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Shoulder impingement and the rotator cuff Author links open overlay panel Ryan L Hillier-Smith , Henry B Colaco

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Cite https://doi.org/10.1016/j.mpsur.2024.11.005 Get rights and content Abstract The rotator cuff muscles include supraspinatus, infraspinatus, subscapularis and teres minor.In the cases of partial rotator cuff tears Surgical management Arthroscopic subacromial decompression involves excision of the inflamed subacromial bursa, release of the coracoacromial ligament from the anterior acromion and acromioplasty, which removes any inferiorly impinging bone from the anterior acromion.However, US scanning is a Rotator cuff tear classification A partial thickness supraspinatus tear describes a noncommunicating tear involving either the articular side, the bursal side or the internal substance of the tendon.

Shoulder impingement and the rotator cuff
Author links open overlay panel
Ryan L Hillier-Smith
,
Henry B Colaço

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Cite
https://doi.org/10.1016/j.mpsur.2024.11.005
Get rights and content
Abstract
The rotator cuff muscles include supraspinatus, infraspinatus, subscapularis and teres minor. The action of their tendons enables the complex movement of the shoulder joint. Rotator cuff disorders are common and can result in significant shoulder dysfunction and pain. Supraspinatus is the most frequently affected tendon. Subacromial impingement syndrome (SIS) represents a spectrum of pathology including subacromial bursitis, rotator cuff tendinopathy, partial thickness and full thickness tears. These are investigated using ultrasound or magnetic resonance imaging. Rotator cuff tears are not always related to SIS and can be divided into traumatic and degenerative. Treatment for tendinopathy and partial tears is normally non-operative through physiotherapy and corticosteroid injections. Full thickness and some partial thickness tears may require surgical repair, which is commonly performed arthroscopically. This involves mobilizing the torn or detached tendon and repairing it back to the native footprint with bone anchors or transosseous sutures. Repairs can be achieved using single or double row anchor techniques. Where tendon repair is not possible, other surgical solutions can be considered. These include patch repair augmentation, superior capsular reconstruction or tendon transfers. Cases of chronic rotator cuff tears can lead to cuff tear arthropathy, which ultimately can be treated with reverse total shoulder replacement.
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Section snippets
The shoulder joint and the rotator cuff
The shoulder girdle is composed of four anatomical articulations: the sternoclavicular, acromioclavicular, glenohumeral and scapulothoracic joints. The coordinated movement of these articulations enable the shoulder to achieve the greatest degree of mobility of any joint in the human body. The majority of this movement occurs at the glenohumeral joint, which is a complex ball and socket encompassing the humeral head articulating with the shallow glenoid fossa of the scapula. This joint is
Rotator cuff pathology and impingement
The intricate architecture and multidirectional movement of the shoulder joint renders it susceptible to a wide array of injuries and pathology. Shoulder symptoms are common and occur in approximately 14% of the population.1 In the United Kingdom, between 1% and 2% of adults seek advice annually from their GP regarding their shoulders, with shoulder concerns constituting 2.4% of all GP consultations made per year.2 Approximately 70% of patients with shoulder symptoms have rotator cuff
Clinical history and examination
Determining the exact site of a patient's shoulder pain can be challenging. Whilst acromioclavicular joint pain and bicipital pain in the bicipital groove are normally well localized, the remainder of shoulder pathologies can cause diffuse and referred pain. Classically, patients with chronic impingement report pain distribution over the anterior and lateral deltoid region. The onset of pain can be acute following injury but commonly cuff tendinopathy pain is insidious in nature.
Typically,
Investigation
The most sensitive imaging modalities to identify rotator cuff pathology and impingement are ultrasound (US) and magnetic resonance imaging (MRI). US enables real-time visualization, has the ability to correlate image findings with point tenderness, is dynamic, allows for contralateral extremity comparison and the feasibility of real-time guided interventions. It is cheaper to perform than MRI, often more comfortable for the patient and takes less time to perform. However, US scanning is a
Rotator cuff tear classification
A partial thickness supraspinatus tear describes a noncommunicating tear involving either the articular side, the bursal side or the internal substance of the tendon. Partial thickness tears are denoted as ‘low grade’ if they occupy less than 50% of the tendon thickness or high grade if fluid signal intensity on the MRI scan spans greater than 50% of the expected tendon thickness.9
A tear is said to be full thickness if there is communication between the bursal and articular side of the tendon
Non-surgical management
Indications for physiotherapy alone include tendinopathies without rupture, partial tears affecting less than 50% of tendon thickness, chronic full thickness tears in elderly patients and irreparable tendon tears. Physiotherapy aims to aid pain control, recover mobility, develop muscular strength and maintain these changes in the long term. The strengthening process involves the scapular stabilizers, the humeral head depressors and the deltoid muscle. In the cases of partial rotator cuff tears
Surgical management
Arthroscopic subacromial decompression involves excision of the inflamed subacromial bursa, release of the coracoacromial ligament from the anterior acromion and acromioplasty, which removes any inferiorly impinging bone from the anterior acromion. The indications for this procedure are persistent, severe subacromial pain combined with functional restrictions that are resistant to conservative measures and corticosteroid injections.
In cases of full thickness repairable rotator cuff tears in an
Irreparable tears and rotator cuff arthropathy
Cuff tears are deemed to be irreparable if the tendon stump cannot be advanced to the tendon footprint with a tension free repair in neutral rotation and abduction. A tear can be determined to be irreparable either on MRI or intraoperatively during arthroscopy. Physiotherapy alone is advocated for these tears when a patient is unfit or does not wish to proceed with surgery. Older patients with decreased functional demands can undergo debridement of the tear with or without biceps tenotomy or
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