the great tuberosity. There is a rotator cuff there, there. Next, the end stage of the disease is a 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 a rotator cuff disease. There is the um excision theory described first by Viani 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 keeps 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, say, let's say acromion that severely impedes the uh impinges the uh super 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 Wolf Woltz 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, elect 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 4045. 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 three collagen. So all these theories are are have 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 discussed so far? Ok. So we do the clinical examination. We do a 10 minute 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 has been tested on this photograph? These photographs, Karim. Super sorry, I didn't hear that for the belly stops. So on the left hand side, this is the lift of test and on the right hand side, this 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 pressure, that means that the subcapillaris is intact if he or she cannot do that. That means that there's a torn subscale. 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 tell me, tell me if anyone has seen the test and what the test is not someone else. Uh It's a jobs test for Super Spinatus. Yes. And how do you do it? How do you examine uh in uh super with job said? What, what is the, so, um the examiner, it's uh it's uh shoulders ab ducted um with uh a ducted 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, resisted movement, uh resisted. Uh it is, it is around 30 to 60 degrees abducted. And why would you turn the thumbs down on this? Th uh it's 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 will eliminated probably two out of four. So um is who else is in the line? Let's see. Mm Anyone else uh testing external rotations? 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 a tendon on this test. And uh yeah, next one has anyone in the test. Um It's just the hornblower. 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 uh 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 mine. 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 the mouth. They, they just keep uh the shoulder in 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 her 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 the shoulders. I usually ask my patients uh can you reach the top self, elderly patients or you know, can you, can you touch your back? Can you, can you do your by 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 Spanos uh logged in? Yeah, I am. Uh I think it's um when they get significant pain and the rotator cuff becomes imbalanced, 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 AAA induction. 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 off from the, 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 the deltoid 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 entire 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 want to make sure that the patient keeps the arm with the uh uh thumb pointing down if that makes sense. So the possible outcomes of the test are either weakness or, nor normal power. The 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 an anyone else. Any other questions? Right? Um How uh specific and, and sensitive for 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 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 done or not. If that makes sense, it will just give you the size. We 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. No. So II 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 a tunnel which is torn. The thing that you cannot pick up is how bad the tear is. Uh Yes, that makes sense. Yeah. What fuck did I show you in a second? Um What arthroplasty surgery most influence posthepatic mentality? Is that the question for, for me? Uh Ay, because that's probably for um for next week I think we're doing for no two weeks time we're doing about arthroplasty. Uh Oh, no worries anyone else regarding the uh the rotator cuff. Um So far. Ok, Jon, do you want to take 10 minutes break and come back? Yeah. Shall we reconvene at uh 250? Yeah. Yeah. Yeah, that's fine. Perfect. Ok. Thank you. All right.