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The Rotator Cuff

Key Points

The majority of symptomatic rotator cuff disease patients respond to a nonoperative program emphasizing the restoration of normal biomechanics, unrestricted motion, and functional force couples.Early surgical management should be considered for acute rotator cuff tears in physiologically young and very active individuals.

The ability to recognize the complex layered anatomy in addition to the tear configuration is critical if an anatomic repair is to be achieved.
The rotator cuff muscles centralize the humeral head and permit a single center of rotation while providing stability and strength. During active shoulder elevation, the rotator cuff muscles depress the humeral head, allowing efficient elevation of the extremity.

When surgery is necessary, the goal should be to properly and anatomically restore the balanced forces of the supraspinatus and deltoid muscles so that their counteraction is maintained.Tearing of the rotator cuff as a function of age is a common occurrence. Many of these tears may be clinically silent.

Mechanical impingement is the most common recognizable source of recurring rotator cuff pain and disability in the active population. When impingement-type symptoms present in a younger patient, great care must be taken to avoid overtreating because the impingement may be internal or may be secondary to instability which effectively moves the cuff closer to the arch.

The unaffected shoulder can serve as a “normal” template for comparison during physical examination. One should survey for atrophy or asymmetry, especially in the supra- and infraspinatus fossae. Long-standing rotator cuff tears are often accompanied by significant, visible atrophy.

The initial evaluation of the painful shoulder should include quality plain radiographs. The standard radiographs should include a true anterior-posterior view with the shoulder in the internal and neutral position, an axillary view and the outlet (supraspinatus) view described by Neer and Poppen which is used to evaluate and classify acromial morphology and arch anatomy.

Magnetic resonance imaging (MRI) is the test of choice when evaluating the soft tissues of the shoulder. T1 weighted images revealing increased signal in the rotator cuff, combined with a focal defect or loss of continuity of the cuff on the T2 weighted image, is a common finding when a full or partial-thickness tear is encountered.
MRI scans for those anticipating shoulder surgery can be helpful in evaluating tears, assessing possible atrophy, and establishing the presence of co-morbidities.

Injuries to the rotator cuff occur commonly. Treatment for these common disorders is most effective when a management algorithm can be developed based on a keen understanding of pertinent anatomy, pathology, and outcomes studies supporting specific treatment.

Suffice to say that the majority of patients with symptomatic rotator cuff disease respond to a well-planned, nonoperative program emphasizing the restoration of normal biomechanics, unrestricted motion, and functional force couples. Clearly there will be those patients in whom the pathology has progressed to a point where surgical intervention may be appropriate.

This chapter is organized into three sections: The first details the anatomy, biology, function, and pathoanatomy; the second section focuses on the physical exam and diagnostic testing; the final section considers treatment alternatives and selected techniques.

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