Understanding Rotator Cuff Tears and Treatment

what's up ninja nerds in this video today we're going to be talking about rotator cuff tears if you guys want to follow along with some awesome notes some great illustrations go down the description box below we'll have a link to our website go check that out also if you guys like this video you benefit from it it makes sense and you have some fun in the process please support us by hitting that like button commenting down in the comment section but most importantly subscribe alright let's start talking about rotator cuff tears all right so let's start talking about rotator cuff tears before we do that we obviously have to understand what is the rotator cuff right we need to know what is it made up of we're not going to go crazy into the shoulder anatomy we'll have another separate video on that where you really understand all the intricacies but for right now i really want you guys to just focus on what are the muscles or the tendons or the specific bursa that are involved within the rotator cuff that because it's important right so first thing is we're going to take a look here kind of the shoulder joint area from an anterior view and there's really one specific muscle that i want you guys to remember so here's our scapula right this is all our scapula here and then here you're going to have like your coracoid process that's your chromium process connecting to the clavicle and then here's your humerus the humeral head sitting into that glenoid cavity right well there's a muscle that sits here in this fossa you know what this muscle is called this muscle is called the subscapularis muscle now the subscapularis muscle it sits in this subscapular faucet that's its origin and then the insertion for it as it comes all the way over here and attaches onto this little bump on the humerus you see that little bump right there that's called the lesser tubercle okay so one of the muscles that's on the anterior side here that i really want you guys to know is called the subscapularis the biggest thing that i want you guys to know about the subscapularis is this function with respect to how it plays a role within the rotator cuff since it kind of pulls imagine that it's pulling on that insertion towards the origin so it's going to kind of try to rotate the humerus internally so we just call that internal rotation okay so it's involved in internal rotation but particularly around what joint well obviously it's at that shoulder joint all right so that's one of the muscles that are involved within the rotator cuff what i want you guys to remember though is how does the muscle connect to the bone it connects to the bone via the tendons right so tendons are what connects muscles to bone so really when we're talking about this muscle this part here which is connecting the muscle to the bone is the tendon sometimes in patients with rotator cuff tears you have tears within the tendon that is connecting to that subscapularis muscle to the bone so we may lose the ability to internally rotate super simple stuff right all right posterior view look um at the scapula shoulder joint area there's a couple more muscles right here again acromion process you have your coracoid process this is going to be the humeral head sitting into that glenoid cavity there's a little like divot or fossa here and you see this fossa here there's a muscle that kind of sits right in here it's a cute little muscle it's called the supraspinatus now the supraspinatus sits and originates in that kind of super spinous fossa and then it's tendon kind of works right underneath this acromion process and then attaches onto this big fat knob here on the humerus what's that called it's called the greater tubercle so imagine again you're pulling from the insertion towards the origin it's going to pull the humerus outwards or away from the body we call that abduction so what's this muscle here this first one will put a 1 there that is called your supra spinatus and again the big function for this one is a b duction now when we talk about abduction it's really only kind of a certain amount of degrees it doesn't bring it up all the way it's only like a first maybe 20 30 degrees that it's helping to be able to pull up okay so again abduction at what point at the shoulder joint again all these movements you're obviously going to know but if we're really being particular we should specify where that movement's occurring all right second one here right underneath so you have we have this again this is a chromium process but this right here how it kind of originates from this part of the bone here this point right here is called the spine of the scapula so obviously above the spine is the supraspinous fossa just below the spine is the infraspinous fossa and there's a muscle that sits right in that infraspinous fossa called the infraspinatus and the infraspinatus originates off of that and then it goes and inserts on that big old knobby there what is that called the greater tubercle so this muscle that sits in the inverse spinous fossa is called the infraspinatus and again remember we're looking at this from the posterior view okay so if we had the infraspinatus pulling on the insertion it's going to pull the humerus the opposite way of the subscapularis it's going to try to externally rotate it so it's going to play a role with external rotation and again it's obvious but at that shoulder joint it's just good to get into a habit of saying where that movements are okay all right and then the last muscle here that's involved is it kind of sits it originates down here towards the bottom of the scapula kind of near the angle like the inferior angle and it comes up and same thing it also inserts near that greater tubercle what is this muscle that kind of sits towards like the bottom part of the scapula and then inserts onto the greater tubercle this muscle here is called the teres minor and again if it's kind of like just like where the infraspinatus is it should pretty much do the same thing right so again it's going to be pulling the humerus externally so it's the same thing external rotation at the shoulder joint all right so we've talked about all the muscles from an anterior and posterior view there's four of them right that we've kind of covered so you're like oh man this is a little bit too much zach how the heck do i remember all of the muscles and how do i remember what they do well i think what they do is actually the easier part but remembering the name sometimes is annoying right so you have a mnemonic to remember the rotator cuff muscles it's called sits okay so it stands for supraspinatus you have your infraspinatus you have your teres minor and then we can finish that puppy off with the subscapularis baby and just remember again with all of these muscles that we're talking about remember their muscles originating from these different like areas like the super spinous infraspinous fossa angle subscapular fossa and then what happens is the muscle extends to the bone via the tendon to attach to that area of the bone if there's any point where there is a break or a tear within these tendons then you can develop a rotator cuff tear okay now the last thing that i want to talk about just quickly is it's easy to see these in an anterior posterior view i want to quickly see what they would look like in a lateral view and just two more quick structures all right so let's take a look here at the shoulder joint from a lateral view so imagine you're looking here from the side right and i just pulled the humerus out of the way so you're staring into that cavity of the scapula so this right here is the glenoid cavity here i'll write in there son of a gun i'll write in there gc to indicate that this is the glenoid kind of cavity and that's where the humeral head will sit in form that the glenohumeral joint okay now surrounding that i don't want you guys to get too bogged down but right around that glenoid cavity there's kind of like this like fibrocartilaginous kind of structure here this like bluish color here this baby bluish this is your labrum this is called the glenoid labrum and then just around the labrum and this is obviously called the capsule all right so this is your capsule now there's a couple other structures that we need to obviously understand so here's the glenoid cavity just above that if you guys can kind of imagine from these views there was a bone that sits right up above it what was that bone called we're just going to put here that this bone is the acromion process okay and then there was a bone that was just anterior to it and it was kind of poking out like right here that was called the coracoid process well there's a ligament that actually has to connect between them just combine the names the the core co-acromial ligament is going to be between these guys now the next thing that i need you guys to know is there's a couple other things here so we got the bony stuff right the glenoid cavity we got the labrum the capsule we got the bones the chromium process the coracoid process the ligament that connects them now what are these purple structures i don't really want you to get bogged down on but they're important for helping to maintain stability to the to the actual shoulder joint in the capsule but these are all the ligaments and you know what's nice about these is they have a very simple name and they're primarily in the anterior portion so i one of the things to get a good understanding of as i should have told you here from a lateral view this is that nice view but this side let's actually kind of annotate this this is the anterior point of this lateral view and this is the posterior point of this lateral view okay so if you guys were to imagine these ligaments are primarily kind of like anterior and inferior and they're called the glenohumeral ligaments it's actually really simple right so you have the superior glenohumeral ligament the middle glenohumeral ligament and the inferior glenohumeral ligament they're just helping to provide some stability all right what else do we have here that's kind of important we have these like fluid filled like synovial like pockets really okay and they're important i really want you to understand this because they're important with the pathology these are called your bursa so this is containing like it's like a fluid filled like like a kind of like a ball if you will and it really is designed to allow for tendons to slide between kind of like areas really nicely to reduce any friction and so these little fluid fluid-filled kind of cavity areas are called bursa and this one here it's just underneath the acromion process so we call it sub so it's the sub acromial bursa this is a really important bursa because a lot of diseases become involved right here with inflammation of this and there's a very special tendon and muscle that runs right underneath it that if it becomes inflamed it can really jack up those tendons this one here is kind of a lesser significant burst but you should still know it because if it gets inflamed same kind of process can happen to the muscle that runs just here but this one is called your sub scapular bursa okay just again imagine them as like little like fluidy kind of like uh synovial fluid kind of like balls that allow for less friction for tendons to move between spaces okay all right so now let's talk about the muscles that are kind of around this area well again if you think about your anterior posterior view where would they be okay just running underneath the acromion process just underneath this bursa there is a muscle that sits right here what's this one called supraspinatus right what's the one that sits right on an anterior on the subscapular fossa and then runs anteriorly connect to the lesser tubercle this one right here is called the subscapularis muscle then you have the ones that will sit on the back ones that will sit on the infraspinous fossa is called the infraspinatus and then the ones that will sit towards the bottom of the scapula is the teres minor and there is a muscle that sits down here as well it's like the long head of the triceps but i don't want you to worry too much about that because these are the primary muscles that are involved in your rotator cuff so it's a good understanding to have a really good kind of view of how these muscles look from the anterior view the posterior view the lateral view and really the other thing that i really wanted you to take away from this is other associated structures that are nearby that can contribute to the pathology in this disease that being the subacromial bursa some of the actual subscapular bursa and also just some of the other bony processes that are nearby all right now that we got the basic anatomy done let's talk about some of the causes and pathophys that lead to this disease all right so let's talk about the causes the reasons why someone can develop a rotator cuff tear right so it's actually really simple if we break it down to like two different kind of pathophysiological mechanisms so we know the muscles we know the anatomy right which is kind of a really important thing once you get that down a lot of this stuff is going to come together really easily so imagine that we have this kind of diagram here again if we were looking at this this is really like a posterior view of that shoulder joint right so this is a posterior view now there's a lot of bones a lot of bursa a lot of ligaments that are nearby in this shoulder joint right if by any reason there's any kind of bony prominence like you know someone who gets like osteoarthritis or they get like bone spurs different types of like osteophytic processes if those things are kind of like let's say that you have here like let's say here's your chromium process and you get some type of like osteophyte or bone spur that's popping off of this bad boy that's going to apply some extrinsic compression and shearing across that tendon that extrinsic compression the shearing of that tendon rubbing up against that bone spur over time is going to produce micro tears lose its integrity and then it's going to pop and then you develop a rotator cuff tear so what i want you to remember is any kind of extrinsic factors think about bony prominences ligaments and things like that so if there's any kind of osteoarthritis of that joint it increases the risk of forming like these little bone spurs and those little bad boy bone spurs may produce like rubbing shearing forces compression of that area the other thing is that there's lots of ligaments nearby right so any kind of ligament that's actually kind of jacked up or inflamed or anything like that that could also provide some compression so another thing that we could say is let's kind of a a comply the ligaments we made them kind of that bluish color we can add that one in there as well any kind of like ligament injury as well that puts the shoulder in kind of any point of instability so if there's any instability of the shoulder that puts stress on that kind of like rotator cuff that also over time can produce micro tears inflammation and it can tear over time so any kind of ligament injury any kind of bony prominence or like bone spurs osteoarthritis changes but the big one that's why i wanted to look at it from the lateral view is sometimes if someone gets that you know that bursa we have this actually kind of a combined one here you have like your subacromial and it extends into what's called the subdeltoid bursa if this subacromial bursa becomes super super inflamed then you lose the ability to reduce the friction of that tendon running between the areas between like the bony prominences and so again there's that compressive factor from the inflamed bursa and the shearing forces on it and so any kind of like subacromial bursitis is a huge risk factor okay so i want you guys to definitely think about that so compressive or extrinsic types of mechanisms that i want you guys to think about is any bony change osteoarthritis is a good example bony spurs that are coming off and compressing another really good example is any kind of subacromial bursitis or what was the other bursa that was in the anterior portion the subscapular burst it's becoming inflamed so any kind of subscapular subacromial bursitis could cause these problems and any ligament injury what's the big like joint though like there's ligaments between this joint that really can become problematic produce instability in the shoulder what joint the ac joint so really kind of any ac joint abnormality puts the shoulder at a super point of instability and increases the risk of rotator cuff tears okay so i think we got the extrinsic mechanisms down that's not too hard right what about the intrinsic mechanisms what about something that's actually wrong what do we say a rotator cuff tear is it's a tear really within the tendon that's connecting the muscle to the bone of the humerus what if there's something that's not wrong with the actual compressive or extrinsic forces it's just something wrong with the tendon itself what could be reasons that the tendon would have some issues that's a good question engineers what if i'm just stretching the crap out of that tendon or not just that i'm putting so much tensile overload on that tendon so there's an increase like let's say i'm stretching the living crap out of this tendon or i'm causing an increase in what's called tensile overload and usually this is whenever there's extreme eccentric contractions okay of the muscles that are involved and what type of activity overhead movements so usually any kind of like overhead movements that's repetitive what's a good athlete that's constantly doing this kind of motion any kind of like quarterback or any kind of baseball player right so pitchers football players things of that nature that are swimmers anything with that consistent repetitive overhead movement with the tensile overload permit the eccentric contractions okay so really think about those types of athletes okay now that's one particular reason tensile overload but you know what else is another reason as people get older right aging so as you get older in aging lots of things unfortunately happen not a good thing right you get micro tears within these tendons it's just a natural part of aging so you get the micro tears on top of that with aging you get calcifications so now i'm going to have these calcifications of the tendon and then on top of that as you get older usually the microvascularity of the tendon becomes even worse so imagine the blood flow to this tendon is also reduced generally it's reduced in general but it's even worse in aging so there is micro tears calcifications and microvascular kind of loss and all of these things puts the patient at a high risk for any kind of like maybe trauma any kind of repetitive overhead movement anything like that could put them at high risk for developing a tendon tear okay so again what i want you guys to remember with the aging process is this leads to micro tears this leads to calcifications and this also causes a change in their microvascular integrity goes down and that causes this area of like a critical zone so if you have like let's say lots of micro tears in this area let's kind of imagine this you have a lot of micro tears in this area right here the blood flow to this area is really diminished and you have lots of calcifications from whatever reason maybe trauma maybe some simple movement it's enough to cause a tear within that tendon so these are very important things so aging and high tensile overload from repetitive activities especially overhead movements what's the last one this one is not a super big one but it's something to think about and patients who have anything like inflammatory like kind of systemic diseases so let's kind of write over here anything like systemically systemic diseases that really just predispose them to developing quick easy kind of maybe a simple motion a simple repetitive motion that involves any of that external rotation internal rotation any abduction overhead movement anything like that enough because of disease in the tendon can cause it to tear what are these diseases that i want you guys to think about what if i have somebody who has a massive inflammatory disease like rheumatoid arthritis where they have antibodies that are attacking their tendons and shoulder joints what's a condition you know rheumatoid arthritis would be one what if i have a condition where they have a poor healing where maybe they have these small tears they have these like small tears and normally your blood vessels you don't have a ton of blood supply to the tendons but it's enough to maybe allow for small repair and patients with diabetes they have microvascular problems right they have very very bad microvasculature so the blood flow is going to be reduced due to their hyperglycemia and they have a poor healing process so another disease that could cause this problem would be diabetes and then what if there's a disease that there's actually intrinsically something wrong with ecology you know collagen is like one of the biggest components of tendons what if the collagen is all jacked up in this bad boy so the collagen or some of the proteins like fibrillin are jacked up in this to this tendon and they're not present or they're mutated or they're just abnormal this would be connective tissue diseases like morphons or ehlers-danlos syndrome okay not super common but something to think about all right we've covered the causes the pathophys let's now start talking about how can we go about clinically diagnosing these patients all right so let's talk a little bit about how we go about diagnosing rotator cuff tears now it's obviously a clinical diagnosis there's some things that you could do particularly with very physical exam specific tests and maybe some imaging and we'll talk about that but some of the things that may cue you up to think oh it could be a rotator cuff tear is their description of pain right so they obviously have shoulder pain that's obvious right so if you're tearing some of those tendons nearby they're definitely going to have some type of shoulder pain but sometimes what's some key things that you may pick up from the history to kind of cue into that is that the shoulder pain tends to be right near like the anterior deltoid so it tends to be more anterior deltoid in location and also the pain is usually worse at night you want to know why it's because if they're laying on the affected side it's really causing a lot of pain in that area so if like for example if i had like an anterior deltoid pain rotator cuff tear that's on that left side and i go to lay on that left side when i'm moving around during sleep the pain tends to be worse in that area so any kind of like compression or any kind of involvement of laying or on that affected area is one of the big things to cue you off on that so obviously shoulder pain is very very obvious so if someone comes into the office they say hey man i've been having some anterior shoulder pain it's worse at night when i'm sleeping how would you go about trying to figure out is this a rotator cuff tear well we take it step by step step we inspect the area so whenever you're inspecting someone with a rotator cuff there some of the big things that'll cue off on your exam is look for any kind of signs of atrophy you know there's what's called the infraspinatus atrophy so sometimes in certain types of tears if you look on the actual posterior aspect of their scapula you may see a complete difference in the muscle bulk on the area if there is any kind of tear that get infraspinatus atrophy next thing is obviously palpate you want to palpate around what are you aiming to palpate palpate near the actual humeral head the greater tubercle lesser tubercle feeling for any pain there palpating your coracoid process the acromioclavicular joint all of those things now the next thing is where you're going to be moving into range of motion so this is a big thing to remember obviously there's a tear so then being able to initiate a movement on their own contracting muscles and involving those muscles is going to be difficult so their range of motion actively meaning they're doing it on their own you're not doing it for them is significantly reduced and the passive range of motion seems to be somewhat preserved okay now we have inspected we're looking for any kind of atrophy we're palpating for any tenderness we're checking the range of motion we'll do it for them passively seeing if they have any pain and then we'll have them do it on their own seeing if there's any pain or inability to perform those movements then we do special strength testing to go back what are the muscles involved we have the supraspinatus what does it do abduction so you're testing for any weakness and abduction then you're testing the infraspinatus and the teres minor what do they do external rotation so you're trying to see are they having any difficulty in being able to externally rotate subscapularis what does it do internally rotate so are they having any difficulty being able to internally rotate so once you've tested the strength if there's any weakness in those you may be able to pick out is there an area where the tendon could be teared or torn in this case okay so we've gone inspected we palpated we checked the range of motion which is reduced and active somewhat preserved in passive check for any weaknesses involving some of the rotator cuff muscles then we get into your special tests now there is so many special tests that you could do from the literature the best kind of approach which seems to really provide a decent sensitivity of maybe a full thickness rotator cuff tears three specific tests that you should always try on these patients the first one is is you try what's called the painful arc test if the painful arc test is positive there could be some signs potentially of a subacromial impingement like a subacromial bursitis which i told you is a very very common cause for someone having a rotator cuff tear the next thing is they have a positive drop arm test this is kind of particularly looking at the activity of the supraspinatus muscle so the supraspinatus is obviously supposed to be involved in abduction if you drop their arm and they're not able to perform that or it drops really quickly there may be something wrong with the supraspinatus lastly is they have any weakness in external rotation and again which muscles are involved in the external rotation the infraspinatus and the teres minor so if there any of these are positive all three are positive it is a high sensitivity for them having a full thickness rotator cuff tear if maybe two out of the three are positive then you have to go maybe to either way you're gonna have to do imaging but your potential like predictive value of it is maybe a little bit lower but all three of these tests being positive is a very strong sign of them having a rotator cuff tear there's many other tests that we can do but these are the big ones that i want you to know we'll talk about those other tests when we do these on on cue what are the things that after we've done our special tests that we would do we want to employ some imaging so we could start off with an x-ray the x-ray is really just good to rule out any kind of other pathologies is there any dislocations is there any ac joint separation is there any kind of fracture or any obvious osteoarthritic changes or here's the big thing and someone who has a rotator cuff tear sometimes the humeral head remember the rotator cuff is also important for just maintaining like the humeral head in that glenoid cavity so if you have a weakness in that that head is not going to be kind of held tightly into that glenoid socket there and so it can actually superiorly migrate and so sometimes what you may see is you see there's a space between the acromion process and the humeral head if that space becomes obliterated it becomes smaller that means that there's superior migration of the humeral head and it could be a sign of instability in the rotator cuff secondary to a rotator cuff tear so what i want you guys to remember is any loss of space between the acromion process and humeral head we call that superior migration of the humeral head which can be sometimes seen in a rotator cuff tear now these other two exams so i would start off with an x-ray if i have these three tests positive go with the x-ray you can rule out some other issues and then i like to use ultrasound it's a dynamic test it's really cool so i can look at the dynamic movement of the actual the tendon if you get a good enough view and you're looking having them abduct you'll be able to see the tendon in its dynamic motion seeing if there's any kind of weakness if there is any tears it's also good at picking up tears okay and or tears okay the best test the gold standard if you will is going to be your mri if they have a contraindication to mri they can get what's called a ct arthrogram they inject some dye into the actual joint and get a ct scan and that may also be kind of an extra test that you could do if they can't tolerate an mri but the mri is the best because it can pick up any kind of tear whether it be a minor partial tear to a full thickness tear it's going to be the best sensitivity of any test okay so we've gone through how we're going to suspect a diagnosis of a rotator cuff tear let's actually do a nice quick physical exam on someone that we think may have a rotator cuff tear looking at the big big test that i want you guys to know on a person that we suspect has a rotator cuff tear we're going to bring our boy q in all right ninja so let's go ahead and do a rotator cuff examination on cue we're going to go ahead and talk about this very very specifically so cue what i'm gonna have you do is i'm gonna have you take your shirt off so we can expose the muscles and the skin all right so when we're doing a rotator cuff exam obviously any kind of examination you always do inspection you palpate and then from there we're going to go ahead and do some specific strength testing and then after that we'll do maybe some special tests all right so the first thing i'm going to be doing is obviously just inspecting the you know the muscular area around cue shoulder looking for any signs of atrophy looking for any asymmetry do i see one shoulder maybe shrugging up a little bit more do i see one sagging a little bit very simple things then i'm going to go ahead and palpate i'm just palpating near the area of the shoulder do it and asking if he has any pain when i palpate around these areas and again i'm just kind of feeling around the coracoid process feeling near the acromion process feeling there like the greater tubercle and lesser tubercle and seeing if there was any pain upon that palpation if there is there may be some particular pathology going on there all right so we've inspected the shoulder we've palpated around for any tenderness now let's go ahead and just check his range of motion so cumin have you stand up all right so we'll check his range of motion we're going to do passive and active range of motion we would be comparing this bilaterally but we're just going to focus on the right side for right now so what i'm going to do is i'm just going to test all the range of motion here so particularly of those rotator cuff muscles so obviously if i wanted to i could do all of the motions if we wanted to i could check here i could check flexion at the shoulder joint if i wanted to i can also check abduction at the shoulder joint this is specifically looking for that kind of supraspinatus involvement and then if i wanted to i could also if i want to i could bring them up here to isolate these and i could check external rotation or i could check internal rotation okay and what i'm noticing is when i'm doing that for him does he have any pain is there any kind of restriction to movement and then i can have him do that on his own so i can go ahead and say cute can you go ahead and flex your arms in front of you good and can you go ahead and abduct away from your body good and then if i have you can you do external rotation for me good and then internal rotation for me good with any pain or any difficulty with that good all right so we've tested his passive range of motion his active range of motion again we'd be comparing these bilaterally to see if there's any abnormalities then we can test strength okay so let's say that we want to focus specifically on the supraspinatus so it's involved in abduction but really within the first like maybe 20 to 30 degrees so what i'll do is i'll just bring his arm up to about where the extreme of that motion would be and what i'm going to do is i'm just going to go ahead and stabilize that shoulder and i'm going to push down i want him to resist me from pushing down okay so good cue can you go ahead and resist me from pushing down good normal strength he's jacked right so there's no res there's no difficulty in him being able to resist that movement so definitely some good strength there five out of five strength in this supraspinatus muscle okay the other ones that i would test is i could test particularly maybe the subscapularis right so the subscapularis is involved in internal rotation so if i wanted to i could go ahead and bring him again to like the extreme of this motion here and i'm going to have them kind of pull inwards okay so i'm going to have you go ahead and stabilize here can you go ahead and rotate your arm inward good normal strength there i don't see any difficulty in being able to perform that movement okay next one there is i would test external rotation so this is hitting kind of that and again if we did the internal rotation we could do it here or we could bring it up here if we wanted to as well so if i wanted to i can go ahead and have him kind of push down good same thing i'm testing that internal rotation if i wanted external rotation i could have him right here and again i'm going to have him push outwards against me good and i'm testing the external rotation particularly of the infraspinatus the teres minor and again i could come up here and i could again have him push backwards good and again i'm testing the external rotation there as well all right so normal strength i don't see any kind of abnormalities there and again i would always be comparing bilaterally the next thing that you would be doing here is you would go on and say okay let's do some special tests let's see if there's any particular abnormalities so first thing you want to look for is there any signs of subacromial impinge remember that's a high risk factor for someone for the rotator cuff injury so there's a couple tests that we could do for that the first thing that we could do is we could test what's called the painful arc test and so what i'm looking for is i'm looking to see if he has any pain within about 45 to 60 degrees to about 120 degrees of that abduction up above okay so can i have you do that painful arc test for me q sure good any pain during that movement no so there's no pain during that movement then the painful arc test is negative there's no obvious signs of potentially subacromial impingement all right so the next test i could do is what's called the hawkins impingement test again it's looking for any subacromial impingement so what i'm going to have him do is i'm going to bring his arm like this i'm just going to go ahead and stabilize right there and what i'm going to do is when i have him kind of flexed to about 90 degrees elbow kind of flexed here at 90 degrees i'm just going to go ahead and internally rotate and what you'll be looking for is do i see any wincing do i see any obvious pain do you have any pain when i do this cue no so no obvious signs of kind of subacromial impingement there as well the next test i could do was what's called the nears test and again i'm going to have him kind of pronate his arm and again i'll be doing this bilaterally and i'm going to passively bring the arm up for him okay and do you have any pain with this cue no good okay so again no kind of issues there and the reason why we're doing that is sometimes whenever you're bringing the arm up and kind of get that greater tubercle stuck around that area where there could be like some subacromial bursitis okay so no subacromial impingement science okay the next thing i could do is i could test the supraspinatus okay so what i could do for that one is i could do the drop arm test it's a very simple one so obviously when you're having the arm out here there's going to be the supraspinatus involved in being able to keep the arm away from the body abduction so if i were to hold his arm up and i say okay cue i'm going to drop your arm see if you can hold it up i'm going to let go his ability to hold that arm up means that there is a negative type of drop arm test if it was positive it would fall okay the other thing i could do is i could do what's called the empty can test or what's called the job's test and so what i'm going to have him do is again i can have him kind of put his arm like this and what i'm going to do is again i'm going to have i'm going to push down and have him push against any kind of resistance there and his ability to do that as well as no pain no pain that could be again no sign of particularly any kind of supraspinatus tear there all right next thing we could do is we could do the subscapularis so the subscapularis there's two tests that we could do for that one so what we can do first is i can have him kind of go ahead and push on his belly and when he's pushing on his belly as long as he's not bringing that elbow in he's utilizing internal rotation to push against his belly so i'm going to go ahead and have you push against your belly and again i don't see that elbow rearing in anywhere okay let's get a good view of this so cue i'm going to have you look that way and do that test again squeeze down on that belly again do you see his elbow staying pretty much in the same position good positive there oh actually there's no abnormality within this test all right so good there next test that we can do is we can do what's called the lift off test i believe it's also called the gerber's test so what you can do is you can again i'm going to have him turn around all the way and then what i'm going to have him do is let's go ahead and put that right arm on the lower back and just first thing see if he has that normal range of motion to perform that activity can you push your arm off of your back there for me good all right now what i'm going to do is i'm going to come on the side i want to actually test make sure that there is no true weakness here or any kind of problems here so i'm just going to kind of stabilize his elbow okay and i'm going to put my hand on his hand and i'm going to have him push off against good okay so there is again no abnormality there within that subscapularis okay now we can look at this from another view we're going to have them look this way and again you can have them come bring that arm back on there good and again let's just test that normally can you push your arm off the back good and then what i'm going to do here is i'm just going to go ahead and have him push off against my resistance good and that subscapularis is intact okay generally if there was also any kind of abnormality they would also try to kind of extend their arm outwards like they're doing a tricep extension and it might be a little cheat so watch out for that as well okay all right we hit the subscapularis we hit the supraspinatus okay we're looking for any tears within those so i like to start off is there any signs of impingement if there is then go on to the next thing which is looking for any signs of particular tears within those muscles infraspinatus and teres minor are next so we can do is we can do the hornblowers test the hornblower's test is pretty good for the teres minor as well as for the infraspinatus so what we're going to do here is we're going to bring his arm up flexion about 90 degrees elbow extension to about 90 degrees scapular plane and again there's two different variations to this what we're going to have him do is i'm going to have him push his arm against me and i'm just kind of trying to test this external rotation basically okay let's do it from this view so you guys can see that as well bring that arm up 90 degrees deflection at the shoulder 90 degrees deflection at the elbow and again i'm just going to have him push against my resistance testing that external rotation so if there was any significant pain or inability to be able to perform that movement externally rotating against my resistance so for example if i was doing this and he started to give out then that would be potentially a sign of maybe some type of teres minor tear or infraspinatus tear now there is another variation to this so the other uh variation of the hornblower's test what you could do is you could have q come up like this like he's actually going to be blowing a horn and if there was an abnormality in this particularly infraspinatus or teres minor tear what would he do he may start kind of actually utilizing the trap muscles to compensate and start shrugging up that shoulder and so that could also be a sign potentially of an infraspinatus arteries minor tear the last thing that i could do to test the infraspinatus is i could do what's called the lag test so it's a kind of similar as the hornblower's test i'm going to bring him up to 90 degrees of flexion at the shoulder and at the elbow and then what i'm going to do is i'm going to try to pull his arm back into as much extension as i can external rotation as i can and i'm going to let go and i want him to hold it in this position so if he holds it there then that means that the infraspinatus is intact but if i were to pull back and all of a sudden i let go and it flies forward then he may have an inability to be able to maintain that type of position so there could be a tear of the infraspinatus same thing let's get a good look at it here so again 90 degrees deflection at the shoulder at the elbow pull back into external rotation let go that's normal if i pull pull pull pull pull let go he flies forward that could be a positive test for the infraspinatus tear okay now all of these tests are great but again to really get a good good idea of someone potentially having a high likelihood of a full thickness rotator cuff tear there's three specific tests that i want you guys to remember there should always be the gateway and then you can do all these other tests as well first thing that you do is we did the painful arc test so if you were to do the painful arc test go ahead and do that from eq it was positive at any point that 45 60 degree all the way up to 120 degree that's a potential sign of impingement next thing drop arm if i had them up here i let go it flops down that's a supraspinatus tear potentially and last thing is there is any weakness in any of the tests of x like for example infraspinatus test i had him try to externally rotate or any of those that could be also a sign of a full thickness rotator cuff there those three are positive high likelihood all right that covers our examination let's get back to the white board all right so let's talk about the treatment of a rotator cuff tear now how do we go about treating this well you got your conservative management right for someone maybe he has like a chronic hair maybe you're not going to go in there and do anything really about it immediately so what kind of things could we trial before we kind of go straight to the surgical option well things that you obviously are going to try to reduce any of the inflammation if there is any kind of subacromial impingement any inflammation from the rotator cuff tear itself you give medications to reduce the inflammation so what medications can i get let's say that there's a lot of inflammation obviously you know you guys know you're kind of your pathophysiology stuff right whenever there's lots of inflammation there's lots of what's called arachidonic acid arachidonic acid gets broken down into what's called prostaglandins leukotrienes and these bad boys just rev up the inflammation right well what kind of drugs can we give that can help to be able to particularly reduce the inflammatory process well we can give drugs like nsaids why do nsaids work i can start off with nsaids i can do things like naproxen i can do things like ibuprofen and i can do the insets because it specifically works by inhibiting the cyclooxygenase enzymes you know cyclooxygenase is involved in being able to stimulate the conversion of arachidonic acid which is from breakdown products of like different tissue parts from like inflammation obviously from the rotator cuff tear if i inhibit this enzyme i reduce the prostaglandin leukotrienes and i reduce the inflammation effectively there's another thing that you can do you can also give drugs so this would be kind of your first thing that you would try nsaids the second thing that you would go to is you would actually inject steroids into there you know there's a test it's kind of a diagnostic and therapeutic test you can do what's called a sub acromial lidocaine test actually so you may be able to inject some subacromial lidocaine into the area and if there's actually maybe some resolution of the pain okay there could be potentially maybe some tendinopathy in there as well so we could do the subacromial lidocaine again remember this is more for like the tendinopathy so if there is any kind of like tendinopathy or like bursitis related issues it's really good for these kinds of things it's not really going to help the tear itself it'll help some of the inflammation surrounding that area the third thing that we could do is we could do corticosteroids so corticosteroids you can actually inject into the joint because you can get kind of a local effect within that area and so we can have what's called intra articular injections all right so we've tried insets we've tried maybe some subacromial lidocaine you can do it as a test like a diagnostic and kind of a therapeutic test if it's positive they have some resolution of some of the pain or some minimization of the pain it could be indicative of a tendinopathy it's not going to fix the issue but it may help to say oh there's something going on with the burst or the tendon in that area and you can try intra-articular corticosteroids to help to reduce a lot of that inflammation as well obviously after you've done your nsaids you've tried the subacromial lidocaine test and you've had some intra-articular injections of corticosteroids you may have them go and see your friendly pt you guys know that on the ninja team we have our own pt robert beach and so if we have our man here that you got to go and say hey dr beach can you help me my rotator cuff's all jacked up what can i do to get this thing better well our good old robbie will say okay buddy what we got to do is is we have to first and strengthen your range of motion so we're going to work on strengthening some of that range of motion then the second thing we're going to do is we're going to really work to stabilize that shoulder joint remember i told you that sometimes if there's any kind of instability in the shoulder joint that can be somewhat problematic and causing issues with the rotator cuff tears so we'll work on shoulder stability and the last thing is we'll work on strengthening some of those muscles around their actual rotator cuff and rotator cuff itself okay and so we'll work on strengthening muscles around the shoulder joint okay so that's kind of the whole approach we're not going to go through all the exercises and things that we can do in this area but what i want you to know is conservative nsaids you can try your corticosteroids intra-articularly and pt if those things do not work there's a failure of that conservative therapy there is a traumatic tear or you have a person who's super super active they're an athlete and they need a quick repair that's this is not the best option for them then we'll push them to get a surgical type of treatment what is that kind of treatments that we'll go with all right so what's an indication for a surgical intervention right so we have someone they've tried the conservative measures and it failed so that's obviously one thing so we've conservative treatment fails the second thing is if it's any kind of like traumatic so sometimes if there's any kind of traumatic tears that may also be an indication a third one is if they're like a highly like competitive athlete and these conservative measures aren't going to be best for them or their job their occupation requires like full range of motion it requires a lot of activity and you know these conservative measures just aren't going to provide that for them we may go that route of being a little bit more aggressive okay so if there is um kind of a high mobility need and for example i like to you know put down like athletes so if you have a professional athlete they're not probably going to try the conservative therapy they might go straight to maybe a surgical option if they need it to gain regain that full mobility a lot quicker or certain occupations that are requiring you to again have that full mobility and also if you're younger someone who's a little bit younger is more likely to be someone that will kind of push to perform these surgeries for because if you're a little bit older the healing process is going to be a little bit more delayed it's a lot tougher to be able to have that full-on healing in that area so failure of the conservative measures any kind of traumatic tears or there's like a high mobility need in persons who are athletes they have an occupation that requires it and also if they're younger you can be a little bit more aggressive now what are those options of surgical therapy we can either open them up find where the tendon is torn and then repair it obviously that's not that you don't want to go the super invasive route so the option is the preferred option is we do something called an arthroscopic approach which is way more preferred and why is this preferred well you're sticking a camera right you're sticking a camera into the shoulder joint you're looking like oh there that sound of a gun is there's the tear i'm gonna go ahead and fix that this way so that's the options of treating someone with a rotator cuff tear ninjas i hope this made sense i hope that you guys enjoyed it i hope you had some fun and engineers love you thank you and as always until next time [Music] you

what&#39;s up ninja nerds in this video today we&#39;re going to be talking about rotator cuff tears if you guys want to follow along with some awesome notes some great illustrations go down the description box below we&#39;ll have a link to our website go check that out also if you guys like this video you benefit from it it makes sense and you have some fun in the process please support us by hitting that like button commenting down in the comment section but most importantly subscribe alright let&#39;s start talking about rotator cuff tears all right so let&#39;s start talking about rotator cuff tears before we do that we obviously have to understand what is the rotator cuff right we need to know what is it made up of we&#39;re not going to go crazy into the shoulder anatomy we&#39;ll have another separate video on that where you really understand all the intricacies but for right now i really want you guys to just focus on what are the muscles or the tendons or the specific bursa that are involved within the rotator cuff that because it&#39;s important right so first thing is we&#39;re going to take a look here kind of the shoulder joint area from an anterior view and there&#39;s really one specific muscle that i want you guys to remember so here&#39;s our scapula right this is all our scapula here and then here you&#39;re going to have like your coracoid process that&#39;s your chromium process connecting to the clavicle and then here&#39;s your humerus the humeral head sitting into that glenoid cavity right well there&#39;s a muscle that sits here in this fossa you know what this muscle is called this muscle is called the subscapularis muscle now the subscapularis muscle it sits in this subscapular faucet that&#39;s its origin and then the insertion for it as it comes all the way over here and attaches onto this little bump on the humerus you see that little bump right there that&#39;s called the lesser tubercle okay so one of the muscles that&#39;s on the anterior side here that i really want you guys to know is called the subscapularis the biggest thing that i want you guys to know about the subscapularis is this function with respect to how it plays a role within the rotator cuff since it kind of pulls imagine that it&#39;s pulling on that insertion towards the origin so it&#39;s going to kind of try to rotate the humerus internally so we just call that internal rotation okay so it&#39;s involved in internal rotation but particularly around what joint well obviously it&#39;s at that shoulder joint all right so that&#39;s one of the muscles that are involved within the rotator cuff what i want you guys to remember though is how does the muscle connect to the bone it connects to the bone via the tendons right so tendons are what connects muscles to bone so really when we&#39;re talking about this muscle this part here which is connecting the muscle to the bone is the tendon sometimes in patients with rotator cuff tears you have tears within the tendon that is connecting to that subscapularis muscle to the bone so we may lose the ability to internally rotate super simple stuff right all right posterior view look um at the scapula shoulder joint area there&#39;s a couple more muscles right here again acromion process you have your coracoid process this is going to be the humeral head sitting into that glenoid cavity there&#39;s a little like divot or fossa here and you see this fossa here there&#39;s a muscle that kind of sits right in here it&#39;s a cute little muscle it&#39;s called the supraspinatus now the supraspinatus sits and originates in that kind of super spinous fossa and then it&#39;s tendon kind of works right underneath this acromion process and then attaches onto this big fat knob here on the humerus what&#39;s that called it&#39;s called the greater tubercle so imagine again you&#39;re pulling from the insertion towards the origin it&#39;s going to pull the humerus outwards or away from the body we call that abduction so what&#39;s this muscle here this first one will put a 1 there that is called your supra spinatus and again the big function for this one is a b duction now when we talk about abduction it&#39;s really only kind of a certain amount of degrees it doesn&#39;t bring it up all the way it&#39;s only like a first maybe 20 30 degrees that it&#39;s helping to be able to pull up okay so again abduction at what point at the shoulder joint again all these movements you&#39;re obviously going to know but if we&#39;re really being particular we should specify where that movement&#39;s occurring all right second one here right underneath so you have we have this again this is a chromium process but this right here how it kind of originates from this part of the bone here this point right here is called the spine of the scapula so obviously above the spine is the supraspinous fossa just below the spine is the infraspinous fossa and there&#39;s a muscle that sits right in that infraspinous fossa called the infraspinatus and the infraspinatus originates off of that and then it goes and inserts on that big old knobby there what is that called the greater tubercle so this muscle that sits in the inverse spinous fossa is called the infraspinatus and again remember we&#39;re looking at this from the posterior view okay so if we had the infraspinatus pulling on the insertion it&#39;s going to pull the humerus the opposite way of the subscapularis it&#39;s going to try to externally rotate it so it&#39;s going to play a role with external rotation and again it&#39;s obvious but at that shoulder joint it&#39;s just good to get into a habit of saying where that movements are okay all right and then the last muscle here that&#39;s involved is it kind of sits it originates down here towards the bottom of the scapula kind of near the angle like the inferior angle and it comes up and same thing it also inserts near that greater tubercle what is this muscle that kind of sits towards like the bottom part of the scapula and then inserts onto the greater tubercle this muscle here is called the teres minor and again if it&#39;s kind of like just like where the infraspinatus is it should pretty much do the same thing right so again it&#39;s going to be pulling the humerus externally so it&#39;s the same thing external rotation at the shoulder joint all right so we&#39;ve talked about all the muscles from an anterior and posterior view there&#39;s four of them right that we&#39;ve kind of covered so you&#39;re like oh man this is a little bit too much zach how the heck do i remember all of the muscles and how do i remember what they do well i think what they do is actually the easier part but remembering the name sometimes is annoying right so you have a mnemonic to remember the rotator cuff muscles it&#39;s called sits okay so it stands for supraspinatus you have your infraspinatus you have your teres minor and then we can finish that puppy off with the subscapularis baby and just remember again with all of these muscles that we&#39;re talking about remember their muscles originating from these different like areas like the super spinous infraspinous fossa angle subscapular fossa and then what happens is the muscle extends to the bone via the tendon to attach to that area of the bone if there&#39;s any point where there is a break or a tear within these tendons then you can develop a rotator cuff tear okay now the last thing that i want to talk about just quickly is it&#39;s easy to see these in an anterior posterior view i want to quickly see what they would look like in a lateral view and just two more quick structures all right so let&#39;s take a look here at the shoulder joint from a lateral view so imagine you&#39;re looking here from the side right and i just pulled the humerus out of the way so you&#39;re staring into that cavity of the scapula so this right here is the glenoid cavity here i&#39;ll write in there son of a gun i&#39;ll write in there gc to indicate that this is the glenoid kind of cavity and that&#39;s where the humeral head will sit in form that the glenohumeral joint okay now surrounding that i don&#39;t want you guys to get too bogged down but right around that glenoid cavity there&#39;s kind of like this like fibrocartilaginous kind of structure here this like bluish color here this baby bluish this is your labrum this is called the glenoid labrum and then just around the labrum and this is obviously called the capsule all right so this is your capsule now there&#39;s a couple other structures that we need to obviously understand so here&#39;s the glenoid cavity just above that if you guys can kind of imagine from these views there was a bone that sits right up above it what was that bone called we&#39;re just going to put here that this bone is the acromion process okay and then there was a bone that was just anterior to it and it was kind of poking out like right here that was called the coracoid process well there&#39;s a ligament that actually has to connect between them just combine the names the the core co-acromial ligament is going to be between these guys now the next thing that i need you guys to know is there&#39;s a couple other things here so we got the bony stuff right the glenoid cavity we got the labrum the capsule we got the bones the chromium process the coracoid process the ligament that connects them now what are these purple structures i don&#39;t really want you to get bogged down on but they&#39;re important for helping to maintain stability to the to the actual shoulder joint in the capsule but these are all the ligaments and you know what&#39;s nice about these is they have a very simple name and they&#39;re primarily in the anterior portion so i one of the things to get a good understanding of as i should have told you here from a lateral view this is that nice view but this side let&#39;s actually kind of annotate this this is the anterior point of this lateral view and this is the posterior point of this lateral view okay so if you guys were to imagine these ligaments are primarily kind of like anterior and inferior and they&#39;re called the glenohumeral ligaments it&#39;s actually really simple right so you have the superior glenohumeral ligament the middle glenohumeral ligament and the inferior glenohumeral ligament they&#39;re just helping to provide some stability all right what else do we have here that&#39;s kind of important we have these like fluid filled like synovial like pockets really okay and they&#39;re important i really want you to understand this because they&#39;re important with the pathology these are called your bursa so this is containing like it&#39;s like a fluid filled like like a kind of like a ball if you will and it really is designed to allow for tendons to slide between kind of like areas really nicely to reduce any friction and so these little fluid fluid-filled kind of cavity areas are called bursa and this one here it&#39;s just underneath the acromion process so we call it sub so it&#39;s the sub acromial bursa this is a really important bursa because a lot of diseases become involved right here with inflammation of this and there&#39;s a very special tendon and muscle that runs right underneath it that if it becomes inflamed it can really jack up those tendons this one here is kind of a lesser significant burst but you should still know it because if it gets inflamed same kind of process can happen to the muscle that runs just here but this one is called your sub scapular bursa okay just again imagine them as like little like fluidy kind of like uh synovial fluid kind of like balls that allow for less friction for tendons to move between spaces okay all right so now let&#39;s talk about the muscles that are kind of around this area well again if you think about your anterior posterior view where would they be okay just running underneath the acromion process just underneath this bursa there is a muscle that sits right here what&#39;s this one called supraspinatus right what&#39;s the one that sits right on an anterior on the subscapular fossa and then runs anteriorly connect to the lesser tubercle this one right here is called the subscapularis muscle then you have the ones that will sit on the back ones that will sit on the infraspinous fossa is called the infraspinatus and then the ones that will sit towards the bottom of the scapula is the teres minor and there is a muscle that sits down here as well it&#39;s like the long head of the triceps but i don&#39;t want you to worry too much about that because these are the primary muscles that are involved in your rotator cuff so it&#39;s a good understanding to have a really good kind of view of how these muscles look from the anterior view the posterior view the lateral view and really the other thing that i really wanted you to take away from this is other associated structures that are nearby that can contribute to the pathology in this disease that being the subacromial bursa some of the actual subscapular bursa and also just some of the other bony processes that are nearby all right now that we got the basic anatomy done let&#39;s talk about some of the causes and pathophys that lead to this disease all right so let&#39;s talk about the causes the reasons why someone can develop a rotator cuff tear right so it&#39;s actually really simple if we break it down to like two different kind of pathophysiological mechanisms so we know the muscles we know the anatomy right which is kind of a really important thing once you get that down a lot of this stuff is going to come together really easily so imagine that we have this kind of diagram here again if we were looking at this this is really like a posterior view of that shoulder joint right so this is a posterior view now there&#39;s a lot of bones a lot of bursa a lot of ligaments that are nearby in this shoulder joint right if by any reason there&#39;s any kind of bony prominence like you know someone who gets like osteoarthritis or they get like bone spurs different types of like osteophytic processes if those things are kind of like let&#39;s say that you have here like let&#39;s say here&#39;s your chromium process and you get some type of like osteophyte or bone spur that&#39;s popping off of this bad boy that&#39;s going to apply some extrinsic compression and shearing across that tendon that extrinsic compression the shearing of that tendon rubbing up against that bone spur over time is going to produce micro tears lose its integrity and then it&#39;s going to pop and then you develop a rotator cuff tear so what i want you to remember is any kind of extrinsic factors think about bony prominences ligaments and things like that so if there&#39;s any kind of osteoarthritis of that joint it increases the risk of forming like these little bone spurs and those little bad boy bone spurs may produce like rubbing shearing forces compression of that area the other thing is that there&#39;s lots of ligaments nearby right so any kind of ligament that&#39;s actually kind of jacked up or inflamed or anything like that that could also provide some compression so another thing that we could say is let&#39;s kind of a a comply the ligaments we made them kind of that bluish color we can add that one in there as well any kind of like ligament injury as well that puts the shoulder in kind of any point of instability so if there&#39;s any instability of the shoulder that puts stress on that kind of like rotator cuff that also over time can produce micro tears inflammation and it can tear over time so any kind of ligament injury any kind of bony prominence or like bone spurs osteoarthritis changes but the big one that&#39;s why i wanted to look at it from the lateral view is sometimes if someone gets that you know that bursa we have this actually kind of a combined one here you have like your subacromial and it extends into what&#39;s called the subdeltoid bursa if this subacromial bursa becomes super super inflamed then you lose the ability to reduce the friction of that tendon running between the areas between like the bony prominences and so again there&#39;s that compressive factor from the inflamed bursa and the shearing forces on it and so any kind of like subacromial bursitis is a huge risk factor okay so i want you guys to definitely think about that so compressive or extrinsic types of mechanisms that i want you guys to think about is any bony change osteoarthritis is a good example bony spurs that are coming off and compressing another really good example is any kind of subacromial bursitis or what was the other bursa that was in the anterior portion the subscapular burst it&#39;s becoming inflamed so any kind of subscapular subacromial bursitis could cause these problems and any ligament injury what&#39;s the big like joint though like there&#39;s ligaments between this joint that really can become problematic produce instability in the shoulder what joint the ac joint so really kind of any ac joint abnormality puts the shoulder at a super point of instability and increases the risk of rotator cuff tears okay so i think we got the extrinsic mechanisms down that&#39;s not too hard right what about the intrinsic mechanisms what about something that&#39;s actually wrong what do we say a rotator cuff tear is it&#39;s a tear really within the tendon that&#39;s connecting the muscle to the bone of the humerus what if there&#39;s something that&#39;s not wrong with the actual compressive or extrinsic forces it&#39;s just something wrong with the tendon itself what could be reasons that the tendon would have some issues that&#39;s a good question engineers what if i&#39;m just stretching the crap out of that tendon or not just that i&#39;m putting so much tensile overload on that tendon so there&#39;s an increase like let&#39;s say i&#39;m stretching the living crap out of this tendon or i&#39;m causing an increase in what&#39;s called tensile overload and usually this is whenever there&#39;s extreme eccentric contractions okay of the muscles that are involved and what type of activity overhead movements so usually any kind of like overhead movements that&#39;s repetitive what&#39;s a good athlete that&#39;s constantly doing this kind of motion any kind of like quarterback or any kind of baseball player right so pitchers football players things of that nature that are swimmers anything with that consistent repetitive overhead movement with the tensile overload permit the eccentric contractions okay so really think about those types of athletes okay now that&#39;s one particular reason tensile overload but you know what else is another reason as people get older right aging so as you get older in aging lots of things unfortunately happen not a good thing right you get micro tears within these tendons it&#39;s just a natural part of aging so you get the micro tears on top of that with aging you get calcifications so now i&#39;m going to have these calcifications of the tendon and then on top of that as you get older usually the microvascularity of the tendon becomes even worse so imagine the blood flow to this tendon is also reduced generally it&#39;s reduced in general but it&#39;s even worse in aging so there is micro tears calcifications and microvascular kind of loss and all of these things puts the patient at a high risk for any kind of like maybe trauma any kind of repetitive overhead movement anything like that could put them at high risk for developing a tendon tear okay so again what i want you guys to remember with the aging process is this leads to micro tears this leads to calcifications and this also causes a change in their microvascular integrity goes down and that causes this area of like a critical zone so if you have like let&#39;s say lots of micro tears in this area let&#39;s kind of imagine this you have a lot of micro tears in this area right here the blood flow to this area is really diminished and you have lots of calcifications from whatever reason maybe trauma maybe some simple movement it&#39;s enough to cause a tear within that tendon so these are very important things so aging and high tensile overload from repetitive activities especially overhead movements what&#39;s the last one this one is not a super big one but it&#39;s something to think about and patients who have anything like inflammatory like kind of systemic diseases so let&#39;s kind of write over here anything like systemically systemic diseases that really just predispose them to developing quick easy kind of maybe a simple motion a simple repetitive motion that involves any of that external rotation internal rotation any abduction overhead movement anything like that enough because of disease in the tendon can cause it to tear what are these diseases that i want you guys to think about what if i have somebody who has a massive inflammatory disease like rheumatoid arthritis where they have antibodies that are attacking their tendons and shoulder joints what&#39;s a condition you know rheumatoid arthritis would be one what if i have a condition where they have a poor healing where maybe they have these small tears they have these like small tears and normally your blood vessels you don&#39;t have a ton of blood supply to the tendons but it&#39;s enough to maybe allow for small repair and patients with diabetes they have microvascular problems right they have very very bad microvasculature so the blood flow is going to be reduced due to their hyperglycemia and they have a poor healing process so another disease that could cause this problem would be diabetes and then what if there&#39;s a disease that there&#39;s actually intrinsically something wrong with ecology you know collagen is like one of the biggest components of tendons what if the collagen is all jacked up in this bad boy so the collagen or some of the proteins like fibrillin are jacked up in this to this tendon and they&#39;re not present or they&#39;re mutated or they&#39;re just abnormal this would be connective tissue diseases like morphons or ehlers-danlos syndrome okay not super common but something to think about all right we&#39;ve covered the causes the pathophys let&#39;s now start talking about how can we go about clinically diagnosing these patients all right so let&#39;s talk a little bit about how we go about diagnosing rotator cuff tears now it&#39;s obviously a clinical diagnosis there&#39;s some things that you could do particularly with very physical exam specific tests and maybe some imaging and we&#39;ll talk about that but some of the things that may cue you up to think oh it could be a rotator cuff tear is their description of pain right so they obviously have shoulder pain that&#39;s obvious right so if you&#39;re tearing some of those tendons nearby they&#39;re definitely going to have some type of shoulder pain but sometimes what&#39;s some key things that you may pick up from the history to kind of cue into that is that the shoulder pain tends to be right near like the anterior deltoid so it tends to be more anterior deltoid in location and also the pain is usually worse at night you want to know why it&#39;s because if they&#39;re laying on the affected side it&#39;s really causing a lot of pain in that area so if like for example if i had like an anterior deltoid pain rotator cuff tear that&#39;s on that left side and i go to lay on that left side when i&#39;m moving around during sleep the pain tends to be worse in that area so any kind of like compression or any kind of involvement of laying or on that affected area is one of the big things to cue you off on that so obviously shoulder pain is very very obvious so if someone comes into the office they say hey man i&#39;ve been having some anterior shoulder pain it&#39;s worse at night when i&#39;m sleeping how would you go about trying to figure out is this a rotator cuff tear well we take it step by step step we inspect the area so whenever you&#39;re inspecting someone with a rotator cuff there some of the big things that&#39;ll cue off on your exam is look for any kind of signs of atrophy you know there&#39;s what&#39;s called the infraspinatus atrophy so sometimes in certain types of tears if you look on the actual posterior aspect of their scapula you may see a complete difference in the muscle bulk on the area if there is any kind of tear that get infraspinatus atrophy next thing is obviously palpate you want to palpate around what are you aiming to palpate palpate near the actual humeral head the greater tubercle lesser tubercle feeling for any pain there palpating your coracoid process the acromioclavicular joint all of those things now the next thing is where you&#39;re going to be moving into range of motion so this is a big thing to remember obviously there&#39;s a tear so then being able to initiate a movement on their own contracting muscles and involving those muscles is going to be difficult so their range of motion actively meaning they&#39;re doing it on their own you&#39;re not doing it for them is significantly reduced and the passive range of motion seems to be somewhat preserved okay now we have inspected we&#39;re looking for any kind of atrophy we&#39;re palpating for any tenderness we&#39;re checking the range of motion we&#39;ll do it for them passively seeing if they have any pain and then we&#39;ll have them do it on their own seeing if there&#39;s any pain or inability to perform those movements then we do special strength testing to go back what are the muscles involved we have the supraspinatus what does it do abduction so you&#39;re testing for any weakness and abduction then you&#39;re testing the infraspinatus and the teres minor what do they do external rotation so you&#39;re trying to see are they having any difficulty in being able to externally rotate subscapularis what does it do internally rotate so are they having any difficulty being able to internally rotate so once you&#39;ve tested the strength if there&#39;s any weakness in those you may be able to pick out is there an area where the tendon could be teared or torn in this case okay so we&#39;ve gone inspected we palpated we checked the range of motion which is reduced and active somewhat preserved in passive check for any weaknesses involving some of the rotator cuff muscles then we get into your special tests now there is so many special tests that you could do from the literature the best kind of approach which seems to really provide a decent sensitivity of maybe a full thickness rotator cuff tears three specific tests that you should always try on these patients the first one is is you try what&#39;s called the painful arc test if the painful arc test is positive there could be some signs potentially of a subacromial impingement like a subacromial bursitis which i told you is a very very common cause for someone having a rotator cuff tear the next thing is they have a positive drop arm test this is kind of particularly looking at the activity of the supraspinatus muscle so the supraspinatus is obviously supposed to be involved in abduction if you drop their arm and they&#39;re not able to perform that or it drops really quickly there may be something wrong with the supraspinatus lastly is they have any weakness in external rotation and again which muscles are involved in the external rotation the infraspinatus and the teres minor so if there any of these are positive all three are positive it is a high sensitivity for them having a full thickness rotator cuff tear if maybe two out of the three are positive then you have to go maybe to either way you&#39;re gonna have to do imaging but your potential like predictive value of it is maybe a little bit lower but all three of these tests being positive is a very strong sign of them having a rotator cuff tear there&#39;s many other tests that we can do but these are the big ones that i want you to know we&#39;ll talk about those other tests when we do these on on cue what are the things that after we&#39;ve done our special tests that we would do we want to employ some imaging so we could start off with an x-ray the x-ray is really just good to rule out any kind of other pathologies is there any dislocations is there any ac joint separation is there any kind of fracture or any obvious osteoarthritic changes or here&#39;s the big thing and someone who has a rotator cuff tear sometimes the humeral head remember the rotator cuff is also important for just maintaining like the humeral head in that glenoid cavity so if you have a weakness in that that head is not going to be kind of held tightly into that glenoid socket there and so it can actually superiorly migrate and so sometimes what you may see is you see there&#39;s a space between the acromion process and the humeral head if that space becomes obliterated it becomes smaller that means that there&#39;s superior migration of the humeral head and it could be a sign of instability in the rotator cuff secondary to a rotator cuff tear so what i want you guys to remember is any loss of space between the acromion process and humeral head we call that superior migration of the humeral head which can be sometimes seen in a rotator cuff tear now these other two exams so i would start off with an x-ray if i have these three tests positive go with the x-ray you can rule out some other issues and then i like to use ultrasound it&#39;s a dynamic test it&#39;s really cool so i can look at the dynamic movement of the actual the tendon if you get a good enough view and you&#39;re looking having them abduct you&#39;ll be able to see the tendon in its dynamic motion seeing if there&#39;s any kind of weakness if there is any tears it&#39;s also good at picking up tears okay and or tears okay the best test the gold standard if you will is going to be your mri if they have a contraindication to mri they can get what&#39;s called a ct arthrogram they inject some dye into the actual joint and get a ct scan and that may also be kind of an extra test that you could do if they can&#39;t tolerate an mri but the mri is the best because it can pick up any kind of tear whether it be a minor partial tear to a full thickness tear it&#39;s going to be the best sensitivity of any test okay so we&#39;ve gone through how we&#39;re going to suspect a diagnosis of a rotator cuff tear let&#39;s actually do a nice quick physical exam on someone that we think may have a rotator cuff tear looking at the big big test that i want you guys to know on a person that we suspect has a rotator cuff tear we&#39;re going to bring our boy q in all right ninja so let&#39;s go ahead and do a rotator cuff examination on cue we&#39;re going to go ahead and talk about this very very specifically so cue what i&#39;m gonna have you do is i&#39;m gonna have you take your shirt off so we can expose the muscles and the skin all right so when we&#39;re doing a rotator cuff exam obviously any kind of examination you always do inspection you palpate and then from there we&#39;re going to go ahead and do some specific strength testing and then after that we&#39;ll do maybe some special tests all right so the first thing i&#39;m going to be doing is obviously just inspecting the you know the muscular area around cue shoulder looking for any signs of atrophy looking for any asymmetry do i see one shoulder maybe shrugging up a little bit more do i see one sagging a little bit very simple things then i&#39;m going to go ahead and palpate i&#39;m just palpating near the area of the shoulder do it and asking if he has any pain when i palpate around these areas and again i&#39;m just kind of feeling around the coracoid process feeling near the acromion process feeling there like the greater tubercle and lesser tubercle and seeing if there was any pain upon that palpation if there is there may be some particular pathology going on there all right so we&#39;ve inspected the shoulder we&#39;ve palpated around for any tenderness now let&#39;s go ahead and just check his range of motion so cumin have you stand up all right so we&#39;ll check his range of motion we&#39;re going to do passive and active range of motion we would be comparing this bilaterally but we&#39;re just going to focus on the right side for right now so what i&#39;m going to do is i&#39;m just going to test all the range of motion here so particularly of those rotator cuff muscles so obviously if i wanted to i could do all of the motions if we wanted to i could check here i could check flexion at the shoulder joint if i wanted to i can also check abduction at the shoulder joint this is specifically looking for that kind of supraspinatus involvement and then if i wanted to i could also if i want to i could bring them up here to isolate these and i could check external rotation or i could check internal rotation okay and what i&#39;m noticing is when i&#39;m doing that for him does he have any pain is there any kind of restriction to movement and then i can have him do that on his own so i can go ahead and say cute can you go ahead and flex your arms in front of you good and can you go ahead and abduct away from your body good and then if i have you can you do external rotation for me good and then internal rotation for me good with any pain or any difficulty with that good all right so we&#39;ve tested his passive range of motion his active range of motion again we&#39;d be comparing these bilaterally to see if there&#39;s any abnormalities then we can test strength okay so let&#39;s say that we want to focus specifically on the supraspinatus so it&#39;s involved in abduction but really within the first like maybe 20 to 30 degrees so what i&#39;ll do is i&#39;ll just bring his arm up to about where the extreme of that motion would be and what i&#39;m going to do is i&#39;m just going to go ahead and stabilize that shoulder and i&#39;m going to push down i want him to resist me from pushing down okay so good cue can you go ahead and resist me from pushing down good normal strength he&#39;s jacked right so there&#39;s no res there&#39;s no difficulty in him being able to resist that movement so definitely some good strength there five out of five strength in this supraspinatus muscle okay the other ones that i would test is i could test particularly maybe the subscapularis right so the subscapularis is involved in internal rotation so if i wanted to i could go ahead and bring him again to like the extreme of this motion here and i&#39;m going to have them kind of pull inwards okay so i&#39;m going to have you go ahead and stabilize here can you go ahead and rotate your arm inward good normal strength there i don&#39;t see any difficulty in being able to perform that movement okay next one there is i would test external rotation so this is hitting kind of that and again if we did the internal rotation we could do it here or we could bring it up here if we wanted to as well so if i wanted to i can go ahead and have him kind of push down good same thing i&#39;m testing that internal rotation if i wanted external rotation i could have him right here and again i&#39;m going to have him push outwards against me good and i&#39;m testing the external rotation particularly of the infraspinatus the teres minor and again i could come up here and i could again have him push backwards good and again i&#39;m testing the external rotation there as well all right so normal strength i don&#39;t see any kind of abnormalities there and again i would always be comparing bilaterally the next thing that you would be doing here is you would go on and say okay let&#39;s do some special tests let&#39;s see if there&#39;s any particular abnormalities so first thing you want to look for is there any signs of subacromial impinge remember that&#39;s a high risk factor for someone for the rotator cuff injury so there&#39;s a couple tests that we could do for that the first thing that we could do is we could test what&#39;s called the painful arc test and so what i&#39;m looking for is i&#39;m looking to see if he has any pain within about 45 to 60 degrees to about 120 degrees of that abduction up above okay so can i have you do that painful arc test for me q sure good any pain during that movement no so there&#39;s no pain during that movement then the painful arc test is negative there&#39;s no obvious signs of potentially subacromial impingement all right so the next test i could do is what&#39;s called the hawkins impingement test again it&#39;s looking for any subacromial impingement so what i&#39;m going to have him do is i&#39;m going to bring his arm like this i&#39;m just going to go ahead and stabilize right there and what i&#39;m going to do is when i have him kind of flexed to about 90 degrees elbow kind of flexed here at 90 degrees i&#39;m just going to go ahead and internally rotate and what you&#39;ll be looking for is do i see any wincing do i see any obvious pain do you have any pain when i do this cue no so no obvious signs of kind of subacromial impingement there as well the next test i could do was what&#39;s called the nears test and again i&#39;m going to have him kind of pronate his arm and again i&#39;ll be doing this bilaterally and i&#39;m going to passively bring the arm up for him okay and do you have any pain with this cue no good okay so again no kind of issues there and the reason why we&#39;re doing that is sometimes whenever you&#39;re bringing the arm up and kind of get that greater tubercle stuck around that area where there could be like some subacromial bursitis okay so no subacromial impingement science okay the next thing i could do is i could test the supraspinatus okay so what i could do for that one is i could do the drop arm test it&#39;s a very simple one so obviously when you&#39;re having the arm out here there&#39;s going to be the supraspinatus involved in being able to keep the arm away from the body abduction so if i were to hold his arm up and i say okay cue i&#39;m going to drop your arm see if you can hold it up i&#39;m going to let go his ability to hold that arm up means that there is a negative type of drop arm test if it was positive it would fall okay the other thing i could do is i could do what&#39;s called the empty can test or what&#39;s called the job&#39;s test and so what i&#39;m going to have him do is again i can have him kind of put his arm like this and what i&#39;m going to do is again i&#39;m going to have i&#39;m going to push down and have him push against any kind of resistance there and his ability to do that as well as no pain no pain that could be again no sign of particularly any kind of supraspinatus tear there all right next thing we could do is we could do the subscapularis so the subscapularis there&#39;s two tests that we could do for that one so what we can do first is i can have him kind of go ahead and push on his belly and when he&#39;s pushing on his belly as long as he&#39;s not bringing that elbow in he&#39;s utilizing internal rotation to push against his belly so i&#39;m going to go ahead and have you push against your belly and again i don&#39;t see that elbow rearing in anywhere okay let&#39;s get a good view of this so cue i&#39;m going to have you look that way and do that test again squeeze down on that belly again do you see his elbow staying pretty much in the same position good positive there oh actually there&#39;s no abnormality within this test all right so good there next test that we can do is we can do what&#39;s called the lift off test i believe it&#39;s also called the gerber&#39;s test so what you can do is you can again i&#39;m going to have him turn around all the way and then what i&#39;m going to have him do is let&#39;s go ahead and put that right arm on the lower back and just first thing see if he has that normal range of motion to perform that activity can you push your arm off of your back there for me good all right now what i&#39;m going to do is i&#39;m going to come on the side i want to actually test make sure that there is no true weakness here or any kind of problems here so i&#39;m just going to kind of stabilize his elbow okay and i&#39;m going to put my hand on his hand and i&#39;m going to have him push off against good okay so there is again no abnormality there within that subscapularis okay now we can look at this from another view we&#39;re going to have them look this way and again you can have them come bring that arm back on there good and again let&#39;s just test that normally can you push your arm off the back good and then what i&#39;m going to do here is i&#39;m just going to go ahead and have him push off against my resistance good and that subscapularis is intact okay generally if there was also any kind of abnormality they would also try to kind of extend their arm outwards like they&#39;re doing a tricep extension and it might be a little cheat so watch out for that as well okay all right we hit the subscapularis we hit the supraspinatus okay we&#39;re looking for any tears within those so i like to start off is there any signs of impingement if there is then go on to the next thing which is looking for any signs of particular tears within those muscles infraspinatus and teres minor are next so we can do is we can do the hornblowers test the hornblower&#39;s test is pretty good for the teres minor as well as for the infraspinatus so what we&#39;re going to do here is we&#39;re going to bring his arm up flexion about 90 degrees elbow extension to about 90 degrees scapular plane and again there&#39;s two different variations to this what we&#39;re going to have him do is i&#39;m going to have him push his arm against me and i&#39;m just kind of trying to test this external rotation basically okay let&#39;s do it from this view so you guys can see that as well bring that arm up 90 degrees deflection at the shoulder 90 degrees deflection at the elbow and again i&#39;m just going to have him push against my resistance testing that external rotation so if there was any significant pain or inability to be able to perform that movement externally rotating against my resistance so for example if i was doing this and he started to give out then that would be potentially a sign of maybe some type of teres minor tear or infraspinatus tear now there is another variation to this so the other uh variation of the hornblower&#39;s test what you could do is you could have q come up like this like he&#39;s actually going to be blowing a horn and if there was an abnormality in this particularly infraspinatus or teres minor tear what would he do he may start kind of actually utilizing the trap muscles to compensate and start shrugging up that shoulder and so that could also be a sign potentially of an infraspinatus arteries minor tear the last thing that i could do to test the infraspinatus is i could do what&#39;s called the lag test so it&#39;s a kind of similar as the hornblower&#39;s test i&#39;m going to bring him up to 90 degrees of flexion at the shoulder and at the elbow and then what i&#39;m going to do is i&#39;m going to try to pull his arm back into as much extension as i can external rotation as i can and i&#39;m going to let go and i want him to hold it in this position so if he holds it there then that means that the infraspinatus is intact but if i were to pull back and all of a sudden i let go and it flies forward then he may have an inability to be able to maintain that type of position so there could be a tear of the infraspinatus same thing let&#39;s get a good look at it here so again 90 degrees deflection at the shoulder at the elbow pull back into external rotation let go that&#39;s normal if i pull pull pull pull pull let go he flies forward that could be a positive test for the infraspinatus tear okay now all of these tests are great but again to really get a good good idea of someone potentially having a high likelihood of a full thickness rotator cuff tear there&#39;s three specific tests that i want you guys to remember there should always be the gateway and then you can do all these other tests as well first thing that you do is we did the painful arc test so if you were to do the painful arc test go ahead and do that from eq it was positive at any point that 45 60 degree all the way up to 120 degree that&#39;s a potential sign of impingement next thing drop arm if i had them up here i let go it flops down that&#39;s a supraspinatus tear potentially and last thing is there is any weakness in any of the tests of x like for example infraspinatus test i had him try to externally rotate or any of those that could be also a sign of a full thickness rotator cuff there those three are positive high likelihood all right that covers our examination let&#39;s get back to the white board all right so let&#39;s talk about the treatment of a rotator cuff tear now how do we go about treating this well you got your conservative management right for someone maybe he has like a chronic hair maybe you&#39;re not going to go in there and do anything really about it immediately so what kind of things could we trial before we kind of go straight to the surgical option well things that you obviously are going to try to reduce any of the inflammation if there is any kind of subacromial impingement any inflammation from the rotator cuff tear itself you give medications to reduce the inflammation so what medications can i get let&#39;s say that there&#39;s a lot of inflammation obviously you know you guys know you&#39;re kind of your pathophysiology stuff right whenever there&#39;s lots of inflammation there&#39;s lots of what&#39;s called arachidonic acid arachidonic acid gets broken down into what&#39;s called prostaglandins leukotrienes and these bad boys just rev up the inflammation right well what kind of drugs can we give that can help to be able to particularly reduce the inflammatory process well we can give drugs like nsaids why do nsaids work i can start off with nsaids i can do things like naproxen i can do things like ibuprofen and i can do the insets because it specifically works by inhibiting the cyclooxygenase enzymes you know cyclooxygenase is involved in being able to stimulate the conversion of arachidonic acid which is from breakdown products of like different tissue parts from like inflammation obviously from the rotator cuff tear if i inhibit this enzyme i reduce the prostaglandin leukotrienes and i reduce the inflammation effectively there&#39;s another thing that you can do you can also give drugs so this would be kind of your first thing that you would try nsaids the second thing that you would go to is you would actually inject steroids into there you know there&#39;s a test it&#39;s kind of a diagnostic and therapeutic test you can do what&#39;s called a sub acromial lidocaine test actually so you may be able to inject some subacromial lidocaine into the area and if there&#39;s actually maybe some resolution of the pain okay there could be potentially maybe some tendinopathy in there as well so we could do the subacromial lidocaine again remember this is more for like the tendinopathy so if there is any kind of like tendinopathy or like bursitis related issues it&#39;s really good for these kinds of things it&#39;s not really going to help the tear itself it&#39;ll help some of the inflammation surrounding that area the third thing that we could do is we could do corticosteroids so corticosteroids you can actually inject into the joint because you can get kind of a local effect within that area and so we can have what&#39;s called intra articular injections all right so we&#39;ve tried insets we&#39;ve tried maybe some subacromial lidocaine you can do it as a test like a diagnostic and kind of a therapeutic test if it&#39;s positive they have some resolution of some of the pain or some minimization of the pain it could be indicative of a tendinopathy it&#39;s not going to fix the issue but it may help to say oh there&#39;s something going on with the burst or the tendon in that area and you can try intra-articular corticosteroids to help to reduce a lot of that inflammation as well obviously after you&#39;ve done your nsaids you&#39;ve tried the subacromial lidocaine test and you&#39;ve had some intra-articular injections of corticosteroids you may have them go and see your friendly pt you guys know that on the ninja team we have our own pt robert beach and so if we have our man here that you got to go and say hey dr beach can you help me my rotator cuff&#39;s all jacked up what can i do to get this thing better well our good old robbie will say okay buddy what we got to do is is we have to first and strengthen your range of motion so we&#39;re going to work on strengthening some of that range of motion then the second thing we&#39;re going to do is we&#39;re going to really work to stabilize that shoulder joint remember i told you that sometimes if there&#39;s any kind of instability in the shoulder joint that can be somewhat problematic and causing issues with the rotator cuff tears so we&#39;ll work on shoulder stability and the last thing is we&#39;ll work on strengthening some of those muscles around their actual rotator cuff and rotator cuff itself okay and so we&#39;ll work on strengthening muscles around the shoulder joint okay so that&#39;s kind of the whole approach we&#39;re not going to go through all the exercises and things that we can do in this area but what i want you to know is conservative nsaids you can try your corticosteroids intra-articularly and pt if those things do not work there&#39;s a failure of that conservative therapy there is a traumatic tear or you have a person who&#39;s super super active they&#39;re an athlete and they need a quick repair that&#39;s this is not the best option for them then we&#39;ll push them to get a surgical type of treatment what is that kind of treatments that we&#39;ll go with all right so what&#39;s an indication for a surgical intervention right so we have someone they&#39;ve tried the conservative measures and it failed so that&#39;s obviously one thing so we&#39;ve conservative treatment fails the second thing is if it&#39;s any kind of like traumatic so sometimes if there&#39;s any kind of traumatic tears that may also be an indication a third one is if they&#39;re like a highly like competitive athlete and these conservative measures aren&#39;t going to be best for them or their job their occupation requires like full range of motion it requires a lot of activity and you know these conservative measures just aren&#39;t going to provide that for them we may go that route of being a little bit more aggressive okay so if there is um kind of a high mobility need and for example i like to you know put down like athletes so if you have a professional athlete they&#39;re not probably going to try the conservative therapy they might go straight to maybe a surgical option if they need it to gain regain that full mobility a lot quicker or certain occupations that are requiring you to again have that full mobility and also if you&#39;re younger someone who&#39;s a little bit younger is more likely to be someone that will kind of push to perform these surgeries for because if you&#39;re a little bit older the healing process is going to be a little bit more delayed it&#39;s a lot tougher to be able to have that full-on healing in that area so failure of the conservative measures any kind of traumatic tears or there&#39;s like a high mobility need in persons who are athletes they have an occupation that requires it and also if they&#39;re younger you can be a little bit more aggressive now what are those options of surgical therapy we can either open them up find where the tendon is torn and then repair it obviously that&#39;s not that you don&#39;t want to go the super invasive route so the option is the preferred option is we do something called an arthroscopic approach which is way more preferred and why is this preferred well you&#39;re sticking a camera right you&#39;re sticking a camera into the shoulder joint you&#39;re looking like oh there that sound of a gun is there&#39;s the tear i&#39;m gonna go ahead and fix that this way so that&#39;s the options of treating someone with a rotator cuff tear ninjas i hope this made sense i hope that you guys enjoyed it i hope you had some fun and engineers love you thank you and as always until next time [Music] you

Transcript for:Understanding Rotator Cuff Tears and Treatment

Transcript for:
Understanding Rotator Cuff Tears and Treatment